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 Table of Contents  
CHAPTER 6: SCIENTIFIC BACKGROUND OF PHYSICAL AND REHABILITATION MEDICINE
Year : 2019  |  Volume : 2  |  Issue : 2  |  Page : 125-129

6.5 Scientific background of physical and rehabilitation medicine: Rehabilitation sciences


Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea

Date of Web Publication11-Jun-2019

Correspondence Address:
Prof. Moon Suk Bang
Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul
Korea
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisprm.jisprm_29_19

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How to cite this article:
Bang MS. 6.5 Scientific background of physical and rehabilitation medicine: Rehabilitation sciences. J Int Soc Phys Rehabil Med 2019;2, Suppl S1:125-9

How to cite this URL:
Bang MS. 6.5 Scientific background of physical and rehabilitation medicine: Rehabilitation sciences. J Int Soc Phys Rehabil Med [serial online] 2019 [cited 2019 Aug 20];2, Suppl S1:125-9. Available from: http://www.jisprm.org/text.asp?2019/2/2/125/259355




  Introduction Top


In the 1940s after the World War II, physical medicine, including electricity, heat, light, mechanotherapy, and exercise,[1] became affordable to war veterans who experienced spinal cord injury (SCI) or amputation mainly in the United States, providing medical as well as a more specialized field; rehabilitation service. There was an attempt to clarify the physiologic basis by emphasizing science.[2],[3] Thereafter, a term called rehabilitation medicine (RM), which is regarded as a broader term, was used, and now, attempts are being made to make the RM's scientific basis.[4] Because the theoretical basis was weak, empirical or practice-driven treatment became the mainstream of RM. In 1972, Downey published a textbook called “Physiological Basis of RM” to make physiology as the scientific basis of RM. Downey's book focused on underlying physiology and used physiology to explain how the human body adapts and compensates for the loss of overall function due to physical loss and stress due to original injury through physiology.

Since then, there were several efforts to make RM to be more scientific according to the trend of modern medicine to establish a treatment based on science.[5] Until the 1990s, there were very few randomized controlled trials (RCTs) in RM, and RCTs began to thrive in rehabilitation after 1990, mainly in the United States and Europe.[3] In the regional society including Asia-Oceanian countries, properly designed RCTs seems to have been started since around 2011.[6] Now, there are quite a lot of RCTs in the field of RM. Worldwide, there are 2169 RCTs when searching for rehabilitation medicine as a keyword and 5955 as rehabilitation registered in https://clinicaltrials.gov in May 2017.[7]

In the past, injured veterans, industrial accident victims, and congenital anomalies were the main target populations of rehabilitation, but patients requiring rehabilitation had been shifting to the elderly, cancer, and stroke.[8],[9],[10] The needs of rehabilitation are growing as the average life expectancy goes up, according to the WHO Global Disability Action Plan 2014–2021.[10] According to the Global Burden of Disease Study, 74% of the total number of years lived with disability (YLDs) in the world is linked to health conditions for which rehabilitation might be beneficial [Table 1]. To strengthen and extend rehabilitation services across countries, it is very important to have extensive and comprehensive evidence based on researches in all regions of the world.
Table 1: Global prevalence and years lived with disabilities for health conditions associated with severe levels of disability (2005–2015)

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Trials in the Field of Physical and Rehabilitation Medicine and in rehabilitation in general must not only look for the effectiveness of single interventions but also on (standardized) multidimensional rehabilitation programs. Scientific studies also must be performed to evaluate how rehabilitation programs can be integrated into health systems and how they can be optimized. This includes research on interfaces, e.g., in between the different sectors of health systems and other relevant areas of life (e.g., workplace, educational institutions, or institutions of social care and integration). This article highlights some examples of outcome studies of rehabilitation programs in patients with neurological disorders.


