Time to end the global neglect of rehabilitation.

Abstract

Most of us will need rehabilitation at some point in our lives, whether after an illness, injury, or surgery, or because of age-related decline in functioning. Rehabilitation is a fundamental element of disease management for those with chronic conditions, including individuals with rheumatic and musculoskeletal diseases, and is crucial to enabling independence and managing pain. Yet rehabilitation is often viewed as an expensive, non-essential service only needed by a minority. On Dec 1, 2020, WHO and the Institute for Health Metrics and Evaluation published the first global estimates of the need for rehabilitation services, showing that a third of the world's population—2·41 billion people—could benefit from rehabilitation at some point during the course of their illness or injury. The need for rehabilitation has increased by 63% from 1990 to 2019, clearly signalling the need for health-care systems worldwide to incorporate rehabilitation into their approach to integrated service delivery for all individuals at all levels of care. Musculoskeletal diseases are the top contributors to global disability, accounting for 150 million disability-adjusted life-years in 2019—an increase of almost 20% since 2010. Musculoskeletal conditions are also the largest contributors to the need for rehabilitation services, accounting for two-thirds of all need in adults, with low back pain the main contributor. As disability becomes an increasingly large component of disease burden across the lifespan, there is a fundamental need to prioritise musculoskeletal disease and rehabilitation in health-care systems globally. Health expenditure for musculoskeletal disorders already exceeds expenditure for other non-communicable diseases in many high-income countries—US$380 billion in the USA in 2016—yet funding for rehabilitation services is minimal in comparison to the costs of targeted drugs for rheumatic and musculoskeletal diseases, which are among the most expensive drugs on the market. Despite huge health-care expenditure, research budgets for musculoskeletal diseases are not keeping pace with the escalating unmet need for these disabling conditions. For example, the 2021 US National Institutes of Health (NIH) budget for arthritis is estimated at $251 million, which is less than its 2019 budget and with negligible change since 2016. And although the NIH budget for back pain has increased substantially in the past 5 years—to $122 million in 2021—the prioritisation of musculoskeletal conditions falls far short of that for many other diseases, such as cardiovascular disease. In response to the ever-increasing unmet need for rehabilitation, WHO launched the Rehabilitation 2030 initiative in 2017, calling for coordinated and concerted global action towards strengthening rehabilitation services, including expanding financing and research. The NIH budget for rehabilitation has increased by 23% since 2017, corresponding to almost $700 million in 2021, but more is still needed. For many health conditions, there is a scarcity of robust evidence for the effectiveness of rehabilitation, but the evidence is ample in many musculoskeletal conditions—eg, axial spondyloarthritis. Despite this evidence, gaps remain in provision of rehabilitation services for patients with axial spondyloarthritis. In England, a fifth of services do not offer specialist physiotherapy, according to a recent enquiry, despite these services being crucial for managing the disease flares, chronic stiffness, and joint pain typical of the condition. The challenges of rehabilitation delivery have been particularly apparent during the COVID-19 pandemic. A WHO survey showed that rehabilitation services were among the most commonly disrupted essential health services—75% of countries surveyed reported partial or complete disruption of rehabilitation services. These service disruptions are particularly difficult for those with rheumatic and musculoskeletal diseases, for whom rehabilitation is a mainstay of self-management. Indeed, a survey by the UK charity, the National Axial Spondyloarthritis Society, reported that access to physiotherapy (more specifically, hydrotherapy) is the main concern of patients with axial spondyloarthritis. Yet, 38% of services in England could not maintain specialist physiotherapy support during the pandemic, with most of these having no plans in place to reopen hydrotherapy services. At a time when health-care delivery faces unprecedented challenges, the sheer scale of the global need for rehabilitation must serve as a call to action, galvanising health-care systems to formally prioritise the funding and delivery of rehabilitation for musculoskeletal diseases and beyond. Rehabilitation must no longer be viewed as an optional service for the few; it is crucial to ensure the health outcomes of the many.