Adv. Cardiol., vol. 24, pp. 187 -191 (Karger, Basel 1978)
Activities of Rehabilitation International K.
RENKER
It is a great honour for Rehabilitation International to be a co-organizer of this First International Congress on Cardiac Rehabilitation. On behalf of Rehabilitation International I wish to offer my most cordial congratulations to the Council on Rehabilitation of the International Society of Cardiology on the success of this congress. At the same time we wish to accentuate the extraordinary performances of Mr. DENOLIN and Mr. KoNIG. We are grateful to them for the pleasant collaboration in the preliminary phase of this meeting. Rehabilitation International, a non-governmental international organization comprehends 80 countries and 130 organizations. With the aid of the Council of the World Organizations Interested in the Handicapped (CWOIH), the president of which is the Secretary General NORMAN ACTON, we co-ordinate the work of 46 important international organizations in the field of the rehabilitation of the disabled. Rehabilitation International is a working organization dealing with quite variant questions of rehabilitation. In all parts of the world, it renders help to introduce and improve the rehabilitation. A vital component of our efforts is the regional working in the world. This is achieved by the national secretaries in each country, together with the Council Members residing in the respective regions forming a corporation, every year holding a meeting. They pursue the purpose to exchange experiences, to develop programmes, and to render the activities of Rehabilitation International ever improved. Guided by the Rehabilitation International vice-president for Europe, Dr. TERESA SERRA, Rome, 11th regional meeting for Europe, e. g., was hold in Budapest, in April 1977. Important activities of Rehabilitation International also are (a) counsels for developing countries; by the aid of Rehabilitation International the Institute for Rehabilitation of the Disabled in the Developing Countries in Teheran was set up; rehabilitation services in these countries are developed
Downloaded by: University of Cambridge 131.111.164.128 - 3/20/2019 8:32:07 AM
Faculty of Medicine, Hygiene Institute and Department of Social Hygiene, HaIle/SaaIe
188
and turned working by the aid of Rehabilitation International experts; (b) realization of courses of instruction and conferences; participants from more than 85 countries took part in such courses till now; (c) advising in questions of rehabilitation; (d) loaned supply with films, and (e) information service. A peculiar support of the work of Rehabilitation International is constituted by the Standing Commissions. These international commissions deal with single questions of rehabilitation. Experts of the respective spheres from the member countries belong to them. The four chief commissions are the Rehabilitation International Social, Educational, Vocational and Medical Commissions. A recent Rehabilitation International Commission for Administration and Organization was settled in 1976. An important world-renowned Commission is the sixth one, the International Commission for Technical Aids (lCTA). Thus, Rehabilitation International attempts its best, since 55 years, to help to solve the great problems of rehabilitation in the world. Today, the Rehabilitation International Medical Commission co-operates well with 19 international medical organizations in order to help to solve the problems of the medical rehabilitation universally. The symposium of this international commission in HallejSaale (GDR), from June 13 to 16, 1977, showed the advance in this direction. The extent of the problems is presented very well by the WHO Policy and Programme for Disability Prevention and Rehabilitation, accepted unanimously by the 29th WHA (A 29 Inf.Doc.jl). According to it, at least 400 millions of disabled persons exist in the world, a great part of which indeed needs rehabilitation, but does not receive any measures of the like or only insufficient ones. The second International Seminar of the Rehabilitation International Medical Commission at HallejSaale in October 1973 dealt with the rehabilitation of chronically sick persons, among them also cardiac-circulatory patients. In general, the participants were of the opinion that an exact definition of the concept 'chronic disease', existing along with long-term disease and permanent disability, is not absolutely necessary. The treatment methods in the activation field are generally similar to each other. There also are diseases, possibly capable of transgressing into a chronic state, but later on appearing curable, as for instance cancer and certain cardiac-circulatory diseases. Chronically sick persons do not suffer only from the primary impairment, but also from a retardation of their physical and psychical efficiency and their reduced social competence, e. g. by isolation, inactivity and vocational unfitness.
