European PRM Bodies Alliance

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

European Academy of Rehabilitation Medicine (EARM),
European Society of Physical and Rehabilitation Medicine (ESPRM),
European Union of Medical Specialists PRM Section (UEMS-PRM Section)
European Union of Medical Specialists PRM Board (UEMS-PRM Board)
The editors of the 3rd edition of the White Book of Physical and Rehabilitation Medicine in Europe: Stefano Negrini, Pedro Cantista, Maria Gabriella Ceravolo, Nicolas Christodoulou, Alain Delarque, Christoph Gutenbrunner, Carlotte Kiekens, Sasa Moslavac, Enrique Varela-Donoso, Anthony B Ward, Mauro Zampolini.
The Presidents of the European PRM Bodies: Xanthi Michail (President of the European Academy of Rehabilitation Medicine EARM), Alain Delarque (President of the European Society of Physical and Rehabilitation Medicine ESPRM), Nicolas Christodoulou (President of the Physical and Rehabilitation Medicine Section of the European Union of Medical Specialists UEMS-PRM Section), Maria Gabriella Ceravolo (President of the Physical and Rehabilitation Medicine Board of the European Union of Medical Specialists UEMS-PRM Board).

Abstract

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 reached now its third edition: the first was published in 1989, and the second in 2006/7. The WB 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, present all over Europe, with a specific corpus disciplinae, a common background, and history throughout Europe. PRM is internationally recognised and partner of all the major International Bodies, starting from the World Health Organization (WHO). PRM has strong basis in the documents of the United Nations (UN) and WHO, such as the Convention of the Rights of Persons with Disabilities (2006), the World Report on Disability (2012), the WHO Global Disability Action Plan 2014-2021 (2014) and the WHO initiative “Rehabilitation 2030: a call for action” (2017).

The text is organized in four sections, 11 chapters and some appendices. The contents start with basic definitions and concepts of PRM, before discussing why rehabilitation is needed by individuals and society. Rehabilitation not only focuses on health conditions, while PRM is the medical specialty focusing on improving functioning of people experiencing disabilities. The fundamentals of PRM, the history of PRM specialty, and the structure and activities of PRM organizations in Europe are reported before moving to a thorough presentation of the practice of PRM: knowledge and skills of PRM physicians, the clinical field of competence of PRM, the place of the 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. The book concludes with the way forward for the specialty: challenges and perspectives for the future of PRM.

Foreword

The 1st edition of the White Book of PRM in Europe has been edited with the ambition of becoming a working instrument which would enable Health Sector authorities and teachers of medicine to take the necessary regulatory steps towards compulsory inclusion of PRM in medical studies, as well as to achieve effective, optimized harmonization of training of Specialists in Physical and Rehabilitation Medicine in Europe.

The 2nd edition of the White Book of PRM in Europe aimed to ensure that PRM is seen as one significant European specialty, where high quality practitioners working to good standards of care can practice in accordance with the scientific evidence and within the context of their differing national practices by defining the specialty, its work, the competencies of its practitioners and its relationships to other medical disciplines and professions allied to health.

Both, 1st and 2nd editions of the White Book of PRM in Europe were well received not only by health professionals but also by policymakers who have widely used the information contained in the White Book for organizing rehabilitation delivery. After 10 years from the 2nd edition, the European PRM bodies consider it timely to update the information in order to illustrate how the specialty has developed and how recent trends are influencing practice.

The new 3rd edition of the White Book of PRM in Europe is produced by the Alliance of the European PRM Bodies (UEMS PRM Section, European College [Board] of PRM, European Society of PRM and European Academy of Rehabilitation Medicine). As the result of a joint effort of all representatives of those institutions responsible for setting standards of PRM clinical practice, education, and scientific research, in Europe, it reflects all the different aspects related to the development of appropriate , widely accessible, sustainable rehabilitation care. It constitutes the reference book for PRM physicians in Europe, in their relations both to individuals with disability and to other medical disciplines and health allied professionals or in negotiations with their national governments and national health systems authorities.

This updated 3rd edition of the White Book of PRM in Europe aims at:

Describing the work of the PRM specialty and its PRM specialists in a changing world of health care systems and shrinking resources;
Reacting and contributing to medical innovation;
Developing strategies to meet the challenge of scientific and technological advances;
Dealing with changing perspectives of disability;
Promoting and facilitating the participation of people with disabilities in everyday life and autonomy;
Being a didactic reference for PRM practice and academic life to young health professionals (especially medical doctors in training);
Having a European perspective.

The text is organized in four sections, 11 chapters and some appendices and although it is a “collective effort”, the excellent methodology followed by the editors, under the coordination of Prof. Stefano Negrini, guarantees the success in its impact and implementation.

