SOUTH AFRICAN PHYSIOTHERAPISTS’ PERCEPTION OF REHABILITATION C T Eales ** L Nowitz *** B M otona INTRODUCTION In a n e d ito ria l c o m m e n t in the S ou th A frican Jo u rn al of P h y sio th erap y (4 1 (1 ):1 9 9 1 ), D avid s p osed the follow ing question: "W h e re d o w e stan d in this c o u n try w ith reg ard to rehabilita­ tio n ? " "D o w e m a n a g e to rehab ilitate o u r p atients fu lly?" "D o w e even try ? " She go es o n to say th at the tim e h as co m e for the p rofession to d e v o te m o re atten tio n and effort to the "reh ab ilita­ tion s c e n e " .1 Th e a u th o rs w e re o f the op in ion that these questions cou ld n ot be a n sw ered in a m ean in gfu l w a y u nless p h y sio th erap ists could define rehabili ta tion accu rately . This p ro m p ted u s to d o an assess­ m en t of S ou th A frican p h y sio th erap ists' u n d erstan d in g and p er­ cep tio n o f reh ab ilitation, as w ell as their ability to define the term "reh ab ilitatio n ". Th e aim o f the 1 9 9 0 's is, acco rd in g to N ad olsk y , an "all o u t effo rt" to im p ro v e, to the g re a te st possible exten t, the quality of p atien ts' lives th ro u g h rehab ilitation 2. In o rd er to p ro v id e reh a­ bilitation serv ices that w ill ach iev e this goal, it b eco m es essential to carefu lly d efine reh abilitation. Th e m o st recen t d efinition o f rehab ilitation b y the W H O in­ clu d es b oth p rev en tativ e an d c u rativ e m easu res as w ell as in volv­ ing th e p atien t and his fam ily in the rehab ilitation p ro cess3. T h e definition o f rehabilitation b y C arad o c-D av ies and Disler (1990), w e feel best d escrib es the w h o le co n cep t o f rehabilitation4. In this d efinition rehab ilitation is d ivid ed into th ree distinctive p h ases, n am ely; • re s to rativ ereh ab ilitatio n • m ed ical rehabilitation • d isability m an agem ent. Th e resto rativ e p h ase em b od ies p rim a ry clinical treatm en t tog eth er w ith c u ra tiv e an d p rev en tativ e m easu res, the aim being to p lan and ach iev e early d isch arg e o f the patient in an op tim al fu n ctio nal state. M ed ical rehabilitation aim s at red u cin g the dis­ ability an d h an d icap w h ich o c c u r se co n d a ry to im p airm ents. D isability m a n a g e m e n t w o u ld enable those p atients w ith a d is­ ability to lead a satisfacto ry lifestyle w ith in the lim its of the reso u rces availab le to them . Th e au th o rs d ecid ed to ev alu ate the p ercep tio n and definition o f rehab ilitation b y p h y sio th erap ists in the sam p le, again st this definition. METHOD In o r d e r to establish the p h y sio th erap ists' p ercep tio n s of reh a­ bilitation and their ability to define rehabilitation, a q uestionnaire w a s d istrib u ted a m o n g st qualified p h y sio th erap ists. A ran d o m selection w a s m ad e from a list, obtained from the South A frican M ed ical an d D ental C o un cil, of all registered p hysio th erapists in S ou th A frica. There w ere 2 9 0 0 registered p h ysiotherapists in South A frica in 1 990. F o u r h u n d red and fifty questionnaires w ere d istribu ted. T he q uestion naire w a s fo rm u lated w ith the aid o f a p sy ch o lo g ­ ist from the D e p artm en t o f P sy ch o lo g y o f the U n iv ersity o f the fABSTRACT ^ In response to questions in an editorial comment by L Davids in the South African Journal of Physiotherapy in February 1991, a questionnaire