rehabilitation in medicine

From Big Medical Encyclopedia

REHABILITATION in medicine (Latin rehabilitate recovery) — a complex of the medical, pedagogical, professional and legal measures directed to recovery (or compensation) the broken functions of an organism and working ability of patients and disabled people.

The term «rehabilitation» is used in legal practice in relation to the persons rehabilitated for a long time. In medicine the concept «rehabilitation» for the first time was applied officially to TB patients when in 1946 in Washington the congress on rehabilitation of these patients was carried out. Despite wide use of this term in medical science and practice, concerning essence of rehabilitation, and also the purposes and tasks it there is no uniform point of view so far. In one countries understand as rehabilitation only recovery of health, in others this concept belongs also to recovery of working capacity, in the third — to rendering financial support by the victim etc.

In the 2nd report of Committee of WHO experts on rehabilitation (1969) it called the combined and coordinated use of the medical, social, educational and professional actions including training or retraining of disabled people for achievement by rehabilitants whenever possible of the most high level of functional activity. In the socialist countries the concept about rehabilitation is considerably expanded and deepened according to the social and economic relations in socialist society and reflects comprehensive care of the state of the benefit and health of the person. In the resolution of the IX Meeting of Ministers of Health of the socialist countries (1967) rehabilitation is defined as system of the governmental, social and economic, medical, professional, pedagogical, psychological and other activities directed to the prevention of development of the pathological processes leading to temporary or permanent disability on effective and early return of patients and disabled people to society and to socially useful work.

History of rehabilitation ascends by years of World War I when in Great Britain were created orthopedic hospital for treatment of disabled veterans. In these hospitals the work therapy which was carried out under the leadership of skilled workers was widely applied. Experience of these hospitals was used also in our country, in particular in orthopedic hospital in St. Petersburg, medico-mechanical institute in Kharkiv, etc. Work therapy found the application in psychiatric practice as remedy for the insane. Also the medical pedagogics which exerted huge impact on formation of rehabilitation not only mental patients, but also somatic began to develop.

Considerable development of rehabilitation happened after World War II when began to create various rehabilitation services and the centers when R. became a subject of cares of some public organizations and was allocated in separate discipline.

In the USSR business of rehabilitation disabled became a national objective. Our Constitution guarantees free, public medical care and material security at disability that opened ample opportunities for further development of rehabilitation of disabled. This sphere of activity is considered in our country as the state problem and is regulated by the relevant acts and government resolutions.

On this basis the harmonious system of rehabilitation of patients and disabled people develops in the USSR. In an out-patient and polyclinic link a number of offices of recovery treatment (physical therapy, psychotherapy, mechanotherapy, physiotherapy exercises and, etc.) combine in a uniform complex of departments of recovery treatment. At many of them groups of health function (see. University of health ), in to-rykh not only the former patients, but also almost healthy contingents of the population are engaged. Such groups have, except rehabilitation, and preventive appointment. In a stationary link both independent rehabilitation departments, and specialized hospitals of recovery treatment for rehabilitation of certain contingents of patients are created. Treat their number organized in post-war years hospital for recovery treatment of wounded and disabled people of the Great Patriotic War. In system of step-by-step rehabilitation of the persons who had a myocardial infarction, the great value belongs to 24-day free treatment in the sanatoria which are specially created for this purpose.

The profile specialized centers of rehabilitation (all-Union, republican) are created by hl. obr. on the basis of head (on a problem) on - uchno-research institutes. Further development of network of the rehabilitation centers and improvement of their work will allow to achieve optimum results in business of familiarizing of disabled people with socially useful work.

Besides, in our country societies of rehabilitation for specialists (scientific and practical societies) and for disabled people (public and production societies) function. The scientific and practical societies of doctors-reabilitologov operating in some cities of our country (Moscow, Leningrad) combine doctors of various specialties which are engaged in rehabilitation work among patients and disabled people. In other science foundations of doctors (all-Union, republican and regional) various medical specialties (surgical, therapeutic, pediatric etc.) sectors of rehabilitation are created.

For discussion of related issues holding joint meetings of several societies practices. Societies of rehabilitation for disabled people are organized for blind and deaf citizens. Such societies are created in each federal republic. They are voluntary public organizations, have the boards and work according to the charter of society. Their main objective — familiarizing of blind and deaf citizens with socially useful work, improvement of their cultural and community service, assistance to increase in their general education and technological level, involvement of this category of disabled people in active public life. Societies have the material and financial base, edges allows to organize the labor and household device of blind people and deafs, their vocational education, cultural and educational and sports work etc. on a high level.

