White Book of PRM

Chapter 6 – Knowledge and skills of PRM physicians

European PRM Bodies Alliance

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

  • European Academy of Rehabilitation Medicine (EARM), 
  • European Society of Physical and Rehabilitation Medicine (ESPRM),
  • European Union of Medical Specialists PRM Section (UEMS-PRM Section)
  • European Union of Medical Specialists PRM Board (UEMS-PRM Board)
  • The Editors of the 3rd edition of the White Book of Physical and Rehabilitation Medicine in Europe: 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:Jean-Pierre Didier, Sara Laxe, Gilles Rode, Piotr Tederko, Carine Michel, J Paysant, Yves Rossetti, Anthony Ward, Basaglia, Walter Frontera, Andrew Haig, Leonard Li, Jianan Li, Luca Padua, Dominique Perennou

Abstract

In the context of the White Book of Physical and Rehabilitation Medicine (PRM) in Europe, this paper deals with the fundamentals of PRM from a physiological perspective, looking at the human mechanisms both physical and behavioural which are at the base of PRM physicians’ work. After a discussion on the development and evolution of PRM that leads to its unique and specific approach, the mechanisms considered include:

  • repairing processes (and potential of recovery evaluation): repairing processes are mainly related to the quantity and natural history of diseases and impairments, while potential of recovery are also linked to the individual and environmental factors; PRM physicians work on impairments to favour healing or recovery, and propose rehabilitation if there is a potential of recovery: this is related to the prognostic role of PRM physicians;
  • learning processes: PRM is the specialty of teaching new physical ways and behavioural approaches to make patients participate at best through improvement of impairments and modification of activities; in this perspective, during repair and rehabilitation processes, PRM physicians and the rehabilitation team are teachers of new motor and behavioural strategies;
  • compensatory processes (adaptation/habilitation/rehabilitation): PRM physicians teach patients how to adapt to the new (acquired) health condition using compensatory mechanisms based on other body structures/functions, behavioural changes and/or assistive devices (or technical aids) (prosthesis and orthosis); during growth PRM physicians aim at allowing a complete (and compensatory) development of the intact function, not to be impaired by the original disease; compensatory processes are related to activities;
  • management skills: PRM physicians are managers of people and resources; they manage patients and their caregivers, to teach and allow them to reach the best possible participation, also focusing on maintenance; they manage the team, with the aim to make it function at best for the sake of the patient; finally, they manage resource allocation for the functioning of patients and team;
  • communication skills: PRM physicians need to develop very good communication skills, so to teach, inform and educate patients and their caregivers: this will allow the proper behavioural changes and also the correct physical compensations.

Key words

Physical and Rehabilitation Medicine, Europe, learning, recovery of function, case management, communication

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 fundamentals of PRM from a physiological perspective, looking at the human mechanisms both physical and behavioural which are at the base of PRM physicians’ work. After a discussion on the development and evolution of PRM that leads to its unique and specific approach, the mechanisms considered include:

  • learning processes: PRM is the specialty of teaching new physical ways and behavioural approaches to make patients participate at best through improvement of impairments and modification of activities; in this perspective, during repair and rehabilitation processes, PRM physicians and the rehabilitation team are teachers of new motor and behavioural strategies;
  • repair processes (and potential of recovery evaluation): repair processes are mainly related to the quantity and natural history of diseases and impairments, while potential of recovery are also linked to the individual and environmental factors; PRM physicians work on impairments to favour healing or recovery, and propose rehabilitation if there is a potential of recovery: this is related to the prognostic role of PRM physicians;
  • compensatory processes (adaptation/habilitation/rehabilitation): PRM physicians teach patients how to adapt to the new (acquired) health condition using compensatory mechanisms based on other body structures/functions, behavioural changes and/or assistive devices (or technical aids) (prosthesis and orthosis); during growth PRM physicians aim at allowing a complete (and compensatory) development of the intact function, not to be impaired by the original disease; compensatory processes are related to activities;
  • management skills: PRM physicians are managers of people and resources; they manage patients and their caregivers, to teach and allow them to reach the best possible participation, also focusing on maintenance; they manage the team, with the aim to make it function at best for the sake of the patient; finally, they manage resource allocation for the functioning of patients and team;
  • communication skills: PRM physicians need to develop very good communication skills, so to teach, inform and educate patients and their caregivers: this will allow the proper behavioural changes and also the correct physical compensations.

The aim of this Chapter is to discuss in detail all these mechanisms of the PRM medical specialty, that makes PRM physicians the rehabilitation physicians.