was sent out to 450 physiotherapists to determ ine their perception and understanding of rehabilitation. Respondents w ere also requested to define rehabilitation. The questionnaire was completed by 131 physiotherapists, giving a re­ sponse rate of 29%. On analysis of the questionnaire it became evident that the respondents had a limited and superficial understanding of rehabilitation. Despite this, they were of the opinion that a large percentage of ttje ir work involved rehabilitation, and they were in fact, the most important Members of the rehabilitation team. In view of the findings of the questionnaire the authors agree with Davids that more attention and effort should be devoted to the “rehabilitation scene” . V____________________ _______________ W itw atersran d . The first sev en question s o f the q u estion n aire req u ired infor­ m ation on asp ects o f the sub jects' train ing , p a s t and p resent o ccu p atio n and y ears o f e xp erien ce. It w a s felt th a t these factors could influence the resp on se. Q uestions 8 -1 2 h asv e b earin g o n the sub jects' c o n ta ct w ith rehabilitation in their p resen t e m p lo y m en t. O b viou sly this factor w o u ld b e o f p rim ary im p o rtan ce in the sub jects' p ercep tio n and d efinition of rehabilitation. The final section of the q uestion naire d ealt w ith th e subjects' p ercep tio n of rehabilitation. P h y sio th erap ists w e re also req uested to define rehabilitation in their o w n w o rd s. T he question naire w as a cco m p an ied b y a c o v e rin g letter w h ich assu red p articip an ts of strict con fid entiality and an on ym ity . The p roject w a s cleared b y the H u m a n E th ics C o m m itte e o f the U n iv ersity of the W itw atersran d . D ata w e re an alysed in con ju n ctio n w ith the In stitu te o f B iostat­ istics at the U niv ersity of the W itw atersran d . E ach q uestionnaire w a s giv en a s ep arate n u m b er. Th e in form a­ tion to be an alysed w a s p u t on to the M R C c o m p u tin g cen tre statistic sheet. RESULTS O f the 4 5 0 questionnaires d istrib u ted , 145 w e re retu rn ed and of those on ly 131 h ad been com p leted , g iv in g a final resp o n se rate of only 29% . The larg est n um ber o f resp on den ts (21.4% ) w e re in the age g rou p 2 5-29 y ears. In each o f the age g ro u p s 2 0 -2 4 y e a rs an d 30-34 y ears, there w ere 19 (14.5% ) resp on den ts. T h ere w e re v e r y few resp on den ts in the ag e g ro u p s o v er 60 years. O f the resp on d en ts, seven ty-six (58.5% ) w e re g ra d u a n d i, 41 (31.5% ) w e re d ip lo m ates and 13 (10% ) had p o s t-g ra d u a te d egrees. The m ajority o f the resp on d en ts (87) h ad less than five y ears of clinical exp erien ce, w h ile 31 h ad 5 -15 y ears of exp erien ce. O f the 131 resp on den ts, 59 (45% ) w o rk ed in p ro v in cial h osp i­ tals and 40 (31% ) w e re e m p lo y ed in p riv ate p ractices. T he m ajority o f physio therap ists (72% ) claim ed th at there w as so m e a sp ect o f rehabilitation in ev ery treatm en t they g av e. H o w ­ ever, 27.8% felt that there w as n o a sp ect of rehab ilitation in an y of their treatm ents. Fig u re 1 illustrates the tim e sp en t on rehabilitation p er treat­ m en t session; S ixty-nine resp o n d en ts (52.7% ) felt th at they spen t less than 25% o f a treatm ent session on rehab ilitation w h ere as only 22 (16.8% ) resp on den ts spen t m o re th an 75% of their