We wish to use this opportunity to congratulate all the authors who have contributed to the content of this important publication.

On behalf of the European PRM Bodies Alliance

The Presidents of the European PRM Bodies

Xanthi Michail (European Academy of Rehabilitation Medicine)

Alain Delarque (European Society of Physical and Rehabilitation Medicine)

Nicolas Christodoulou (Physical and Rehabilitation Medicine Section of the European Union of Medical Specialists)

Maria Gabriella Ceravolo (Physical and Rehabilitation Medicine Board of the European Union of Medical Specialists).

Preface

The White Book (WB) of Physical and Rehabilitation Medicine (PRM) in Europe constitutes the reference book for PRM physicians in Europe since 1989, when the first edition was published by the Universidad Complutense of Madrid (1) on the initiative of the European Academy of Rehabilitation Medicine (EARM), the Section of Physical Medicine and Rehabilitation of the European Union of Medical Specialists (UEMS), and the European Federation of Physical Medicine and Rehabilitation (EFPMR). That edition has now a historical value, since many things have changed in the world, but also in PRM. Particularly, the term of reference of the specialty has changed due to the conceptual evolutions that the World Health Organization (WHO) recognised and defined first in 1980 with the International Classification of Impairment, Disability and Health (ICIDH) (2) and then in 2001 with the International Classification of Functioning, Disability and Health (ICF) (3). This evolution is testified by the name of the specialty, that changed to PRM. Accordingly, also the European Bodies have changed: now they are the European Academy of Rehabilitation Medicine (EARM – ethical and “philosophical” function), the European Society of PRM (ESPRM – scientific function), the Section (political function) and the Board (UEMS Board – educational function) of the European Union of Medical Specialists.

They produced the second edition in 2006, published at that time by Europa Medicophysica (now European Journal of PRM) (4) and the Journal of Rehabilitation Medicine (5). In this third Edition, the European PRM Bodies have come together under the umbrella ~~are for the first time joined together under the~~ name “European Bodies Alliance”, to state a collaboration existing and growing since years. The Alliance holds the intellectual property and copyrights for the WB as well as for its editions in the various languages.

Since the 2^nd Edition of the WB, the United Nations (UN) Convention of the Rights of Persons with Disabilities (6) has implemented the important Article 26 “Habilitation and Rehabilitation” (7). For the first time, rehabilitation was defined as one of the most important interventions to “enable persons with disabilities to attain and maintain maximal independence, full physical, mental, social and vocational ability and full inclusion and participation in all aspects of life”. Consequently, the Convention urged sovereign states to “organise, strengthen and extend comprehensive habilitation and rehabilitation services and programmes, particularly in the areas of health, employment, education and social services”. This Article also included “the development of initial and continuing training for professionals and staff working in habilitation and rehabilitation services”. For PRM, there are two important messages, which are: 1) access to rehabilitation is a human right and 2) training of highly qualified rehabilitation professionals are key to contributing to the Convention’s goals.

Responding the UNCRPD, WHO and the World Bank produced the World Report on Disability (8) in 2011, which relied on scientific evidence for the first time to describe the life experiences and situation of persons with disability and from which relevant recommendations were made. One of the main findings was that the prevalence of disability is higher than expected (amounting to around 15% of the world population). The WRD highlighted the contribution of rehabilitation to “a person achieving and maintaining optimal functioning in interaction with their environment”. The report described “Rehabilitation Medicine” as being “concerned with improving functioning through the diagnosis and treatment of health conditions, reducing impairments, and preventing or treating complications” and it highlighted the role of doctors with specific expertise in medical rehabilitation called “physiatrists, rehabilitation doctors, or physical and rehabilitation medicine specialists”. It also recognised that “Rehabilitation Medicine has shown positive outcomes, for example, in improving joint and limb function, pain management, wound healing, and psychosocial well-being”.

Finally, the WHO Global Disability Action Plan 2014-2021, “Better Health for All People with Disabilities”, has the objective to “strengthen and extend rehabilitation, habilitation, assistive technology, assistance and support services, and community-based rehabilitation”. One of the success indicators for these goals is “the number of graduates from educational institutions per 10. 000 people – by level and field of education”. In this indicator, Physical and Rehabilitation Medicine is explicitly mentioned (9).

During the WB’s preparation, WHO launched “Rehabilitation 2030: a call for action” (10) in February 2017 involving over 200 stakeholders and presented the WHO Recommendations on rehabilitation in health systems. These initiatives are meant to

draw attention to the increasing unmet needs for rehabilitation in the world;
highlight the role of rehabilitation in achieving the Sustainable Development Goals proposed by the United Nations; and
call for coordinated and concerted global action towards strengthening rehabilitation in health systems.

