European PRM Bodies Alliance

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

• European Academy of Rehabilitation Medicine (EARM), 
• European Society of Physical and Rehabilitation Medicine (ESPRM),
• European Union of Medical Specialists PRM Section (UEMS-PRM Section)
• European Union of Medical Specialists PRM Board (UEMS-PRM Board)
• The Editors of the 3rd edition of the White Book of Physical and Rehabilitation Medicine in Europe: Carlotte Kiekens, Pedro Cantista, Maria Gabriella Ceravolo, Nicolas Christodoulou, Alain Delarque, Christoph Gutenbrunner, Sasa Moslavac, Enrique Varela-Donoso, Anthony Ward, Mauro Zampolini, Stefano Negrini
• The contributors: Filipe Antunes, Paolo Boldrini, Christoph Gutenbrunner, Alvydas Juocevicius, Carlotte Kiekens, Francois Boyer, John Burn, Pedro Cantista, Mark Delargy, Enrique Varela Donoso, Calogero Foti, Alessandro Giustini, Jean-Jacques Glaesener, Jacinta McElligott, Angela McNamarra, Anda Nulle, Aydan Oral, Daiana Popa, Christina-Anastasia Rapidi, Rapin, Katharina Stibrant Sunnerhagen, Peter Takač, Jiri Votava, Andreas Winkelmann, Alarcos Cieza, Jan Geertzen, Kurtis Hoppe, Ilse van Nes, Steven Rimbaut, Coleen T Dy Rochelle, Christof Smit, Raquel Valero, Anthony Ward, Alain Yelnik.

Abstract

In the context of the White Book of Physical and Rehabilitation Medicine (PRM) in Europe, this paper deals with a global overview of the role of PRM in healthcare systems in Europe. Several documents and reports by WHO and the UN call for the worldwide strengthening of rehabilitation as a key health strategy of the 21st century. Therefore, further implementation of PRM in healthcare systems is crucial. Many aspects need to be considered when implementing PRM in a health system. Since PRM should be provided along the whole continuum of care, a specific phase model has been developed. Those phases depend on patients’ functional needs as well as on temporal aspects of a health condition: it can be congenital or acquired, and  the disorder can have an acute onset or a progressive or degenerative course. The following phases are described in the paper: Habilitation, Prehabilitation, PRM in acute settings, in post-acute and in long-term settings. Regular triage and reassessment to assign the patient to the appropriate level and setting of rehabilitation care is mandatory. Therefore rehabilitation services should be stratified and organised in networks, in order to allow for the best possible care adapted to the individual’s needs and goals, over the continuum of care. Providing correct PRM services requires good planning of service delivery, capacity building and resource allocation. The needed resources are human (with complex multi-professional teams), technical (therapeutic equipment, rehabilitation technology and assistive devices), and financial. Decisions on the allocation of the usually limited resources require a reasoned process and clear and fair criteria. Principles of clinical governance must be respected and appropriate competencies are required. Disease prevention (primary, secondary and tertiary), health maintenance and support in chronic conditions as well as global health promotion are gaining growing importance in PRM. They include encouraging physical activity and promoting healthy behaviour aiming at the maintenance of maximum function and avoiding complications in disabling or progressive conditions. This is discussed in the paper together with some ethical reflections on the choices PRM physicians continuously have to make during service delivery. 

Keywords

Physical and rehabilitation medicine, Europe, Delivery of Health Care, Health Plan Implementation

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.

A healthcare system is the organisation of people, institutions, and resources that deliver health care services to meet the health needs of target populations. According to WHO its primary intent is to promote, restore or maintain health.

The place of PRM relates to different aspects and phases of healthcare for people with many different health conditions. This chapter gives a global overview of the role of PRM in healthcare systems in Europe, more specifically with regard to: implementation of PRM in a healthcare system, capacity building and resource allocation, clinical governance and competencies, the different phases of the PRM process and finally disease prevention, health maintenance and health promotion in PRM.

Implementation of PRM in Healthcare Systems

According to WHO, Rehabilitation is part of universal health coverage and should be incorporated into the package of essential services along with prevention, promotion, treatment and palliation (1). Physical and Rehabilitation Medicine has to take an important role in health systems, in particular, in rehabilitation but also in prevention, treatment and support (2). The World Report on Disability describes the central role of the specialty as “improving functioning through the diagnosis and treatment of health conditions, reducing impairments, and preventing or treating complications” (3). Consequently, the Global Disability action plan defines the “number of graduates from educational institutions per 10 000 population – by level and field of education (for example, physical and rehabilitation medicine, physical therapy, occupational therapy, and prosthetics and orthotics)” as one of the success indicators for the implementation of rehabilitation services. As rehabilitation interventions are applied by numerous medical specialties and health professionals the role of PRM in health and rehabilitations systems must be considered carefully^[1].  

Like rehabilitation in general, PRM has to take a role at all levels of the healthcare system and along the continuum of care (see table 1). These rehabilitation services are categorised as following (the subgroups of services not taken into consideration), more details are described below in the paragraph  on the different phases of the PRM process: 

1.  Acute rehabilitation services are delivered in hospitals at the secondary and tertiary levels. Acute rehabilitation services should start even during intensive care and should be performed in multi-professional teams (including PRM physician, PT, OT, and other rehabilitation professionals). Acute rehabilitation services may be delivered in specialized acute rehabilitation wards or by mobile acute rehabilitation teams.
2. Post-acute rehabilitation services: Post-acute rehabilitation services are being delivered immediately or shortly after discharge from acute care units. For more severe cases (substantial nursing and medical needs, important limitations in mobility and activities of daily living) post-acute rehabilitation should be done in in-patient post-acute rehabilitation units. Patients with less restrictions also can be referred to out-patient post-acute rehabilitation services. For patients with minor deficits simple interventions may be sufficient, even at the primary healthcare level. Post-acute rehabilitation services at secondary/tertiary level should be specialized for the specific health condition (disease or trauma) and also must have a multi-professional rehabilitation team. 
3. Long-term rehabilitation services: Long-term rehabilitation services aim to maintain (and improve) functioning for persons with long-term disability including congenital disability, acquired disability and chronic disease. They can be an entrance point for more specialized rehabilitation if needed. Long-term rehabilitation can be performed by rehabilitation professionals (e.g. PRM physicians, PT’s, OT’s). In some cases, primary health care professionals (e.g. primary health care rehabilitation workers such as PTs, OTs or speech therapists, general practitioners) may take a role in long-term rehabilitation. Long-term rehabilitation can be delivered in primary care rehabilitation centres and as mono-professional long-term rehabilitation services. There is growing evidence for the benefit of exercise and adapted physical activity in this phase (see below under the paragraph “Prevention, health maintenance and health promotion in PRM”). If no specialized rehabilitation exists, Community Based Rehabilitation (CBR) is a model to provide some rehabilitation services to persons in need. It should be closely connected to an inclusive Community Development Policy (CBP). Intermittent in-patient rehabilitation services can be used to induce and booster rehabilitation effects in patients with chronic health conditions, also if they are related to psychosocial stress and vocational problems. 

