Need For Medical Rehabilitation Research Articles

Do health literacy, physical health and past rehabilitation utilization explain educational differences in the subjective need for medical rehabilitation? Results of the lidA cohort study

BackgroundMedical rehabilitation can be helpful for maintaining workers’ health and work ability. Its contribution to longer working lives is of high economic relevance in aging populations. In Germany, individuals must apply for rehabilitative measures themselves. Therefore, the subjective need for rehabilitation (SNR) is a prerequisite for rehabilitation access. A low education level is associated with poor health, lower health literacy and more frequent utilization of health services. In the present study, we investigated whether lower educational levels are also associated with a greater SNR and whether health literacy, past rehabilitation utilization and physical health play a mediating role in this path in older employees.Methods3,130 socially insured older employees (born in 1959 or 1965) who participated in the German prospective lidA (leben in der Arbeit) cohort-study in 2011, 2014 and 2018 were included. A causal mediation analysis with an inverse odds weighting approach was performed with the SNR as the dependent variable; educational level as the independent variable; and health, health literacy and past rehabilitation utilization as the mediating variables. Sociodemographic variables were adjusted for.ResultsThe SNR was significantly greater in subjects with a low education level, poor physical health, inadequate health literacy and those who had utilized rehabilitation in the past. For health literacy, past rehabilitation utilization and physical health, a significant partial mediating effect on the SNR was found for employees with low compared to those with high education levels. However, the combined mediating effect of all the mediators was lower than the sum of their individual effects. Among those with medium or high education levels, none of the variables constituted a significant mediator.ConclusionsThe path between a low education level and a high SNR is mediated by inadequate health literacy, past rehabilitation utilization and poor physical health; these factors do not act independently of each other. Promoting health education may lower the SNR by improving physical health and health literacy. While improving physical health is beneficial for individuals, improved health literacy can be economically advantageous for the health system by reducing inappropriate expectations of rehabilitation benefits and subsequent applications for rehabilitation.

On the organization of interdepartmental interaction of institutions of medico-social expertise and rehabilitation of disabled people in the region (on the example of the Perm territory)

BACKGROUND: Currently, a rehabilitation system for people with disabilities is actively developing at the federal and regional levels. Institutions of medical and social expertise occupy an important place in it, developing an individual program of rehabilitation or habilitation (IPRН) and evaluating the results of its implementation.
 AIM: Assess the need of persons recognized as disabled for rehabilitation measures, analyze the organization of interdepartmental interaction of institutions for medical and social examination and rehabilitation of disabled people at the regional level.
 MATERIALS AND METHODS: A retrospective analysis of the needs of persons recognized as disabled for rehabilitation measures within the framework of IPRH for five years (2018–2022) was carried out according to the Federal state information system “Uniform automated vertically integrated information and analytical system on conducting medico-social examination” of Main Bureau of Medical and Social Expertise in Perm Territory, forms Federal State Statistical Observation № 7-Sobes “Information on the medical and social examination of persons aged 18 years and older”, № 7-D (Sobes) “Information on the medical and social examination of children under the age of 18”. The indicators of the effectiveness of rehabilitation based on the results of re-examination at the ITU bureau were studied, and an analysis of organizational technologies of interdepartmental interaction on issues of rehabilitation or habilitation of disabled people in the region was given. Statistical data processing was carried out using Microsoft Office Excel 2010.
 RESULTS: The analysis showed that, against the backdrop of a high need for medical rehabilitation, in the region there were higher indicators of the need for disabled people in social rehabilitation measures, technical means of rehabilitation, and information on adaptive physical education and sports compared to the Russian average. An assessment of the effectiveness of the implementation of rehabilitation measures shows that in 2022 it was almost possible to achieve the level of indicators of 2019 (“pre-Covid”) for both children and adults. As part of interdepartmental interaction, specialists from the main bureau and executive authorities, branches of the Social Fund of Russia, the Center for Comprehensive Rehabilitation of Disabled People, and public organizations quickly resolve problematic issues, conduct training seminars and conferences, and organize interdisciplinary research.
 CONCLUSION: The study made it possible to identify regional features of the structure of the need of persons with disabilities for rehabilitation or habilitation measures, as well as to analyze organizational approaches and technologies of interdepartmental interaction between the Main Bureau of Medical and Social Expertise and institutions subject to rehabilitation.