Common to all of these initiatives, the training of PRM physicians and improvements in the quality of care are internationally agreed goals to improve health-related rehabilitation services and to enable persons with health conditions experiencing, or likely to experience, disability to achieve and maintain optimal functioning in interaction with their environment. The European PRM Bodies have adopted these goals and this 3^rd Edition of the WB on PRM in Europe aims to contribute to this.

The aim of the WB is thus to describe, in a European perspective, the work of the specialty of PRM and of PRM physicians in:

A changing world of health care systems and shrinking funding;
Reacting and contributing to medical progress and technological innovation;
Developing strategies to meet the challenge of scientific and technological advances;
Dealing with changing perspectives of disability
Promoting and facilitating the autonomy and participation of persons with disabilities in everyday life
Being a didactic reference for PRM practice and academic life to young health professionals (especially medical doctors in training)

Consequently the WB has multi-faceted values that start from the educational role for PRM physicians in training, to the unifying function for European states and to the political utility facing governments across Europe and the EU. These are important for PRM, whose role is sometimes not well understood, particularly from the perception of those outside the specialty. PRM is constantly collaborating with other specialties and other professionals, specifically rehabilitation professionals, on health, education and research activities. This book aims to clarify the role of PRM in collaboration with other:

specialties, with which there are common health conditions and knowledge of body functions/structures needed to treat patients, even if PRM primarily focuses on activity and participation (individual behaviours);
rehabilitation professionals for their interest on activity and participation, while keeping its unique medical role in diagnosis, functional diagnosis and prognosisand team management.

PRM is an independent primary specialty, present in most European Countries, with pecific specialist competences and a common background and history . Moreover, PRM is internationally recognised and a partner of all the major International Bodies, including the WHO Allowing it to have a strong influence in all the UN’s and WHO’s documents. As a result, the publication of the WB by all of the European PRM bodies is of great value for citizens (especially those with a disability) across Europe, for European PRM as a specialty and for politicians, for healthcare planners and for society in general.

All of these concepts will be deepened in this latest Edition of the WB, that follows on from the 2^nd Edition and introduces some specific new concepts. Two are related to the methods: this 3^rd Edition is much more of a “collective effort” compared to the previous ones and the new methodological chapter underlines all the work performed to follow a clear and sound methodology as a guarantee of the contents of the WB. Another departure, already cited, is the Alliance of the European PRM Bodies. There are then some new perspectives in the contents, specifically in the historical chapter and a unique and better conceptualisation of the fundamentals of PRM as a specialty.

The text is presented in four parts (the background of PRM, its organisation and practice in Europe and the conclusions) with appendices (including the methods section). The contents start with basic definitions (the concepts and the specialty) before looking at the relevance of rehabilitation to people with disabling conditions and to society (i.e. why it is needed). The text then moves from general rehabilitation, that is not specifically medical, to PRM, which is the medical specialty devoted to rehabilitating patients and persons with disabilities. The definition of PRM as a primary medical specialty (the core concepts) is presented along with its development (where PRM comes from) and organization (PRM activities and their representation) in Europe. Moving to practice, the fundamentals of PRM (knowledge, skills and abilities of PRM physicians), the field of competence (PRM in practice) and the place in healthcare systems and society are discussed . Education of PRM in Europe (shaping the future) and science and research in PRM (challenges and specificities) are also reported before reaching the conclusions: the way forward for PRM in Europe (challenges and perspectives for the future).

This text is a further important step for the future of the specialty of PRM, not only in Europe, but further afield. It results from the work of the following, whose acknowledgment is in the appendices)

the initiative and authorship of the 4 European PRM Bodies joined in a single productive Alliance,
the coordination of 11 editors,
the efforts of 38 first authors and 63 co-authors, to produce 62 individual contributions,
the voluntary work of 34 internal and 46 external reviewers,
the consensus of 235 delegates and academicians of 36 European Countries reached in 30 months of work,

The editors of the 3^rd Edition of the WB

Stefano Negrini, Pedro Cantista, Maria Gabriella Ceravolo,

Nicolas Christodoulou, Alain Delarque, Christoph Gutenbrunner,

Carlotte Kiekens, Sasa Moslavac, Enrique Varela-Donoso,

Anthony B Ward, Mauro Zampolini

Executive Summary

Overview

The third Edition of the White Book (WB) of Physical and Rehabilitation Medicine (PRM) in Europe is produced by the European PRM Alliance including the European Academy of Rehabilitation Medicine (EARM), the European Society of PRM (ESPRM) and the European Union of Medical Specialists (UEMS) PRM Section and Board. It is the reference book for PRM physicians in Europe. It is dedicated to provide information about PRM and its scope being relevant for (young) PRM physicians, other health professionals, health care planners and other stakeholders as well as for European national governments. It also informs European governing bodies and the general public.