To fulfil their tasks in the different phases of the rehabilitation trajectory PRM physicians may work in many settingssuch as acute, general or university hospitals, rehabilitation centres (in-patient and/or out-patient) as well as in private practices, community health centres and others. Models of PRM delivery may vary in organisational details within different countries but the essential elements have to be availability, accessibility, acceptability and scientifically and clinically appropriate quality. In principle all kinds of care provision should be open for PRM physicians too. Last but not least it should be mentioned that the expertise of PRM can be of importance for advice in decision making for policy makers, insurance institutes and companies, city planners and many other professions and institutions in the field of health and disability as well as designing the environment.   

When it comes to the actual implementation of PRM in a health system, the UN Convention on The Rights of Persons with Disabilities calls on state parties to organise, strengthen and extend comprehensive habilitation and rehabilitation services and programmes, particularly in the areas of health, employment, education and social services (Art. 26). (4)

Strengthening health-related rehabilitation services is one of the aims of the WHO’s Global Disability Action Plan (5). For this purpose, and as part of the WHO-ISPRM Collaboration Plan 2014-2017, Gutenbrunner et al. proposes the following activities (6):

• to develop a matrix and checklists to analyse existing rehabilitation services as well as to identify gaps in service provision;
• to establish a Rehabilitation Services Advisory Team (RAT) of experts with global and regional health systems understanding who can provide guidance;
• to provide advice to the requesting country by Rapid Response Projects providing support to build up rehabilitation services and educational programs for the rehabilitation workforce, as requested by the WHO.

An essential issue when strengthening health systems to respond to patients’ health and rehabilitative needs is information on functioning. Health systems should address what matters to people about their health, their ‘lived health’ and not only the ‘biological health’.  So functioning is the third health indicator, beyond morbidity and mortality. The ICF is the best prospect for the documentation and collection of functioning information (7). Health systems can profit from using functioning information to improve interprofessional collaboration and achieve cross-cutting disease treatment outcomes (8). 

An example of this way of collecting data is the ‘International Spinal Cord injury Survey  (InSCI)’, which is at the core of the ‘Learning Health System for Spinal Cord Injury Initiative (9).

In February 2017 WHO launched “REHABILITATION 2030: a call for action”. This is an important initiative with the objective to scale up rehabilitation services in countries around the world in light of current global trends in health (rising prevalence of noncommunicable diseases and injuries) and ageing. The extent of disability worldwide has been studied in the ‘Global Burden of Disease Study 2013’ (10). 

To ensure that rehabilitation is available and affordable for those who need it, WHO made seven recommendations on rehabilitation in health systems:

1. Rehabilitation services should be integrated into health systems
2. Rehabilitation services should be integrated into and between primary, secondary and tertiary levels of health system
3. A multi-disciplinary rehabilitation workforce should be available
4. Both community and hospital rehabilitation services should be available
5. Hospitals should include specialized rehabilitation units for inpatients with complex needs
6. Financial resources should be allocated to rehabilitation services to implement and sustain the recommendations on service delivery
7. Where health insurance exists or is to become available, it should cover rehabilitation services

Within the Disability and Rehabilitation department of WHO, Guidelines on health-related rehabilitation are under development, which will provide recommendations to assist Member States and relevant stakeholders to make informed decisions when building or strengthening rehabilitation systems (11). The research questions and subsequent recommendations of the guidelines are based on the six building blocks of the health system: leadership and governance, service delivery, workforce, information systems, access to essential medicines/assistive technologies, and financing. The Guidelines on health-related rehabilitation therefore will provide recommendations about systems-level implementation of rehabilitation as a health strategy, rather than specific rehabilitation interventions.

Service delivery is one these six building blocks of health systems. So for the area of health-related rehabilitation, a conceptual description of rehabilitation services has been proposed (12). In order to close gaps in national and/or regional rehabilitation systems and to further develop appropriate rehabilitation services, it is crucial to define uniform criteria and a widely accepted language to describe and classify rehabilitation services. A working group of the ISPRM-WHO-Liaison Committee is developing a list of dimensions and categories to describe the organisation of health-related rehabilitation services within for an “International Classification System for Service Organisation in Health-related Rehabilitation“(ICSO-R) (13).  In a European initiative for the implementation of ICF and ICSO-R in a rehabilitation quality management system, a workshop of experts of the UEMS PRM Section and Board was held in Nottwil, Switzerland, in January 2016. During this workshop feasibility and applicability of ICSO-R to describe health-related rehabilitation was clearly demonstrated (14). The use of ICSO-R leads to more precise and comparable description of rehabilitation services as compared to a narrative approach. Thus it is recommended to use the ICSO-R to describe and compare existing rehabilitation services as well as model services for benchmarking, implementation of rehabilitation services into health systems, and within a clinical quality management schedule.

In most European countries PRM -as a medical specialty- and rehabilitation services are quite well developed over the continuum of care for patients with rehabilitation needs and goals. However some gaps remain. As such, the specialty is currently absent in one European Union (EU) country (Denmark) as well as in some European countries that are not EU members. 

In Russia, and now also in Ukraine a taskforce of the UEMS PRM Section is supporting the development of the PRM specialty. In Russia an implementation pilot project has recently been set up: “Development of the System of Medical Rehabilitation in the Russian Federation (DOME)”. The main goal is to demonstrate the effectiveness of the “new” model of the medical rehabilitation system compared to the traditional model in three categories of patients (with acute cerebrovascular event, acute coronary syndrome and after hip arthroplasty).

