Authors: Christoph Gutenbrunner, MD Matthias Bethge, PhD Gerold Stucki, MD, MS Jianan Li, MD Jorge Lains, MD John Olver, MBBS, MD Walter Frontera, MD, PhD Per von Groote, MA Alessandro Giustini, MD Marta Imamura, MD, PhD
Affiliations: From the Department of Rehabilitation Medicine, Hannover Medical School, Hannover, Germany (CG, MB); Department of Health Sciences and Health Policy, University of Lucerne, Lucerne, Switzerland (GS, PvG); Swiss Paraplegic Research, Nottwil, Switzerland (GS, PvG); Center of Rehabilitation Medicine, Nanjing Medical University, Nanjing, China (JL); Centro de Medicina de Reabilitac¸a˜o da Regia˜o Centro, Rovisco Pais Hospital, Tocha, Portugal (JL); Epworth Healthcare and Monash University, Melbourne, Australia (JO); Department of Physical Medicine and Rehabilitation, Vanderbilt University School of Medicine, Nashville, Tennessee (WF); Rehabilitation Hospital San Pancrazio, Arco, Trento, Italy (AG); and Institute of Physical and Rehabilitation Medicine, University of Sao Paulo School of Medicine, Sao Paulo, Brazil (MI).
Correspondence: All correspondence and requests for reprints should be addressed to Matthias Bethge, PhD, Department of Rehabilitation Medicine, Hannover Medical School, Carl-Neuberg-StraQe 1, 30625 Hannover, Germany.
Disclosures:
ANALYSIS
Dissemination, Analysis, and Implementation of the World Report on Disability The Roadmap of the International Society for Physical and Rehabilitation Medicine ABSTRACT Gutenbrunner C, Bethge M, Stucki G, Li J, Lains J, Olver J, Frontera W, von Groote P, Giustini A, Imamura M: Dissemination, analysis, and implementation of the world report on disability: the roadmap of the international society for physical and rehabilitation medicine. Am J Phys Med Rehabil 2014;93:S68YS72. The International Society for Physical and Rehabilitation Medicine has recognized the World Report on Disability as a guide for its future activities and endorsed its responsibility to disseminate, to analyze, and to implement the report’s recommendations. The activities of the International Society for Physical and Rehabilitation Medicine on the global stage are embedded in a strategy that includes national and regional associations. This article reports on recent and forthcoming activities of the International Society for Physical and Rehabilitation Medicine regarding the World Report on Disability and identifies five major challenges that will impact future International Society for Physical and Rehabilitation Medicine activities. These challenges relate to (1) education and training, (2) the support of strong role models, (3) disaster management, (4) the development of innovative rehabilitation services, and (5) rehabilitation research. Key Words:
Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.
0894-9115/14/9301(Suppl)-S68/0 American Journal of Physical Medicine & Rehabilitation Copyright * 2013 by Lippincott Williams & Wilkins DOI: 0.1097/PHM.0000000000000026
S68
Health Policy
Rehabilitation, Persons with Disability, Policy
T
he International Society for Physical and Rehabilitation Medicine (ISPRM) as the leading society in the field of rehabilitation medicine has put the dissemination of the main contents of the World Report on Disability (WRD) and the implementation of the WRD recommendations as one of the main topics on its political agenda.1 In June 2011, during a retreat in Puerto Rico, the president’s cabinet and members of the World Health Organization (WHO) Liaison Committee developed a roadmap of ISPRM activities to disseminate, analyze, and implement the recommendations of the WRD. The participants also made a commitment to work on a special journal issue about the WRD with articles that analyze national challenges. Various practitioners and researchers from the field of physical and rehabilitation medicine (PRM) have followed this call for action since then and worked intensively to produce the present supplement of the American Journal of Physical Medicine & Rehabilitation. This special issue is, however, Am. J. Phys. Med. Rehabil. & Vol. 93 No. 1 (Suppl), January 2014
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
only one of several ISPRM activities related to the WRD. The aim of this final article is to give an overview of further recent and forthcoming ISPRM activities.
