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Up until a few decades ago,
having a disability was synonymous with resignation, and the meagre
attempts dedicated to functional recuperation consisted only of modest
adaptive measures, mostly concerned with supporting the residual function
and leaving only a mere vicarious function to the performance capabilities
left intact.
However, in recent years, Rehabilitative Medicine has registered extraordinary
progress, conquering a place in the limelight and claiming it's own
autonimous space, also in the realm of high specialisation (as has happened,
for example, in the case of Intensive Rehabilitation of serious cranio-encephalic
traumas and in the Spinal Unities).
Moreover, Rehabilitative Medicine has been enriched by a vast range of
technological aids which, alongside traditional rehabilitation, are
able to greatly help the monitoring and the power of recuperation.
These new technologies at the service of Rehabilitation (and in particular,
neuro-rehabilitation) are so numerous that it would be impossible in
this single paper to list them all.
I would like, however, to talk about a series of principles with reference
to some examples.
In the case of neurological damage which results in invalidity, we can
divide these invalidities with very rough  approximation,
into two large 'families': motor disabilities and those related to upper
cortical functions (leaving aside, for reasons of synthesis, those others
such as sensitive-sensorial, bladdersphincter etc.).
With motor disability there is a disturbance (of greater or lesser seriousness)
of a fundamental biological function, especially in the case of man:
movement.
I'm referring to disability caused as a result of central neurolesions
(encephalo-midollar) or peripheral  neurolesions,
in which, for various reasons, the ways of movement or of co-ordination
don't function as they did prior to the lesive event.
In central or peripheral paralysis, the accompanying syndromes and disturbances
in muscle tone, are what propels the physiotherapist to apply a whole
series of rehabilitative resources to try to attenuate the disturbance
of the quality and quantity of the movement.
With the pathologies which damage the the upper cortical functions the
disturbance is related to those functions which enable man to relate
to the outside world , to communicate and interact with it.
I'm referring, in this second case, to the disturbances of the upper
noetic functions (language, attention span,memory, intelligence, calculation
capability, etc.) which, in these recent years, have received a large
contribution from Rehabilitative Medicine which has sped up the processes
of post-lesional recuperation.
Therefore, in both sectors (that of the pathology of movement and that
of the pathology of the cognitive functions) the physiotherapist
requires two fundamental tasks from this new technology:
that of contributing to improve the performance and
that of measuring the extent of the damage, within the sphere
of a correct physiotherapeutic balance.
On the subject of measures, it has to be said that, up until a few years
ago, the various evaluations were empirical and exclusively based on
clinical criteria.
Today, modern technology allows us to arrive at balances with appreciable
precision and to extend our capacities of diagnosis.
Just to give an example, analysis of muscular force and potential, of
posture and of the possibility of transferral of the patient, can be
correctly quantified with the use of platforms of force, posture-stabilising
footboards and treadmill, isokinetic machines, polielectromiographic
telemetric investigations, computerised vectorial analysis of walking,
etc.
 So, all these
resources available to measure the events of physiotherapeutic interest,
have enabled Rehabilitative Medicine to bring itself up to the rigorous
criteria of science and to the standards of research and cure.
Rightly it has been affirmed that this is a historical moment for
Medicine in which, more than ever, we affirm the culture of documented
rationality(1).
This means that the results which are obtained (or those boasted of)
must no longer be subject to the age-old vice of 'doctoring' and must
be solidly based on objective, imperfect but above all documented
evidence.
Now truer than ever is the slogan “Art appraises, Science measures”.
Perhaps an excessively manichean paradigm, at least in Rehabilitative
Medicine. In this context, indeed, where the damage to the body and
the consequences for the person are so rarely synonymous, it is worthwhile
bringing to mind a provocative thought, which opportunely recommends:
“It is necessary to reconcile new scientific evaluations with
the old arts”(2).
A difficult task, because the ice of precision so often melts in the
heat of the old arts, and the measures, even those most worthy, often
don't seem to have been recorded with the same vision, as always happens
in the conflict between feeling and measurement.
To illustrate this Oliver Sachs' tale about the twins who didn't know
how to count comes to mind.
“One day, recalls Sachs,I dropped a box of matches and they went
all over the floor.
An instant later, in unison, the two twins shouted out:ninety-nine! It
was true, there really were ninety-nine matches”.
How did they do it? The two didn't know how to count, and yet had “measured”-in
an instant-the numerical entity of the matches on the ground.
This episode brings us to certain capabilities revealed in
numerous elements belonging to the aborigine tribe
of North Australia.
Also these subjects had not learned to count, not using the mental
instruments required in making a numerical calculation such as adding,
subtracting or dividing. And yet, faced with a pen containing
one hundred sheep,  they were
instantly able to specify the quantity, without proceding as we would,
to a 'counting' of the animals, but seeing them altogether.
This is a model of “iconic” evaluation, where the numerical
data is replaced by information concerning the whole.
Where a mere quantative result is taken over by an 'embrace of all things
sensorial'.Where, as well as the mere numerical data, also sounds, scents
and whatever else is included to fill out the scene.
