Physical Medicine

The 1920s and 1930s saw the beginnings of professional organizational development in the nascent field of PM&R. The so-called “physical therapy physicians” (i.e., physicians practicing early forms of physical medicine) began efforts to organize themselves and vied for a voice in the AMA. Specifically, in 1923, the American College of Radiology and Physiotherapy was founded as a professional organization of physicians who used physical methods to diagnose and treat illness and disability. Samuel B. Childs, MD, a radiologist from Denver, was elected as the first president. Very soon, however, radiologists separated and developed their own organizations so that, by 1925, the organization became the American Congress of Physical Therapy. Subsequent developments included the assimilation in 1933 of the American Physical Therapy Association (whose membership comprised only physicians) and various changes in the name of the organization initially intended to clarify the distinction between physicians and nonphysician therapists using physical methods in treatment (until the present name of the American Congress of Rehabilitation Medicine was selected in 1966).

Specialty physical medicine journals also developed during this period, corresponding to the increasing professional orientation of a small group of physicians to this new area of specialization. The journal Radiology began publication in 1920 under the editorship of Albert Franklin Tyler, MD (1881–?), and in 1926, it was renamed the Archives of Physical Therapy, X-ray, Radium to reflect its expanded focus. Subsequent name changes in the journal reflected an early shift away from radiology; a later distinction between physician and nonphysician therapists utilizing physical methods in treatment; and, ultimately, a broadening emphasis on rehabilitation (until the present name of the Archives of Physical Medicine and Rehabilitation was selected in 1952).

Most physicians who practiced physical medicine in this era used it as an adjunct to their regular general medical practices, but starting in the mid-1920s, some physicians began devoting their careers to this area and were recognized with academic faculty appointments. The first of these was John Stanley Coulter, MD, who joined the faculty of Northwestern University Medical School in Chicago in 1926 as the first full-time academic physician specializing in physical medicine. He initiated the first continuing teaching program in physical medicine in the form of 3- to 6-month, and later, 12-month courses. He became chairman of the AMA Council on Physical Therapy (18). For the next two decades, he was a key leader in the development of educational programs for the practice of physical medicine as well as in the development of professional organizations for physical medicine.

Physical Therapy

Formal training for allied health professionals in civilian practice was not available until 1918, when the Mayo Clinic initiated a training program in physiotherapy (19). In 1920, Lieutenant Colonel Hard D. Corbusier wrote to former reconstruction aide Mary McMillan, proposing the formation of a professional society of physical therapists to “advertise to all the physicians and surgeons of the country the importance of treatment by physical means and to elevate and standardize the work and place it on a more substantial basis” (6). In 1921, McMillan organized a group of nearly 300 former reconstruction aides to form the American Women’s Physical Therapeutic Association, which elected McMillan as the first president. The first issue of the association’s official publication, The P.T. Review, was published in March 1921, and the same year McMillan published Massage and Therapeutic Exercise, the first textbook written by a physical therapist (10,20). The organization was renamed the American Physiotherapy Association in 1922, and in 1930 the organization was incorporated to establish educational standards for physical therapists to support regulation of physical therapy practice and to cooperate with the medical profession to establish a central registry of physical therapists (10,21).

Occupational Therapy

In 1914, George Edward Barton—a disabled architect who had benefited from care he received at a convalescent hospital—introduced the term occupational therapy at a meeting of the Massachusetts State Board of Insanity in Boston (22) and subsequently founded Consolation House in Clifton Springs, New York, where he provided vocational assistance and workshop activities to other disabled people (13,22–24). In 1917, Barton organized the first meeting of the National Society for the Promotion of Occupational Therapy at Clifton Springs for “the advancement of occupation as a therapeutic measure, the study of the effects of occupation upon the human being, and the dissemination of scientific knowledge on this subject” (25). In addition to Barton, the founding members included Dr. William Rush Dunton, Jr., a Maryland psychiatrist, who was responsible for the occupations program at the Sheppard and Pratt Institute and had written monographs and articles on using occupational activities as therapy, including one of the first textbooks on occupational therapy, Occupational Therapy—A Manual for Nurses (1915) (26,27); Eleanor Clarke Slagle, who worked with Dunton at Johns Hopkins in Baltimore and who developed a regimented treatment program (“habit training”) for chronic schizophrenic patients; Susan Cox Johnson, director of occupations for the New York State Department of Public Charities; Thomas Kidner, an architect who was the vocational secretary of the Canadian Military Hospitals Commission; Isabel Newton, who was Barton’s secretary; and Susan Tracy, a nurse who was a training school superintendent and instructor of occupational therapy courses for nursing students, including the first such course (in 1911) at the Massachusetts General Hospital Training School for Nurses (13,22–24,28,29). Barton became the first president (22). The organization was renamed the American Occupational Therapy Association in 1923 (22). The Maryland Psychiatric Quarterly, edited by Dunton, became the official organ of the National Society for the Promotion of Occupational Therapy until 1922, when the Archives of Occupational Therapy was first published as the official publication of the organization (13,22).

In 1929, Colonel James A. Mattison described the purposes of occupational therapy as employed at the National Home for Disabled Volunteer Soldiers:

The first textbook in the United States concerning occupational therapy, written primarily by occupational therapists, was Principles of Occupational Therapy, edited by Helen S. Willard and Clare S. Spackman and first published in 1947 (31).

Speech Therapy

Speech therapy had 18th- and 19th-century antecedents—particularly in the practical treatment approaches of the elocutionists (i.e., focused on improving speaking, orating, or singing); the beginnings of aphasiology with French neurologist Paul Broca (1824–1880), German neuropsychiatrist Carl Wernicke (1848–1905), and others; and the various “methods” for treating speech impediments, mispronunciation, and articulatory disturbances among the deaf (32,33). Development of professional organizations for speech therapy in the United States began with the founding of the American Speech and Hearing Association in 1925 as the American Academy of Speech Correction (33–35). In 1927, a nomenclature committee of the American Speech Correction Association outlined and described the conditions treated by “speech correctionists” under seven major categories: dysarthria, dyslalia, dyslogia, dysphasia, dysphemia, dysphonia, and dysrhythmia (33,36).