Activities of the ISPRM The activities of the ISPRM on the global stage are embedded in a strategy that includes coordinated activities of national and regional associations (Table 1). The ISPRM is particularly interested in and feels responsible for three issues. Firstly, in accordance with its current collaboration plan with the WHO, the ISPRM intended to spread information about the contents of the WRD. This objective was primarily achieved by articles in international journals2 including the current special issue and sessions in international PRM meetings such as in Beijing during the 7th World Congress of the ISPRM. In addition, the subcommittee BImplementation of the World Report on Disability[ of the ISPRM’s WHO Liaison Committee presented the key points of the report in a recent letter to national PRM societies and provided a slideshow that is useful to present the report’s contents to national entities. Secondly, the ISPRM declared to analyze the report’s recommendations in the context of global, regional, and national rehabilitation policies and services especially with respect to the epidemiology of disability, the met and unmet needs in rehabilitation care, and the role of PRM in improving the functioning of people with disabilities. These analyses and reflections were done during several meetings and conferences, for example, in Sao Paulo, Thessaloniki, Atlanta, Geneva, and Beijing, and were primarily driven by the subcommittees of the ISPRM’s WHO Liaison Committee. Important milestones that guided the ISPRM’s analysis of the report were the development of the conceptual descriptions of rehabilitation and PRM that characterized rehabilitation as a major health
strategy and PMR as the medical specialty that fulfills the needs of medical assessment and intervention for persons who experience disabilities.3,4 The needed theoretical and conceptual framework for effective analysis are currently strengthened by the development of a conceptual description of rehabilitation services and the work that has commenced on a classification of rehabilitation services. Furthermore, the report’s emphasis on the relevance of communitybased rehabilitation (CBR) initiated the formation of a new CBR subcommittee within the ISPRM’s WHO Liaison Committee in June 2013. Thirdly, the ISPRM determined to develop principles for the implementation of the WRD and to assist implementation of the WRD within global organizations. Particular input is assumed from publishing best practice models related to the implementation of the recommendations from the health and rehabilitation chapters of the WRD. Moreover, as part of the collaboration plan of the WHO and the ISPRM, the WHO expects expert input about the contributions of rehabilitation medicine to the improvement of the life situation of people with disabilities. In this regard, the ISPRM participated, for example, in the WHO discussion about the Disability Resolution of the 66th World Health Assembly in Geneva in May 2013. Important forthcoming tasks and challenges will be the ISPRM’s contributions to the WHO rehabilitation guidelines; the WHO action plan for disability-inclusive communities and societies; and the preparation of the United Nations High Level Meeting on disability and development, which will be held in New York on September 23, 2013. Associations and representatives of people with disabilities will be consulted about these activities. In addition, close cooperation with other professional organizations in official relation with the WHO is needed to provide input for the development of global policy. This includes cooperation with organizations and institutions such as Rehabilitation International, the International Society for Prosthetics and
TABLE 1 Concept of the ISPRM for the implementation at an international, regional, and national level Level
Dissemination
Analysis
Implementation
World
Spread out information about content
Analyze general recommendations
Define principles, develop guidelines Implement into health strategies
Areas, regions Nations
www.ajpmr.com
Analyze recommendations and transfer them to the regional situation Analyze recommendations and transfer them to the national rehabilitation system
Implement into rehabilitation systems and services
The Roadmap of the ISPRM Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
S69
Orthotics, the World Federation of Occupational Therapists, the World Confederation of Physical Therapy, and the International Spinal Cord Society.
Activities of Regional and National Societies Although dissemination of the WRD is a task of the ISPRM as well as regional and national PRM societies, implementation activities might differ. Aiming at coordinated action, the ISPRM included the dissemination, analysis, and implementation of the WRD in its collaboration agreements with regional PRM societies and offers support to national societies in conceptualizing implementation plans.5 The regional societies should concentrate more on the impact on the regional situation and the implementation into health strategies appropriate to the specific regional situation. According to the WRD, the situation of persons with disabilities differs significantly among regions. On the other hand, the impact of the WRD on national rehabilitation systems must be evaluated at the level of each country. Similarly, the development of implementation concepts must consider particular realities at the national level. This might include the development of shadow reports on the situation of persons with disabilities in individual countries and the provision of scientific and policy advice to governments. The specific role of national PRM societies in the dissemination, analysis, and implementation of the WRD could be the following: & To disseminate the contents of the WRD within the medical and rehabilitation communities, for example, on national meetings and congresses and in national journals6 & To disseminate the conceptualization of rehabilitation as a major health strategy and to define the role of rehabilitation medicine in such a strategy3,4 & To propose studies on the epidemiology of persons with disabilities especially with regard to unmet needs and to perform such studies7,8 & To develop recommendations for analyzing and improving rehabilitation services & To develop new rehabilitation concepts and to perform studies on the outcomes of rehabilitation interventions using disability measures based on the International Classification of Functioning, Disability, and Health9Y13 & To develop concepts of multiprofessional and person-centered interventions & To develop rehabilitation services that target equally the social and medical aspects of disability & To support governments to develop solutions for better services
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Gutenbrunner et al.
