Introduction to Rehabilitation at the Primary Care Level

Original Editor - Jess Bell Top Contributors - Jess Bell and Ewa Jaraczewska

The Growing Need for Rehabilitation Services

Rehabilitation is effective for many conditions across the lifespan, helping to reduce recovery time, prevent complications, and enhance physical and mental functioning and well-being. Rehabilitation supports participation in work, community, and family life, and it has been identified as an essential health service in the World Health Organization’s definition of universal health coverage.

Currently, it’s estimated that one in three people will need rehabilitation at some point during their life. However, in many parts of the world, this need is largely unmet. As populations age, injury survival rates improve, and non-communicable diseases increase in prevalence, the demand for rehabilitation services will continue to increase.

The Potential of Primary Care

Bringing rehabilitation services into primary care is one way to address this unmet need. "When rehabilitation is integrated into primary care, services are brought closer to people’s homes, making them more accessible and affordable."

Historical Context: Declarations of Alma-Ata and Astana

The 1978 Alma-Ata Declaration highlighted the role of primary health care in achieving the goal of “Health for All”. Forty years later, the Declaration of Astana was signed. It reiterated the key role of primary health care, but acknowledged that there is still significant work to do, with an estimated 2.4 billion people in need of rehabilitation services.

The following optional videos provide some context about these declarations.

Primary Health Care Versus Primary Care

It’s important to understand the distinction between primary health care and primary care.

"Primary health care (PHC) is the cornerstone of strong and resilient health systems." It is a holistic, integrated approach that prioritises the equitable distribution of health services. It has three components:

• primary care and public health functions
• multisectoral policy and action
• empowering people, families and communities to take control of their health

Primary care is, therefore, a subset of primary health care. In primary health care-oriented systems, primary care aims to provide person-centred and people-informed care. It provides promotive, protective, preventive, curative, rehabilitative, and palliative services, and should be able to address most of a person’s health needs over their lifetime.

Primary Care Core Characteristics

The four core functions of primary care are:

• first contact access
• continuity
• comprehensiveness
• coordination

If you would like more information on how these functions are defined, please see: Revisiting the four core functions (4Cs) of primary care: operational definitions and complexities.

The Primary Care Operational Context

Primary care providers tend to be generalists with a broad scope. They must consider the whole person and be able to adapt their skills based on the situation. They are embedded in the community and tend to have a deep understanding of the local context and available resources. They often have ongoing relationships with patients and families that span years and are built on trust.

However, due to high workloads, primary care providers may see more than 20 patients per day. Appointment length varies considerably—in some countries, consultations last less than a minute on average, while in others, they are over 20 minutes on average. Unfortunately, this pace can impact the level of care provided, especially for patients who have more complex conditions. Rehabilitation professionals working in primary care need to adapt to this faster pace, broader focus, and different relationship dynamics.

What is Rehabilitation at the Primary Care Level?

Rehabilitation at a primary care level is preventive. This means that the focus is on identifying and addressing functional limitations before they impact participation or quality of life. For example, a primary care provider identifies that a patient appears unsteady while walking into their consultation room. They conduct a fall risk assessment and provide basic fall prevention interventions prior to the patient having a fall.

Rehabilitation in primary care integrates a range of services rather than focusing on a single intervention from one discipline. Using the same example of a patient at risk of falling, the patient’s primary care physician considers other risk factors (e.g., medical conditions) and completes a medication review, as well as a basic functional gait and balance assessment.

Rehabilitation in primary care is pragmatic, focusing on interventions that meet each person’s goals, preferences, and functional requirements rather than aiming for perfection. For our patient at risk of falling, their goal might be "walking safely to the mailbox" rather than achieving a "normal gait pattern."

Rehabilitation in primary care must also be collaborative. Different members of the healthcare team should work together to achieve common goals. Building on the same patient example, the primary care physician initially noted that the patient appeared unsteady and completed a basic assessment before providing general fall prevention advice. The physician then referred the patient to a primary care occupational therapist and physiotherapist for more focused rehabilitation.

