Introduction

1. 7 PRACTICE OF PHYSICAL AND REHABILITATION MEDICINE IN EUROPEThe clinical field of competence: PRM in practice European Physical and Rehabilitation Medicine Bodies Alliance. White Book on Physical and Rehabilitation Medicine in Europe. Chapter 7. The clinical field of competence: PRM in practice. Eur J Phys Rehabil Med. 2018 Apr;54(2):230-260. doi: 10.23736/S1973-9087.18.05151-1.

2. Introduction • Thisparagraphsystematicallypresentsthepracticalworkof PRM physiciansdescribing: • thescopeandcompetenciesof PRM • therehabilitationprocess • thespectrumofdiseasestreatedby PRM physicians • thediagnosisin PRM • theinterventionsin PRM • themulti-professional PRM team • theoutcomesof PRM interventionsandprograms

3. Scope of competencies of PRM • PRM physicians are involved in the management of patients with a multitude of different health conditions and the impact of these conditions on personal functioning and participation. • It is specific for PRM to combine therefore the curative and rehabilitative strategy. • PRM treatments and programs may also refer to other health strategies, such as prevention as well as maintenance and support. • The field of competence includes education and training as well as management, coordination and advice.

5. Interactionsofthecurativeandrehabilitativestrategiesandtheintegrative role of PRM (modifiedfromReinhardtetal.)

6. Pyramidofthelevelsofspecializationinhealthrelatedrehabilitation as well as the role of PRM inservicedelivery, coordinationofservices, andeducationandtraining (fromGutenbrunneretal.)

7. The rehabilitation process: assessment, goal-setting, intervention, and evaluation • PRM physiciansmanage, leadandcoordinatetherehabilitationprocesswithin a problem-oriented, patient-centeredandholisticapproach, aloneorwithin a teamofrehabilitationprofessionals. • Therehabilitationprocessregularlycomprises 4 stages: • assessment (includestheassessmentoffunctioning) • goal-setting (withinrehabilitation plan, short-termandlong-termgoals, involvementofthepatientandthefamily/carer, assignmentofestablishedgoals to specificinterventionsandsubsequently to theresponsiblemember(s) ofthemulti-professional PRM team) • intervention (to prevent, stabilize, improveorrestoreimpairmentsofbodyfunctionsandstructures, and to optimizeactivitiesandparticipation) • evaluation (ofgoalachievementsandinformingoffurthermaintenanceofhealth, follow-upvisitsifneededand how to re-accessservices)

8. Therehabilitationcycle (modifiedfromStuckietalandRauchetal).

9. Spectrum of health conditions treated by PRM physicians: • Anydisease, pathology, orhealthconditioncausingimpairmentsofbodyfunctionsand/orstructures, activitylimitations, orparticipationrestrictions. • Thepromotionoffunctioningandreductionofunfavorablefunctionalconsequencesarisinginacuteor post-acutephases as well as for patientswithlong-termconditions. • Thereis a numberof general problemsacrossthemanyhealthconditions, e.g: • prolonged bed restandimmobilization • motor deficitsand/orsensorydeficits • spasticity • painsyndromes • communicationdifficulties • mood, behavior, andpersonalitychanges • bladderandboweldysfunctions • pressureulcers • dysphagia • sexualdysfunction • changes to familydynamics, personal relations, careeropportunitiesandfinancialsecurity

10. …etc… . .

11. Diagnosis of diseases in PRM (medical diagnosis) • Diagnosisin PRM includesmedicaldiagnosisandfunctionalassessment. • PRM physicians take a detailedhistoryaboutthepresenthealthcondition, past medicalconditions, reviewofsystems as well as functional status (mobility, self-care activities, cognition, communication, vocationalandrecreationalactivities), andfamilyandsocialhistory. • A thoroughphysicalexaminationincluding general medical, neurologicalandmusculoskeletalexaminationisofparamountimportance. • Imagingtechniques are of major relevance: X-ray imaging, ultrasound, Computerizedtomography (CT), Magneticresonanceimaging (MRI), electrodiagnosticorurodynamictesting… laboratorytesting… • Technologies aboutmusclestrength (power, work), rangeofmotion, kineticandkinematicanalysis, equilibriumcapacityandmuscularelectricalactivity… • Finalassessmentofthefunctionalityofthepatient.