& To develop curricula for the training of all health professionals about disability and rehabilitation issues and to train rehabilitation professionals & To make institutions and events accessible for persons with disabilities
Forthcoming Challenges Although the WRD strengthens the role of rehabilitation and rehabilitation medicine, the report also poses several challenges that will impact future ISPRM activities. Among others, these challenges relate to (1) education and training, (2) the support of strong role models, (3) disaster management, (4) the development of innovative rehabilitation services, and (5) rehabilitation research.
Education and Training Aging is one of the major challenges for global development. In Europe, persons 65 yrs or older increased from 9.6% in 1960 to 16.0% in 2010. It has been predicted that by 2060, nearly every third (29.3%) European resident will be 65 yrs or older. At the same time, the number of working-aged persons is decreasing.14 Aging societies will have a higher need for rehabilitation, but several statistics from various countries already reveal shortages of rehabilitation professionals. In the long-term, a shortage of medical doctors will probably be more significant in specialties with lower reputation and lower earnings. Education and training of rehabilitation physicians will therefore be one of the main missions of the ISPRM. Moreover, the WRD and some country reports in this special issue show the dramatic and severe lack of rehabilitation specialists in African, Eastern Mediterranean, and some Asian countries. Despite recent efforts to build capacity for education and training, the supply of rehabilitation physicians will probably remain deficient for several decades. Consequently, the role and the tasks of rehabilitation physicians in developing countries may fundamentally differ from the tasks in developed countries and may, for instance, shift to training in and coordinating of communitybased and other basic rehabilitation services. The ISPRM could support mutual agreements between national PRM societies in developed and developing countries on joint courses in rehabilitation medicine and initiate a multinational Web-based program on rehabilitation medicine. Finally, the ISPRM, in collaboration with national PRM societies, has to continue its effort to promote the inclusion of basic knowledge about disability and rehabilitation in the curriculum of training programs for all health professionals. The
Am. J. Phys. Med. Rehabil. & Vol. 93 No. 1 (Suppl), January 2014
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
purposes of this initiative are to ensure that rehabilitation is recognized as a major health strategy by all professionals and to avoid deficient service provision, uncoordinated care, and delayed referrals to rehabilitation.
Supporting Tolerance and Strong Role Models As pointed out by Tuakli-Wosornu and Haig in this special issue, common conceptions of disability within societies provoke bidirectional stigma resulting in exclusion of people with disabilities on the one hand and avoidance and disengagement by persons with disabilities on the other hand. Overcoming these attitudinal challenges needs strong role models presenting persons with disabilities as active citizens. Grants could, for example, support the education and training of physicians with disabilities, and there is a need to increase the number of physicians with disabilities in the activities of ISPRM as well as in regional and national PRM societies.
Disaster Management Natural disasters occur worldwide. However, the risk for death and disability as a consequence of disasters is strongly increased in developing and emerging nations.15,16 Dramatic humanitarian tragedies such as the Bangladeshi storm flood in 1970, the Chinese earthquake in 1976, the East Asian Tsunami in 2004, the Myanmarian tropic cyclone in 2008, and the Haitian earthquake in 2010 resulted in the death of hundreds of thousands and many more people with injuries associated with permanent disability. Shortages of rehabilitation professionals contribute to the high risk in case of disasters that need a focused and immediate response. Recent experiences after the Sichuan earthquake in 2008 showed that the shortage of trained rehabilitation professionals, in addition to other measures, can effectively be addressed by international support for the training of hospital staff in rehabilitation principles and basic rehabilitation services.16,17 The ISPRM Committee on Rehabilitation Disaster Relief has developed strong and recognized competence to give organizational and technical advice to governments to develop disaster management plans. In the future, a mobile task force could be established by the ISPRM that can be sent into disaster areas to support emergency rehabilitation training of helpers.
Development of Innovative Rehabilitation Services In many countries, the development of rehabilitation services has resulted in reputable and highly www.ajpmr.com
specialized institutions that offer evidence-based and intensive rehabilitation programs to persons in need. These large and often remote facilities, however, do not have the capacity to provide the basic rehabilitation services that many persons with disabilities need. Innovative rehabilitation services, as described by Guzman and Salazar in this issue, can substantially improve service provision. This also applies to CBR services. Moreover, the conceptualization of rehabilitation as a health strategy means that rehabilitation is a process that includes many stakeholders. Innovative rehabilitation services, therefore, will be characterized by intelligent referral and interface management. In the future, the work of the ISPRM subcommittees on BCommunity-based Rehabilitation[ and BStrengthening Medical Rehabilitation[ will foster the exchange of ideas on innovative service models within and outside ISPRM.