Downloaded by: University of Cambridge 131.111.164.128 - 3/20/2019 8:32:07 AM
RENKER
189
The methods of activating therapy necessary for the treatment of chronically sick persons are ergotherapy (general activation, functional training, preparation for and orientation on the vocation), psychotherapy, social activation (including reliance on vocational services of rehabilitation), and sports therapy. These forms of activating therapy generally are applicable to all diagnostic groups - also for cardiac-circulatory patients, though for several patients and groups particular variants in the treatment programmes become necessary. The use of activating therapeutic forms should be an essential part of the entire medical treatment also in the field of rehabilitation of cardiaccirculatory sick person. To the tasks of an institution for medical rehabilitation belong the instruction and education of physicians and nurses during and after the study in this field, playing an important role in the instruction of physiotherapists, ergotherapists, and the other personnel within the rehabilitation teams. It is possible to reconcile herewith the diagnostic and therapeutic necessaries of chronically sick persons, particularly the cardiac-circulatory patients. At present, seen internationally, the attention is mainly concentrated on the acute appearance. An alteration of this approach is dependent, to a great extent, on the success of the efforts in the instruction aiming at the goal to alter the opinion on long-term or chronic impairments in our society. The obvious necessity of co-operation with professional groups exterior to medicine means the obligation to instruct also these to a sufficient extent. We do not desire to enter into details of the extant systems of rehabilitation. This is done by the WHO programme. We only want to mention that there are more or less rehabilitation systems being governmental or governmentally sponsored. Such ones exist with regard to the special school system, for the medical and vocational rehabilitation. They function more or less internationally for the blind, deaf, motion-disabled, and in the field of psychiatry. We fully join the opinion of the WHO recommending the utilization of extant systems. The improvement of specific centres is expensive. Only rich countries can afford such systems. The utilization of organizational forms of public health for the rehabilitation of cardiac-circulatory sick persons, therefore, is the means of choice. Therein any possibility of sterotyping is not given. The national peculiarities of the development of public health care have to be regarded. We only on principle express our opinion to find such organizational forms of high effectiveness for a large group of cardiac-circulatory patients. In this context, the utilization of the system of primary health care is of great importance for the prevention and rehabilitation of the cardiac-circulatory diseases. It is known that we must distinguish
Downloaded by: University of Cambridge 131.111.164.128 - 3/20/2019 8:32:07 AM
Activities of Rehabilitation International
190
three phases of rehabilitation in case of cardiac infarction: the acute phase, the phase of convalescence (restitution) and the phase of post-convalescence or maintenance. Precisely, the latter phase is of great importance for the team-work of different experts of rehabilitation; it is the phase of maintenance and further enhancement of the physical and psychical capacity performance achieved during the second phase, by a health training programme to be carried out regularly ambulatorily, connected with all further measures of rehabilitation. If during the third phase the main tasks consist of steady medical care, occupational therapy, and other forms of activating therapy and training in the sense of sports therapy, then it is even possible to organize this system not only particulary for persons suffering from heart diseases, but to rehabilitate in this way disabled persons with different kinds of handicaps together. This also has a positive psychological effect. Especially the team-work in the field of medical and vocational rehabilitation seems to us to be of importance. Rehabilitation International organized by the aid of Rehabilitation International Medical and the Rehabilitation International Vocational Commission an inquiry on this set of problems. Rehabilitation International offers its experiences just in this field. It has as a comprehensive non-governmental organization good relations to all centres of the vocational rehabilitation and it is able to assist the clinician in this field. The clinician has to assert something about the loading capacity of the disabled. The person being responsible for the vocational rehabilitation, then, has to find the correct place of employment. The full use for the disabled emerges only in case of a seamless team-work here. To this also belongs that the physician takes care that the necessary confidential well-timed flow of information to the person responsible for the vocational and social rehabilitation is guaranteed in order to introduce all measures of rehabilitation in time. For this purpose, one has to reason out anew the vocational rehabilitation and the special nosological groups, according to the morbidity of the population. The vocational rehabilitation at present mostly has fixed its aim to retrain younger people having an impairment into other jobs or vocational possibilites. But cardiac infarction and hypertonia concern divergent groups of vocation and age than hitherto. We are to a large extent confronted with members of highly qualified vocational categories. By retraining we cannot achieve anything here. Rehabilitation also means alteration of the organization of work! Therewith, prophylactic and health-educative aspects gain an increasing importance. We agree with the WHO on considering rehabilitation and pre-
