Chapter 7 –The clinical field of competence: PRM in practice

European PRM Bodies Alliance

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

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: Christoph Gutenbrunner, Pedro Cantista, Maria Gabriella Ceravolo, Nicolas Christodoulou, Alain Delarque, Carlotte Kiekens, Sasa Moslavac, Enrique Varela-Donoso, Anthony Ward, Mauro Zampolini, Stefano Negrini
The contributors: Filipe Antunes, Ayse Kucukdeveci, Aydan Oral, Peter Takač, Catarina Aguiar Branco, Mark Delargy, Alessandro Giustini, Jean-Jacques Glaesener, Klemen Grabljevec, Karol Hornaček, Slavica Jandrić, Wim Janssen, Jolanta Kujawa, Renato Nunes, Rajiv Singh, Aivars Vetra, Jiri Votava, Mauro Zampolini, Alain Delarque, Gabor Fazekas, Francesca Gimigliano, Ayse Kucukdeveci, Vera Neumann, Tatjana Paternostro-Sluga, Othmar Schuhfried, Luigi Tesio, Tonko Vlak, Alain Yelnik.

Abstract

In the context of the White Book on Physical and Rehabilitation Medicine (PRM) in Europe this paper deals with the scope and competencies of PRM starting from its definition as the “medicine of functioning”. PRM uses the rehabilitative health strategy as its core strategy together with the curative strategy. According to the complexity of disabling health conditions, PRM also refers to prevention and maintenance and provides information to the patients and other caregivers.

The rehabilitation process according to the so-called rehabilitation cycle including an assessment and definition of the (individual) rehabilitation goals, assignment to the rehabilitation program evaluation of individual outcomes.

PRM physicians treat a wide spectrum of diseases and take a transversal across most of the medical specialties Thea also focus on many functional problems such as immobilization, spasticity, pain syndromes, communication disorders, and others.

The diagnosis in PRM is the interaction between the medical diagnosis and a PRM specific functional diagnosis. The latter is based on the ICF conceptual framework, and obtained through functional evaluations and scales: these are classified according to their main focus on impairments, activity limitations or participation restrictions; environmental and personal factors are included as barriers or facilitators.

Interventions in PRM are either provided directly by PRM physicians or within the PRM team. They include a wide range of treatments, including physical therapies, medicines, exercises, education and many others. Standardized PRM programs are available for many diseases and functional problems. In most cases rehabilitation is performed in multi-professional teams working in an interdisciplinary and patient centred approach.

Outcomes of PRM interventions and programs, showed reduction of impairments in body functions, activity limitations, and impacting on participation restrictions, and also reduction in costs as well as decrease in mortality for certain groups of patients.

Key words

Physical and Rehabilitation Medicine (PRM), Field of competence, PRM diagnosis, PRM assessments, PRM treatments, rehabilitation process, PRM 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 Paragraph systematically presents the practical work of PRM physicians describing:

the scope and competencies of PRM starting from its definition as the “medicine of functioning” responsible of the rehabilitative strategy to be applied together with the curative strategy when the latter is not enough for the best recovery of patients’ participation; according to the complexity of the health condition, PRM also refers to prevention and maintenance, as well as to rehabilitation training for other health professionals and to management of patients and caregivers;
the rehabilitation process according to the so-called rehabilitation cycle: all patients require an assessment with definition of their individual goal(s) before providing the intervention(s); finally, an evaluation will be performed to check if the patient has achieved all what is needed, or if it is necessary to start again the rehabilitation cycle;
the spectrum of diseases treated by PRM physicians: a comprehensive but not exclusive list of the most important individual health conditions is given. The transversal role of PRM across most of the medical specialties is clear, but the overlap is only apparent, since the focus of PRM is rehabilitation (sometimes also improperly called “conservative treatment”). Also, the most common general problems such as immobilization, spasticity, pain syndromes, communication disorders, etc are presented;
the diagnosis in PRM is the interaction between the classical medical diagnosis (that uses all the typical tools of the profession) and the PRM specific functional diagnosis. The latter is based on the ICF conceptual framework, and obtained through functional evaluations and scales: these are classified according to their main focus on impairments, activity limitations or participation restrictions; environmental and personal factors are included as barriers or facilitators;
the interventions in PRM, provided directly by PRM physicians or indirectly through the PRM team; in this respect, standardized PRM programs have been recognised by the UEMS PRM section;
the multi-professional PRM team is one of the way with which PRM physicians provide treatments, particularly in the most complex rehabilitation settings; the team work with an interdisciplinary methodology, under the responsibility of PRM physician;
the outcomes of PRM interventions and programs, that are patient-centred, and include functional and personal outcomes (reducing impairments in body functions, activity limitations, and impacting on participation restrictions), reduction in costs as well as decrease in mortality for certain groups of patients.

Scope of competencies of PRM

Physical and Rehabilitation Medicine (PRM) physicians are involved in the management of patients with a multitude of different health conditions. They are concerned with the impact of these conditions on personal functioning and participation (1,2). The medical specialty of PRM is conceptually described as the ‘medicine of functioning’ (3,4) based on the WHO’s Integrative Model of Functioning (see appendix 1). Problems in functioning involve impairments in body functions and/or structures, activity limitations and participation restrictions which are represented by the umbrella term ‘disability’, as specified in the International Classification of Functioning, Disability and Health (ICF) (5).

