White Book of PRM

Chapter 3 – A primary medical specialty: the fundamentals of PRM

For this paper, the collective authorship name of European PRM Bodies Alliance includes:

  • European Academy of Rehabilitation Medicine (EARM), 
  • European Society of Physical and Rehabilitation Medicine (ESPRM),
  • European Union of Medical Specialists PRM Section (UEMS-PRM Section)
  • European Union of Medical Specialists PRM Board (UEMS-PRM Board)
  • The Editors of the 3rd edition of the White Book of Physical and Rehabilitation Medicine in Europe: Stefano Negrini, Pedro Cantista, Maria Gabriella Ceravolo, Nicolas Christodoulou, Alain Delarque, Christoph Gutenbrunner, Carlotte Kiekens, Sasa Moslavac, Enrique Varela-Donoso, Anthony Ward, Mauro Zampolini.
  • The contributors: Gordana Devečerski, Calogero Foti, Stefano Negrini, Rajiv Singh, Henk Stam, Carlotte Kiekens, Ayse Kucukdeveci, Rosulescu, Amparo Assucena, Basaglia, Aguiar Branco, Andrew Haig, Alvydas Juocevicious, Renato Nunes, Perennou, Nicola Smania, Gerold Stucki, Luigi Tesio, Aivars Vetra

Abstract

In the context of the White Book of Physical and Rehabilitation Medicine (PRM) in Europe, this paper deals with the core concepts at the base of the PRM specialty. These are the essential constituents that makes PRM a primary medical specialty, different from all the other medical specialties, and PRM physician the primary medical specialist among the rehabilitation professionals. The core concepts that will be discussed in this Section include:

•          PRM is a person/functioning oriented specialty, and this makes the specialty different from the organ/disease oriented, or treatment/age specific medical specialties

•          PRM physicians have medical responsibilities, like all the other medical specialists, but with an additional specificity of making a functional diagnosis

•          Like the other specialists, PRM physicians provide direct treatments, but they also work coordinating the multi-professional rehabilitation team, using an interdisciplinary work model

•          Due to its function oriented approach, PRM has a multimodal approach including a wide variety of treatment tools (frequently provided by other rehabilitation professionals) and manages all persons’ morbidities (health conditions), since it focuses on decreasing impairments and activity limitations to allow the best possible participation of patients

•          As PRM bases its work on functioning, it has a transversal role to all the other specialties: it overlaps with most of them, sharing part of their knowledge, but it is also totally independent from all of them, since it is based on a different and transversal body of knowledge

•          PRM is focused on the person and neither on the disease nor on the setting; in fact PRM is not only transversal to specialties, but also to the settings of care, and PRM physicians should know these different realities: persons with disabilities and those with long-term health conditions in fact move inside the national health systems between various facilities to obtain the best possible functioning and participation through an appropriate rehabilitation process.

Key words

Physical and Rehabilitation Medicine, Europe, diagnosis, person, patient care team

Introduction

The White Book (WB) of Physical and Rehabilitation Medicine (PRM) in Europe is produced by the 4 European PRM Bodies and constitutes the reference book for PRM physicians in Europe. It has multiple values, including to provide a unifying framework for the European Countries, to inform decision-makers at the European and national level, to offer educational material for PRM trainees and physicians and information about PRM to the medical community, other rehabilitation professionals and the public. The WB states the importance of PRM, that is a primary medical specialty. The contents include definitions and concepts of PRM, why rehabilitation is needed by individuals and society, the fundamentals of PRM, history of PRM specialty, structure and activities of PRM organizations in Europe, knowledge and skills of PRM physicians, the clinical field of competence of PRM, the place of PRM specialty in the healthcare system and society, education and continuous professional development of PRM physicians, specificities and challenges of science and research in PRM and challenges and perspectives for the future of PRM.

This Chapter is new in the context of the White Books produced until now, and it has been introduced to better focus on the core concepts at the base of the PRM specialty. These are in fact the essential constituents that makes:

  • PRM a primary medical specialty, different from all the other medical specialties
  • PRM physician the primary medical specialist among the rehabilitation professionals.