treat­ m en t tim e on rehabilitation. If one is gu id ed b y the d efinition o f rehab ilitation as sug gested b y C arad o c-D av is and D isler (1990) then all p h y sio th e ra p y could be con sid ered rehabilitation4. * Senior Lecturer, Physiotherapy Department, University o f Witwatersrand * * Physiotherapy Student (1992) *** Physiotherapy Student (1992) Physiotherapy, August 1993 Vol 49 No 3 Page 45 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) It w a s in terestin g to n o te th a t 8 2.3% (93) o f th e resp o n d en ts felt th a t p h y sio th erap ists w e re in c h a rg e o f rehabilitation (F ig u re 2) and 93% felt th at th e p h y sio th erap ists an d th e p atien t w e re the REHABILITATION TE A M IMPORTANCE OF MEMBERS 120 100 8 0 6 0 4 0 20 I I i p I I V— I N U R S E PATIENT S O C IA L P H Y S IO PSYCH O DR S P E E C H O T FAMILY i m p e r c e n t a g e FIGURE 1 IN C H A R G E O F REHABILITATION ^ P E R C E N T A G E FIGURE 2 REHABILITATION ■ TIME PER TREATMENT < 2 5 2 5 - 5 0 5 0 - 7 5 E H 3 P E R C E N T A G E FIGURE 3 m o st essential m em b ers of th e team (F ig u re 3 )2. In th e p h y sio th erap ists' d efinition o f reh ab ilitatio n , th e co n ­ ce p ts o f function, m en tal ability m a x im u m in d ep en d en ce and p h y sical asp ects o f rehab ilitation w e re id entified a s the m o st im p o rta n t (Table I). DISCUSSION O f the 4 5 0 question naires sen t ou t, o n ly 131 w e re com p leted (29% ). Th e au th o rs a ssu m e th a t the p o o r resp o n se c o u ld h a v e been d u e to a n u m b er o f factors: T h e q uestion naire w a s d istrib u ted o v e r the D ecem b er holidays w h en m a n y p eop le are a w a y o n v acatio n . Ju d g in g from th e n u m b e r o f q u estion n aires th a t w e re in co m ­ p lete (14) w e can o n ly a s su m e th a t the sub jects d id n o t h a v e a clear en o u g h u n d erstan d in g o f rehab ilitation to resp o n d . In n on e o f th ese 14 q uestion naires d id th e subjects a tte m p t to defin e rehabili­ tation in their o w n w o rd s. A g ain o n e can o n ly a s su m e that, seeing th at th ey h ad m a d e the effort to re tu rn th e q u estion n aire, th ey w e re a ctu a lly u nable to define rehabilitation. T h e au th o rs feel th at a b etter resp o n se w o u ld h a v e been ob­ tained h ad the q u estions b een asked in th e fo rm o f an in terview . This is con sisten t w ith th e v ie w s o f the H u m a n S cien ces R esearch C ouncil. Results co n cern in g th e a g e o f p articip an ts sh o w ed th at m o st resp o n d en ts w e re fifty y e a rs an d y o u n g e r, 5 0% b ein g b etw een the ages tw en ty to th irty -fo u r y e a rs (F ig u re 1). T h e g ro u p w ith the h igh est n u m b er o f resp o n d en ts w e re th e a g e g ro u p 2 5 -2 9 years. This g ro u p rep resen ts th e a c tiv e ly in v o lv ed , w o rk in g g ro u p of p hy sio th erapists. Qf o u r resp on d en ts, 4 5% w o rk ed in p ro v in cial h osp itals and 31% w o rk ed in p riv a te p ractices. In p ro v in cial h osp itals, th ere is m u ch g re a te r em p h asis on a c u te c a re than th ere is on an y o th er a sp ect o f rehabilitation. P atients a re d isc h a rg e d from hospital before rehabilitation is co m p lete an d th ere a re v e r y few rehabili­ tation cen tres in South A frica to w h ich th e y c a n be referred. A cc o rd in g to o u r resu lts the m a jo rity o f o u r resp o n d en ts w o rk ed m ain ly w