The WB informs about the importance of PRM for the individual patient or person experiencing disability and to society. It describes how PRM is a primary medical specialty, present in almost all European Countries (from West to East), with specific core competencies and a common background and history throughout Europe.

The scope of PRM and its role in rehabilitation has a strong basis in the documents of the United Nations (UN) and World Health Organization (WHO), like the WHO International Classification of Functioning, Disability and Health (ICF) (2001), the UN-Convention of the Rights of Persons with Disabilities (2006), the World Report on Disability (2012), the WHO Global Disability Action Plan 2014-2021 (2014) and the WHO initiative “Rehabilitation 2030: a call for action” (2017). PRM organisations are internationally well recognised and working as partner of all relevant major international organisations like the WHO.

The White Book has four parts and is presented in a series of 11 chapters, after introductions and methodological notes. It starts by explaining basic definitions and concepts of PRM, the relevance of PRM for people and society and the definitions of disability and rehabilitation. It presents PRM as a primary medical specialty, its development and its organization in Europe. Knowledge, skills and aptitudes of PRM physicians, its field of competence and its position and role in healthcare systems are discussed. Last but not least principles of education and training as well as science and research are also described. Finally, the challenges and future perspectives for PRM in Europe are discussed.

Definitions and basic concepts of PRM

PRM is the primary medical specialty responsible for the prevention, medical diagnosis, treatment and rehabilitation management of persons of all ages with disabling health conditions and their co-morbidities. PRM physicians are treating health conditions, physical, mental and cognitive functions as well as activity limitations aiming at improving participation and quality of life. This includes improving health behaviour and modifying personal and environmental factors.

The profile of PRM includes the following:

PRM is a person and functioning oriented specialty (different from the organ and disease oriented or treatment ore age specific medical specialties)
PRM physicians have medical responsibilities and additional competencies in setting-up a functional diagnosis
PRM physicians can directly provide treatments, and/or coordinate the multi-professional rehabilitation team (using an interdisciplinary team work model)
PRM has a multimodal approach including a wide range of treatment tools (including medicines, exercises, physical modalities and other rehabilitation interventions, some of which provided by other rehabilitation professionals)
PRM is treating the individual’s health conditions focusing on reducing impairments and activity limitations in order to empower patients to achieve full participation
PRM has a transversal role and collaborates with all other specialties

PRM is focused on the person and not on a specific disease or setting, thus PRM physicians collaborate with many other medical specialists and health professionals and hava a role in different health care settings (e.g. acute and/or post-acute rehabilitation hospitals, rehabilitation centres, out-patient services, community services). PRM physicians take care of persons experiencing disabilities and patients with long-term health conditions but also acute dysfunction to prevent secondary impairments.

The relevance of PRM for the society evolves from the increase of the number of people experiencing disability including ageing populations. Thus, any planning of services has to take into account the burden of disability within the society and should include PRM services at all levels of care.

Organization and history of PRM in Europe

Historically, PRM developed from some main streams: One is the use of physical agents (water, heat, cold, massage, joint manipulations, physical exercise, etc.) (Physical Medicine). The other the practice of rehabilitation that gained importance due to the survivals of wounded in the 2^nd World War, as well as to various epidemics (e.g. poliomyelitis) (Rehabilitation Medicine). Moreover, it developed in relation with other specialties like neurology, rheumatology, orthopaedic medicine or in specific settings like balneology. Nowadays, all these streams converged in the single PRM multidimensional specialty.

For a uniform definition and positioning in Europe, different organizations of PRM have been created: the EARM, the ESPRM; the , and the PRM Section and Board of the UEMS. Nowadays such a uniform definition of the specialty exists in Europe, which is concordant with the internationally accepted description of PRM (based on the ICF-model).

Additionally, regional fora, such as the Mediterranean Forum of PRM and the Baltic and North Sea Forum of PRM, have been established and national PRM societies exist in most European countries. They take an important role to develop PRM at the interface of Europe with neighbouring regions as well as at national levels. The European PRM associations also take a strong role in related activities across the world.

Moreover, research in PRM has been significantly improved and the number of PRM journals increased (many of them indexed in international data bases and with impact factor), and scientific congresses and courses developed. Last but not least, the recent creation of the Cochrane Rehabilitation field will also give a great boost to this primary medical specialty

Practice of Physical and Rehabilitation Medicine in Europe

From a physiological perspective, the fundamental principles of PRM include physical and behavioural mechanisms including:

repairing processes and functional adaptation (incl. tissue regeneration, improvement of functional capacity, training processes etc.) as well as supporting recovery processes
learning processes and behavioural change (incl. patient education and teaching new motor and behavioural strategies)
compensatory processes both at the physical mental and intellectual levels as well assistive technologies and environmental adaptations

Additionally, PRM physicians have management skills and play a role in supporting people to manage their resources to achieve optimal participation (including giving advice to their families and caregivers). Furthermore, PRM physicians have a high level of communication skills in order to teach, inform and educate patients and their relatives.

