Neurologic Rehabilitation: A Guide to Diagnosis, Prognosis, and Treatment Planning.

Neurologic Rehabilitation: A Guide to Diagnosis, Prognosis, and Treatment Planning Mills VM, Cassidy JW, Katz DI. Malden, MA 02148, Blackwell Science Inc, 1997, paperback, 355 pp, illus, $45.

The primary authors of this textbook include a physical therapist and 2 physicians (a neurobehavioral scientist and a professor of neurology). The invited contributors include 3 physical therapists, 4 neurologic physicians, and a research psychologist. The authors note that, while rehabilitation services have proliferated over the last 30 years, little compelling evidence exists for the efficacy of any particular intervention. Neurorehabilitation is being questioned for "promising more than it can deliver" and for its "perceived inefficiency and increasing cost." The authors criticize neurorehabilitation as an expensive "compensatory technology" that cannot cure underlying pathologies, but which is the best that medicine can offer at this time. Because current interventions are of an inherently "primitive nature," the authors invite rehabilitation teams to change the way they think about their work and their approach to patients. Specifically, they encourage clinicians to incorporate "reasonable expectations" into patient goals and interventions.

To help clinicians make this paradigm shift, the authors have developed the Neurologic Rehabilitation Model. This model places great emphasis on accurate diagnosis and prognosis of neurologic disorders, so that clinicians can realistically determine when and where intervention would be beneficial, when treatment should not be provided, and how to set realistic treatment goals. An accurate diagnosis would be made by the neurologist, neuropsychologist, or neurobehavioral physician. This diagnosis would be based on a thorough understanding of neuroanatomy and neurophysiology and the clinical behaviors that are seen when various areas of the brain are damaged. The authors admit that not all physicians take the time to report the etiology, site, scope, and extent of neurologic damage or to develop an accurate diagnosis of concomitant symptomatology. In addition, not all clinical sites use neuropsychologists or neurologists in rehabilitation. However; they believe that, if therapists can learn to "bring specific and limited questions to a neuropsychologist, they should get helpful information."

Once an accurate and detailed diagnosis has been provided, the natural history of the disorder, recovery sequence, and available research data will be used to develop a realistic prognosis, anticipated recovery profile, and trajectory of recovery. Factors such as age, weight, premorbid status, motivation, and cognition are also used to determine a prognosis. Armed with this knowledge, the therapist can establish reasonable goals and avoid providing unnecessary treatment.

Chapters 1 to 3 provide information on the pathophysiology of stroke and the prognosis for recovery from various syndromes. Chapters 4 and 5 convey similar information regarding traumatic brain injury. Chapter 7 deals with multiple sclerosis, and chapter 8 presents an algorithm for assessing impaired functional activities. Chapter 9, "The Use of the Neurologic Rehabilitation Model in the Assessment and Treatment of Patients With Balance Impairments," was written by 2 physical therapists and is a joy to read. Forty-five pages are devoted to the review of postural mechanisms, pathophysiology and resultant clinical signs, and extensive assessments and interventions. One case report isn't enough, but it does help integrate concepts. Chapters 10 and 11 cover behavioral and cognitive problems associated with traumatic brain injury again, including minimal brain injury and an example of a patient who appears to be malingering.

This book is not a broad neurologic text, nor is it a thorough neurologic rehabilitation guide. It covers only a few of the many conditions that may be treated and offers little in the way of specific therapeutic interventions. The Neurologic Rehabilitation Model is not a new concept: Therapists have long wished for complete, accurate diagnoses for their patients with neurologic conditions, including the area and the depth and breadth of damage. A detailed prognosis would be very helpful in treatment planning and goal setting. Research study outcomes and recovery profiles could be helpful in developing a prognosis and setting patient goals, but this book does not supply adequate data in that realm either. Most of the information in this text centers on the perceptual, cognitive, and behavioral problems associated with brain injury, This information would be of interest to psychologists, speech pathologists, occupational therapists, and perhaps physical therapists who work in very specific clinical situations.

After reading the book, I can say what the text is not more easily than I can say what it is. Perhaps its goal was too lofty, or perhaps it tries to do too much. However, it does not appear to do enough to be really helpful to physical therapists. The experienced therapist might find it interesting, and at tithes provocative, reading. This book might be somewhat useful as a reference for students, particularly those studying stroke and traumatic brain injury. The model represents an ideal situation--a theoretical concept--and it would be very beneficial if it were used by more physicians, who might be the true intended audience.

Sondra E Dunkle, EdD, PT
Pocatello, Idaho

Dr Dunkle is a consultant with a special interest in gerontology and balance disorder.