The core concepts that will be discussed in this Section include:

  • PRM is a person/functioning oriented specialty, and this makes the specialty different from the organ/disease oriented, or treatment/age specific medical specialties
  • PRM physicians have medical responsibilities, like all the other medical specialists, but with an additional specificity of making a functional diagnosis
  • Like the other specialists, PRM physicians provide direct treatments, but they also work coordinating the multi-professional rehabilitation team, using an interdisciplinary work model
  • Due to its function oriented approach, PRM has a multimodal approach including a wide variety of treatment tools (frequently provided by other rehabilitation professionals) and manages all persons’ morbidities (health conditions), since it focuses on decreasing impairments and activity limitations to allow the best possible participation of patients
  • As PRM bases its work on functioning, it has a transversal role to all the other specialties: it overlaps with most of them, sharing part of their knowledge, but it is also totally independent from all of them, since it is based on a different and transversal body of knowledge
  • PRM is focused on the person and neither on the disease nor on the setting; in fact PRM is not only transversal to specialties, but also to the settings of care, and PRM physicians should know these different realities: persons with disabilities and those with long-term health conditions in fact move inside the national health systems between various facilities to obtain the best possible functioning and participation through an appropriate rehabilitation process.

The aim of this chapter is to discuss, in detail, all the core concepts of the medical specialty of PRM, that makes it unique, specific and essential in the current trend of health care, which includes acute and long-term health conditions, characterized by increasing disability from better survival and progressive ageing in populations.

The person/functioning oriented versus disease oriented approach in PRM

After the first dissections, and the understanding of anatomy and physiology, science in modern medicine has progressed deeply rooted in the knowledge of body structures and functions: this strict relationship with the physical human being allowed to overcome the almost magic traditions orally handed down from masters to disciples that had ruled official medicine since the dawn of history. Consequently, medicine organised mainly around topics centred on body structures/functions – like heart (cardiology), lungs (pneumology), joints, bones, and muscles (orthopaedics), brain and neuromuscular functions (neurology), eyes (ophthalmology) and so on. There are a few exceptions to this general rule, with fields that could be considered “transversal” to the previous “vertical” ones, like general medicine, paediatrics and geriatrics. This organ-based approach led to the classical “biomedical model” of treatment, where the search for aetiology and patho-anatomy/physiology of a disease is considered the way to develop a good therapy, to eradicate the cause of illness and cure the patient (Figure 1). Physicians grow with this model in mind: in fact, after the basic topics of their first years of studies, “anatomical pathology” is one of the first subjects introducing medical students to the clinical world. 

PRM was born in a different way, and not around a specific body structure/function: in fact, the progress of Medicine and Surgery allowed more and more the survival of acute patients, (eg after important impairments due to accidents, war injuries and/or infectious diseases – like poliomyelitis) and this required a specific attention to their sequelae. Therefore, the focus of PRM from the start has been the achievement of the best possible “functioning” in a long-term health condition. It was quite immediately clear that the classical biomedical model was not applicable to PRM, but decades had to pass before this concept of functioning was totally understood. A breakthrough came through the International Classification of Impairments, Disabilities and Handicaps (ICIDH)  (1) (Figure 2) and, following this, with the International Classification of Functioning, Disability and Health (ICF) (2) (Figure 3). At the same time, the “bio-psycho-social model” of treatment (3,4) was developed, where therapy focuses on the care of the whole person. In fact, it was clear since the beginning that the core of PRM was not a single body structure/function, but the total person and human being, including his psychology and motivation (called today “personal factors”) and social environment (called today “participation” and “environmental factors”).

