Physical and Rehabilitation Medicine in Community Based Rehabilitation

The WHO Liaison Committee_ Community Based Rehabilitation has developed a document about the meaning of CBR and the role of specialists in Physical and Rehabilitation Medicine in CBR. Some of the issues and concepts discussed were:

Community based Rehabilitation (CBR) seems to be a widely accepted model to improve the delivery of rehabilitation in the community, especially in countries with low income. It includes among others the access to health care, education, labor and accessible environments. The development of concepts and guidelines CBR also is part of the collaboration plan of the Internationals Society of Physical and Rehabilitation Medicine (ISPRM) and the World Health Organization (WHO). Regarding the health component of CBR, the rehabilitation guidelines [6] define as main goal that “CBR programs support people with disabilities in attaining their highest possible level of health, working across five key areas: health promotion, prevention, medical care, rehabilitation and assistive devices.”

We did an international consultation and discussion with the ISPRM members about the meaning of CBR and the role of specialists in Physical and Rehabilitation Medicine in CBR. After analyzing and extracting all of the comments that were received, the following major questions were identified:

What is CBR?

• Is it a strategy for inclusive development based in the community?

• Does it mean rehabilitation services delivered in the community?

• Or does it include both aspects?

• Is CBR a strategy based on the best scientific evidence?

• What is the role of specialists in Physical and Rehabilitation Medicine in CBR?

• Are PRM providers of treatments?

• Are they rehabilitation managers?

• Are they part of the whole strategy?

Summarizing, it is of major importance to distinguish between the two concepts of CBR: The first one is the policy or management strategy of CBR that was developed by WHO about 30 years ago. The second one is the provision of basic rehabilitation services offered at the community level.

Regarding the role of specialists in Physical and Rehabilitation Medicine in CBR there are four possibilities:

• The first one is that PRM doctors contribute to the design and management of CBR strategies.

• The second one is to manage CBR programs including the necessary referrals in between services.

• The third one is to deliver rehabilitation services in the community and

• The fourth one is to act as trainer for persons (professionals and non-professionals) that deliver rehabilitation interventions.

On the one hand the CBR strategy must also addresses the need for optimal access to specialized rehabilitation services. On the other hand, and expanding the discussion, will have a key role in the design and building of so-called "Basic Rehabilitation Services". Further discussion must clarify:

• What are such basic rehabilitation services?

• What rehabilitation services are essential and which are specialized?

• What health professionals should provide these services (nurses, therapists, general practitioners, physiatrists, or others)?

PRM is called not only to answer these questions, but also to help establish such services, carry out activities such as staff training, designing and implementing these programs, researching in techniques and interventions in rehabilitation to be used in community centers.

Another major aspect to be taken into account is the need for CBR strategies to be part of physical medicine and rehabilitation curriculums, including theoretical aspects and practical aspects.

The authors proposed a scheme, which integrates all relevant aspects surrounding the concept of CBR with emphasis on health component but without forgetting that it is framed within the overall strategy; levels of care rehabilitation services and the roles proposed for medical physiatrists. In addition, encompassing all, the convention for the rights of persons with disabilities and the conceptual framework of the ICF.

References:

[1] World Health Organization. Community Based Rehabilitation Guidelines: Health component 2010. Access date: 12/10/2013. Available from: http://whqlibdoc.who.int/publications/2010/9789241548052_health_eng.pdf? ua = 1.

[2] World Health Organization. Draft 1 – 31 july 2013: World health organization action plan 2014 – 2021 “Better health for persons with disabilities”. 2013. Access date: 29/10/2013. Available from: http://who.int/disabilities/policies/actionplan/disability_action_plan_en.pdf.

[3] Meyer T, Gutenbrunner C, Bickenbach J, Cieza A, Melvin J, Stucki G. Towards a conceptual description of rehabilitation as a health strategy. J Rehabil Med. 2011;43(9):765 – 9.

[4] Meyer T, Gutenbrunner C, Kiekens C, Skempes D, Melvin JL, Schedler K, et al. ISPRM discussion paper: Proposing a conceptual description of health-related rehabilitation services. J Rehabil Med. 2014;46(1):1 – 6.