The clinical work of PRM physicians can be characterized as the “medicine of functioning”. Its core health strategy is rehabilitation aiming at optimizing functioning in light of health conditions. However, PRM physicians also use curative (to cure the disease), preventive (to prevent disease and/or complications and progression) and supportive strategies (aiming at to maintain optimal functioning). Clinical PRM processes are following the so-called rehabilitation cycle (all patients require an assessment with definition of their individual goals before providing the intervention; finally, an evaluation will be performed to check if the patient has achieved all what is needed, or if it is necessary to start again the rehabilitation cycle)

The spectrum of diseases treated by PRM physicians is extremely wide as many health conditions are associated with some form of disability. This includes diseases in musculoskeletal, nervous, circulatory, respiratory, urogenital system as well as to the skin and the digestive tract. PRM clinical activities also relates to some most common problems across diseases such as immobilization, spasticity, pain, communication disorders and others

The diagnosis in PRM is a combination between the medical diagnosis (diagnosis of the disease) and the PRM specific functional diagnosis (assessment of functioning). The latter is based on the ICF conceptual framework, and obtained through functional evaluations and scales.

PRM physicians may apply a wide range of interventions, ranging from medications, exercises, manual therapies, physical modalities, technical aids, educational programs and environmental adaptations. Standardized PRM programs have been developed for many health conditions and functional problems based on scientific evidence and providing best practice models

PRM interventions and programs are always patient-centred, and outcomes include functional and personal dimensions (reducing impairments, activity limitations, and participation restrictions). They also aim at reducing costs as well as decrease in mortality for certain groups of patients. PRM programs in most cases are delivered by the multi-professional rehabilitation teams using an interdisciplinary methodology.

As numerous documents and reports from WHO and the UN call for the strengthening of rehabilitation as a key health strategy of the 21^st century worldwide, further implementation of PRM in healthcare systems is crucial. Within this context, PRM should be provided along the whole continuum of care and at all levels of health care aiming at appropriate services functional needs of the individual as well as on temporal aspects of a health condition (congenital or acquired, and acute, progressive or degenerative). This includes aspects of habilitation, prehabilitation as well as PRM in acute settings, in post-acute and in long-term settings.

Education and training in PRM

To achieve a good rehabilitation approach as needed by the European societies, all physicians and health professionals should receive an adequate undergraduate education. To acquire the wide field of competence needed, PRM physicians have to undergo a well organised and appropriately structured postgraduate training of adequate duration. Besides achieving medical knowledge, competencies in patient care, specific procedural skills, and attitudes towards interpersonal relationship and communication, profound understanding of the main principles of medical ethics and public health, ability to apply policies of care and prevention for disabled people, capacity to master strategies for reintegration of disabled people into society, apply principles of quality assurance and promote a practice-based continuous professional development. At the European level, recommendations and standards required are provided by the European UEMS-PRM Board. Last but not least, continuing professional development and medical education programs are provided by the European PRM bodies (in collaboration with the European Accreditation Council of Continuous Medical Education).

Science and research in the field of PRM

Related to the wide spectrum of tasks of PRM, science and research in PRM also has a wide scope of topics. It ranges from basic research in mechanisms of disease and disability, mechanisms of action of interventions, studies on clinical outcomes, epidemiological studies as well as scientific approaches of the implementation of PRM services in health systems and developing the theoretical background on disability and rehabilitation. This is reflected in the topics of European and international congresses and PRM journals. However, the current situation of science and research activities in PRM in Europe is facing new possibilities and challenges.

The importance of rehabilitation research is defined, and its peculiar methodology due to the problem to bridge the gap between biology and behaviour, and facing topics like the relationship between biomedicine and PRM and PRM outcome research. PRM also has to face the challenges of Evidence Based Medicine that are also dealt with in the new Cochrane Rehabilitation Field. Finally, the transfer of scientific knowledge into clinical practice is of major importance.

The way forward

Challenges and future perspectives of PRM in Europe are emerging from the dramatic changes in demography, life expectancy, survival rates, disability burden, increasing prevalence of long-term health conditions, progress in technology, but also health costs and society changes in terms of requirements of wellness and quality of life together with health. All these challenges combine with the specificities of PRM, that is the medical specialty focusing on the whole person and its functioning in the various health conditions, with the aim to guarantee the best possible participation through improvement of activities and reduction of impairments. The possible consequences of these changes in the future evolution of PRM clinical practice, services, education, research are presented; moreover, the vision on the progress to harmonization of the development of PRM across Europe, and the possible contribution of PRM to policy planning are presented.