Evolution driving to the actual fundamentals of PRM

Traditionally, medicine has based its treatments of making aetiological diagnosis, setting pharmacological or surgical treatments, and ultimately analysing the outcome based on measures such as blood tests or radiological improvements. This “anatomo-clinical” model created the foundations of medical knowledge and has long been the dominant and sometimes even exclusive model in medical practice and teaching. This model is based on the following logical sequence: an aetiology or cause results in a disease that is manifested by clinical symptoms and laboratory findings. Doctors sought an anatomically constrained origin for conditions (in the form of tissue damage, hence the place of pathology) and retained the notion of a nosology (classification of diseases). This classification of diseases is now operating as the ICD-10 (and ICD-11, pending publication) (1). This anatomo-clinical model focuses on the disease and it has shown to be very effective for medical diagnosis and in the context of acute diseases for which there is a causal treatment (aetiology or cause) or symptomatic treatment (symptoms or manifestations). Nevertheless, this approach is insufficient when there is no cure and the disease results in disability and handicap (ICIDH model 1980) or activity limitation and participation restriction (ICF 2001 model) (2), especially (but not only) in severe acute conditions with long-term sequelae and irreversible pathologies.

The model known as “functional” is centered, not on the disease, but on the patient, describing the functioning limitations and environmental factors (personal and environmental). And this is precisely the paradigm of interest to the PRM physicians, since the focus of the intervention is not merely the etiological reason of the disease but its consequences in the functioning of the individual. This model is more relevant to the description and analysis of chronic conditions and their treatment because it considers the situation of disability as a mismatch between an individual, the environment and its personal desires (projects) (3). Therapeutic interventions do not aim to cure the patient only by treating the disease and impairments: they aim also at activity limitations and participation restrictions. Therefore the actions of Physical and Rehabilitation Medicine (PRM) focus on three targets: first, the individual, by promoting not only the repair process (disease and impairments) but also the compensatory processes (intrinsic – compensation developed by the individual – or extrinsic – with external devices); second, the environment (physical, personal, professional, etc), and finally, on individual projects (education, work, personal and social life), that will be modified and adapted.

The ICF: a key concept for PRM

The medical specialty of PRM has adopted the International Classification of Functioning, Disability, and Health (ICF) developed by the World Health Organization (2). This classification includes a new approach to persons with disabilities relying on a multi-dimensional approach (4). An example of the application of this approach is the identification of a lesion (aetiology) using modern imaging techniques that allow us to see details of the injured tissue and the identification of undamaged structures that could be used in the process of rehabilitation. For the PRM physician, the challenge is to consider these findings to propose rehabilitation methods that could favour plasticity and regeneration. The second aspect is the assessment of different body structures and functions using the clinical examination and selective assessments scales. For the PRM physician, one objective is to measure the severity of the impairment and also to make precise correlations between impairments and underlying lesions. This anatomico-clinical approach is particularly important in musculo-skeletal and neurological disorders, as well as cognitive losses due to focal lesions. The third aspect is the assessment of limitations in activity. This is at the core of PRM, which considers the remaining abilities of the persons with disabilities to be more important than impairments in body structures and functions. This is a more positive vision relying on the activity itself. The fourth level corresponds to the assessment of social consequences of the injury or disease (5). In this context, the previously used terms “disadvantage” and “handicap” have been replaced with the more positive term of participation, placing the patient in the context of his/her personal, professional, and social life. The ICF also constitutes a good model for rehabilitation strategies (6). The dimensions of the ICF can also refer to distinct targets or outcome measures for rehabilitation. The ‘body structure/impairment’ can correspond to the possibility to stimulate the undamaged structures with a technique or a treatment stimulating plasticity capabilities (7,8). The ‘body function/impairment’ can refer to the recovery of a function such as strength, coordination, or dexterity in the case of motor function; discrimination or identification in the case of sensory function; and planning, verbal comprehension, memorisation for cognitive functions. The ‘activity/limitation’ can refer to the reduction of the disability and the possible generalization of functional recovery to others activities and the enhancement of activity limitation by compensation. The ‘participation/restriction’ corresponds to the reduction of the disadvantage by social interventions based on recognition and inclusion considering personal and environmental factors. The “contextual factors” and their possible role of facilitators and/or barriers, have to be taken into account. In the context of ICF, it must also well considered that the development of the capacity does not correspond necessarily to the final performance of the patient, that should in any case be the final end of PRM action. 

This multi-dimensional approach of the disease and its consequences for diagnosis, treatment, and rehabilitation reinforce the acceptance that PRM may be considered as a medicine of the human person in complementarity with the medicine or specialities of organs.

Learning Processes in Physical and Rehabilitation Medicine

Learning is a part of the rehabilitation process and, recently, has had a higher profile and recognition of its importance in PRM practice. The PRM physician is a teacher, especially when new concepts of adaptation (e.g. plasticity) and motor learning must support rehabilitation programmes. The principles of adaptation and plasticity are covered in the PRM training programme and PRM physicians thus know and understand the theoretical background of the principles of teaching and learning (10).

During training, PRM physicians learn how individuals learn motor skills (motor learning) and this requires an appreciation of the following factors (11):

  • Motor development: how to gain a capacity to develop motor skills to increase the final performance;
  • Motor control: how the neurological system controls movement;
  • Motivation: how to motivate individuals to want to learn motor skills and participate in their programme;
  • Teaching practice for physical training: how the treatment environment can optimise the acquisition of motor skills.