The “Iron Lung”

In 1928, following the early epidemics of poliomyelitis in the United States, industrial hygienist Philip A. Drinker (1894–1972) and physiologist Louis Agassiz Shaw, Jr. (1886–1940) at Harvard University designed an electrically powered tank respirator to facilitate the breathing of patients paralyzed by poliomyelitis (Figure 1.5) (52). This “iron lung” was the first practical means of respiratory support, and in 1929, Drinker and pediatrician Charles F. McKhann soon demonstrated the potential of artificial respiration, using the iron lung for an 8-year-old girl with poliomyelitis who had developed respiratory failure and coma (53,54). Manufacture of these “iron lungs” began in the early 1930s and expanded in the 1940s and early 1950s, until the respirators were replaced in the late 1950s and early 1960s by more sophisticated ventilation devices. The iron lung required intensive nursing care and respiratory therapy, and a supporting hospital infrastructure. Although the iron lung saved thousands of lives, many patients, who would otherwise have died, survived with severe disabilities requiring considerable physical therapy, orthotics, and adaptive equipment.

FIGURE 1.5

A U.S. Army nurse and two corpsmen attending a poliomyelitis patient in an iron lung, 1949.

Courtesy of the U.S. National Library of Medicine.

“Sister” Kenny: An Outspoken Nurse Challenges the Orthodox Treatment of Polio

From the 1920s through at least the early 1940s, the orthodox treatment for polio consisted largely in absolute immobilization of affected limbs through splinting or the use of plaster casts (often for many months) and, subsequently, orthopedic braces (often permanent), leading to disuse atrophy, joint contractures, and lifelong disability (10,55–57). However, since 1911, an unregistered independent nurse practitioner named Elizabeth Kenny (1880–1952) had been treating patients with poliomyelitis using an alternative approach she had developed empirically in a sparsely populated backcountry area of Australia in ignorance of the prevailing orthodox treatments (58–60). Later, when she came into prominence, Kenny employed the title of “Sister,” an honorific designation for a head nurse in the British system that she earned during her military service in the Australian Army Nurse Corps during World War I (60–62). “Sister” Kenny’s approach to the treatment of poliomyelitis used physical methods (e.g., the labor-intensive application of moist warm wraps of heavy woollen cloth for muscle spasms, aggressive use of passive range of motion, and massage), avoidance of immobilization and bracing, and strong encouragement of functional independence, as well as early mobilization and prompt return to normal activities, coupled with confident optimism for improvement (58,59,61,63–65). Kenny later criticized the immobilization approach then in vogue, claiming that it prolonged muscle spasms, promoted joint stiffness, and prevented restoration of normal muscle action:

During the 1930s, 10 Sister Kenny Clinics were established in eastern Australia, initially as “Muscle Re-Education Centres” (58). However, Kenny was not accepted by orthodox medicine in Australia, was denounced by an Australian Royal Commission in the late 1930s, and was widely criticized by orthopedic surgeons and other physicians, who charged that she understood neither the pathophysiology of the disease nor the physiology of muscle (58,59). Nevertheless, her approach was empirically successful and she developed a large popular following. In 1939, the Queensland government—in spite of the unpopular conclusions of its own Royal Commission—ordered that the Kenny treatment be made available in the Queensland public hospital system (58,59).

Kenny came to the United States in 1940, where her ideas were initially ignored or resisted until tested by Dr. Wallace Cole, chief of orthopedic surgery at the University of Minnesota Medical School and Dr. Miland Knapp, a surgeon who chaired the school’s department of physical therapy (66). The Kenny methods were eventually found to reduce length of hospital stay, greatly diminish contracture formation, and improve functional recovery (66–69). As a result, with encouragement from the American Medical Association and initial funding from the National Foundation for Infantile Paralysis and other donors, a well-regarded and very successful Sister Kenny Institute (later known as the Sister Kenny Rehabilitation Institute) was established in Minneapolis in early 1942 and developed a strong affiliation with the University of Minnesota Medical School, with rotating residents and various specialist staff including physiatrists, orthopedic surgeons, neurologists, and others (Figure 1.6) (10,50,58,60,62). The Kenny methods were widely adopted in the United States and elsewhere in the 1940s (though not in Australia), and were taught to physical therapists and physicians at training satellites around the country. Although the controversial Kenny had her detractors, she also had numerous supporters, including Krusen of the Mayo Clinic. Kenny’s approach represented a significant advance in the care of paralyzed patients and helped foster the growth of physical therapy and physical medicine (6,50,70).

FIGURE 1.6

“Sister” Elizabeth Kenny (1880–1952), shown here demonstrating therapy techniques at the Sister Kenny Institute in Minneapolis, Minnesota, c. 1942.

Courtesy of the Minnesota Historical Society, St. Paul, Minnesota.

FDR, the National Foundation for Infantile Paralysis, and the March of Dimes

Franklin Delano Roosevelt (1882–1945), the most famous victim of polio, contracted the disease in the summer of 1921 and was permanently paralyzed from the waist down (57). Despite his disability, Roosevelt was later elected to the first of four terms as President of the United States in 1932 (57). From the time he became disabled, Roosevelt played an important role in the development of rehabilitation medicine, helped remove some of the social stigma from physical disability, provided inspiration and hope, promoted the idea that polio victims could become “normal” again (even if this was partly because of careful media management limiting the public’s knowledge of the extent of his disability), and provided a mechanism for widespread supportive social action and philanthropy. In 1926, Roosevelt purchased a spa in Warm Springs, Georgia, to help facilitate his personal rehabilitation. By 1927, Roosevelt had founded the Georgia Warm Springs Foundation, which helped develop physical therapy and rehabilitation approaches for polio victims (50). In 1937, the Foundation was reorganized as the National Foundation for Infantile Paralysis (and officially incorporated in 1938), under the direction of Roosevelt’s former law partner, D. Basil O’Connor (1892–1972). Under O’Connor’s effective organizational leadership, the National Foundation began an unprecedented, innovative, and highly successful fundraising campaign utilizing an annual “President’s Birthday Ball” with President Roosevelt and a variety of celebrities promoting the event and print advertisements with images of happy children (“poster children”) in wheelchairs or braces and crutches asking for financial support, as well as public appeals requesting people to send dimes directly to the White House to help find a cure for polio; this latter campaign was labeled the “The March of Dimes” by entertainer Eddie Cantor (1892–1964) as a play on the words of “The March of Time” newsreel series (72–76). The first March of Dimes appeal in 1938—during the severe 1937 to 1938 recession following closely on the heels of the Great Depression of 1929 to 1934—generated extraordinary interest and raised an unprecedented $268,000 (the equivalent of over $3.4 million in year 2007 currency) (76–78). A stunned President Roosevelt commented on the eve of his birthday:

The public’s fear of contracting the disease, appeals to altruism with heartbreaking stories of afflicted children, requests from admired role models (movie stars and politicians), and hope that the disease would soon be conquered were all used so effectively in the campaigns that the nonprofit National Foundation became the largest private charity in history. The National Foundation led the “first large-scale, nationwide biomedical initiative” by a charitable organization (75) and, as a result, was instrumental in subsidizing the hospital and rehabilitation costs of polio patients, funding basic and applied research concerning the causes and prevention of polio in the 1940s and early 1950s, training nurses and physical therapists in rehabilitation, sponsoring pilot programs to improve the teaching of rehabilitation medicine in medical schools in the early 1950s, and, ultimately, underwriting the Salk Vaccine Field Trial in 1954 (6,72,73,75). The National Foundation officially changed its name to the March of Dimes in 1979 (after the threat of polio in the United States had passed) (75).