The actual reference framework of the specialty, the ICF, includes all these aspects (Figure 3). It is interesting to look at this graph thinking where our “functioning-based” specialty, with its broad approach to the person, is in comparison with the classical “organ-based” ones, with their disease-oriented approach. According to the “biomedical model”, the latter are mainly focused on the disease, as well as on the body structures and functions (Figure 4). Instead, PRM is focused in general on functioning and disability (that in fact is all the person); PRM clinical work (Figure 5) has a specific focus on reducing “activity limitations”, and improving “impairments”, while addressing also “participation restrictions” at a micro-level (personal), while the meso- and macro-levels can be addressed, with the expert help of PRM physicians, by those who work on society at large, including educators and politicians or other decision makers. In doing so, it is mandatory for PRM physician to perfectly know the medical diagnosis (“health condition” and “disease”), and to strongly interfere with the “contextual factors” (“personal” and “environmental”). The best possible “participation” for the individual is the final goal.

The following points generally distinguish the person-centred approach of PRM from the disease-oriented of the organ based specialties:

  1. A comprehensive bio-psycho-social approach to health conditions to account for all aspects of functioning. 
  2. The practical medical approach to impairments and activities limitations, with the main and final aim to positively influence and finally improve participation;
  3. Taking patients’ contextual factors into account, when planning rehabilitation programmes; in ICF terminology they serve as “facilitators” and/or “barriers” to achieve best functioning: psychological, cognitive, motivational, and economical individual factors, but also the environmental factors (including care-givers, geographical location, legislation, overall economical country level…) are crucial for the outcome.
  4. Ensuring a focus on the patient’s optimal participation, is high on patients’ aims for rehabilitation and this is a final outcome.
  5. The underlying health condition is the context of a PRM programme. Setting up services for someone with a rapidly progressive illness may be quite different from that for someone with a chronic slowly evolving condition. Knowledge of the diagnosis allows the PRM physician to provide an optimal treatment, anticipate potential complications and associations, slow deterioration (where relevant) and give a prognosis, which may include end-of-life considerations. 
  6. PRM interventions are different around the world, coherently with the existing contextual factors and the participation required and allowed by that specific society (5,6)

Another word widely used with respect to PRM is “holism”, to state that PRM is focused on the whole person. This word perfectly paints the specialty focused on “functioning” and “disability” (that are “holistic” by definition). In this context the meaning of the term “holism” is totally different from that in alternative/complimentary practices, and it is not used to justify scientifically unproven treatments: PRM in fact is a primary medical specialty totally based on evidence.

In front of the characteristics of PRM today, as a specialty with a transversal knowledge (person oriented), but an application that is vertical inside the other specialties (disease oriented), there are many possible approaches in clinics. We could consider them looking at the two possible extremes:

  • the “general PRM physician” (in analogy with the “general practitioner”), that must have a very good knowledge of all health conditions requiring a PRM approach; he should be able to manage all patients with all pathologies. This model is mostly diffused in acute wards and post-acute inpatients practice in general PRM wards (primary rehabilitation care). The advantage in this case is the possibility to manage as a single medical specialist with a multidisciplinary team almost all patients, and the possibility to perform a triage to orient most complex patients to secondary/tertiary care; the disadvantage is the possible loss of specificity (a lot of time to manage the disease and not enough time to focus on rehabilitation) and of deep knowledge of specific fields.
  • and the “specialised PRM physician”: in this case a clinician becomes highly expert also in the basic “organ” specialty, so losing some general competence and focusing mainly on the evaluation, treatment and rehabilitation of patients with specific diseases. This is most diffused in tertiary PRM wards, research and university PRM post-acute wards, but also in some outpatient settings. The advantage in this case is the high specificity of work, the easiness of contacts with “organ” specialists (sometimes even the possibility to reduce their specific contribution in the most common cases), the deep specific knowledge; disadvantage, the focused knowledge closely resembling that of “organ” specialists. 

Among these two extremes, all possibilities exist in PRM practice today, and PRM physicians are trained for both extremes and all the intermediate clinical situations.

Diagnostic responsibilities of PRM physicians

As stated above, in the context of the ICF, rehabilitation is a medical strategy aimed at enabling people with disabilities to achieve optimal functioning in interaction with the environment (7). This primary function is achieved through the rehabilitation process itself, but firstly, is based on a specific medical diagnosis. This gives the “boundaries” of PRM interventions, defining the medical prognosis, and consequently a lot of the patient’s expectations from a medical perspective. This perspective provides a stable basis, around which all the other components of the PRM programme can be developed. In fact, the medical diagnosis forecasts a range of possible residual impairments, activity limitations and also (to a lesser extent) participation restrictions. What the medical diagnosis does not define is the level of these impairments, limitations and restrictions: in fact, they will be the results of the rehabilitation process together with the personal and environmental factors.