This knowledge equips PRM physicians to design strategies to enhance outcomes and avoid mal-adaptation. Effective modern concepts of motor learning and recovery are developed with the aim of inducing skill-acquisition relevant to the patient daily’s life. Such an approach is beneficial in preventing the learned non-use phenomenon and to restore function. However, too intensive a programme can be counter-productive and does not allow for natural adaptation (12). Commonly, learning involves instructions about “how to do something”/“how to perform a task”. Even without any explicit instruction, a person often has the capacity to understand how to do a task, simply using implicit learning. 

Explicit and implicit learning are thought to tap into different neural pathways. The implicit learning process is more robust in neurological injuries, especially when memory has been severely impaired. Even though the first approach is currently more often used, explicit and implicit learning procedures have potential in all aspects of Physical and Rehabilitation Medicine (13,14). Recovery of function, whether spontaneous or enhanced by therapy, is a dual process of plasticity. This is largely interdependent, and it is driven by changes in both the nervous and the musculo-skeletal systems. The neuroplastic process depends on the muscle effector activity, while its expression depends on the neurological command and regulation.

More generally, in all conditions affecting physical activity, where there is a disorder of muscle recruitment or control, or where there is a loss of performance, strengthening muscles and physical reconditioning are essential, but cannot be considered as stand-alone. They must not be split from all the other aspects of conventional neuromotor rehabilitation, as far as the activity is both due to plasticity (15).

PRM physicians thus embrace this new functional concept, to work with therapists, to advance the concepts of both neurological and orthopaedic rehabilitation (16). This is seen, for instance in action and observation treatments and in the interest of virtual reality increasingly used in rehabilitation programmes.

The cerebellum and basal ganglia are critical for motor learning, which allows people to gain skilled behaviours. If these are intact after brain injuries, regaining this skill is possible through repetitive training to overcome difficulties in learning new motor skills as well as limited postural control and deficits in sensory-motor coordination. (17). PRM clinicians see that repetitive practice is a feature of any intervention as part of motor learning, but clinical practice principles are not entirely based on the findings from research studies of motor control and motor learning research and rehabilitation practice. An example of motor learning paradigms includes robot arm paradigms, where the resistance of patients is measured while using a hand-held device throughout specific arm movements. Another principle is the important concept of the actual amount of practice undertaken in the intervention under study. There is a relationship between the impact of the retention of memory gained from repeating task practice over time and the amount of training given (18). Excessive efforts at learning thus may result in considerable improvements in long term retention, but have little effect on the individual’s performance. Thus, PRM physicians prescribe and propose different practice treatment schedules to get around the inadequacies of simple repetition of movement. Skill relearning acquisition is variable, as it thought that true brain recovery is elicited through repetition alone (14). Compensation methods develop through pure repetition and to elicit cortical changes (true recovery), individuals should be exposed to more challenging tasks. Rehabilitation techniques should be geared towards patients’ specific motor deficits and possibly combined, for example, with constraint induced movement therapy with virtual reality. Two critical questions are posed of a rehabilitation technique are whether the gains persist for a significant period after training and whether they generalise to untrained tasks. Motor learning and repetitive practice is thus used in the stroke and brain injury population and includes (14):

  • Arm ability training: impairment-oriented training for mild hemiparesis;
  • Constraint induced movement therapy;
  • Electromyography-triggered neuromuscular stimulation;
  • Interactive robot therapy;
  • Virtual reality-based rehabilitation.

Understanding the repair processes and using the compensatory processes in PRM for adaptation, habilitation and rehabilitation

Recovery of function, improvement of activities and reduction of participation restrictions constitute major goals in PRM. These objectives primarily concern patients with motor deficits which are the first cause of disability into the world. Motor recovery corresponds to the spontaneous or rehabilitation induced improvement of motor function after a musculo-skeletal and/or nervous system damage. Longitudinal studies about natural motor recovery after stroke showed that recovery curves do not follow a linear process, but mainly proceed through a first phase (within 3 months) with fast recovery and a second phase with slower improvement of motor function (19) or more rarely by steps and plateaus (20). 

Motor recovery includes two components: the true recovery ‘per se’ and the compensation. In the musculo-skeletal system recovery can imply a “restitutio ad integrum”, sometimes even anatomical, normally mostly functional (with some residual scars requiring prevention of future impairments). Neurologically, the true motor recovery refers to the vicariant capacity of the human motor system to restore totally or partially motor function after lesion. It results from brain plasticity mechanisms as regression of a diaschisis (21), reorganization of the controlateral sensorimotor cortex and involvement of undamaged hemisphere (22), restoration of conduction in the corticospinal tract or in alternate motor fibers (23), recruitment of pre-existing parieto-frontal connections (24) and modifications of the inter-hemispheric connectivity (25). 

Compensatory mechanisms are adopted to achieve the best possible functioning (activity and participation) when a complete anatomical recovery is not possible. The compensation can rely on the involvement of alternative muscles to perform the movement (eg the shoulder and elbow muscles for grasp after stroke (26) or wrist muscles extensors for tenodesis grasp in C6 tetraplegia – (27)), the use of the contralateral unimpaired upper limb or the environmental changes. Another possible compensation is the use of another body structure/function to compensate for the damaged one (eg proprioception and vision for a damage of the internal ear in equilibrium and balance disorders). Prosthesis and orthosis are compensatory devices widely used in PRM, even if they require adequate training and the activation of compensatory and/or new motor functions to be effective.