Who Provides Rehabilitation Services in Primary Care?

Various rehabilitation professionals work in primary care, including physiotherapists, occupational therapists, speech and language therapists/pathologists, psychologists, orthotists and prosthetists, and social workers. They act as direct service providers for basic rehabilitation needs, assessing, treating and monitoring progress. They consult with the rest of the multidisciplinary team, providing guidance on functional issues and interventions. In addition, they provide education, helping the team recognise and provide basic treatments. If you would like to find out more about the role of these rehabilitation professions, please see: Who Provides Rehabilitation and Assistive Technology.

However, specialist rehabilitation services or rehabilitation workers are not always available at a primary care level. In these cases, other healthcare providers, including doctors and nurses, are often the first contact point for people with rehabilitation needs. They must, therefore, be able to identify rehabilitation needs and provide basic interventions.

These primary care providers can:

• identify unmet rehabilitation needs
• provide basic rehabilitation strategies and advice to enhance participation in daily activities
• make timely and appropriate referrals

In some settings, rehabilitation providers may be able to provide support and training to primary care workers to ensure optimal delivery of these services.

The Primary Care Rehabilitation Toolbox

Assessment and screening form the foundation of primary care rehabilitation. At a basic level, all primary care providers can ask specific questions to identify if patients are having difficulty with any functional tasks, from mobility to communication, vision, hearing and cognition. When they identify difficulties, they can conduct relevant medical or diagnostic assessments that might influence rehabilitation interventions, such as referring for imaging or completing a neurological examination.

The ICF Framework in Primary Care Practice

ICF framework

The International Classification of Functioning, Disability and Health (ICF) provides a systematic framework to help clinicians describe a person's functioning and disability in relation to a health condition. This biopsychosocial model shifts the clinical focus from treating diseases to optimising function. The ICF has traditionally been used in specialised rehabilitative settings, but it is relevant to all healthcare settings, including primary care.

The ICF considers the impact of various interconnected domains on a person's functioning:

• Health condition: a disease or health condition that is affecting function
• Body functions: the physiological functions of body systems (including psychological functions)
• Body structures: the anatomical parts of the body, such as organs, limbs and their components
• Activity limitations: the ability of a person to complete a task or activity
• Participation restrictions: the challenges a person faces when undertaking work, social roles, or meaningful activities
• Environmental factors: the barriers or facilitators in a person's physical, social and attitudinal environment

If you would like to learn more about using the ICF in clinical practice, please see: ICF and Application in Clinical Practice.

Validated Assessment Tools

There are also many validated tools that can be used in busy primary care settings for efficient, functional assessments. Some examples of outcome measures you can use are listed below.

Functional screening:

• Timed Up and Go Test (TUG): a quick mobility and fall risk assessment
• Brief Balance Evaluation Systems Test (Brief-BESTest): a comprehensive balance assessment takes around 10 minutes on average
• 2-Minute Walk Test: a practical alternative to the 6-minute version
• Nine-Hole Peg Test: acts as a quick upper limb function screen

Pain and function:

• Brief Pain Inventory (Short Form): determines the impact of pain on function
• Oswestry Disability Index (10-item): assesses the functional impact of back pain
• QuickDASH: assesses upper limb function for daily activities

Basic Intervention Strategies

“Rehabilitation provides sets of interventions designed to optimize functioning [...] in individuals with health conditions, in interaction with their environment."

Rehabilitation is ideally delivered by multi- or interdisciplinary teams, especially for individuals with more complex health conditions. However, all primary care providers can be trained to provide basic rehabilitation strategies and advice to manage daily activities and health at home, including simple environmental modifications. They can also provide some basic assistive technology or direct patients to local providers of assistive technology.

Package of Rehabilitation Interventions (PIR)

Rehabilitation interventions target aspects of functioning (e.g., body functions, body structures, activities and participation) and factors that influence functioning (e.g., environmental and personal factors). They focus on strengthening exercises, language training, breathing exercises, training of activities of daily living, social and communication skills, provision and training in the use of assistive products, environmental modifications, education on self-management, and caregiver and family training.