Method for finding subsets of consensus features in predicting the effectiveness of rehabilitation of patients after COVID-19

Coronavirus infection causes long-term post-Covid syndrome, which determines the need for medical rehabilitation. The use of modern machine learning technologies to predict the effectiveness of rehabilitation can personalize the process of providing assistance.Aim: To create a method for constructing a model to predict the effectiveness of patients rehabilitation who have suffered COVID-19.Material and Methods. The study included 64 patients admitted for inpatient rehabilitation after COVID-19. The average age was 56.92±9.29 years. To obtain information about the patients' health status, a physical examination, six-minute walk test (SHT), clinical and biochemical blood tests, and spirometry were performed in order to obtain information about the health status of the patients. The collected data were anonymized and transformed into a data set for the classification task, the output label of which was a binary attribute indicating the presence or absence of an improvement in the six-minute walk test result by at least 15 %. The proposed method for determining a consistent subset of features was tested by ReliefF, χ2-squared filters and the minimum redundancy and maximum information content algorithm; the binary genetic algorithm NSGA2 was used as a wrapper. The construction of preliminary machine learning models on the found subsets of features using the linear support vector machine was carried out.Results. In the process of testing the proposed method in the task of predicting the effectiveness of rehabilitation of patients after COVID-19, a subset of signs was identified that made it possible to achieve the maximum value of the concordance coefficient. The found set includes the following characteristics: gender, concomitant diseases, shortness of breath, cough, complaints about the gastrointestinal tract, six-minute walk test result, D-dimer level, assessment of shortness of breath according to the Borg scale.Conclusion. The proposed method allowed identifying the signs that are of the greatest importance for predicting the effectiveness of patients’ rehabilitation who have had COVID-19.

Some problematic issues of rehabilitation of patients with the stroke consequences at the present stage

Background. Acute cerebrovascular disorders are one of the main causes of severe disability in modern society. Russian and foreign researchers register the emerging trend towards rejuvenation of the patients with stroke, which, in turn, significantly increases the relevance of the treatment and rehabilitation of these patients at various stages.The aim. To study the social and hygienic characteristics of the stroke patients and to determine their need for medical rehabilitation in the early recovery period.Materials and methods. We studied the social and hygienic characteristics of 109 patients who had stroke in 2020 and 2021 and underwent rehabilitation in the specialized rehabilitation department of the Southern District Medical Center of the Federal Medical and Biological Agency, and determined their need for medical rehabilitation using the analytical method, the method of expert assessments and questionnaires.Results. The average portrait of a patient with a stroke in the early recovery period is as follows: this is a man aged 61 to 70 years with a higher or secondary specialized education, unemployed, living in the city. Up to 30 % of stroke survivors were recognized as disabled; among which, the persons with more severe disability (groups I and II) predominate – up to 90 %. Implementation of rehabilitation measures in the acute period in the hospital and in the early recovery period in the outpatient clinic is carried out at a fairly low level. The percentage of patients being examined by a multidisciplinary rehabilitation team ranges from 17.4 to 10.1 %.Conclusion. The availability of medical rehabilitation measures in a specialized rehabilitation center is quite limited; more than half of the surveyed contingent (52.3 %) experienced problems in obtaining a referral to treatment, about half of the respondents (46.8 %) waited up to 6 months for a referral, which indicates the need to expand the network of such institutions at the regional level.

Comprehension and Perspectives of the Need for Medical Rehabilitation - Results of a German Online Survey

In Germany, medical rehabilitation usually requires an application of the persons in need. Therefore, these persons have to understand what rehabilitation is and in what case they need this type of health care service. In addition to people with health problems, their close persons (e. g. family members) should also have rehabilitation-related knowledge. Since there is only limited data on the perspective towards medical rehabilitation services, a survey was conducted. In September 2020, we invited 2,401 registered participants (age: 18-79 years) of a population-based online panel study to participate in an online survey. The cross-sectional survey asked about the understanding of need, subjective information as well as attitudes and expectations towards medical rehabilitation services. We analysed the data descriptively, taking into account the participants' rehabilitation experience and health impairment. In a subgroup analysis, the potential factors influencing the subjective need for rehabilitation were tested using logistic regression. Data from 1,464 persons (Ø age: 52.5±14.5 years; 55% non-male) were analysed, 44% of the participants considered themselves to be "rather well" or "very well" informed about medical rehabilitation. The majority associated a need for rehabilitation with the access requirements related to service providers. In case of an emerging need for rehabilitation, family doctors would be the first point of contact. The participants mainly had function-oriented expectations of rehabilitation services and a majority prefer inpatient rehabilitation if necessary. Among 383 persons with long lasting and pronounced health-related impairment, the concrete individual need for rehabilitation was associated by a higher subjective degree of impairment as well as their own previous rehabilitation experience and rehabilitation experience in their personal social environment. Despite an overall good understanding of the need for rehabilitation, different rehabilitation views were found in certain population groups. In order to improve the general understanding of rehabilitation in the public and particularly in close persons, adequate dissemination of low-threshold, population-based rehabilitation information is recommended.