To better understand the scope of competencies of PRM, the interaction between the curative and the rehabilitationstrategy is demonstrated in figure 1 (6). If a patient with a health condition reports no relevant limitations in functioning, curing the disease is sufficient to solve the problem. If a patient experiences disability related to his or her health condition, a second strategy must be applied in order to reduce disability or supporting functioning respectively. This strategy has been described as rehabilitation strategy (3,4). In this case the sole application of curative strategies may not solve the problem and some exclusion from society may remain. It is specific for PRM to combine therefore the curative and rehabilitative strategy by applying a multitude of interventions aiming at both, treatment of the pathology and overcoming disability (7).

However, PRM treatments and programmes may also refer to other health strategies, such as prevention (e.g. of complications of immobilisation or treatments, diseases related to lack of physical activity), as well as maintenance and support (e.g. provision of assistive devices for long-term use, palliative care). In many cases these interventions and programs combine these strategies according to the individual needs of the patient (8). (see also paragraph 9)

This chapter predominantly describes the clinical approach of PRM physicians with the disease or impairment as starting point. However, the field of competence includes education and training as well as management, coordination and advice. The complexity of tasks in rehabilitation is demonstrated in figure 2 (9) by a hierarchical structure with increasing complexity (level 1 to 5). While at levels 1 and 2 the immediate environment and primary health care works have a strong role, PRM physicians should take care, either alone or within a multi-professional team, in more complex situations (levels 3 and 4). The top of the pyramid describes very highly specialised services for patients with complex rehabilitation needs and goals and/or less prevalent health conditions early in specific circumstances, rehabilitation for health conditions (e.g. spinal cord injury, traumatic brain injury, chronic pain, growing age).

At levels 3 to 5 PRM physicians are delivering treatments and services by themselves. However, PRM may also contribute to levels 1 and 2, in particular by providing education and training to other health care providers. As in many cases, different levels of rehabilitation care may be needed and the process must be coordinated. Such coordination is a main competency of PRM physicians, too, and may also be relevant for health care planners in need of advice from an expert’s perspective.

The rehabilitation process: assessment, goal-setting, intervention, and evaluation

As mentioned above, PRM physicians manage, lead and coordinate the rehabilitation process within a problem-oriented, patient-centred and holistic approach. Depending on the characteristics and the requirements of the patient, PRM physicians might carry out the process alone or within a team of rehabilitation professionals (see below). The rehabilitation process starts with the diagnosis and continues as long as the person needs rehabilitation interventions (10). The rehabilitation process regularly comprises 4 stages (figure 3):

assessment,
goal-setting,
intervention,
evaluation (11).

They can be described as follows (see also box 1):

Assessment: In the first stage, the presence and the severity of the patient’s problems are identified. This identification includes the assessment of functioning based on the ICF framework and therefore lists the impairments of body functions and structures, activity limitations, and participation restrictions (12). In addition, environmental factors (such as support and attitudes of family, friends, employer or community, physical environment, health and other services, etc.), personal factors (such as lifestyle, habits, education, race/ethnicity, life events or social background), prognostic factors, the individual’s rehabilitation potential and needs, as well as his/her wishes and expectations are identified. Different members of the interdisciplinary PRM team may contribute to this assessment stage with their specific professional knowledge of the person and his/her functioning (example see table 1).
Goal-setting: Considering the problems and potentials identified at the assessment stage, a rehabilitation plan, specific for the individual rehabilitation plan, is established at the goal-setting stage. This plan comprises short-term and long-term goals for the patient proposing the time-frame in which it should be delivered. Involvement of the patient and the family/carer in the goal-setting stage in order to set realistic and achievable goals is of paramount importance. This stage also includes the assignment of established goals to specific interventions and subsequently to the responsible member(s) of the interdisciplinary PRM team to carry out the interventions (13).The selection of interventions is greatly facilitated using the ICF model (14).
Intervention: At the intervention stage, all therapeutic, educational and supportive interventions specified in the rehabilitation plan are undertaken according to the goals set (see below). Interventions should aim to prevent, stabilize, improve or restore impairments of body functions and structures, and to optimize activities and participation taking into account the individual’s capacity and performance as well as the relevant environment (4).
Evaluation: Finally, the effects of intervention programs vs. the goals set are evaluated. In other words, outcome assessment is done in order to evaluate goal achievement. At this point, the PRM team needs to determine whether there are still unresolved but resolvable problems and in which case the rehabilitation process should continue. To do so, the existing PRM program is reviewed and re-planned according to the new goal, or if the rehabilitation process will be completed (11). This process is iterative and if there are still problems/issues requiring intervention, the cycle continues until the goals are achieved (see figure 1). At most stages of this rehabilitation process, the PRM team uses various assessment tools to establish the presence and the severity of problems, to inform intervention planning, to monitor progress, and to predict recovery and discharge planning (15). Using standard assessment tools (outcome measures) within an ICF-based assessment procedure enhances the communication among the team members (see below). At the end of the rehabilitation process, the patient and his/her family/carer should be informed about further maintenance of health, follow-up visits if needed and how to re-access services.

PRM management also includes management of referral and transition between services. The use of ICF may enhance a structured approach to rehabilitation process and ease the communication of the PRM team with respect to the problems, goals, and interventions (6). Goal-setting helps patients achieve a higher quality of life or sense of well-being and a higher self-efficacy (16). The evaluation of changes in the functioning state and goal achievement are important outcome measures in clinical practice to demonstrate effectiveness of services (17).

Spectrum of health conditions treated by PRM physicians

In accordance with the conceptual description of PRM (3,4), any disease, pathology, or health condition causing impairments of body functions and/or structures, activity limitations, or participation restrictions is in the scope of PRM. The most important groups of health conditions (diseases and disorders, including congenital anomalies, stress, and age-related problems, as well as injuries and trauma) which PRM physicians treat are listed in table 2 (comprehensive list seeappendix 2) (1,2,18). The list refers to the most current version of the International Statistical Classification of Diseases and Related Health Problems (ICD) of the World Health Organization (WHO) (19). The list has been expanded based on the results of a workshop held by the International Society of Physical and Rehabilitation Medicine (ISPRM) which identified health conditions requiring rehabilitation (20,21) (see also box 2).

