There is little consensus among rehabilitation specialists for what constitutes the essential elements of SCI rehabilitation. As with most forms of rehabilitation, rehabilitation programming directed towards persons with SCI has been likened to a “black box”, with research endeavours focused on the entire “rehabilitation package“ but little emphasis on investigating the effectiveness of specific therapeutic practices (Whiteneck et al. 2009).
Although an internationally accepted definition of SCI rehabilitation and its essential elements remains to be determined, we have provided an operational definition that distinguishes between specialized and general programs of SCI rehabilitation on which this Chapter is based. This definition was informed by a preliminary review of service offerings among the 16 SCI US Model System rehabilitation programs (http://www.spinalcord.uab.edu/show.asp?durki=104757&site=1226&return=21392) and of Canadian SCI rehabilitation programs (SCISN Rehabilitation Escan; SCI Definitions Framework: http://www.gtarehabnetwork.ca/uploads/File/tools/self-assessment-tool-sci-community.pdf). In addition, other resources were reviewed including the WHO definition of rehabilitation (World Health Organization, 1981), the International Classification of Functioning, Disability and Health (World Health Organization 2001) and efforts of clinicians and researchers to characterize the specialized treatment outcomes and methods involved in general (Stucki et al. 2007) and SCI-specific rehabilitation (Harvey et al. 2009; DeVivo 2007; Blackwell et al. 2001). Given these resources, a definition of specialized SCI rehabilitation could be described as follows:
A specialized SCI rehabilitation program provides comprehensive, and patient-focused rehabilitation services, for inpatient, transitional living, outpatient and follow-up care, to empower people with SCI and their families to achieve optimal quality of life continuing into the community (focusing on increasing self-reliance and gaining independence). Through organized regional referrals, care is delivered through a multidisciplinary team provided by board certified physician specialists and accredited allied health professionals (i.e. physical/occupational/speech/ recreational therapists, nurse specialists, psychologists, dieticians, engineers, social workers, etc.). As a rehabilitation program specialized in the care of people with SCI (experienced through trauma or disease), active participation in research is facilitated through university affiliated teaching institutions.
Areas of further expertise may include specialized clinics (i.e. seating, audiology, pain, wound, sexuality/reproduction), respiratory/paediatric services, community/peer-support/fitness-wellness/health-maintenance/injury-prevention/day/combined (i.e. brain injuries, strokes, amputations, orthopedic conditions, neuromuscular diseases, burns and related disabilities) programs, support groups, vocational counseling, innovation/research updates, education, etc. Such specialized programs will be nationally (and possibly internationally) recognized and may be accredited through independent accreditation bodies (e.g., CARF/Commission on Accreditation of Rehabilitation Facilities; JCAHO/Joint Commission on Accreditation of Healthcare Organizations; AC/Accreditation Canada).
Up to date, general rehabilitation programs would likely follow the ICF-based conceptualization of rehabilitation that “aims to enable people with health conditions experiencing or likely to experience disability to achieve and maintain optimal functioning in interaction with the environment” (Stucki et al 2007). In contrast to a specialized SCI rehabilitation program, the general rehabilitation program is designed for individuals who have a medically stable disability, without additional active medical problems that could affect participation in therapies, with identifiable rehabilitation goals and a high potential to achieve those goals towards upgrading or maintenance of independence in the home and community. General medical oversight, nursing, and physical/occupational/speech therapies are commonly provided to facilitate a return to work or to functional independence for activities of daily living. A general program of rehabilitation may not be able to provide acute medical services and diagnostics, especially for complex medical conditions that involve multiple body systems such as spinal cord injury with or without impaired cognition. Special considerations could be made for these latter individuals but referral to an appropriate specialized rehabilitation program is the preferred option. Services are intended for residents of the regions immediately surrounding the rehabilitation facility and are not usually affiliated with a university-based teaching institution. Some general rehabilitation programs may have further areas of expertise such as wound treatment or pain management, etc.
There are currently efforts underway to “unravel” the “black box” of rehabilitation as applied to persons with SCI (Whiteneck et al. 2009). These investigators are employing a practice-based evidence approach across multiple centres to identify and investigate the myriad of practices that are conducted across the rehabilitation enterprise. They intend to link this information with appropriate and systematic outcome measurement so as to evaluate the effectiveness of rehabilitation interventions (or combinations thereof). A critical step that was required before embarking on this ambitious endeavour was to develop a taxonomy of rehabilitation interventions associated with every discipline contributing to SCI rehabilitation (Gassaway et al. 2009). The taxonomies provide a systematic means to enable clinicians to document the specific interactions and interventions they conduct with their patients and this has been completed for seven disciplines including physical and occupational therapy, psychology, speech language pathology, therapeutic recreation, social work and nursing (e.g., Natale et al. 2009; Ozelie et al. 2009; Wilson et al. 2009; Gordon et al. 2009; Cahow et al. 2009; Abeytal et al. 2009; Johnson et al. 2009).