The World Health Organization has created a Package of Rehabilitation Interventions (PIR) for 20 common conditions that can be provided in any setting, including primary care. This "facilitates their accessibility to all people in need when multidisciplinary rehabilitation is unavailable."

To view this package, please see: Package of interventions for rehabilitation.

Building Collaborative Relationships in Primary Care

Effective communication is essential in primary care. A collaborative approach is necessary if patients are to receive coordinated, comprehensive care. Effective communication involves regular team meetings where cases are discussed, shared documentation systems so everyone knows what's happening, and clear referral pathways in both directions.

Speaking the Primary Care Language

To communicate effectively with primary care colleagues, rehabilitation professionals must understand primary care priorities:

• using functional language can help: instead of "limited shoulder flexion to 90 degrees," include that they have "difficulty reaching overhead cupboards"
• connect rehabilitation approaches to medical management: "improving walking tolerance will help blood pressure control through increased activity"
• be conscious of time limitations: "this 2-minute screen can identify individuals who need a detailed assessment"
• focus on outcomes valued in primary care settings: e.g., medication adherence, hospital admission prevention, patient satisfaction

As mentioned, the ICF framework also provides a standardised language to describe and classify functioning in relation to health conditions. Most primary care providers will already consider how conditions affect patients' daily lives and roles—the ICF provides a systematic way to organise this thinking.

Effective Team Communication

Making the most of limited time in primary care settings requires a strategic approach. The SBAR (Situation, Background, Assessment, Recommendation) is a recommended method of enhancing communication between healthcare professionals.

Situation: identify yourself and describe the situation. Make sure you identify the patient and note changes in status, treatment plan, and any relevant issues related to the patient's care.

Background: describe the patient's background or context, including their age, diagnosis, prior procedures, treatment plan to date, and the specialist involved.

Assessment: identify the problem, your clinical impressions and concerns.

Recommendation: explain what you think the next step in the patient's management should be, including the time frame.

It can also help to prepare concise, one-page summaries with clear action items. Focus on bringing solutions rather than just identifying problems. Track and report outcomes to demonstrate the value of rehabilitation input (e.g., reduced fall risk, reduced hospital admissions, etc.).

The following two videos provide additional information on the SBAR tool. The first video describes its use in an urgent care setting, while the second compares two primary care handovers—one using SBAR and one not.

Addressing Common Misconceptions

Despite these communication strategies, there may still be resistance to or misunderstanding about the role of rehabilitation in primary care.

Rehabilitation is sometimes perceived as a “fallback strategy” for a small number of people when other preventive, promotive or curative approaches haven’t been successful. However, rehabilitation is much more than this.

Rehabilitation is often viewed as an expensive, specialised service that is the domain of secondary and tertiary care. In practice, however, many basic interventions can be provided in primary care.

Another misconception is that rehabilitation is “only for simple cases” and has limited impact. In reality, it can benefit people with varying rehabilitation needs from simple sports injuries to complex, progressive conditions or multi-morbidity. Related to this is the belief that rehabilitation is “just basic exercises”. While exercises are of great importance, rehabilitation encompasses much more—including education, environmental modification, assistive technology provision, family training, etc.

If you would like to read more about rehabilitation misconceptions that impact access to care, please see: When Are Rehabilitation and Assistive Technology Provided.

Conclusion

The integration of rehabilitation into primary care represents both an opportunity and a necessity. With one in three people requiring rehabilitation services and significant unmet need globally, primary care offers a pathway to make rehabilitation more accessible and affordable.

Primary care providers are well-placed to identify people with rehabilitation needs and deliver basic rehabilitation interventions using validated tools and basic interventions. But successful integration of rehabilitation services into primary care requires providers to build collaborative relationships and communicate effectively with multidisciplinary teams.

Additional Resources

• Primary Health Care
• Package of Interventions for Rehabilitation
• ICF Beginner's Guide: Towards a Common Language for Functioning, Disability and Health