  Evidence-Based Medicine in Rehabilitation Top


In the early stages of rehabilitation, when empirical therapy was mainstream, there were few evidence-based therapies. Neurodevelopmental treatment (NDT), which is a practice in the field of neurorehabilitation, has been widely accepted and performed globally, but it had not shown clear evidence in RCTs. With decades of RCTs, the concept of empirical treatment is no longer acceptable and there had been a move to rehabilitate the patient based on scientific evidence. However, since rehabilitation treatment is different from common drug trials, double-blind treatment is hard to implement. For example, placebo treatment of physical modalities and exercise therapy are difficult to apply practically and ethically. Even if a researcher tries to cross-design, it makes this design impossible because the difference in the time it takes to start rehabilitation after an injury affects the outcome. Nonetheless, it is important to focus resources on interventions that can be expected to have clear effects based on neuroscience knowledge rather than on a nonscientific basis.[11]

Even if evidence for specific rehabilitation treatments is apparent,[12] there is a limit to the practical application of this to many patients. Rehabilitation treatment has a tendency of geographical dependence, and treatment preference differs according to national health system and policy.[13] Political pressures are increasing worldwide to provide clear evidence of the effectiveness of neurorehabilitation, with the aim of enabling optimal treatment provided by the healthcare system. In line with this social and political trend, rehabilitation should reflect local healthcare system and its acceptability, not just evidence alone.

In a review of Novak et al.'s article in 2013,[14] constraint-induced movement therapy (CIMT) has a strong evidence, while NDT and Vojta treatment, commonly practiced worldwide, have a weak evidence. One of the expected reasons for this result is that CIMT has narrow treatment indications, which only include hemiplegia patients with bad hand function, compared to NDT and Vojta. It could be interpreted that evidence is available only when treatment is applied to a specific group, limited population. Treatment with a broader indication seems to have less evidence of effectiveness. Because NDT and Vojta are well tolerated and have a wide range of patients in the treatment indication, dilution effect might take a place. However, treatment with a broad indication has a greater range of acceptability, is broader in acceptance, and is easier to apply to most patients. Those facts should be considered in establishing the evidence, and treatment choice should not be based solely on the level of evidence.


  Evidence from Rehabilitation Medicine Top


If the study is to accurately demonstrate the therapeutic efficacy, the target group, treatment, and outcome measure must be precisely defined as proposed by Whyte and Hart.[15] They supposed that definitions of rehabilitation treatments are important, and a taxonomy that categorizes rehabilitation treatments should support rehabilitation not to be remain as a black box. They also said that it is meaningful to develop research to demonstrate efficacy, only if the taxonomy is clear.

In terms of outcome measures, RM differs from other medical specialties. In medicine, the outcome measures such as survival rate, radiology, and serology are generally used. On the other hand, RM requires additional indicators such as International Classification of Functioning, Disability, and Health (ICF) – including body structures and functions, activities and participation,[16] satisfaction with goal attainment scaling to reflect satisfaction of patient and caregivers,[16] and other evaluation scales. In this article, we introduces RCT and meta-analysis of several disease groups that involve the large stem of RM: stroke,[17],[18],[19],[20],[21],[22],[23] SCIs,[24],[25],[26] and cerebral palsy (CP).[14],[27]


  Stroke Rehabilitation Top


The area of evidence in a stroke rehabilitation is not only confined to treatment but also in a symptom, disease, and community reintegration.[17] There are 1220 RCTs registered in https://clinicaltrials.gov in May 2017 when searching for stroke rehabilitation as a keyword.[7] In a review[17] of 272 RCTs and 150 non-experimental or uncontrolled designs, stroke rehabilitation improved functional outcome and reduced hospital stay and mortality in severe stroke cases. There have been studies to reveal evidence of remedial, compensatory approach[28] and treatment intensity[29] for inpatients and hospital-based[30] or home-based rehabilitation program[31] for outpatient rehabilitation. In addition, there have been researches to find evidence of Bobath technique,[32] functional electrical stimulation,[33],[34] biofeedback, assistive device and ankle-foot orthoses,[35],[36] CIMT,[12],[37] and botulinum toxin.[27],[38] Furthermore, systematic reviews have shown evidence of rehabilitation by disease classification, including painful hemiplegic shoulder,[39] cognitive-perceptual disorders,[40],[41],[42] aphasia poststroke,[19],[43],[44] dysphagia,[45],[46] aspiration, and poststroke depression.[19] It is also noteworthy that some evidence has been established regarding community reintegrations such as social support,[47],[48],[49] family function,[50] family education,[50],[51],[52] and leisure therapy.[53],[54],[55]


