Chapter 11 –Challenges and prospectives for the future of PRM

European PRM Bodies Alliance

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: Maria Gabriella Ceravolo, Nicolas Christodoulou, Christoph Gutenbrunner, Stefano Negrini, Nikolas Barotsis, Pedro Cantista, Calogero Foti, Slavica Jandrić, Črt Marinček, Xanthi Michail, Daniel Wever, Jerome Bickenbach, Kristian Borg, Leonard Li, Marta Imamura, Simon Tang

Abstract

In the context of the White Book of Physical and Rehabilitation Medicine (PRM) in Europe, this paper deals with the future perspectives of PRM in Europe according to the actual vision of the European Bodies. All Chapters stress the big changes that Europe is facing in terms of demography, life expectancy, survival rates, disability burden, increasing prevalence of long-term health conditions, progress in technology, but also health costs and society changes in terms of requirements of wellness and quality of life together with health. All these challenges combine with the specificities of PRM, that is the medical specialty focusing on the whole person and its functioning in the various health conditions, with the aim to guarantee the best possible participation through improvement of activities and reduction of impairments. The possible consequences of these changes in the future evolution of PRM clinical practice, services, education, research are presented; moreover, the vision on the progress to harmonization of the development of PRM across Europe, and the possible contribution of PRM to policy planning are presented.

Key words

Physical and Rehabilitation Medicine, Europe, forecasting, health services, education, research

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 focuses on the future perspectives of PRM in Europe according to the actual vision of the European Bodies. All Chapters focus on the big changes that Europe is facing in terms of demography, life expectancy, survival rates, disability burden, increasing prevalence of long-term health conditions, progress in technology, but also health costs and society changes in terms of requirements of wellness and quality of life together with health. All these challenges combine with the specificities of PRM, that is the medical specialty focusing on the whole person and its functioning in the various health conditions, with the aim to guarantee the best possible participation through improvement of activities and reduction of impairments. The aim of this chapter is to present the impact of these changes and challenges on clinical practice, service development, education, and research; moreover, the vision on the progress to harmonization of the development of PRM across Europe, and the possible contribution of PRM to policy planning are presented.

Physical and Rehabilitation Medicine service development

Even if no one can accurately predict the future, some trends in demography, epidemiology and societal attitudes are likely to continue for the next 10 to 30 years. Some of these are:

Life expectancy is going to grow further and people with long-term health conditions and disabilities will live longer. Some problems of aged people such as frailty, dementia and difficulties in mobility, self-care and communication will grow. This will increase the need for rehabilitation (1).
Due to the progress in therapies, survival rates after severe disease (including cancer) and trauma will further increase. Many of these diseases will evolve in chronic health conditions, while many survivors will experience some kind of disability: most will need rehabilitation.
Also, new infectious diseases may lead to an increased need for rehabilitation (one recent example is the Zika virus epidemic).
In almost all European countries the demographic change will put some pressure on social systems. One of the consequences will be the need for longer working life time. Thus the need for vocational rehabilitation may also increase.
Other social evolutions, like growing inequalities and rich/poor gaps (2,3), or the function of families and caregivers, will greatly change the contextual factors, requiring new solutions to reduce activity limitations and achieve the best possible participation.
The progress in technology and digital data management is developing with an extremely high speed. Some of these technologies are already used in rehabilitation but this trend will accelerate in the next few years. PRM must take part in these developments and take leadership in the development and use of new technologies to improve functioning of persons with disabilities.
The expectancy of independent and active living and quality life in the population also will further increase. This will increase the demand of sophisticated and innovative rehabilitation programs and strategies.
As health costs will further increase it will be more and more required that treatments must be based on evidence and shown to be cost-effective. Thus, the need for scientific studies in the field of PRM will further increase.
Last but not least, low and lower-middle income countries will have an increased demand for rehabilitation service implementation and training of rehabilitation professionals (this will be in particular the case in sub-Saharan Africa and some south-east Asian countries). European PRM will be challenged to contribute to the solution of this problem that has humanitarian, public-health and developmental impact.

