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 The
health challenge today (and not only in this country) is centered
upon this point: how to reconcile quality as perceived by the “consumer”
(especially valued and made use of for aspects of personal independence,
subjective wellbeing, good health freely chosen and actively practiced),
with quality as manifestly sustained by objective bio-functional parameters
and evident scientific efficacy.
Rehabilitation seems to be strongly and intimately involved in this challenge.
On the one hand, suffice it to consider that in rehab. one can never
separate the individual from active involvement in the recovery protocol;
and on the other hand, to think of the way our discipline relies on
specific clinical and therapeutic instruments, which because of their
very nature and complexity, demonstrate their effectiveness with more
difficulty than in most of the more traditional branches of medicine.
This is also why it might appear urgent to define efficacious monitoring
instruments for rehab care, which would be accepted by the scientific
world and used by practitioners. Such instruments ought to have as
much capacity to represent sectorial parameters (cells, organs, systems)
as the overall functional parameters of the individual. The WHO indications
in this area confirm this in its new ICIDH-2 classification as targets
that any remedial intervention should aim for: activity and participation.
 It
is nowadays substantially clear that rehab, like any other healthcare
aspect, cannot think of dodging the potentially humiliating “Caudine
Forks” of quantized and scientifically repeatable controls on
assessment procedures, check-up criteria and therapeutic programs.
And so it is that rehab too is absolutely obliged to submit its services,
operations, organizational structures and results to a serious evaluation
of the balance between costs and benefits. Not so much because our
country is in a period of more or less evident economic cut-backs,
as because it is neither ethical nor deontologicaly correct to strengthen
and administer therapeutic (and obviously diagnostic) services when
their qualitative value is not sufficiently sustainable and shared.
 This
has unfortunately sometimes occurred in the past in Italian rehabilitation,
accrediting presumed therapies, spreading superficial news of miraculous
cures, deluding the hopes of the disabled and their families, with
the solitary effect of an economic advantage for the “ santons
and healers” every time. It is therefore essential to defend
both the credibility and the validity of investment in rehabilitation
from such fraud, but first of all to defend the rights of our disabled
citizens.
All of this confirms the urgency and the need for basing the evaluation
criteria on the true contents of substance and the real objectives
in rehabilitation (both as regards efficacy and financial congruity).
The damage and disability are sectorial and necessitate specific therapeutic
interventions (which are also, of course, scientifically accredited
and effective) but the parameters for starting, orientating and controlling
the remedial process cannot be other than primarily global: i.e. founded
upon the “whole-person” dimensions of the activity, autonomy
and participation to be recovered.
 The
central element of this operation of qualification, scientific and
economic at the same time, cannot but be the establishing, on a clear,
explicit and checkable prognosis, of the complex of rehabilitation
interventions, i.e. that which is defined as the “rehabilitation
project”. This is made up of the various care program combinations
from the pools of pharmacology, physiotherapy, kinesitherapy, orthotics
and prosthetics, technological and informatic aids, environmental
adjustments, etc., that are proposed to each individual disabled person
to accept as treatment.
Among the many reasons why it clearly cannot be anyone other than a specialist
in Physical Medicine and Rehabilitation to put the disabled under
remedial therapy is this: only someone with adequate and specific
experience and culture can assume the prognostic responsibility regarding,
contemporaneously, the individual patient and the structure that sustains
the financial burden of the treatments. This is to settle at its roots
any remaining debate with other specialists over their right to independently
carry out such rehabilitative treatment.
 The
scientific roots and professional growth of our discipline now allow
us, calmly and transparently, always to confront this need for the
clear and preventive taking of responsibility by whoever assumes to
treat the person to be rehabilitated. What other meaning could
and should the sacrosanct principle of “informed consensus”
and the citizen's “active involvement” have, in the treatments
that the Health Service could and should, in science and in conscience,
make available in response to the individual's right to health?
This must prevail in all cases: in the face of grave and complex disabilities
just as in less serious situations, or the segmental disabilities
that anyhow very often, even if temporarily, have a bearing on the
subject's independence and quality of life.
In the past (and still nowadays), unfortunately, the remedial treatments
were administered in residential centers or in-office, sometimes very
prolonged and burdensome for the Health Service, only by virtue of
a mistaken welfare and almost charitable sensitivity towards the disadvantaged
and severely handicapped. This has been the behavior defined as compensatory
or substitutory, which instead can only be justifiable in terms of
economico-retirement acknowledgement. It is certainly no longer tolerable
in the clinical therapeutic field. Remedial treatments must only be
offered and carried out if founded upon clear prerequisites and aimed
at achieving precise and declared objectives.
Not for nothing is “Medicine based on the evidence” increasingly
and justly spoken about, and thus undoubtedly also of “Rehabilitation
based on the evidence”.
Another aspect becoming increasingly significant and delicate is the
following: people generally have become increasingly aware of their
subjective rights to health protection, the dimensions (also subjective)
of health have grown, the parameters are contextually broadening concerning
the free choice over what health and what life the individual chooses
to follow.
Returning to that challenge being faced by healthcare generally (and
by rehab, as far as we are concerned) that I mentioned at the start
of this article, it could be summarized in the following three factors
and in how they come into conflict with each other or are composed
in orders of priority:
- social and cultural priorities and values;
- scientific information;
- available resources.
