Global estimates suggest one in three people need rehab during illness, injury

Researchers from the World Health Organization (WHO) found that a staggering 2.41 billion people from around the globe had conditions that would benefit from rehabilitation, a result that suggests that rehabilitation services should be folded into standard primary care services.

For the most part, rehabilitation is seen as “a fallback strategy when preventive, promotive, or curative interventions fail, and as a disability-specific service needed by only few of the population,” wrote Alarcos Cieza, PhD, of the Sensory Functions, Disability and Rehabilitation Unit, Department for Noncommunicable Diseases at WHO, Geneva, Switzerland, and colleagues explained in the Lancet. “Furthermore, rehabilitation has often been incorrectly perceived as an expensive clinical and specialized service provided predominantly at secondary and tertiary care levels.”

To challenge this idea, Cieza and colleagues used data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 (GBD 2019) to calculate the global prevalence and years of life lived with disability (YLDs) for a list of 25 diseases and impairments.

“To our knowledge, this is the first study to produce a global estimate of the need for rehabilitation services,” they wrote. “Our findings show that 2.41 billion people (95% UI 2.34-2.50) could benefit from rehabilitation services. This finding means that at least one in every three people in the world needs rehabilitation at some point during the course of their disease or injury. This result counters the common view of rehabilitation as a service for the few.”

Rod Taylor, MSc, PhD, of the Institute of Health and Wellbeing at the University of Glasgow in the U.K., Ann-Dorthe Zwisler, MD, PhD, of the Knowledge Centre for Rehabilitation and Palliative Care in Nyborg and the University of Southern Denmark and Odense University Hospital in Odense, Denmark, and Jamal Uddin, BPT, MPH-NCD, of Ibrahim Cardiac Hospital & Research Institute in Dhaka, Bangladesh, applauded the analysis by Cieza and colleagues in a commentary accompanying the study.

Taylor, Zwisler, and Uddin noted that, while it is a fundamental part of care for many people, rehabilitation “has often been a deprioritized service, considered as being nice to have but often not valued by health­care systems that, instead, invest in what are regarded as more essential life­saving treatments of drugs, medical devices, and surgical treatments. However, health­care systems need to value and fund rehabilitation interventions and programs as a core essential service. Addressing the unmet need for rehabilitation is a global priority.”

For their analysis, Cieza and colleagues pulled data from the GBD 2019 study for the twenty conditions that were associated with the highest number of YLDs. From this list, they excluded conditions for which rehabilitation was considered non-essential (e.g., iron deficiency or oral disorders), and then a panel of rehabilitation specialists were convened by WHO to add conditions for which rehabilitation was considered necessary. The study authors eventually settled on a list of 25 health conditions, including:

  • Musculoskeletal disorders: Low back pain, neck pain, fractures, and other injuries — osteoarthritis, amputation, rheumatoid arthritis.
  • Neurological disorders: Cerebral palsy, stroke, traumatic brain injury, Alzheimer’s disease and dementia, spinal cord injury, Parkinson’s disease, multiple sclerosis, motor neuron disease, Guillain-Barré syndrome.
  • Sensory impairments: Hearing loss, vision loss.
  • Mental disorders: Developmental intellectual disability, schizophrenia, autism spectrum disorders.
  • Chronic respiratory diseases: Chronic obstructive pulmonary disease (COPD).
  • Cardiovascular diseases: Heart failure, acute myocardial infarction.
  • Neoplasms.

Analyses were performed at the country level before being aggregated to seven regions: World Bank high-income countries and the six WHO regions—Africa; North, South, and Central America; Southeast Asia; Europe; Eastern Mediterranean; and Western Pacific.

“Globally in 2019, 2.41 billion (95% UI 2.34–2.50) individuals had conditions that would benefit at some point during the course of disease from rehabilitation services, contributing to 310 million (235–392) YLDs,” the study authors found. “This number had increased by 63% (61–64), from 1.48 billion (1.43–1.54) in 1990. The age-standardized prevalence and YLDs rates showed modest declines since 1990, indicating that the large increase in cases is due to population growth and population ageing.” Cieza and colleagues noted that the prevalence of conditions that would benefit from rehabilitation was similar between men and women (1.19 billion versus 1.22 billion); however, women had more YLDs (163 million versus 146 million).