The Salk Vaccine Field Trial of 1954 and Aftermath

Austrian biologist and physician Karl Landsteiner (1868–1943) and his assistant Erwin Popper demonstrated as early as 1908 that poliomyelitis was transmitted by a virus, work for which Landsteiner won the 1930 Nobel Prize in Physiology or Medicine (70,79,80). By 1948, neuroscientist David Bodian, MD, PhD (1910–1992) and colleagues at Johns Hopkins University, and virologist John Rodman Paul, MD (1893–1971) and epidemiologist James Dowling Trask, MD, PhD (1890–1942) at Yale University independently showed that there were three strains of poliovirus (rather than one) as defined by cross-protection within the same group—a finding confirmed by the more extensive work of the Committee on Typing of the National Foundation for Infantile Paralysis in 1951 (in which Jonas Salk was a participant) (70, 80–85). In 1949, microbiologist John Franklin Enders, PhD (1897–1985), along with virologist Thomas Huckle Weller, MD (1915–2008) and microbiologist and pediatrician Frederick Chapman Robbins, MD (1916–2003), working at Harvard Medical School and Children’s Medical Center in Boston, first cultivated the poliovirus in (nonnervous) tissue culture, for which they were later awarded the 1954 Nobel Prize in Physiology or Medicine (86–90). Also by 1954, several researchers, including epidemiologist, virologist, and pediatrician Dorothy Millicent Horstman, MD (1911–2001) at Yale, had demonstrated that there was a period of viremia preceding neurologic involvement (91,92). These important advances made possible the development, by virologist Jonas Edward Salk, MD (1914–1995), of an inactivated trivalent poliovirus vaccine, which was tested in 1954 in a huge clinical trial funded by the National Foundation for Infantile Paralysis (Figure 1.7) (74,93–96). The 1954 Field Trial of the Salk vaccine was the largest public health experiment ever, involving 1.8 million childre who were labeled “Polio Pioneers” and were inoculated with either vaccine or placebo, or were simply observed (70,72,93,97,98). On April 12, 1955, at a press conference in Ann Arbor, Michigan, epidemiologist and virologist Thomas Francis Jr., MD (1900–1969), who had conducted the field trial, declared that the Salk inactivated polio vaccine was both safe and effective (93,98,99). That same afternoon, an advisory committee to the Laboratory of Biologics Control, the federal agency that was responsible for licensing biologic products, recommended that vaccine licenses be granted to five pharmaceutical companies: Eli Lilly, Parke-Davis, Wyeth, Pitman-Moore, and Cutter Laboratories. However, shortly thereafter, unforeseen manufacturing difficulties with clumping of material and inadequate formaldehyde inactivation of the virus during large-scale processing resulted in a huge outbreak of iatrogenic paralytic poliomyelitis (the so-called “Cutter Incident”) with muscle weakness developing in 70,000 people, of whom 164 developed severe paralysis and 10 died (100–104). The litigation that followed (particularly Gottsdanker v. Cutter Laboratories, 1957) led to new legal interpretations (i.e., the doctrine of liability without fault) and, ultimately, the development of the National Vaccine Injury Compensation Program in 1986 (103,104). Although these legal issues dragged on for decades, the manufacturing problems were soon corrected, and with wide-scale immunization using the Salk vaccine, the rates of paralytic poliomyelitis plummeted.

FIGURE 1.7

American virologist Jonas Salk (1914–1995). Salk developed a killed-virus polio vaccine.

Photograph taken by Yousuf Karsh (1908–2002) for Wisdom Magazine Cover photograph August 1956, Vol. 1, No. 8). (Public domain photograph courtesy of Wikimedia Commons).

FIGURE 1.8

Russian-American virologist Albert Sabin (1908– 1993). Sabin developed a live attenuated-virus polio vaccine. From Theodore Woodward’s The Armed Forces Epidemiolog-ical Board: Its First Fifty Years (1990).

This image is a work of a U.S. Army soldier or employee, taken or made as part of that person’s official duties. As a work of the U.S. federal government, the image is in the public domain.

In 1957, Russian-American virologist Albert Sabin, MD (1908–1993), utilizing the time-consuming process of infecting monkeys with poliovirus, developed a trivalent live attenuated polio vaccine that was then tested in Russia, endorsed by the American Medical Association in 1961 even before American field trials were begun, and, ultimately, licensed in the United States in 1963 (Figure 1.8). The Sabin vaccine soon became the polio vaccine of choice, because it (a) was less costly, (b) required minimal training to administer, (c) prevented the disease carrier state, and (d) helped prevent the spread of wild poliovirus. However, by this time, the rates of polio in the United States had dropped to 50 to 100 cases per year—down from tens of thousands per year—so the Sabin vaccine had a relatively limited impact on overall polio incidence in the United States, but it did have an important role around the world. By the early 1970s, the remaining incident cases of paralytic poliomyelitis in the United States were almost exclusively either imported cases or those caused by the vaccine itself. The Sabin oral polio vaccine was discontinued in the United States in 2000, because the continued risk of vaccine-related polio outweighed the potential benefits of a live-virus vaccine.