Without a precise medical diagnosis, it is not possible to start and adequately plan the PRM programme in either the very short-, short- or long-term. The medical diagnosis determines also the style of the communication with the patient and the agreement to be reached on achievable goal setting. At the start of the rehabilitation process, it is necessary for the patient and his/her family/ caregivers to accept the patient’s new “status”. This will then interact with his or her personal and environmental factors to set and determine the outcomes of the rehabilitation process. 

Consequently, PRM physicians have a major medical diagnostic responsibility. In some clinical situations, typically when the patient’s impairment is mild (e.g. following “conservative” treatment in orthopaedic and/or sports medicine), the PRM physician is the first health professional to see the patient and arrive at the diagnosis. In these cases, the PRM physician has a primary role in assessing patients for possible alternative treatments and/or referring for more specific diagnostics by other specialists. In other clinical situations, typically in post-acute wards, PRM physicians are called in after the intervention of other specialists. In these situations, the PRM physician’s role is to check and confirm the patient’s primary medical diagnosis and to identify any comorbidities and already known impairments and activity limitation. Other medical specialists sometimes feel uncomfortable in evaluating these as they are “out of their specialty-specific competence”. Patient follow-up in the medium and long term sometimes allows a refining of the medical diagnosis, when the course of the condition does not follow its usual expected pattern. An exception to this general rule is that it is sometimes impossible to make a definitive diagnosis immediately and treatment can be proposed to elucidate this further (diagnosis “ex adjuvantibus”). 

Apart from the general medical diagnosis, the PRM physician is specifically responsible for the functional diagnosis of patients before starting the PRM process. This aims primarily at identifying the impairments and activity limitations, measuring their level and consequently setting the goals of the PRM programme to achieve the best individual participation. Moreover, PRM physicians have competences in eliciting the meaning of an illness or a disability to an individual patient, the impact on their sense of personal identity and the resulting emotional reaction. The functional diagnosis is also done by the other rehabilitation professionals (and sometimes also by other medical specialists), but PRM physicians importantly perform it for all the domains of body structures/functions and activities, while other focus on their specific competences. PRM physicians maintain in this way a wider perspective, that allows to define, in agreement with the other rehabilitation professionals, priorities and temporal timing of the different interventions. Moreover, the functional diagnosis is the overlap of competence between the different rehabilitation professionals that constitute the common background for dialogue, interaction, and team building. Nevertheless, also in a team perspective, the functional diagnosis responsibility finally rests on the shoulders of PRM physicians.

In this functional perspective, there are some diagnostic tools that are specific to PRM and have been widely developed inside the specialty, such as disability and quality of life questionnaires, but also motion analysis systems, electrodiagnostic and ultrasound instruments, etc.

Moreover, PRM physicians have been among the first to recognise the importance of ICF for further development of rehabilitation, better information about healthcare and stimulation of research with the common goal of achieving optimal functioning and minimising disability of both individuals and general health aspects (8–10).

The PRM multimodal approach and multiple morbidities management.

PRM covers a broad range of disorders and includes the consequences of trauma, surgery, diseases and congenital conditions (see also chapter 8.3). This is in sharp distinction with/to other medical specialties that treat organs or organ-systems (e.g. cardiology, nephrology, dermatology), specific age groups (e.g. paediatrics, geriatrics) or that apply a certain skill or technical instrumentation (e.g. surgery, radiology, radiotherapy). 

Therefore PRM usually is considered as a “horizontal speciality”. Moreover, PRM is not primarily focused on prevention or treatment of the disorder itself, but focuses on the consequences in terms of activity limitations and restrictions in participation. The prevention and reduction of activity limitations and optimisation of participation are the core of PRM. 