ith acu te c ases an d h ad n ot b een qualified for lo n g er than fiv e y e a r s . O n th e b a sis o f th e s e f a c ts , th e S o u th A fric a n p h y sio th erap ists' inability to define reh ab ilitatio n can b e ex ­ plained. In o r d e r to assess p h y sio th erap ists' p ercep tio n an d u n d er­ stan d in g of rehabilitation th e resp o n d en ts w e re ask ed to define rehabilitation in th eir o w n w o rd s . T his d efinition w a s an alysed by d eterm in ing th e freq u en cy w ith w h ich certain c o n ce p ts ap p eared in th e definitions. T h ese co n ce p ts w e re su b seq u en tly ran k ed in o rd e r of freq u en cy of a p p e a ra n c e (Table 1). Th e term "fu n ctio n al ab ility " w a s m o st c o m m o n ly m en tioned in the definition o f reh ab ilitation w h ile th e p hy sical ability of the patien t w a s also re g a rd e d as im p o rtan t. This clearly in d icates that p h y sio therap ists feel th at th ey d eal p rim arily w ith the p hysical TABLE I: Frequency of terms mentioned in the definition of rehabilitation TERMS NUMBER OF RESPONDENTS Functional ability 61 Mental ability 32 Maximum independence 32 Physical ability 31 Social ability 17 Quality of life 12 Self-responsibility 9 Vocation 8 Education 3 Continued on page 49.. Bladsy46 Physiotherapy, August 1993 Vol 49 No 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Higher Degrees in Physiotherapy The University of Queensland Australia M usculo-Skeletal Physiotherapy C ardio-R espiratory Physiotherapy Neurological Physiotherapy P aed iatric Physiotherapy Ergonom ics P ain About the Department: Over 20 years experience in PhD and other postgraduate supervision Internationally recognised supervisors with clinical and research skills Modem research equipment and purpose built laboratories Engineering and statistical research support staff W e offer you: Postgraduate Research Degrees to Master and PhD levels Master o f Physiotherapy Studies (Manipulative Physiotherapy) Graduate Certificate (Paediatrics) ‘ Access to the teaching, library and recreational facilities o f Queensland’s oldest University The camaraderie o f an active postgraduate student group All this in one o f Australia’s most beautiful States, boasting the B a r ­ rier Reef, Tropical and Sub-Tropical rainforests, beautiful beaches and the country outback. F or more information contact: Dr. Yvonne Bums, Head, Department of Physiotherapy, The University o f Queensland, Brisbane, Queensland, AUSTRALIA, 4072 Telephone: +61 7 365 2019 Facsim ile: + 6 1 7 365 2775 WORK IN THE USA PHYSIOTHERAPISTS E X C E L L E N T JO B S W e handle all licensure and visa paperwork. M inim um c o m m itm en t of one y e a r required. T R N fe e s paid by employer. T herapy R e s o u rc e N e tw o rk , Inc. P .O . Box 5 4 3 0 199 North M ain Street Plymouth, Michigan, 4 8 1 7 0 Call: 0 9 1 -3 1 3 4 5 5 -6 6 6 0 THE SOUTH AFRICAN JOURNAL OF PHYSIOTHERAPY MISSION • To function as a co m m u n icatio n m ed ia for the p h y sio th er­ a p y com m unity. AIMS • To p ro p ag ate p rofessional k no w led g e and e n co u ra g e the science of p h y sio th erap y • T o sh are w ith m em b ers new id eas and techniques in clinical p ractice locally and abroad • To p ro m o te the interests o f the p rofession and keep m e m ­ b ers inform ed o f the activities of the society • To inform m em bers of the u nd ertak in g s o f W C P T , W C PT - A frica, the P rofessional Board for p h y sio th erap y and o th er relev ant organ isations • To en co u rag e w ritten co m m u n icatio n and scientific w ritin g b y m em bers of the SASP V_______________ :_______________________ y vX' ■ If you’d lik e to w o rk in th e US, c o n ta c t HPI. W e ’ve h e lp ed m o re physical th e ra p is ts fin d g r e a t jo b s in A m e ric a th a n an y o th er recru iter. Top pay, e x p e rt lic e n s in g a n d visa pro cessin g. F e es p a id by your em p lo ye r. 