12. Multidimensional assessment of functioning (functional assessment) • In addition to medicaldiagnosis, functionalassessmentis a prerequisite for the PRM physician. • Bodyfunctionsrequiringassessmentin most musculoskeletalconditions are pain, mobilityofjoints, stabilityofjoints, musclepower, muscle tone, muscleendurance, energy, sleep, emotionalfunctions, exercisetolerance, gaitpatternandsexualfunctions. • Bodyfunctionsinneurologicalconditionsshouldalsoincludecognitivefunctions, sensoryfunctions, voiceandspeechfunctions, controlofvoluntarymovement, defecationandurination. • Jointdeformities, muscleatrophy, structuralimpairments are impairmentsofbodystructures. • Assessmentsofperformancesuch as gaitanalysis, dynamometricmuscletestingandothermovementfunctions. • In the PRM processofpatientswithcertainconditions,specializeddiagnosticmeasureswillberequirede.g. dysphagiaevaluation, electro-diagnostictests, urodynamicmeasurementsorcognitivefunctiontests.

13. Theterm „functionalassessment“ usedinthemedical literature corresponds to assessing „activitiesandparticipation“. • Assessmentscanbemadeofperformance (whatanindividualisdoinginhisorhercurrentenvironment), or on capacity (ability to execute a task). • Environmentaland personal factors (such as motivation) have a greatimpact on theperformanceofactivitiesandshouldbeassessedeither as a barrieror facilitator. • The WHO ispursuingthegoaloftheintegrationofthe ICD and ICF duringthe ICD revisionprocess (ICD-11); thiswill make holisticinformationavailableregarding a medicaldiagnosisanditsimpact on thefunctioning (i.e. functionalassessment) at the same time in a commonframework.

14. Table III.—_Diagnostic Tools and Assessments in Physical and Rehabilitation Medicine: activities, participation and contextual factors. Special clinical and technical assessments of activities and participation • Dexterity: Nine Hole Peg Test, Box & Block test, Jebsen-Taylor hand function test • Hand and arm use: Motor Activity Log, ABILHAND, Action Research Arm Test, Cochin Hand Scale, The Disabilities of the Arm, Shoulder and Hand (DASH) Score, and other scales • Balance: Berg Balance Scale, Timed “Up and Go Test”, Functional Reach Test, Balance Subscale of the Fugl-Meyer test, Postural Assessment Scale for Stroke, static and dynamic posturography, wearable inertial sensors, and other performance scales • Mobility: Functional Ambulation Category, 10-Meter Walking Test, 6-MinuteWalking Test, Rivermead Mobility Index, and others • Activities of daily living: Health Assessment Questionnaire, Barthel Index, Functional Independence Measure (FIM™) • Instrumental/extended activities of daily living: Frenchay Activities Index, Rivermead ADL Scale, and others. • Activities & participation: World Health Organization Disability Assessment Schedule II (WHODAS II), Modified Rankin Scale, London Handicap Scale, Impact on Participation and Autonomy Questionnaire, Participation Profile, Participation Scale, Keele Assessment of Participation, LIFE-H, EuroQol 5 and other self-report scales • Telemonitoring systems for rehabilitation • Electromyographic devices • Diagnostic ultrasounds devices • Work: Assessment of work and productive activities (including functional capacity evaluation and job site analysis), self-report questionnaires (e.g. Work Limitations Questionnaire, World Health Organization Health and Work Performance Questionnaire, Workplace Activity Limitations Scale...) • Driving assessment Assessment of contextual factors and needs • Relevant environmental factors: Products and technology for personal use in daily living, indoor/outdoor mobility and transportation; natural and physical environment; support from family, friends, caregivers, community, health professionals, employer etc.; attitudes of individuals and society, services, systems and policies • Personal factors: lifestyle, habits, education, race/ethnicity, life events or social background care needs • Equipment needs, personal transportation (e.g. wheelchairs) • Environmental adaptation needs (e.g. accommodation) • Access to information technology, health literacy

15. Interventions in PRM • PRM uses a wide range of biomedical and technological interventions: • medical interventions (e.g. medication and practical procedures) • physical treatments and physiotherapy • occupational therapy • speech and language therapy and dysphagia management • neuropsychological interventions, psychological interventions • nutritional therapy • assistive technology, prosthetics, orthotics, technical supports and aids • patient education and PRM/rehabilitation nursing

16. …etc.. . .

17. Standardized PRM programs • PRM physiciansplay a complex role: medicaldiagnosis, a functionalandsocialassessment, thedefinitionofdifferentgoals, the set-upof a comprehensivestrategy, theachievementof personal interventionandthesupervisionofteamor network cooperation. • Itendsafter a finalassessmentoftheprocess - „PRM Program of Care“. • TheClinicalAffairsCommitteeofthe UEMS-PRM Sectiondevelopedstandards for accreditationofsuchprograms. • PRM Programsof Care are a goodbasis for a qualityapproach. • Themainentrance to the program maybeanimpairment, anactivitylimitationandparticipationrestriction, a vocationalgoalorindependentliving, a period oflife, with some specificfeatures. • Professional PracticeCommitteeofthe UEMS-PRM SectiondescribestheFieldofCompetenceof PRM inspecificareas.

