Rehabilitation of the neurologically disabled patient: principles, practice, and scientific basis

Rehabilitation is a therapeutic program specifically directed toward restoring the optimum level of function available to patients with severe permanent disabilities. It complements standard care, which focuses on curing the primary pathology. Preventive rehabilitation is designed to minimize the complications of inactivity that tend to develop during a protracted curative process (contractures, pressure sores, muscle atrophy, cardiopulmonary deconditioning, cognitive dulling). Comprehensive rehabilitation focuses on the restoration of function. It encompasses physical reconditioning, teaching new ways to accomplish the basic tasks of locomotion, object handling, personal care, relationships with family and society, employment, and recreation. The rehabilitation program is largely designed and provided by a team of allied health professionals, each an expert in one area of function. Reverting to a less dominant role, the physician provides leadership by defining the stress (activity) tolerance of the patient's pathology, coordinates the team, and manages intercurrent problems that arise. Comprehensive rehabilitation is an in-hospital program. Less intense elements can be provided in a skilled nursing facility, out-patient clinic, or the patient's home. The details of the rehabilitation process vary with the nature of the patient's primary pathology. These have been illustrated in this review of the programs for two very diverse situations. Spinal cord injury introduces varying levels of physical incapacitation. Conversely, brain injury primarily creates a cognitive and behavioral deficit. Both are complex problems requiring comprehensive rehabilitation if the impairment is severe.