Motor learning refers to the capability of the human motor system to learn through practice and experience. Motor learning includes motor adaptation, skill acquisition and decision-making (28). These capabilites may be mobilized in normal subject for acquiring new motor abilities and in patients for improving motor recovery. 

Motor adaptation

For a PRM physician, motor adaptation must be understood in a broad sense. In biological terms, adaptation is the process of change by which an organism or species becomes better suited to its environment. Motor adaptation appears as the process able to produce the better plan to minimize the energetic cost and optimize the efficiency of the movement, whatever is the environment and the state of the effector. A lot of environmental perturbations or biological changes, such as growth or ageing, needs such adaptation. Moreover, in PRM practice, motor adaptation is needed because pathological process is responsible for skeletal, neurological, muscular lesions or bioenergetics impairment. In that view, motor adaptation is not only a form of motor learning in which the nervous system learns to predict and cancel effects of a novel environment, but rather a process developed to maximize performance in that environment (29). This view is in accordance with the ICF considering all the contextual factors, associating environmental and personal factors in the limitation of the patients functioning. Bearing that in mind, it would be useful to widen the sense of the term “motor adaptation”, which must involve both nervous system and musculoskeletal system strongly linked by cooperative interaction (30).

The mechanisms involved are complex, eliciting a lot of behavioural or computational models of motor control and motor adaptation (31). These models implicate a wide range of disciplines notably neurosciences, psychology, robotics, mathematics, or computer sciences. Such models are useful for understanding motor behaviour in computational terms, but they are less successful when the link between computational and neurobiological models is considered, or when they are applied to functional and pathological issues (32). However, we can emphasize the role of the plasticity of the motor function. If neuroplasticity is involved, notably in the synaptic function (33), we must remember that the plasticity is a general biological property concerning also the effector, with its different constitutive tissues, bones, joints, and skeletal muscles. 

The skeletal muscle plasticity is well understood, it is responsible for the conditioning resulting from physical training and for deconditioning appearing during chronic immobility or starvation. These conditions are frequent in patients with neurological, cardiovascular, respiratory, or renal diseases. Sometimes their independence is severely compromised. However, using some endurance activity programs, it is possible to “maximize” their motor performances, avoiding a severe dependency (34). 

Motor strategies

To achieve a particular goal we can use more than one motor plan. Theoretically there is an abundance of solutions more or less energetically economic and mechanically efficient, but among all these motor strategies practically we choose the best one. Such skill depends from motor development and from motor learning, leading progressively to the construction of internal models that predict sensory consequences of motor commands. Because of individual morphological and biological different characteristics, these models are specific for one person and sometimes they can be very unusual. Taylor based a review upon the role of strategies in motor learning on the Fosbury Flop, which led to an innovative paradigm shift in high jump (35). This example emphasizes the relativity of the concept of “normality”. Moreover, in PRM field the patients develop a learning characterized by a re-optimization process considering the new conditions imposed by their impairments. At that point it is necessary to put forward the idea that rehabilitation has not to be “a particular ideal of health or performance, determined externally” by the medical team (36).

The main processes leading to neural functional representations, so called internal models, have supported a new approach in rehabilitation of hemiplegic patients: the bilateral transfer (37). In patients with subacute stroke, a functional improvement in the affected hand by means of a training performed with the unaffected hand can be observed. The processes involved in this sensorimotor learning are not definitively known, but it allows for important prospects for the PRM speciality. 

Sensorimotor adaptation

Motor adaptation may be induced in response to an external perturbation as a sensory conflict induced by prismatic lenses creating a shift of visual environment (Figure 1A). This sensorimotor adaptation is produced after repeated rapid pointing movements in the direction of visual targets. Their initial shift to the side of the optical deviation and towards the virtual target progressively decreased, reflecting the capability of the motor system to consider the spatial error consecutive to prism deviation. The proprioceptive realignment corresponds to the displacement of the perceived position of the arm in the direction of the optical deviation. It is responsible for proprioceptive straight-ahead estimation (i.e. pointing in the sagittal axis) in the direction opposite to the optical deviation after prism removal. The visual realignment corresponding to the displacement of the perceived direction of the gaze in the direction opposite to the optical deviation. It is responsible for visual straight-ahead estimation in the direction of the optical deviation after prism removal (38). The algebraic sum of proprioceptive and visual realignment was equal to the total realignment in the eye-hand coordination, as measured by pointing to a visual target without visual feedback or knowledge of results (39). 

The awareness of error pointing detection/correction during prism exposure is not necessary for sensorimotor realignment. Experimental procedures, using growing optical displacements, allow significant realignment free of contamination by deliberate correction (40,41). Likewise, neglect patients do not detect the visual disturbance during prism exposure show substantial and long-lasting after-effects (38,42). Adaptation can even develop during imagined visuo-manual pointing movements (without any overt execution) during prism exposure. Therefore, when intersensory spatial discrepancy of the hand location (visual shifted location vs proprioceptive non-shifted location) is available, motor preparation is sufficient to drive realignment (43).

