Int Rehab Med 1979.1.208-212 0 EULAR PUBLISHERS Bade
REVIEW
Rehabilitation Medicine in Sweden Part 1 - Organizational concepts
Olle Hook
Insiitute of Rehabilitation Medicine, Universiry of Goteborg
The Swedish National Board of Health and Wel- fare recently presented the general outlines of its program for rehabilitation medicine (1). The recom- mendations previously available were the “Advice and Directions” issued in 1964 by the National Board of Health, for the detailed organization of departments of rehabilitation medicine at central general hospitals and instructions for the care of paraplegics.
The aim of the new program is to bring rehabili- tation medicine into line with the general changes in health and medical services according to the new organization plan for Swedish health.
Increasing need for rehabilitation With due reservation for uncertainty factors for
such estimations these are the facts for Sweden* - about 500,000 adults between 16 and 64 years of age have impaired physical function, and about 100,000 of these are severely ADL-handicapped, i.e. have difficulty in coping with the activities of daily living. Nearly 30,000 persons of all ages have to use a wheel-chair. About 190,000 persons sick- listed for 90 days or more are recorded annually. It is estimated that one-third of these, or about 60,000 need to undergo investigation with a view to possi- ble rehabilitation measures. In many instances these examinations have to be done at medical rehabilita- tion units.
The number of pre-retirement pensioners, which in January 1967 was just over 167,000, nearly dou- bled over a 10-year period, amounting in January 1976 to 297,000. At least half of these were under
Sweden’s population is 8,300,000
60 years of age. Even taking into consideration the fact that disability pensions are granted today for many different reasons, the number in this category of pensioners is alarmingly high. In all probability, the main reason why it has not been possible to offer many handicapped persons a more active life is our lack of sufficient resources for rehabilitation.
Between 135,000 and 140,000 persons who have sustained occupational injuries are recorded annually. About 3,000 of these become incapacitat- ed, and severe invalidism (of 50 per cent or more) arises in about 200 cases.
About 16,000 persons are hospitalized annually for injuries resulting from traffic accidents. Accord- ing to the report “Road Accidents and Medical Costs” (SOU 1975:13), the annual expenses incurred by the community for medical care in connection with road injuries is estimated to have exceeded 220 million Swedish crowns* in the early 1970s.
An investigation carried out on sequelae follow- ing traffic accidents in a year’s hospitalized cases (1 965-1 966) in the Uppsala region showed that 5 1 per cent of the patients were still suffering from some form of after-effect five years later. Serious physical disability was noted in 3 per cent. Seven per cent had been affected mentally, and for 18 per cent the injury had caused social problems. These per- centages, if applied to the whole country, indicate an annual addition of 7,000-8,000 persons with seque- lae resulting from traffic accidents. Slightly over 6,000 would probably have relatively moderate aft- er-effects. 1,400 would have more serious sequelae,
.
$l.OOU.S. = 4.35 Swedish Crowns (February 1979)
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HOOK: REHABILITATION MEDICINE IN SWEDEN. PART 1
and 450 would be severely incapacitated. This inves- tigation also showed that in 9per cent of the patients in the material the rehabilitation measures did not give wholly satisfactory results, due in part among other things to insufficient medical check- ups. This rate corresponds to about 1,000 persons annually, for the whole country (2).
Among patients severely injured in road acci- dents, those with spinal-cord injuries require special skills for rehabilitation. Whereas an investigation in 1953 showed that about 50 persons became severely disabled annually, through traumatic spinal lesions, more recent studies reveal that the annual increase of such cases is now approaching an annual total of 150. Although that annual spinal-injury rate may seem relatively low, the survival time today is long. As those who sustain injury are often young people the average survival time may be estimated to be 25 years. This means that at present there may be between 3,000 and 4,000 survivors with spinal-cord injury.
Structure and componentsof the rehabilitationservice The following points have been proposed in the
program : All treatment (somatic, psychosocial etc.) coordinated and concentrated in time and based on a holistic view of the patient and his situation. Medical rehabilitation activities coordinated for the medicare area. Medical rehabilitation services decentralized to the greatest possihle extent, and with the main emphasis on primary health care. A medically trained team cooperate in planning rehabilitation activities and developing treatment methods. Department of rehabilitation medicine with high-quality resources for medical care and treatment, as nuclei in the rehabilitation work localized in all counties. Cooperation between rehabilitation medicine and other forms of medical care in the use of treatment resources. Established research and reporting procedures.
