Current Status of Rehabilitation Engineering/Technology

C. Gerald Warren Association for the Advancement of Rehabilitation Technology

EHABlLlTATlON is currently the fastest growing segment R of the health care and social services industry. This growth has been brought on primarily by the major efforts t o reduce the costs of acute medical care, the deregulation of medicine, renewed efforts .to gain a return on the investment of public money, and, most importantly, the liberation of disabled people. What we are learning, very rapidly, is that "rehabilitation is no longer a religion, it is a business." In all areas of rehabilitation this implies the notion of maximizing benefits wi th the least expenditure of resources. Rehabilita- tion has always been reported t o have a high return on investment, wi th figures ranging from 7 t o 14 gained on each dollar spent on rehabilitation. These gains are the result of reducing the downstream costs of maintaining disabled individuals and returning people to the tax-paying status; t o say nothing of the personal implications for the disabled individual or for society as a whole.

"Traditional" rehabilitation has applied the skills of a variety of professionals, i.e., physicians, physical therapists, occupational therapists, speech pathologists, augmentative communication specialists, prosthetists and orthotists, reha- bilitation nurses, recreation therapists, clinical psychologists, and vocational rehabilitation specialists. The combined goal of these professionals is t o rnaximize the functional capability of an individual who is disabled and living with a handicap. The evolution of rehabilitation engineering and technology has provided a means to augment the ability of each of these disciplines t o achieve even greater functional gains with their patients or clients.

We are now entering the era of Rehabilitation Technology Service Delivery. Technology is being integrated into the entire rehabilitation process, both by increasing the technical capability of the existing team members and by adding key members who are specialists in the use of rehabilitation technology, i.e., the rehabilitation technologists and the rehabilitation engineer.

For many years, w e in this field have struggled t o move engineering and technology from the laboratory to the disabled person. We have c:hampioned information dissemi- nation and technology transler in our attempts to increase the flow, but have not been totally successful. The restricted f low not only deprives di:;abled persons the benefits of technology, but it also severely limits demonstrating the results of rehabilitation research and development. The opportunity t o show impact more directly and gain a higher interaction wi th qualified users of technology would certainly stimulate the development of science and engineering needed to meet the new demands for technology. This is why the major emphasis in rehabilitation engineering and technology today is service delivery. It is the key t o the future of the field.

The status of rehabilitation engineering and technology today is likely best reflected in the organization that repre- sents its constituents, the Association for the Advancement of Rehabilitation Technology. This organization was founded after approximately 20 years of activities. It began wi th well- organized effprts t o use engineering in prosthetics and orthotics, followed in the mid 1960s with more general

attention t o rehabilitation issues in bioengineering. In 1971, a series of annual conferences on Systems and Devices for the Disabled were launched, and in 1 9 7 8 an Inter-agency Conference on Rehabilitation Engineering was held. In 1979, at the second Inter-agency Conference, the Rehabilitation Engineering Society of North America (RESNA) was founded.

By 1983, it was realized that the focus of engineering and the title of the association did not fully reflect the professional constituency of the field, and the name was changed t o the Association for the Advancement of Rehabilitation Technol- ogy. The acronym RESNA was maintained for identity. RESNA has undergone rapid recent growth, wi th over 1000 members. RESNA's stated purpose is "to promote and support the research, development, dissemination, integra- tion, and utilization of knowledge in rehabilitation technology and t o assure that these efforts result in the highest quality of service delivery and care for all disabled citizens." To meet this end, RESNA has organized itself w i th the standard array of administrative committees and maintains an Executive Office in Washington, DC. The organization has recently established itself as the technical expert in public policy issues that relate t o rehabilitation technology. In its member- ship, RESNA is made up of a wide cross-section. In many cases, these are people who are basically orphans of their primary professions by virtue of their special interest and dedication t o the use of science, engineering, and technology in rehabilitation. To organize the diverse interests, the associ- ation has established 1 6 Special Interest Groups (SIGs) that are in charge of the scientific, engineering, and technological "content" of the Association. A listing of the SlGs illustrates the breadth and depth of the association.

