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 Table of Contents  
Year : 2019  |  Volume : 2  |  Issue : 2  |  Page : 15-18

2.1 Rehabilitation: Rehabilitation as a health strategy

Department of Rehabilitation Medicine, Hannover Medical School, Hannover, Germany

Date of Web Publication11-Jun-2019

Correspondence Address:
Prof. Christoph Gutenbrunner
Department of Rehabilitation Medicine, Hannover Medical School, Hannover
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jisprm.jisprm_7_19

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How to cite this article:
Gutenbrunner C, Nugraha B. 2.1 Rehabilitation: Rehabilitation as a health strategy. J Int Soc Phys Rehabil Med 2019;2, Suppl S1:15-8

How to cite this URL:
Gutenbrunner C, Nugraha B. 2.1 Rehabilitation: Rehabilitation as a health strategy. J Int Soc Phys Rehabil Med [serial online] 2019 [cited 2019 Aug 20];2, Suppl S1:15-8. Available from: http://www.jisprm.org/text.asp?2019/2/2/15/259368

  Background Top

In published scientific and medical literature, numerous and sometimes divergent definitions and descriptions of rehabilitation can be found. Sometimes, rehabilitation is seen as a specific service for high-performance athletes, and in other cases, it is seen as an aftercare after injuries. In other cases, the term “rehabilitation” is used to describe interventions such as physical training or in-patient programs to increase vocational performance. Thus, it seems necessary to define rehabilitation in the context of other health interventions and strategies.

Since 2010, the World Health Organization (WHO) has described five main health care strategies: curative care (curative strategy), rehabilitative care (rehabilitative strategy), maintenance care (supportive strategy), prevention (preventive strategy), and palliative care (palliative strategy[1] [Chapter 1]). The classification of health-care services as provided by the Organization for Economic Co-operation and Development (OECD) coincides with these categories [Table 1].[2] Our common understanding is that prevention aims at avoiding the occurrence of disease, and the curative strategy targets to cure the disease. However, the rehabilitation strategy aims at reducing the burden of disease and to improve functioning as defined in the International Classification of Functioning, Disability and Health (ICF;[3] Chapter 1). Maintenance is the health strategy that supports persons with health condition with lacking capacity for functional improvement to maintain functions and maintain quality of life (e.g., palliative care).
Table 1: Dimensions of the International Classification of Health Accounts; Organization for Economic Co-operation and Development 2011 and main health-care strategies (Stucki et al. 2016)

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  The Rehabilitation Strategy Top

More specifically, the rehabilitation strategy conceptually has been described as the health strategy that is based on the WHO's integrative model of functioning, disability, and health and aims to enable persons with health conditions experiencing or likely to experience disability to achieve and maintain optimal functioning in interaction with the environment.[4] This conceptual description also refers to rehabilitation interventions described as approaches to assess functioning, to optimize a person's capacity, to strengthen the resources of the person, to provide a facilitative environment, to develop a person's performance, and to enhance a person's quality of life. It emphasizes that these goals only can be achieved in partnership between person and provider and in appreciation of the person's perception of his or her position in life. Finally, this definition stresses that rehabilitation must be provided over the course of a health condition and for all age groups and across the continuum of care (including hospitals, rehabilitation facilities, and the community) and across sectors (including health, education, labor, and social affairs).

Functioning is defined as the interaction of a person with a health condition and the environment [Figure 1].[5] This at the same time shows the complexity of rehabilitation that on the one hand must target body functions and structure as well as activities and aim at full participation in society. However, it also must focus on environmental factors that should be designed to facilitate the person's participation and provide an inclusive society. Finally, empowerment of the person is an important principle. This shows the multidimensionality of rehabilitation that besides health interventions must include social support, environmental adaptations (e.g., barrier-free environments), and psychological empowerment strategies.
Figure 1: International Classification of Functioning, Disability and Health, and the interaction of a person with a health condition and the environment[5] (with permission)

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  Rehabilitation Services Top

For health services, it is important to realize that rehabilitation interventions must be implemented in all phases of health care [Figure 2]. For sudden-onset disease (e.g., stroke and myocardial infarction) or trauma (e.g., spinal cord injury and multiple trauma), it is very important to start with appropriate rehabilitation measures in the acute phase (starting in intensive care) that must be delivered within the hospital. After discharge from hospital in many cases, postacute rehabilitation will be needed aiming at independent living and return to normal life (including return to work). In many cases, in particular, if chronic disability occurs, long-term rehabilitation will be needed. This must be delivered where the patient lives. In high-income countries, this mostly will be delivered by specialized rehabilitation professionals. In low-income countries, it often will be delivered in community-based rehabilitation (CBR) service. For progressing diseases, the rehabilitation service chain may look different as low-level, long-term rehabilitation will be necessary for long periods of time, and – if the disease is progressing – more intensive rehabilitation measures will be needed (see also Turner-Stokes).[6],[7]
Figure 2: Phases of rehabilitation service provision after acute incidents (upper part) or for chronic progressive diseases (lower part) (with permission)