From these examples, it is clear that the need for rehabilitation will further increase in the future and many challenges lay ahead of us. It already has been stated that rehabilitation will be the health strategy of the 21st century (4). What consequences for PRM can be derived from the above-mentioned challenges? This must be discussed in all European bodies for PRM, and a European strategy should be developed. However, some points can already be extracted:

As the need for PRM physicians will grow, we must ensure:
- a sufficient capacity of residency and training programmes and attract young doctors to a career in PRM
- a sufficient number of physicians are trained in PRM (this is mainly a political issue)
- available and fully qualified rehabilitation professional to be part of the the rehabilitation team
We must make sure that the future PRM physicians have sufficient skills and aptitudes to train patients with severe and comprehensive problems and in all phases and at all levels of health care. This includes
- Rehabilitation in elderly people
- Rehabilitation in the acute and early post-acute phases
- “High-end” rehabilitation for patients with complex and specific needs, such as organ transplantation, regenerative therapies, multiple trauma, SCI specific types of malignancy and many others
- Knowledge and experience in modern rehabilitation technology
- Skills in solving complex psychosocial problems
It has to be discussed whether different accreditation PRM areas will be needed in the future such as “Rehabilitation for the Elderly”, “Acute Rehabilitation”, “Pain Rehabilitation, “SCI and TBI Rehabilitation”, “Vocational Rehabilitation”, “Musculoskeletal Rehabilitation”, “Cardio-respiratory Rehabilitation”, “Cancer Rehabilitation”, and others
Research activities must be significantly increased and improved, including pathophysiology of disabling health conditions, mechanism of rehabilitation interventions, assistive technologies, outcomes of rehabilitation programmes
Strategies to adequately react to the societal challenges in Europe and the neighbouring regions must be developed within the PRM community, e.g. response to the demographic change, the expectation shift of society, the need for more rehabilitation in low resources countries etc.

Another challenge needs to be taken into consideration (that also may be an opportunity). Other health professionals improve their knowledge and skills and tend to do rehabilitation on their own and/or take leadership of the rehabilitation team. In some countries, professional groups of therapists fight against PRM and claim for the responsibility of the entire rehabilitation process. In other countries, there is a good collaboration respecting each others tasks and expertise for working in a team. Of course, it cannot be accepted if one profession denies the role of another, and in particular rehabilitation teamwork must be the guiding principle (5). On the other hand, it must be welcomed if any profession intends to take responsibility for the care for persons with disabilities. Another aspect is the growing research activities in other health profession that significantly contribute to the scientific basis of rehabilitation. Is there a solution for this issue? In any case, it is not an easy one and it requires conceptual discussions within and among professional organisations at a European level. Such debate must be done under the precondition of respecting each other’s skills and role in rehabilitation, and aim at developing rehabilitation care models that are best to meet the needs of persons with health conditions experiencing any kind of disability. Another important challenge could become the pressure of Health National Systems, but also of patients, to better face the burden of disability and aging, that could end-up in the creation of new PRM services in the hand of non-PRM physicians, i.e. other specialists entering into the field of PRM. This could in fact also be the result of a shortage of PRM physician’s workforce, due to the increased needs. This challenge could be faced in an inclusive or exclusive model. In the first one, some requirements could be defined for other specialists to be recognized as PRM physicians, eventually only inside some specific sub-specialisms of PRM, if created. In the exclusive model, PRM would fight a battle for exclusivity that in any case could not afford to lose. This should also be well discussed at an European level, where these problems are already present in some countries, perhaps only in some specific PRM areas (cardiac and/or respiratory/pneumological rehabilitation, sometimes also neurological rehabilitation, sports medicine rehabilitation, etc.). All in all, it seems to be clear that PRM needs to work very intensively on the solution of future problems and take its responsibility for society, the health systems and the individuals suffering from severe and/or long-term health condition experiencing disability.