Fig. 1: The geographical distribution of the medical rehabilitation services in June Z977.
Table I Extent of the medical rehabilitation services up to June 1977
AB
C D E F L M
OA P T U AC
Karolinska sjukhuset (KS) KS’s after-care unit at Roda Korsets sjukhus Siidersjuk huset (SOS) Danderyds sjukhus Akademiska sjukhuset Eskilstuna sjukhus Linkopings regionsjukhus Jonkopings sjukhus Kristianstads sjukhus Lunds sjukhus Orups sjukhus Sahlgrenska sjukhuset Boris sjukhus Orebro regionsjukhus Vasteris sjukhus Umei regionsjukhus
Total number of beds
Hospital care
1)
923) 1)
22 4)
28 20 18 6
10 675) 436) 60’) 27 41 14*)
448
~ ~~
Day care
2)
53) 45 30 20 20 10 18 20 20
2 90
15 15 30
340
1 ) The neurologic units at KS and SOS have special depart- ments for rehabilitation, with 12 and 6 beds, respectively. The departments are managed by doctors specially engaged for the purpose.
2) Unspecified number of day beds. 3) In accordance with a special agreement the beds are avail-
able for the after-care of patients from KS, especially for those from the departments of internal medicine and sur- gery,
4) The rehabilitation unit at Akademiska hospital was expected to have 20 beds for hospital care in 1978.
5) The beds are also used for long-stay and after-care patients.
6) 18 beds are intended mainly for neurologic cases. 7) 20 beds are intended mainly for neurologic cases. 8) The beds are at present used mainly for neurologic cases
Earlier recommendations from the National Board of Health (1964), stated that “for a catch- ment area comprising 200,000 persons, 30 beds would not seem to be too many”. It was also sug- gested that special beds for paraplegic patients should be available in 4 regions: in UmeA for Norr- land, in Uppsala or Stockholm for Central Sweden, in Gothenburg for Western Sweden, and in Lund or Malmo for Southern Sweden.
The present Commission has found it more diffi- cult to prescribe the size of the rehabilitation units. Their size will depend on the resources available for rehabilitation within the medicare area.
The distribution of rehabilitation medicine serv- ices in June 1977 appears in Figure 1 and Table I.
The National Board of Health and Welfare has proposed a model plan for extending health and medical services with goals to be achieved in 10 or 15 years. This model has also guided the planning
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Int Rehab Med Vol 1 No 4- 1979
for rehabilitation medicine which - if rapid expan- sion is to be achieved - must place special emphasis on primary care.
In the recommended model, the health and medi- cal plan specifies three units: regional services, county services, and primary-care services.
The Commission points out that in addition to the unit at the regional hospital “there should also be a unit for rehabilitation medicine at the central gen- eral hospital of the county, to handle the special work of rehabilitation medicine in each area served by the hospital. This unit, besides having certain coordinating functions, should be reserved for com- plicated cases and those presenting problems of interpretation, and for cases needing the attention of several medical specialities simultaneously.
Certain possibilities for medical rehabilitation treatment should also be available at the smaller general hospitals of the county.
A service to provide technical aids should be available at all levels.”
The program also includes the suggestion that, besides certain coordinating functions, the rehabili- tation unit could also be responsible for the follow- ing duties:
To take charge of patients with mainly somatic diagnoses, for skilled rehabilitation work in the form of investigations, sup- plementary examinations, treatment programs and other suggestions for suitable measures, training, coordination and
To act as a service unit for other departments within the relevant hospital, in physiotherapeutic and occupational ther- apeutic matters and in the management of technical aids and appliances. To have good contacts with other bodies and institutions with rehabilitation functions, as for instance The Social Insurance Board, The Central Board for Social Welfare, and the Public Employment Office, since their services can often enhance the resources and competence of the rehabilitation unit. To promote development of methods and encourage continuity and cooperation in the rehabilitation work. To conduct training in rehabilitation medicine.