The involvement of PRM physicians in these conditions are mainly related to the promotion of functioning and reduction of unfavourable functional consequences arising in acute or post-acute phases as well as for patients with long-term conditions (18).

PRM physicians may also provide treatments for certain gynaecological and urological conditions (1,2) or disorders of the skin and subcutaneous tissue relevant to PRM (e.g. decubitus ulcers, skin breakdown secondary to contractures).

There are a number of general problems across the many health conditions, which PRM doctors face on a daily basis (1,2). These may include:

prolonged bed rest and immobilisation, deconditioning patients and causing loss of physical and psychological functioning
motor deficits producing weakness and/or sensory deficits with loss of personal functioning
spasticity leading to limb deformity and self-image problems
pain syndromes
communication difficulties
mood, behaviour, and personality changes
bladder and bowel dysfunctions commonly found in disabled patients
pressure ulcers as a risk of immobility in spinal cord injured, diabetic, deconditioned and elderly patients
dysphagia – people with swallowing disorders who lose the enjoyment of eating and who are also at risk of aspiration pneumonia and malnutrition
sexual dysfunction covering identity and self-image issues as well as organ functioning
changes to family dynamics, personal relations, career opportunities and financial security.

As reported in the World Report on Disability (22), disability is expected to increase worldwide and it remains a challenge for PRM physicians to be able to intervene in a wide variety of rehabilitation-relevant health conditions. This increase affords an opportunity for promoting the PRM medical specialty and emphasizing its importance.

The importance of PRM in the treatment of various diseases sometimes is neglected with regard to the tasks of PRM in rehabilitation. However, PRM in most countries is the specialty that treats acute and chronic musculoskeletal diseases (e.g. low back pain, neck and shoulder pain, pelvic and knee pain and many others), disorders of the nervous system (e.g. spasticity, imbalance, ataxia) chronic widespread pain syndromes, as well as cardiovascular, metabolic and respiratory dysfunction, lymphatic disease and incontinence. Additionally, PRM has specific competence in the treatment of specific syndromes such as burn-out syndrome, sleep disorders, fatigue, as well as dysfunction of abdominal and pelvic organs (chronic pelvic pain syndrome, irritable bowel syndrome and others) (23).

Diagnosis of diseases in PRM (medical diagnosis)

Diagnosis in PRM includes medical and functional diagnosis. Health condition is an umbrella term for disease, disorder, injury, or trauma as well as other circumstances such as pregnancy, aging, congenital anomaly or genetic predisposition (12). As a broad range of health conditions are covered by the PRM, the PRM physician recognises the need for a (or several) definite medical diagnosis prior to treatment and problem-oriented PRM interventions.

For medical diagnosis, PRM physician focuses on patient’s history and clinical examination as well as the clinical diagnostic procedures such as laboratory tests, imaging techniques, electrophysiological tests, etc. The International Classification of Diseases and Related Health Problems (ICD-10) is the current used classification system for coding the diagnosis of health conditions (19).

PRM physicians take a detailed history about the present health condition, past medical conditions, review of systems as well as functional status (mobility, self-care activities, cognition, communication, vocational and recreational activities), and family and social history (24). A thorough physical examination including general medical, neurological and musculoskeletal examination is of paramount importance. Special tests or provocative manoeuvres, such as shoulder impingement tests, Finkelstein test, McMurray test or others, might be necessary for the diagnosis of some musculoskeletal conditions (24).

For the diagnosis of many health conditions, imaging techniques are of major relevance. One of the common methods is X-ray imaging. It enables diagnosis and monitoring inpatients. Primarily, X-rays provide information on bone lesions, but also on calcifications on tumours, soft tissue, blood vessels and so on. Because of its many advantages, ultrasound of the locomotor apparatus plays a significant role in diagnosis, but also in monitoring of various disorders of the musculoskeletal system. Unlike X-ray and CT scan, it does not require radiation exposure, it is non-invasive and above all there are no known contraindications. Besides, there is a possibility of repeated ultrasound examination and it is highly sensitive on changes. It allows potential use of ultrasound in monitoring disease progression and in evaluating therapeutic efficacy of local and systemical treatment. In addition to a standard ultrasound examination, there is a growing use of colour and Power Doppler ultrasound in the diagnosis of synovitis, tenosynovitis, enthesitis and bursitis. Power Doppler, which is very sensitive in illustrating inflammation, is usually used in rheumatic diseases, for diagnosis and monitoring of synovitis (), traumatic injuries, e.g. during tendinitis treatment, or in evaluating mass lesions (comparison of benign and malignant changes) (25).

Computerized tomography (CT) is highly sensitive, modern diagnostic method. It is painless and of satisfactory accuracy, but it exposes patient to X radiation. It is superior to MRI in diagnosis of bleeding, calcification and changes in head bones. Magnetic resonance imaging (MRI), together with computerized tomography, is one of the most important medical innovations in terms of patient’s care improvement (27-). If clinical examination indicates neuromuscular disease, complete evaluation of these patients includes electrodiagnostic testing as well. In order to obtain most likely diagnosis and exclude others, testing should be conducted in technically competent manner and results should be correctly interpreted. Results of this analysis should enable identification of the basics of pathological processes such as: sensory, motor, or sensorimotor polyneuropathy, mononeuropathy, multiple mononeuropathy, polyradiculoneuropathy, radiculopathy, myopathy, disturbances at the level of the neuromuscular junction. In certain cases, electrodiagnostic data can be used to evaluate the prognosis of recovery of neurologic function or for assessing disease progression itself (28-).