Education

We are currently facing an impressive increase in life expectancy in both high and low or middle income countries. Population ageing together with reduced mortality following severe injury and acute illness will result in an increased need for rehabilitation services in all European countries, where the expectation of a high quality of life will also increase. Moreover, technology development has favored a widespread access to information, leading disable people to claim for appropriate rehabilitation delivery, for equitable access to hospital and community facilities and for a responsible care of their chronic health problems. Last, but not least, the two recent decades have seen an exponential development in assistive and information technology, domotics, bioengineering, robotics and tele-rehabilitation; at the same time, the knowledge on the neural bases of motor control, decision making and functional recovery has flourished: the interdisciplinary research combining the neuroscience with engineering potential is expected to provide the rehabilitation professionals with a wide range of innovative diagnostic and therapeutic tools. As a result, the standard of rehabilitation care (including quality assurance and treatments based on scientific evidence) and of PRM physicians’ education as well, will be expected to grow. Postgraduate PRM training will have to stimulate future specialists to adopt a rigorous scientific approach to clinical practice and cultivate their disposition towards continuous learning and self-assessment. Moreover, in order to satisfy a growing demand for services, without renouncing to equity, PRM physicians must be committed to assess and safeguard the sustainability of care pathways and treatment protocols, in strong alliance with policy makers. The increased circulation of EU citizens beyond national borders will be a further stimulus towards the need for harmonisation of PRM training and rehabilitation delivery, across the European countries. All in all, these evolutions will require to be faced at two levels: undergraduate training, to improve the awareness about PRM in future physicians; PRM physicians specialist training, on one side to increase their number due to the increased needs, on the other to improve their competence and capacity to manage more patients with reducing resources (using technology, but also adopting best practices on the base of efficacy, effectiveness but also efficiency). These challenges will be faced through the actions of the UEMS-PRM Board, with its contribution in defining the core-curricula for undergraduate and specialists training.