Rehabilitation Research The WRD indicates that research has to provide valid estimates of met and unmet needs for rehabilitation to inform governments and to enable strategic planning of rehabilitation services especially in developing countries. However, research capacity in many countries is limited. Possibly, the ISPRM, in collaboration with national PRM societies, can establish grants that promote research in developing countries regarding the most urgent issues that need clarification. Moreover, although the WRD expresses strong optimism about the effects of CBR, some articles in this issue indicate that implementation is challenging and potential effects might be lower than expected. More sophisticated study designs including methods such as propensity score matching18,19 could provide a more precise effect estimation and higher-level evidence of the effects of CBR. This would be particularly relevant if randomized controlled trials are not seen as ethical or legitimate as in the case of some CBR programs. In addition, studies should include qualitative research methods to explore the relevance of regional and cultural contextual factors that might impact the feasibility of CBR programs in different settings.
CONCLUSIONS The ISPRM has recognized the WRD as a guide for its future activities. During the 7th World Congress of the ISPRM in Beijing this year, the WRD was a leading topic especially of the opening lectures. The emphasis on the report during the congress was intended to enable and to encourage the congress The Roadmap of the ISPRM
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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participants to spread out the report’s essence in their regional and national PRM societies. International collaboration by PRM specialists will strengthen their position in national discourse about reasonable and sound implementation efforts. REFERENCES 1. Stucki G, Reinhardt JD, Imamura M, et al: Developing the International Society of Physical and Rehabilitation Medicine (ISPRM): Following through. J Rehabil Med 2011;43:1Y7 2. von Groote PM, Bickenbach JE, Gutenbrunner C: The World Report on DisabilityVImplications, perspectives and opportunities for physical and rehabilitation medicine (PRM). J Rehabil Med 2011;43:869Y75 3. Gutenbrunner C, Meyer T, Melvin J, et al: Towards a conceptual description of physical and rehabilitation medicine. J Rehabil Med 2011;43:760Y4 4. Meyer T, Gutenbrunner C, Bickenbach J, et al: Towards a conceptual description of rehabilitation as a health strategy. J Rehabil Med 2011;43:765Y9 5. Imamura M, Gutenbrunner C, Li J, et al: 2012VAn ISPRM landmark year. J Rehabil Med 2013;45: 417Y22 6. Meyer T, Gutenbrunner C: Relevance of the World Report on Disability by WHO and World Bank for participation research [in German]. Rehabilitation 2012;51(suppl 1):S21Y7 7. Bethge M, Egner U, Streibelt M, et al: Risk Index Disability Pension (RI-DP): A register-based case-control study with 8,500 men and 8,405 women [in German]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2011;54:1221Y8 8. Bethge M, Radoschewski FM, Gutenbrunner C: The Work Ability Index as a screening tool to identify the need for rehabilitation: Longitudinal findings from the Second German Sociomedical Panel of Employees. J Rehabil Med 2012;44:980Y7 9. World Health Organization: International Classification of Functioning, Disability, and Health: ICF Short Version. Geneva, Switzerland, World Health Organization, 2001
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10. Posl M, Cieza A, Stucki G: Psychometric properties of the WHODASII in rehabilitation patients. Qual Life Res 2007;16:1521Y31 11. Post MW, de Witte LP, Reichrath E, et al: Development and validation of IMPACT-S, an ICF-based questionnaire to measure activities and participation. J Rehabil Med 2008;40:620Y7 12. Farin E, Fleitz A, Frey C: Psychometric properties of an International Classification of Functioning, Disability and Health (ICF)Yoriented, adaptive questionnaire for the assessment of mobility, self-care and domestic life. J Rehabil Med 2007;39:537Y46 13. Kohler F, Xu J, Silva-Withmory C, et al: Feasibility of using a checklist based on the International Classification of Functioning, Disability and Health as an outcome measure in individuals following lower limb amputation. Prosthet Orthot Int 2011;35:294Y301 14. Lanzieri G: The greying of the baby boomers. A century-long view of ageing in European populations. 2011. Available at: http://epp.eurostat.ec.europa.eu/ cache/ITY_OFFPUB/KS-SF-11-023/EN/KS-SF-11-023EN.PDF. Accessed July 10, 2013. 15. Gosney J, Reinhardt JD, Haig AJ, et al: Developing post-disaster physical rehabilitation: Role of the World Health Organization Liaison Sub-Committee on Rehabilitation Disaster Relief of the International Society of Physical and Rehabilitation Medicine. J Rehabil Med 2011;43:965Y8 16. Reinhardt JD, Li J, Gosney J, et al: Disability and health-related rehabilitation in international disaster relief. Glob Health Action 2011;4:7191 17. Zhang X, Reinhardt JD, Gosney JE, et al: The NHV rehabilitation services program improves long-term physical functioning in survivors of the 2008 Sichuan earthquake: A longitudinal quasi experiment. PLoS One 2013;8:e53995 18. Guo S, Fraser MW: Propensity Score Analysis: Statistical Methods and Applications. Los Angeles, CA, Sage Publications, 2010 19. Cousens S, Hargreaves J, Bonell C, et al: Alternatives to randomisation in the evaluation of public-health interventions: Statistical analysis and causal inference. J Epidemiol Community Health 2011;65:576Y81
