Conclusiones

Rehabilitation, initially conceived of as ‘an art and science’ was only established and became considered as a core part of medical treatment following the national organisation and policies instituted following the second world war (Eagger 1960). Rehabilitative pioneers had demonstrated the possibilities of rehabilitative practices and the benefits of rehabilitative programmes during and following the first world war. These early programmes focussed primarily on orthopaedic injuries and blindness. The field of neurological rehabilitation, the learning of both the symptoms and care required for those with severe brain injuries also developed during this time as many returned home with traumatic brain injuries from bomb blasts and bullet wounds (Boake and Diller 2005; Atenalov et al. 2015).

87 Boake and Diller (2005) explain that prior to World War I, it is estimated that 70% of penetrating traumatic brain injuries sustained in war were fatal. Only developments in neurotrauma care made during World War I made survival from brain injuries a possibility and hence the subsequent need for brain injury rehabilitation. Brain injury rehabilitation is therefore a 20th _{century development, emerging from militarism}

(Boake and Diller 2005; Atenalov et al. 2015).

Although early rehabilitation programmes focussed on orthopaedic conditions such as the need for prosthesis following amputations and blindness, brain injury rehabilitation programmes and the first brain injury rehabilitative centres were established during World War I - in Germany and Austria (Poser et al. 1996). Awareness of these centres and their innovative work comes from translated writings from two key directors of Rehabilitation Centres in Frankfurt – Kurt Goldstein (1942) and Walther Poppelreuter (1917/1990). The contribution of neuropsychological problems to disability post injury was the initial focus pursued by Goldstein and Poppelreuter who arranged for patients to undergo clinical tests focussing on memory, visual perception and speech and language comprehension. The limitations of psychologically based testing were soon identified by these early rehabiltationists and so Goldstein and Poppelreuter insisted upon both clinical testing and the observation of functional abilities within vocational workshops (Boake and Diller 2005).

Alongside clinical testing and observation, Goldstein and Poppelreuter instigated a therapeutic approach of adapting strategies to work around impairments (see ‘the adaptive approach’ discussed later) and focussed on employment as the main aim and hopeful outcome of their rehabilitation programmes (Boake and Diller 2005). These approaches and rehabilitative aims fit most closely with the modern-day underpinnings on the allied health profession of occupational therapy.

Following the second world war rehabilitation took its place as a co-ordinated effort made across the world to support those with both temporary and permanent physical impairment. People with disabilities were constructed as both a problem

88 for society but also a potential resource – a resource much needed following the loss of a generation of working aged men and many working aged women (Eagger 1960). The development of brain injury rehabilitation was resumed and centres specialising in the care and rehabilitation of people with brain injuries were established in the UK (Babington 1954; Zangwill 1979), the Soviet Union (Luria 1979) and within military hospitals in the United States of America (Atenalov et al. 2015). In 1951 the world’s first university-affiliated comprehensive rehabilitation centre was founded by Dr Howard Rusk at New York University which was later renamed the Howard A. Rusk Institute of Rehabilitation Medicine (Atenalov et al. 2015).

At that time, compensatory strategies were employed rather than thoughts of cure or influencing physiological change. Vocation and predictors for returning to work were the focus of rehabilitative programmes, alongside an interest in the development of other medical post brain injury complications such as epilepsy and posttraumatic amnesia. Also, during this post war period, the beginning of multi - professional working in brain injury rehabilitation was initiated, with psychologists and speech and language therapists coming together to take responsibility for both cognitive and communication disorders (Boake and Diller 2005).

Post war research sought to establish the numbers of people within the populous with long-term disabilities in order to plan provision for those in need. At that time, there was a slow recognition that ‘the community has a moral responsibility for the

disabled’ (Eagger 1960, p. 31) Rehabilitative efforts following the second world war

focussed on the restoration of mobility for those with loss of limbs and burns, the re- education of those with loss of eyesight and the rehabilitation of those with brain injuries. In response to the vast numbers and needs of post war veterans, the professions of physical therapy (physiotherapy), occupational therapy, psychiatry, psychology, speech and language pathology (speech and language therapy) underwent vast and rapid development (Gritzer and Arluke 1985). These professions began to all work together in the rehabilitation of amputees, post stroke and brain injured patients in the 1950s and 1960s in newly formed rehabilitative centres (Boake and Diller 2005).

89 According to Boake and Diller (2005), the 1970s saw a rapid rise in the interest in brain injuries. Again, stimulated by need, interest grew as the severity of brain injuries (and people’s survival with such injuries) increased. With the development of faster cars, unregulated speed limits (in 1965 for the UK) and motorways came high speed crashes and subsequent complex and severe brain injuries sustained through high speed impacts. Neurosurgeons became more interested in the eventual outcomes of and for their patients and recognition of traumatic brain injury (now included with the term acquired brain injury) as a public health problem grew. As a result, there was growth and further developments in rehabilitative programmes dedicated to TBI (Evans 1981; Hook 1972). In particular, this period saw the development of organised outpatient programmes (Boake and Diller 2005).

In the 1990s the changes and developments in brain injury rehabilitation follow developments in material technologies, innovation of therapeutic equipment and the growth of singular intervention effect trials (such as the randomised control trial). The changes seen in rehabilitation practice during this period, which also underpin rehabilitative work in the 21st _{century, are also the result of organisational changes}

in health care more broadly. For example, in the United States of America (USA), the 1990s brought a shift towards ‘efficiency’ and cost reduction of rehabilitati on services. As a result rehabilitative length of stays shortened and the need for the measurement of patient outcomes and rehabilitative effectiveness increased (Boake and Diller 2005). This latter shift was also required to satisfy third party funders of medical and health care in the USA; and in the UK, was the impact of a ‘managed care’ approach18_{. These changes can also been seen in a UK context where the effect}

of ‘baby boomers’ on the population, the resultant extension of life expectancy, subsequent pressures on finance and NHS provision of resources and the expansion of the hospital to include managers alongside clinicians has shifted the focus of services from just clinical or functional improvement of the patient, to cost effectiveness and value for money.

18_{Managed care is an approach to financing and delivering health care that seeks to control costs and}

90 A dominant effect of this shift in health care towards demonstration of clinical effectiveness as well as economic value, is the measurement of outcomes and the extensive subsequent development of ‘outcome measures’ or ‘functional rating scales’ to capture both clinical concerns relating specifically to neurological conditions and to assist in the evidencing of progress or decline (Turner-Stokes 1992; Tyson et al. 2012). More focussed, specifically targeted measures evolved from more global scales used in general medicine (Boake and Diller 2005) and were developed by both rehabilitationists and individual nursing and allied health professions. These measures hold a critical and pervasive presence in contemporary justification and provision of rehabilitation services.

In the 21st _{century ‘rehabilitation medicine’ is a field dominated by concentrated}

efforts to support people with neurological diseases and impairments – both acquired and progressive. The next section of this chapter discusses modern day rehabilitative definitions and the formation of neurological rehabilitation in practice.