Origins of Comprehensive Rehabilitation During World War II

In 1942, internist Howard Rusk, MD (1901–1989) (Figure 1.8) left his well-established medical practice in St. Louis to join the Army Air Corps. As Chief of Medical Services at the 1,000-bed hospital at Jefferson Barracks in St. Louis, Rusk observed both a high degree of boredom among the patients and a high rate of readmission because patients were not physically fit enough to return to active duty in their units after hospital discharge, even though they were no longer in need of acute hospitalization (1,48,105–107). Rusk, therefore, sought to engage the patients in mental and physical restorative and training activities that would utilize their time efficiently, increase their fitness, and decrease the rate of recidivism. Rusk’s approach to rehabilitation emphasized treating the entire person, including his or her emotional, psychological, and social needs, and not just the illness or a specific disability. By 1943, seven special “convalescent hospitals” had been established in the Army Air Corps, with multidisciplinary staff comprising

FIGURE 1.9

Dr. Howard A. Rusk (1901–1989), the father of comprehensive rehabilitation medicine.

Courtesy of the National Library of Medicine.

Rusk’s efforts were soon recognized by generals (Dr.) David N.W. Grant (1891–1964) and Henry Harley (Hap) Arnold (1886–1950), whereupon Rusk was sent to Washington, DC, in 1943 to set up similar programs for all 253 Army Air Corps hospitals (1,105,108). Rusk’s novel Convalescent Training Program was highly effective in decreasing hospital readmissions, saving man-hours, and giving injured and disabled soldiers hope and purpose (Figure 1.10).

Later, similar programs, loosely modeled after Rusk’s Convalescent Training Program, were adopted by all branches of the service at the instigation of Bernard Baruch and the subsequent request of President Franklin Delano Roosevelt (1882–1945) to Secretary of War Henry Lewis Stimson (1867–1950) (1). Rusk had sought Baruch’s assistance, and the letter drafted by Baruch for the President’s signature became de facto military policy giving official standing to rehabilitation medicine:

Because of the limited rehabilitation programs available prior to World War II, and the widely held expectation at the time that disabled people could not be productive, people with strokes or other brain and spinal cord injuries received, at best, custodial care and often died within a short time (1).

Rusk’s experience in the rehabilitation of wounded soldiers during World War II helped usher in the concept of comprehensive rehabilitation, with both utilitarian and humanitarian aims (1).

FIGURE 1.10

Vocational rehabilitation posters of the U.S. Army Air Forces during World War II. Photomechanical print created by Jack Wittrup (1912–1987). Published by the Training Aids Division, 1944.

Courtesy of the U.S. National Library of Medicine.

The development of comprehensive rehabilitation in the military during World War II was truly novel and the outcomes were unprecedented (1):

Rusk earned a Distinguished Service Medal for his work in the U.S. military, and retired as a Brigadier General in the U.S. Air Force Reserve.

Later, in retrospect, he was struck by the irony of such progress having been made in the field of rehabilitation medicine as a result of a brutal war:

Change in Management of Disability After Stroke

As an internist prior to World War II, Rusk had been frustrated with the options available for treating patients disabled by stroke, and had felt that his own knowledge was woefully inadequate. Rethinking his prior management and discussing his career options with several former patients who had suffered from stroke reinforced Rusk’s belief in the concept of comprehensive rehabilitation and gave him the determination to abandon his previous internal medicine practice and seek opportunities to develop this concept for civilian patients.

Moreover, by this time Rusk had an entirely different view of the potential for rehabilitation of patients following a stroke, emphasizing what could be done, focusing on remaining abilities, and utilizing simple techniques and equipment to minimize contractures and other secondary impairments and to maximize function:

Not only did Rusk feel that such approaches were extremely helpful, but he also felt strongly that failure to provide rehabilitation to patients was a form of medical negligence:

Rusk later explained the potential for rehabilitation of stroke patients to colleagues at a meeting of the American College of Physicians in Boston:

Although such information generated considerable interest, referral options were extremely limited because of the lack of comprehensive rehabilitation programs across the country.

Program for Civilian Rehabilitation

After World War II, Rusk began efforts to establish a program for civilian rehabilitation, based in large part upon what he had learned in the military (1). He initially intended to open a rehabilitation institute in St. Louis, where he had practiced internal medicine for 16 years prior to his military service, but colleagues there were not supportive.

In 1945, Rusk joined the staff at New York University Medical School, and several wards in Bellevue and Goldwater Hospitals were designated for rehabilitation, although initially the beds were also simultaneously utilized by other services. The previously separate programs for physical and occupational therapy were combined into a new Department of Rehabilitation Medicine (3), and Rusk hired George Gilbert Deaver, MD (1890–?), from New York’s Institute of Crippled and Disabled as the medical director (Figure 1.11) (3,46). Deaver had been a pioneer in rehabilitating the severely handicapped, including those with spinal cord injury, cerebral palsy, muscular dystrophy, multiple sclerosis, and rheumatoid arthritis. “At a time when these patients were being rejected and discarded as permanently disabled, Deaver was accepting of them and patiently working with them to achieve the best possible outcomes through rehabilitation” (3). Deaver made unprecedented progress in rehabilitating those with spinal cord injury to independence in self-care, crutch or brace-assisted ambulation, or wheelchair living (3,46): According to Rusk, “It was he who first taught paraplegics how to walk” (46). Deaver had also developed tools and techniques for assessing activities of daily living (as a guide for independent living capability), crutch walking, and prevocational evaluation (3,46). By 1947, Rusk and Deaver had established the “first comprehensive, total medical rehabilitation program in any community hospital” in the United States at Bellevue Hospital in New York (109).

FIGURE 1.11

American physician and rehabilitation medicine pioneer George Gilbert Deaver (1890–?).

Courtesy of the U.S. National Library of Medicine with permission of the New York University Archives.

Despite Rusk’s enthusiasm and his previous successes, his initial civilian efforts were regarded skeptically by colleagues:

Nevertheless, Rusk persevered and gained the support of prominent philanthropists, including Bernard Baruch, Polish-American builder and developer Louis J. Horowitz (1875–1956) and his wife Mary Decker Horowitz (c. 1877–c. 1966), and retail innovator Bernard Feustman Gimbel (1885–1966) and his wife Alva Bernheimer Gimbel (1893–1983). In 1950, Rusk founded the Institute of Physical Medicine and Rehabilitation at New York University Medical Center. The institute opened its doors in 1951, but was initially derided as “Rusk’s Folly” by former colleagues in St. Louis (108). Renamed the Howard A. Rusk Institute of Rehabilitation Medicine in 1984, 2 years after Rusk’s retirement in 1982, the institute is now the largest university-affiliated center for treatment of civilians with disabilities and for research and training in rehabilitation medicine (110).