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Tel. (011) 803-9320/1/2/3/4 Telefax (011) 803-7085 Durban Office: 127 Davenport Rd., Glenwood, Durban. Tel. (031)21-2254/79 Fax (031) 21-2571 C ape Office: 18 Vlei Str. Bellville, Cape. Tel. (021) 946-4560/1 Telefax (021) 948-8401 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) ...continued from page 46 as p e c ts of the p atien t, b e ca u se in o r d e r to be fu n ctio nal, o n e has to re s to re th e p h y sical ability o f th e p a tie n t to its fullest exten t. H o w e v e r, m en tal ability o f th e p a tie n ts w a s also c o n sid ered im p o rta n t. P h y sio th e ra p ists s e e m to realise th at th e m en tal ability o f th e p atien t is o n e o f th e m o st c ritical a sp ects of su ccessfu l reh ab ilitatio n, as it w ill h a v e an effect o n the p hy sical o u tco m e. It w a s in terestin g to n o te tha t alth o u g h im p ro v e d q u ality of life w a s th o u g h t to b e an im p o rta n t a s p e c t of reh abilitation, m a x im u m in d ep en d en ce w a s ra te d h igh er. P a tie n ts ' resp on sib ility fo r their o w n h ealth w a s n o t re g a rd e d as v e r y im p o rta n t. H o w e v e r, if it is felt th at in o r d e r to be reh ab ili­ tated su ccessfu lly , th e p atien t sh o u ld b e co m e resp on sib le for him self, th en p atien t e d u c a tio n w o u ld p la y a vital role5. O nly th ree re s p o n d e n ts m en tio n ed the te rm " e d u c a tio n " in th eir defini­ tion o f reh ab ilitatio n. This w a s th e g re a te st w eak n ess the a u th o rs identified in the p h y sio th e ra p is ts' defin ition o f rehab ilitation. The v o ca tio n a l p o ten tial o f a p atien t w a s ran k ed by p h y sio th erap ists as the s eco n d least im p o rtan t. This finding is o n e th at is sh ared by R o y et a l (1 9 8 8 ) w h o b elieve th at v o catio n al reh ab ilitatio n is n o t a p rim a r y aim o f reh ab ilitatio n an d if p atien ts w ish to retu rn to w o rk , this d ecisio n w ill be in flu en ced m o re b y social factors and ft less b y m e d ic a l reh ab ilitatio n . T h e social p o ten tial o f a p atien t w a s co n sid ered reason ab ly im p o rta n t in the d efin ition, b u t p h y sio th erap ists ran k ed it as less im p o rta n t fo r su ccessfu l reh ab ilitatio n, than p hy sical o r m en tal ability (T ab le 1). W h e n ask ed w h o w a s in c h a r g e o f reh ab ilitatio n in the units w h e re th e y w e re w o rk in g , 8 2 ,3 % s ta te d th at the p h y sio th erap ists w e re . It w a s fe ltb y 3 9 .6 % o f re s p o n d e n ts th at the p h y sio th erap ists sh o u ld b e in c h a rg e o f reh ab ilitatio n a n d on ly 2 2 .5 % felt th at the d o c to r sh o u ld be in c h a r g e (F ig u re 2). L e h m a n (1982) w a s of the o p in io n h o w e v e r, that th e d o c to r sh o u ld be in co n tro l b e ca u se the p ro b le m u su ally b e g a n w ith a medicEil co n d itio n w h ich w o u ld d e te rm in e w h a t