After having studied some of the Swedish depart- ments of rehabilitation medicine, the Commission has summed up in outline the forms of treatment in use at present:
Medical treatment, as for example continuation of measures already prescribed earlier. Remedial gymnastics with function testing and functional training as well as other forms of physical therapy such as thermotherapy, electrotherapy, and hydrotherapy. Occupational therapy with function testing and functional training, as for example ADL and occupational training. Measures connected with technical aids, as for example fit- ting, training in the use of ADL-aids. and testing of new appliances. Measures with a vocational bearing, as for instance supportive pedagogic and vocational counselling. Measureswith a bearing on the environment,asforinstance ergo- nomic measures connected with housing,education,andwork. Measures of a psychiatric or psychologic nature, as for exam- ple psychotherapy and supportive measures in family matters. Measures connected with social problems, advice and assist- ance on different personal matters such as domestic problems and financial arrangements.
follow-ups.
Particular mention should be made of the special- ist training given at rehabilitation units, which calls attention to new methods in the fields of physio- therapy and occupational therapy and new technical aids for the handicapped. Rehabilitation medicine is the only specialty which gives systematic instruction in these subjects.
Demarcation from long-term Care Coordination between rehabilitation medicine
and long-term care has been under discussion in various connections.
Although the work in long-term care is in some respects similar to that of rehabilitation medicine there are also considerable differences, as for exam- ple in the age of the patients, the functional impair- ment, and the possibilities for profiting by different forms of treatment. The two services, to some extent, have different goals. It might also be stressed that the physicians in charge of long-term care must be well trained in gerontology whereas physicians in rehabilitation medicine must know physical medi- cine, vocational counselling, etc.
The patients in long-term care are for the most part elderly. About three-fourths of them are over 70 years and roughly half of them are over 80 - a trend in the direction of increasingly high ages is predicted for some time to come. This will obviously have a significant effect on the plans for the service.
In this connection, the Board of Health and Wel- fare expresses the following viewpoints in its pro- gram: “Many old people require care and attention over a long period but they do not have the same needs and possibilities for utilizing the intensive training and treatment of the type given to persons of working age. This is one of the distinct differ- ences between the long-care service and the medical rehabilitation service. Another essential difference is that the medical rehabilitation service seeks to apply measures which are more clearly oriented towards the labour market. The goal of the rehabilitation is in general to facilitate a return to some form of work, or to resettlement. This requires special coor- dinating and cooperating contacts, as well as a knowledge on the part of the staff concerning the problems encountered in the placement of the dis- abled on the labour market.
Thus, these arguments would indicate that an amalgamation of the two services is unsuitable, and that they should continue to operate as two separate entities. However, close cooperation is necessary in consideration of the many similarities between the two services as well as of the considerable advan- tages to be gained, for instance, through the use of common resources for treatment and through other joint activities of various kinds.
Another point stressed in the program is that according to studies of patients at rehabilitation units, the number of patients on sick leave or absent
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HOOK: REHABILITATION MEDICINE IN SWEDEN. PART 1
from work for at least one year before the prelimi- nary assessment at the unit is very high. At one department for rehabilitation medicine in the Stock- holm area, an investigation carried out a few years ago revealed that only 25 per cent had presented themselves for examination and treatment within three months from the first day of sick-listing or the last day at work. This indicates that resources - especially for early referral - do not correspond to rehabilitation needs.
Primary health care Stress has also been laid on the fact that if satis-
factory medical care is to be achieved by the prima- ry-care services it is necessary that resources allow- ing continuing treatment, training and other mea- sures for the handicapped and others should be available at that level. I t is also desirable for one of the doctors in the primary-care service to possess a good knowledge of rehabilitation medicine. Phy- siotherapists and occupational therapists play an important part in the rehabilitation work in primary care, and they should be available in sufficient num- bers. Advice and guidance in the work, in the form of treatment programs or similar measures, in the case of patients in need of special attention, should be given by specialists from the county medical care services. This consultative requirement could be met through regular visits by staff members from the medical rehabilitation unit.