Promoting Rehabilitation Medicine

Rusk worked tirelessly, promoting the nascent field of rehabilitation and increasing public awareness of the need for rehabilitation in the spectrum of medical practice in numerous speeches and consultations across the country and around the world, in a weekly column on health issues for The New York Times (which Rusk continued until 1971), through influential private sector and government contacts, and through the establishment of rehabilitation training programs, which helped expand the message through various disciples (1). In 1955, Rusk founded the World Rehabilitation Fund to provide technical assistance for the development of rehabilitation programs in underdeveloped countries, as well as funding for education and training programs on prosthetics around the world, and grants for foreign physicians to study rehabilitation in the United States: “Its basic aim was to sponsor international projects which would help the handicapped and create a better understanding of them and their problems” (105). Rusk also authored several books, including New Hope for the Handicapped (1949) and Living with a Disability (1953), both with his colleague Eugene (Jack) Taylor (1913–1978); served as the senior author of Rehabilitation Medicine (1958); and wrote his acclaimed autobiography, A World to Care For (1972), which summarized the development of his concepts of comprehensive rehabilitation.

In his autobiography, Rusk explained why he got such satisfaction from working with disabled people:

Rusk promoted these ideas among medical students as well:

Rusk emphasized that physical disability could be accommodated and that through vocational rehabilitation, many disabled people could live productive lives and be valuable members of the workforce:

In 1955, Rusk received a Christmas card from Adlai Stevenson containing what has been attributed to be the personal prayer of an unknown Confederate soldier in the Civil War (46):

Rusk’s disabled patients found personal meaning in this prayer, as did their families, so much so that the father of one young patient had the prayer cast in bronze. The prayer that the boy’s father cast in bronze now hangs on the wall in the lobby of the institute Rusk founded (46). The prayer continues to be widely reproduced, and is sometimes referred to as the “Prayer of the Disabled.”

Rusk closed his autobiography with a quote from French chemist and microbiologist Louis Pasteur (1822–1895), emphasizing the patient’s role in rehabilitation, and in Pasteur’s particular case, his successful rehabilitation following a serious stroke:

Rusk never stopped promoting the concept of rehabilitation. As he noted in 1969:

Rusk received many awards and honors, including three Lasker Awards, the first an Albert Lasker Public Service Award in 1952 “for his pioneering work in the service of the physically disabled and as distinguished rehabilitation mentor to the world,” the second an Albert Lasker Award given by the International Society for the Rehabilitation of the Disabled in 1957, and the third an Albert Lasker Medical Journalism Special Award in 1959 “for his editorial leadership in advancing medical research and public health programs in his weekly columns in the New York Times” (111,112). In 1966, Rusk was recognized by the American Congress of Physical Medicine and Rehabilitation with a gold medal bearing the inscription: “Physician, teacher, author, inspiration to patients and disciples and a prime mover in the development and spread of medical rehabilitation throughout the world” (111).

In 1981, in the “Year of the Disabled,” Rusk—then 80—was nominated for the Nobel Peace Prize. At that time, a reporter for the American Medical Association interviewed Rusk, who was still actively promoting comprehensive rehabilitation.

Despite Rusk’s statement to the contrary, many of his colleagues continued to apply that label to him (3), and to this day the Association of Academic Physiatrists continues to label Rusk the “Father of Rehabilitation Medicine” (and Krusen the “Father of Physical Medicine”) (11).

The fully formulated definition of rehabilitation by Rusk, the acknowledged father of comprehensive rehabilitation medicine, is worthwhile recounting:

At the time of renaming of the Institute of Rehabilitation Medicine as the Rusk Institute in 1984, Rusk noted that he used “the phenomenon of hope” to train people “not just within the limits of their ability, but up to the heights of their latent ability—to help them live the very best lives possible with what is left” (110). Rusk’s framework and focus on treating the “whole person” has been the basis of subsequent programs and developments in the field, and has been incorporated into definitions of the field used by major rehabilitation organizations (11).

The World Health Organization’s Impairments-Disabilities-Handicaps Framework (1980)

In 1980, the World Health Organization (WHO) introduced the International Classification of Impairments, Disabilities, and Handicaps (ICIDH)—a tool for the classification of the consequences of disease as a complementary framework for the International Classification of Diseases (ICD) (122,127). ICIDH defined the terms “impairment,” “disability,” and “handicap,” and provided a preliminary classification and grading scale for each based on a conceptual framework developed initially in the 1970s by epidemiologist Dr. Philip H.N. Wood (1928–2008) of the University of Manchester Medical School in Manchester, England (122,127). Impairment was considered to represent “exteriorization” of a pathological state (disease), that is, an organ-level disturbance evident through symptoms or signs. Disability was considered “objectification” of impairment, a person-level restriction or lack of ability to perform a normal activity such as personal care or walking. Handicap was considered to represent “socialization” of a disability or impairment: a social disadvantage for an individual that limits or prevents fulfillment of a normal social role such as self-sufficiency. Under this framework, disease → impairment → disability → handicap.

ICIDH listed the goals for intervention as they pertain to disability:

Under this framework, rehabilitation focuses on the latter three categories (i.e., enhancement, supplementation, and substitution) to minimize handicap.

In many ways, the initial WHO formulation relied heavily on a medical model of disability (115,116), even though it recognized that social factors were inherent in what it called “handicap” (122). This approach resulted in charges that ICIDH promoted the “medicalization” of disability and failed to adequately address the major impact of social and environmental factors (115,121).

The Institute of Medicine’s “Disabling Process” Framework (1991)

In a 1991 report of the Institute of Medicine (IOM) titled Disability in America, the components of the “disabling process” were refined from those initially described by sociologist Saad Z. Nagi of Ohio State University in the 1960s (115,119–121). Under this framework, the disabling process has four major components: pathology, impairment, functional limitation, and disability, with the usual (although not universal) progression being pathology → impairment → functional limitation → disability.

There are exceptions to this typical progression:

There are clearly overlaps and differences between the IOM model and the earlier WHO model (122). In the IOM model, pathology concerns the abnormal interruption or interference of normal bodily structures or processes because of factors (e.g., disease, infection, trauma, and genetic defect) operating at the molecular, cellular, or tissue level. Impairment concerns the loss or abnormality of a mental, physiological, or biochemical function at the organ or organ systems level. A functional limitation is the impaired ability or inability to perform a specific task at the level of the whole organism, such as walking or climbing a flight of stairs. A disability is a limitation in performing roles and tasks expected of an individual within a social and physical environment—an abnormal gap between the individual’s capabilities and the environmental and societal demands.

