Enabling America Assessing the Role of Rehabilitation Science and Engineering (1997) / Chapter Skim
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5 FUNCTIONAL LIMITATIONS RESEARCH IN REHABILITATION SCIENCE AND ENGINEERING
5 FUNCTIONAL LIMITATIONS RESEARCH IN REHABILITATION SCIENCE AND ENGINEERING
Pages 100-146
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From page 100... ...
Proper measurement of functional limitations is difficult and expensive, and many clinicians are not aware of the extraordinary deficiencies that exist in the functional limitations literature. For example, the functional benefits of strengthening exercises for older people with one or more weakness-producing impairments are essentially unknown, despite the obvious appeal of such a commonsensical notion.
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From page 101... ...
New impairments have been shown to engender locomotor compensatory mechanisms; to date, however, no data are available to link impairments to such compensatory mechanisms in individuals with specific functional limitations or disabilities. Until this link is established, it will be impossible to discern compensatory mechanisms such as Trendelenburg gait resulting from primary disabling and functionally limiting mechanisms such as hip abductor muscle weakness or range of motion limitation.
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From page 102... ...
Until more functional limitations research is done, however, it will be impossible to know how much activity limitation is imposed by the environment and how much is imposed by the whole person's functional capacity. Virtually all rehabilitation texts suggest that strength, restriction of movement, and other impairments be measured during assessments of people with disabling conditions, but the current emphasis of health maintenance organizations and preferred provider organizations on rapidly returning patients to premorbid functional status is beginning to cause this paradigm to shift.
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From page 103... ...
Functional limitations research usually attempts to obviate such IADL differences, but in practice, some standardization is required even in basic ADL. For example, stair or chair height contributes substantially to performance variation (Krebs et al., 1992~.
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From page 104... ...
In people with disabling conditions, depending on the compensatory strategies used, secondary conditions and comorbidities, can affect functional status throughout a person's life. Secondary conditions are impairments, functional limitations, disabilities, diseases, injuries or other conditions that occur during the life of a person with a disability, where the primary disabling condition is a risk factor for that secondary condition, or may alter the management of health and medical conditions.
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From page 105... ...
than prevention or intervention strategies. To illustrate, Table 5-1 provides some examples in various body systems of age-related changes, potential secondary conditions, and prevention strategies for people with mobility limitations such as spinal cord injury.
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From page 107... ...
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From page 108... ...
Locomotion Functional Limitations Strength Impairment Relationships to Locomotor Functional Limitations Scant data exist on strength training among people with impairments, still fewer studies include people with functional limitations, and to date no reports relate strength changes to disability measures and locomotor activities among people with disabling conditions. "Although high-intensity training increases force-generating capacity, little is known about its effects on functional performance.
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From page 109... ...
No study has examined the extent to which potentially destabilizing postural compensations for weakness, such as excess abductor lurch or forward trunk rotations, are ameliorated following strength gains. Balance Impairment Relationships to Locomotor Functional Limitations Rehabilitation scientists have begun to study whether exercise improves impairments and performance of ADL; the important missing component that should be addressed includes the relationship of impairments
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From page 110... ...
However, no systematic research studies of the efficacy of proprioceptive neuromuscular facilitation for patients with CbD have been reported. There is sparse evidence of successful treatment of chronic CbD, and it has been regarded as a condition refractive to treatment (Sage, 1984~.
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From page 111... ...
Engineering and technology, when combined with appropriate surgical management, with appropriate prosthetics and orthotics assistance, and with proper therapy and training will be able to advance the area of aided-ambulation at a rapid pace. Upright mobility can be significantly improved for persons with spinal cord injury, cerebral palsy, spine bifida, stroke, and other conditions through better engineering understanding of the biomecham~s of walking and of aided walking.
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From page 112... ...
improvements are not related to dynamic functional locomotor performance, then current impairment-level interventions should be abandoned. More studies of whole-body locomotion during naturalistic gait, rising from a chair, climbing stairs, and other locomotor ADL should be investigated following the implementation of interventions to determine the relevance of such impairment rehabilitation to whole-person functional limitations (Krebs and Lockert, 1995~.
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From page 113... ...
Improved understanding of human ambulation will enable functional electrical stimulation to be used more effectively. The orthotic field in general can be complemented with new engineering ideas and with advanced materials and fabrication techniques.
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From page 114... ...
4 ENABLING AMERICA struction may involve transfer of toes to the hand. When coupled with good therapeutic follow-up often by occupational therapists remarkable rehabilitation of hand injuries can be achieved.
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From page 115... ...
