About a quarter of the Brazilian population was diagnosed with a stroke, arthritis, WMSD, COPD, or reported back pain, and one in three affected by these diseases and conditions had moderate, intense, or very intense limitations of their usual activities. However, about one in four Brazilians with the chronic diseases listed in this study and moderate to severe limitations in their usual activities reported using rehabilitation therapy for their conditions or diseases.
The scenario of relatively low use of rehabilitation therapies among people with chronic diseases and limited daily activities may indicate challenges in accessing rehabilitation services, including barriers on both the demand and the supply for these services 11,12. Examples of barriers in demand are the high cost of accessing services, including transport costs, waiting time, and lack of awareness of rehabilitation needs. In terms of supply, the absence of an integrated national policy on rehabilitation, inadequate provision of services, insufficient infrastructure, lack of professionals and professionals with little training can be included11,12,13.
Although the PNS-2013 does not address the possible barriers to the use of rehabilitation therapies in the population studied, all individuals should be able to access quality rehabilitation services without fear of financial difficulties, according to the WHO. In Brazil, about 72% of the Brazilian population depends exclusively on the Unified Health System (SUS), and, despite social inequalities in access to medical and dental services, they are offered almost universally14,15. However, the offer of rehabilitation services through the Unified Health System does not have a consolidated policy, legislation, or even a specific budget 13, having sparse regulations from different areas of the Ministry of Health, such as Occupational Health, Elderly Health, and Disability, Trauma and Violence Program13.
In Brazil, rehabilitation services are offered predominantly in urban areas, concentrated in the most economically developed regions, and with a low assistance coverage, mostly offered in a precarious network with little articulation with an integrative and multidisciplinary proposal 16,17. The concentration of these services occurs in hospital care at the expense of primary health care, with few reference services and difficulties reported by patients related to distance, cost, transport, and accessibility, in addition to the delay in scheduling these services and the vulnerability of the lower-income population 17,18,19. These barriers may explain the present study's findings, where we observed higher chances of using rehabilitation therapies among the female population, with higher education, higher socioeconomic status, older, and living in the Southern region of Brazil.
Although the clear benefits of rehabilitation therapies in the conditions and chronic diseases studied, this was not often reported by the subjects20,21. In the case of post-stroke patients, who had moderate to very severe limitations, less than 1/3 were undergoing any therapy due to stroke, an even lower proportion (slightly more than ¼) when considering all the chronic diseases studied22.
Although stroke is less prevalent among the conditions studied, it has the highest percentage of individuals with moderate to very intense impairment. Schmidt et al. noted that the change in the epidemiological profile that has taken place in recent decades in Brazil has highlighted diseases of the circulatory system and, among the most important, stroke, one of the leading causes of hospitalization and mortality23. The literature indicates that most post-stroke patients have chronic sequelae that require rehabilitation to restore their functionality in their daily activities22,23. In this study, the percentage of people who reported medium, intense, or very intense degrees of limitations in activities of daily living was 38%. Considering the disabling potential of stroke, the active monitoring of patients should occur from the onset of the disease, with a rehabilitation program aimed at joint protection, maintenance of the functional state of the locomotor system, and the cardiorespiratory system24.
In the present study, individuals who reported having WMSD were the ones who most frequently used rehabilitation therapies. WMSDs are damage resulting from overuse imposed on the musculoskeletal system, without adequate time for recovery26. According to a study developed by the Ministry of Health, WMSD affects 50% to 80% of the economically active population27. Age, gender, time working in the profession, and education may be factors associated with WMSD, considering economic activity and occupation. One study observed high proportions of symptoms related to WMSD, such as limit or inability to perform tasks, in addition to withdrawal from work activities28.
In this study, individuals who reported having COPD, aged between 40 and 59 years, were significantly more likely to use rehabilitation therapies when compared to the other reference categories. COPD is among the leading causes of morbidity and mortality in developing countries29. In Brazil, COPD is among the ten leading causes of death29. The specialized literature indicates that pulmonary rehabilitation improves exercise capacity, reduces dyspnea, and improves the overall quality of life, and its benefits surpass any other therapy. In addition, pulmonary rehabilitation increases the functional exercise capacity, reduces hospitalizations, and reduces the cost of treatment30,31.
The study's main limitations are related to the structure of the PNS-2013 questions, which limits the possible answers for the use of rehabilitation therapies to up to three options, at most, for each chronic disease. Another limitation of the questionnaire is related to the option "physical exercise" as rehabilitation therapy, sometimes offering the option "exercise or some physical activity" (in case the respondent has reported a stroke), sometimes offering the option "exercise or physiotherapy," combined, without the possibility of analyzing the two separately or distinguishing whether the practice was prescribed or monitored by a health professional.
For the present study, we decided to use any positive response (exercise or exercise and physiotherapy) to characterize the use of rehabilitation therapies, implying putting on the same level the use of physiotherapy, which depends on access to health professionals, and physical activity, which can be guided by a health professional or practiced spontaneously by the respondent. Future studies should separate possible rehabilitation therapies in their analysis.
The authors' option to analyze all chronic diseases and the resulting use or not of rehabilitation therapies together, without discriminating the factors that interfere in using these therapies for each chronic disease listed, can be considered a limitation as a fortress. The potential limitation stems from the fact that each disease has different consequences on the individual's health, with variations in the frequency and intensity of limitations in daily activities caused by morbidities. However, we consider this option an opportunity since rehabilitation therapies are necessary for moderate or severe limitations resulting from morbidities. The use of one or more therapies can be a marker of both access to health services and self-care in the case of physical activity.
We recommend studies to assess individual perceptions of the need for rehabilitation, access to and barriers to health services, factors that improve patient adherence to rehabilitation therapies, and the geographic distribution of these services.