These are definitely not some predetermined and absolute parameters but
rather the function and result of mechanisms (slow or very fast, conscious
and not), partly within the healthcare world and largely deriving
from the world of “politics”. In fact, it seems clear
that the scientific information we avail of is the result of the investment
allocated to research and to the priority goals that “Society”
wanted to lend to this research and, ultimately, to the politico-cultural
mechanisms that guided such research.
 Similarly,
the values that Society is progressively making its own largely come
down from the scientific information and from how it is being “administrated
and distributed”. For instance, if one truly wishes to support
rehabilitation, it would suffice to let this be known, not so much
as an almost miraculous, compassionate and extreme intervention, but
rather as an effective, therapeutic intervention, validated by a welter
of scientific controls, applicable to many different situations and
in every age range, with costs that are proportional to the achievable
advantages.
And finally, it is crystal clear how the available resources are those
that politics and the social value priorities decide to place at the
disposal of this or that sector. Certainly not justified for epidemiological
reasons or for therapeutic efficiency is the investment, for example,
in AIDS or narcotics addiction, in comparison with investment in the
treatment (absolutely not proportional) of cranial injuries or the
handicapped in the elderly population.
Fortunately, there are another two factors inserted, which are shifting
the stationary status that has prevailed for much too long:
- humanization of the treatments;
- freedom of choice.
These are aspects of potent and positive change. This is why rehab can
be capable of interrupting some of the “vicious cycles”
that penalize it. Indeed, the subjective hold and active participation
aspects that a rehab program is obviously able to instill in the disabled
individual are very strong.
Just as natural
are the humanization and personalization that should be features of
remedial treatments. The risk that we have the (moral and scientific)
duty to avoid, is that of instrumentalizing this option in order to
delude or manipulate the user. In this we are aided by the obligatory
principle of rehabilitation based on the evidence.
 The growth of the rehab culture,
activities and structure, can make a substantial contribution to the
overall reform of healthcare in our country. Restating the very role
of the physician and the relationship with patients, and the visibility
and credibility of his/her task, both in professional and social terms.
The physician, then, as the qualified and responsible promoter of
complex systems for the awareness of the values of health and their
concrete practicality, and not just the depositary (a little paternalistic)
of some technical interventions. In the rehabilitation world, this
change has already taken place because of the commitment of physiatrists
and other professionals. It is the fruition of managerial abilities
and financial backing from the many private structures grown and qualified
in this sector. It has happened in the quality of inter-professional
relations and of team involvement in decisions and responsibilities.
Finally, it has been encouraged and sustained by recent regulatory
signals and regional ministerial planning.
And finally, already
existing in rehab as a reality is that rightful practice of checking
the congruity of the treatments given, both towards the scientific
evidence of the effectiveness and the sustainability of the overall
financial costs. In recent years, in fact, the application on the
in-office side of the planned cost ceilings, and on the in-hospital
side of the daily tariffs, has begun to induce a progressive rationalization
of services, although not without many difficulties and disparities.
 It is essential that the Minister
and the Regions complete as soon as possible the cost-checking mechanisms
in relation to the needs and to the quality of the outcomes, and it
is above all necessary that these mechanisms be truly applied to all
subjects, public and private equally. It is likewise urgent to bring
to a conclusion the definition of the accrediting procedures so that
the financial checks can be made parallel and synergic with that of
the guttural and functional ability of the structure proposed for
such cash flows. The Italian rehab structures, public and private,
can and indeed wish to demonstrate their being up to the mark for
this kind of check-over, having for some time consolidated their credibility
on the grounds of quality, competence and professionalism, also internationally.
On these bases we
may say that all the essential investment for the urgent development
of the rehabilitation activities in our Nation is without doubt the
best and most efficacious that the National Health Service could make.
Efficacious and qualified
of itself for the activities it would bring about, but at the same
time powerfully capable of backing up the re-qualification of the
whole healthcare structure: bringing the acute nosocomial structures
back to their specific and proper tasks, favoring the reinstatement
in their own homes of as many as go (the elderly and others too) thanks
to the activities of the General Medicine physicians, co-operating
with the functions of the social welfare services, integrating them.
A lot of the confidence
in these affirmations may be exchangeable for presumption, on the
other hand it is based on a wide-ranging knowledge of the structures,
the culture and the professional abilities of the rehabilitation world
in all the European nations and beyond. In fact, I have the good fortune
and pride of representing, on behalf of my discipline and for a good
8 years now, the Italian FNOOM in the Union of Specialist Physicians
of the European Community and of having recently been appointed (in
Marseilles, April 1999) Vice-President of the European Federation
of Specialists in Physical Medicine and Rehabilitation.
 This may be placed alongside knowledge
of the Italian rehabilitation sector, of its profound and widespread
culture (obviously not only among the specialists in Physical Medicine
and Rehabilitation), of the outcomes achieved despite the enormous
legislative, organizational and economic difficulties of our country's
entire healthcare sector, and of the quality of the structures developed
in all Regions in recent years.
With all this, I
have come to this conviction: the prospects for the activities of
Italian rehabilitation are truly excellent, both as regards the qualitative
side and the cost/benefit ratio, provided that the politico-administrative
decisional responsibilities at ministerial and regional levels continue
in the innovative and coherent commitment that has been the case recently.
Alessandro Giustini
Primario Rep. Riabilitazione
Neuromotoria
Casa di Cura Madonna della
Letizia
Velletri
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