Am. J. Phys. Med. Rehabil. & Vol. 93 No. 1 (Suppl), January 2014
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Affiliations: From the Department of Rehabilitation Medicine, Hannover Medical School, Hannover, Germany (CG, MB); Department of Health Sciences and Health Policy, University of Lucerne, Lucerne, Switzerland (GS, PvG); Swiss Paraplegic Research, Nottwil, Switzerland (GS, PvG); Center of Rehabilitation Medicine, Nanjing Medical University, Nanjing, China (JL); Centro de Medicina de Reabilitac¸a˜o da Regia˜o Centro, Rovisco Pais Hospital, Tocha, Portugal (JL); Epworth Healthcare and Monash University, Melbourne, Australia (JO); Department of Physical Medicine and Rehabilitation, Vanderbilt University School of Medicine, Nashville, Tennessee (WF); Rehabilitation Hospital San Pancrazio, Arco, Trento, Italy (AG); and Institute of Physical and Rehabilitation Medicine, University of Sao Paulo School of Medicine, Sao Paulo, Brazil (MI).
Correspondence: All correspondence and requests for reprints should be addressed to Matthias Bethge, PhD, Department of Rehabilitation Medicine, Hannover Medical School, Carl-Neuberg-StraQe 1, 30625 Hannover, Germany.
Disclosures:
ANALYSIS
Dissemination, Analysis, and Implementation of the World Report on Disability The Roadmap of the International Society for Physical and Rehabilitation Medicine ABSTRACT Gutenbrunner C, Bethge M, Stucki G, Li J, Lains J, Olver J, Frontera W, von Groote P, Giustini A, Imamura M: Dissemination, analysis, and implementation of the world report on disability: the roadmap of the international society for physical and rehabilitation medicine. Am J Phys Med Rehabil 2014;93:S68YS72. The International Society for Physical and Rehabilitation Medicine has recognized the World Report on Disability as a guide for its future activities and endorsed its responsibility to disseminate, to analyze, and to implement the report’s recommendations. The activities of the International Society for Physical and Rehabilitation Medicine on the global stage are embedded in a strategy that includes national and regional associations. This article reports on recent and forthcoming activities of the International Society for Physical and Rehabilitation Medicine regarding the World Report on Disability and identifies five major challenges that will impact future International Society for Physical and Rehabilitation Medicine activities. These challenges relate to (1) education and training, (2) the support of strong role models, (3) disaster management, (4) the development of innovative rehabilitation services, and (5) rehabilitation research. Key Words:
Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.
0894-9115/14/9301(Suppl)-S68/0 American Journal of Physical Medicine & Rehabilitation Copyright * 2013 by Lippincott Williams & Wilkins DOI: 0.1097/PHM.0000000000000026
S68
Health Policy
Rehabilitation, Persons with Disability, Policy
T
he International Society for Physical and Rehabilitation Medicine (ISPRM) as the leading society in the field of rehabilitation medicine has put the dissemination of the main contents of the World Report on Disability (WRD) and the implementation of the WRD recommendations as one of the main topics on its political agenda.1 In June 2011, during a retreat in Puerto Rico, the president’s cabinet and members of the World Health Organization (WHO) Liaison Committee developed a roadmap of ISPRM activities to disseminate, analyze, and implement the recommendations of the WRD. The participants also made a commitment to work on a special journal issue about the WRD with articles that analyze national challenges. Various practitioners and researchers from the field of physical and rehabilitation medicine (PRM) have followed this call for action since then and worked intensively to produce the present supplement of the American Journal of Physical Medicine & Rehabilitation. This special issue is, however, Am. J. Phys. Med. Rehabil. & Vol. 93 No. 1 (Suppl), January 2014
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
only one of several ISPRM activities related to the WRD. The aim of this final article is to give an overview of further recent and forthcoming ISPRM activities.