The great value in many countries of the world is attached to a problem of rehabilitation of disabled. In the capitalist states rendering the rehabilitation help to victims gained development after the economic benefit of rehabilitation was recognized. At the same time in one capitalist state the obligation of the state to provide disabled at the expense of society is not recorded in the constitution. Rendering such help is made at the expense of means of workers (insurance agencies, the companies). For many businessmen in the capitalist countries rehabilitation of disabled people, generally professional, represents a peculiar business and turned into a source of commercialization. Receiving on rehabilitation of disabled people the solid sums from insurance companies or from the state treasury, they without own expenses train the cheap, but qualified and stable labor for the enterprises. In the conditions of capitalism in cases of prolonged or partial reduction of working ability of the victim there are great difficulties in his definition for work aggravated by existence of chronic unemployment. Therefore persons after rehabilitation are forced to be reconciled with low earnings and to perform any work.

Not all disabled people can receive the rehabilitation help in the capitalist countries. The official statistics demonstrates that the number of the disabled people needing recovery of working capacity grows in these countries.

At the same time it should be noted also a certain progress of the capitalist states in the solution of some private questions of rehabilitation. It is first of all development of devices for simplification of work and life of rehabilitees, some architectural concepts (see below), creation of a number of the specialized centers of rehabilitation etc.

The organization of rendering the rehabilitation help is in developing countries at various levels and tolerates great difficulties. Many of these countries have no appearance of social security at all. Low level of development of economy of most of them does not allow to allocate more or less considerable appliances for development of service of rehabilitation. Besides so far in many developing countries the heritage of the colonial past, huge disabilities in connection with tuberculosis, poliomyelitis, a leprosy and other «classical» diseases of backwardness, colonialism affects. In many of these countries treatment-and-reabilitation institutions are created at the initiative of various nation-wide and public organizations in which use services of foreign personnel and financing from abroad.

In other situation there are young states which became on the way of noncapitalistic development as the developed socialist countries give them constant help. With their help in Vietnam, Angola and iyek-ry other countries the centers for rehabilitation of ortopedo-traumatologic patients are equipped; significant assistance is given in this direction to India, Mozambique, etc. The international organizations working on a problem of rehabilitation of disabled people under the auspices of the UN and WHO promote formation of service of rehabilitation disabled in developing countries, preparation of national shots of specialists in various questions of rehabilitation.

In the socialist countries snowballing of business of rehabilitation both in theoretical, and in the practical relation is observed. The services of rehabilitation including the rehabilitation centers are created. Since April, 1966 the Standing committee of experts of the socialist countries on rehabilitation of disabled people which carries out the symposiums every two years began to function.

The beginning of organizational actions in the field of rehabilitation internationally belongs to 1958 when the first meeting of WHO experts on medical rehabilitation took place. In 1960 the International society on rehabilitation of disabled people (ISRD) which is the member of WHO and working in close contact with the UN, and also with UNICEF, UNESCO and the International Working Bureau (IWB) was organizationally registered. At the initiative of ISRD each three years are spent the international congresses on which various problems of rehabilitation are considered. Science foundations on rehabilitation are organized and work in many countries.

The purposes and problems of rehabilitation

the Purpose of rehabilitation is improvement of the patient and rendering the help in recovery or development of an art to it taking into account specifics of the injury transferred it or a disease. According to G. S. Yumashev and To. Renkera (1973), options of rehabilitation can be the following: first, adaptation of the rehabilitant in a former workplace, secondly, a readaptation — work in a new workplace with the changed working conditions, but at the same enterprise; thirdly, work on the new place according to the acquired new qualification close to former specialty, but the different lowered loading; fourthly, at impossibility of implementation of the above points full retraining with the subsequent employment at the same enterprise; fifthly, retraining in the rehabilitation center with identification of work on new specialty. Thus, the main objectives of rehabilitation are in making the patient or the disabled person capable to life in society, to create the corresponding premises for involvement it in public labor process, proceeding from the fact that work is not only a necessary social condition of full existence of the person, but sometimes and a decisive factor of treatment.

Components of rehabilitation

Rehabilitation is reached by the combined use of rehabilitation actions — medical, psychological, pedagogical, social, labor, technical and legal, making a uniform complex.

