Journal of Rehabilitation Medicine: Special Issue 50-4bokBW | Page 12

314
G. Stucki et al.
applied mainly for chronic health conditions. Inte-
restingly, in some instances, university departments
for physical therapy (referring not to the physical
body but physical modalities such as electrical
currents, heat and cold) were not only the predeces-
sors of physical and rehabilitation medicine, but
were at the same time the roots of related medical
specialties, including radiology, as in Munich, and
rheumatology, as in Zurich. However, already in the
late 19 th century such treatments were included in
the social security system aiming to prevent social
compensation payments (42). Another root, in par-
ticular for the development of orthoses, prosthesis
and assistive devices, was the care for congenital
disability (so-called “cripple care”).
Rehabilitation specialists and researchers have
always been clear about the aims and methods of
this health strategy: rehabilitation does not expli-
citly aim to prevent, reverse or undo the damage
caused by disease or injury, but rather to restore
functioning, ameliorate the impact of the reduction
in capacity, and minimize further effects of the
initial health problem (13, 22, 43–45). The focus
of rehabilitation is on living with a health condi-
tion, often a chronic or incurable condition with a
progressively debilitating trajectory (characteristic
both of some chronic illnesses, such as arthritis
and dementia, and the ageing process itself). Also,
early rehabilitation aims towards minimizing
disability after the occurrence of acute disease
and trauma. Although the primary focus is on the
decrement in capacity in domains of functioning,
rehabilitation science and practice, since its incep-
tion, has intuitively understood that enhancing
what people can do in their lives will also involve
some form of environmental modification. This
may be a prosthetic hand or other prosthesis, or
a mobility aid, such as a cane or wheelchair, a
sensory aid, such as glasses or hearing aid, or
indeed any form of assistive technology.
With this focus, it was a short step, taken roughly
mid-20 th century, for specialties such as occupatio-
nal therapy to expand the range of environmental
modification to include facilitating alterations to
the home environment to enhance independence,
or the work or educational environments to make
it possible for the person with reduced capacity
in physical or mental domains of functioning to
participate fully in these realms of social life (46).
The massive growth in the development of assistive
technologies, and the more recent international ef-
forts to increase equity of distribution worldwide by
lower prices and wider markets (47), further extends
the impact of rehabilitation as a health strategy,
aimed at optimizing functioning.
www.medicaljournals.se/jrm
Against the background of multimorbidity and
the challenge of maintaining biological health in
light of these co-morbidities, for rehabilitation to
reach its goal, it must be combined with suitable
interventions rooted in the curative and promotive
strategies. Both the curative and promotive strate-
gies in these populations pose unique challenges.
Most health promotion programmes currently focus
on keeping the public healthy and ignore the issue
of what needs to be done to keep people who are
living with impairments and disability healthy. This
is ironic, since people living with NCDs and ageing
are, in epidemiological terms, populations at risk,
and hence likely to benefit from such interventions.
Although the objective of rehabilitation is well
known, unlike the other health strategies rehabili-
tation has never enjoyed a particularly high level
of public recognition and regard. It is difficult to
imagine, for example, any other health strategy or
health professional attracting the kind of criticism
that has been levelled by disability activists against
rehabilitation: that it forces persons with disabilities
into a dependent social role rather than seeking
their independence (48). Arguably, this stance can
be explained by the need for disability advocates
to identify themselves as a “discrete and insular
minority” in order to enhance their political case
for recognition as a socially marginalized group.
Yet once this political agenda is set aside, and re-
habilitation is understood as a service, universally
available to anyone with functioning needs, then
this critique disappears (49). More often, especially
in high-income settings, rehabilitation is written off
either as a highly specialized service for athletes
or an optional, post-injury service for return-to-
work or general recovery after surgery. Because
of this image, low- and medium-income countries,
struggling to put into place adequate curative and
preventive strategies, may be tempted to sideline
rehabilitation as a kind of luxury health service that
can be postponed.
FUNCTIONING, FUNCTIONING
INFORMATION AND REHABILITATION
Only relatively recently have rehabilitation profes-
sionals themselves taken on the conceptual task
of clarifying their rationale and role as providing
a distinct, and equally important, health strategy
(23). In no small part this conceptual task been
made possible by the WHO’s ICF, which has pro-
vided: (i) the framework for the most appropriate
conceptual model of rehabilitation as a health
strategy (43–44, 50); (ii) the conceptualization,
development and organization of functioning and