cou ld o r co u ld n o t b e d o n e fo r th e p atien t7. H e also s tressed th at a te a m req u ired a g o o d w o rk in g relatio n ­ ship o f all h ealth p ro fessio n als in v o lv ed in reh ab ilitatio n c a re of p atien ts o n a d a y to d a y b asis w ith a c o m p le te u n d erstan d in g of th e p o ten tial co n trib u tio n o f e a c h m em b er. This o p in io n is co n sist­ e n t w ith v ie w s e x p re s se d b y S oric et a l an d C h am b erlain 8,9. P h y sio th e ra p is ts felt th at th ey an d the p atien t w e re :the m o st essen tial m e m b e rs o f th e reh ab ilitatio n te a m (99% ) b u t u n fo rtu ­ n ately 9 7% re g a rd e d the fam ily o f the p atien t as n ot im p o rta n t at all. A cc o rd in g to S oric et a l (1 9 8 5 ), a fam ily th at is s u p p o rtiv e will m a rk e d ly influence the final o u tc o m e o f treatm en t. This is con sist­ en t w ith the W H O 's v iew , w h ich co n firm s th at the p atien ts, their fam ilies an d the co m m u n itie s in w h ich th ey live sh o u ld be p a rt o f the reh ab ilitatio n p ro cess. This w o u ld g re a tly en h an ce the p a ­ tien t's qu ality o f life8 . PANEL DISCUSSION PHYSIOTHERAPY IN THE FUTURE - CAN WE MAKE A CHANGE? A lth o u g h the q u estio n w a s n o t an sw e re d an d the tim e allow ed fo r a u d ie n ce p a rticip a tio n w a s -really n ot e n o u g h (p erh ap s w e w e re all tired b y the e v e n in g o f the fo urth d ay !) the panel d is­ c u ssio n , d u b b ed " r o le o r d o le " b y the c o n g re s s co m m ittee, g av e p le n ty o f fo od fo r th ou gh t. P ro fe s s o r B ru c e S p ark s, of the d e p a rtm e n t o f c o m m u n ity h ealth , w h o also c h a ire d th e d iscu ssio n , ou tlin ed the p ro b lem s to b e faced in the n e x t few y e a r s - th o se o f political a n d eco n o m ic u n certain ty , m a s s u n e m p lo y m e n t an d p o v e rty , in creasin g v i­ o len ce an d con flict, co llap se o f fam ily stru ctu re s , d e-racialisatio n and loss o f p riv ileg ed p o sitio n fo r m in o rity g ro u p s . A g ain st this b a ck g ro u n d w e shall also h a v e to c o p e w ith a s o c ie ty in w h ich first the y o u th a n d then the eld erly p re d o m in a te , an d w ith a p red icted W h en o n e co n sid ers su ccessfu l reh ab ilitatio n in term s o f im ­ p ro v e d q u ality o f life an d an a c c e p ta n c e b y th e p atien t o f self­ resp onsib ility, th en the S ou th A frican p h y sio th e ra p ists d o n ot h a v e a cle a r u n d e rs ta n d in g o f reh ab ilitatio n . W ith o u t p atien t ed u catio n , the p atien t c a n n o t b e co m e resp o n sib le fo r h im self and this a s p e c t of reh ab ilitatio n w a s ra te d v e r y low b y th e p h y sio th e r­ ap ists. T h e c o n ce p t o f self-resp o n sib ility in reh ab ilitatio n h as b een d escrib ed b y m an y au th o rs. B ran d o n (1 9 8 5 ) s tates th at the p atien t sh o u ld b e in volv ed in his o w n reh ab ilitatio n p ro g ra m m e as a " c o -m a n a g e r " 10. T h e im p o rta n c e o f self-resp o n sib ility is fu rth er stressed b y L a n g e r an d R o d in w h o s ta te th at " p e rs o n s w h o are g iv en g re a te r p erso n al resp on sib ility an d ch o ice in life activ ities d e m o n s tra te h ig h er levels o f alertn ess an d m o re a c tiv e p a rticip a ­ tio n " in their reh ab ilitatio n p r o g r a m m e 11. T he au th o rs w o u ld like to stre ss