Downloaded by: University of Cambridge 131.111.164.128 - 3/20/2019 8:32:07 AM
RENKER
Activities of Rehabilitation International
191
Prof. Dr. sc. med. K. RENKER, Faculty of Medicine, Hygiene Institute and Department of Social Hygiene, Martin Luther University, Halle-Wittenberg, Harz 42-44, GDR-402 Halle/Saale (GDR)
Downloaded by: University of Cambridge 131.111.164.128 - 3/20/2019 8:32:07 AM
vention in their unity. The present knowledge on the causes of ischaemic cardiac diseases, hypertonia, and the peripheral tissue diseases allows an efficient prevention so that these cases of illness and invalidity might be restricted substantially. We also want to point out that the cardiac-circulatory diseases are based for the most part on social conditions, that is out of the social environment of man. Therefore, the consideration of man in his sociobiological unity is important. We believe the study of the interrelations between social factors and cardiac circulatory diseases as well as the elaboration of measures for the promotion of health and prevention of cardiac-circulatory diseases to be as important as the development of rehabilitation programmes. In our opinion, it is important to unite two systems: (a) the general system of rehabilitation (in many countries still too one-sidedly directed to the locomotor system and the psychical disabilities) and (b) the system of diagnostics, therapy, and metaphylaxis in cardiac-circulatory diseases. The latter system, hitherto, means not yet rehabilitation in the classic sense. Rehabilitation is defined by the WHO as 'the combined and co-ordinated use of medical, social, educational and vocational measures for training or retraining the individual to the highest possible level of functional ability'. By combining the two systems there will simultaneously emerge a further development of the rehabilitation of cardiac-circulatory patients. With regard to the further research work, we assume that the assessment and evaluation of an impairment of the disabled present the most important problems. We dealt with these problems in Catania at the Third International Seminar of the Rehabilitation International Commission in June 1976. Apart from extreme cases, the assessment and evaluation of an impairment hitherto can be only estimations, at best. In our opinion, it is the task of rehabilitation to offer each disabled person - even the cardiac-circulatory patients - a comprehensive health care as well as to meet the following criteria: (1) universality - appropriate services for the whole problem; (2) flexibility - to respond to changing patterns of diseases and handicaps, advances in technology and changing social structures; (3) accessibility - for all those who require it; (4) comprehensiveness - covering all aspects of rehabilitation, effectively co-ordinated and directed; (5) continuity - from the onset of disease or disability, and (6) completeness - until the disabled person is reintegrated into society.
Activities of Rehabilitation International K.
RENKER
It is a great honour for Rehabilitation International to be a co-organizer of this First International Congress on Cardiac Rehabilitation. On behalf of Rehabilitation International I wish to offer my most cordial congratulations to the Council on Rehabilitation of the International Society of Cardiology on the success of this congress. At the same time we wish to accentuate the extraordinary performances of Mr. DENOLIN and Mr. KoNIG. We are grateful to them for the pleasant collaboration in the preliminary phase of this meeting. Rehabilitation International, a non-governmental international organization comprehends 80 countries and 130 organizations. With the aid of the Council of the World Organizations Interested in the Handicapped (CWOIH), the president of which is the Secretary General NORMAN ACTON, we co-ordinate the work of 46 important international organizations in the field of the rehabilitation of the disabled. Rehabilitation International is a working organization dealing with quite variant questions of rehabilitation. In all parts of the world, it renders help to introduce and improve the rehabilitation. A vital component of our efforts is the regional working in the world. This is achieved by the national secretaries in each country, together with the Council Members residing in the respective regions forming a corporation, every year holding a meeting. They pursue the purpose to exchange experiences, to develop programmes, and to render the activities of Rehabilitation International ever improved. Guided by the Rehabilitation International vice-president for Europe, Dr. TERESA SERRA, Rome, 11th regional meeting for Europe, e. g., was hold in Budapest, in April 1977. Important activities of Rehabilitation International also are (a) counsels for developing countries; by the aid of Rehabilitation International the Institute for Rehabilitation of the Disabled in the Developing Countries in Teheran was set up; rehabilitation services in these countries are developed
Downloaded by: University of Cambridge 131.111.164.128 - 3/20/2019 8:32:07 AM
Faculty of Medicine, Hygiene Institute and Department of Social Hygiene, HaIle/SaaIe
188