The elaboration of approaches to medical rehabilitation of participants in warfare

The article considers social hygienic characteristics of participants in warfare underwent treatment and rehabilitation in specialized medical organization. It is established that patients of neurological profile and with diseases of cardiovascular system predominated in the studied contingent. The high need for medical rehabilitation was determined according results of examination of participants in warfare by multidisciplinary rehabilitation team. The necessity of observance staging and continuity in carrying out rehabilitation measures at all levels is emphasized.

Assessment of rehabilitation in children with infectious diseases of the lower respiratory tract using the categories of the International Classification of Functioning, Disability and Health

BACKGROUND: Solving the issues of rehabilitation of children after lower respiratory tract infections requires putting up rehabilitation diagnoses in the categories of the International Classification of Functioning, Disabilities and Health (ICF).
 AIMS: The study aimed to define the key problems in the ICF categories and make quantitative and qualitative assessments of the changes in the ICF domains in convalescent children with infectious diseases of the lower respiratory tract at the outpatient stage and in one month after the disease.
 MATERIALS AND METHODS: The assessment of rehabilitation was performed using the ICF categories for 201 convalescent children with lower respiratory tract infections.
 RESULTS: Most of the patients had significant impairments in the following functions: b134 Sleep functions; b152 Emotional functions; b280 Feeling of pain; b440 Respiratory functions; b450 Additional respiratory functions; b455 Exercise tolerance function; b460 Sensations associated with cardiovascular and respiratory functions; b730 Muscle strength functions; b740 Muscular endurance functions; b780 Sensations associated with muscles and motor functions, both at the time of discharge from the hospital and a month after the discharge. Environmental factors (e115 Products and technologies for personal use in daily life; e225 Climate; e260 Air quality; e310 Close relatives; e355 Medical workers; e410 Relationships with immediate family members; e450 Relationships with medical workers; e580 Medical services; e585 Services in education and training) were shown to have an influence on rehabilitation process.
 CONCLUSION: The identified range of functioning disorders and the influence of environmental factors indicates the need for medical rehabilitation for convalescent children with lower respiratory tract infections. The rehabilitation should be multidisciplinary and involve psychological and pedagogical techniques, work with the family, and motor rehabilitation techniques to restore workload tolerance.

Medical rehabilitation of older employees with migrant background in Germany: Does the utilization meet the needs?

Due to demographic change with an ageing workforce, the proportion of employees with poor health and a need for medical rehabilitation is increasing. The aim was to investigate if older employees with migrant background have a different need for and utilization of medical rehabilitation than employees without migrant background. To investigate this, self-reported data from older German employees born in 1959 or 1965 of the first and second study wave of the lidA cohort study were exploratory analyzed (n = 3897). Subgroups of employees with migrant background were separated as first-generation, which had either German or foreign nationality, and second-generation vs. the rest as non-migrants. All subgroups were examined for their need for and utilization of medical rehabilitation with descriptive and bivariate statistics (chi-square, F- and post-hoc tests). Furthermore, multiple logistic regressions and average marginal effects were calculated for each migrant group separately to assess the effect of need for utilization of rehabilitation. According to our operationalizations, the foreign and German first-generation migrants had the highest need for medical rehabilitation while the German first- and second-generation migrants had the highest utilization in the bivariate analysis. However, the multiple logistic model showed significant positive associations between their needs and utilization of rehabilitation for all subgroups. Further in-depth analysis of the need showed that something like under- and oversupply co-exist in migrant groups, while the foreign first-generation migrants with lower need were the only ones without rehabilitation usage. However, undersupply exists in all groups independent of migrant status. Concluding, all subgroups showed suitable use of rehabilitation according to their needs at first sight. Nevertheless, the utilization does not appear to have met all needs, and therefore, the need-oriented utilization of rehabilitation should be increased among all employees, e.g. by providing more information, removing barriers or identifying official need with uniform standards.