In the IOM model, the amount of disability a person experiences is directly linked to the “quality of the surrounding environment—for example, whether appropriate and adequate care is accessible and whether a social support network is in place” (118). Thus, a major focus of rehabilitation is minimizing disability by physical and social environmental modifications so that an individual can participate fully in society.

Although to some degree a mixed bio-psycho-social model, the IOM framework is based heavily on a social model of disability:

Further, the IOM report correctly emphasized that disability prevention can be directed at any of the stages of the disabling process. Even at the disability stage, “efforts can focus on reversal of disability, restoration of function, or prevention of complications (secondary conditions) that can greatly exacerbate existing limitations or lead to new ones” (115). However, the focus of disability prevention was placed heavily on social and environmental modification:

The IOM’s “Enabling–Disabling Process” Framework (1997)

In 1997, the IOM published a report titled Enabling America as a follow-up to and revision of its previous Disability in America report from 1991 (115,118). The 1997 report revised the earlier “Disabling Process” model to formally recognize that the focus of rehabilitative efforts is to assist the individual in reversing the disabling process through an “enabling process”:

A person without disability is considered to be “fully integrated into society” and has access to social opportunities (e.g., education, employment, and parenthood) and physical space, whereas a person with a potentially disabling condition has increased needs that can manifest as a true disability if the social and physical environment are inadequate for these needs. The enabling (or rehabilitative) process attempts to counteract the disabling process by functional restoration and environmental modification.

The WHO’s Functioning-Disability-Health Framework (2001)

The initial version of ICIDH promulgated by the WHO in 1980 was widely adopted around the world and was very influential in stimulating research as well as discussion of the best framework for considering disability. Beginning in 1995, ICIDH underwent an exhaustive revision process, with comments from more than 80 countries, field tests in 42 countries, and input from scientists, disability groups, and other nongovernmental organizations. The culmination of this revision process was the publication of the International Classification of Functioning, Disability and Health (ICF) in 2001 (123,124).

In a shift from the previous WHO formulation, ICF emphasized health and functioning, rather than disability:

“Functioning” in the ICF framework is specifically structured around two broad components: (a) body functions and structure; and (b) activities and participation (i.e., involvement in a life situation). Further, participation can be viewed from either a performance perspective (i.e., what an individual does in the current environment) or a capacity perspective (i.e., what an individual can do in an optimized environment). The discrepancy between capacity and performance, the capacity–performance gap, suggests what could be changed in the current environment to improve performance (128).

ICF is based on a bio-psycho-social model that integrates medical and social frameworks of disability from earlier models:

Health conditions (i.e., diseases, disorders, and injuries) lead to impairments (i.e., problems in body functions and structure) that may be associated with activity limitations (i.e., difficulties in executing activities), and/or participation restrictions (i.e., problems with involvement in life situations). Thus, a stroke (a health condition) can cause hemiparesis (an impairment), which is associated with impaired mobility (an activity limitation), and which may cause inability to use mass transit, find a job, and so on (participation restrictions). Under this framework, the impairments, activity limitations, and participation restrictions are different categories subsumed under the broad umbrella of “disability.” This spectrum of disability is dependent on further interactions with the underlying health condition, and also with contextual factors, including environmental and personal factors. The ICF framework can also be linked to different treatment, rehabilitation, and social/environmental interventions and prevention approaches (116).

Organized Inpatient Multidisciplinary Stroke Rehabilitation

Since the 1970s, and particularly since the 1990s, it has become clear that organized inpatient multidisciplinary rehabilitation in the postacute period provides clinically important benefits (138–143). Most data supporting the clinical benefits of inpatient stroke rehabilitation are based on studies of comprehensive stroke units (that provide acute stroke care and rehabilitation) or rehabilitation stroke units (dedicated to rehabilitative care of postacute patients with stroke), rather than the more common mixed rehabilitation units (that provide stroke rehabilitation in a mixed rehabilitation setting) (142). Stroke patients who receive inpatient rehabilitation provided by a coordinated multidisciplinary team are more likely to recover the ability to perform activities of daily living, more likely to return to the community, and less likely to die—results that are fairly robust in different meta-analyses and across recent controlled trials (140,144–151). A Danish population-based study comparing two communities—one where care was provided in a dedicated comprehensive stroke unit with both acute care and rehabilitation care, and the other in which care was provided on general medical and neurologic wards—found that stroke unit care reduced the length of hospital stay by 30%, reduced the risk of discharge to nursing home by 40%, and reduced the relative risk of death by 50% (140). In a systematic review of 9 trials recruiting 1,437 patients, Langhorne and Duncan found that for every 100 patients who received organized inpatient multidisciplinary rehabilitation, 5 more returned home in an independent state compared to those who do not receive such care (141). Functional, independence, and survival benefits to those who underwent early multidisciplinary stroke rehabilitation after stroke are sustained even 5 to 10 years after stroke (152–156). Patients with moderate or severe strokes appear to benefit the most (150).

FIGURE 1.12

In the late 1870s and 1880s, prior to the development of movie cameras or projectors, American photographer Eadweard Muybridge (1830–1904) photographed sequential images of people and animals in motion, using arrays of sequentially triggered single-image cameras. In 1885, Philadelphia neurologist Francis Dercum (1856–1931) collaborated with Muybridge at the University of Pennsylvania. This figure shows sequential images of lateral and frontal views from a portion of Muybridge’s “Plate 552. Spastic, walking with cane” (Source: From Ref. 133). This sequence shows a man with a dense spastic left hemiparesis with the arm held in a fiexed posture. As noted by Dercum, “the paralyzed leg is quite stiff, little or no fiexion taking place at the knee ….” Circumduction of the left leg (seen especially on the frontal views) is quite prominent, with the leg first swinging outward during forward motion and then returning toward the midline in an arc. Notice as well, the equinovarus deformity, or as Dercum commented, “the exaggeration of the normal tendency of bringing the outer edge of the foot to the ground in advance of the sole”

(Source: From Refs. 131, 132, and 133).

FIGURE 1.13

Sequential images of lateral and posterior views from a portion of Muybridge’s “Plate 547. Spastic, walking with crutch” taken in 1885 (Source: From Ref. 134). This shows an elderly man with a dense spastic right hemiparesis with the arm held in a fiexed posture while using a crutch to walk. As noted by Dercum, “the paralyzed leg is quite stiff, little or no flexion taking place at the knee … [The foot is] raised from the ground by the enormous swaying of the trunk toward the sound side, to which additional support is given to receive the sway by means of the crutch.” See the legend for Figure 1.4 for further details

(Source: From Refs. 131, 132, and 133).

