Rules for Rehabilitation: An Agenda for Research

National Center for Medical Rehabilitation Research, National Institute of Child Health and Human Development, National Institutes of Health, Rockville, MD 20852, USA.
Neurorehabilitation and neural repair (Impact Factor: 3.98). 07/2005; 19(2):72-83. DOI: 10.1177/1545968305275718
Source: PubMed


Rehabilitation services have grown tremendously in the United States over the past 2 decades. Rules originally designed to guide Medicare reimbursement policies have had substantial effects in shaping the design of clinical services. This article traces the development of the most significant federal rules regarding rehabilitation, outlines the existing empirical evidence to support these rules, and discusses an agenda for research to improve the evidence for future policy development.

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    • "Moreover, the value of such a program needs to be realistic given prevailing practice patterns; any superiority cannot simply be related to the amount of therapy provided. Such an intervention would incorporate a number of dynamic and competing processes with the following critical goals: 1) enable a balanced interaction between processes associated with experience-dependent and injury-induced cortical reorganization to best guide functional recovery [21-23]; 2) attenuate the detrimental effects of maladaptive compensatory strategies (e.g., learned non-use), often currently promoted during inpatient rehabilitation [2], that may with time persist and become more difficult for the patient and clinician to reverse [24]; 3) foster an early, but not too early, aggressive approach during a more vulnerable period both physiologically and psychologically [21,25,26]; and 4) overcome the challenges of introducing a principle-based, distributed, upper extremity task-specific training program into an already dwindling acute inpatient length of stay where UE use is frequently minimal [2,17,27]. "
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    ABSTRACT: Residual disability after stroke is substantial; 65% of patients at 6 months are unable to incorporate the impaired upper extremity into daily activities. Task-oriented training programs are rapidly being adopted into clinical practice. In the absence of any consensus on the essential elements or dose of task-specific training, an urgent need exists for a well-designed trial to determine the effectiveness of a specific multidimensional task-based program governed by a comprehensive set of evidence-based principles. The Interdisciplinary Comprehensive Arm Rehabilitation Evaluation (ICARE) Stroke Initiative is a parallel group, three-arm, single blind, superiority randomized controlled trial of a theoretically-defensible, upper extremity rehabilitation program provided in the outpatient setting. The primary objective of ICARE is to determine if there is a greater improvement in arm and hand recovery one year after randomization in participants receiving a structured training program termed Accelerated Skill Acquisition Program (ASAP), compared to participants receiving usual and customary therapy of an equivalent dose (DEUCC). Two secondary objectives are to compare ASAP to a true (active monitoring only) usual and customary (UCC) therapy group and to compare DEUCC and UCC. Following baseline assessment, participants are randomized by site, stratified for stroke duration and motor severity. 360 adults will be randomized, 14 to 106 days following ischemic or hemorrhagic stroke onset, with mild to moderate upper extremity impairment, recruited at sites in Atlanta, Los Angeles and Washington, D.C. The Wolf Motor Function Test (WMFT) time score is the primary outcome at 1 year post-randomization. The Stroke Impact Scale (SIS) hand domain is a secondary outcome measure. The design includes concealed allocation during recruitment, screening and baseline, blinded outcome assessment and intention to treat analyses. Our primary hypothesis is that the improvement in log-transformed WMFT time will be greater for the ASAP than the DEUCC group. This pre-planned hypothesis will be tested at a significance level of 0.05. ICARE will test whether ASAP is superior to the same number of hours of usual therapy. Pre-specified secondary analyses will test whether 30 hours of usual therapy is superior to current usual and customary therapy not controlled for dose. Trial registration Identifier: NCT00871715
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