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Another important aspect of the delivery of rehabilitation services is the different levels of specialization [Figure 3].[8] There is no doubt that for persons living with chronic disability daily support by family members and peers is of major relevance. In addition, some basic care and management of disability might be delivered by trained CBR workers. If it comes to more specialized rehabilitation interventions, medical doctors and therapists will deliver rehabilitation service (at different levels of specialization). In patients with more complex needs, for example, because of the severity of the underlying pathology, multimorbidity or in elderly people specialized rehabilitation services will be needed. These services must be delivered as team-integrated services in multiprofessional teams. In most cases, acute and postacute rehabilitation services as well as long-term rehabilitation for progressive disorders will be organized as multiprofessional services. Additional to that, highly specialized rehabilitation teams will be required, for example, for rehabilitation care in intensive care units and for patients with spinal cord injury, multiple trauma, or neurodegenerative diseases.
Figure 3: Levels of rehabilitation services and service delivery[8] (modified) (with permission)

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  Conclusion Top

The relevance of rehabilitation as an important strategy of intervention for persons with disabilities has been underlined by the United Nations in the Convention of the Rights of People with Disabilities.[9] Consequently, the WHO emphasizes that rehabilitation must be available for everyone who is in need and therefore includes rehabilitation into the concept of Universal Health Coverage. (Universal Health Coverage means that all people and communities can use the promotive, preventive, curative, rehabilitative, and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship (WHO, 2010).)[1] The principle, that rehabilitation services must be available along the continuum of care and at all levels of the health-care system, has been stressed in many WHO documents (World Report on Disability,[10] Global Disability Action Plan,[11] and Recommendations: Rehabilitation in Health Systems).[12] Most recently, the WHO initiative has been started with the aim of strengthening the implementation in health systems worldwide (For more details about implementation strategies for rehabilitation services in health systems as well as methods to assess the situation at country or province level, see Gutenbrunner et al. (2018) and Gutenbrunner and Nugraha (2018)) by 2030 (rehabilitation 2030 – a call for action.)[13]

Summarizing, rehabilitation can be defined as one of five major health strategies. It is essential for all persons experiencing disability in light of any health condition including chronic diseases. It must be implemented in all phases and at all levels of health care. On the background of recent trends in epidemiology (decreasing prevalence of communicable diseases, increase of chronic non-communicable diseases, ageing populations) and health care (e.g. optimised trauma care, new treatment strategies increasing survival rates in cancer and infectious disease) rehabilitation even can be seen as the core health strategy of the 21st century.[14]

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Conflicts of interest

There are no conflicts of interest.

  References Top

World Health Organization. The World Health Report: Health Systems Financing: the Path to Universal Coverage. Geneva: World Health Organization; 2010.  Back to cited text no. 1
Organization for Economic Co-operation and Development, Eurostat, World Health Organization. System of Health Accounts; 2011. http://www.who.int/health-accounts/methodology/sha2011.pdf. [Last accessed on 2018 Aug 02].  Back to cited text no. 2
World Health Organization. International Classification of Functioning, Disability and Health: ICF. Geneva: World Health Organization; 2001.  Back to cited text no. 3
Meyer T, Gutenbrunner C, Bickenbach J, Cieza A, Melvin J, Stucki G, et al. Towards a conceptual description of rehabilitation as a health strategy. J Rehabil Med 2011;43:765-9.  Back to cited text no. 4
Gutenbrunner C, Nugraha B. Physical and rehabilitation medicine: Responding to health needs from individual care to service provision. Eur J Phys Rehabil Med 2017;53:1-6.  Back to cited text no. 5
Turner-Stokes L. Politics, policy and payment – Facilitators or barriers to person-centred rehabilitation? Disabil Rehabil 2007;29:1575-82.  Back to cited text no. 6
Turner-Stokes L, Disler R, Williams H. The rehabilitation complexity scale: A simple, practical tool to identify 'complex specialised' services in neurological rehabilitation. Clin Med (Lond) 2007;7:593-9.  Back to cited text no. 7
Gutenbrunner C, Nugraha B. Rehabilitation, physical and rehabilitation medicine and community based rehabilitation – A comment to the debate towards a differentiated view of PRM on rehabilitation system, services and training of rehabilitation professionals. IndoJPMR 2016;5:60-6.  Back to cited text no. 8
United Nations. Convention on the Rights of Persons with Disabilities; 2006. Available from: http://www.un.org/disabilities/convention/conventionfull.shtml. [Last accessed on 2018 Aug 02].  Back to cited text no. 9
World Health Organization. The World Bank. World Report on Disability. Geneva: World Health Organization; 2011.  Back to cited text no. 10
World Health Organization. Global Disability Action Plan. Geneva: World Health Organization; 2014.  Back to cited text no. 11
World Health Organization. Recommendations: Rehabilitation in Health Systems Geneva: World Health Organization; 2017. Available from: http://www.apps.who.int/iris/bitstream/10665/254506/1/9789241549974-eng.pdf. [Last accessed on 2018 Aug 02].  Back to cited text no. 12
World Health Organization. Rehabilitation 2030: A Call for Action Geneva: World Health Organization; 2017. Available from: http://www.who.int/disabilities/care/Rehab2030MeetingReport_plain_text_version.pdf. [Last accessed on 2018 Aug 02].  Back to cited text no. 13
Stucki G, Bickenbach J, Gutenbrunner C, Melvin J. Rehabilitation: The health strategy of the 21st century. J Rehabil Med 2018;50:309-16.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]


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