18. ….etc… . .

19. Management skills and advisory role of PRM • PRM physicians have a wide range of management skills: • to manage a patient-case • to manage a rehabilitation hospital or other service • to influence health policies and environmental design to facilitate participation of persons with disabilities • To fulfil these tasks PRM training includes many aspects of management skills: team work, planning skills, health systems knowledge, process management, principles of service provision including financial aspects, basics of health policies and others.

20. Multi-professional collaboration and collaborative teamwork • In PRM literature theterms are mostlyused to describecollaborationpartnersworkingtogetherintheteam: • multi-professionalteam: teamconsistingofmultiplerehabilitationprofessionals (e.g. PRM, PT, OT, SLT, nursesand/orothers) • inter-disciplinarycollaboration: collaborationamongdifferentmedicalspecialties (e.g. PRM, trauma surgeon, neurologistand/orothers). • In teamtheory, theterms are used to describethewayofcollaborationandtheinteractionbetweenteammembersirrespectiveoftheirprofessionalbackground: • multi-disciplinaryteamwork: teamworkwithoutsystematicstructureandwithoutanorganizeddecisionmakingprocess • inter-disciplinaryteamwork: collaborationofteammemberswithdifferentbackgroundsputtingtogethertheirknowledge, expertiseandexperience to solveproblemstogether • suchteamsgatherregularly, discussallproblemsandworkbased on equalityofcontributionofeveryteammember. Decisions are taken as a team (mostlybased on consensus). Communicationisalwaysmultilateral.

21. Theterm „multi-professionalteam” willbeused for a rehabilitationteamconsistingofdifferentrehabilitationprofessionalscollaborativelyworkingundertheleadershipof a PRM physician, • theterm „interdisciplinarycounselling” for collaborationof PRM physicianswithothermedicalspecialists, and • theterm „collaborativeteamwork” for a teamworkinginaninterdisciplinary, multidisciplinaryortransdisciplinarywayaccording to thesettingandneeds. In most cases, structuredmulti-professionalteamsworkingcollaborativelyundertheleadershipof PRM physicians, based on sharedethicalandscientificbases as well as commonmethodologyandlanguage, are needed - fundamental to achieveoptimallevelofoutcome.

22. Most important principles of successful team work are: • appropriate range of knowledge and skills for the agreed task • mutual trust and respect • willingness to share knowledge and expertise • speak openly • The team involves directly the patient and his/her significant others/family. • Cooperation within the rehabilitation team is ensured by structured team communication and regular team meetings. • PRM physicians have a duty to provide adequate information, training and clinical support, but each health professional has an individual responsibility to uphold his or her profession’s standards.

23. The competencies of the members of the team should be: • physicians: diagnosing, prognosis, medical assessment and treatment, setting-up treatment and rehabilitation plan, prescription of pharmacological and non-pharmacological treatments and assessment of response to these • rehabilitation nurses: day-to-day care needs, tissue viability, continence problems, emotional support, education • physiotherapists: assessment of posture and movement problems, administering physical treatments including exercise • occupational therapists: assessing the impact of physical or cognitive problems on activities of daily living, return to work, education and/or leisure activities, strategies that can be used by the patient and his/her family, use of assistive technology and environmental adaptations • speech and language therapists: assessing and treating cognitive, communication, orofacial motility problems and swallowing disorders • clinical psychologists: assessment of cognitive, perceptual and emotional/ behavioral problems, strategies to manage these with the patient, his/her family and with other health professionals • social workers: promoting participation, community reintegration and social support • prosthetists and orthotists: provision of technologies • bioengineers and rehabilitation engineers: regarding technologies and data collection • dieticians: assessing and promoting adequate nutrition

24. The PRM physician’s role intheteamisessential for establishingthemedicaldiagnosis, thefunctionalevaluation, theprescription, thetreatment plan andtheleadershipoftheteam. • Theclinicalinterventionhas to addressthehealthcondition, impairments, activitylimitationsandparticipationrestrictions. • However, virtuallyeveryrehabilitationinterventionhasrisksthat must beassumedwithresponsibility. For thisreason, a thoroughmedicaldiagnosisandassessmentisessential prior to everyrehabilitationintervention. • PRM physicianshavetheresponsibility for providinganintegrateddescriptionofeachindividual’spatternand care pathway, leadingthedecision-makingprocess.