Even where evidence supports a clinical benefit of stroke rehabilitation, it has generally been unclear which specific factors, including which therapies or combinations of therapies, among the entire package of individualized treatments for a given patient are most important for providing benefit (142,157–159). Although data supporting the value of individual team members in the multidisciplinary team are limited, most authorities and clinical care guidelines have advocated a broad team composition, including physicians, nurses, physical therapists, occupational therapists, speech therapists, and social workers (140). Although available studies are limited, the intensity of rehabilitation services is a modest predictor of recovery among stroke patients (151,160–164), as is, particularly, an early start to intensive treatment (158,159). It has also been unclear to what extent findings of randomized clinical trials could be generalized to the routine clinical setting: the limited available data suggest that the routine clinical rehabilitation setting can reproduce the benefits of stroke rehabilitation units in controlled trials and meta-analyses, but the magnitude of benefit is smaller outside of the formalized experimental setting (165). Inpatient rehabilitation is also expensive, and the limited available cost–benefit analyses have not strongly supported the cost-effectiveness of inpatient stroke rehabilitation overall (166–168), making it imperative to carefully select patients who will benefit most from such intensive care (169), and also to identify the least expensive care settings that will provide maximum clinical benefit to individual patients (170).

Clinical Pathways

Integrated care pathways have not been shown to improve the outcome of inpatient stroke rehabilitation (171–178). In fact, care pathways for rehabilitation programs have most often resulted simply in decreased patient satisfaction (171–174,178), and some studies have actually reported slower recovery and lower quality of life among patients receiving rehabilitation as part of an integrated care pathway as opposed to conventional multidisciplinary rehabilitative care (171,175). As noted by Teasell, “This apparent paradox may signify the importance of using evidence or guidelines to assist rehabilitation clinicians in individualizing the rehab of stroke patients as opposed to a ‘one size fits all’ approach” (178). Furthermore, despite potential benefits, many clinical pathway programs for acute or rehabilitation care of stroke fail because of inadequate planning and implementation (173,174). Effective implementation of such programs requires strong administrative and medical staff leadership, active participation of all clinical disciplines involved in the rehabilitative care of patients on the pathway, provision of regular feedback to clinicians, sufficient resources, improved (and often more detailed) documentation, incorporation of the entire rehabilitation period of care into the pathways, integration with ongoing quality and utilization management programs, and periodic evaluation and modification (173,174).

Specific Therapies

Based on expert opinion and limited controlled trial data, physical therapy is modestly beneficial for stroke patients (159,164,179,180). However, there continues to be considerable variation in the beliefs (181) and treatment approaches (182,183) of physical therapists concerning the treatment of stroke patients, in part a function of the treatment approach in vogue when the physical therapists were trained (184). Particularly since the 1950s, several different physical therapy approaches have been developed and applied in the treatment of stroke patients (139,180–194). Some physical therapists advocate and apply Bobath’s “neuro-developmental” approach developed by physiotherapist Berta Bobath (c. 1908–c. 1991) and her husband, psychiatrist and neurophysiologist Karel Bobath, MD (c. 1906–c. 1991) (187), both Jewish refugees from Nazi Germany to England; the “motor re-learning programme” of Janet H. Carr, MA, EdD, and Roberta B. Sheperd, MA, EdD (188); Swedish physiotherapist Signe Brunnström’s approach utilizing abnormal synergies (186); and various others. Controlled trial data are as yet inconsistent, and no clearly better approach has been identified from among the available approaches for the physical therapy of stroke patients (180,183). Progressive resistance exercises several times a week can help improve strength and functional abilities in patients with adequate motor control (138,195). The intensity of therapy initiated early seems to be important in maximizing the degree of functional improvement (161–164).

Based on the results of systematic reviews, comprehensive occupational therapy is modestly beneficial in improving activities of daily living and social participation among stroke patients (196,197), although there is limited or insufficient evidence supporting many specific occupational therapy interventions, including provision of splints for decreasing muscle tone (196,198). Even when provided in the community, occupational therapy can improve basic activities of daily living, as well as domestic and leisure skills, as indicated by systematic reviews (196,197). Different task-oriented practice strategies can be helpful, especially if intensive training in specific skills is provided (138,161–163,196). Constraint-induced-movement therapy—based on the idea that “learned nonuse” of a weak arm develops because of the greater effort required to use it—seeks to encourage the use of the weak arm and promote helpful cerebral plasticity (138,199); this approach can be helpful in increasing the amount and efficiency of the use of the weak arm in the relatively small subset of patients with fairly good motor control to begin with (138,200–202).

Available data from randomized controlled trials concerning the efficacy of speech therapy in stroke rehabilitation are limited and not entirely consistent (203), with some trials supporting a modest benefit within the first 3 to 6 months after stroke (160,204,205), and others finding lesser or no significant benefit for most patients (206–208). A greater intensity of therapy in the first several months poststroke seems to be an important factor in the degree of improvement (160,203,209).

Early Supported Discharge

In most countries, into the 1990s, stroke patients were treated initially in the hospital, followed by a variable period of inpatient rehabilitation, but rehabilitation often stopped after discharge (210). In some countries, early supported discharge (ESD) approaches have been developed since the 1990s that shorten the period of acute hospital stay and provide rehabilitation services beginning in the hospital and continuing for the first few weeks at home. Proponents have claimed that this approach is not only less costly, but can also improve care by providing “seamless service” spanning inpatient and home care environments; however, until recently there were limited data to evaluate such claims (210). Single-blind randomized controlled trials have been reported from the United Kingdom, Scandinavia, Australia, and Canada (211–224). Although some studies of ESD have not identified any significant benefits of this approach (213), others have reported similar efficacy compared with traditional inpatient rehabilitation along with significant cost savings (212,224); reductions in total hospitalization (of approximately 50%) (217,218,220); reduction in use of inpatient rehabilitation beds (211); improved patient satisfaction (214,217,220); less caregiver stress (221); and, in some cases, improved performance of activities of daily living (215,218,219,222), and longer sustained noninstitutional care (215). In one well-designed study from Norway, stroke patients who received ESD rehabilitation services spent less time in hospital and were also more likely to be independent and to be living at home after one year (215). As suggested by Langhorne, presumably “the ESD service has improved the patient’s ability to regain normal activities despite residual impairment. In particular, the patient’s own home is probably the best place for him or her to relearn the skills needed to function in that environment” (210). A home environment for rehabilitation may also facilitate patients with moderate neurologic impairments taking greater responsibility and exercising a greater influence over their own rehabilitation (223). A systematic review of the economic costs of different settings of rehabilitation care found “‘moderate’ evidence that ESD services provide care at modestly lower total costs than usual care for stroke patients with mild or moderate disability” (166).