The benefits of different kinds of physical medicine therapies for arthritis need further study. Disabling conditions of the hand or arm system due to stroke, spinal cord injury, and brachial plexus injuries may be mediated through therapeutic techniques such as exercises, range-of-motion equipment, electrical stimulation, functional training, compensatory skill development, and splinting.
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From page 116... ...
In any case, eating aids will likely have to be customized to the user in most cases. Future Needs Artificial hands, artificial arms, upper-limb orthoses, and robots that assist with rehabilitation provide the capacity for people with disabling conditions to physically manipulate unstructured environments (the kind most of people find on their desks)
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From page 117... ...
Pain as a cause of lifting functional limitations must be further delineated; most rehabilitation interventions address spinal mobility, trunk strength, and fatigue and Reconditioning of peripheral muscle, as well as the cardiovascular system. For example, transporting loads and manual lifting capacity are key to manual laborers' productivity, but their supervisors
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From page 118... ...
Indeed, any test that could be used to relate strength, range of motion, and other impairments to lifting functional limitations would provide an important improvement to rehabilitation strategies. Future Needs and Best Strategies Most prior and current research on lifting in general and back pain in particular focus on impairment and capacity measures, typically focusing
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From page 119... ...
An inability to validly quantify lifting functional limitations is an important shortcoming of the rehabilitation research arena (Vasudevan, 1992; Fordyce, 1995~. An important problem in lifting research is measuring impairments such as strength and mobility, but reporting these as if they are functional limitations measures.
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From page 120... ...
Impairments at any stage from mechanical or neuromusculoskeletal disorders, and with consideration of age and state of development, can result in an eating functional limitation. Dysphagia can result from congenital or acquired central neurological disorders (e.g., stroke, cerebral palsy, traumatic brain injury, or polio)
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From page 121... ...
The occurrence of dysphagia in individuals who experienced a brain injury is reported to be about 27 percent, and cognitive impairment is often the most significant factor (Winstein, 1983~. Children with cerebral palsy often require treatment programs that address tonal abnormalities, postural control, adverse behavior, and primitive reflexes, along with the specific oral motor dysfunctions (Morris, 1989; Morton, 1993~.
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From page 122... ...
Standardized outcomes measures regarding functional limitations are needed for better comparison of different studies and different interventions. Finally, research is needed to determine the impact of different interventions on disability and quality of life, particularly over a lifetime.
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From page 123... ...
Any pathological process that causes a neurogenic bladder may result in the following problems or functional limitations: (1) the inability to void voluntarily, (2)
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From page 124... ...
Functional Limitations and Disabilities The function of the bladder should be viewed from the total aspect of the person's ability to function in the society in which he or she lives (Cardenas, 1992~. The expectations of society are that older children and adults can maintain continence and empty the bladder at acceptable intervals, usually not more than once in 3 to 4 hours.
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From page 125... ...
A young man with a spinal cord injury that resulted in paralysis of most of the muscles of his arms and all of his trunk and leg muscles was hired at a bank in an urban community. The bank building did not have a wheelchair-accessible toilet, and the young man managed his neurogenic bladder by performing intermittent catheterization every 6 hours.
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From page 126... ...
Other changes in the treatment of spinal cord injury have also occurred, however, including the introduction of newer antibiotics and formalized systems of rehabilitative care and follow-up. Physiological urinary tract changes over time have received minimal attention.
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From page 127... ...
These potentially major breakthroughs may dramatically alter the future care of people with bladder and bowel control problems. Bowel Functional Limitations The normal function of the bowel, like the bladder, may be altered by various types of pathologies, especially those that cause primary damage to the central nervous system and autonomic nervous system.
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From page 128... ...
Sexual Functioning Functional Limitations Sexual functioning is an important aspect of human life and wellbeing. Impairment of sexual functioning may result from disease processes that alter neurological, vascular, or endocrine function such as spinal cord injury, multiple sclerosis, atherosclerosis, and diabetes mellitus, as well as from mental disorders and even common medications used to treat numerous conditions.
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From page 129... ...
Orgasm is less well studied than erection, lubrication, or ejaculation. The subjective experience of orgasm is paralleled by certain physiological changes, but measuring these changes has not received much attention in those with a loss of sensation such as may occur after spinal cord injury.
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From page 130... ...
When depth perception is adversely affected by poor lighting, lack of color or visual contrast, or deceptive visual patterns, depth cues send the brain erroneous information about one's immediate environment, and then a loss of function can occur. Another functional limitation is contrast sensitivity, which is a function of the M pathway and which is the difference In light intensity between an object and its immediate surroundings.
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From page 131... ...