Up to now, there has been very little literature available on the implementation of rehabilitation projects in high and middle income countries. In 2013, an Australian Agency for Clinical Innovation published a very detailed “Rehabilitation Implementation Toolkit” that can be consulted as a reference model describing six care settings in which rehabilitation services are delivered. (15). They state that it is fundamental to the effective and efficient delivery of Rehabilitation Services,  that the patient receives ‘the right care in the right place at the right time’ with overarching key components of the patient journey common to all care settings. As a patient enters rehabilitation and transitions between care settings there is a repeating pattern of the following stages: referral/admission, assessment/service delivery and discharge/transfer of care.

Some other important building blocks for implementation of PRM in a health system will be discussed in the next chapters (workforce, financing and clinical governance including accreditation).

Lastly, the implementation of PRM in health care systems needs to be context-specific, based on evidence informed decision making including best practices and in close collaboration with all stakeholders, including the patients or other consumers.

Capacity Building and Resource Allocation in PRM

Capacity building can be defined as interventions which have changed an organization’s or community’s ability to address health issues by creating new structures, approaches and/or values. (16)

It is any specific action or series of actions that improves the effectiveness of individuals, organizations, or systems—including organizational and financial stability, program service delivery, and program quality—to create positive change and perform better to improve public health results (17)

In some European settings, medical and rehabilitation services for people with disabilities are still less than optimal. Articles 20, 25 and 26 of the Convention on The Rights of Persons with Disabilities (4) require Member States to develop initial and continuing training for professionals and staff to improve access to disability-inclusive health care, assistive devices and technologies and rehabilitation services. The objectives of the WHO global disability action plan 2014-2021 also call for Member States to strengthen and improve access to rehabilitation services, assistive technology and community-based rehabilitation (CBR). Building these capacities is of growing importance in light of the rising trends of noncommunicable diseases, ageing populations and the increasing number of people living with the consequences of injuries. (18). To build and plan the appropriate PRM capacity in the different European countries different types of resources are needed, such as human resources and technical resources.

Concerning the human resources there are first of all the PRM physicians, they need to be trained properly (see chapter 9). The number of PRM physicians in a country needs to be sufficient to cover the rehabilitation needs of the population but should not exceed this number in order to avoid overconsumption of rehabilitation care. Policy makers need to make evidence informed decisions based on correct data and prognoses. This obviously also applies to the other rehabilitation health professionals composing the rehabilitation teams (see chapter 3 and 7). Not all professions are yet well represented in all countries and this issue should be tackled on a European level by the European bodies. PRM physicians have an important role in the training curricula of rehabilitation health professionals such as for example physiotherapists or occupational therapists.

Technical resources comprise facilities, equipment and rehabilitation technologies, dependent on the type of health condition and specific rehabilitation goals of the patients.

The way financial resources are provided to rehabilitation services are different across the European countries (see chapter 2). In most of the European countries, PRM interventions are covered by the public insurance package, especially for acute specialist rehabilitation, often completed with an out of pocket supplement for the patient, usually largest in more chronic and long-term care.  So resource allocation towards PRM activities is mostly being decided by health policy makers. Adequate data collection as well as research on the effectiveness of rehabilitation interventions is crucial to help politicians and administrators make equitable and evidence informed budgetary decisions. Research that is likely to enhance clinical practice presupposes the existence of a critical mass of investigators working as teams in supportive environments. Unfortunately, far too little research capacity of that kind exists in rehabilitation medicine to ensure a robust future for the field. So also in the field of rehabilitation science capacity building is an important issue (19).

Deciding on the macro-level how to allocate resources for rehabilitation versus other health care foci – mainly treatment and (primary) prevention – and how to allocate resources among the various areas of rehabilitation – amputation rehabilitation, stroke rehabilitation, cardiac rehabilitation, spinal injury rehabilitation, and more – requires a reasoned process. There is more than one way of determining what is fair, e.g. according to severity of a health problem (whereupon the more severely health-challenged a population is, the more deserving it is) versus according to prospects of (healthcare) success. Different values underlie such different ways of determining fairness, e.g. need underlies severity, implying a welfare theory of justice, whereas outcome underlies success, implying a utilitarian theory of justice (recognizing that these approaches are not mutually exclusive or exhaustive). The solution to this and other such problems of resource allocation in relation to rehabilitation may require policy making that is highly informed by formal public debate, grounding ethics in the political realm in a broad sense (20).

At the meso- and micro-level selection of patients who are to be admitted to a rehabilitation service should be made by the PRM physician. Because in many centres demand for admission exceeds the number of available beds, difficult decisions have to be made daily. PRM physicians often are forced to play the role of gatekeeper to the rehabilitation centre. If patients’ needs exceed available resources, then resource allocation decisions must be made. The PRM physician must attempt to strike a balance between beneficence and justice. (21)

Clinical Governance and Competencies in PRM

Physical and Rehabilitation Medicine is a medical specialty that focuses on the successful management, from an individual’s perspective, of change and loss.  PRM is most distinctive when it teaches and disseminates a way of thinking that equips patients and clinicians to manage disabling situations rather than focusing on the treatment of the underlying condition (22). PRM specialists are most effective and necessary in the management of more complex and disabling conditions, in such a context the PRM specialist will fulfil several roles including a public health role that addresses marginalisation and disempowerment from environmental or social structures and establishes rehabilitation as a key part of all medical interventions. Disabled people are at particular risk from poor quality healthcare (23).

Clinical Governance

Clinical governance is a transparent and accountable process that scrutinizes both individual and service performance in order to prevent or remedy problems before patients suffer injury or staff are disciplined.  It should enhance the quality of person centred care and demonstrate to both commissioners, managers and patients that the service meets acceptable standards (24). It depends upon:

• The implementation of national and international standards and guidelines.
• The design, undertaking and dissemination of audits conducted against such standards, the implementation of recommendations and subsequent re-audit (The Audit Cycle).
• Institutional visits to ensure that the needs of vulnerable people attending rehabilitation services are being met (Table 2).
• The collection of nationally agreed performance data for rehabilitation services within such institutions (Table 2).  Larger services may seek individual accreditation by international bodies such as the Clinical Affairs Committee of the UEMS PRM Section or CARF.
• Regular supported appraisal of the performance and development needs of PRM physicians (Table 3).
• Peer review.  The performance of a PRM specialist cannot be separated from the performance of a rehabilitation team.  A multidisciplinary visit that includes a PRM physician, a nurse, a manager and therapists can assess how both a whole team or service are functioning and the PRM physicians within it.
• Patient and family feedback.  PRM should be a highly person centred discipline with due weight given to capturing the lived experience of both patients and families.