Study of the relevance of the problem of autism spectrum disorders for the clinical activities of doctors of different specialties planning to work in the field of physical and rehabilitation medicine

BACKGROUND: The problem of medical rehabilitation of patients with autism spectrum disorders (ASD) is extremely urgent. The prevalence of ASD among the world's population is about 1%. It is known that children with ASD are difficult to respond to psychological and speech therapy correction and drug treatment. Today, one of the pressing issues is the choice of non-drug methods of treatment. Given the variety of functional disorders in ASD, these patients require special rehabilitation programs and therefore physicians planning work in the field of physical therapy and medical rehabilitation should be oriented in this problem.
 AIMS: Of the study was to study the relevance of the ASD problem for the clinical activities of doctors of various specialties planning to work in the field of physical and rehabilitation medicine, their level of qualifications, activity and motivation in providing medical care to patients with ASD.
 MATERIAL AND METHODS: A survey was conducted on the author's questionnaire of 116 doctors of 8 medical specialties who underwent primary retraining in the cycle "Physical and Rehabilitation Medicine" at the Department of Physical Therapy, Sports Medicine and Medical Rehabilitation of the RMANPO of the Ministry of Health of Russia.
 RESULTS: The study showed that pediatricians and neurologists are significantly more likely to meet patients with ASD in their practice than doctors of other specialties (p 0.05). An analysis of the answers of all respondents indicates the importance of additional informing doctors about modern research on the problem of ASD. When asked "What sources of information about medical support for children with autism spectrum disorders would you definitely use" 81 (69.8%) respondents indicated seminars and conferences, 50 (43.1%) Russian magazines, books, textbooks, 46 (39.7%) special sites and materials of social networks, 30 (25.9%) advanced training programs in the system of continuing professional education, the rest of the doctors preferred modern foreign literature and the experience of colleagues. Absolutely all respondents indicated the need for medical rehabilitation for children with ASD, however, 28 (24.1%) respondents believe that it is necessary to consider each case of the disease individually. The majority of the respondents indicated the expediency of sanatorium-resort treatment for patients with ASD. Doctors were also asked about the need to use basic ICF kits in the rehabilitation of patients with autism: 64 (55.2%) respondents answered positively, 44 (37.9%) found it difficult to answer and 8 (6.9%) gave a negative answer. In matters of non-drug treatment of patients with ASD, the leading positions are taken by: art therapy, hydrotherapy, music therapy, physiotherapy exercises and animal therapy. However, methods with proven effectiveness in this category of patients, such as transcranial forms of brain stimulation and biofeedback, were chosen by only 65.5% of respondents. Only 34.5% of respondents indicated the possibility of using Bobath therapy, Vojta therapy and PNF therapy in patients with ASD.
 CONCLUSION: Doctors are not sufficiently knowledgeable in the field of modern methods of physical and rehabilitation medicine that can be successfully used in children with ASD. The totality of all the respondents' answers indicates the importance of additional informing doctors about modern research on the problem of ASD, as well as the need to implement educational programs that will take into account current trends in the development of physical and rehabilitation medicine for this category of patients.

Age-specific rates of population requirements in outpatient medical rehabilitation

Improving organizational approaches of medical rehabilitation is one of the important directions in Russian healthcare system.Aim. To determine the age-specific rates of adult population requirements in outpatient medical rehabilitation in Russia.Material and methods. The article provides data on the estimated age-specific rates of population requirements in outpatient medical rehabilitation, determined by expected attendance of a rehabilitation physician by classes of diseases and individual diseases according to the ICD-10 codes. For the study, the adult population was divided into 6 age groups (18-29, 30-39, 40-49, 50-59, 60-69 and 70 and older). Medical experts, taking into account the stage of the disease and the severity of the patient’s condition, have developed indications for outpatient medical rehabilitation immediately after the treatment of acute conditions, exacerbation of chronic diseases, the consequences of injuries and operations. And also the type of rehabilitation (inpatient or outpatient) was determined. Taking into account these indications, competent experts decided on the need and duration of further medical rehabilitation of patients after hospitalization.Results. The age-specific rates of population requirements in outpatient medical rehabilitation were determined and analyzed. The number of visits to a rehabilitation physician was calculated according to the main classes and some individual diseases. The largest number of persons in need of outpatient medical rehabilitation naturally falls on the older age groups 60-69 years (3917,5 visits per 1000 population) and 70 years and older (4716,9 visits per 1000 population), while the smallest — the patients 18-29 years old (832,2 visits per 1000 population). This is due to the fact that in older age groups the number of diseases requiring outpatient medical rehabilitation both in inpatient and outpatient settings is increasing. In other age groups, the need for medical rehabilitation per 1000 population was as follows: 985,6 visits per year in the 30-39 age group; 1672,0 — in the 40-49 age group; 2713,1 — in the 50-59 age group.Conclusion. Based on the data obtained, the healthcare executive authorities in the subjects of the Russian Federation can calculate the population requirements in outpatient medical rehabilitation in region, taking into account age composition and the estimated number of visits to a rehabilitation physician by the adult population.