and turned working by the aid of Rehabilitation International experts; (b) realization of courses of instruction and conferences; participants from more than 85 countries took part in such courses till now; (c) advising in questions of rehabilitation; (d) loaned supply with films, and (e) information service. A peculiar support of the work of Rehabilitation International is constituted by the Standing Commissions. These international commissions deal with single questions of rehabilitation. Experts of the respective spheres from the member countries belong to them. The four chief commissions are the Rehabilitation International Social, Educational, Vocational and Medical Commissions. A recent Rehabilitation International Commission for Administration and Organization was settled in 1976. An important world-renowned Commission is the sixth one, the International Commission for Technical Aids (lCTA). Thus, Rehabilitation International attempts its best, since 55 years, to help to solve the great problems of rehabilitation in the world. Today, the Rehabilitation International Medical Commission co-operates well with 19 international medical organizations in order to help to solve the problems of the medical rehabilitation universally. The symposium of this international commission in HallejSaale (GDR), from June 13 to 16, 1977, showed the advance in this direction. The extent of the problems is presented very well by the WHO Policy and Programme for Disability Prevention and Rehabilitation, accepted unanimously by the 29th WHA (A 29 Inf.Doc.jl). According to it, at least 400 millions of disabled persons exist in the world, a great part of which indeed needs rehabilitation, but does not receive any measures of the like or only insufficient ones. The second International Seminar of the Rehabilitation International Medical Commission at HallejSaale in October 1973 dealt with the rehabilitation of chronically sick persons, among them also cardiac-circulatory patients. In general, the participants were of the opinion that an exact definition of the concept 'chronic disease', existing along with long-term disease and permanent disability, is not absolutely necessary. The treatment methods in the activation field are generally similar to each other. There also are diseases, possibly capable of transgressing into a chronic state, but later on appearing curable, as for instance cancer and certain cardiac-circulatory diseases. Chronically sick persons do not suffer only from the primary impairment, but also from a retardation of their physical and psychical efficiency and their reduced social competence, e. g. by isolation, inactivity and vocational unfitness.
Downloaded by: University of Cambridge 131.111.164.128 - 3/20/2019 8:32:07 AM
RENKER
189
The methods of activating therapy necessary for the treatment of chronically sick persons are ergotherapy (general activation, functional training, preparation for and orientation on the vocation), psychotherapy, social activation (including reliance on vocational services of rehabilitation), and sports therapy. These forms of activating therapy generally are applicable to all diagnostic groups - also for cardiac-circulatory patients, though for several patients and groups particular variants in the treatment programmes become necessary. The use of activating therapeutic forms should be an essential part of the entire medical treatment also in the field of rehabilitation of cardiaccirculatory sick person. To the tasks of an institution for medical rehabilitation belong the instruction and education of physicians and nurses during and after the study in this field, playing an important role in the instruction of physiotherapists, ergotherapists, and the other personnel within the rehabilitation teams. It is possible to reconcile herewith the diagnostic and therapeutic necessaries of chronically sick persons, particularly the cardiac-circulatory patients. At present, seen internationally, the attention is mainly concentrated on the acute appearance. An alteration of this approach is dependent, to a great extent, on the success of the efforts in the instruction aiming at the goal to alter the opinion on long-term or chronic impairments in our society. The obvious necessity of co-operation with professional groups exterior to medicine means the obligation to instruct also these to a sufficient extent. We do not desire to enter into details of the extant systems of rehabilitation. This is done by the WHO programme. We only want to mention that there are more or less rehabilitation systems being governmental or governmentally sponsored. Such ones exist with regard to the special school system, for the medical and vocational rehabilitation. They function more or less internationally for the blind, deaf, motion-disabled, and in the field of psychiatry. We fully join the opinion of the WHO recommending the utilization of extant systems. The improvement of specific centres is expensive. Only rich countries can afford such systems. The utilization of organizational forms of public health for the rehabilitation of cardiac-circulatory sick persons, therefore, is the means of choice. Therein any possibility of sterotyping is not given. The national peculiarities of the development of public health care have to be regarded. We only on principle express our opinion to find such organizational forms of high effectiveness for a large group of cardiac-circulatory patients. In this context, the utilization of the system of primary health care is of great importance for the prevention and rehabilitation of the cardiac-circulatory diseases. It is known that we must distinguish
Downloaded by: University of Cambridge 131.111.164.128 - 3/20/2019 8:32:07 AM
Activities of Rehabilitation International
190
