The Lancet: One in three people worldwide could benefit from rehabilitation at least once in the course of their illness or injury, first global study estimates
Published December 1, 2020
**Country-level data available**
- Need for rehabilitation services, such as physical and occupational therapy or speech and language therapy, has increased 63% since 1990, from 1.48 billion to 2.41 billion people who could benefit at least once in the course of their illness or injury
- The rise in need is mostly a result of growing and aging populations, but some conditions, such as short-sightedness in children, have increased in prevalence.
- Lower back pain (568 million people), hearing loss (403 million people), and bone fractures (436 million people) accounted for the greatest need for rehabilitation therapies.
- Low back pain is associated with the highest need for rehabilitation in 160 of 204 countries, including the US (52 million people) and the UK (9 million people). In India, the greatest need is for fractures (90 million people), and in China, it is hearing loss (95 million). 
- China (460 million), India (411 million), the US (149 million), Indonesia (76 million) and Brazil (70 million) are the top five countries in terms of greatest number of people in need of rehabilitation services. However, the countries with the greatest need in terms of rate per 1,000 people were Slovenia (515 per 1,000), Bulgaria (511 per 1,000), Czech Republic (502 per 1,000), New Zealand (494 per 1,000) and Bosnia and Herzegovina (493 per 1,000). 
- Authors argue rehabilitation services, which include physical and occupational therapies, as well as assistive devices such as hearing aids, are often seen as expensive and specialised, but their findings should overturn that thinking.
As many as one in three people worldwide (2.41 billion people) could benefit from rehabilitation (such as physical and occupational therapy or speech and language therapy) at some point in their illness or injury, according to estimates published today in The Lancet in the first global study of its kind.
This includes 568 million with low back pain, 732 million people with hearing and vision loss, and 1 billion with injuries such as fractures, amputations, spinal cord injury, traumatic brain injury or other injuries.
When selecting health conditions to include in the study, the researchers included any that may benefit from rehabilitation at any point during the course of the disease or illness. They caution that their findings do not mean that 2.41 billion people have immediate need for rehabilitation therapies at any one time.
Dr Somnath Chatterji, one of the authors of the study, from the World Health Organization, said: “Rehabilitation services are often seen as a fallback strategy when preventive or curative interventions have failed, or as a disability-specific service needed only by a minority of the population. Our findings turn that thinking on its head, as we show that rehabilitation therapies are needed by 2.41 billion people worldwide at some point during their injury or illness. As people are living longer, but often with disability, we believe rehabilitation services require urgent attention from political leaders to give people the best chance of living a healthy life.” 
Rehabilitation is a type of care or intervention that people need when the abilities they require for daily life become compromised, either as a result of ageing or a health condition or injury. These abilities could be physical, mental or social. Examples of conditions that benefit from rehabilitation include vision or hearing loss, neurological disorders, difficulties with mobility, and autism.
Rehabilitation services have been shown to be cost effective and studies have shown they can provide a successful model of care for various health conditions in low and lower-middle income countries [3,4]. However, rehabilitation has not been prioritised in many countries and is often under-resourced.
Dr Alarcos Cieza, lead author of the study, from the World Health Organization, said: “Rehabilitation is often seen as a very specialised and expensive service, but that is not necessarily true. Bringing these services closer to the community, by integrating with primary care for example, could be a cost-effective way to scale up provision to reach all those in need. Integrating rehabilitation into training and certification for doctors in general practice could be one way to help achieve this, as well as educating and empowering other healthcare professionals to be an integral part of the process.” 
This study is based on data from the Global Burden of Diseases, Injuries and Risk Factors Study (GBD) from 1990 to 2019 (the latest year for which data is available), which estimates the incidence and prevalence of more than 300 diseases and injuries . It also estimates the disabling consequences of those conditions in all countries, including the years lived with disability for each illness (YLD, i.e., time spent in less than optimal health), calculated by multiplying the prevalence of a health condition by the short- or long-term loss of health associated with that condition.