  Spinal Cord Injury Rehabilitation Top


Spinal cord injury rehabilitation records (SCIRE)[56] synthesize the evidence of rehabilitation interventions to improve the health of SCI patients. SCIRE covers a comprehensive set of topics including SCI inpatient rehabilitation practices, gait strategies, upper extremity reconstructive surgery, spasticity treatments, cardiovascular health, and bone health.[24] The full SCIRE compendium is available at www.icord.org/scire.[56] In SCIRE v. 5.0, more than 3500 articles were reviewed and 107 outcome measures were evaluated and continuously updated. Members of the SCIRE team have reviewed and rated the scientific research on SCI rehabilitation to make quality information more available and ultimately improve the health of people living with SCI.

SCIRE classifies the problems of SCI patients as detailed items such as aging, autonomic dysreflexia, bladder management, bone health, bowel dysfunction and management, cardiovascular health and exercise, depression, economic evaluation, epidemiology of traumatic SCI, heterotopic ossification, housing and attendant care, lower limb, nutrition issues, orthostatic hypotension, pain management, physical activity, pressure ulcers, primary care, rehabilitation practices, respiratory management, sexual and reproductive health, spasticity, syringomyelia, upper limb, and venous thromboembolism. SCIRE describes the pathophysiology, symptoms, management, and systematic reviews for each topic.


  Cerebral Palsy Rehabilitation Top


In 2013, Novak et al. published a review article that systematically described useful interventional evidence for children with CP.[14] A total of 166 articles were analyzed, and 64 interventions were investigated. Of the 64 CP interventions, 24% were proven to be effective, 70% had uncertain effects, and 6% were ineffective. Interventions presumed to be effective in this article were based on current neuroscience pharmacological knowledge, and these interventions only work at one ICF level.

However, there was a lot of controversy about Novak's review article.[57] The authors with different opinion argue that to develop recommendations for treatment, clinical parameters should be considered in addition to the evidence. Patient values and individual preferences should be incorporated into clinical decisions. In addition, clinically valid guidelines that can be used internationally require more complex procedures than those applied in the Novak's systematic review.


  Emerging Scientific Technology Top


RM can benefit from emerging scientific technologies such as assistive devices and regeneration medicine. Appropriate assistive technology/devices and rehabilitation engineering can help people with disabilities to accomplish greater independence, community integration, and improved quality of life.[58] Rehabilitation robotics, three-dimensional printing,[59] and brain–computer interface (BCI)[59] are the promising technologies in rehabilitation,[60],[61],[62],[63] and artificial intelligence (AI) will be available in the future.

Another emerging interdisciplinary field is regenerative medicine. Regenerative medicine combines advances in molecular biology, gene therapy, cell therapy, and tissue engineering to replace or regenerate human cells, tissues, or organs.[64] Increasing rehabilitation approaches using regenerative medicine which is expected to become a more promising treatment in the future will accelerate the restoration after injury and disease.

To make these treatments more scientific, evidence should also be generated through translational research that converts bench to bedside, bedside to practice, and practice to population.


  Summary Top


Since the demand for establishing a scientific basis in RM is increasing, more science-based therapies, outcome measures, and RCTs for evidence are needed. It is also important to clarify the target group, treatment method, and outcome measure to clarify the efficacy of rehabilitation therapy. In addition, RM utilizes technical science by using emerging technology such as regeneration medicine and assistive technology including robotic rehabilitation. Because there are a lot of inputs including existing treatment, procedure, social support, and emerging technology, it is important to utilize translational research for rehabilitation using robots, biomedical science, etc., in order not to leave these treatments as a black box.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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