Introduction

The White Book (WB) sets out the nature, area of work and parameters of Physical and Rehabilitation Medicine (PRM) in Europe. It describes the specialty and the competencies expected of fully trained specialists (PRM physician) in the field, as well as the clinical context of the work and the nature of education and specialist training. The book builds on the two previous editions of WB, which appeared in 1989 (1) and in 2006/2007 (4,5).

The WB primarily targets five groups:

PRM physicians and other rehabilitation professionals;
health care professionals in other medical specialties and professions allied to medicine.
PRM residents, medical and other rehabilitation professional students;
policy makers and planners in healthcare, rehabilitation and disability issues;
the general public and, in particular, persons with disabilities and representatives of their organisations;

The European medical community is continuously enlarging, and this offers further opportunities and challenges, particularly from the East of the continent to learn what the PRM European community is doing by developing specific projects with the PRM Section of the European Union of Medical Specialists (UEMS) and the European Society of PRM (ESPRM). This publication seeks to assist the process of harmonisation of specialist PRM activity to help ensure that persons experiencing disabilities are well served by the specialty irrespective of where they live in this enlarged community. The WB is offered to the PRM community across the world as a reference, even in the face of different situations and challenges.

Healthcare is undergoing great changes both at European and at national levels. The general public have increasing expectations of medical care , which mirror the philosophical debate about human rights and responsibilities across society, particularly in relation to the full participation of persons with disabilities. Medical practice is continually evolving, with the improvement in clinical standards and the need for excellence through continuing professional development, revalidation and enhancement of specialist training. As the need for greater competency increases, it is important for PRM to re-define what it is, what it can offer, how it can best deliver its services and expertise, and what standards of training should be demanded of entrants into the specialty. This book aims to respond to these requirements.

The text is presented in four parts (the background of PRM, its organisation and practice in Europe and the conclusions) with appendices (including the methods section). The contents start with basic definitions (the concepts and the specialty) before looking at the relevance of rehabilitation to people with disabling conditions and to society (i.e. why it is needed). The text then moves from general rehabilitation, that is not specifically medical, to PRM, which is the medical specialty devoted to rehabilitating patients and persons with disabilities. The definition of PRM as a primary medical specialty (the core concepts) is presented along with its development (where PRM comes from) and organization (PRM activities and their representation) in Europe. Moving to practice, the fundamentals of PRM (knowledge, skills and abilities of PRM physicians), the field of competence (PRM in practice) and the place in healthcare systems and society are discussed. Education of PRM in Europe (shaping the future) and science and research in PRM (challenges and specificities) are also reported before reaching the conclusions: the way forward for PRM in Europe (challenges and perspectives for the future).

Methodology of the third edition of the WB of PRM in Europe

The 3^rd edition of the White Book (WB) of Physical and Rehabilitation Medicine (PRM) in Europe has been developed according to a specific methodology in order to achieve the most consistent and true representation of the text. It has been produced and approved by all delegates and academicians of the European PRM Bodies Alliance. All delegates are officially nominated by their national competent authorities or national societies and consulted the members of their relevant authorities during the process. Consequently, the WB represents the views of the whole PRM European community. Its production has been a truly collective effort involving the 4 European PRM Bodies, 11 editors, 38 first authors, 63 co-authors, 34 internal and 46 external reviewers, 235 delegates and academicians, representing 36 PRM specialists in the continent.

During 2014 the idea of a new edition of the WB was proposed inside the European Academy of Rehabilitation Medicine (EARM) and a discussion was started inside the other European PRM Bodies: the European Society of PRM (ESPRM) and the European Union of Medical Specialists (UEMS) PRM Section and Board. According to the methods of work of the Bodies, motions were proposed and were all unanimously approved throughout the process. The list of motions related to the WB production is reported in Table 1.

Among the first decisions was the creation of a Steering Committee, including 2 members per European Body. The Steering Committee included:

Stefano Negrini (UEMS PRM Section) – Coordinator;
Sasa Moslavac (UEMS PRM Board) – Secretary;
Pedro Cantista (ESPRM),
Gordana Devecerski (ESPRM),
Alvydas Juocevicius (UEMS PRM Board),
Christoph Gutenbrunner (EARM),
Enrique Varela Donoso (UEMS PRM Section),
Anthony B Ward (EARM).