Sensorimotor adaptation and cognitive expansion

Interestingly this visuomotor adaptation induced by prismatic exposure can interact with higher brain functions related to multisensory integration, as proved by surprising effects reported on left unilateral neglect after a rightward optical deviation of the visual field in right brain damaged patients (44) (Figure 1B). This improvement affects some symptoms, which are free from manual responses (auditory neglect, representional neglect) and others no neglect deficits such as constructional deficits, navigation, and even reduction of complexe regional pain syndrome suggesting thus an expansion of sensorimotor after-effects to spatial cognition through a bottom-up track (38,45).

Mirror effects, i.e. simulation of neglect was also observed in numerous cognitive functions in healthy individuals following prism adaptation. Neglect simulation was not only described in peripersonal, extrapersonal and bodily space representation but also in the mental numbers and letters scales. The influence of prism adaptation extends also to spatial attention, hierarchical processing and spatial remapping (46). The term ‘cognitive’ used to depict after-effects, refers to the fact that effects take place beyond the usual framework of compensatory sensorimotor after-effects and involves mental abilities as judgement, comparison or mental representation of space. The occurrence of cognitive after-effects is even more interesting when considering that they cannot be explained in terms of sensorimotor after-effects but that they strictly depend on spatial realignment. Furthermore, spatial realignment must be strong enough (by using at least 10° optical deviation in both neglect patients and healthy individuals) to produce cognitive after-effects (45,46).

Other mechanisms of adaptation

Apart from the direct neurophysiological adaptations considered till now, there are adaptations that can be considered “external” to the anatomical site of the original lesion, and/or even external to the considered person. The former include the use of other body structures and functions to vicariate the damaged one; the latter, the use of prosthesis/orthosis to compensate the loss of function. In both cases a good PRM approach and teaching process, including information, education and exercises, is necessary to optimize the adaptation and achieve the best possible functional results.

Adaptation, habilitation and rehabilitation

Adaptation processes, and firstly motor adaptation are important in PRM. Motor adaptation involves sensorimotor interactions solicited in response to an external perturbation or changes in the body, and relied on practice of repeated exercises during a short duration. Adaptation is learned implicitly without subject awareness, making it an easy applicable method in patients with brain damage and attentional deficits. It involves long-lasting sensorimotor after-effects, but also cognitive after-effects, showing thus that sensorimotor interactions may influence cognitive processes via a bottom-up track. The characteristics of adaptation and its beneficial effects should lead to promote more rehabilitation methods based on adaptation in PRM. 

Even if they are used in the same way, these neurophysiological processes play a different role in rehabilitation (mainly related to the adults) and in habilitation (during growth). In the first the aim is to recover the best possible participation in front of what has been partially or totally lost, in the latter the aim is to avoid a negative impact on the development of the intact body structures/functions due to the originally damaged ones, so avoiding secondary impairments, preserving the best possible activity achievements, and finally participation. During habilitation, growth can be considered a driving force leading to “natural” sometimes ineffective or even damaging compensations; but growth can also be a strong force that, if well guided through correct adaptation processes, can lead in time to good compensations producing better functioning then what expected according to the natural history of the original disease.

Potential of recovery evaluation and prognosis in PRM

Functional recovery is the aim of a person after facing a disease, an injury or other health condition (e.g. aging) and the search of a rehabilitation treatment is the mean to gain back the best possible functioning. A PRM physician is trained to see the patient not as a group of organs and systems with a certain preserved function or structure but as a whole with a certain level of functioning. 

The rehabilitation plan needs to start determining the premorbid functioning level but also needs to start with the image in mind of the final functioning. Longitudinal studies about natural history of diseases showed that recovery curves do not follow a linear process, but mainly proceed through a first phase with fast recovery and a second phase with slower improvement of motor function or more rarely by steps and plateaus. The length of the first phase is different in the various pathologies, and it is considered the most important for rehabilitation: most of PRM efforts should focus on this phase (post-acute rehabilitation), so to increase the quality and quantity of recovery.

In a PRM perspective focused on the person beyond the disease, though, the prognosis is only partly based on this natural history of the original disease. On one side comorbidities must also be considered, and on the other the personal and environmental factor as barriers and/or facilitators of recovery. Moreover, the individual participation aims required high attention and contribute to determine the final prognosis and the entire rehabilitation treatment project.

Nevertheless, in times of shrinking resources, it is mandatory to set appropriate goals for each patients according to the disease related prognosis, and to the other concept of “rehabilitation potential”: will the patient be able to improve his condition to a better functional state? Will the rehabilitation intervention be able to really change the participation of the patient? In a purely “compassionate” model, rehabilitation is not denied to anybody; in an exclusively “disease-centred” model, rehabilitation is not given, since the patient is believed able to recover spontaneously without any intervention as soon as the disease has been treated. In a modern approach, though, rehabilitation should be given to patients really able to improve, in a specific period of time of the health condition, with a start and an end of treatment (to be followed by maintenance, also called post-rehabilitation).

Highly specific to PRM is the problem of communicating to patients the expectations (prognosis) due to medical factors, which is not done in many disabling diseases by the medical specialist treating in the acute phase. This is itself one of the highest challenges in rehabilitation, especially nowadays, when medical and scientific developments have impact on a society, which believes that “anything is possible”: thus, reaching a consensus of the aims of rehabilitation agreed by patient/ proxy and medical team can be stressing (47). The PRM physician must be informed about the diseases that cause disability in order to have more information regarding the prognosis, but despite all the available medical information there are still some conditions (for example minimally conscious patients after TBI) whose prognosis is uncertain and proxies and patients will normally have an optimistic bias (48) towards their prognosis which means that they will demand for unrealistic objectives and treatments. In this sense the training in communicating skills of the PRM physician as well as leadership skills will help in pursuing a better understanding of the rehabilitation planning (49). 

PRM physicians play an important role in the rehabilitation process, since they have been trained into the development of skills to lead interdisciplinary teams and have the capacity to give a throughout assessment of the complex functional status of the patient and the possibilities of acquiring a certain outcome in the future (50). It also faces with the responsibility of providing an image of the potential value of functional status to plan needs for the future, determine provision of services and allocation of resources of treatment. In the current times in which health resources are limited, it is very important to give the accurate scientific evidence of the rehabilitation methods and its impact in the patient, their families, and the society.

Management skills

PRM physicians are responsible for facilitating the patients’ efforts to achieve as optimal as possible a life after illness or injury or in the development of someone with an health condition. Being a good PRM physicians requires excellent technical, scientific but also management skills.

Developing management skills has been a part of medical training over the last two decades and several studies have pointed out that those better managed health systems produce not only higher quality care of patients and improved productivity, but also increase satisfaction among patients and staff (McKinsey). 

Traditionally, as many sociological studies show, physicians hold a negative attitude towards managerial practices, which probably is the result of a now obsolete traditional paternalistic approach of practising medicine. The emphasis on medical education has focused on increasing knowledge and apprenticeship instead of prioritising efficiency and quality. Over many years in the history of practising medicine, doctors were used to working in small individualized consults or centres, were used to leading an unquestioning team and practising without regard for costs and other economic factors. 

This has now changed in the 21st century, where medicine faces several challenges such as:

  • The shift from the paternalistic approach of medicine to a patient-centred approach, in which the professional´s role becomes a provider of solutions for the patient´s problem and should be adapted per the patient´s moral decisions and expectations.
  • The rise of new tests, new treatments, new drugs and, of course, the increase of longevity and the greater impact of several long-term conditions of certain diseases are the responsible for the enormous cost of health services.
  • The financial threats to the survival of many health care systems is the result of the situation mentioned above and there is a trend to focus towards improving health care not only in medical results but in measuring quality of care, transparency, and efficiency. (Voogt).

In the field of rehabilitation, the same pattern can be observed with even some paradigmatic considerations. PRM physicians treat patients who often have complicated conditions such as polytrauma, spinal cord injury, traumatic brain injury or chronic pain. They work with multiprofessional interdisciplinary teams, in which good communication and coordination is essential for success. They also deal with the higher expectations of recovery by patients and their families. With internet access and the ease, with which patients can find information on their condition, it is now quite common for patients to seek multiple opinions on services within the same or different hospitals increasing also the cost of care. But also, many of the above-mentioned diseases with the scientific and technological advances become chronic conditions which increase the demand of constant care and constant demand of treatment, for example the need for physiotherapy or speech therapy.

In this context, the need of good leadership adapted to the current societal changes and way of thinking is mandatory,otherwise there would be a management failure. As stated by the Royal College of Physicians in 2005, leadership skills should be incorporated in the doctor´s training in order to support professionalism and improve productivity (Royal College of Physicians of London 2005.).

Doctors need to learn to have a macroscopic view on health provision and resource allocation (Gonzalo). They need to be able to achieve a common goal, not only from and individual point of view of his or her patient but as the whole society. This implies a need to learn and understand the political, economic, and social environment of the system as well as and ethical based decision making process.

A PRM physician should actively take part in the design of healthcare pathways for the provision of care of people with disabilities and develop clinical guidelines to recommend treatments across the continuum of care, for example the needs in the acute, subacute, and long term phases of the diseases.

Within a rehabilitation service, at the meso-level, the PRM physician should develop management skills to build an effective team. It is already known that team care approach is more effective than fragmented care for patients and the PRM physician should coordinate the care of the patient throughout the different members of the team (physiotherapist, occupation therapists, social workers…etc). Typical leadership qualities (Mc Gregor) should be encouraged to promote a better satisfaction and dynamic of the group. These qualities include good communication skills, the ability to encourage different members of the team to participate and join in, suggest aims and objectives of treatments, avoid personal criticism and reach the final aim through a majority consensus. These team meetings should result in the establishment of a care team individualized plan with specific objectives, with the determination of the clinical interventions, duration of treatment and assignment of duties. The PRM physician should be able to detect and arbitrate over conflicts that can emerge among the different team members and should be able to handle it in a successful way like for example opening a space for debate, trying to avoid personal details or accusations or promote a team building session for conflict resolution (DeLisa chapter 13).

At the micro-level, the challenge for PRM physicians is strictly related to patients’ long-term management, which may include long term care, including home adaptations, long-term and post-rehabilitation care, adapted physical activity, continuous counselling. Rehabilitation patients have needs of general management that goes beyond the simple management inside the PRM facility, and this should be taken care by PRM physicians.

Finally, many patients needing rehabilitation may move through a series of PRM facilities and services usually provided by different teams. In some specific areas, like stroke or spinal cord injury, specific pattern of coordinated care have been developed and proved effective, such as the Stroke Units or the Spinal Centres. Nevertheless, it must be recognised that, beyond spinal cord or stroke, it is highly frequent that a rehabilitation patient moves from the acute hospital to a PRM ward / hospital, then finishing in long term treatment facilities that could be outpatient ambulatory, home-care or long term hospitals. Some of these patients can have new episodes due to the natural history of disease, and start the same circuit again perhaps with a different end. The problem is that usually there are not definite organizational pathways, and the different rehabilitation structures are usually managed as “silos”: each time new arrangements must be taken, always for the same patient with the same problem. Management solutions have been proposed, like PRM loco-regional inter-facilities Departments, to facilitate these pathways, and under development in some EU regions.

In conclusion, PRM physicians should be able to develop good management skills within the reference of the needs of the current state of medicine and health care systems. They should be able to coordinate the multidisciplinary team to bring primary and secondary goals of rehabilitation together, plan interventions, delegate tasks for the different members of the team and communicate in an effective an empathic way to patients and their families. They should be able to manage patients in the long term, as well as in the short term in their individual pathways of care throughout different rehabilitation facilities, possibly through the creation of PRM loco-regional Departments. Within these criteria, the satisfaction with the treatment as well as an efficient and cost saving allocation of health resources should be warranted. 

Communication skills (including information and patient education)

Effective communication with patients and their caregivers, as giving adequate information and providing health education, play a central role in rehabilitation and is a determinant skill for PRM physicians. 

Core aims of communication between patient and rehabilitation team include fostering of relationships, exchange of information, enhancement of the patient and caregivers participation in decision making, enabling of self-management, responding to emotions, and managing of uncertainty (51). The patient knows very well his disability: he chooses his future and for this reason must actively participate in the decision-making process. 

Communication may be therapeutic itself when it leads to better management of emotions, social support, empowerment, and appropriate setting of rehabilitation goals. Several randomized controlled and cross-chapteral studies have shown that patient-centered communication (clear explanations, compassion, enhanced patient participation) have correlated with favourable biological effects (lower blood pressure, less anxiety, less organ damage in patients with systemic lupus erythematosus, higher quality of life among breast cancer patients) (52). 

Good collaboration within the interdisciplinary team helps to avoid redundant and incoherent information. Team collaboration provides the patient with an adequate communication formulated by proper and competent professional. Moreover, a key point is the coherence of messages received, not to create in patients and their families’ confusion.

Comprehensive information delivered by a PRM physician regarding the cause, natural history and prognosis of a health condition, proposed therapy, its mechanisms of action, expected functional outcome and possible side effects helps the patient to form a rational attitude towards the treatment, favours compliance and promotes active participation in therapy. In the context of serious, potentially intractable illness (like cancer) with a poor prognosis related to the disease, individuals usually rely on others to help them think and feel their way through difficult decisions. On the other hand, in front of the poor prognosis of functional recovery (in spinal cord injury), that is much less understood and where hopes (and expectations) of recovery are bigger, the patient and caregivers may be unable to retain information provided when they are not ready (53). Communication style is very important in this context; PRM physicians should be trained on how to give information that may contradict the patient´s initial expectations.

Impaired psychosocial adjustment to disability is more frequent in patients with evidence of a cognitive deficit (54). A patient who, due to a health condition, is disabled, or may get disabled, should be informed how disability can lead to handicap or social withdrawal, how this process could be prevented, and about the rights of persons with disability (55). The relation between a healthcare provider and patient, his/her significant others and her/his caregivers should not be limited to unidirectional information flow, but rather warrant the process of reciprocal information exchange. Knowledge learned from the patient regarding their lived experience of disability is important for proper goal setting in rehabilitation, selection of adequate assistive technologies and appropriate social intervention. In the decision-making process, the perspective of a person with the disability allows integrating a multitude of factors with the aim of opening a constructive discussion about the life plan.

Patient education

An important role of the PRM physician is to respond to the patient’s demand for comprehensive information on the actual evidence of some methods and means of treatment (eg dietary supplements, certain complementary and alternative therapies) that are well advertised, though usually with poor evidence. Much of the information on these methods that users are exposed to is commercial in intent and fraught with misinformation (56). 

Health education as an intervention addressed both to individuals and to society, is recognized by the Council of Europe as a fundamental element in disability prevention (55). Among many definitions of health-related patient education, a Cochrane collaboration group agreed to launch ‘‘teaching or training of patients concerning their own health needs” (57). 

Recent changes in healthcare and rehabilitation practice (reduced hospital length of stay, staff shortage, increasing the popularity of advanced technologies) increase the demand of effective patient education directed on self-management and health promotion. Dimensions of patient education include: 

  • Knowledge, perception and beliefs of one’s health condition, its consequences, treatment, and preventive options. Cognitive dimensions of health knowledge encompass: identity (name of a condition and self-perceived severity), duration (chronic or acute problem), consequences (physical, social, and economic), cause (personal ideas about causes of the condition) and control (patient’s opinion on a capacity to control the illness) (58);
  • Problem-solving abilities: problem orientation (motivation, attitudes, thinking styles) and solving skills (defining the problem, generating alternatives, decision-making and solution implementation) (59); 
  • Health locus of control and perceived self-efficacy (60): 
  • Health behaviours;
  • Coping strategies. 

Also families play an important role in education of the patients. Their inclusion into a group education for in-patients contributes in more realistic discharge planning and increases participation of the caregivers in further care (61). Interventions addressing families of patients with severe disability usually consist of individual counselling, education, and group support. Both education and counselling significantly improve caregiver’s knowledge and stabilize significant others functioning, though counselling is more effective than education alone (62). 

Timing in delivering educational content is important. This also applies to giving information to the patient and caregivers(63). In early rehabilitation, when biomedical themes are prevalent, educational goals should mirror the therapeutic process. Psychological and medico-social aspects targeting health-related behaviours, every-day habits, vocational education, learning social skills should be commenced in post-acute rehabilitation considering the psychological processes of disability acceptance. Immediate effects of education depend on the context of care. It may consist of skills (ability to use a wheelchair, communicate a need, caregiver’s ability for a performance of passive exercises) attitudes and knowledge (motivation to self-performed exercising, conviction that cancer-related pain may be effectively controlled). During the chronic phase, education contents should cover socially important issues as well as prevention of secondary conditions. 

Long-term goals of patient education usually include social integration, independence, improved health risk profile, maintenance of physical and vocational activity, custom of protective health behaviors (eg. regular exercising, adequate diet, foot protection in a diabetic), retention of adequate knowledge of the health condition, realistic expectations regarding outcome, active attitude towards therapy. A list of exemplary educational contents in selected health conditions is displayed in Table 1.

The methodology of patient education should complement the overall rehabilitation process, and be the result of interdisciplinary team collaboration. All team members are responsible for carrying out elements of patient education per their fields of competence. The PRM physician, as team leader, is responsible for coordination of the educative process, including delivering crucial information (regarding diagnosis and prognosis, particularly in a case of permanent functional loss) and assessing factors influencing patient’s abilities to set rehabilitation goals (64). Educative methods should be adapted to the patient’s experience and most common psychological profiles typical for a given health condition (60). The intensity of education, expected immediate effect and range of information provided should be adjusted to treatment phase and patient’s demand (for example, education regarding sexuality in acute rehabilitation of a paraplegic should be limited to simple information that the ability to achieve satisfaction has not been lost, whereas in chronic stage the content and form of education should fully comply with patient’s and partner’s needs) (53). The process of education should consist in the identification of learning barriers, gain of both knowledge and practical skills, evaluation, and positive reinforcement. Application of modern educational methods (biofeedback, teleeducation) and materials (interactive platforms, games) should correspond with methods used in biopsychosocial interventions (53). PRM societies and rehabilitation centers should publish educational evidence-based resources (60,65). Peer participation in patient education is increasingly popular in certain health conditions (spinal cord injury, limb loss). This approach raises the role of PRM physician who should look at quality and substance of learning (66).

Systematic reviews and meta-analyses show that interventions for encouraging patients to understand and manage their chronic conditions, enhancing patient’s compliance, contribution of caregiver’s in the continuation of treatment, although promising and rational, appear to be inconsistently evidenced regarding the functioning, participation, quality of life, service use, reduction of direct and indirect costs of treatment. The effect of education appears to be more evident in complex patients (57,66,67).

Health-related and personal factors hindering the efficacy of communication and patient education comprise speech, language, comprehension, perception and memory deficiencies, poor anger control, depression, history of learning disability, abuse, chronic pain (68). Intractable health conditions cannot always be addressed per patient’s demands: this can decrease trust in healthcare professionals (63). Among environmental factors decreasing the efficacy of patient education the most important are lack of social support (68), and health provider related factors. These include: availability unmatched with the time when the patient and caregivers fully understand their educational needs (53,69); being less cooperative or using controlling behavior; lack of adequate knowledge or noncompliance with guidelines (eg. in assistive devices provision) (69,70); negative attitudes and beliefs concerning a subject of education (eg. sexuality) (53); providing the patient with inadequately good feeling about his health (57); neglecting broader environmental context of care, patient’s knowledge, values, experience and preferences.

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