PRM specialists work in relative medical isolation in some countries and have to address a broad range of complex medical conditions.  Governance arrangements should ensure that senior clinicians are in regular professional contact with other PRM specialists and integrated with, and supported by, colleagues in other specialties  (25) so that they do not need to practice beyond the limits of their expertise.

In order to achieve this it is recommended that each service identifies a lead clinician who has particular responsibility for governance.  This clinician would:

1. Identify relevant guidelines and standards.
2. Organise and lead regular local and regional governance meetings and promote contact with linked specialties.
3. Describe governance activity to relevant bodies and report adverse incidents and complaints together with a proposed plan to address perceived difficulties.
4. Promote quality improvement throughout the service.  This is only feasible if there is a common management structure and budget.  Services should avoid team members being employed by different agencies and having multiple line managers.

PRM depends upon the application of multiple skills in a customised and co-ordinated way to address complex and individual problems.  As such, it depends for its success on good communication and relationships within the rehabilitation team and on the confident trust by the patient in the expertise of those given responsibility for their treatment.

The competencies and clinical governance structures described in this chapter should go some way to ensuring that this trust is not misplaced. 

Different Phases of the PRM Process

The phase model of the PRM process comprises phases over the continuum of care. These different phases of the PRM process depend on the temporal aspects of a health condition: congenital or acquired, and if acquired whether it is acute or rather progressive or degenerative.

During growth, the term ‘habilitation’ is used. Habilitation refers to a process aimed at helping disabled people attain, keep or improve skills and functioning for daily living (Rehabilitation International: http://www.riglobal.org/projects/habilitation-rehabilitation/). This term comes from the high adaptability and connection of all body functions during growth, and includes: the best possible residual development of the impaired function, the acquisition of new (compensatory) skills, and avoiding interference with the normal development of functions not directly affected. Habilitation in children with a (congenital or early acquired) impairment or disability consists of a continuous process, with more intensive phases according to the developmental milestones. These services are often provided within Child Development Services.

When a health condition is acutely acquired the phases of PRM are traditionally divided in an acute, a post-acute and a long-term phase. More recently also “prehabilitation” has been developed as a PRM strategy.  It consists of an educational programme and pre-operative physical and/or psychological conditioning enhancing functional and mental capacity aimed at improving postoperative functional outcomes. Literature, mostly in the field of orthopaedic or oncologic surgery, provides early evidence that prehabilitation may reduce length of stay and possibly provide postoperative physical benefits. (26).

PRM in acute settings 

Acute or early PRM consists of a programme of specialist medical rehabilitation during an acute hospital admission following injury or illness or in response to complex medical treatment or its complications. It can also apply to an acute event in a person with an established disability (for example a sudden Multiple Sclerosis relapse, but also a hip fracture in a stroke patient, or a severe infection in a spina bifida patient). The rehabilitation activities are under the clinical responsibility of a PRM physician, including the contribution of the multiprofessional rehabilitation team as well as other relevant medical and surgical specialties, starting as from the intensive care episode. This has extensively been described by Ward, and the clinical activities have been detailed by Stam (25,27). Acute rehabilitation aims to prevent complications of immobilisation (e.g. sarcopenia, orthostatic dysfunction, contractures, thrombosis) and improve functions and activities (e.g. mobility, coordination, activities of daily living). The emphasis of rehabilitation therapy also includes pain management, informing and educating patients and their families, educating acute care staff, prognostication and establishing a rehabilitation plan in order to provide a triage for further rehabilitation programmes. So the role of PRM in acute rehabilitation is to assess and monitor the health status of the patients (e.g. respiration, circulation functions, motor functions) applying pharmaceutical and physical treatments and coordinating the multi-professional rehabilitation team (25). This requires a high level of training in acute medicine and intensive care and must be done in close collaboration with other medical specialists. Team work with regular consultations and team meetings is crucial for a successful acute rehabilitation care (25,28).  In many European countries such as Germany the leadership of acute rehabilitation teams by a PRM are mandatory due to health care regulations (29). 

Acute rehabilitation can be delivered in several ways which can also be combined, depending on the size and context of the hospital:

• Transfer of patients to PRM beds or to a PRM unit in the acute hospital (acute rehabilitation unit or ARU).
• Establishment of a mobile visiting PRM team under the responsibility of a specialist in PRM, while the patient remains in the referring specialist’s bed (acute rehabilitation team or ART). PRM diagnostic procedures and treatment can be performed in the PRM department or at the ward, depending of the general and medical condition of the patient.
• Daily visits to the acute wards by specialists from a standalone PRM facility.
• Establishment of acute facilities in PRM centres or rehabilitation hospitals able to treat patients with persisting acute medical treatment, to accept patients very early to start their PRM programme.

Acute and early acute setting PRM programmes accelerate the rate of recovery of independence and result in an earlier discharge. Furthermore they reduce complications and pain, optimize functioning, identify cognitive and emotional problems of TBI in the absence of physical impairments, and improve chances of living independently and returning to work.

There is an increasing trend for ‘early acute rehabilitation’. Recent studies evaluating the early introduction of physical rehabilitation in the intensive care unit (ICU) have demonstrated improvements in physical function and quality of life, and in post-hospital readmissions, institutionalization, and mortality, as well as reductions in mechanical ventilation duration and ICU and hospital length of stay (LOS) (30). Cost savings or neutral cost may be attained with Early Physical Rehabilitation  programmes in intensive care units (ICU). The reader is referred to Bailey et al (31) for a selection strategy on good candidates for early physical rehabilitation to combat ICU-acquired comorbidities. In academic tertiary centres, acute PRM beds or units are sometimes installed close to or alongside ICU (32,33).