Outpatient Rehabilitation

The role of outpatient rehabilitation services (i.e., therapy-based rehabilitation services targeted at stroke patients living at home) has only recently been studied in any detail, and the results remain less certain than in the case of traditional inpatient multidisciplinary stroke rehabilitation (225–229). This is complicated by differences in the types of community-based rehabilitation provided, the setting in which such care is provided (day hospital versus the home), and the clinical circumstances for which this approach is used instead of traditional inpatient rehabilitation (228,229). Several studies have evaluated the use of day hospital rehabilitation care with inconsistent results compared with either inpatient multidisciplinary care or home care (230–232). Costs are generally higher for day hospital rehabilitation than for home care (230,232), but not universally so (231). Functional outcomes for day hospital rehabilitation are generally similar to rehabilitation provided in other settings (230,231), although one study reported better functional outcomes with day hospital rehabilitation than with home care (232). Nevertheless, preliminary results suggest that some therapy-based rehabilitation services provided in the home can result in a greater ability to perform activities of daily living and reduce the risk of deterioration in ability compared with conventional care (i.e., normal practice or no routine intervention) (225–229). Other studies have indicated no benefit for some outpatient services that were not primarily therapy-based, including the use of an outreach nursing support program (233,234). Further studies are needed to define the most appropriate level of service delivery, the most effective services and interventions, and their cost-effectiveness compared with other approaches (225). At present, there is “insufficient” evidence concerning the economic costs of community-based rehabilitation (166).

Caregiver Training

Family involvement in support of the poststroke patient has long been recognized as a strong independent predictor of discharge to home as opposed to an institution (169). Because the degree of family involvement can sometimes be influenced by the rehabilitation team, family and caregiver training has been a major target of therapeutic intervention, and is being increasingly recognized as a predictor of functional outcome as well (169). Caregiver training during the rehabilitation of stroke patients can reduce the cost of care and improve the overall quality of life among caregivers, even as long as a year poststroke (235,236). Problem-solving training, including an in-home visit and subsequent telephone contacts by a trained nurse, may also be useful for family caregivers of stroke survivors even after the latter’s discharge from rehabilitation (237). Caregiver training and education may help caregivers be better prepared to deal with issues, facilitate development of caregiver problem-solving skills, lessen caregiver stress and depression, minimize secondary complications among the patients, and facilitate patient motor tasks that promote functional improvements and lessen the risk of further functional declines (e.g., safe swallowing and walking for exercise) (138,237).

Gaps in Theoretical Foundations and Practical Implementation Remain

The development of stroke rehabilitation concepts is still limited, with the recognition in the field that many of the therapeutic approaches currently employed have, at best, limited benefit in a select subgroup of patients; that much of the theoretical justification for different rehabilitation models and approaches remains speculative; and that there is no overall foundation for an accepted “theory of rehabilitation” that could help to prevent fragmentation and division, provide coherence, focus research and development in this area, and facilitate competition for limited research funding (138,142,238,239). Moreover, because rehabilitation interventions are typically multidisciplinary, multifaceted, and customized to the individual patient’s needs and goals, they are, in practice, difficult to standardize, and therefore difficult to measure and compare (138,142,238). Available treatment studies are further complicated by the heterogeneity of impairments and disabilities of the patients studied, poor descriptions of the specific treatments administered, inadequate controls, lack of blinding, small sample sizes, and insensitive outcome measures (138).

Current expert consensus has strongly supported the importance of integrating rehabilitation into systems of care to ensure that all patients who could potentially benefit from appropriate stroke care and rehabilitation are provided with the appropriate treatment in a time frame that will maximize recovery and minimize disability (151). According to the American Stroke Association’s Task Force on the Development of Stroke Systems:

Practice guidelines are now available for stroke rehabilitation (240–242), but in many cases patients do not receive care consistent with the guidelines (142,151,243,244). Further, there are sociodemographic inequalities in the use of rehabilitation services, suggesting inappropriate underuse among certain populations (245).

Even when patients receive inpatient stroke rehabilitation, they spend only a small amount of their inpatient stay participating in potentially rehabilitative activities, and this low intensity of therapy is less likely to produce beneficial outcomes (138,142,227,246). In an observational behavioral mapping study of five stroke units, patients had therapist contact during only 5% of the day, participated in minimal or moderate therapeutic activity for less than 13% of the therapeutic day (8 a.m. to 5 p.m.), and were resting in bed 53% of the time and alone 60% of the time (247). Poor participation in therapeutic activities is common during inpatient rehabilitation, and is associated with longer lengths of inpatient stay and lower degrees of improvement in functional performance (248). In addition, for financial or policy reasons, formal therapy is typically stopped when there are no evident qualitative gains in function after several weeks of treatment, even though, as Dobkin notes: “A plateau in recovery … does not necessarily imply a diminished capacity for further gains in physical speed or precision or in learning a new task” (138).

Furthermore, despite modern treatment and multidisciplinary rehabilitation, perhaps half of the patients with stroke are ultimately discharged home with serious, persistent neurologic impairments, functional limitations, and, often, disability resulting from inadequate environmental supports (249). Stroke survivors (whether residing at home or in institutional care environments) are prone to multiple secondary conditions that further erode health, including social isolation, depression, physical inactivity, painful joint contractures, deep venous thromboses and pulmonary emboli, decubitus ulcers, incontinence, aspiration pneumonia, inadequate nutrition, falls, hip fractures, and seizures. Such patients are often frail and susceptible to aggravation of existing disease or development of new illness, with resulting functional decline, high resource utilization, high rates of rehospitalization, significant added morbidity, and a high risk of death within the first year after stroke onset. Indeed, in the United States, approximately one-fifth of stroke patients die in the first month after stroke, a quarter within 2 months, and a third within 6 months (250). Patients and caregivers can benefit from a close liaison between inpatient and community care programs, and also from continuing professional support and counseling after discharge following a stroke (249).

Further studies are needed to define the most appropriate level of service delivery for stroke rehabilitation, the most effective services and interventions among the “complex packages of care” that comprise current rehabilitation programs, and the most cost-effective stroke rehabilitation service among the different types available (142,225).