Research

Speaking of future is always a big challenge. Moreover, when research is involved, there is another factor beyond unpredictability of human events: the unpredictability of researchers and of the ways in which knowledge grows, that are rarely drivable from outside. Nevertheless, there is a certainty in PRM: research is steadily growing (6), and this will lead to big changes in our perspective. The rate with which general knowledge of the human being increases continually: this means that the future of research is even faster then what usually expected. In this chapter, instead of making any real prevision, we will look at the overall scenarios challenging research, and their respective needs. In a general scenario, we are facing a period of shrinking resources. The continuous improvement of medicine drove to growing rate of survivals, leading to ageing of the population and increase of disability and chronic conditions. Unfortunately, all health systems in Europe have reached what is considered to be their maximum possibility of absorbing resources (between 7% and 10% of the gross country incomes), and consequently research should focus on how to do with less expenses the same (or even better) procedures. A rapid development of molecular and genetic research will reveal backgrounds for different disorders with decreased function, for individual abilities for rehabilitation and an increased knowledge of neural plasticity. This will have an impact on the other parts of the ICF spectrum and it urges PRM to be an active part of translational research. Another interesting point is the progressive increase of technology. Apparently in medicine we are facing the same process faced in industrial production more than a century ago: technology seems to allow to increase our results, and in PRM this happens mainly through robotics and prosthetics/orthotics, but also with virtual reality and game-therapies. Another clear challenge of modern European Societies is the progressive movement of medical needs from into and out of hospitals: people want to stay home and prefer to be treated there, chronicity is increasing, and hospitals cost a lot. At the same time, telemedicine is growing in all fields of medicine. All these situations greatly challenge PRM and its research. This can clearly be combined with the need of increasing person centred outcomes that are the most meaningful for both our patients and societies. Another crucial challenge is the need of a different distribution of funding, since the old ones are totally based on body anatomy/function specialties (7) The routine of PRM work is greatly changing. While the introduction of the acute phase is already well established, new phases are being more studied and refined, like pre-habilitation (8), and/or maintenance or post-rehabilitation. This challenges all PRM organization, that should probably move to a transversal Department including all PRM physicians and allied professionals to help the patients move properly in the various phases: Stroke Units or Spinal Cord Injury Units are already described, but the problem is common to all pathologies and not only to these two. Another challenge is the improvement of competencies, both clinical and organizational, of allied professionals, that involves our actual professional position and makes it evolve. The challenge of classifications (ICF, but not only) and reimbursement of PRM treatments remains world-wide relevant and not resolved. The place of PRM in the general picture of Health is becoming more and more clear. All these challenges in a PRM context would need specific research. But research about organization is on the one hand more difficult and on the other, less rewarding in terms of Impact Factor. Financing is consequently more difficult, but nevertheless, it is urgently needed. In a general research scenario, there are some clear trends. Lower level research remains very practiced, but Evidence Based Medicine has clearly shown the importance of running Randomised Controlled Trials (RCTs). At the same time the importance of clinical expertise and patients preferences is growing, with new qualitative research methodologies being applied, including Narrative Medicine. Translational studies in order to find correlates between molecular findings and function, activity and participation become more and more important. In pharmacology, to be able to find little changes resulting from treatments, RCTs involve now thousands of patients: this calls for the creation of big networks, but also for a lot of money to do research. On the same trend is the increased production of metanalyses and metastudies, with the creation of big databases and the call for open access data. The creation of registers and the development of observational studies from these clinical databases is increasing too: the difference from RCTs is that they offer real clinical everyday world information, sometimes strikingly different from the results coming from experimental trials, that look by definition to very specific and well selected populations. The concept of big data analysis is applied to clinics and all these data bases. In PRM we are far from these consequences, but we are at the same time inside them. Networks, data bases, open data are challenges to be faced. Anyway, we also cannot ignore that we are still looking if some treatments have any efficacy, and this can be achieved also with studies involving reduced populations; it cannot be ignored that our patients are almost always carrying many co-morbidities, and this makes observational trials and registers very interesting for us. All these research challenges could become occasions for growth. In the meantime, we cannot ignore that the general picture characterizes how research is financed: to avoid being excluded, we must in any case fit to this overall picture. Finally, a PRM research scenario. Functional diagnosis and outcome measurements are key factors still underdeveloped: we have now some tools, but the way is still long to go. Moreover, technology is increasing its help, but still needs to be made totally clinically meaningful. The understanding of what PRM is (9), makes us move also inside the so-called humanistic research, with its challenging qualitative methodology, while medical science is still dominated by the quantitative research methods and approaches. Also statistical analysis changed in these years: a clear example is Rasch analysis (a statistical approach to improve our outcome instruments based on questionnaires) and its importance in PRM. This is probably only an example, and in PRM there is the need to move forward beyond the classical statistics to understand how to better manage our data. PRM is by definition multi-professional, since it involves all the other non-physician members of the team. As in PRM, rehabilitation professionals also find that there are methodological problems to develop good and adequate research on their specific areas of interests. A good terminology, specific definitions of most of the practices applied to rehabilitation and measurement instruments are still lacking. We miss compliance. Good definitions are not yet refined on how to describe rehabilitation practices (even if some attempts have been made – (10)- and recently adopted also by PRM journals – (11) and this applies to the material and methods section: research results are, most of the time, not replicable by other teams, since there are too many unknowns. Further basic work still needs to be well defined – as do the research results and their applicability. These are only some examples of the actual challenges of the PRM research scenario, but it is clear how much all the world of PRM science production is involved including, beyond researchers, also editors and third party payers. In conclusion, PRM research will face in the next years a series of challenges, coming from the general and PRM scenarios, as well as from research in general and specifically PRM research. If faced properly, through adequate research, performed with adequate methods, and presented with adequate quality of scientific writing, all these challenges will become occasions for growth of the reputation and importance of our PRM specialty.

Harmonizing the development of PRM across Europe

The harmonization of PRM across Europe is an ongoing process faced by the UEMS PRM Section and Board, in collaboration with the European Society of PRM and the European Academy of Rehabilitation Medicine. As a consequence, what will be done in the next future will be the direct prosecution of what has been done until now, and will be presented below. Life expectancy is increasing in both developed and developing countries. More importantly, improvements in survival following injury and illness, as well as an ageing population will result in an increased need for rehabilitation services in all European countries, where the expectation of a high quality of life will also increase (12).

As a result, rehabilitation systems have to be developed continuously considering the following principles:

Rehabilitation following injury or illness and in chronic conditions is a basic human right (13);
Equitable and easy access to all aspects of rehabilitation including specialist rehabilitation medicine, assistive technology and social support for the entire population in Europe;
Uniformly high standards of care in rehabilitation, including quality assurance and treatments based on scientific evidence;
A scientific basis to develop rehabilitation models and standards of care to guide clinical practice.

In particular, the Professional Practice Committee (PPC) of the UEMS PRM Section has worked extensively over many years to describe the professional competence of PRM physicians. This is shown by the publication of papers in international journals. The White Book of PRM in Europe, which was published in 2006 in two referred PRM journals and the current 3^rd Edition edition of the White Book is one example of the contribution of the PPC and the high standard of collaboration with the other European PRM Bodies. A series of published research papers for the role and competence of PRM physicians have been collected in an e-book under the title “The Field of Competence of the Physical and Rehabilitation Medicine Physicians -Part One” (14). This e-book contains the following published papers:

Action plan of the Professional Practice Committee-UEMS Physical and Rehabilitation Medicine Section: description and development of our field of competence (15).
Describing and developing the field of competence in Physical and Rehabilitation Medicine in Europe – preface to a series of papers published by the Professional Practice Committee of the PRM Section of the Union of European Medical Specialists (UEMS) (16).
Interdisciplinary team working in physical and rehabilitation medicine (5).
Physical and Rehabilitation Medicine in acute settings (17).
Physical and Rehabilitation Medicine programmes in post-acute settings (18).
Physical and Rehabilitation Medicine and persons with long-term disabilities (19).
New technologies designed to improve functioning: the role of Physical and Rehabilitation Medicine physician (20).
Role of the Physical and Rehabilitation Medicine specialist regarding of children and adolescents with acquired brain injury (21).
European models of multidisciplinary rehabilitation services for traumatic brain injury (22).
The role of Physical and Rehabilitation Medicine specialist in lymphoedema (23).
Generalised and regional soft tissue pain syndromes. The Role of Physical and Rehabilitation Medicine Physicians. The European Perspective Based on the Best Evidence (24).
Inflammatory Arthritis. The Role of Physical and Rehabilitation Medicine Physicians. The European Perspective Based on the Best Evidence (25).
Osteoporosis. The Role of Physical & Rehabilitation Medicine Physicians. The European Perspective Based on the Best Evidence (26).
Osteoarthritis. The Role of Physical & Rehabilitation Medicine Physicians. The European Perspective Based on the Best Evidence (27).
Spinal pain management. The Role of Physical and Rehabilitation Medicine Physicians. The European Perspective Based on the Best Evidence (28).
Local soft tissue musculoskeletal disorders and injuries. The Role of Physical and Rehabilitation Medicine Physicians. The European Perspective Based on the Best Evidence (29).
Shoulder pain management. The Role of Physical and Rehabilitation Medicine Physicians. The European Perspective Based on the Best Evidence (30).
Musculoskeletal perioperative problems. The Role of Physical and Rehabilitation Medicine Physicians. The European Perspective Based on the Best Evidence (31).

Research continues in the PPC for the Competence of our physicians in other health conditions and the results will be first published in referred journals. Also, the intensive work continues in the other committees in close collaboration with the European Society and the European Academy. The aim is to give helpful e-books to our colleagues for their daily practice and for defending and promoting the PRM specialty among medical professionals of other specialties and in the negotiations with the authorities of national health systems. A very important and significant work is done in the Clinical Affairs Committee (CAC) of the UEMS PRM Section concerning the accreditation of quality of care programs in Europe. This work continues with the contribution of all the members of the CAC. As an example of the work in front of us to achieve all these goals, we present here the UEMS PRM Section and Board ambitious Action Plan set for the period 2014-2018:

A. General:

Further development of the relations with UEMS.
Development of the relations with all the other UEMS Sections & Boards, especially with the relevant to PRM Sections.
Close cooperation with the ESPRM and EARM: revision of the 2006 White Book of PRM in Europe, coordinated action plans (with avoidance of redundant actions).
Balanced cooperation with ISPRM and other international PRM Bodies.
Development of relations with the WHO Services for Disability And Rehabilitation (DAR).
Promote the WHO action plan for disability and implement some actions to practically implement it.
Change the title of PRM specialty in Annex V of the EU Directive of Professional Qualifications to “Physical and Rehabilitation Medicine” and the minimum training period from 3 to 4 years.
Support the development of Medical Rehabilitation Systems in Eastern European countries (e.g. Russia, Ukraine etc).
Reorganize the website to promote our Section and Board activity.
Circulate our documents to the other UEMS Sections & Boards to inform for our activities.
Promote the implementation of the ICF (International Classification of Functioning, Disability and Health) into the daily practice of the PRM physicians.

B. Board:

Increase the participants for Board Certification by Examinations by:
1. Giving special incentives for a period of 2-3 years.
1. Advertising intensively through NM and national PRM societies the validity of being Fellow of the EBPRM which is a “Seal of Excellence” on European level.
1. Publishing of a paper promoting the status of a European Board Fellow (advantages, benefits, ways of achieving the Fellowship).
1. Cooperating with interested countries, the Board Examinations to be the national theoretical Examinations.
Increase the number of Accredited Training Sites in each EU country
Increase the Recertifications of Fellows, Senior Fellows, Trainers and Training Sites.
E-Book for the pre-graduate PRM lessons.
Harmonisation of the PRM curriculum and training among the EU countries. Re-write it in details for including it in the revised White Book of PRM in Europe.
Support continuing medical education and research in PRM field (accreditation of European Congress and teaching programmes, e-books and selected resources, etc.).

C. Professional Practice Committee:

E-book for the Field of Competence of PRM physicians – Part 2.
Publication of the papers on the role of PRM in several services, need for the E-book.
Cooperation for the Cochrane Rehabilitation Field.
Develop Standards of Practice in Europe.

D. Clinical Affairs Committee:

Further development of the European Accreditation of quality of care programs.
Position paper on patients’ rights.
Harmonized Guidelines of PRM Services on European level.
Promote Standards of Ambulatory Rehabilitation.

E. Permanent working group on Balneology:

Collect all papers for EBM Balneology Services
Publish a position paper on Balneology.

Another example on how to face the future harmonization is the opening of dialogue and relations in 2014 for PRM specialty with physicians from Russia, practising a part of Rehabilitation Medicine or of Physical Medicine. They wished to collaborate with the UEMS PRM Section and Board to transform the way of their practice according to the model of the Western Europe and eventually create the specialty of Physical and Rehabilitation Medicine in Russia. A plan was set up in cooperation with the Russian Association called ARUR (All Russian Union Rehabilitators). Four Seminars were organized of one week each and were attended by 35 Russian colleagues, consultants of several Russian Rehabilitation departments. The first seminar was organized in Vilnius in December 2014, the second in Moscow in March 2015, the third in Kazan in June 2015 and the fourth in December 2015. The lectures presented covered all the fields of PRM specialty as they are described in our curriculum. Since September 2015 a pilot project started in thirteen Regions of Russia for comparing the old system of Rehabilitation with the new system. The project lasted for one year and the Section was asked for reviewing the process of this project. Several Professors accepted to contribute their knowledge and experience. They travelled all the 13 Regions of the project, from Moscow to St. Petersburg to Kazan, to Vladivostok, to Siberia to Urals, to Samara etc. The attendants of the seminars carried out the project successfully with enthusiasm and they have started teaching other younger physicians in Russia to become PRM physicians in their own country for the benefit of their patients. The collaboration of ARUR with the Section and Board will continue in the long run and delegates from ARUR participate as observers to the meetings of the Section and Board and of the European Society as well. Very recently the UEMS PRM Section was asked by the newly found Ukrainian Society of PRM, to help for transforms in the country concerning the practice of Rehabilitation and implementing the EU standards for Physical and Rehabilitation Medicine. The plan will be to a large extent the same as the one described above for Russia.