PRM in post-acute settings 

Patients with (potential) residual disability after an acute illness or injury and/or remaining rehabilitation needs and goals will be referred for further PRM interventions after the acute phase to a post-acute PRM service. This can be an inpatient rehabilitation facility or an ambulatory facility in PRM departments (34). Patients enter a programme of goal-oriented multiprofessional rehabilitation under the responsibility of a PRM physician. PRM services should be planned and delivered through co-ordinated networks (“hub and spokes”), in order to cover the whole continuum of care, based on the triage process. The patient should be assigned to the appropriate level of rehabilitation care, based on the results of the triage assessment using a patient classification system (figure 1). These levels depend on the complexity of the rehabilitation needs and goals as well as on the incidence/prevalence of the health condition: general or primary, specialised or secondary and highly specialised or tertiary level, (Kiekens KCE study, national rehab plan Italy). After triage, a rehabilitation programme will be defined, based on the assessment, and then interventions are being delivered. On a regular basis evaluation needs to be performed in order to define new targets, to be achieved either in the same service, or at another level of care if appropriate. This reiterating process is also called rehab-cycle (see chapter 7). Patients can be admitted to a post-acute care setting when:1) medically sufficiently stable and fit to actively participate in a PRM programme, 2) they can benefit from a multi-professional approach, 3) defined goals, motivation and enough learning potential are present. The PRM physician will refine the diagnosis, communicate the prognosis to patient, family and caregivers, and lead the team and service in all aspects. Post-acute settings will treat mostly patients with sudden onset conditions. However also patients with intermittent, progressive or stable conditions can benefit in phases of changing needs. 

In post-acute rehabilitation services, PRM will take care of the comprehensive rehabilitation process (34). This includes continuing the treatment of the underlying health condition and/or consequences of surgery or other invasive therapies, as well as training of body functions and activities. In the post-acute phase, to plan and prepare for reintegration into society moves into the foreground more and more. This includes independent living, employment, education and other participation areas. This also means working with families, social services and employers as well as education and training of the patient.

PRM in long-term settings

After a period of post-acute care, whether inpatient or outpatient based, some patients may need long-term care.  Long-term rehabilitation is assistance given over a long-term period of time to people who are experiencing long-term disabilities or difficulties in functioning. Long-term care may also be associated to chronic disease (35).  Long-term rehabilitation services can be provided in the form of intermittent inpatient care, or continuous outpatient/community/home based rehabilitation. 

In long-term care, PRM can provide many important rehabilitation services. The spectrum reaches from the continuous monitoring of functioning and disability, long-term medication, prescription of physical therapies provision or assistive devices. PRM physicians are also trained to give advice to patients and families as well as to employers and other society institutions. PRM should participate in CBR Programs, e.g. as advisor and/or trainer of community rehabilitation workers. PRM can support General Practitioners and other medical specialists by giving advice and/or coordination of rehabilitation networks. This is of particular importance in rare diseases or disabilities respectively.

In the long-term phase of PRM care special emphasis lays on maintenance and secondary prevention activities but this will be further explained in the next chapters.

Following case history gives an example of a patient throughout the different phases of the PRM process.

Box 1: case history of a patient with limb loss.

A 55 year old man suffers from chronic osteomyelitis and open wounds at the left calcaneus since a motor vehicle accident five years earlier. Multiple surgical and medical interventions have been performed but no healing occurred and his quality of life is severely impaired. He stopped working as a technician since 3 years.  He is referred to the PRM physician for counselling with regard to an eventual amputation. After multidisciplinary assessment a transtibial amputation is being advised and the patient is included in a prehabilitation programme comprising reconditioning, reinforcement of the right lower and both upper extremities, walking with crutches and an educational programme. Two months later the amputation is being performed, followed by immediate post-operative rehabilitation without prosthesis (“acute rehabilitation”). After discharge there is post-acute follow-up and two months later a 4 weeks inpatient rehabilitation programme is provided after fitting of a prosthesis (“post-acute rehabilitation”). Two months later the patient can drive his car after assessment and return to work. On a long-term base a yearly follow-up is being organised for calibration and renewal of the prosthesis (“long-term phase”).

Conclusion 

Depending on the type of health condition and functioning needs the PRM process will comprise different phases. Regular reassessment and triage with assignment of the patient to the appropriate level and setting of rehabilitation care is mandatory.  Therefore rehabilitation services should be stratified and organised in networks in order to allow for the best possible care adapted to the individual’s needs and goals, over the continuum of care.

Prevention, Health Maintenance and Health Promotion in PRM

In literature the terms prevention, health maintenance and health promotion are often used interchangeably and related activities overlap (e.g. physical activity or healthy nutrition) substantially. Therefore they are dealt with in one section. There is no clear consensus on the respective definitions. After a general introduction in order to distinct the different terms, the different topics will be dealt with from a PRM perspective.

Health can be seen as a continuum with neutral health in the middle, negative health (illness) at the left and positive health (wellness) at the right and relate respectively to each of the three concepts (36). 

Disease prevention involves actions to reduce or eliminate exposure to risks that might increase the chances that an individual or group will incur disease, disability, or premature death. Primary prevention refers to actions to avoid or remove the cause of a health problem in an individual or a population before it arises (3). Secondary prevention involves actions to detect a health problem at an early stage in an individual or a population, facilitating cure, or reducing or preventing spread, or reducing or preventing its long-term effects (3). Tertiary prevention aims to reduce the impact of an already established disease by restoring function and reducing disease-related complications (3). 

Health maintenance relates to maintaining the level of a stable health situation and maximum function for example by means of screenings, respecting a healthy lifestyle and taking care of a psychosocial and spiritual issues (37).

When health stability is present, improvement of health and wellbeing can be achieved through health promotion: the development of behaviours that improve bodily functioning and enhance an individual’s ability to adapt to a changing environment. Health promotion is defined by WHO as the process of enabling people to increase control over their health and its determinants, and thereby improve their health (38). So, health promotion helps individuals move upwards the health continuum.

Prevention, health maintenance and health promotion related to PRM

The work of PRM physicians focuses among other issues on strategies to enable people with chronic disease and long-term or pre-existing disabilities to achieve as high a level of health and quality of life as possible through health promotion efforts and preventive and maintenance strategies. Health promotion efforts targeted at people with disabilities can have a substantial impact on improving lifestyle behaviours, increasing the quality of life, and reducing medical costs (39).

Maintaining or improving health can be more challenging for people with disabilities because they are at increased risk for several physical, psychological, social, and emotional problems that are referred to in the published literature as secondary conditions. These conditions appear to have a profound negative impact on the health and function of people with disabilities and, in the aggregate, have the potential to severely restrict participation in general activities (40).

The prevention or management of secondary conditions, the risk factors and mediating variables associated with them, or both is an important priority. (3). Several   cross-sectional   studies reported an average of 4 to 13 secondary conditions in people with physical and cognitive disabilities (41–43). Although many of these conditions (e.g., pain, fatigue, weight gain, depression) also occur in people without disabilities, what makes them unique in people with disabilities is that they occur at a much higher frequency in both children and adults with disabilities. This higher frequency is one of the criteria that is used in considering a condition to be a secondary condition (44). 

A decision-making algorithm for management of  secondary conditions begins with the identification and management of risk factors (i.e., the primary condition that predisposes an individual to the secondary condition) and continues with subsequent management (e.g., through interventions) of the secondary condition.(44) It embraces the onset and course of secondary conditions (nonmodifiable  antecedents  and  modifiable risk factors), and identifies the outcomes associated with secondary conditions at the individual and societal levels.

Nonmodifiable antecedents are sociodemographic factors, pre-existing conditions, disability-related factors, and associated conditions.

Modifiable risk factors are separated into personal and environmental risk factors. Personal risk factors include behaviours such as overuse or disuse, reduced or no physical activity, poor diet, poor use of medications, poor participation in rehabilitation, and increased use of substances (e.g., tobacco, alcohol, prescribed medications, and illicit drugs). Environmental risk factors include reduced or poor-quality health care, decreased access to the built environment, poor health promotion access (e.g., a lack of transportation to community health promotion programs), and limited or no social support.

Additionally addressing social and environmental barriers that hinder adults with disability from adopting more healthy lifestyles and improving health is needed (45).

Disease prevention in PRM

As mentioned above, disease prevention is classified as primary, secondary or tertiary.

Medical rehabilitation is traditionally considered a tertiary prevention strategy (46), but PRM specialists may be involved in disease or injury prevention at all levels. 

The PRM physician plays a role within primary prevention, through various stimulus in the field of PRM (e.g. physical therapy or exercise) that can significantly improve the regulatory mechanisms of almost all organ systems. Benefit can be achieved by delaying or preventing the incidence of number of chronic diseases, for example cardiovascular, such as hypertension or atherosclerosis, metabolic e. g.  metabolic syndrome, or musculoskeletal e.g. osteoporosis. Physical activity is associated with lower risks of many cancer types (47).

As proposed in the ‚Exercise is Medicine‘ initiative in the US, physical activity and exercise should be standard parts of disease prevention and medical treatment, urging healthcare providers to assess and review patients’ physical activity programs at every visit. Also in the Lancet a call for scaling up physical activity interventions worldwide has been published recently promoting  stepping up to larger and smarter approaches to get people moving (48). In addition to morbidity and premature mortality, physical inactivity is responsible for a substantial economic burden (49).

PRM also has an important role in prevention of low-back and cervical pain, circulatory and metabolic diseases and in the prevention of job-related complaints. There is a wide range of preventive measures applied by PRM such as aerobic exercise programs, muscle and balance training, back school, job prevention programs and education and advice for healthy behaviour (50). In the elderly, PRM program also can prevent falls and independence of patients (51).  Concerning road traffic accidents PRM physician can for example support the promotion of wearing a helmet when biking.

In people with disabilities, primary prevention comprises efforts toward preventing a worsening of impairments and should include appropriately tailored measures to eliminate risk factors for chronic conditions (46).

Secondary prevention through physical therapeutic modalities is an example in case of regulatory disorders of blood pressure, back pain or osteoporosis.  In hypertension functional adaptation can lead to improvement of regulatory mechanisms that can prevent or at least delay the onset of clinically manifest hypertension. The first line of treatment for hypertension are lifestyle changes, including physical exercise. In secondary prevention of back pain a muscle strengthening and improving of movement patterns can play a significant role. In osteoporosis, it is important to prevent bone degradation by a loading dose of physical activity (52). Cardiac Rehabilitation/Secondary Prevention programs are considered standard of care and provide critically important resources for optimizing the care of cardiac patients (53).There is strong evidence for rehabilitation interventions favouring intensive high repetitive task-oriented and task-specific training in all phases post stroke (54). Interventions in medical rehabilitation focused on the enhancement of activity, such as provision of assistive tech­nology, can be considered as secondary prevention (46).

For people with disabilities, tertiary prevention is designed to limit the restriction of a person’s partici­pation in some area by the provision of a facilitator or the removal of a barrier. Environmental modifications, provision of services, removal of physical barriers, changes in social attitudes, and reform in legislation and policy are tertiary prevention strategies (46).

Tertiary prevention involves treatment once a disease becomes symptomatic to avoid complications (e.g., deep venous thrombosis prophylaxis and appropriate mobilisation to prevent skin breakdown in post stroke patients). Tertiary prevention incorporates ongoing interval efforts to maximize and maintain functional capacity over the life course. Thus, longer-term contact with the person with disabilities is important in order to provide rehabilitation until natural recovery is complete and to prevent the later development of avoidable complications.

Many survivors of a critical illness experience significant physical, psychological and cognitive deficits, especially in case of long “bed-rest” regimen. Emerging research supports the inclusion of physical activity and movement programmes into the care routines of Intensive Care Patients as tertiary prevention (55).

Health management in PRM

Maintenance and support are also part of the field of competence of PRM. This has a great importance in elderly patients, but also in chronic conditions such as chronic pain, spinal cord injury, limb loss, brain damage and many others. Maintenance interventions are necessary to prevent the loss of the achieved functional level after a more intensive rehabilitation phase.

Maintenance interventions in PRM aim at the maintenance of maximum function and the avoidance of predictable and preventable complications in stable, chronic disabling and progressive deteriorating conditions. Therefore, when PRM physicians address the longitudinal health care needs of those with chronic disabilities, they must view disability-related health management and general health– promoting strategies as equally important components of care. In order to do this, they must enhance their frames of reference and incorporate the concepts of health promotion and secondary condition risk reduction (56).

Medical rehabilitation has several features that overlap with both primary care and health promotion: all emphasise education and encouragement of self-management and -responsibility, address the potential or actual impact of a given physical or cognitive/emotional condition across several dimensions of health. Finally, all address both health maintenance and disease prevention so as to enhance and protect functional capacity over the life span (56).

As physicians concerned with function, PRM physicians understand the dangers of activity reduction in all settings from all causes; both medical and environmental. In fact, often PRM physicians are the only physicians who have familiarity with the maintenance of function via physical activity in collaboration with physiotherapists, motor scientists, occupational therapists, nurses, and family members. The knowledge of how to modify physical and social environments to maximise functional movement and overall function for their patients allows PRM physicians to improve and maintain function in their patients. The focus on activities of daily living (ADLs) is an effort to return functional movements to an individual who is disabled allowing him to maintain his baseline degree of physical activity required for autonomy and independent movement (46). Maintenance activities include programmes established by a PRM physician that consist of activities and/or mechanisms that will assist a beneficiary in maximising or maintaining the progress he or she has made during therapy or to prevent or slow further deterioration due to a disease or illness, on the long-term.

