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June 2004

RIC HOLDS "AMBIGUOUS LOSS" SEMINAR
On July 9, the Rehabilitation Institute of Chicago (RIC) Academy will offer a course on "ambiguous loss," a topic that affects families and professionals who deal with patients suffering from a life-altering disability. The one-day seminar, entitled Ambiguous Loss: A New Theoretical Lens for Rehabilitation Work, will be lead by Pauline Boss, the author of a book dealing with the same topic.

"Ambiguous loss is a term that originated from Pauline Boss to differentiate a kind of loss that occurs when the individual is physically still present, but they have been changed (through a disability that affects their cognitive ability), so they are no longer the same person that you previously had a relationship with," says Glenn Paustian, RIC Academy program manager and Allied Health manager.

In the seminar, Boss will address the commonly held belief in psychological literature that once an event takes place for which there is a loss, there is a certain amount of time given to a grieving individual to come to terms with that loss, and then move on with their lives. This process is significantly different, however, when that person is not lost to death. The loss is not recognized by funerals or ceremonial get-togethers to sanctify the passing of an individual's life.

"When a person is lost to neurological change, so that they are cognitively different, but physically present, that grief process does not end as it might with a death of a person," says Paustian. "The situation is different-the physical person is still there, but the attributes of that person are totally different, and you are mourning the loss of the person you used to know."

According to Paustian, ambiguous loss impacts family members, care-givers, and significant others who provide care for, interact with, live with, or are responsible for an individual who has become a significantly different person.

Recognizing that ambiguous loss is an important process of the rehabilitation process, the RIC has a team of rehabilitation specialists who work closely with each patient and family to help cope with their therapy goals and loss. The team, led by a physiatrist, may include physical and occupation-al therapists, speech-language pathologists, recreational therapists, and others as needed.

The RIC Academy expects a large turnout for this course, since the topic is broad. Course pamphlets that were sent out generated positive feedback.

"The fact that the title of the course is Ambiguous Loss: A New Theoretical Lens for Rehabilitation Work, shows that Boss is telling us that we have a new perspective on how the grieving process is different for the significant others of the individuals who are lost to us in this (cognitive) way," says Paustian.

IRFs FACE NEW PAYMENT CRITERIA
The Centers for Medicare and Medicaid Services (CMS) has issued a final rule that revises the criteria for classifying hospitals as inpatient rehabilitation facilities (IRFs) that receive Medicare payments.

Currently, the conditions accepted by CMS as requiring intensive inpatient rehabilitation therapy are spinal cord injuries, congenital deformity, stroke, major multiple traumas, fracture of femur, amputations, brain injuries, burns, neurological disorders, and polyarthritis. Medicare pays for treatment in an IRF at a higher rate than for rehabilitation in other facilities due to the level of intensity of the rehabilitation procedures needed to treat these specific conditions. CMS had received recommendations to update this list with new conditions that would fit the criteria of needing intensive rehabilitation.

The final rule addresses that concern with a major change-the elimination of polyarthritis as a specified condition that is covered by Medicare. The rule replaced polyarthritis with four arthritis-related medical conditions, including severe or advanced osteoarthritis involving two or major joints. Another change is the inclusion of patients who undergo joint replacement of the knee, hip, or both, during acute hospitalization immediately preceding their stay at an IRF.

The rule also outlines a plan to target payments to facilities that treat a large number of patients who require intensive rehabilitation. The final rule requires limited percentages of patients of an IRF's total patient population to have one of the qualifying medical conditions in order for the facility to be classified as an IRF; these percentages increase incrementally every year until the compliance threshold of 65% is met.

The final rule was published in the May 7 Federal Register, and will become effective on July 1, 2004.

TBI PATIENTS BENEFIT FROM VOCATIONAL REHAB
Researchers from the University of Missouri, Columbia, have found that people who suffer from traumatic brain injuries (TBI) are more likely to return to work if they receive vocational rehabilitation services; those with severe neuropsychological impairments saw the greatest improvements from vocational rehabilitation.

"We found vocational rehabilitation is most successful for the clients with the most significant TBIs," said Brick Johnstone, a professor of health psychology at the University of Missouri. "Patients with a mild injury might return to work without any kind of rehabilitation, but they may or may not be successful. Those with moderate injuries might try the services but not follow through. Those patients with the most severe injuries know they need the help and stay with their rehabilitation to ensure they get the most out of it."

For the study, Johnstone worked with the Missouri Division of Vocational Rehabilitation to follow nearly 200 patients over a period of 10 years. Johnstone found that 24% of the patients were able to return to work after receiving vocational rehabilitation services, such as on-the-job training and career counseling.

Gender and area of residence played a big role in determining the success of a patient's recovery after vocational rehabilitation. Johnstone found that males are more likely to return to work after TBI (24% versus 4% of females), and people living in urban areas are more likely to work again as opposed to TBI patients living in rural areas.

"It is important to know that women with TBI may face distinct issues when considering returning to work, including issues related to being primary homemakers and child-care providers," Johnstone said. "People who live in urban areas are more successful returning to work for several reasons. There are not as many jobs or rehabilitation professionals in rural areas, and there are fewer transportation opportunities in rural areas. This shows we must find new ways to work together to provide job services to people who live in rural areas."

To address the concern for providing care to rural-area patients, researchers studied the effectiveness of telehealth services (video interviews done using telephone networks), and found that results were just as effective as in-person interviews. The TBI patients in rural areas who received telehealth services were more likely to return to work than those who did not receive the telehealth interviews.

THE SEARCH FOR MORE NATURAL PROSTHETICS
Advances in prosthetic limb technology offer hopes of eventually achieving more natural, human-like functionality, according to an article in the HealthDay Reporter (health.yahoo.com/ search/healthnews?lb=p&p=id%3A5538). Research from this report shows high-tech prosthetic devices with built-in microprocessors provide hope of gaining some functionality similar to that of real limbs and offer a better alternative than amputation.

However, they currently still lack the ability to completely mimic the capabilities of real human limbs.

Despite the limitations of high-tech prosthetics, developments in the technology do offer advantages over a stiff artificial limb, such as a wooden leg, which lacks flexibility of movement. Among the problems associated with artificial limbs is the chance that if someone moves too quickly, a prosthetic lower leg could whip back and slap the user. New prosthetic knees with microprocessors are able to detect the motions of the user and adjust the joints of the knee accordingly. High-tech prosthetics also offer users more control over the limbs.

Although improved prosthetic limb technology offers patients hope of regaining some functionality, physicians noted that there are still a lot of advancements to be made.

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