A sort of flash, therefore, which pans out on the data to give not only
a quantative judgement but an evaluation of the whole, even if this
is characterised by limited powers of resolution (as always happens
in panoramic or wideangled shots which embrace the whole without focusing
in on the detail).
In clinical practice, measurement must serve if not as proof at least
as clue, because nowadays, in medicine it has become imperative to 'devaluate
intuition and emphasize consistency of the information' (3).
This means the elimination where possible of empirical evidence which
then gives way to new rules of methodology. These then, in the various
specialisations, can generate the appropriate guidelines to standardise
the processes of investigation and the handling of data.
Only then will it be possible to pass into another phase, which consists
in making the step from the data to the information, this latter being
nothing if not “data clothed”, which has passed from “the
rough” to the “specific”, and which is then able to
“help us understand the reason why”.
Nevertheless,epistemology has discussed and substantially refused the
strong idea of “proof”, to the point that this end has almost
disappeared from the methodological treatments and has been substituted
by the word Control: indeed in the most rigorous sciences, a determinate
hypothesis can be proved with difficulty but can only be controlled
(and if that control reaches a good conclusion, only then
can it be declared
verosimilar) (4).
In any case, whether you want to obtain a proof, or you want to carry
out a control, it is necessary to refer to a measurement.
 And all the
measurements together represent an informative feedback from which
the diagnostic conclusions and clinical behaviour can then be derived.
A measurement - in order to be congruous, correct and accepted
- must be adorned with a seal of credibility (given by the objectivity
documented and the experience shared): this mark of reliability is called
qualification.
But can you measure everything?
And which peculiarities intervene in Rehabilitative Medicine?
Here the subject becomes rather large.
Indeed, even if we want to confine ourselves to the field
of measurement relating to one single motor ability, we soon realise
that the task is all but easy.
Anyhow, for a physiotherapist, motor ability, if we understand
by that the mere realisation of a movement, isn't of great
value.
Indeed, what is understood to be movement is a displacement
from one point to another in space in a determinate time.
If we limit ourselves to this, in a parapathetic
subject who, in sitting position, manages to extend a leg by some degrees,
it could be said that a result has been obtained (and the event is easily
measured, by means of a banal goniometre).
Nevertheless, if this result should be limited to the movement of the
limb, without this enabling the patient to walk, the rehabilitative
result would be completely unsatisfactory.
In the area of physiotherapy, that which counts is not so much the capacity
of motor performance, but that it obtains a determinate motor function.
When the movement becomes useful for functional purposes, then the result
appears appreciable.
From this we can state that the measurement of the motor capability must
be correlated not only to the quantification of a movement in itself,
but also to the documentation of the pursual of a functional end result,
connected to the movement.
We can derive from this that the measurements which qualify for the motor
capability in rehabilitation must be arrived at through the use of instruments
and systems able to quantify those parameters that document the level
of regain of the function.
If this is true, it follows that the apparatus for testing required to
obtain these results must be very complex as it is very difficult to
separate off the kernal of information related to a specific motor capability
from the subjective elements involved (those of the patient and the
examiner).
 The whole
argument is made even more difficult by the existence of a historical
gap between the worlds of medicine and technology and-above all-by the
different'wavelengths'used by doctors and engineers, which little by
little are being brought closer together( but very slowly and with great
difficulty).
It can be seen therefore,that the moments of satisfaction following a
technical evaluation are not rarely seen to be redimensioned to a clinical
evaluation and vice versa; if to that we also add the increasingly insistent
need for an economic evaluation(with the implications of the commerciability
of the product),so the evaluations of the efficiency
and the efficacy of an instrument or a system become an increasingly
unavoidable necessity.
It is worthwhile, in relation to this, recounting an example directly
from our own experience.
At the time when we were equipped to give the go-ahead on a European
research program on the use of Virtual environments in Rehabilitation,we
necessarily organised a consortium of competent individuals, able to
plan the system(technical part), verify the possiblity of fruition in
the area of physiotherapy (clinical part) and determine the cost/benefits
relation and it's commercial potential(economic and economic-management
part).
The first element which emerged was that relating to the heavy imbalance
between the suggestions of theoretical hypotheses and the possibilities
of the present technology.
In other words this means that a vast canyon opened up between the requests
of the customer(that is, the doctor) and the realisations of the technician.
On one side stood the expectations (sometimes oversimplistic, sometimes
exaggerated) of those who chose to ignore the technical difficulties
connected to some requests, and on the other side the practical realisations
-although perhaps technically perfect- of those who didn't know the
real clinical requirements which the final product should meet.
For example,
the preparation of a data-glove and of an esoskeleton(necessary to replicate
movement in a virtual environment) had been perfected from the engineering
point of view, but presented notable obstacles in the clinical 'usability',
where the system seemed heavy, awkward and limited.
Not to speak of then
the evaluation on the economic side, where the 'salability'of the system,
connected to the cost/benefits relation, seemed practically non-existent.
From this we can derive
that “the need to interface increasingly insistently the medical
requirements with the engineering know-how” must come about, even
before reaching the final objective of qualification, by a maturing
process aimed at consolidating an interacted standard practice, where
the theoretical expectations of the clinic will correlate with the knowledge
of the possibilities of the instruments available.