Rehabilitation science and engineering has much potential to assist in the further development of technical aids for people with low vision or blindness. If the science and engineering can be carried out in close proximity to rehabilitation centers for blind people and in close proximity to blind and partially sighted people and their caregivers, the potential for major practical advances is enhanced.
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From page 132... ...
This may help in the development of visual training programs, behavioral strategies, and environmental adaptations that can contribute to the optimal functioning of individuals with disabling conditions that otherwise may be ignored. Hearing Relationship of Impairment and Functional Limitation The sense of hearing is used primarily for communication, for localizing sounds in the environment, and for aesthetic purposes such as the enjoyment of music.
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From page 133... ...
Virtually all peripheral hearing impairments result in some degree of hearing loss, that is, a reduction in hearing sensitivity, and as a result, sounds must be made more intense for the individual to detect them. In many cases, the peripheral hearing impairment also results in a decrement in the ability to discriminate sounds, so that even if the sounds are made intense enough to be detected, they are still not perceived correctly.
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From page 134... ...
A professional musician with a very mild hearing loss in one ear that may not affect communication ability but that may still reduce the ability to play a musical instrument may be considered substantially disabled. Some hearing impairments are the result of transient diseases or are able to be corrected with medical or surgical intervention.
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From page 135... ...
a microphone (lapel microphone worn by the lecturer, classroom teacher, or performer) can be positioned to pick up the acoustic signals of interest and transmit the signals wirelessly to special earphone devices or personal hearing aids worn by the people in the audience with hearing losses.
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From page 136... ...
Incorrect responses to certain questions by an individual who has experienced a stroke may be interpreted as a cognitive deficit when in fact the responses may be the result of misperceptions due to a preexisting, mild peripheral hearing impairment, a common condition in people who are elderly. Flearing: Engineering Advances Hearing loss, after having normal hearing, is common, particularly among elderly people.
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From page 137... ...
The coordination, sequencing, and programming of these activities is directed by the brain, most specifically, the left frontal cortex. An impairment at any organ level involved in the process will influence speech production, and lead to a functional limitation in speech.
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From page 138... ...
Effectiveness of speech interventions for individuals with spastic dysarthrias has been documented through case reports, single-subject design studies, and uncontrolled group treatments (Aten, 1988~. Study outcomes measure changes in muscle strength and control, reduction in consonant imprecision, and improved intelligibility and speaking rate (Yorkston, 1995~.
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From page 139... ...
Interventions in this age group have been longstanding (Sommers, 1992~. Hearing impairments must be considered in the pediatric group in particular when speech delays are noted.
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From page 140... ...
They also create functional limitations for the families of such individuals. Cognitive problems are common following stroke or head injury in people with Parkinson's and Alzheimer's disease and in some people with multiple sclerosis and other chronic conditions.
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From page 141... ...
The major cognitive deficits that create functional limitations are described below. Aphasia is the term attributed to difficulties with language comprehension and expression.
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From page 142... ...
During the past decade, the emphasis on biomedical science has generated new knowledge about brain plasticity and brain structure-function relationships. As this emphasis expands to include issues of functional limitation and disability, it should be possible to test the application of these findings in clinical interventions to determine how individuals with brain injuries can improve their performance of functional, real-world tasks (e.g., selfcare, meal preparation, parenting, and employment)
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From page 143... ...
For example, it would be possible to explore whether the cerebellum's contributions to motor learning generalize beyond the purely motor domain and whether the preserved function demonstrated by some people with disabling conditions is mediated by sparing of critical tissue or by compensatory neural pathways. It would be important to know how a deficit in inhibitory control affects everyday function; that is, can different aspects of attentional processing (e.g., divided attention, visual search, and vigilance)
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From page 144... ...
In turn, functional limitations become paramount concerns because they alone prevent the person from returning to the premorbid environment after rehabilitation. Altering the environment to accommodate functional limitations, such as by adding a raised toilet seat following hip replacement or providing durable medical equipment following major amputation or spinal cord injury, are time-honored rehabilitation approaches.
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From page 145... ...
RECOMMENDATIONS Recommendation 5.1 The National Institutes of Health (NILE should ensure that rehabilitation scientists in general, andfunctional limitation researchers in particular, are well represented on study sections. NIH also should expand the research capacity of its Institutes to include functional limitations and rehabilitation research as important aspects of their missions.
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From page 146... ...
Recommendation 5.6 More research is needed to improve the understanding of the impact of aging and other lifelong disabling conditions unfunctional limitations and secondary conditions. Recommendation 5.7 The science supportingfunctional limitations depends on integrative studies of the whole person.
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