three phases of rehabilitation in case of cardiac infarction: the acute phase, the phase of convalescence (restitution) and the phase of post-convalescence or maintenance. Precisely, the latter phase is of great importance for the team-work of different experts of rehabilitation; it is the phase of maintenance and further enhancement of the physical and psychical capacity performance achieved during the second phase, by a health training programme to be carried out regularly ambulatorily, connected with all further measures of rehabilitation. If during the third phase the main tasks consist of steady medical care, occupational therapy, and other forms of activating therapy and training in the sense of sports therapy, then it is even possible to organize this system not only particulary for persons suffering from heart diseases, but to rehabilitate in this way disabled persons with different kinds of handicaps together. This also has a positive psychological effect. Especially the team-work in the field of medical and vocational rehabilitation seems to us to be of importance. Rehabilitation International organized by the aid of Rehabilitation International Medical and the Rehabilitation International Vocational Commission an inquiry on this set of problems. Rehabilitation International offers its experiences just in this field. It has as a comprehensive non-governmental organization good relations to all centres of the vocational rehabilitation and it is able to assist the clinician in this field. The clinician has to assert something about the loading capacity of the disabled. The person being responsible for the vocational rehabilitation, then, has to find the correct place of employment. The full use for the disabled emerges only in case of a seamless team-work here. To this also belongs that the physician takes care that the necessary confidential well-timed flow of information to the person responsible for the vocational and social rehabilitation is guaranteed in order to introduce all measures of rehabilitation in time. For this purpose, one has to reason out anew the vocational rehabilitation and the special nosological groups, according to the morbidity of the population. The vocational rehabilitation at present mostly has fixed its aim to retrain younger people having an impairment into other jobs or vocational possibilites. But cardiac infarction and hypertonia concern divergent groups of vocation and age than hitherto. We are to a large extent confronted with members of highly qualified vocational categories. By retraining we cannot achieve anything here. Rehabilitation also means alteration of the organization of work! Therewith, prophylactic and health-educative aspects gain an increasing importance. We agree with the WHO on considering rehabilitation and pre-
Downloaded by: University of Cambridge 131.111.164.128 - 3/20/2019 8:32:07 AM
RENKER
Activities of Rehabilitation International
191
Prof. Dr. sc. med. K. RENKER, Faculty of Medicine, Hygiene Institute and Department of Social Hygiene, Martin Luther University, Halle-Wittenberg, Harz 42-44, GDR-402 Halle/Saale (GDR)
Downloaded by: University of Cambridge 131.111.164.128 - 3/20/2019 8:32:07 AM
vention in their unity. The present knowledge on the causes of ischaemic cardiac diseases, hypertonia, and the peripheral tissue diseases allows an efficient prevention so that these cases of illness and invalidity might be restricted substantially. We also want to point out that the cardiac-circulatory diseases are based for the most part on social conditions, that is out of the social environment of man. Therefore, the consideration of man in his sociobiological unity is important. We believe the study of the interrelations between social factors and cardiac circulatory diseases as well as the elaboration of measures for the promotion of health and prevention of cardiac-circulatory diseases to be as important as the development of rehabilitation programmes. In our opinion, it is important to unite two systems: (a) the general system of rehabilitation (in many countries still too one-sidedly directed to the locomotor system and the psychical disabilities) and (b) the system of diagnostics, therapy, and metaphylaxis in cardiac-circulatory diseases. The latter system, hitherto, means not yet rehabilitation in the classic sense. Rehabilitation is defined by the WHO as 'the combined and co-ordinated use of medical, social, educational and vocational measures for training or retraining the individual to the highest possible level of functional ability'. By combining the two systems there will simultaneously emerge a further development of the rehabilitation of cardiac-circulatory patients. With regard to the further research work, we assume that the assessment and evaluation of an impairment of the disabled present the most important problems. We dealt with these problems in Catania at the Third International Seminar of the Rehabilitation International Commission in June 1976. Apart from extreme cases, the assessment and evaluation of an impairment hitherto can be only estimations, at best. In our opinion, it is the task of rehabilitation to offer each disabled person - even the cardiac-circulatory patients - a comprehensive health care as well as to meet the following criteria: (1) universality - appropriate services for the whole problem; (2) flexibility - to respond to changing patterns of diseases and handicaps, advances in technology and changing social structures; (3) accessibility - for all those who require it; (4) comprehensiveness - covering all aspects of rehabilitation, effectively co-ordinated and directed; (5) continuity - from the onset of disease or disability, and (6) completeness - until the disabled person is reintegrated into society.