Medical actions (medical rehabilitation) combine the medical measures directed to recovery of health. They should be begun immediately after detection of a disease and to carry out in a complex with use of all means promoting development compensatory processes (see) and adaptive reactions of an organism (see. Adaptation , Adaptation ). At the same time all ways of treatment are widely applied: recovery surgical, medicamentous and sanatorium, active labor therapy and physical therapy. In necessary cases it is used physiotherapy exercises (see). Medical events are in most cases held at all stages of rehabilitation and quite often for a long time remain in respect of dispensary service.

Psychological actions (psychological rehabilitation) are inseparably linked with medical as promote even during treatment to psychological training of sick (victim) for necessary adaptation, a readaptation or retraining at partial reduction of its art. Psychological rehabilitation is of great importance during the training of the patient for surgical intervention for installation of faith in him in ability after operation to continue work and to recover the social full value. Psychoprophylaxis (see) and psychotherapy (see) facilitate rehabilitation at the subsequent stages. In most cases psychological training of the victim is carried out by the attending physician though it is more effective if the psychotherapist is engaged in it.

Pedagogical actions in most cases treat children and teenagers with the inborn or acquired defects (see. Disability ). For their training and education the network of specialized institutions is created (kindergartens, elementary, high and technical schools, technical schools, etc.), in to-rye direct children with defects of hearing, the speech, sight, disfigurations and the combined defects. There are same institutions for the children needing long hospitalization with a bradygenesis, for mentally retarded teenagers. The decision on need of rehabilitation of the child is passed by the special commission which defines whether the child is able to master a certain specialty, whether can sustain intellectual loading in school, whether the combination during training of .meropriyatiya of medical and professional rehabilitation is possible.

Labor actions (professional rehabilitation) consist in training of the disabled person for work. They shall begin as soon as possible and be carried out in parallel with medical, psychological, etc. rehabilitation actions. Even before obtaining certain production skills or retraining the disabled person (patient) shall be professionally oriented in the main specialties and know requirements to the profession elected by him. Quality of professional rehabilitation certainly depends on material equipment therefore it is more rational to provide vocational education at the industrial enterprises. For disabled people, to-rye cannot work in usual working conditions, specialized workshops and sites where they work in specially created conditions are created (reduced working day, individual performance standards, etc.) under constant medical observation. With the same purpose home work of disabled people with home delivery of materials and collecting finished goods by forces of priyemnorazdatochny points of plants of home work will be organized.

Training of disabled people is carried out, besides, in system of technological preparation (vocational schools, schools, technical schools). After training (the term of preparation no more than 6 months) disabled people take special examinations — a technical minimum. Labor (professional) rehabilitation comes to the end with the labor device of the disabled person.

Social rehabilitation of the disabled people who lost sight or hearing, working at the industrial practice enterprises (IPE) of societies of blind people and deafs is most successfully carried out (see. Society of deafs , Society of blind people ), where not only conditions for their rational employment, but also for constant medical control are created.

The decision on need of retraining of the disabled person is passed vrachebnotrudovy commissions of experts (VTEK) (see); the direction on training is carried out by departments of social security. For intellectually defective teenagers at insane hospitals special medical and production are created labor workshops (see) where patients receive an art.

Technical actions (technical rehabilitation) — provide use of achievements of scientific and technical progress for recovery of functional full value of an organism of the disabled person (patient) and for his inclusion in socially useful work. Almost technical means are widely used at all stages of recovery process. The role them is especially big at damages of a musculoskeletal system. System of modern prosthetics (see) and prosthetic engineering it was allocated in independent scientific and practical discipline of a medical and technical profile. Improvement and development of new types of prostheses (see. Prosthetic and orthopedic products , Prostheses ) of different function allows to return tens of thousands of disabled people to work. Development of various vehicles (microcars, hand-operated cars, etc.) considerably facilitates to many disabled people of a condition of life and promotes attraction them to work and public work. Development of technology allows to create special designs of many devices and means of household purpose (a spoon, forks, locks, sinks, toilet bowls, clothes, etc.) that provides to disabled people a possibility of self-service and simplifies it. Architects and builders build special buildings with wide doorways, corridors, ramps, special elevators, etc., allowing the disabled person to get to the room and to move in it on a carriage.

Medical, professional and technical rehabilitations, combined, provide social rehabilitation of sick (victim), recovery of its normal relations in society, first of all in the field of work. The feeling of social inferiority connected with disability is as a result overcome, concentration by the disabled person of all attention on the mutilation or a disease is eliminated, it finds belief in own forces.