To improve the efficiency of the diagnosis and definition of the patient’s condition and his/her physical capacities, the PRM specialist can use a validated set of technologies which inform with remarkable precision about basic features like muscle strength (power, work), of most muscle groups, three-planar range of motion of body segments, the way of walking (kinetic and kinematic analysis), equilibrium capacity in different conditions and muscular electrical activity with surface or needle electrodes during motion or rest. All these studies prove to be excellent tools to define the status and for monitoring the therapeutic process engaged. Taking into account characteristics of most commonly used diagnostic method in injuries and diseases of locomotor apparatus, the PRM physician has considerable responsibility when choosing them. She/he has the task to diagnose the problem as precisely as possible, but at the same time not to harm the patient. In addition, upon completion of the rehabilitation program and exhaustion of all further treatment possibilities, specialist in physical medicine and rehabilitation has to give a final assessment of the functionality of the patient. Based on that information, estimation of the patient’s independence in daily living activities is made, i.e. need for someone else’s care and work capacity assessment i.e. need to change the job or go to disability pension. It is of big health significance, but also of social and economic one. The large spectrum of laboratory testing may be used by PRM physicians as well.

In addition to clinical examination, imaging and laboratory testing, measurement of functional restrictions and functional potential with respect to the PRM program constitute a major part of diagnostics in PRM. These measurements may include muscle function analysis (strength, electrical activity and others), goniometry for joint range of motion, testing of circulatory functions (blood pressure, heart rate, exercise stress test), pulmonary function, balance and gait, hand grip and others (18).

Multidimensional assessment of functioning (functional diagnosis)

In addition to medical diagnosis, functional diagnosis as medical specialty mainly focussing on the improvement of functioning is a prerequisite for the PRM (4). Diagnostic process in rehabilitation has traditionally been termed as “assessment” (26), thus “assessment of functioning” is the preferred term for functional diagnosis (4). Table 3 gives an overview of frequently used tests and assessment tool in PRM.

Functioning is the lived experience of human being, in which body, person and society are intertwined (12). According to the WHO’s conceptual model of the International Classification of Functioning, Disability, and Health (ICF), functioning is an umbrella term including body functions and structures, and activities and participation (5). Assessment of functioning should be performed based on the conceptual framework provided by the ICF and should include body functions and structures, as well as activities and participation (3)(see box 3). In order to fully depict functioning of a specific individual, there is a need for assessment data of the dimensions of functioning, including impairments of body functions and structures, activity limitations, participation restrictions, environmental barriers and facilitators, as well as individuals’ perceptions and expectations (26).

Body functions and body structures are classified systematically in eight corresponding sections in the ICF (5). Body functions requiring assessment in most musculoskeletal conditions are pain, mobility of joints, stability of joints, muscle power, muscle tone, muscle endurance, energy, sleep, emotional functions, exercise tolerance, gait pattern and sexual functions. Assessments of body functions in neurological conditions should also include cognitive functions (consciousness, orientation, attention, memory, language, perception), touch and other sensory functions, voice and speech functions, control of voluntary movement, defecation and urination. Joint deformities, muscle atrophy, structural impairments of various musculoskeletal regions determined by X-rays or other imaging methods, structural impairments of brain or spinal cord demonstrated by various imaging techniques and pressure ulcers of the skin are examples of impairments of body structures usually assessed in the field of PRM. Body functions and body structures can be assessed by means of history taking, physical examination, laboratory investigations, imaging techniques, some clinical, electrophysiological or neurophysiological tests or self-report questionnaires. Beck Depression Inventory for depression,Mini Mental State Examination for some cognitive functions, and the Modified Ashworth Scale for muscle tone are examples of widely used assessment instruments of body functions (27).

PRM physicians may also use standardised technical assessments of performance such as gait analysis, dynamometric muscle testing and other movement functions. In the PRM process of patients with certain conditions, specialised diagnostic measures will be required, e.g. dysphagia evaluation in stroke, electro-diagnostic tests in peripheral nerve injury, urodynamic measurements in spinal cord injury, or cognitive function tests in brain injury (1,2).

‘Activities and Participation’ are presented in 9 domains as a single list in the ICF (5). Activities are basic tasks or actions which represent the individual perspective of functioning. In PRM, it would be reasonable to operationalize ‘activities’ as a separate level of assessment. In this case, the domains, learning and applying knowledge, general tasks and demands, communication, mobility, self-care and to some extent domestic life could be considered as ‘activities’. ‘Participation’ represents the societal perspective of functioning and includes interpersonal interactions and relationships, life activities such as domestic life, education, work and employment, and community, social and civic life (28). The term ‘functional assessment’ used in the medical literature corresponds to assessing ‘activities and participation’. Assessments can be made of performance, describing what an individual is doing in his or her current environment, or on capacity, which describes an individual´s ability to execute a task or an action and ought to be done in a ‘standardized’ environment (28). Although moderate to high correlations have been observed between capacity and performance, environmental and personal factors (such as motivation) have a great impact on the performance of activities (29).

Assessment of activities and participation can be performed by various methods including directly questioning the functional history, observing the activity, standardized functional scales (questioning activities of daily living, instrumental activities of daily living, cognitive functioning, participation etc.) or by special performance tests such as dexterity, balance or walking. Most of the assessment tools used in the PRM field assess activities (30,31). The assessment may focus upon a special activity such as mobility or dexterity or a combination of such activities. For example, the Rivermead Mobility Index assesses mobility whereas the Nine Hole Peg Test evaluates dexterity. The Barthel Index and the Functional Independence Measure (FIM™) are commonly used generic activity limitation scales, the former assessing physical activities of daily living, the latter evaluating both physical and cognitive aspects of daily life (32) (for a comprehensive list of questionnaires and other comprehensive assessment tools used in PRM see appendix 3).