the p o in t again : th at fo r a p a tie n t to b e self-respo nsib le h e h as to b e e d u c a te d ab o u t his d isease. P h y sio th erap ists resp o n d in g to this q u estio n n aire sh o w little ap p reciatio n o f the im p o rta n c e o f e d u c a tio n as w ell as the ro le of th e fam ily an d the c o m m u n ity in th e su ccessfu l reh ab ilitatio n of a p atient. It is in terestin g to n o te th at a lth o u g h th ey h a v e a lim ited an d su p erficial k n o w led g e o f reh ab ilitatio n th ey feel th at they sho uld b e an d are the m o s t im p o rta n t m e m b e rs o f the reh ab ilita­ tion team . In v iew of the resu lts o f the q u estio n n aire an d th e fact that reh ab ilitatio n w as so p o o rly d efin ed, th e a u th o rs c o n c lu d e that the q uestion s p o sed b y D av id s c a n n o t b e an sw e re d m ean in gfu lly. B ecau se o f this, it is felt th at the tim e h as c e rta in ly c o m e to d e v o te m o re tim e to all the im p o rta n t as p e c ts o f reh ab ilitation. References 1. Davids LM. Rehabilitation restore to effectiveness or normal life by training. The South African Journal o f Physiotherapy X991;4X(1):2. 2. Nadolsky JN. The "1984" crisis in rehabilitation. Journal o f Rehabilitation Jan/Feb/Mar 1984;4-5. 3. Report of a WHO expert committee, Disability prevention and Rehabili­ tation. WHO Technical report series 668 Geneva W HO 1981:8-9. 4. Caradoc-Davies TH, Disler PB. Rehabilitation in New Zealand: now and the future. New Zealand Medical Journal 1990;103:210-214. 5. Oldridge NB. Cardiac Rehabilitation, Self-responsibility and quality of Life. Journal o f Cardiopulmonary Rehabilitation 1986;6:153-156. 6. Roy CW et al. Work of a Rehabilitation Medicine Service. British Medical Journal 1988;297(3):601-604. ' ■: / 7. Lehmann JF. Rehabilitation medicine: past, present and future. Archives o f physical medicine and rehabilitation i982;63:291V297: 8. Soric R et al. Rehabilitation Medicine: Its time has come. Post Graduate Medicine 1985;77(8):13-18. 9. Chamberlain MA. What is rehabilitation? British Journal o f Hospital Medicine 1989;4(1):311. 10. Brandon JE. Health promotion and wellness in rehabilitation. Journal o f Rehabilitation Oct/Nov/Dec 1985:54-57. 11. Sawyer HW, Crimando W. Self Management strategies in rehabilita­ tion. Journal o f Rehabilitation Jan/Feb/March 1984;50(1):27-31. 6 ,0 0 0 ,0 0 0 infected b y A IDS b y the y e a r 2 0 1 0 , m o st o f these in tht in co m e g en eratin g a g e -g ro u p . T h e challen ges facin g S ou th A frica in clu de: • defining a n ew S ou th A frican vision • a ch iev in g tran sitio n w ith o u t p o larisatio n • g en eratin g fertile o p p o rtu n ities fo r c o llab o ratio n • en co u ra g in g ec o n o m ic g ro w th • re s tru ctu rin g e d u catio n , h ealth a n d w elfare serv ices • in teg ratin g the "m a rg in a lis e d " y o u th of the c o u n try • tackling p eri-u rb an an d s lu m p ro b lem s • p lan n in g fo r ru ra l c h a n g e an d lan d refo rm s • m ain tain in g ju stice an d d e v e lo p in g an a c c e p ta b le p olicin g sy stem Th e h ealth challen ges to be faced are d ire c tly rela te d to the ab ove. H ealth costs are rising steep ly a t a tim e w h e n the d e v e lo p ­ m e n t o f h ealth services, esp ecially p re v e n ta tiv e c a re , is n eeded Continued on page 52... Physiotherapy, August 1993 Mot 49 No 3 Page 49 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )