White Book of PRM

Chapter 4 – History of the specialty: where PRM comes from

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: Enrique Varela-Donoso, Pedro Cantista, Maria Gabriella Ceravolo, Nicolas Christodoulou, Alain Delarque, Christoph Gutenbrunner, Carlotte Kiekens, Sasa Moslavac, Anthony Ward, Mauro Zampolini, Stefano Negrini
  • The contributors: Gunnar Grimby, Christoph Gutenbrunner, Xanthi Michail, Stefano Negrini, Philippe Bardot, Nikolaos Barotsis, Carlo Bertolini, Kristian Borg, Quim Chaler, Anne Chamberlain, Nicolas Christodoulou, Alain Delarque, Franco Franchignoni, Alessandro Giustini, Alvydas Juocevicius, Črt Marinček, , Perennou, Henk Stam, Ulrich Smolenski, Jiri Votava, Derrick T Wade, Castellote, Maria Gabriella Ceravolo, Gordana Devečerski, Garreta-Figuera, Miangolarra-Page, Avellanet-Viladomat, Mauro Zampolini

Abstract

In the context of the White Book of Physical and Rehabilitation Medicine (PRM) in Europe, this paper deals with the history of the PRM medical specialty. The specialty evolved in different European countries, and sometimes also into the single countries, from different medical streams that finally joined. These included among others balneology, gymnastic, use of physical agents (water, heat, cold, massage, joint manipulations, physical exercise, etc.). Another important role has been played by the increasing number of people with disability due to improvement of medicine, and consequent survivals from wars, accidents and/or big infective epidemics (like polio); this evolutions happened in strict relationship with other specialties like cardiology, neurology, orthopaedics, pneumology, rheumatology, traumatology, creating a knowledge transversal to all of them. Consequently, the PRM specialty has been gradually introduced in the different European countries, however with no uniformity, and subsequently, European Organizations were created for its diffusion and coordination at the level of medical competences and patient care as well as medical teaching and research: The European Federation of Physical Medicine and Rehabilitation, later European Society (ESPRM), The Académie Médicale Européenne de Médecine de Réadaptation (EARME), The PRM Section of the European Union of Medical Specialists and the Board (UEMS-PRM Section &Board), were crated and work today regarding these general aims. Nowadays a uniform definition of the specialty exists in Europe, which is concordant with the internationally accepted description of PRM (based on the ICF-model).  Moreover research in PRM has been mainly improved during recent decades in Europe due to some external as well as internal scientific influences, thus increasing its scientific importance, together with a parallel increase in rehabilitation journals, many of them indexed and some with impact factor (Cr, EJPRM, JRM, among other), as well as a parallel increase in scientific congresses and courses. Last but not least, the recent creation of the Cochrane PRM field will also give a great boost to this primary medical specialty, as well as the discovery on new physical agents and technologies that diminish activity limitation and participation restriction of disable persons.

Key words

Physical and rehabilitation medicine, Europe, history, research, scientific journals

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 deals with the history of PRM in Europe. It has been introduced for the first time in the WB because the present of the specialty is heavily conditioned in many respect by its historical growth. Moreover, an overall understanding of what happened all over Europe is still missing, and its understanding opens new perspectives to the national histories that are sometimes highly different from what happened in other European Countries. In fact the specialty includes today all these streams, and it is part of the unification of European practices understanding the history and where national practices are to be collocated in comparison with other countries.

In this Chapter also the evolution of the European Organizations is presented, including the European Bodies, other Scientific Societies, and the journals that are in the field of PRM

Historical notes on the evolution of the specialty

The PRM medical specialty has gone through different phases until its consolidation in the last century .In different periods of history, both concepts of, physical medicine and rehabilitation have undergone changes in the interpretation of its meaning overall the second one. There have also been changes in the praxis of its clinical activity (1).

The use of physical agents by physicians, and above all centered in the European region, began in the remote antiquity. Approximately 100,000 years BC in Gánovce in Slovakia Neanderthal woman sinks her body to thermal mineral springs. (2).  Greeks and later the Romans, advocating in such practice: aquatic therapy, massage and other manual medicine modalities, heat and cold procedures as well as physical exercise. All these medical interventions were performed by physicians during the Old Age (Hippocrates, Galen, etc) and Middle Age (Avicenna, Averroes, etc), with the objectives to achieve pain relief, disability diminishing and well being in general. In many cases these modalities were also used to prepare people for battles (3,4)

With the advent of Renascence and along with advances in the knowledge of modern anatomy and physics, a great effort was made to use the physical modalities as a treatment. Thus, renowned doctors like Paracelsus (15th century) recommended massage as an indispensable means for maintaining health. Ambroise Paré in the 16th century applied massage on amputated stumps and on war scars and also Hieronymus Mercurialis was the link between Greek and modern medical gymnastics since he recommended, among other things, the realization of physical exercise along with diet and hygiene for treatment of different processes.

During the following centuries, physical agents continued to be used as a therapeutic modality and this included aquatic therapy, creating in the 17th and 18th century multitude of thermal establishments for rest and medical cures (Richard Russell, Vicente Pérez, Siegmund Hahn, etc.) (3,4).

In the 19th century, electricity began to be used also as treatment thanks to dr. Duchenne de Boulogne, considered the father of the electrotherapy (5); although previously, during the 17th century, the Royal Academy of Sciences of France had begun to publish annual reports on medical electrotherapy. In the same century, a great push was given to physical exercise as a therapeutic modality for musculoskeletal disorders thanks to dr. Pier Henrich Ling, creator with his disciples, of Swedish Medical Gymnastics (3). Later, other medical gymnastic modalities were also described in Europe. In that same century, another doctor, Sebastian Busqué y Torró (Spain) (6), follower of Ling, was the first to use the word “rehabilitation” in the medical literature. Somewhat later, Dr. Zander (Sweden) created what we now know as mechanotherapy. In this last way, at the end of that century there were already in some European hospitals and clinics, mechanotherapy institutes that functioned as really rehabilitation cabinets as well as in some factories where physical treatments were provided to their own workers.

Also in 19th century, the concept of locomotive re-education was developed by the French school of Neurology, being used the physical exercise since then for the treatment of nervous system processes; and Jaques Delpech created in Montpellier the scoliosis school for spinal deformities treatment (7). 

In the same century underwent a great push aquatic therapy thanks to Sebastian Kneipp (Germany), Vinzenz Priessnitz (Austria) among other; who despite not being doctors, their methods were accepted and further developed by SPA-physicians (8). On the other hand, Andrew Taylor Still (USA-physician), father of Ostheopaty as well as Palmer, (USA-Non physician), father of Chiropractic, created the basis for the development of manual medicine in the later century (9).

As mentioned before, PRM was created as primary speciality during the 20th century. The procedure of its development across European Countries has not been uniform with its origins in some cases being from the combined specialties of Rheumatology and Rehabilitation (previously Physical Medicine) in others from Balneology and yet others arising de novo (1). The push for such creation came mostly after both World Wars and polio epidemics, due to this, the large number of disabled people in need of physical and non physical medical cares, including today the attention to refugees and to ill-treated persons have to be taken into account as motors of this specialty. Also the increase and improvement of medico-surgical treatments and techniques during the last and current centuries as well as orthopaedic treatment developments, longevity of the population, sports injuries etc, pushes, and it continue today in such direction (1).

On the other hand and based somehow on Still’s works as mentioned before,, renowned doctors created different European schools of orthopaedic and manual medicine such as James Cyriax and Leon Chaitow (United Kingdom) (9–11), Robert Maigne (France) (12),  Vladimir Janda and Karel Lewitt (In the former Czechoslovakia) (13–15), among others; Thus promoting the use of the means of diagnosis and manual treatment as work tools highly appreciated and practiced today by physicians of this speciality, specially for musculoskeletal disorders (16).

Also the discovery of the existence of neuroplasticity allowed many subjects suffering from central nervous system processes (stroke, cerebral palsy, acquired brain injury, etc.) who were previously not considered for rehabilitation, to be treated using therapeutic exercise (17).  

Moreover, the discovery of new physical treatment, diagnostic and research modalities such as: extracorporeal shock waves (18,19), walking laboratories, robotic, virtual reality (20) and advanced neuroimaging techniques, among other, is leading this specialty to its current and modern conception. 

All this combined with the impending reform of the PRM curricula at European and National levels.

PRM Speciality has had a large development of clinical practice, publications, meetings and education based on hospitals and rehabilitation centres sharing experiences and perspectives practically in all European Countries. All its procedures are done in patients of all ages and also combining socio-cultural and ethical matters focused on global recovery towards full autonomy. The term that demonstrates this broad development is “individual recovery potential” reflecting the main sources and final goals for rehabilitation.

Taking into account this history of common steams but also diversity, it is remarkable that now in Europe a uniform definition of the specialty exists, which is concordant with the internationally accepted description of PRM (based on the ICF-model) (21). The current general aim of the speciality is to focus on the many different interventions necessary to reach the highest possible level of functional efficiency and participation in relation to the person’s will and context.

History and development of PRM Organizations in Europe

As mentioned before, following the Second World War, the idea of a specific policy in the field of Rehabilitation Medicine began to come into mind worldwide and especially in Europe. The idea of a new medical specialty therefore began to materialize by founding national scientific societies (1).

On the initiative of Philippe Bauwens on May 10, 1950, a project to found an international federation of physical medicine was born in London. This organization was to federate the national scientific societies in Physical Medicine worldwide. The 1st Congress of the International Federation of Physical Medicine (later renamed for International Federation of Physical Medicine and Rehabilitation), under the presidency of Frank Krusen, was held in London in 1952. The first three congresses held in Europe (1956 Copenhagen, 1964 Paris, 1972 Barcelona) have promoted the crystallization of a knot of European doctors actuated by the same bound to create the specialty in Europe.

It is of interest to observe that Physical and Rehabilitation Medicine (PRM) in Europe, began to be organized during the years of laborious birth of the great political European organizations, Council of Europe in 1949, and then European Community (Belgium, France, Germany, Italy, Luxemburg, Netherlands by the Treaty of Rome) in 1957. The specialty of PRM, in Europe, has therefore found its strength and spirit in the foundations of the European mind (22).

From the 1950s to the 1970s, some doctors, from different European countries, linked by the same mind and spirit and the same will to go ahead, got to work in order to individualize, to make autonomous, and to develop the new specialty which was neither known nor named at that time.

Their work resulted in the foundation of four European organizations which, growing and enhancing their own activities, resulted in the setting up of a new autonomous specialty in all the European countries. These four organizations were, chronologically: in 1963, the European Federation of Physical Medicine and Rehabilitation; in 1969 the Académie Médicale Européenne de Médecine de Réadaptation; and in 1971 the PRM Section of the European Union of Medical Specialists (UEMS), whilst in 1991 The European Board of PRM has been developed according to the directives of UEMS.

The organization founders, and those who, over the years, have dedicated themselves to working within the organizations (and people working for the same goal, later on), were considered convinced “Europeans” and also saw their mission as integrated in European community growth.

The European Society of Physical and Rehabilitation Medicine (ESPRM)

European Federation of Physical Medicine and Rehabilitation [EFPMR] has evolved toward the European Society of Physical and Rehabilitation Medicine (ESPRM):

The official birth of The European Federation of Physical Medicine and Rehabilitation [EFPMR], (Fédération Européenne de Médecine Physique et Réadaptation as written in French in Belgium) was on April 25, 1963 as published in the Official Journal of the Belgian Kingdom. The Federation was an organization with a scientific goal, gathering the national Scientific Societies. The aims of this federation were essentially scientific. It established the following purposes:

(1) the organization of scientific collaboration with the view to develop PRM;

(2) the harmonization across European countries of both specialist training and qualification criteria in rehabilitation medicine;

(3) the promotion in each European country of a national PRM scientific society and of a theoretical organization to defend the general interests of the PRM specialist; and

(4) the harmonization on an international level of the actions taken by different organizations and the representation of the PRM specialization in various European authorities.

Since the beginning, the EFPMR’s mission has been to promote specialist training in PRM by instituting an “etudes commission” (studies commission).

This commission, after an inquiry carried out by A. Tonazzi on the situation of teaching in different European countries, produced a draft paper, “Training specialists in Europe.” It was presented by R. Waghemacker at the 5th Congress of the International Federation in Montreal. In 1970, this report was considered by the European Regional Bureau of the World Health Organization as a useful reference document for drafting the conference program entitled “Teaching Medical Rehabilitation” held in Poland, November 10 –16, 1971. In this conference, it was established that the responsibility of rehabilitation medicine practitioners was to leave the expertise to an “ad hoc” instructed specialist and not to other discipline specialists.

This choice was decisive because, at the beginning, the national society members came from similar disciplines (orthopedics, neurology, rheumatology, radiology, etc.), the discipline was referred to by various names, and practice seemed to be different throughout European regions. So, in this time in which the specialty did not exist in any European country, the Federation created the conditions for the emergence and concretization of a new specialty and for its practitioners’ defense (23).

The EFPMR was represented as a nongovernmental organization at the European Council and, through the collaboration of two experts, A. Van Gestel and F. Isch, the Dutch and French delegates, respectively, who participated in the elaboration of an important paper, published in 1984, entitled “A coherent policy for the rehabilitation of people with disabilities—training of healthcare personnel involved in the field of rehabilitation: the current situation in member states and proposals to improve this type of training.”

The EFPMR began to promote scientific meetings that took the shape of European congresses, which, for many years, were held every 2 yrs. Moreover, the scientific journal Europa Medicophysica, founded by Dario Fiandesio (Italy), has been circulating since 1964. This indexed review, now known as the European Journal of Physical and Rehabilitation Medicine, is an important tool for the development of PRM research in Europe (table 1).

In 2003, the European Federation of PRM, which had so greatly contributed to the foundation and the homogeneous development of our discipline, has been dissolved to make way for the creation of a European scientific society, the European Society of Physical and Rehabilitation Medicine (ESPRM), whose membership is open also to individual members specialized in PRM, although the participation of National Societies remains its central element. This society set the goal of developing a greater homogeneity from a scientific and professional point of view. The National societies (which in 1963 were only 5) in 2003 had reached the number of 21 (Austria, Belgium, Bulgaria, Croatia, Cyprus, France, Germany, Greece, Italy, Latvia, Lithuania, Netherlands, Portugal, Romania, Serbia, Slovenia, Spain Switzerland, Turkey and The United Kingdom). In this period PRM strongly enriched its role all over Europe gaining responsibilities in Health Services in many Countries (unfortunately having several differences in educational and professional fields) and receiving some acknowledgments by the European bodies too.

The mission of ESPRM is a) to be the leading scientific European Society for physicians in the field of physical and rehabilitation medicine, b) to improve the knowledge of fundamentals and the management of activities, participation and contextual factors of people with a disability and c) to improve and maintain a strong connection between research and clinical practice in PRM.

Académie Médicale Européenne de Médecine de Réadaptation / European Academy of Rehabilitation Medicine (EARM)

In 1968, René Waghemacker and Francisco Barnosell, during the preparation of the preparing the 5th Congress of the International Federation, it was observed that colleagues from various countries working for the specialty were changing too often. It was also observed that none of the goals of the Federation was aimed at the philosophy of Rehabilitation Medicine. So it was decided to found an Academy that would be made up of persons, well known in the area of Rehabilitation Medicine, in order to set up an organization in which the members would stay for a long time and especially work on the philosophic and ethical aspects of Rehabilitation Medicine, and encourage the scientific development of the specialty. The Academy was founded in Geneva in 1969 by eight founding members, under the name of Académie Médicale Européenne de Médecine de Réadaptation. This name was changed into Académie Européenne de Médecine de Réadaptation /European Academy of Rehabilitation Medicine in 1996 under the initiative of Alex Chantraine. The founding members were: F. Barnosell (Spain), S. Clemmesen (Denmark), G.H. Fallet (Switzerland), D. Fiandesio (Italy), L. Gutmann (U.K.), G. Valobra (Italy), R. Waghemacker (France), W.M. Zinn (Switzerland). The registered seat of the Academy is in Brussels. Its logo is “Societatis vir origo ac finis” (Man is both the source and the goal of society). Its official language was French, but recently both French and English have declared to be official languages, with English more commonly used.

The aim of the Academy is to improve all areas of rehabilitation for the benefit of those who need it. It thus promotes education and research across Europe, acting as a reference point in scientific, educational and research matters, exchanging ideas and information, facilitating the exchange of PRM doctors between different countries and engaging in moral and ethical debate. EARM is made up of people who are prominent in the European world of Rehabilitation Medicine. They have to be medical doctors specialized in Rehabilitation Medicine, who are particularly distinguished in the field, not only from a technical or scientific point of view, but also for their humanistic aspects. They come from most of countries of Europe and recently membership continues to extend eastwards. The maximum number of members is 50, but it has never exceeded 40 whilst the current number is 35. They are chosen by invitation, elected only by secret ballot, after a complex procedure that entails presentation by three Academy members. EARM, although it has had an autonomous program of activities, has collaborated closely with the ESPRM and with the PRM Section of UEMS. From this collaboration, the first edition of the White Book of Physical and Rehabilitation Medicine was published in 1989. This book was written in 4 languages (Spanish, English, French, Italian) and then re-edited in different countries. A second edition of the European White Book of Physical and Rehabilitation Medicine was published in 2006.

During the past years a number of documents have been published including:

  • Inaugural Lectures of Academicians published in Europa Medicophysica, (Minerva Medica, Torino, Roma, Milano). Médecine de Rééducation et Réadaptation , 235 p, Documenta Geigy, Paris, 1982
  • Many ethical documents have been produced under Academy’s patronage, with “The Accessibility in Rehabilitation of Disabled People” ranking as the most important.

The PRM Section of the European Union of Medical Specialists (UEMS)

The free inter-country circulation of doctors in the six different countries of the European Community (1957) made necessary to organize the harmonization of education and qualification of specialists, in order to obtain the quality of care at the same optimal level in every European country. This was the goal of the UEMS, which was founded in July 1958 in Brussels. The UEMS has maintained close contact with the European Union authorities and the Council of Europe from the beginning. In the following years, the specialist sections were gradually founded (24).

A section called Physiotherapie / Physiotherapy was founded in 1963, but the first autonomous meeting was held in 1971 (Mondorf les Bains, Luxemburg), At this meeting, some historical protagonists and legitimate lawful delegates, such as J. Emmerechts (Belgium), Amedeo Tonazzi (Italy), Fritz Venema (Holland), and Rene Waghemacker (France) with the help of jurists of the UEMS, asserted the autonomy and requested changing the specialty name to Physical Medicine and Rehabilitation (this name in 1974 was changed to Physical and Rehabilitation Medicine). (25)

F. Venema led this section very efficiently as president until 1985, followed by Andre Bardot, as president. Amedeo Tonazzi was general secretary from 1974 to 1990, followed by Antoine Macouin.

At that time, the specialty was not yet the same in the different countries. The main problems to be solved were:

  • to establish a definition of the specialty, exact and official;
  • to give the same name to this specialty in all of the countries of the European Community;
  • to define the role of the doctor specialized in the discipline;
  • to give guidelines for optimal and harmonized education;
  • to examine how and what  Continuous Medical Education (CME) was in the specialty in each country;
  • to establish a convenient and reasonable relation between the specialty and the remedial professions in rehabilitation.

These different goals have been reached, more or less, in 30 years. Even now, it is necessary to continue the work for some of these goals. As an example of this last we can mention the elaboration of the e-book on field of competences by the Professional Practice Committee (PPC) of the Section, as well as the procedure for PRM specialty implementation in European continent countries where it is not established yet as a primary one.

The European Board of Physical and Rehabilitation Medicine

Since 1990, the members of the Section have dedicated themselves to prepare the setting up of the European Board of PRM, the fourth organization of the European specialists. The Collège Europeene de Medecine Physique et de Readaptation statutes were registered on July 19, 1991 in The Hague (Holland), the seat of the European Court of Justice. The founder signees of the statutes were H. Anciaux (Belgium), A. Bardot (France), M.A. Pinto de Vasconcelos (Portugal), A. Macouin (France), L.P.Rodriguez (Spain), and H. Verstappen (Holland). Through the years the name of this Body was adapted (but not registered) as European Board of PRM. The relationship between the Board and the Section was very close. Actually, the Board took all the responsibilities of the Section’s educational affairs. The  main  goal  of  the  Board  was  the  harmonization of  education  and  training  in  the different  countries,  at  the  highest  possible  level. An executive committee of six members was established and assisted by a commission of teachers made up of university professors. The commission of teachers was initially made up from A. Bardot (France), C. Bertolini (Italy), A. Chantraine (Switzerland), J.P. Didier (France), J.Ekholm (Sweden), G. Lankhorst (Holland), L.P.Rodriguez (Spain), H. Stam (Holland), G. Vanderstraeten (Belgium), and A. Ward (UK); A. Mc Namara (Ireland), X. Michail (Greece), and R.Valero (Spain) joined afterwards.

There was a workshop 3 or 4 times a year, in Paris most frequently, gathering the Executive Committee with the Educational Committee. André Bardot, The chairman of the commission of teachers, enthusiastically convinced everyone that they were working on a very significant project for the future growth of our discipline in Europe. In less than 2 years, the PRM training curriculum, a kind of theoretical program made up of sections, the methods of practical training, the rules for obtaining the title of Board certified by equivalence, the conditions of the examination, the criteria for accreditation of trainers and training sites and the bilingual English–France logbook, were established. At the same time, the commission worked on the creation of a databank of examination questions multiple clinical questions (MCQ) and case histories). An archive of more than 500 questions was created for the first session of the European examination held in Ghent (Belgium) in 1993 organized by G. Vanderstraeten, in 1993. Anonymity and objectivity were the key elements maintained during correction of the exams. Since this date, the MCQ Bank has become considerably richer and the examination is held every year in every country with permanently increasing number of candidates. Antoine Macouin, who was the Secretary of the Section since 1990 and then of the Board since its creation, resigned in 2001. Since 2001, , a reorganization of the Section and Board was made. This reorganization was necessary, owing to the workload of the management of a medical specialty under full development.

History and development of science in PRM in Europe. European PRM Scientific Journals

The development of science in PRM may have followed several pathways PRM being an independent medical specialty in nearly all-European countries that has often stemmed –after the 2nd World War– from other both biomedical and clinical. Thus, besides PRM physicians trained from the beginning in PRM, physicians were also recruited from both biological areas (such as anatomy and physiology) and established clinical fields (such as neurology, orthopaedics, sports medicine and rheumatology). There has also been an influence from non-physicians, especially from psychologists and other behavioural science and technical areas. Scientific activities ought to be closely related to the clinical development of a speciality and this has also been the case for PRM. In the scientific development, research mainly related to biomedicine and technology (mostly, mechanical and electronic bioengineering), as well as to clinical practice with observational follow-up studies, appeared early, and later increased the number of randomized controlled trials (RCT) and methodological studies, especially on outcome measurements.

Importance of ”external” influence and the development of research fields

PRM research has been influenced by external factors (such the International Classification of Impairments, Disabilities and Handicaps, ICIDH, and the International Classification of Functioning, Disability and Health, ICF), by new knowledge from modern psychometric techniques, from biomedical fields (as on neural plasticity and stem cell research), and by the development of new technology. ICIDH, published by the World Health Organization (WHO) in 1980, never reached a large use, but had a conceptual impact on PRM, as well as an influence on the development of outcome measures. It was criticized for different reasons, e.g. for being too closely related to the traditional biomedical model and also for its terminology. When in 2001 it was further developed into ICF, a larger impact was noted, already at an early stage. It has also a more relevant terminology and could be expressed in positive not only negative terms. Thank to this classification, PRM research demonstrated an increasing interest and also ability to approach the Bio-Psycho-Social model of disability. Methodology suitable for research within the activity and participation areas had to be developed and used, which to a large extent means use of instruments with categorical data (ordinal scales), requiring modern psychometric methodology. Of great help in that development has been the introduction of Rasch analysis in PRM research. The Danish mathematician Georg Rasch originally developed Rasch methodology. It is based on the relationship between the ability of the subjects and the difficulty of the items and the results are expressed in logit units. If data fit the model, raw scores can be transformed into interval-level ability estimates, a key requisite for measuring change. Early initiatives for the use of Rasch methodology in PRM were taken in the ’90s in USA and the interest further spread to Europe. At the same time, the understanding and practical possibility to use randomized controlled trials (RCT) increased, especially during the last 20 years. In PRM, such studies are important in objectively evaluating intervention programs, but can have some practical limitations. Moreover, the technology with relationship to PRM research has also developed, e.g. in orthotics and robotics, technology for movement analysis and in neurophysiology, and to follow real-life physical activity (e.g. through wearable sensors). All these developments have broadened the possibility for clinical research in PRM.

The increasing number of non-medical rehabilitation professions, such as occupational therapists, physiotherapists and neuropsychologists doing research in the PRM field has broadened the competence of the PRM team. Good models not only for multi-professional research, but also for transitional research, taking the advantage collaboration between basic research and clinical research have developed.

Scientific meetings and congresses of the European PRM organisations. The Cochrane-PRM field creation

Meetings and congresses arranged by different scientific organizations have contributed to communication and development of science in PRM, especially during the last twenty years, when the scientific quality of such meetings has increased. A number of PRM symposia, courses and international schools have also been arranged on special topics, such as biomechanical and movement analysis, neurophysiological background to rehabilitation, methodological aspects on outcome measurements, etc. In several congresses informative and educational sessions on scientific publication–including “Meet the editor” and “How to write a manuscript” sessions– have been included. The international organizations ‘International Rehabilitation Medicine Association’ and ‘International Federation of Physical and Rehabilitation Medicine’, merged 1999 into ‘International Society of Physical and Rehabilitation Medicine (ISPRM)’, a worldwide PRM organisation with strong participation from European scientists. From a European perspective the ‘European Federation of Physical Medicine and Rehabilitation’ was founded in 1963, and among its aim there was the promotion of the national PRM societies and related congresses. The Federation changed 2003 its name to ‘European Society of Physical Medicine and Rehabilitation (ESPRM)’, maintaining its aim of being the leading scientific society for European PRM specialists. In addition, two more locally-based PRM organizations are working in Europe: the ‘Mediterranean Forum of Physical and Rehabilitation Medicine’ with its first congress in 1996, and the ‘Baltic North Sea Forum for Physical and Rehabilitation Medicine’ with its first congress in 2010. Both these organizations have also attracted participants from other parts of Europe and internationally.

Cochrane-PRM field.

Under the initiative of the Evidence Based Medicine Special Interest Scientific Committee of the European Society of Physical and Rehabilitation Medicine with the approval of the other European PRM bodies, the Cochrane Rehabilitation field has been created  and it was launched in December 16th 2016. Thanks to this, as well as to the cooperation in this new field of a large number of PRM physicians and other rehabilitation professionals, it will be possible in the future to give a special boost to the scientific evidence in our speciality, allowing among other things to improve rehabilitation research methodology, creation of new clinical practice guidelines as well as other benefits for rehabilitation (26). (www.rehabilitation.cochrane.org). 

Development of scientific journals within Europe

Scientific Journals are among the most important contributors to the growth of science in PRM specialty. A great number of national PRM journals in Europe, and also journals more spread internationally have been developed. Ten national journals belonging to the European Physical and Rehabilitation Medicine Journal Network (http://www.esprm.net/journal-network) from Bulgaria, Croatia, France, Germany and Austria, Portugal, Slovenia, Spain, Turkey have been presented in a paper (27), but the field is in constant evolution. The three top Europe-based journals with an actual link with PRM scientific societies and an international perspective are (28)- (in alphabetic order): Clinical Rehabilitation, European Journal of Physical and Rehabilitation Medicine, and Journal of Rehabilitation Medicine.

European-international PRM Journals

In order to give some indication on changes in scientific activity in PRM in Europe, we have examined specifically the content of the three above PRM journals at three time points 1975, 1995 and 2015 (as for Clinical Rehabilitation just at the two last time points) with respect to type and topics of the articles over the last 40 years.

Clinical Rehabilitation (Cr) 1987

It is the official journal of the British Society of Rehabilitation Medicine, in association with the Society for Research in Rehabilitation. In 1997 it joined the Journal of Rehabilitation Sciences and became the official journal of the Netherlands Society of Rehabilitation and Physical Medicine. Always published in English it is indexed by Medline since 1995, and has an Impact Factor since 1995. The journal started in 1987. The number of evaluative studies has progressively increased, especially RCT studies five to seven times from 1987-1995 to 2002 (29). In 1995, the journal strongly advocated for more RCT studies in rehabilitation research (30). Indeed, that was successfully done over the years, with an increase in the percentage of RCT from 18% of the published papers in 1995 to 50% in 2015. At the same time the observational studies including qualitative studies decreased from 48% to 2%. The methodological articles decreased from 20% in 1995 to 12% in 2015, and unfortunately very few studies using Rasch analysis have been published. Reviews did not appear in 1995, but were 24% of the articles in 2015. The topics for the articles were rather constant with neurological conditions being around half of the articles with some increase between the two time points. It has developed a specific interest in goal setting and in describing interventions. It is now trying to increase also the very important and very underdeveloped theoretical base for rehabilitation

European Journal of Physical and Rehabilitation Medicine (EJPRM) (1964), formerly “Europa Medicophysica” – Official Journal of ESPRM and UEMS-PRM Section and Board 

The journal started to be published in 1965 as Europa Medicophysica. Since the beginning it was the official journal of the European Federation of Physical Medicine and Rehabilitation, later become ESPRM, with 19 countries in the Editorial Board. It is published in association with the International Society of PRM (ISPRM), and is the official journal of the Mediterranean Forum of PRM (MFPRM). It was published in three languages (Italian, French and English) until 1994, when English become the only language. It is indexed by Medline since 2004, and has an Impact Factor since 2010. It changed to the current name in 2008. It was originally dominated by manuscripts from Southern Europe, but in 2007 become internationally oriented. A few RCTs were published in 1975 and 1995, but they had a marked increase (23% of the published manuscripts) in 2015. The percentage of observational studies has been rather high: 19% (1975), 29% (1995), and 41% (2015), respectively. Methodological studies started to appear in 1995, including occasionally some articles using Rasch analysis. In 1975 review paper and special reports were common (56%), whereas in the later years they have not been as dominating. Manuscripts concerning neurological conditions have been around half or little less of the published manuscripts, with musculoskeletal and pain conditions increasing markedly from 1975 and 1995, and being 29% in 2015. its main scope is publishing clinically meaningful papers, helping to improve PRM clinical practice (31)

Journal of Rehabilitation Medicine (JRM) (1969), formerly “Scandinavian Journal of Rehabilitation Medicine” – Official Journal of UEMS-PRM Board and EARM

It started to be published in 1968 as Scandinavian Journal of Rehabilitation Medicine, and changed its name in 2001. Manuscripts were initially almost exclusively from the Nordic countries, but rather soon the proportion of manuscripts from other parts of the world increased (around 50% in 1996 and 80% in 2015), first due to an increase of European papers, and after 2005 also of non-European manuscripts. RCTs were not published in 1975, but appeared in 1995 as 21% and in 2015 as 27%; in contrast, non-controlled evaluative studies decreased (from 25% in 1975 to 8% in 2015). There has been an interest to publish different types of methodological studies, being around a quarter of the published articles during the period. The number of articles using Rasch analysis has increased, but still being relatively few in relation to the number of articles using ordinal scale data.  Reviews and Special Reports started to appear from around 2000 and in 2015 were 11% of the published articles. The topics for the articles were fairly constant from 2004 to 2011 and over the whole period around 50% on neurological conditions, around a quarter from musculoskeletal and pain conditions, and the rest of the articles either from other conditions, as cardiac and respiratory conditions, or from studies involving several groups of patients or healthy individuals, including the elderly.

Other European PRM scientific journals with international projection

We present here short historical notes about other multinational journals, we will follow an order according to the year of foundation

Annals of Physical and Rehabilitation Medicine (APRM) (1974), formerly “Annales de Réadaptation et de Médecine Physique” – Official Journal of ESPRM and UEMS-PRM Section

Official journal of the French Society of Physical and Rehabilitation Medicine (SOFMER, Société Française de Médecine Physique et de Réadaptation), it is published in association with the International Society of Physical and Rehabilitation Medicine (ISPRM) since 2012. The Publisher is Elevier, which diffuses the Annals via Science Direct. It was exclusively edited in French until 2005, became bilingual from 2009 and is exclusively published in English since 2015. APRM is indexed in Medline since 2001 with no impact factor yet, and is now a scientific journal which meets international standards, and covers all fields and aspects of rehabilitation sciences, from fundamental, to medical and social sciences. The Journal publishes original peer-reviewed clinical and research articles, epidemiological studies, new methodological clinical approaches, review articles, editorials and the guidelines. Are mainly concerned: methods of evaluation of motor, sensory, cognitive and visceral impairments ; functional disabilities ; handicaps in adult and children ; processes of rehabilitation in orthopaedic, rhumatological, neurological, cardiovascular, pulmonary and urological diseases

Rehabilitación (Madr) (1966)

Official journal of the Sociedad Española de Rehabilitación y Medicina Fisica (SERMEF). It was founded in 1966 by the board of directors of the Society. Its publisher is Elsevier España, S.L.U. and draws four issues per year and a monograph on a subject of the greatest interest and topicality appointed by the editorial board. It is published in Spanish (except abstracts that are always both Spanish and English).  It is not indexed by Medline yet, but included in: IME, Eventline, Bibliomed, Sedbase, CINAHL, Scopus, Pascal and IBECS. It’s history goes back to a previous journal: Acta Fisioterápica Ibérica (1956) which was the official journal of the “Sociedad Española de Fisioterapia Reeducativa y Recuperación Funcional”. In 1966, Acta Fisoterápica Ibérica and Revista Española de Rehabilitación del Aparato Locomotor (supplement of the orthopaedic surgery journal) were unified in the new journal. Rehabilitación (Madr) is the main scientific diffusion tool for PRM physicians in Spain as well as for those in Spanish-speaking Latin-America countries. Its main scope is continuous medical education in PRM speciality.

International Journal of Rehabilitation Research (IJRR) (1977)

Official journal of Rehabilitation International from 1977 to 1985, and then, since the establishment, of the European Federation of Research in Rehabilitation that in 2009 was renamed European Forum for Research in Rehabilitation. Publishers: Schindele (1977-1990), Chapman and Hall (1990-1998), and now Lippincot Williams & Wilkins/Wolters Kluwer (since 1998). It was always written in English. It is indexed by Medline since 1978, and has an Impact Factor since 1997. It is a forum for the publication of research into functioning and disability, and the contextual factors which influence the life experiences of people of all ages in both developed and developing societies. Currently it has an impact factor

Physikalische Medizin – Rehabilitationsmedizin – Kurortmedizin – Journal of Physical and Rehabilitation Medicine (JPRM) (1991)

It is the official journal of the German Society of Physical Medicine, the Austrian Society of Physical and Rehabilitation Medicine, the German Professional Association of Rehabilitation Medicine and the Austrian Professional Association of Physical and Rehabilitation Medicine. Published by Georg Thieme. In 2009 the journal’s subtitle Journal of Physical and Rehabilitation was added. It has an Impact Factor since 2015. It publishes articles in English and German. Its history goes back to 1898, with Zeitschrift für diätetische und physikalische Therapie (Journal of Dietary and Physical Therapy), continued in the German Democratic Republic since 1971 as Zeitschrift für Physiotherapie; in West Germany the Zeitschrift für Physikalische Medizin was founded in 1970. In 1991 the two societies and journal of East and West Germany merged. Its main scope is original articles, case reports and educational articles in Physical Medicine and Rehabilitation Medicine. Congress abstracts, news from the societies and associations.

Journal of the Portuguese Society of Physical Medicine and Rehabilitation

The SPMFR Journal is published since 1992, and a reference for all Portuguese specialists in MFR and for Portuguese medical societies. Its printed copies are sent to all members of SPMFR, Sociedades Médicas de Portugal and various medical libraries. It is also spread to other Portuguese speaking countries, through cooperation with colleagues from Brazil, Angola, Moçambique, Cabo Verde, Guiná bissau, . Tomé e Príncipe, East Timor

Articles from the area of Rehabilitation Medicine, original and review, are published, and all manuscripts submitted must be in accordance with the International Committee of Medical Journal Editors.. The SPMFR Review has a complete peer review process, clear definition of its objectives and scope, and conflict of interest statement, in accordance with the Recommendations for the Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals (ICMJE Recommendations ). Articles can be submitted in English, French and / or Portuguese. Abstracts must be in English and in another language (French or Portuguese). The RSPMFR does not consider material that has already been published (except abstracts presented at conferences) or is awaiting publication in other journals. The opinions expressed in the articles are the sole and exclusive responsibility of the authors.

Conclusion

Scientific research in this medical specialty has been increasing over the past century and continues during the present. Research mainly related to biomedicine and technology (mostly, mechanical and electronic bioengineering), as well as to clinical practice with observational follow-up studies, appeared early, and later increased the number of randomized controlled trials (RCT) and methodological studies, especially on outcome measurements. European PRM authors are publishing an increasing number of research reports in both clinical and experimental field, not just in PRM journals (some of them indexed by Medline and with a currently impact factor) but also in other leading journals belonging to different biomedical categories. There has been a clear development in the type of articles being published with randomized control trials (RCT), being much more common now than 40 years ago. Similarly, the number of clinical trials published in medical journals indexed by PubMed, including the keyword “Physical Medicine and Rehabilitation”, has increased from 65 in 2006 to 200 in 2015. In addition, at present the number of clinical trials registered on ClinicalTrial.gov, and located in Europe, is about one third of the world output when searched by keyword either “Rehabilitation Medicine” (583/1764), or “Physical Medicine and Rehabilitation”/ “Physical and Rehabilitation Medicine” (84/264). All that will hopefully strengthen the possibility for the scientific input on clinical practice in PRM, and Europe has a leading position in that. The patient groups in the surveyed journals are mainly neurological conditions, and then musculoskeletal and pain conditions: this reflects the clinical situation in PRM settings. In addition, methodological studies have been performed on both construct and psychometric characteristics of different outcome instruments. Last but not least, there has been a large interest in research connected to ICF, starting already in the beginning of the present century: several papers have been published on conceptual aspects of ICF and on the development of ICF with core sets, and as a basis for outcome measures as well as for structuring PRM research and clinical work. Scientific Journals are among the most important contributors to the growth of science in PRM specialty. There are some commonalities in their history in Europe. They have generally born locally to serve a specific PRM Society and Country and had to face an evolution to become international. The data-bases (mainly PubMed, and ISI with its Impact Factor), born in USA and initially including mainly US journals, created a first main challenge. Another has been the transformation in English language (for journals based in non-English speaking countries), particularly difficult for editors, authors and readers. Finally, the international evolution included for the oldest journals a change of name to make it more modern and/or corresponding to the actual contents.

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