The Steering Committee met regularly and proposed the main motions to be approved. At all stages the Presidents and Secretaries of the Societies have been involved. They have been:

EARM: Guy Vanderstraeten and Xanthi Michail (Presidents), and Angela McNamara (Secretary)
ESPRM: Xanthi Michail and Alain Delarque(Presidents), Elena Ilieva and Carlotte Kiekens (Secretaries)
UEMS PRM Chapter: Nicolas Christodoulou (President), Mauro Zampolini (Secretary)
UEMS PRM Board: Alvydas Juocevicius and Maria Gabriella Ceravolo(Presidents), Nikos Barotsis (Secretary)

In the first semester of 2015 the need of a new edition (3^rd) of the WB, due to the many? changes in the European Societies, and consequently in PRM practice, reflected by European and World documents was finally defined. The WB is authored by the 4 European PRM Bodies, that are also the copyright holders:

European Academy of Rehabilitation Medicine (EARM)
European Society of PRM (ESPRM)
PRM Section of the European Union of Medical Specialists (UEMS PRM Section)
PRM Board of the European Union of Medical Specialists (UEMS PRM Board)

The stakeholders are the National PRM Societies.

The WB follows the outline of the previous editions:

First Edition (1989): Book published by Universidad Complutense de Madrid in four languages: English, French, Italian, Spanish. Author: EARM with UEMS Physical Medicine and Rehabilitation Section and European Federation of Physical Medicine and Rehabilitation;
Second Edition (2006-7): published in Special issues of 2 journals (in PubMed), Europa Medicophysica (now European Journal of Physical and Rehabilitation Medicine); Journal of Rehabilitation Medicine. Language: English, then translated in various other European languages by the National Societies. Authors: EARM and UEMS PRM Section and Board with ESPRM

The aim of the WB is to describe, in a European perspective, the work of the specialty of PRM and of PRM physicians in:

A changing world of health care systems and shrinking funding;
Reacting and contributing to medical progress and technological innovation;
Developing strategies to meet the challenge of scientific and technological advances;
Dealing with changing perspectives of disability
Promoting and facilitating the autonomy and participation of persons with disabilities in everyday life
Being a didactic reference for PRM practice and academic life to young health professionals (especially medical doctors in training)

It was decided to start from the contents of the second edition and accept all what was already written if still applicable, modifying the text as required. This has been true for:

the chapters (some new chapters have been included – specifically chapters 3 and 6) sometimes expanding previous paragraphs
the single paragraphs inside the chapters

In the second semester of 2015 a Provisional Summary was approved including:

11 chapters with an editor for each chapter– it was decided to publish each chapter as an independent paper in PubMed so to better expose the contents to the scientific world audience; each chapter consequently has its own abstract and includes the collective names of authors. In the final version the chapters are:
- Definitions and concepts of PRM
- Why rehabilitation is needed by individuals and society
- A primary medical specialty: the fundamentals of PRM
- History of the specialty: where PRM comes from
- The PRM organizations in Europe: structure and activities
- Knowledge and skills of PRM physicians
- The clinical field of competence: PRM in practice
- The PRM specialty in the healthcare system and society
- Education and continuous professional development: shaping the future of PRM
- Science and research in PRM: specificities and challenges
- Challenges and perspectives for the future of PRM
62 paragraphs – each paragraph has some key persons with specific roles:
- First Author: paragraphs writing: draft (starting from the text of the previous second edition of the WB) and final version; coordination with co-authors; deadlines respect
- Co-authors: correcting and improving the first draft; they come from the authors’ call and/or are nominated by the first authors; in each paragraph, they come from different European areas (North, South, West and East)
- Internal reviewers: from the European PRM Bodies – first review of paragraphs
- External reviewers: PRM experts out of the European PRM Bodies – first review of paragraphs

The first authors of each single paragraph have been decided by the Steering Committee according to specific criteria after a call to all delegates and academicians. The criteria included: specific expertise, number of publications in PubMed listed journals, other specific publications, acceptance to fulfil the task and deadlines.

The editors of the WB have been chosen by the Steering Committee primarily among their members but also in the European Bodies according to their specific expertise in editing and on their chapter. Stefano Negrini serve as Coordinator and Sasa Moslavac as Secretary of the editors. The editors of the single chapters are:

Pedro Cantista, Nicolas Christodoulou
Anthony B Ward
Stefano Negrini
Enrique Varela Donoso
Mauro Zampolini
Stefano Negrini
Christoph Gutenbrunner
Carlotte Kiekens
Maria Gabriella Ceravolo
Alain Delarque
Stefano Negrini

The writing process has been organized with the following steps:

December 31st 2015 – Deadline of first call for authors to all Delegates and Academicians
February 28th 2016 – Deadline of second call for authors to all Delegates and Academicians
July 15th 2016 – Deadline for writing of “sensitive” paragraphs:
- 3.2 Ethical aspects;
- 4.5 Inter-disciplinary and inter-professional team;
- 5.1 The streams of developing the field of competence in PRM;
- 8.9 Relationship with other specialties;
- 8.10 Relationship with other rehabilitation professionals
August 15th 2016 – Deadline for all other paragraphs

The process of reviews and revisions has been quite elaborated and is fully described in Tables 2 and 3. It included:

four Consensus Conferences
four review/revision cycles involving either all delegates/academicians (1^st and 3rd) or all editors and Presidents (2^nd and 4th)

Overall each review and revision round was aimed at improving and refining the text, making it coherent among chapters and paragraphs. Revisions have always been performed by the editors individually and/or collectively to guarantee uniformity to the text.

The first stage of review has concluded with the most important Consensus Conference (the 3^rd) held in Munich on 9^th of March 2017. Participants have been all delegates of ESPRM and UEMS-PRM Section and Board, and all academicians of EARM. Each editor for his chapter has presented: contents of chapter, comments received, answer to the comments, changes to the text according to the comments. Then a very short discussion has been performed according to the following rules: all delegates and academicians had to send their comments (5th review) by February 28th. Since a general discussion was not possible due to time constraints, some comments have been allowed, and then all participants had to send their last comments as reported in Table 3.

Publication of the WB has been planned in January 2018. In spring 2017 it has been decided to ask first to the journals that published the previous Second Edition (the European Journal of PRM and the Journal of Rehabilitation Medicine). If they would accept the rule, they will be the two publishing journals. The rules include:

Copyright remains on the European PRM Bodies Alliance
On-line Open Access
Printed version for free, including only the White Book
Publication in January 2018
A PubMed entry for the whole WB including preface, introduction, executive summary and methodology
Each chapter is published as a single PubMed entry with a common title as follows: White Book of PRM in Europe. “Title”. “Sub-title”
Recognition that the papers will be immediately linked on the website to the Journals, and that there will be a 2 years embargo before publishing the pdf on the European PRM Bodies Alliance website

The official launch will be during the ESPRM (with EARM and UEMS-PRM S&B) Meeting in Vilnius from 2 to 7 May 2018. The WB will be presented during the Opening Ceremony, and the various chapters will be presented as Lectures throughout the Meeting in the appropriate thematic sessions, so to constitute a “fil rouge” of the whole Conference. Also a world presentation is programmed and has been agreed with the International Society of PRM (ISPRM) from 8 to 12 July 2018 during the ISPRM Meeting in Paris.

References

1. European Academy of Rehabilitation Medicine, European Union of Medical Specialists, Physical Medicine and Rehabilitation Section, European Federation of Physical Medicine and Rehabilitation. White Book of Physical and Rehabilitation Medicine in Europe. 1st Edition. Madrid: Universidad Complutense de Madrid; 1989.

2. World Health Organization. International Classification of Impairments, Disabilities, and Handicaps. 1980. 207 p.

3. World Health Organization. WHO | International Classification of Functioning, Disability and Health (ICF) [Internet]. WHO. [cited 2014 Aug 19]. Available from: http://www.who.int/classifications/icf/en/

4. Section of Physical and Rehabilitation Medicine Union Européenne des Médecins Spécialistes (UEMS), European Board of Physical and Rehabilitation Medicine, Académie Européenne de Médecine de Réadaptation, European Society for Physical and Rehabilitation Medicine. White book on physical and rehabilitation medicine in Europe. Eur Medicophysica. 2006 Dec;42(4):292–332.

5. White book on Physical and Rehabilitation Medicine in Europe. J Rehabil Med. 2007 Jan;(45 Suppl):6–47.

6. Convention on the rights of persons with disabilities [Internet]. [cited 2014 Nov 8]. Available from: http://www.un.org/disabilities/convention/conventionfull.shtml

7. Article 26 – Habilitation and rehabilitation | United Nations Enable [Internet]. [cited 2017 Jul 15]. Available from: https://www.un.org/development/desa/disabilities/convention-on-the-rights-of-persons-with-disabilities/article-26-habilitation-and-rehabilitation.html

8. WHO | World report on disability [Internet]. WHO. [cited 2014 Nov 8]. Available from: http://www.who.int/disabilities/world_report/2011/en/

9. WHO | WHO global disability action plan 2014-2021 [Internet]. WHO. [cited 2014 Oct 21]. Available from: http://www.who.int/disabilities/actionplan/en/

10. World Health Organization. Rehabilitation 2030: a call for action: Meeting report [Internet]. WHO; 2017. Available from: http://www.who.int/disabilities/care/rehab-2030/en/

White Book on Physical and Rehabilitation Medicine in Europe