Maintenance, as well as disease prevention and health promotion, must be individually tailored to the person’s health status, functional level and personal life project.

There is extensive evidence that physical activity reduces the risk of non-communicable diseases and promotes health (57). 

The term “adapted physical activity” refers to physical activities adapted to the specific needs of each individual with a disability (58). Adapted physical activity-based rehabilitation is based on the adaptation of different activities to fit each individual’s needs in the rehabilitation setting.

Physical disability and dysfunction through physical inactivity and deconditioning leads to additional/perpetuated physical disability and dysfunction (59). Health promotion and related educational efforts for those with disabilities would therefore be incomplete without the provision of a physical fitness component (56). Such measures also encompass participation issues, such as return to and maintain at work or avoidance of early retirement caused by health problems. Methods used include therapeutic exercise, adapted physical activity and sports, lifestyle changes including dietary and psychological interventions and health education. Individuals with chronic disabilities who participated in an adapted physical activity-based intervention showed statistically significant increases in both physical and mental functioning across the 12 months after the intervention (60).

Regular exercise, physical activity, and maintenance a high level of cardio respiratory fitness are considered necessary elements in cardiovascular disease prevention and treatment and play an important role in reducing the risk of suffering from coronary heart disease in primary and secondary prevention (61). 

All over the world, a lack of physical activity causes 6% of the disease load of coronary heart disease (62). After a cardiac rehabilitation programme, sedentary lifestyle has a negative impact on the major risk factors (63). Exercise capacity is the strongest predictor of mortality compared with the other risk factors (64). Exercise maintenance is one of the factors which improve the quality of life and physical activity level (65). Although the maintenance phase (phase 2) of a cardiopulmonary rehabilitation is the most important part of the program, it often receives the least attention. The benefits of a phase 2 program can be lost in as little time as a few weeks if a patient ceases to exercise. Because of this, patient education of the importance of making exercise a part of their new health habits has to be emphasized and the patient needs to integrate exercise as a part of a healthy lifestyle (46)

In many European centres, a significantly longer course of initial pulmonary rehabilitation is offered (e.g. six months), but evidence that this confers greater benefit and preservation of performance is lacking (66).  In pulmonary rehabilitation (PR) the continuation of physical activity beyond the supervised component of PR is also recommended, as there is evidence to suggest that maintenance programmes offer advantages in preserving the benefits of pulmonary rehabilitation (67).  

Barriers to participation in exercise maintenance programmes, which need to be overcome, are fear, lack of motivation, financial and transportation issues, environmental factors, such as social isolation and changes in physical health. Rehabilitation professionals and social supporters can make rehabilitation more long-lasting and facilitate people with chronic obstructive pulmonary disease to participate in activity by motivating and encouraging them, reducing their fears and reinforcing the benefits of activity participation (68). These exercise, fitness and sports activities are rarely reimbursed which increases the threshold for people with disabilities or chronic disease who often have a limited income.

Effectively supporting stroke survivors to participate in physical activity after stroke is now a priority. Participation in moderate- or high-intensity exercise, reduces the risk of secondary ischemic or haemorrhagic stroke (69,70), improves walking speed, functional mobility (71–73), muscle strength, and bone density (74); and positively affects quality of life (75,76). Cardiorespiratory training and, to a lesser extent, mixed training reduce disability during or after usual stroke care; this could be mediated by improved mobility and balance. There is sufficient evidence to incorporate cardiorespiratory and mixed training, involving walking, within post-stroke rehabilitation programmes to improve the speed and tolerance of walking; some improvement in balance could also occur (77). However, stroke leads to complex disability, which makes participation in physical activity difficult, intensifying cardiovascular deconditioning, (78) which, in turn, negatively affects well-being, disability, and functional independence (79)  and increases the risk of secondary stroke (80). Therefore, understanding how best to support survivors to participate in regular physical activity is vital for their health and well-being.

To improve physical fitness in people with spinal cord injury the following evidence-informed physical activity guidelines are recommended: for important fitness benefits, adults with a SCI should engage in (a) at least 20 min of moderate to vigorous intensity aerobic activity two times per week and (b) strength training exercises two times per week, consisting of three sets of 8-10 repetitions of each exercise for each major muscle group (81).

In some European countries (e.g. Austria, Germany, Italy, Poland), inpatient or day-clinic rehabilitation plays an important role in the management of more chronic conditions, e.g. chronic musculoskeletal or neuromuscular disorders, chronic circulatory, respiratory and metabolic diseases as well as skin diseases and urological or gynaecologic conditions. Intermittent bursts of intensive rehabilitation may also be used to combat decline in function even several years after an acute event (82). 

Global health promotion in PRM

The contribution of PRM to “global health promotion” must be described in reference to the conceptual perspective and objectives of the “Global Disability Action Plan 2014-21 (83). PRM can play a role in supporting the achievement of the three main objectives of the Action Plan, namely: to remove barriers to health services and programs; to strengthen and extend rehabilitation, habilitation, and other supportive technology and services; to strengthen data collection and support research on disability and related services (84).

The Plan recognises Disability as a “global public health issue”, and Rehabilitation as an effective measure to reduce the societal impact of a broad range of disabling conditions, thereby concluding that rehabilitation must be included in the concept of universal health coverage.

Social and clinical-epidemiological trends, such as the ageing of populations, the increasing prevalence of chronic conditions leading to functional limitations, the increased survival rate in many different entities, and the increasing public awareness of the value of social participation, call for an increasing role of rehabilitation in health care. Under the general umbrella of rehabilitation, PRM is the medical specialty that, with respect to many other clinical disciplines, may give a major contribution to the global promotion of health among persons with disabilities and chronic disease. 

PRM operates at the clinical level (aiming at improving people’s ability to interact with the environment) and at the environmental level (aiming at providing an optimal milieu to put in practice such abilities).

The positive impact of PRM on global health promotion can be defined in terms of

• Increase of  the overall level of health, functioning, well-being  and social participation for persons with chronic disease or disability at a population level (e.g. at the level of a Region , Country, etc.… or worldwide);
• Reduction of burden of disease and disability at a societal level, that is mitigating the impact of disabling conditions on families, health care systems and social services;
• Contribution to the recognition of the value and dignity of the differences among human beings, thereby promoting the development of an attitude of social inclusion in the community.