This can be managed,
not only through attempts to understand each other's language (which
will remain nevertheless different),but also through more assiduous
encounters, with the goal of arriving at products capable of achieving
results in the most simple, objective, economic and agreed terms.
It isn't sufficient
that an instrument(or a system) is of excellent technological quality,if
their clinical application then shows itself to be too complex or too
burdensome on the financial side; neither is it permissable to use an
instrument (or a system) which is “easy”, manageable and
cheap, but which then only provides results of an inacceptable approximation.
Moreover, there are
great differences between clinical practice and research: the latter,
indeed, can “permit itself the luxury” of high costs to
obtain complex results, with the work of a few experts to validate a
prototypical experience.
But in clinical practice,
we must transfer a simplification to the system, trying to marry an
economy of management (technical and financial) with a sufficient
expectancy of the results produced by the instrument.
As I previously stated,
we have studied-in these last five years- the possible use of virtual
environments in Rehabilitation.
The aim of the system
developed by us (“V.E.T.I.R.”, Virtual Environments Technologies
in Rehabilitation”)* is the study of the diagnostic
and rehabilitative possibilities connected to the immersion of
the subject in a virtual environment, where he is required to undergo
a series of tests and a series of therapeutic exercises.
The individual conditions
of each subject and the innovative possibilities of the system, make
it possible to measure the motor capability making use of the
added values relating to extremely specific work situations in
which the subject must function.
This means that we
are able to subject the patient to a long series of tests, which then
give forth numerous measurements, in which the environment and it's
contents are subject to numerous variations, not possible in real experience.
The fact, for example,
of being able to determine a remodelling of physical
behaviour (for example, a ball which bounces following a bizarre
trajectory, an object to lift which continually alters it's weight,
a shadow which doesn't follow the object which determines
it, e.t.c.)can generate a series of sensorial tricks which the motor
capability can perceive in a determinate way, giving rise to conditions
previously unknown to the subject under examination.
And what's more, the
measurements of the “dexterity” of the
subject in question to carry out a motor performance are not only
determinable by the parameter of time connected to
the complexity of the operation,the apeed of execution and the
precision.Indeed, the VETIR system also enables us to analyse the patient's
strategy of choice with the motor operation; this allows, that is, to
not only evaluate the motor execution, but the pattern of movement adopted
(especially since certain pathological situations force us to arrive
at adapted solutions to reach their aims).
Moreover, the possibility
of manipulating the sensorial input (for example, taking out the
visual information and privileging other sensorial channels)
puts the subject in a position to be able to make the movement using
unusual parameters.
This
offers us the possibility of not only measuring the the capability in
new conditions, but also of verifying if the contribution of this new
information may be put to use in therapy.
One of the tests developed
by us thought to 'immerse' the patient in a virtual environment, represented
by a kitchen, at the center of which is placed a table.
On top of the table
sits a toaster, out of which comes- at first rhythmically and then in
an aleatory way-slices of toast whose trajectories have different speeds.
Well, the system is
able to modify the normal trajectory course which the toasts make (this
obviously makes them more difficult to catch) but it is also capable
of no longer making the image of the toast come out of the toaster,
but rather a sound, which moves in the space following a determinate
trajectory.
This means that the
subject, in the attempt to catch hold of something
which flies, doesn't put his trust in the visual information but
in that which is acoustic.
In other words, his
catching movement isn't the result of a motor project, thought and put
into practice in relation to the seeing of the object, but rather in
relation to the acoustic information.
This means that the
physiotherapist can calculate the clinical potential of recuperation
of the patient, testing the possibility of activation of accessory neuro-circuitry,
underlining the contribution by means of the follow-up therapeutic exercise.
All
this ( and much more besides, which we can't talk about for reasons
of time) can be very inspiring from a theoretical point of view, but
it is quite another thing in clinical practice, especially in Rehabilitation,
since the measuring of a motor capability doesn't only mean quantifying
the ways and means of a biological phenomenon: for a physiotherapist,
as has already been stated, this is too limited an approach.
Naturally, this doesn't
mean resigning oneself to empiricism and it's inacceptable approximation.
It has served to show,
through a few sporadic examples, how complex it is- in the area of physiotherapy-
to invent new methodologies and instruments of measurement.
However, the road taken
is surely the right one.
There will be a thousand
other things still to perfect and as many will be experimented with
the intention of bringing back to Rehabilitative Medicine scientific
thoroughness.
It is nonetheless certain
that the progress made up until now (which will be elaborated on in
the following articles) are the most valid testimony to document this
very important sector of Medicine.
* Project developed by a European Consortium, in the area
of the TIDE Program, through the competition of St. Anna of Pisa High
School, the Hospital of Terni, of Ferrari of Maranello (Modena), fo
Medialab, Paris, of Head Acoustics of Herzoghenrath and the University
of Bochum.
Note:
1. G. Tognoni (1997),
2. D. Naylor (1995)
3. A. Liberati (1997), 4. G.
Federspil(1998)
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