Activities of the ISPRM The activities of the ISPRM on the global stage are embedded in a strategy that includes coordinated activities of national and regional associations (Table 1). The ISPRM is particularly interested in and feels responsible for three issues. Firstly, in accordance with its current collaboration plan with the WHO, the ISPRM intended to spread information about the contents of the WRD. This objective was primarily achieved by articles in international journals2 including the current special issue and sessions in international PRM meetings such as in Beijing during the 7th World Congress of the ISPRM. In addition, the subcommittee BImplementation of the World Report on Disability[ of the ISPRM’s WHO Liaison Committee presented the key points of the report in a recent letter to national PRM societies and provided a slideshow that is useful to present the report’s contents to national entities. Secondly, the ISPRM declared to analyze the report’s recommendations in the context of global, regional, and national rehabilitation policies and services especially with respect to the epidemiology of disability, the met and unmet needs in rehabilitation care, and the role of PRM in improving the functioning of people with disabilities. These analyses and reflections were done during several meetings and conferences, for example, in Sao Paulo, Thessaloniki, Atlanta, Geneva, and Beijing, and were primarily driven by the subcommittees of the ISPRM’s WHO Liaison Committee. Important milestones that guided the ISPRM’s analysis of the report were the development of the conceptual descriptions of rehabilitation and PRM that characterized rehabilitation as a major health
strategy and PMR as the medical specialty that fulfills the needs of medical assessment and intervention for persons who experience disabilities.3,4 The needed theoretical and conceptual framework for effective analysis are currently strengthened by the development of a conceptual description of rehabilitation services and the work that has commenced on a classification of rehabilitation services. Furthermore, the report’s emphasis on the relevance of communitybased rehabilitation (CBR) initiated the formation of a new CBR subcommittee within the ISPRM’s WHO Liaison Committee in June 2013. Thirdly, the ISPRM determined to develop principles for the implementation of the WRD and to assist implementation of the WRD within global organizations. Particular input is assumed from publishing best practice models related to the implementation of the recommendations from the health and rehabilitation chapters of the WRD. Moreover, as part of the collaboration plan of the WHO and the ISPRM, the WHO expects expert input about the contributions of rehabilitation medicine to the improvement of the life situation of people with disabilities. In this regard, the ISPRM participated, for example, in the WHO discussion about the Disability Resolution of the 66th World Health Assembly in Geneva in May 2013. Important forthcoming tasks and challenges will be the ISPRM’s contributions to the WHO rehabilitation guidelines; the WHO action plan for disability-inclusive communities and societies; and the preparation of the United Nations High Level Meeting on disability and development, which will be held in New York on September 23, 2013. Associations and representatives of people with disabilities will be consulted about these activities. In addition, close cooperation with other professional organizations in official relation with the WHO is needed to provide input for the development of global policy. This includes cooperation with organizations and institutions such as Rehabilitation International, the International Society for Prosthetics and
TABLE 1 Concept of the ISPRM for the implementation at an international, regional, and national level Level
Dissemination
Analysis
Implementation
World
Spread out information about content
Analyze general recommendations
Define principles, develop guidelines Implement into health strategies
Areas, regions Nations
www.ajpmr.com
Analyze recommendations and transfer them to the regional situation Analyze recommendations and transfer them to the national rehabilitation system
Implement into rehabilitation systems and services
The Roadmap of the ISPRM Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
S69
Orthotics, the World Federation of Occupational Therapists, the World Confederation of Physical Therapy, and the International Spinal Cord Society.