Legal actions realize the guarantees caused by the Constitution of the USSR to all citizens of our country — the right for work, for the free qualified medical care, material security in old age, in case of a disease, and also at full or partial loss working capacity (see) and loss of the supporter. Along with these disabled people additional guarantees are provided: needing the facilitated working conditions it is employed according to the labor recommendation of VTEK (performance of conditions of the labor recommendation for administration of the enterprises and institutions is obligatory), medical care is constantly improved, the material security of disabled people improves, side benefits are provided to them.

Main methodical and organizational principles of rehabilitation.

Rehabilitation assumes use of uniform methodical and organizational approaches to the solution of such questions as establishment of extent of disturbances of functions of bodies and systems of an organism, definition of working capacity and the labor forecast, plan of recovery actions etc. It is known that medical diagnosti-chesky process

is developed by lechebnoprofilaktichesky healthcare institutions. At long temporary and at approach of resistant disability extent of disturbance of functions of an organism and ability to compensation estimate it medical labor commissions of experts (see) which are under authority of bodies of social security and are guided in the activity by special requirements of laws on work. Therefore process of rehabilitation assumes the interaction of these bodies and institutions directed to the uniform purpose.

VTEK at survey of the patient solves the following problems: estimates the state of health of wasps-videtelstvuyemogo; studies the factors characterizing its profession and specific sanitary and hygienic conditions of its work and life; establishes labor opportunities of the patient; predicts further development of a disease taking into account compensatory and adaptive abilities of an organism and their influence on working capacity that defines the labor forecast; makes labor recommendations to the patient, explains it the existing precepts of law and possibilities of employment.

If the concept «working capacity» characterizes a physical and mental condition of the person, his ability to perform professional work of a certain character and volume at the time of inspection and in the near future, then the concept «labour forecast» belongs to an estimated condition of working ability of the person in the remote period in connection with dynamics expected it. On the basis of the labor forecast form labor the rivers omen d and c of AI.

The plan of recovery actions is developed, proceeding from the following requirements: 1) rehabilitation actions shall begin perhaps earlier; 2) they shall be carried out continuously, consistently and preemstvenno; 3) their performance shall be complex with participation of health workers, ysikholog, teachers, lawyers, etc.; 4) during the scheduling it is necessary to consider specific features of the identity of the rehabilitee and a current at it pathological process, including its psychosocial, biological features and bonds with labor collective, age, the educational qualification, specialty, a home situation. Implementation of these requirements reaches decrease in level of disability and economy of the material inputs connected with payment of pensions and further treatment of the disabled person.

Process of rehabilitation continues also during the return hurting or the disabled person to active socially useful work. At this time its contents and methods depend on whether employment at former work by creation of the corresponding workplace took place that provides material independence of the worker and finally leads to failure from provision of pensions (full rehabilitation), or rational employment with providing work is carried out, edges corresponds to functionality of the worker, as a rule, in the facilitated conditions that demands further holding rehabilitation actions (incomplete rehabilitation). Rehabilitation if it is about the disabled person, it is necessary to consider as continuous process as it needs constant medical observation and social protection. Eventually the condition of disability can be aggravated or, on the contrary, there will be an improvement of health. Therefore all disabled people of working-age shall be captured by dispensary observation in medical institutions at the place of residence or works (see. Medical examination ).

The age is of great importance during the planning of rehabilitation process; all contingent can be divided on age into 4 groups: children's, in Krom generally pedagogical and labor actions which are carried out in specialized preschool institutions, schools and professional schools are necessary; teenage, in Krom labor and an art is got at vocational schools, schools, technical schools, and at mental disorders in activity therapy workshops; young and middle age (in the presence of industrial or special training), in Krom in most cases preparation is carried out according to the individual program in a workplace under production conditions, as a rule, with preservation of former qualification (decrease in qualification or disqualification are allowed only at the adverse clinical and labor forecast); pre-retirement and pension, in Krom the facilitated working conditions with decrease in qualification are shown. At each age of a profession or occupation, recommended to the rehabilitee, shall correspond strictly to his labor opportunities and properties of the personality.

By preparation of the plan of rehabilitation also the sex of the rehabilitee is considered though it also is less essential, than age distinctions. It is necessary to remember, however, that women in comparison with men endure a condition of disability, first of all in family conditions more deeply. Therefore here into the forefront psychological adaptation acts. Due to physiological osobennostyakhm of a female body to choice of profession or works, the available woman, quite often mothers, needs especially attentive relation. For creation of a normal situation at work and in a family the help of the public and relatives is often necessary.