Due to their impact on functioning, environmental and personal factors should certainly be assessed in the PRM process either as a barrier or facilitator. Assessment of environmental factors can be considered according to the framework of ICF, being listed in five sections as products and technology, natural environment and human-made changes to environment, support and relationships, attitudes, and services, systems and policies (5). Personal factors such as lifestyle, habits, education, race/ethnicity, life events or social background should also be noted, although not listed in the ICF. The relevant contextual factors with respect to the social and physical environment are evaluated by interviews or standardised ICF-based checklists. For the identification of personal factors, standardised questionnaires may be used (e.g. assessment of coping strategies) (18).

While medical and functional diagnosis (assessment of functioning) are discussed separately in this chapter, the two-way interaction between a health condition and functioning properties is well established in the ICF (5). The impact of a health condition on functioning is unquestionable and functioning is an inseparable part of our health perception (33). The World Health Organization is pursuing the goal of the integration of the ICD and ICF during the ICD revision process (ICD-11) (34). The joint use of the ICD and ICF in the ICD-11 will make holistic information available regarding a medical diagnosis and its impact on the functioning (i.e. functional diagnosis) at the same time in a common framework (35).

Interventions in PRM

Physical and Rehabilitation Medicine uses a wide range of biomedical and technological interventions. PRM interventions, which fit to the International Classification of Health Interventions (ICHI) (under development) (36)include medical interventions (medication), physical treatments and physiotherapy, occupational therapy, speech and language therapy, dysphagia management, neuropsychological interventions, psychological interventions (including counselling of patients, families, and caregivers), nutritional therapy, assistive technology, prosthetics, orthotics, technical supports and aids, patient education, and PRM/rehabilitation nursing (see box 4). More details are shown in Table 4 (for a comprehensive list of interventions see appendix 4).

There is growing scientific evidence on efficacy and effectiveness of most of the applied interventions. The new Cochrane field of rehabilitation aims at being a bridge between the available evidence and the field of PRM practice. (http://rehabilitation.cochrane.org/).

Standardized PRM programs

As mentioned above, Physical and Rehabilitation Medicine physicians play a complex role in health-related rehabilitation programs. It starts with a clear medical diagnosis, a functional and social assessment and continues with the definition of different goals to achieve, according to the patient needs, the set-up of a comprehensive strategy, the achievement of personal intervention and the supervision of team or network cooperation. It ends after a final assessment of the overall process. Such process can be named a “PRM Program of Care”.

The Clinical Affairs Committee of the UEMS-PRM Section developed standards for accreditation of such programs and published a series of those already accredited (see table 5). Such accreditation is based on the following (for more details see appendix 5):

Epidemiological needs and scientific evidence sustaining the program design.
A target population, with inclusion and exclusion criteria.
General goals, expressed with respect to the ICF.
A well-structured content, with details about its agenda with possible stages, diagnosis and assessment tools (for the initial, follow up and final periods), scheduled interventions (direct treatment, education and training, rehabilitation), and the exact role of each participant in the programme.
Adapted equipment and manpower, with relevant team management. Assessment tools should help to make individual decisions and to provide objective data for the overall assessment of the programme.
Discharge criteria and final report, with recommendation for the long term follow up.

PRM Programs of Care are a good basis for a quality approach. Defining a Program of Care leads to emphasise the strong points of PRM activity, but also raising some points that may be improved through a further action plan. Structured assessments will produce interesting data about outcomes in real life conditions.

PRM Programs of Care can adapt general principles to any local need and condition. For instance, PRM early intervention in an acute care hospital will make a different program for brain injured people than a community based unit, dealing with people suffering from brain damage. And a Posture and Movement Analysis Unit will provide a third kind of additional assessment and advisory program. In some cases PRM programs may address a very specific population, referred by other specialists. On the opposite, you may have to satisfy the various needs with less technology, but more personal relationship. Therefore, any kind of programme is worth being considered with the same attention.

Programs of Care must address one specific issue, rather than describe the overall activity of a PRM Department. For example, the focus may be on a “stroke program” instead of speaking about “neurological conditions” at large. The main entrance to the program may be:

An impairment (as a consequence of a health condition): hemiplegia, amputation, spinal cord injury, knee ligament reconstruction, low back pain and others.
An activity limitation and participation restriction: walking disability, limitation in self-care, not being able to perform household, leisure or sports activities and others.
A vocational goal or independent living for brain injured people,
A period of life, with some specific features: children with cerebral palsies, athletes with musculoskeletal injuries, manual workers with low back pain, elderly people with falling hazards and others.

The number of accredited PRM programs is continuously growing.

Another approach for more standardization of PRM interventions in treatment and rehabilitation programs for specific health conditions is given by the Professional Practice Committee of the UEMS-PRM section. It described the Field of Competence of PRM in specific areas in detail. The results of this effort are published in an E-Book of the Field of Competence of PRM which is available from the UEMS-PRM Paragraph and Board website (37).