1. Service Delivery Practice 2. Personal Transportation 3. Augmentative and Alternative Communication 4. Prosthetics and Orthotics 5. Quantitative Assessment 6. Service Delivery Policy 7. Technology Transfer 8. Sensory Aids 9. Wheeled Mobility and Seating

10. Electrical Stimulation 1 1. Computer Applications 12. Rural Rehabilitation 13. Robotics 14. Biomechanics 15. Information Networking 16. Gerontology

The scope of these Special Interest Groups covers science, engineering, technology, and service delivery. Obviously, in some there is more science and engineering and in others more technology and service delivery.

The current pressing need in the field is not for new technologies but for the development of appropriate man- power and methods of delivering quality services. This need requires the establishment of many new roles and the modification of many others. It wi l l require pre- and post- service training of a wide variety of rehabilitation profession- als, rehabilitation engineers, and technologists. In addition, we must develop the understanding and confidence of third party payers and establish realistic and appropriate expecta-

0739-51 75/88/0900-0009$01 .OO(C 1988 IEEE SEPTEMBER 1988 IEEE ENGINEERING IN MEDICINE AND BIOLOGY MAGAZINE 9

tions among disabled people, their families, and employers. C. Gerald Warren, M.P.A., is currently presi- Although already underway, all these tasks are yet ahead of dent of the Association for the Advancement us, and must still be accomplished t o achieve fully the goals of Rehabilitation Technology and is president of providing delivery of quality rehabilitation technology of C. Gerald Warren & Associates, a firm services. providing consultation and services in rehabili-

tation technology. His academic appoint- ments are clinical associate professor in the Department of Rehabilitation Medicine and Affilitate Associate Professor in the Center of Bioengineering at the University of Washing- ton in Seattle.

Mr. Warren can be reached at C. Gerald Warren and Associates, 4825 Stanford Ave., NE, Seattle, WA 98105.

Orthopedic Implants Market Passes $1 Billion Mark

Replacements for injured or defective human body parts actually might someday become as common as replacement automobile parts-if growth in the orthopedic implants market is any indica- tion. With the joint prostheses segment leading the way (65 percent market share), this market has surged from total dollar sales of $653.3 million in 1984 to over $1.1 billion in 1987, reports a 321-page study from Frost & Sullivan: Orthopedic Implants Market in the U.S. (#A17691. The study forecasts continued growth averaging 16.8 percent a year and rising to $2.1 billion by 1991 (in constant 1986 dollars).

The obvious macro trends driving the market, Frost & Sullivan finds, are the demographic changes resulting in higher numbers of new materials and devices, and the emphasis today on getting patients up and out of the hospital faster, which in turn puts an emphasis on more sophisticated products to do the job (particu- larly trauma products).

Joint prostheses, the largest market segment, amounted to $738 million in 1987. Total hip prostheses amounted to $348 million, total knees $300 million. Partial hips (endoprostheses) were $60 million, small joints and wrists $1 8.4 million, shoulders $8.6 million, elbows and ankles $2.8 million. The Frost & Sullivan study predicts generally good growth into the 1990s for small joints and shoulders, but with market volume limited by natural

demand. The market for shoulders, for example, is expected to show much slower growth after reaching $22.5 million in 1991.

Technical problems with porous coated prostheses and biologi- cal fixation are creating what the study expects to be a short-term retrenchment in the market for total hips and total knees. Even so, dollar growth will be in the teens, and should begin rising again in the 1990s as new prostheses coatings and materials are intro- duced. The entire joint prostheses segment is forecast to grow from last year's $738.1 million to $1.4 billion by 1991.

A second market segment, trauma products (such as bone screws and plates), is forecast to average a 16 percent annual growth rate, with revenues climbing from $189 million in 1987 to over $340 million in 1991.

For the instrumentation/devices segment, this study assumes that a non-invasive spinal bone growth stimulator with proven clinical results will be available by 1989. In any case, instrument technology keeps improving, with emphasis on lighter, easier-to- handle tools. Instrumentation was a $157.4 million segment in 1987. The forecast is for revenues of $266 million in 1991.

The study sees an entirely new market segment developing by 1989: bone materials. Examined is the exciting research taking place in bone replacement and augmentation materials such as collagen-based inductive implants. Then there is hydroxyapatite, which mimics the microstructure of human bone. From $5.5 million in 1989, the bone materials market is expected to grow quickly to $28.6 million by 1991. By then, too, a synovial fluid replacement is a likely market possibility.

10 IEEE ENGINEERING IN MEDICINE AND BIOLOGY MAGAZINE SEPTEMBER 1988