Activities of Regional and National Societies Although dissemination of the WRD is a task of the ISPRM as well as regional and national PRM societies, implementation activities might differ. Aiming at coordinated action, the ISPRM included the dissemination, analysis, and implementation of the WRD in its collaboration agreements with regional PRM societies and offers support to national societies in conceptualizing implementation plans.5 The regional societies should concentrate more on the impact on the regional situation and the implementation into health strategies appropriate to the specific regional situation. According to the WRD, the situation of persons with disabilities differs significantly among regions. On the other hand, the impact of the WRD on national rehabilitation systems must be evaluated at the level of each country. Similarly, the development of implementation concepts must consider particular realities at the national level. This might include the development of shadow reports on the situation of persons with disabilities in individual countries and the provision of scientific and policy advice to governments. The specific role of national PRM societies in the dissemination, analysis, and implementation of the WRD could be the following: & To disseminate the contents of the WRD within the medical and rehabilitation communities, for example, on national meetings and congresses and in national journals6 & To disseminate the conceptualization of rehabilitation as a major health strategy and to define the role of rehabilitation medicine in such a strategy3,4 & To propose studies on the epidemiology of persons with disabilities especially with regard to unmet needs and to perform such studies7,8 & To develop recommendations for analyzing and improving rehabilitation services & To develop new rehabilitation concepts and to perform studies on the outcomes of rehabilitation interventions using disability measures based on the International Classification of Functioning, Disability, and Health9Y13 & To develop concepts of multiprofessional and person-centered interventions & To develop rehabilitation services that target equally the social and medical aspects of disability & To support governments to develop solutions for better services
S70
Gutenbrunner et al.
& To develop curricula for the training of all health professionals about disability and rehabilitation issues and to train rehabilitation professionals & To make institutions and events accessible for persons with disabilities
Forthcoming Challenges Although the WRD strengthens the role of rehabilitation and rehabilitation medicine, the report also poses several challenges that will impact future ISPRM activities. Among others, these challenges relate to (1) education and training, (2) the support of strong role models, (3) disaster management, (4) the development of innovative rehabilitation services, and (5) rehabilitation research.
Education and Training Aging is one of the major challenges for global development. In Europe, persons 65 yrs or older increased from 9.6% in 1960 to 16.0% in 2010. It has been predicted that by 2060, nearly every third (29.3%) European resident will be 65 yrs or older. At the same time, the number of working-aged persons is decreasing.14 Aging societies will have a higher need for rehabilitation, but several statistics from various countries already reveal shortages of rehabilitation professionals. In the long-term, a shortage of medical doctors will probably be more significant in specialties with lower reputation and lower earnings. Education and training of rehabilitation physicians will therefore be one of the main missions of the ISPRM. Moreover, the WRD and some country reports in this special issue show the dramatic and severe lack of rehabilitation specialists in African, Eastern Mediterranean, and some Asian countries. Despite recent efforts to build capacity for education and training, the supply of rehabilitation physicians will probably remain deficient for several decades. Consequently, the role and the tasks of rehabilitation physicians in developing countries may fundamentally differ from the tasks in developed countries and may, for instance, shift to training in and coordinating of communitybased and other basic rehabilitation services. The ISPRM could support mutual agreements between national PRM societies in developed and developing countries on joint courses in rehabilitation medicine and initiate a multinational Web-based program on rehabilitation medicine. Finally, the ISPRM, in collaboration with national PRM societies, has to continue its effort to promote the inclusion of basic knowledge about disability and rehabilitation in the curriculum of training programs for all health professionals. The
Am. J. Phys. Med. Rehabil. & Vol. 93 No. 1 (Suppl), January 2014
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
purposes of this initiative are to ensure that rehabilitation is recognized as a major health strategy by all professionals and to avoid deficient service provision, uncoordinated care, and delayed referrals to rehabilitation.
Supporting Tolerance and Strong Role Models As pointed out by Tuakli-Wosornu and Haig in this special issue, common conceptions of disability within societies provoke bidirectional stigma resulting in exclusion of people with disabilities on the one hand and avoidance and disengagement by persons with disabilities on the other hand. Overcoming these attitudinal challenges needs strong role models presenting persons with disabilities as active citizens. Grants could, for example, support the education and training of physicians with disabilities, and there is a need to increase the number of physicians with disabilities in the activities of ISPRM as well as in regional and national PRM societies.