Among the more than 1.6 billion adults ages 15-64 years who had conditions that would benefit from rehabilitation in 2019, the study authors pointed out that roughly two-thirds of the conditions were musculoskeletal disorders. For children less than age 15 years, sensory impairments, mental disorders, and musculoskeletal disorders accounted for 91% of the 162.3 million cases, and for people older than age 65, musculoskeletal disorders, neurological disorders, sensory impairments, and chronic respiratory diseases made up most cases.

“Among WHO regions, the Western Pacific region had the highest need for rehabilitation services (610 million people [95% UI 588-636] and 83 million [62-106] YLDs), followed by the Southeast Asia region (593 million people [571-618] and 77 million [58-97] YLDs), World Bank high-income countries (530 million people [515-548] and 70 million [53-90] YLDs), the European region (373 million people [362–386] and 45 million [34–58] YLDs), the region of the Americas (310 million people [301–321] and 35 million [26-45] YLDs), the Africa region (214 million people [206–224] and 27 million [20-34] YLDs), and the Eastern Mediterranean region (182 million people [174-192] and 22 million [17-28] YLDs)” they wrote.

By far, the category of condition that impacted the most people was musculoskeletal disorders (1.71 billion people and 149 million YLDs)—among these, lower back pain caused the highest burden (568 million people and 64 million YLDs). “In fact, low back pain was the leading health condition contributing to the need for rehabilitation services in 160 of the 204 countries analyzed,” the study authors noted.

Cieza and colleagues pointed out that, as the world’s population continues to increase and age, the number of people suffering from low back pain is skyrocketing, becoming the “main reason for a premature exit out of the workforce” among adults around the globe.

“A study from Australia showed that there was 87% less wealth accumulation in individuals who have retired early because of low back problems than in those who had remained in full-time employment with no health condition, controlling for age, sex, and education,” they wrote. “The societal impact of early retirement in terms of direct health-care costs and indirect (i.e., work absenteeism or productivity loss) costs is enormous. Projections show that the number of people with low back pain will increase in the future, and even more rapidly in low-income and middle-income countries.”

Moreover, Cieza and colleagues pointed to the ongoing Covid-19 pandemic as something that could further exacerbate the need for rehabilitation, as there is “emerging evidence that many of the people affected… have long-term consequences regardless of the disease severity or length of hospitalization.”

The only way to meet this global demand for rehabilitation services, they argued, is to integrate it into the health system “and, specifically, for rehabilitation services to be strengthened at the primary care level,” they wrote.

Providing early intervention during primary care visits can get patients into needed rehabilitation programs faster, they argued, which would help to stave off the prevalence and delay the onset of disabling conditions in both children and adults—plus, increasing the prevalence of rehabilitation services will help patients keep up with their treatment and remain in the workforce.

Taylor, Zwisler, and Uddin agreed, saying that the world needs to urgently look towards community rehabilitation provision, including home-based and digital-based delivery. “To achieve the necessary step change in rehabilitation provision and access, health­care systems need to look to affordable, evidence -based delivery models, including community -based, home-­based, and digital­-based models of delivery, especially in [low-income and middle-income countries] where unmet need is likely to be greatest.”

  1. An analysis of data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 found that roughly 2.41 billion people around the world have conditions that would benefit from rehabilitation services.

  2. This study challenges the idea that rehabilitation is a “service for the few.”

John McKenna, Associate Editor, BreakingMED™

Coauthors Causey and Hanson reported personal feed from WHO during the conduct of the study. The remaining study authors had no financial interests to disclose.

Taylor is a co-investigator of the REACH-HF trial of home-based cardiac rehabilitation in people with heart failure. Zwisler and Uddin had nothing to disclose.

Cat ID: 192

Topic ID: 86,192,393,192,925