Comparative characteristics of bioimpedanceometry indices dynamics in young men with normal and insufficient body weight in the treatment of community-acquired pneumonia

The component composition of the body of men with normal body weight and insufficient body weight in the age from 18 to 44, patients with community-acquired pneumonia of non-severe course, was studied. Its changes at various periods of treatment are revealed. These changes were expressed in the statistically significant dynamics of indicators of total water content, total muscle mass with water and total fat content in men with normal body weight, as well as significant changes in the total water content and total muscle mass with water in men with insufficient body weight. At the same time, all examinees showed slight changes in body mass, body mass index and stability of the total defat-dehydrated bone mass. At the same time, the total water content and total muscle mass with water were lower at the 3rd, 7th and 15th days of treatment compared to the day of hospitalization. The lowest values of these parameters were recorded on the 3rd day of treatment. In addition, in men with normal body weight, significant changes in the total fat content on the 3rd and 15th days of treatment were noted, compared with 1 day of treatment. It was found that the total water content of men with insufficient body weight was not normal even by the 15th day of treatment. This fact indicates the need for medical rehabilitation after completion of treatment in order to normalize the body composition and prevent recurrence of the disease.

A Projection of the Need for Rehabilitation in Germany Till 2040 Based on Demographic Factors

The demographic changes in Germany leads to a significant shift in the composition of the population and the workforce, this affecting the future need for medical rehabilitation. This paper estimates the future change in rehabilitation demand based on a forecast for demographic changes till 2040. First, the sensitivity of the rehabilitation demand with respect to demographic factors is estimated. Second, the demographic factors are projected by stochastic methods, resulting in forecasts for the future need for medical rehabilitation. The projections show that the short-term demand is likely to rise. Theoretically, yearly wage increases of about 2.2% are needed for covering the increasing medical rehabilitation costs from 2010 till 2017. For the mid-term demand, the model predicts a slight decline in rehabilitation cases. Considering all these facts, the budget for rehabilitation will probably not cover the future costs for rehabilitation. However, the long-term forecast is subject to considerable uncertainty.

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disorders was analyzed by a continuous method. 24 (20,2 %) of them were recognized as disabled for the first time, 95 (79,8 %) � were recognized as repeatedly disabled; 80,7 % were of working age, but only 10 persons of them (10,4 %) worked. The need for medical rehabilitation was revealed in 100 % of people with disabilities, for professional rehabilitation � in 65,6 %, for social rehabilitation � in 23,5%, for adaptive physical training � in 0,8 %. Full rehabilitation in re-examination was achieved only in 1,3 % of cases, partial rehabilitation � in 1,3 %, employment � in 1 case. Weighting of disability was occurred in 5,2 %. In order to improve the efficiency of complex rehabilitation of disabled people it should include socio-psychological, socio-cultural rehabilitation and adaptive physical education in addition to medical and professional rehabilitation.

Medical rehabilitation in low and middle income countries for adult acquired disability: challenges posed by rapidity of health system change and position on the individualistic/collectivist axis.