Management skills and advisory role of PRM

Physical and Rehabilitation Medicine Physicians have a wide range of management skills. Those include

At the micro-level of care provision: to manage a patient-case in its complexity and, in particular, to support the patient/client to chose the right services, to get social and legal support, to adapt the environment etc. This also includes the management of the multi-professional rehabilitation team, e.g. in organising meetings, documentation of outcomes, follow-up of decisions.
At the meso-level of service organisation: to manage a rehabilitation hospital or other service, to run a PRM department in a bigger institution. This also includes the implementation and follow-up of quality management programs (see paragraph x). Aspects of qualification of team members, appropriate technical equipment and financial resources are part of this area of work.
At the macro-level of health systems and policies: to influence health policies and environmental design to facilitate participation of persons with disabilities, including access to rehabilitation services. To manage this part of the environment is an important factor for successful rehabilitation. In most cases this will not be done by an individual practicing PRM physician but will be done in context of PRM societies or responsible committees and other stakeholder bodies

To fulfil these tasks PRM training includes many aspects of management skills: team work, planning skills, health systems knowledge, process management, principles of service provision including financial aspects, basics of health policies and d others.

Multi-professional collaboration and interdisciplinary teamwork

In the literature dealing with team work and collaboration in rehabilitation medicine terms sometimes are used differently from their definition in scientific literature on team models and interaction between team members. Therefore, a clarification of terms is needed here.

In PRM literature the terms are mostly used to describe collaboration partners working together in the team:

multi-professional team: team consisting of multiple rehabilitation professionals (e.g. PRM, PT, OT, SLT and/or others)
inter-disciplinary collaboration: collaboration among different medical specialties (e.g. PRM, trauma surgeon, neurologist, cardiologist and/or others)

In team theory, the terms are used to describe the way of collaboration and the interaction between team members irrespective of their professional background:

multi-disciplinary team work: team work without systematic structure and without an organized decision making process. Such teams are mostly based on hierarchy, do not meet regularly, discuss only parts of work (or specific patients), have less room for discussion and, in many cases, communicate bilaterally
inter-disciplinary team work: collaboration of team members with different backgrounds putting together their knowledge, expertise and experience to solve problems together. Such teams gather regularly, discuss all problems and work based on equality of contribution of every team member. Decisions are taken as a team (mostly based on consensus). Communication is always multilateral.

In this chapter, the term “multiprofessional team” will be used for a rehabilitation team consisting of different rehabilitation professionals, the term “interdisciplinary counselling” for collaboration of PRM physicians with other medical specialists and the term “interdisciplinary team work” for a team working in an interdisciplinary way (as described above).

As mentioned before, PRM treatment goals, assessments and interventions are multidimensional and very complex. Thus, they must be carried out on the basis of professional knowledge and responsibility requiring the involvement of other health professionals such as physiotherapists, occupational therapists, nurses, speech therapists, orthotist, prosthetist and/or other health professionals. Each of them are contributing with their specific competences, however, in most cases the medical responsibility for the patient will remain with the PRM specialist.

Depending on the phase (acute, post-acute or long-term rehabilitation) and the setting (hospital, rehabilitation centre, outpatient service or community based rehabilitation) the collaboration modalities may differ. In most cases, structured interdisciplinary and multi-professional teams, based on shared ethical and scientific bases as well as common methodology and language, are needed. This is fundamental to achieve optimal level of outcome.

Multi-professional team work is essential for the diagnosis and assessment of impairments, activity limitations and partici-pation restrictions, selection of treatment options, co-ordination of varied interventions to achieve agreed goals, and critical evaluation and revision of plans/goals to respond to changes in the patient’s health and function (see box 5).

In many cases, rehabilitation requires interdisciplinary counselling with other specialised physicians, in particular after surgery, in the diagnostic phase of a disease and for planning a multidimensional treatment plan. The specialists need to agree a common strategy, which incorporates all their interventions at the right times to achieve a common approach to the overall treatment strategy. Continued input may be required from other medical specialists either in acute rehabilitation wards, or in long term rehabilitation (mainly cooperation with the primary care physician).

PRM teams not only comprise members from many different professional backgrounds, but also work towards agreed aims by using shared strategies. It is more than adding different health professionals work if working in interdisciplinary team and understanding the roles and values of the colleagues. The team works to set goals adjusted over time and according to clinical and functional progress of the patient. Most important principles of successful team work are (38):

Appropriate range of knowledge and skills for the agreed task;
Mutual trust and respect;
Willingness to share knowledge and expertise;
Speak openly.

The team involves directly the patient and his/her significant others/ family to establish appropriate and realistic treatment goals within an overall coordinated rehabilitation program. These goals should be patient-centred, endorsed by the team and adjusted repeatedly as the PRM program proceeds.

Cooperation within the rehabilitation team is ensured by structured team communication and regular team meetings, discussing the diagnosis, the functional impact on functioning and activities, the ability of the patient to participate in the society as well as the possible risks and the prognosis of the disease. The team members’ assessments are incorporated into the rehabilitation plan, which is reviewed regularly.

Successful teams will need to include a wide range of knowledge, aptitudes and professional skills, and members will primarily include: PRM specialists, nurses with rehabilitation expertise, physiotherapists, occupational therapists, speech and language therapists, clinical psychologists and neuropsychologists, social workers, prosthetists and orthotists, bioengineers as well as dieticians (39). The structure of the teams may vary in different European countries and depends on specificity of each rehabilitation department.

Team members must be appropriately qualified with a focused scientific and professional education (basic and continuous). Knowledge and respect for the skills and aptitudes of the other team members is required. PRM specialists have a duty to provide adequate information, training and clinical support, but each health professional has an individual responsibility to uphold his or her profession’s standards.