Disaster Management Natural disasters occur worldwide. However, the risk for death and disability as a consequence of disasters is strongly increased in developing and emerging nations.15,16 Dramatic humanitarian tragedies such as the Bangladeshi storm flood in 1970, the Chinese earthquake in 1976, the East Asian Tsunami in 2004, the Myanmarian tropic cyclone in 2008, and the Haitian earthquake in 2010 resulted in the death of hundreds of thousands and many more people with injuries associated with permanent disability. Shortages of rehabilitation professionals contribute to the high risk in case of disasters that need a focused and immediate response. Recent experiences after the Sichuan earthquake in 2008 showed that the shortage of trained rehabilitation professionals, in addition to other measures, can effectively be addressed by international support for the training of hospital staff in rehabilitation principles and basic rehabilitation services.16,17 The ISPRM Committee on Rehabilitation Disaster Relief has developed strong and recognized competence to give organizational and technical advice to governments to develop disaster management plans. In the future, a mobile task force could be established by the ISPRM that can be sent into disaster areas to support emergency rehabilitation training of helpers.
Development of Innovative Rehabilitation Services In many countries, the development of rehabilitation services has resulted in reputable and highly www.ajpmr.com
specialized institutions that offer evidence-based and intensive rehabilitation programs to persons in need. These large and often remote facilities, however, do not have the capacity to provide the basic rehabilitation services that many persons with disabilities need. Innovative rehabilitation services, as described by Guzman and Salazar in this issue, can substantially improve service provision. This also applies to CBR services. Moreover, the conceptualization of rehabilitation as a health strategy means that rehabilitation is a process that includes many stakeholders. Innovative rehabilitation services, therefore, will be characterized by intelligent referral and interface management. In the future, the work of the ISPRM subcommittees on BCommunity-based Rehabilitation[ and BStrengthening Medical Rehabilitation[ will foster the exchange of ideas on innovative service models within and outside ISPRM.
Rehabilitation Research The WRD indicates that research has to provide valid estimates of met and unmet needs for rehabilitation to inform governments and to enable strategic planning of rehabilitation services especially in developing countries. However, research capacity in many countries is limited. Possibly, the ISPRM, in collaboration with national PRM societies, can establish grants that promote research in developing countries regarding the most urgent issues that need clarification. Moreover, although the WRD expresses strong optimism about the effects of CBR, some articles in this issue indicate that implementation is challenging and potential effects might be lower than expected. More sophisticated study designs including methods such as propensity score matching18,19 could provide a more precise effect estimation and higher-level evidence of the effects of CBR. This would be particularly relevant if randomized controlled trials are not seen as ethical or legitimate as in the case of some CBR programs. In addition, studies should include qualitative research methods to explore the relevance of regional and cultural contextual factors that might impact the feasibility of CBR programs in different settings.
CONCLUSIONS The ISPRM has recognized the WRD as a guide for its future activities. During the 7th World Congress of the ISPRM in Beijing this year, the WRD was a leading topic especially of the opening lectures. The emphasis on the report during the congress was intended to enable and to encourage the congress The Roadmap of the ISPRM
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participants to spread out the report’s essence in their regional and national PRM societies. International collaboration by PRM specialists will strengthen their position in national discourse about reasonable and sound implementation efforts. REFERENCES 1. Stucki G, Reinhardt JD, Imamura M, et al: Developing the International Society of Physical and Rehabilitation Medicine (ISPRM): Following through. J Rehabil Med 2011;43:1Y7 2. von Groote PM, Bickenbach JE, Gutenbrunner C: The World Report on DisabilityVImplications, perspectives and opportunities for physical and rehabilitation medicine (PRM). J Rehabil Med 2011;43:869Y75 3. Gutenbrunner C, Meyer T, Melvin J, et al: Towards a conceptual description of physical and rehabilitation medicine. J Rehabil Med 2011;43:760Y4 4. Meyer T, Gutenbrunner C, Bickenbach J, et al: Towards a conceptual description of rehabilitation as a health strategy. J Rehabil Med 2011;43:765Y9 5. Imamura M, Gutenbrunner C, Li J, et al: 2012VAn ISPRM landmark year. J Rehabil Med 2013;45: 417Y22 6. Meyer T, Gutenbrunner C: Relevance of the World Report on Disability by WHO and World Bank for participation research [in German]. Rehabilitation 2012;51(suppl 1):S21Y7 7. Bethge M, Egner U, Streibelt M, et al: Risk Index Disability Pension (RI-DP): A register-based case-control study with 8,500 men and 8,405 women [in German]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2011;54:1221Y8 8. Bethge M, Radoschewski FM, Gutenbrunner C: The Work Ability Index as a screening tool to identify the need for rehabilitation: Longitudinal findings from the Second German Sociomedical Panel of Employees. J Rehabil Med 2012;44:980Y7 9. World Health Organization: International Classification of Functioning, Disability, and Health: ICF Short Version. Geneva, Switzerland, World Health Organization, 2001
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