As a result PRM has adopted a patient-centred approach that also includes the personal characteristics of the patient. The consequence of this “holistic” approach is that PRM physicians do not work alone, but need to involve a large number of other healthcare professionals. The healthcare professionals operate with an interdisciplinary approach in a multi-professional team, which also includes the patient and/or his caregivers. 

Assessing, treating, training, exercising, coaching and supporting this broad range of patients with a large interdisciplinary team in the acute, subacute and chronic phases requires expensive and well equipped facilities. Usually a PRM department provides facilities (and its personnel) including: electromyography, strength measurement, gait analysis, neuropsychological testing, gymnasium, occupational therapy rooms, swimming pool, physical modalities etc.

The broad range of patients, the focus on impairment, activity limitations and participation restrictions, the attention to personal factors, and environmental factors, the multidisciplinary team and the necessity of equipment and other facilities make PRM a complex, multimodal and comprehensive specialty. 

Each patient is usually treated with a broad range of therapies, provided by a broad range of health professionals (see also chapter 8.6). These can include, among others, exercise therapy, occupational therapy, speech therapy, neuropsychological treatments, behavioural therapies, physical therapies, manual therapies. Each patient is treated with a unique approach, according to his disease, impairments, activity limitations, participation restrictions, environmental and personal factors, in a totally multimodal and individualised approach.

The ageing of the population has a huge impact in service providing, as well as on people with disabilities: this conversely impacts on PRM specialty and treatments. Rarely patients after a certain age have only one disease; rarely the main disease for the PRM intervention is not influenced by other important morbidities. The recently developed “syndemic” conceptual framework (11) fit quite well into the approach of PRM to comorbidity. In fact, it emphasises the synergistic role of diseases and (social) context in affecting the clinical course, and strongly relies upon a biosocial conception of health

Therefore, treatments must be continuously adapted, making approaches even more individualised. PRM’s holistic approach focuses on the entire person with the aim of improving his or her activities and increasing his or her participation and inevitably takes into account all the comorbidities, that influence treatments and outcomes. 

Moreover, comorbidities are usually scarcely evaluated by the referring specialists in case of patients coming from acute wards and they frequently require a diagnostic workout by PRM physicians at the admission to the post-acute wards. Comorbidities heavily impact on the burden of care and on final outcomes: specific scales are under development to better understand, study and clinically manage their impact in the PRM process.

The multi-professional interdisciplinary PRM team

PRM physicians provide treatments in two different ways: as in many other specialties, they do it personally, using specific techniques (e.g. interventional PRM, injections, manipulations “manu medica”, etc); instead, quite specific to PRM is the delivery of treatments through team work. The latter is particularly true, when a rehabilitation process is concerned and other non-physician rehabilitation professionals are included.

The achievement of successful rehabilitation requires multiple health care professionals with a wide range of clinical skills and expertise. They must work together harmoniously, but also effectively as a team, in order to achieve rehabilitation goals for patients and their families. It is this style of multi-professional teamwork that differentiates PRM from many other specialties. The combined group activity of an effective team should provide synergy and result in better outcomes than the sum of each individual working alone. (12–14).

Even if being multi-professional in nature, the terms used in medical and management literature can be confusing as different team approaches or models exist and are defined according to the interaction among team members. Consequently, the means, in which the multi-professional team works, has been defined by different models: multi-, inter- and trans-disciplinary, with different meanings. A multidisciplinary team model utilises the skills of individuals from different disciplines but each discipline still approaches the patient from his own perspective and usually the physician communicates with other professionals of the team. An interdisciplinary team model integrates the approach of different disciplines with a high level of collaboration and communication among the team professionals using an agreed and shared strategy; the leadership of the team remains in the hands of one physician. In a transdisciplinary team model the boundaries of professionals’ practice are blurred and any professional is capable of working in any particular team role. (15,16)

An interdisciplinary approach in the multi-professional team is the preferred pattern of team working. However, even if it is not the most appropriate to answer to the needs of the patient and provide a good rehabilitation programme, other models can also be found in various rehabilitation settings, such as a multidisciplinary approach in an acute-care unit or a transdisciplinary approach in long-term community care for a patient with educational needs. In most settings, an interdisciplinary model is most effective because it allows a collaborative, holistic and patient-centred approach to rehabilitation (17). The PRM team, under the responsibility of the PRM physician, should agree and set realistic goals along with patients and their families and then work together to achieve these goals using a shared strategy. This is often best done in joint sessions which may serve to avoid over-stimulation, fatigue or repetition.