The competencies of the members of the team should be (39):

Physicians: diagnosing the underlying pathology and impairments, prognosis, medical assessment and treatment, setting-up treatment and rehabilitation plan, prescription of pharmacological and non-pharmacological treatments and assessment of response to these.
Rehabilitation nurses: addressing and monitoring day-to-day care needs. Expertise in the management of tissue viability and continence problems. Providing emotional support to patients and their families. Education to patients and their families.
Physiotherapists: detailed assessment of posture and movement problems, administering physical treatments including exercise to restore movement and alleviate pain, etc.
Occupational therapists: assessing the impact of physical or cognitive problems on activities of daily living, return to work, education and/or leisure activities, etc. Providing expertise on strategies that can be used by the patient and his/her family, use of assistive technology and environmental adaptations to facilitate independence.  
Speech and language therapists: assessing and treating cognitive, communication, orofacial motility problems and swallowing disorders.  
Clinical psychologists and neuropsychologists: detailed assessment of cognitive, perceptual and emotional/behavioural problems. Development of strategies to manage these with the patient, his/her family and with other health professionals.
Social workers: promoting participation, community reintegration and social support. 
Prosthetists and orthotists: expertise in the provision of technologies ranging from splints and artificial limbs to environmental controls.
Bioengineers and rehabilitation engineers: regarding technologies and data collection.
Dieticians: assessing and promoting adequate nutrition.

The PRM physician’s role in the team is essential for establishing the medical diagnosis, the functional evaluation and the prescription the treatment plan. This is based on medical and ethical principles, the ICF-model of body function and structure, activities, participation and contextual factors as well as scientific results (evidence-based healthcare). The clinical intervention has to address the health condition, impairments, activity limitations and participation restrictions. However, virtually every rehabilitation intervention has risks that must be assumed with responsibility. For this reason, a thorough medical diagnosis and assessment is essential prior to every rehabilitation intervention.

For optimising PRM programmes, interdisciplinary members must understand their specific contribution to the interdisciplinary team, but PRM specialists have the responsibility for providing an integrated description of each individual’s pattern and care pathway, leading the decision-making process.

Interdisciplinary team working establishes a strong relationship with all stakeholders of the PRM team based on open and mutual respect and considering the technical skills of each other. The team’s success lies in the communication established, making efforts in order to overcome the difficulties experienced by the patient.

PRM specialists have an essential role to play in interdisciplinary teams: they diagnose, promote discussion, develop and evaluate new management strategies, in order to lead the rehabilitation plan and ensure the clinical success.

Ethics in clinical PRM practice

PRM professionals centrally involve patients and caregivers in the goal setting process and address ethical dilemmas as part of this. This also applies for end of life decisions for which each specific country has its legal framework. For instance in Belgium and the Netherlands patients in unbearable suffering due to a severe incurable health condition can choose for euthanasia if they comply with the prescriptions of the law.

PRM specialists thus routinely consider the rights of their patients in their daily practice and ethical and moral decisions are made on a daily basis in the field of PRM. Many of these are minor, such as the decision to explain the risks and obtain consent for a joint injection or electrodiagnostic procedure. Others, however, are more complex and difficult, and may involve the participation of several different people. Some issues are fairly specific to the speciality. Keeping in mind the ethical principles just mentioned, ethical issues in three settings commonly encountered in rehabilitation medicine will be discussed: resource allocation and patient selection, the ethics of team care and ethical issues in goal setting. The aim is not necessarily to provide firm answers, but to consider the issues and the various possibilities that may be used to assist the decision-making process. This text cannot go into this in great detail, but two examples are patient selection and resource allocation. Who decides on which patients should be admitted to rehabilitation facilities and which should not and how do clinicians deal fairly with the allocation of limitation of stretched resources?

Siegert, et al. (40) looked at the way that rehabilitation professionals were protecting their patients‘ human rights and dignity amid the rapidly growing literature on human rights particularly as it relates to health and rehabilitation. This article aimed to introduce rehabilitation professionals to the place of human rights in rehabilitation practice and to stimulate further discussion and debate. It highlighted some important milestones in the recent history of the human rights movement and explained some important terms in the rights literature. It described the Ward and Birgden model of the structure of human rights as an example of a rights perspective that might have particular relevance for health and social services and rehabilitation (41).

Ultimately, the goal of rehabilitation medicine is to ensure patient autonomy, beneficience and justice, while striving to give the best care possible, at the same time as respecting the wishes and guidelines of society as a whole within the restraints of the available resources. Other factors include the selection of patients for rehabilitation, the PRM team’s activities & competencies, goal setting in context of PRM, and resource allocation (42).

In conclusion, in rehabilitation practice, we are increasingly confronted with often very delicate ethical questions. The macro level exists as a framework, but decisions are taken daily on the micro- and meso-levels. This evolution is the consequence of a number of significant medical, technical and societal evolutions during the last decades. Ethical values and cultural beliefs of professionals as well as patients influence choices in rehabilitation. We need to be aware that cultural differences can affect outcome of treatment. Ethical and cultural issues should be part of rehabilitation curricula and postgraduate training. Professionals delivering PRM services should take time (and do) to reflect on these issues.

Outcomes of PRM interventions and programs

As Physical and Rehabilitation Medicine is defined as ‘medicine of functioning’ with ‘rehabilitation’ as its core strategy(3,4,43), ‘functioning’ as well as various aspects of quality of life and the perception of health and well-being (4,44) are most important goals of PRM treatments and programs. Therefore, the essential outcome specific to PRM is ‘functioning’.

There are extensive examples where the PRM programs and rehabilitation services have been shown to be effective in improving functioning (functional outcomes) and reducing disability (please see supplementary references).