Chronic illness prevalence has rapidly increased in low or middle income countries (LMIC) and with it, the need for medical rehabilitation for adults with acquired conditions that stem from aging and long-term conditions. While Western medical rehabilitation programs have had at least two generations to develop, in LMIC, post-acute health care delivery change has been much more rapid. As a result, there has been little opportunity for models of medical rehabilitation to deliberately emerge in LMIC that reflect societal values. While adaptation of an independence-foremost model of medical rehabilitation may succeed in non-Western societies, there is a risk that adaptation of such a model will be ineffective where many value collectivism more than individualism. The rapid change in medical rehabilitation service delivery in LMIC gives Christian providers and organizations an opportunity to pause and reflect whether the dominant Western medical rehabilitation paradigm serves LMIC cultures and reflects Biblical principles.

Is acuity enough? Other considerations in clinical investigations of visual prostheses**The views and opinions are those of the author and do not necessarily reflect those of the US Food and Drug Administration, the US Department of Health and Human Services or the Public Health Service.

Visual impairing eye diseases are the major frontier facing ophthalmic research today in light of our rapidly aging population. The visual skills necessary for improving the quality of daily function and life are inextricably linked to these impairing diseases. Both research and reimbursement programs are emphasizing outcome-based results. Is improvement in visual acuity alone enough to improve the function and quality of life of visually impaired persons? This perspective summarizes the types of effectiveness endpoints for clinical investigations of visual prostheses that go beyond visual acuity. The clinical investigation of visual prostheses should include visual function, functional vision and quality of life measures. Specifically, they encompass contrast sensitivity, orientation and mobility, activities of daily living and quality of life assessments. The perspective focuses on the design of clinical trials for visual prostheses and the methods of determining effectiveness above and beyond visual acuity that will yield outcomes that are measured by improved function in the visual world and quality of life. The visually impaired population is the primary consideration in this presentation with particular emphases on retinitis pigmentosa and age-related macular degeneration. Clinical trials for visual prostheses cannot be isolated from the need for medical rehabilitation in order to obtain measurements of effectiveness that produce outcomes/evidence-based success. This approach will facilitate improvement in daily function and quality of life of patients with diseases that cause chronic vision impairment.

Identifikation von potenziellem Reha-Bedarf in der Hausarztpraxis: Idee und Wirklichkeit

Medical rehabilitation is a basic component in the German health care system. However, several studies have shown only moderate effects by rehabilitation treatment. The effectiveness of medical rehabilitation depends on different factors, like rehabilitation need, access, preparation for rehabilitation treatment, therapy intensity and rehabilitation aftercare. During the past few years the lack of cooperation and communication between cost carriers and general practitioners has been emphasized. Since general practitioners play a central role in the patients' decision for rehabilitation treatment, the aim of the present study was to facilitate the identification of rehabilitation need by general practitioners. The project group integrated different professions. To facilitate assessment of rehabilitation need in patients attending a medical practice, two different approaches were applied: First, a self-administered patient questionnaire was developed, containing different subjective indicators of rehabilitation need (e. g., subjective health, problems in activities and participation as well as daily or occupational stress). Secondly, the project group worked out a short checklist for general practitioners, containing a number of criteria confirming patients' potential need for rehabilitation. Both instruments were tested in nine medical practices with 60 patients presumably in need for medical rehabilitation. The short checklist as well as the patient questionnaire proved to be practicable and economical. Nine of 40 general practitioners participated. Based on the checklist a need for rehabilitation was identified in 85% of their patients. In another 10% of the patients the result was questionable, and in three patients the finding was negative. In the self-assessment of the patients, 98% stated a subjective need of rehabilitation (global rating), only one patient indicated no rehabilitation need. The agreement between physician and patient assessments was only weak (kappa: 0.11, p=0.08). Defining deviation by one category as still indicative of agreement of the two ratings, an agreement of 78% is reached. Both instruments in principle proved to be useful in medical practice. They allow quick and easy assessment of a potential rehabilitation need in everyday practice. Despite these positive results and the supportive function of the checklist, the participation rate among general practitioners was unexpectedly low, possibly mainly due to the additional bureaucracy, a negative image of the rehabilitation system, and the concurrence with DMPs. Poor accessibility of general practitioners regarding questions of medical rehabilitation is well-known from numerous earlier research projects. Satisfying integration of physicians could not be reached, although the approach of needs assessment seems to be promising. Further research should focus on how the urgently required cooperation could be achieved.