One of the more important tasks for the primary- care services would seem to be cooperation in the rehabilitation of persons suffering mainly from med- icosocial handicaps. For this group, it is mainly a question of social adjustment not so much of the individual himself, but of the social background. It is the responsibility of the social welfare service to see that the necessary measures are taken; the medical cooperation that could be relevant in certain cases ought to be mainly applicable at the primary-care level.
It will take time before the new, coordinated pri- mary-care service has become fully organized in Sweden, and the program, therefore, looks toward a wider cooperation in the rehabilitation and disable- ment sector than exists at present. This could be achieved through a provisional arrangement, pend- ing the development of more established forms of cooperation within the primary-care service. Among other things, it would be desirable to arrange work- ing routines giving the district medical officer the possibility of maintaining close contact with the medical rehabilitation unit.
Patients with spinal cord injuries It is reported in the program that about 150 cases
of traumatic spinal cord injury are recorded annually in Sweden as well as about SO-100 cases of spinal lesions resulting from disease of the spinal
cord (tumours, myelitis, multiple sclerosis, etc.) who need specialized comprehensive rehabilitation care. The number of patients suffering from spinal cord injury is not large enough to allow the central gen- eral hospitals of the counties to acquire both a rou- tine and sufficient experience to ensure adequate treatment. It is stressed, therefore, that the more competent preliminary treatment must usually be carried out at a regional hospital.
I will add the following viewpoints in this connec- tion:
The necessity of admitting the patient at once,. as an emergency case, to a spinal unit has been stressed by all competent specialists. Only then can the patient have: 1 A joint assessment, in the acute stage, by a team
of doctors experienced in this type of case, among others a neurosurgeon, an orthopedic surgeon, a urologist, and a rehabilitation doctor, for the planning of the initial treatment, especially in cases of traumatic injury.
2 Intermittent catheterization under scrupulous aseptic conditions - if this can be organized - from the first day, by a staff with special training in this work. This will result in patients with bet- ter bladder function and a much lower rate of complications such as urinary tract infections, uri- nary and renal calculi, epididymitis and orchitis, and urethral structures.
3 Early mobilization achieved with a so-called halo- vest, by early fusion and/or by some form of grad- ual, carefully regulated tilting on a tilting table.
4 Prophylactic treatment against thrombo-embol- ism from the first day onwards.
5 Prophylactic treatment against decubitus. 6 Training of intact muscles, maintenance of joint
mobility, compensatory functional training, tech- nical aids, reorganization of the home and occu- pation, discussion regarding psychosocial func- tions and other such aspects.
7 Greater possibilities for preventing other compli- cations such as osteoporosis and vasomotor dis- turbances.
8 The possibility of performing reconstructive hand surgery in patients with tetraplegia. These opera- tions can only be carried out at a few centres, since the surgeon needs to have constant experi- ence in performing them and every tetraplegic patient has individual differences as regards the remaining muscle innervation. The goal is optimal independence, with retained
(or alternative) social relationships (family, work, leisure time).
I t is of great importance that we in Sweden, with our comparatively well-developed medical services, should create adequate facilities for taking charge of these patients in the acute stage at special units, in order to prevent complications. As is often the case in other countries, these spinal
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Int Rehab Med Vol 1 No 4 - 1979
units should be attached to a rehabilitation unit, so that they may utilize the administrative responsibil- ity of the unit, where the staff also has the training necessary for this group of patients.
Questions regarding resources The Commission has also touched upon staff
problems and the present shortage of physiotherap- ists, occupational therapists and doctors with spe- cialized training. However, it is expected that the shortage of doctors will gradually be remedied as a result of the increasing numbers of qualified doctors. The supply of doctors undergoing further education and of those who have completed their post-gradu- ate training and are actively engaged is expected to increase by 50 per cent between 1976 and 1985.
References
1 . The Swedish Board of Health and Welfare, Principle program
2. THORSON J. Long-term effects of traffic accidents. Thesis.
3. Concepts and organization of rehabilitation medicine in Swe-
for rehabilitation medicine, Stockholm 1978.
Stockholm: Karolinska Institute, 1973.
den. Lakartidningen 1976; 20: 1912-1915 (in Swedish).
Reprints from: Olle HMk, M.D., Institute of Medical Rehabilitation, Owe Husargatan 36, S-413 14 Goteborg, Sweden.
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