Contribution to policy planning

PRM should be a major contributor to the establishment of modern health policies due to its specific focus on functioning and the entire person, instead on single diseases. The binomial health/disease relation is still more focused on “pathogenesis” (approach focusing on factors that cause disease) rather than in “salutogenesis”(approach focusing on factors that support human health and well-being). This paradigm however is slowly changing. Nevertheless there isn’t yet sufficient awareness of the population and of the politicians for the relevance of Functioning in what it really represents to Health (in its holistic sense) and to the socioeconomic consequences of Disability. It is a fact that statistical reports and political attention goes more to the figures of Childhood Mortality Rate, Diseases Incidence and Prevalence or Life Expectancy rather than on functional scales such as Health Quality of Life, Functional Independence Measure, Healthy Life Expectancy (HALE) or Disability-Adjusted Life-Years (DALYs). It is of course an ethical principle to make all our efforts to make people survive; also, it is normal that it was the most important focus in Europe before the progresses of medicine in the last centuries. Nevertheless, it doesn’t seem logical that with better chances of survival, patients are not given the necessary support to achieve a good life. Moreover, it is quite absurd measuring “health” by scales of mortality or evaluating our life by statistics of death. We all know that, while reaching the excellent figures of such a low rate in Childhood Mortality Rate, we find ourselves with a significant number of severely disabled children, who also ethically deserve all our dedication. The same could be said with people that survive after very severe traumatic injuries, serious diseases or either live much longer under chronic and disabling conditions. They all deserve the needed rehabilitation care. While PRM focused its attention on all these aspects, this is not yet clear to politicians and the general population. ICF has been developed by the World Health Organization and taken up by PRM as its reference framework. This is not yet true at a more general level, even if there are examples of applications not only in education, but even in fields like engineering and architecture. The contribution in the next years of PRM in shifting the focus from mortality and morbidity only to health and functioning is crucial. Another issue is the health resources distribution between services for acute and long-term health conditions, including disability. We see today the well-established enormous effort in providing acute care, with the noble goal of saving the greater number of lives possible. Conversely, there are no comparable investments on the immediate or subsequent care for the best recovery and to reach the maximal functional performance. Nevertheless these investments would allow not only benefits for life quality and wellbeing of the patients, but also less expenses in future care. In the same line is all the hurry and priority to drive a patient to acute emergency units, while rehabilitation is frequently neglected or delayed. Assistance on acute states should be made comparable to support on the recovery process. In this endeavour, PRM is the medical specialty able to provide Governments with the necessary expertise in planning rehabilitation policies according to the population needs. PRM is able to help the planning of efficient Rehabilitation Care Networks; to give its expertise to develop facilities, equipment and human resources; to build the more desirable operative models. Another growing issue, is the concern about chronic patients continuously moving from one facility to another without a specific organizational model. While General Practitioners can offer the adequate competence in front of new morbidities, the patients disabled and/or with chronic conditions facing relapses or requiring continuous care and maintenance, need a harmonization of their care creating a continuum of care throughout the actually existing “silos” of the Health National Systems in Europe. Chronic patients and disabled people move from acute to post-acute to long-term to outpatients to home care in various moments during their personal clinical history: this requires coordination. National Health Services should have specialized Departments concerning Rehabilitation Care, and PRM should raise the knowledge about this need. The legislation should take into consideration the right to Rehabilitation Care by the population. This means that all the health insurances (public or private) should take in count the possible need of Rehabilitation interventions after a trauma, an acute illness or within a chronic condition that may appear along our lives. In policy making, rehabilitation systems have to be developed continuously considering the following principles:

Rehabilitation following injury or illness and in chronic conditions is a basic human right;
Equitable and easy access to all aspects of rehabilitation including specialist rehabilitation medicine, assistive technology and social support for the entire population in Europe;
Uniformly high standards of care in rehabilitation, including quality assurance and treatments based on scientific evidence;
A scientific basis to develop rehabilitation models and standards of care to guide clinical practice. Guidelines, pathways and recommendations should be implemented with the participation of PRM.

In order to reach these the following measures are required:

to improve the general understanding and awareness of the needs of people with disabilities
to publicise the benefits of rehabilitation. This will lead to a culture in which access to adequate rehabilitation is seen as a basic human right
to deepen the understanding and cooperation between non-governmental organisations of people with and the specialty of PRM;
to establish comprehensive rehabilitation facilities across Europe with specialized and well-trained rehabilitation teams and well-resourced rehabilitation facilities. Additionally community based rehabilitation structures should be in place for the management of chronic disabling diseases. ;
to set up systems to ensure that Physical and Rehabilitation Medicine has sufficiently well-trained and competent PRM physicians available in all European countries;
to establish common high standards of care on the basis of current evidence. These should take into account quality control and access to assistive technology;
to incorporate new technical developments into PRM practice. This has a great deal to offer in assisting rehabilitation to produce better outcomes. Increasingly technology should contribute significantly to independent living and quality of life of people with disabilities in Europe. ;
to promote scientific activities and research in the field of rehabilitation with adequate funding to improve the outcomes for those experiencing disabilities;
to support an environment where people with disabilities can fully participate in society. The PRM physician will work with people with disabilities in furthering this aim.

All these measures will better enable people with disability to contribute to society substantially.

References

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