The importance of functional outcomes

Functional outcomes relate to three dimensions including body functions and structures, activities, and participation as defined under the umbrella term, ‘functioning’, in the International Classification of Functioning, Disability and Health (ICF) (5), covering domains of life including understanding and communicating, mobility, self-care, interacting with other persons, domestic life, work/employment, school, leisure, and joining in community activities/participation in society (5,45). Functioning is experienced by all humans and any person may experience problems in functioning, ranging from mild to severe, in his/her lifespan (46). The consensus view of the World Health Organization (WHO) is that health is not merely non-occurrence of a certain disease or injury, but it contains functioning (i.e. capability to perform physical and mental actions/tasks) (47). Hence, functioning is a core element of health and improvement in functional outcomes is a vital goal.

Indeed, evidence suggests that an individual’s level of functioning in interaction with the current environment, termed as ‘lived health’, is more important than biological health. Self-reported general health has been demonstrated as highly relevant in large cohort of about eighteen thousand community-dwelling and about ten thousand institutionalized individuals. The perception of general health in the institutionalized population with a lower level of biological health is closer to those of the community-dwelling population when assistive devices and/or personal assistance was provided (48). This finding clearly points to the value and importance of functional outcomes specifically relevant to PRM on the evaluation of health from the perspectives of individuals. To conclude, real benefit to functional outcomes provided by PRM approaches focusing on function seems to be the entity that matters most for individuals. The initiative of the WHO on the integrated use of the International Statistical Classification of Diseases and Related Health Problems (ICD) (19)and the ICF (5) in the ICD revision process aiming to represent the effect of the health condition on functioning is an important endeavour (35) underlining the importance of functional outcome in PRM.

Person Centred Outcomes

The primary responsibility of PRM physicians is to produce treatment outcomes to affect persons’ lives in accordance with their valued aspects. It may be argued that despite the notion that PRM physicians pay attention to quality of life of the person as a whole, PRM targets health-related quality of life which forms an important portion of whole quality of life (49).

Therefore, PRM outcomes are associated with various aspects of health-related quality of life resulting from improvements in functioning and/or perceptions of health and well-being (4,44). Demonstrating a person’s well-being and social participation is an important feature of the fundamental outcome of patient-centred rehabilitation (50). Well-being is probably a more secure indicator of success than quality of life. Many current quality of life measures implicitly make judgments about the relevance of specific objective factors, such as the ability to climb stairs, which may not be perceived as equally important by all people with disabilities (1,2).

To meet persons’ outcome expectancies, shared goal-setting is a central issue in PRM and a core competency of PRM physicians and the rehabilitation team. Goal-setting is associated with improvement in PRM outcomes enhancing persons’ functioning as well as evaluation of treatment outcomes (51). Mutually agreed goals and outcomes are essential in person and goal oriented rehabilitation process prioritizing functional outcomes. ICF tools such as ICF Categorical Profile, ICF Evaluation Display, and ICF Assessment Sheets can be used for the identification, definition, and illustration of rehabilitation goals, intervention targets, and goal achievement (13). The assessment of changes in functioning after a goal and outcome oriented rehabilitation intervention and goal achievement are significant outcome measures in rehabilitation settings (17). At an individual level, outcome measures are very important to show the evidence of the effectiveness of particular rehabilitation interventions and services. These outcome measures have to relate directly to the specifically set goals addressed in the rehabilitation plan. The evaluation of rehabilitation has fundamental differences from the evaluation of disease-orientated medical treatments aimed at limiting pathology or curing disease (1,2). It is important to determine which outcome to measure in person-centred outcome measurement approach to see whether specific goals set for a particular individual were achieved. If the problem of an individual is an impaired function, then the primary outcome should relate to that function. If the goal is the achievement of ‘participation in society’, which is the ultimate goal of rehabilitation, then participation restrictions should be measured as the primary outcome (28). Patient-centred outcome measurements in research serve as cornerstones for evidence-based medicine defined as “the integration of best research evidence with clinical expertise and patient values” (52). Evidence-based practices do improve outcomes of care if the best compromise between person deemed goals (goals which are important and meaningful to the persons) and rehabilitation plan can be achieved.

In summary, rehabilitation has the ability to reduce the burden on disability both for individuals and for society. It is shown to be effective in enhancing individual functioning and independent living by achieving greater activity, better health and by reducing complications and the effects of co-morbidities. This benefits the individual and society to include greater personal autonomy, improved opportunities for employment and other occupational activity. While many societal factors are involved in return to independent living and work, PRM can prepare the individual and families/carers to take maximal advantage of the opportunities that are available (1,2).

Cost-effectiveness outcomes

The effectiveness of rehabilitation is not only associated with enhanced functioning and living independently but also with reduced costs of dependency due to disability (1,2). The effects of PRM on cost-savings has been discussed in the chapter on economic burden of disability.

Survival outcomes

Finally, PRM outcomes are also associated with survival. There is considerable evidence that rehabilitation reduces the risk of mortality in certain groups of patients as can be exemplified for exercise-based cardiac rehabilitation for coronary heart disease which leads to a decrease in cardiovascular mortality (53). There are other examples where rehabilitation has been shown to be effective in improving survival (references).

Rehabilitation can be successfully achieved in conditions where there is no biological recovery and indeed in conditions that are intermittently or steadily deteriorating. In the latter, rehabilitation may need to be delivered in a continuing programme that enables the patient to maintain levels of participation and well-being that would otherwise not have been achieved. It should be standard practice to audit services (1,2).

In conclusion, PRM programs and rehabilitation services for persons with disabilities produce concrete benefits including improvement in functioning (via reducing impairments in body functions, activity limitations, and participation restrictions) and reduction in costs as well as decrease in mortality for certain groups of patients which justify the importance of PRM outcomes. The outcome measures related to functioning, patient centred, should be considered as primary outcome in rehabilitation clinical studies.

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