25. Ethics in clinical PRM practice • PRM professionalscentrallyinvolvepatients, familiesandcaregiversinthegoalsettingprocessandaddressethicaldilemmas as partofthis. • Ethicalissuesinthreesettingscommonlyencounteredinrehabilitation medicine are: • resourceallocationandpatientselection • theethicsofteam care • ethicalissuesingoalsetting • Ultimately, thegoalofrehabilitation medicine is to ensurepatientautonomy, beneficenceandjustice, whilestriving to givethebest care possible, at the same time as respectingthewishesandguidelinesofsociety as a wholewithintherestraintsoftheavailableresources.

26. Outcomes of PRM interventions and programs:The importance of functional outcomes • Functioning is experienced by all humans and any person may experience problems in functioning, ranging from mild to severe, in his/her lifespan. • Evidence suggests that an individual’s level of functioning in interaction with the current environment, termed as „lived health“ is more important than biological health. • Findings clearly point to the value and importance of functional outcomes specifically relevant to PRM on the evaluation of health from the perspectives of individuals.

27. Person-centered outcomes • Theprimaryresponsibilityof PRM physiciansis to producetreatmentoutcomes to affectpersons’livesinaccordancewiththeirvaluedaspects. • PRM outcomes are associatedwithvariousaspectsofhealth-relatedqualityoflife. • Demonstrating a person’swell-beingandsocialparticipationisanimportantfeatureofthefundamentaloutcomeofpatient-centeredrehabilitation. • Sharedgoal-settingis a centralissuein PRM and a corecompetencyof PRM. • ICF tools (ICF Categorical Profile, ICF Evaluation Display, and ICF AssessmentSheets) canbeused for theidentification, definition, andillustrationofrehabilitationgoals, interventiontargets, andgoalachievement. • Theassessmentofchangesinfunctioningafter a goalandoutcomeorientedrehabilitationinterventionandgoalachievement are significantoutcomemeasuresinrehabilitationsettings.

28. Theevaluationofrehabilitationhasfundamentaldifferencesfromtheevaluationofdisease-orientatedmedicaltreatmentsaimed at limitingpathologyorcuringdisease. • Ifthe problem ofanindividualisanimpairedfunction, thentheprimaryoutcomeshouldrelate to thatfunction. • Ifthegoalistheachievementof „participationinsociety” whichistheultimategoalofrehabilitation, thenparticipationrestrictionsshouldbemeasured as theprimaryoutcome. • Evidence-basedpractices do improveoutcomesof care ifthebestcompromisebetweenpersondeemedgoals (goalswhich are importantandmeaningful to thepersons) andrehabilitation plan canbeachieved. • Rehabilitationhastheability to reducetheburden on disabilityboth for individualsand for society. Itisshown to beeffectiveinenhancingindividualfunctioningandindependentlivingbyachievinggreateractivity, betterhealthandbyreducingcomplicationsandtheeffectsofcomorbidities.

29. Cost-effectiveness outcomes and Survival outcomes • Theeffectivenessofrehabilitationisnotonlyassociatedwithenhancedfunctioningandlivingindependently but alsowithreducedcostsofdependencydue to disability. • PRM outcomes are associatedwithsurvival; Rehabilitationreducestheriskofmortality. • Rehabilitationcanbesuccessfullyachievedinconditionswherethereis no biologicalrecoveryandinconditionsthat are deteriorating. • In thelatter, rehabilitationmayneed to bedeliveredin a continuing program thatenablesthepatient to maintainlevelsofparticipationandwell-being. • PRM programsandrehabilitationservices for personswithdisabilitiesproduceconcretebenefitsincludingimprovementinfunctioningandreductionincosts as well as decreaseinmortality for certaingroupsofpatientswhichjustifytheimportanceof PRM outcomes.

30. Contributors For Chapter 7, 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 College of Physical and Rehabilitation Medicine (served by the UEMS-PRM Board). • The Editors: Christoph Gutenbrunner, Pedro Cantista, Maria Gabriella Ceravolo, Nicolas Christodoulou, Alain Delarque, CarlotteKiekens, SašaMoslavac, Enrique Varela-Donoso, Anthony B Ward, Mauro Zampolini, Stefano Negrini. • The contributors: Filipe Antunes, Ayşe A. Küçükdeveci, Aydan Oral, Peter Takáč, Catarina Aguiar Branco, Mark Delargy, Alessandro Giustini, Jean-Jacques Glaesener, KlemenGrabljevec, Karol Hornáček, SlavicaDj. Jandrić, Wim G.M. Janssen, Jolanta Kujawa, Renato Nunes, Rajiv K Singh, AivarsVetra, Jiri Votava, Mauro Zampolini, Alain Delarque, Gabor Fazekas, Francesca Gimigliano, Vera Neumann, Tatjana Paternostro-Sluga, OthmarSchuhfried, Luigi Tesio, TonkoVlak, Alain Yelnik.