The reasons and severity of a disease or defeat which caused disability are the most various in all set of the circumstances influencing the organization of rehabilitation process. It should be noted that studying of these questions has the most long history in rehabilitation, however so far many of them did not get due permission. Rather in detail the system of rehabilitation is developed at damages of a musculoskeletal system in connection with injuries, inborn defects and paraplegiya, and also at mental disorders and tuberculosis. Possibilities of holding rehabilitation actions at diseases of cardiovascular system are intensively studied now, first of all at coronary heart disease, myocardial infarctions and a hypertension. Demand further studying questions of rehabilitation at diseases of the digestive system, nonspecific diseases of respiratory system, malignant new growths etc.

It is important to consider, besides, whether the rehabilitee is city or the villager. Questions of vocational training are better developed for the city dwellers occupied in the industry or the administrative sphere; rehabilitation of workers and employees is facilitated by existence professiogramm, and also classifications of suitability to work in the corresponding professions and in different workplaces. In rural areas among the persons who are engaged in agricultural types of work, measures of professional rehabilitation are used still insufficiently, but with the accruing differentiation of work they increase in this sphere also in the conditions of the village. The further development of agricultural production connected with the organization of the agro-industrial complexes provided Food programme (see), the CPSU approved by a May Plenum of the Central Committee of 1982, undoubtedly, will promote the rational labor device of patients and disabled people in state farms and collective farms.

Level of the general and professional education affects rehabilitation actions too. Persons with a high level of general education and vocational training have more opportunities to recovery of working capacity on or related to it specialty. Training of such persons of a new profession also demands rather small material and time expenditure. However they in a condition of disability rather often have an alarming state (neurotic fixing on the inferiority) which is slowing down process of recovery and adaptation. Therefore they demand the strengthened psychological rehabilitation at early stages of a disease. At persons with low level of the general and professional education into the forefront the problem of vocational training and especially labor device acts.

Planning rehabilitation actions, it is necessary to observe, at last, the corresponding sanitary and hygienic recommendations, especially during the performing work therapy and vocational training — requirements for labor protection, sanitary and epidemiologic norms and conditions of the treatment-and-prophylactic help. Special attention shall be paid at the same time on the physical and psychological tension, weather conditions, production pollution, beam factors, currents of high frequency, vibration, etc. that can significantly affect efficiency of the held rehabilitation events.

Statistics, account, reporting and analysis of data on rehabilitation. The account and the reporting, and also the analysis of full and incomplete rehabilitation (decrease in weight of disability) and degree of efficiency of rehabilitation actions are carried out to VTEK. The specified data receive, generalizing results of repeated surveys of disabled people; the corresponding indicators include in the annual reports which are summed up on areas (edges) and the republics. The analysis of these data is provided in an explanatory note to the report.

The condition of employment of disabled people socially useful work (disabled people of the III group, and also I and II groups having labor recommendations) is studied by departments of social security. On the basis of such data actions for adaptation of jobs to labor opportunities of disabled people are developed. These departments carry out also the account and the reporting containing the information about number of the disabled people studying in schools and technical schools.

The detailed statistical accounting of N the analysis of rehabilitation of children is carried out by departments of national education under which authority preschool and school institutions for children with vision disorders, hearing, the speech, intellectually underdeveloped, etc. are.

In healthcare institutions disabled people of the Great Patriotic War stay on the dispensary registry. Reporting data about received medical and other rehabilitation help are analyzed by bodies of health care. Since 1982 the information about number of the persons who are initially recognized as disabled people (I, II, III groups) and about consisting on dispensary observation concerning individual diseases is provided in reports of treatment and prevention facilities. For the characteristic of rehabilitation of patients the statistics of incidence with temporary disability can serve to some extent, the account and the analysis a cut is kept by industry committees of labor unions. They combine elements of activity of various institutions and organizations in a single whole: medical, VTEK, technical training colleges, departments of social security, prosthetic enterprises.

Scientific research on a problem of rehabilitation is directed generally to development of necessary medical, professional and social actions, and also to creation of adaptive means for disabled people. The extreme importance belongs to development of new methods of recovery of functions and creation of scientific criteria of objective assessment of results of rehabilitation; to definition of standards of need of the population for stationary and out-patient measures of rehabilitation, and also specification of medico-social criteria for evaluation of working ability of patients; to studying of influence of scientific and technical progress on a possibility of familiarizing of persons with the lowered working capacity to labor process and development of measures for implementation of these purposes; to improvement of training programs on rehabilitation for medical institutes and institutes of improvement of doctors, and also for training of average health workers, teaching and service personnel.

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E. A. Turovich, E. S. Skoblya.