The researchers selected 25 health conditions from the GBD study based on those with the highest number of associated years lived with disability. They excluded conditions for which rehabilitation is not essential and added others where rehabilitation is considered a key intervention as part of an overall management plan. The conditions selected explain 77% of the total years lived with disability globally and can be broadly categorised into musculoskeletal disorders, neurological conditions, sensory impairments, mental disorders, chronic respiratory diseases, cardiovascular diseases and cancer. The team used mathematical modelling to account for people who experience multiple health conditions at the same time.
The researchers analysed data for all 204 countries and territories in the GBD study. They also pooled the data from individual countries into seven regions of the world: World Bank High Income countries and all six of the WHO regions, excluding the high-income countries from each region .
Overall, the researchers found the total number of people living with one or more of the health conditions that would benefit from rehabilitation therapies has increased 63% worldwide since 1990, from 1.48 billion to 2.41 billion. For conditions such as low back pain, this increase is due to population growth worldwide and people living longer, rather than an increased prevalence of health conditions, the researchers say.
The prevalence of rehabilitation need was nearly equal between men and women (1.19 billion men, 1.22 billion women), but women experienced more years lived with disability than men (men, 146 million YLD; women, 163 million YLD).
The study also provides detailed region and country-specific information on the disease areas that contribute the most to rehabilitation needs. For example, the greatest need for rehabilitation services was found in the Western Pacific, which includes China (610 million people and 83 million YLD). The Eastern Mediterranean region, which includes north African countries and the Middle East, had the lowest need for rehabilitation services, but the need was still high (182 million people, 22 million YLD). Further country-level data available. 
The greatest need for rehabilitation in terms of number of people was found in China (460 million people), followed by India (411 million), the US (149 million), Indonesia (76 million) and Brazil (70 million). However, in terms of rate per 1,000 people, Slovenia (515 per 1,000), Bulgaria (511 per 1,000), Czech Republic (502 per 1,000), New Zealand (494 per 1,000) and Bosnia and Herzegovina (493 per 1,000) are the five countries with the greatest need. 
Musculoskeletal disorders were responsible for the biggest need for rehabilitation services worldwide, affecting 1.71 billion people and accounting for 149 million years lived with disability. Among those, lower back pain caused the highest burden and was the most prevalent condition in 160 out of 204 countries, with 568 million people affected and 64 million years lived with disability globally.
Another group of conditions that makes a significant contribution to the overall need of rehabilitation is injuries. Almost 1 billion people live with the consequences of fractures, amputations, spinal cord injury, traumatic brain injury or other injuries, the study estimates. Of these, bone fractures represent the greatest need, accounting for 436 million people.
Sensory impairments, including hearing and vision loss, were also a large contributor to rehabilitation needs in terms of number of people (732 million people). They are amongst the largest contributors to the need for rehabilitation in children under 15 and older adults, the study found. This can be largely attributed to the growing increase in conditions such as short-sightedness in school-aged children, and an increase in the number of older adults with age-related conditions such as glaucoma and age-related hearing loss, the authors say.
The authors argue that operating rehabilitation services through primary care could offer an opportunity to intervene early in the course of a person’s illness and reduce the disabling consequences of chronic conditions. Offering these services closer to home would also allow people to stay in education and the workforce, and to remain independent for longer, leading to significant cost benefits for both the individual and society.
The researchers acknowledge that the available evidence on the effectiveness of rehabilitation for certain health conditions is limited. They also note several limitations to their study. Notably, where there are no primary data on disease prevalence, estimates rely on predictions based on geographical proximity to countries that do have data. Although the researchers accounted for people who may experience multiple health conditions at the same time, their analysis may not have captured all overlapping conditions and so may have led to an over-estimation of prevalence. However, the number of people in need of rehabilitation may also be an underestimate because only 25 conditions were selected for analysis, the researchers say.
Writing in a linked Comment, Professor Rod Taylor, from the University of Glasgow, who was not involved in the study, said: “As with all predictive modelling, these numbers are subject to some uncertainty and are framed around some key assumptions: the choice of 25 conditions, how to quantify the impact of comorbidity and the reliability of previously derived disability weights. Nevertheless, the authors are to be congratulated. They provide much-awaited baseline information on rehabilitation needs by disease, age and WHO region that can be used to lobby service providers, policy makers and governments to set priorities to act and address those needs. Given that such lobbying often happens at a country level, the presentation of more granular data will be important in the future.”
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