The system for medical rehabilitation in Croatia

Purpose. To describe the framework for medical rehabilitation in Croatia and to discuss its influence on the practice of the specialty.Methods. Collection, analysis and interpretation of data pertaining to the need for medical rehabilitation in the country and to its elements of structure, process and outcome of care.Results. The practice of medical rehabilitation in Croatia has evolved without strategic planning on the national level and therefore without a designed system. This lack in the present framework causes shortcomings in all three elements of rehabilitation care and impedes the advancement of the specialty.Conclusion. Medical rehabilitation in Croatia needs a national strategic plan for a three-level system that incorporates inpatient, outpatient and community-based rehabilitation.

Spiritual Factors and Adjustment in Medical Rehabilitation: Understanding Forgiveness as a Means of Coping

Spirituality is an important factor in the lives of people in rehabilitation and healthcare providers must be prepared to address spiritual issues in a competent and informed manner that includes distinguishing between spirituality, religiosity and existentialism. It is important to understand the role of specific spiritual factors in rehabilitation. The need for medical rehabilitation often arises from human error or seemingly unfair circumstances, resulting in a variety of negative emotions and forgiveness can be a powerful tool in the rehabilitative healing process. As such, it is critical to accurately understand the construct of forgiveness, including its definition, steps, and dynamics.

Rehabilitation score for patients with type 2 Diabetes mellitus: An instrument to standardize assessment of the need for rehabilitation

Type 2 diabetes is considered a multidimensional health impairment which includes several components like risk factors, cofactors and complications. The early and consequent therapy of all of these components reduces secondary complications. Instead of simply applying drug treatment, a more holistic concept including behavioural medicine therapy and empowerment of patients has been found much more effective. The facilities required for such a multifactorial therapy by different health care professions could easily be provided by the medical rehabilitation services available under the German pension insurance scheme. However, this emphasizes the demand for standardized protocols to achieve an objective allocation of rehabilitation services to individuals in need. In an epidemiological study on 12 429 working insurants (age 41 - 60 years) of the pension insurance fund in the region of Luebeck, persons suffering from type 2 diabetes were identified and evaluated regarding a need for medical rehabilitation. Therefore, an algorithm was developed quantifying the multidimensional disturbances which accumulate in type 2 diabetes mellitus. The following indicators are taken into consideration: risk factors like eating behaviour, lack of physical activity, smoking and stress; metabolic parameters such as HbA1c and plasma lipids; cofactors like hypertension and depression and, additionally, the acute complication of hypoglycaemia. Based on this rehabilitation score, 19 % of cases in a preliminary evaluation of 79 patients with type 2 diabetes showed a need for medical rehabilitation therapy.

The emerging science of functional assessment: Our tool for outcomes analysis

The need for medical rehabilitation is great and is growing. 1 Hoffman et al analyzed the 1987 National Medical Expenditure Survey 2 and showed that the relative risk of needing medical care or experiencing disability days because of a chronic condition increases with age. The risk for noninstitutionalized persons was 24.6% for ages 0 to 17 years, 35.1% for ages 18 to 44, 67.7% for ages 45 to 64, and 87.6% for ages 65 years and older. Use of health care services was dominated by persons with chronic conditions in terms of home care visits (96.1%), number of prescriptions (83.3 %), hospital days (79.9%), hospital admissions (68.6%), emergency room visits (55.1%), physician visits (66%), and visits to other health practitioners (70.3%). The picture was reinforced by the annual health care costs for noninstitutionalized persons in 1987. As expected, total costs increased with age, but in each age bracket, the costs for chronic conditions exceeded by far the costs for acute conditions. Looked at another way, of the population incurring health care costs, less than half (45.8%) had chronic conditions but they accounted for three fourths (76.1%) of the costs. Over the years, the proportion of the population with limitations in activity due to chronic health conditions and impairments has increased. Also, the elderly population has been increasing. However, the rate of disability for persons 65 years of age or older has remained constant. Thus, the increase in disability is because more people are surviving into old age. 3 Similarly, the proportion of disabled persons in the age range of 45 to 64 years has remained relatively constant. Before 1990 the rate of disability among persons under age 45 was constant, but since then, the proportion of persons under age 45 with disability has increased. Because 70% of the population is under age 45, these rate increases are significant. These changes may be due to increases in asthma and mental disorders, including attention deficit, retardation, and learning disabilities. Also, rates of orthopedic impairments and mental and nervous disorders have increased. Between 1990 and 1994 the number of children with disabilities increased by 1.5 million and the number of working-age adults with disabilities increased by 3.1 million. Of those presumably eligible, only 40% of children and 55% of adults were added to the public support rolls between