The International Classification of Functioning, Disability and Health (ICF) (85) is the widely diffused and acknowledged reference conceptual model of PRM and can serve as a reference model for global health promotion. A relevant aspect of the ICF model is the emphasis put on “component of health” rather than on “consequences of diseases”, thereby stressing the concept of a continuum in health conditions, as opposed to a dualism between health and illness. Another aspect is that ICF is explicitly aimed at operationalizing the bio-psycho-social model which is widely accepted in PRM.

The strategies by which PRM can contribute to global health promotion are based on:

• The relationship with a broad range of health care professionals, not only in the field of rehabilitation, but also in other disciplines. Under this perspective, the relationship with the general practitioners and other primary care professionals seem to play a crucial role;
• The relationship and cooperation with a range of professionals and services in the areas of social protection, welfare and community services, labour, education…;
• The relationship and cooperation with communities, volunteer organizations, associations of persons with disability or other consumers, and families…;
• The cooperation with many professional and nonprofessional organisations in fostering an interdisciplinary and interprofessional approach in the delivery of rehabilitation services.

The actions by which PRM can contribute to global health promotion are:

• facilitate the access of persons with disability or disabling health conditions to health services and programmes;
• educate health professionals on disability and the effects of disabling health conditions on medical issues, as well as  the reverse; 
• increase the awareness of institutions, professionals and community at large on the themes of disability and participation;
• promote healthy lifestyles of persons with disability. In particular, PRM is involved in actions to promote engagement in regular physical activity;
• promote the recognition of “functioning” as a relevant clinical feature in several areas of health care, including primary care and acute care settings;
• promote the widespread inclusion of functional assessment in health care systems, and the adoption of a common language for the description of functioning (e.g. by fostering the development of simple, intuitive evaluation tools based on the ICF taxonomy (86–88);
• cooperate with primary care professionals (general practitioners and other professionals) to extend primary rehabilitation services, and provide links and connections of primary services with secondary and tertiary rehabilitation centres and facilities, thereby fostering the development of integrated networks of rehabilitation services at a local, regional and national level;
• cooperate in promoting community based rehabilitation and in connecting this area of intervention with more specialized levels of rehabilitation;
• increase the awareness and improve access and attitudes of institutions and health professionals concerning preventive health screenings (e.g. dental care) for people with disabilities, in particular women with regard to gynaecological screenings (89);
• contribute to data collection and research on disability at a population level (e.g. epidemiology of functional limitations) and on development and implementation of innovative models to satisfy the emerging needs of persons with disability.

Ethics and PRM Services

Rehabilitation has been proposed by WHO as the key health strategy of the 21st century (90).  Moreover, rehabilitation needs are increasing due to current trends in healthcare such as ageing populations, improved knowledge and new medical technologies, growing survival rates and life expectancy, expanding chronic conditions, early start of rehabilitation and early discharge from acute care. Consequently, rehabilitation costs are growing in contrast with shrinking budgets. This implies choices, at the macro- meso- and micro-level of healthcare (91). Bioethical problems -ethical problems in the context of healthcare- are linked to three main moral principles: respect for autonomy, beneficience versus non-maleficience, and justice (20). Respecting these principles can result in conflicting situations and ethical dilemma’s. 

Ethical issues submerging at the macro- (healthcare policy),  and micro-level (level of patient interaction) have been discussed in the previous chapters (respectively 2 and 7). This chapter deals with choices that need to be made at the meso-level (healthcare organization: hospitals, rehabilitation services,…). 

An important task of PRM physicians is the selection of patients or “triage” to access a rehabilitation programme or service (21). The objective is to have the right patient at the right level of care at the right moment with the appropriate financing. The triage should be based on the patient’s multidimensional functional status and include medical as well as non-medical factors. Therefore a patient classification system or triage instrument is needed.  This should also take into account the complexity of the patient’s rehabilitation needs and goals as well as his preferences. The incidence and prevalence of the underlying health condition is another parameter and less frequent conditions require more specific services, especially in the case of complex goals. The patient classification/evaluation system should be used as from the acute phase in order to assign the patient to a service offering the right level of rehabilitation care, throughout the continuum of care (see figure 1). However, most rehabilitation services have a limited number of in- or outpatients and difficult decisions on admission and discharge of patients must be made daily. The best choice for the patient (beneficience principle) should prevail but this choice may be in conflict with the available budget and more utilitarian considerations. The same conflict may occur when discharging a patient. In most of the European countries the number of specialised facilities for adults with severe disabilities, not able to return home, is insufficient. This creates discharge problems and consequently admission problems (“bed-blockers”). Moreover, some patients are being discharged to inadequate facilities, such as non specialised elderly homes. Within the limited (and currently shrinking) budgets the available financial resources must be allocated in a “just” way (priniciple of justice).

Another issue at the meso-level concerns the attitude of healthcare professionals towards persons with disabilities and chronic disease. This may vary depending on the vision and priority setting of the healthcare institution.  For example the accessibility of gynecological and obstetrical services to women in a wheelchair, as well as the lack of awareness and knowledge of the concerned health professionals are often a barrier to the regular medical screenings of these women with specific needs.

The inclusion of the patient and his/her family, as well as the involvement of peer counsellors in the rehabilitation team, will depend on the patient-centredness of a particular rehabilitation service or institution in general.

The last decades the use of technology in rehabilitation has increased  significantly. Robotics and bionics belong to daly practice. So the ethical question here is not anymore whether to use technology but rather “how to use technology?”, or “how does technique influence our life and our behaviour as technique shapes our actions and experiences?” (92).

In conclusion, in rehabilitation practice, we are increasingly confronted with delicate ethical questions. Decisions must be taken daily on the micro- meso- as well as the macro-level of healthcare. Ethical values and cultural beliefs of professionals as well as patients influence choices in rehabilitation practice. We need to be aware of the fact that cultural differences can affect the outcome of treatment. Therefore, ethical and cultural issues should be part of rehabilitation curricula and postgraduate training, also with regard to the use of technology. Rehabilitation professionals should take time to reflect on these issues with colleagues and peer counsellors.

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^[1] For the specific role of PRM in the prevention, treatment and rehabilitation in specific disorders or disabilities see the Book on the Field of Competence of PRM, edited by the Professional Practice Committee of the UEMS-PRM Paragraph (www.euro-prm.org )