Evidence shows that improved functional outcomes and even better survival can be achieved with multi-professional interdisciplinary teamwork in several conditions particularly stroke, traumatic brain injury, hip fracture, pulmonary rehabilitation and back pain. (17–19)

The interpretation and the means to obtain a good interdisciplinary approach for the multi-professional team are different according to the settings. In the post-acute PRM hospitals all professionals work together in the same facility under the responsibility of the PRM specialist. The turn-over of patients is relatively low, the rehabilitation time long enough, and the answer of patients to treatments quite rapid. All these factors play a major role in determining the approach to team management that is considered “classical” in PRM, since it is the most studied.

In the acute hospital with a central PRM department the multiprofessional team of the PRM department is responsible for all rehabilitation issues in the acute hospital. The multiprofessional PRM team acts on a consultant basis for all wards. The multiprofessional team consists of PRM doctors and rehabilitation professionals under the responsibility of the PRM specialist. The multiprofessional team works in an interdisciplinary setting at the different wards  whereever they are needed.

Outpatients’ settings often provide multiprofessional interdisciplinary teams under the responsibility of the PRM specialist. Nevertheless, teams may be incomplete or sometimes do not seem to exist, particularly when the PRM physician and the rehabilitation professionals providing treatment are not even working in the same place. Other specific characteristics of this setting include huge number of patients, rapid turn-over, short time for evaluation and treatments (a few sessions) and rapid answers to treatments. Obviously the difficulties of a team approach increase in these cases, and management is based on protocols and/or simple prescriptions: in case of exceptions to protocols, disagreement and/or particular clinical cases, direct written and/or speaking contacts between the professionals are needed. Possibly, team meetings should also be planned, even if with reduced frequency. Very close to this setting, is the situation of the so-called “post-rehabilitation” and/or maintenance activities in chronic patients. Sometimes, it is argued that these settings are not clinical and outside the rehabilitation team, but the management of these complex patients is usually difficult and they intermittently require classical rehabilitation interventions: consequently, also in these cases a team management of maintenance is more appropriate, even if light strategies should be adopted.

Another different situation for team work management is in long term PRM facilities, where turn-over and clinical changes are very slow, and rehabilitation treatment reduced. In these cases team meetings are still possible, but a very low pace. 

Successful rehabilitation team work requires some specificities, even if not all are possible in the different settings proposed:

  • Management and leadership: PRM physicians are clinical managers and should be good leaders of the rehabilitation team: in addition they should be able to manage groups, solve problems, facilitate discussion, make decisions and listen;
  • Hierarchy: even if there is no direct hierarchical relationship (not possible when in different facilities), there must be in all health systems someone, who is ultimately responsible for the patients, and for making clinical decisions: this is the physician, usually the PRM physicians, in a functional hierarchical relationship;
  • Time: appropriate time must be devoted to team building, which may vary according to the setting. Since rehabilitation is not possible without the team, this is proper working time and not only improves the standards of clinical work, but really allows it to function;
  • Respect of roles and professions: all the team members have different competences that must be recognised by all the others; the roles are different, and even, if nobody is superior to the another, a hierarchy exists and needs to be respected;
  • Personal factors: teams function, if people make it function. There are clearly personal factors, such as the availability to change, the ability to collaborate, team work education, a balance of personal strength to accept to have one’s own work discussed and sometimes challenged, and the ability to listen and permission to speak. These factors can only partially be learned, but are necessary to practise rehabilitation for all professionals
  • Environmental factors: general attitudes in the working place (in and out the rehabilitation ward, including the administrative management) plays a major role in facilitating or inhibiting team work; PRM physicians have a major role in facilitating the environmental attitude. Moreover, specific instruments and communication tools should be developed according to the setting.

References

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