Rehab Works Wonders — Especially For the Wealthy
A young woman has a stroke and can’t speak or move her left side; five years later she gives birth and can care for her son. An armed forces veteran with PTSD gets cognitive behavioral therapy and finally sleeps through the night. An adult with cerebral palsy who has never worked enters a vocational services agency and gets a customized job in administrative support.
These success stories are remarkable but not uncommon in areas with good and affordable rehabilitation services. But in some parts of Canada and in low- and middle-income countries in particular, people with disabilities are much less fortunate.
One billion people have disabilities, and 80 per cent of them live in developing countries. These areas have high rates of disability due to heavy burdens of disease, violence and injury, and limited health infrastructure with few or no rehabilitation services. In Africa and Eastern Mediterranean regions, for example, the World Health Organization estimates there is just a tenth of the trained rehab professionals needed to meet demand.
“There is huge inequality among — and sometimes within — countries,” says Andrea Furlan, a professor in the Department of Medicine at the University of Toronto and a scientist at the Institute for Work & Health and the Toronto Rehabilitation Institute. “The rich have access to rehab services and the poor often do not. And without it, a debilitating condition can become chronic.”
This glaring inequity helped drive Furlan’s research for a new guideline released last month by the World Health Organization. The guideline provides recommendations for the WHO’s member states on how best to strengthen and expand the availability of rehab services — which many states pledged to do. Health conditions associated with severe disability have increased more than 20 per cent since 2005.
“The World Bank has seen the acute need for rehabilitation in developing countries, but there has been a lot of uncertainty about where and how to invest,” says Furlan, whose group provided the research for five of the WHO’s nine recommendations. “What should rehab services look like, based on the best available evidence? It’s not just wheelchairs for everyone.”
Furlan’s team, based at the Institute for Work and Health and at U of T, assessed the quality of evidence for broad approaches to rehabilitation, such as whether to embed services in primary, secondary or tertiary care and how quickly to provide interventions for good patient outcomes that are cost-effective.
“This guideline is a big step forward on improving rehabilitation and related services, which is one of the three key planks that comprise the WHO’s global disability action plan,” says Stephanie Nixon, a professor in the Department of Physical Therapy and director of the International Centre for Disability and Rehabilitation, who was one of several U of T professors to attend the recent WHO launch of the guideline. “Andrea and her team deserve great kudos. The WHO has based their recommendations for all member states worldwide on this research.”
Furlan’s team was one of only three in the world to compile and analyze the current evidence on rehab services. The group spent a year on the project, and at times included 12 members skilled in meta-analyses and systemic literature reviews.
One of the biggest challenges, says Furlan, was how to make the guideline relevant to countries very different from Canada. “We can’t just tell low-income nations to have multi-disciplinary teams everywhere, for example, because it’s too expensive. So we looked for evidence on where those teams are effective, which turns out to be in the most complex cases of disability such as acute stroke and spinal cord injury. One take-away is that maybe some countries don’t need that kind of team in each town.”
Nixon says there are many players working on disability and rehabilitation around the world, but they sometimes move in different directions. She says the new guideline should help bring unity and cohesion to those disparate efforts.
But most importantly, Nixon says, the guideline brings the credibility of the best available science to underscore the importance of dealing with disability. “Rehabilitation is not a luxury for those who can afford it. It’s an essential part of the health care continuum. And it will become even more important with aging populations all around the world and the growth of technologies that keep people alive longer.”
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