Chapter 61 International Physical Medicine and Rehabilitation

John L. Melvin, Marta Imamura, Jose Jimenez

The specialty of physical medicine and rehabilitation (PM&R) has grown steadily since the recognition of the American Board of PM&R by the American Board of Medical Specialties (ABMS) in 1949. The American Academy of PM&R reported at its last annual business meeting that membership was more than 8000. PM&R in the United States is a recognized and viable specialty whose members uniformly meet rigorous standards of competency.

PM&R as a medical specialty also exists in many other countries. The same influences that resulted in the specialty’s growth in the United States exist globally. Both developing and developed countries have significant numbers of people with disabilities. PM&R physicians in all countries focus on maximizing the function of those with disabilities.

The number of PM&R physicians is large and growing globally. The International Society of Physical and Rehabilitation Medicine (ISPRM) reported 47 national societies of physical and rehabilitation medicine (PRM) as constituent members in 2006.⁴⁷ The Fifth International Congress of Physical and Rehabilitation Medicine in 2009 at Istanbul had almost 3000 attendees.

The “world is shrinking” in general, and with rehabilitation medicine in particular, as a result of advances in electronic communication. Both visual and verbal communication now occurs faster than ever before, and to many more places than ever before. E-mail and electronic attachments make communication with international colleagues virtually as easy as with those in one’s own immediate vicinity. Web-based information is now available whenever and virtually wherever the user wishes to access it.

PM&R has gone global because of three basic influences: the universal presence of conditions causing disability, existence of PM&R specialists worldwide, and the use of effective and efficient communication techniques.³⁷ This globalization provides benefits to PM&R specialists in the United States and throughout the world. It also creates the need to develop consensus or accommodation when different groups approach specialty issues differently. For example, differences in terminology related to the specialty have developed between PM&R specialists internationally and those in the United States.

One basic terminology issue is what to name the specialty. U.S. physicians have called the specialty physical medicine and rehabilitation since the ABMS recognized it in 1949. Many international specialty organizations, however, refer to the specialty as physical and rehabilitation medicine. This language resulted from international deliberations on how to name the new organization that resulted from the merger of the International Federation of PM&R and the International Rehabilitation Medicine Society. After these deliberations the name of this organization became the International Society of Physical and Rehabilitation Medicine.

Another issue related to terminology is to what extent authors and speakers use the specific definitions included in the International Classification of Functioning, Disability, and Health (ICF) published by the World Health Organization (WHO).⁵⁴ Terms defined specifically by the ICF include health condition, functioning, activity, participation, environmental factors, and personal factors. Some of these definitions differ from those commonly used in the United States. One example is the term disability, which the ICF defines as an umbrella term to designate the existence of any impairments, activity limitations, or participation restrictions.⁵⁴ The international authors of this chapter refer to the specialty as PRM and use the ICF terms as published by the WHO.

There have been international professional organizations for many years that have focused on assisting PMR physicians and other physicians interested in providing medical rehabilitation care. The following section discusses these organizations and their activities. The section after that provides an analysis of education of PM&R/PMR specialists and of medical students in the knowledge, skills, and attitudes needed to provide appropriate care to their patients around the world. The Education Committee of the ISPRM provided the educational perspective of this section. The ISPRM has identified education of PRM physicians, PRM trainees, and medical students as high priority activities, in the belief that education is the best way to improve the standards of PMR care worldwide.

Brief History of International Physical Medicine and Rehabilitation Organizations

International cultural exchange, interaction, and cooperation are not new events. Throughout history, there have always been communal and cross-border efforts in the development of science and “finding the cause.” As far back as the Babylonian civilization, physicians were travelers spreading their knowledge for a fee and publishing medical texts.³² In the Hellenic civilization, learning and knowledge development were based on schools in which foreign physicians and medical students mixed with the locals to create an international learning environment.³³ Some of these schools also promoted the itinerant physician (periodeute), who traveled with what today would be considered a “team” formed by assistants, students, and midwives. This group not only treated patients but also gave lectures to the local students.

Pre-1950 International Physical Medicine

It is well known that many different physical agents have been used throughout history for therapeutic purposes. The first international congress of one of these agents, hydroclimatology, was held in 1886.³⁰ Sidney Licht stated that six international congresses of what today is known as “physical medicine” were held between 1905 and 1936.²⁹ Licht acknowledged his indebtedness in the compilation of this material to an international group including Drs. P. Bauwens of London, P. Farneti of Milan, J. Gunzburg of Antwerp, J. Michez of Brussels, and J. van Breemen of Amsterdam. It is not surprising that the term physiotherapy was used for the designation of most of these early congresses. This is because during the first and second decades of the twentieth century, physicians who used physical agents for diagnostic and therapeutic procedures were recognized under multiple names: electrotherapist, hydrologist, physical therapeutist, physiotherapist, and physiotherapy physicians. In some instances they were also included under the broad term of radiologist. The expression “physical medicine” was first used by the London Hospital in England in 1921.^2,^29,30 In the United States, the official recognition of the term physical medicine as a specialty with an independent board took place in 1947, thanks to the efforts of a group of physicians led by Dr. Frank Krusen.^2,³⁸ It was at the sixth and last of these early international congresses that the name physical medicine was first used as a Congress designation.^1,^30,⁴⁹ This occurred largely because this congress was organized by L’Association Internationale de Médicine Physique et de Physiothérapy (which was founded in Liége in 1930 and disappeared during World War II) (personal communication, Mail Information Office of the Archives of Physical Medicine and Rehabilitation, September 2, 2009).

International Federation of Physical Medicine

An international committee met in London in 1950 that included Dr. Frank Krusen (United States), Dr. Philippe Bauwens (United Kingdom), Dr. Hugh Burt (United Kingdom), Dr. Sven Clemmensen (Denmark), and Dr. Will Fegner (United Kingdom), members at large. This Committee agreed to form “The International Federation of Physical Medicine” (IFPM), with the mission “to advance all aspects of Physical Medicine for the benefit of mankind.”

The First International Congress of the IFPM was held at King’s College in London on July 13 to 18, 1952. This congress was attended by more than 200 physicians representing 23 countries.^16,²⁹ At the time of the Fourth Congress (Paris, 1964) it was resolved to apply for membership as an affiliate of the WHO to better fulfill the objectives of the organization. The application was approved, and the Federation then began a close working relationship with the Rehabilitation Offices of WHO. The name of the Federation was changed in 1972 to the International Federation of Physical Medicine and Rehabilitation (IFPM&R).

Since the 1980s, the IFPM&R and the International Rehabilitation Medicine Association (IRMA) continued to improve communications and linking of national societies and individual physicians interested in the academic, clinical, and social aspects of disabilities. These conversations became more formalized in 1992 with the creation of the International Task Force that eventually led to the creation of the new International Society of Physical and Rehabilitation Medicine.

International Rehabilitation Medicine Association

According to Dr. H. J. Flax, the International Rehabilitation Medicine Association (IRMA) was Dr. Sidney Licht’s idea and was founded in 1968. Dr. Licht wanted “to establish an international forum where physicians from countries that had not yet recognized the specialty of Physical Medicine and Rehabilitation as well as physicians from other specialties who utilized physical modalities or were interested in Rehabilitation, could meet and discuss their work.”⁸ To achieve this aim, in November 1968, an international committee was formed that included Dr. Christopher B. Wynn Parry, Dr. J. Poal, Dr. W. J. Erdman II, and Dr. S. Licht. It was decided that membership in the association would be offered exclusively “to doctors of medicine (physicians and/or surgeons), who are members of a national medical society of their country of residence or citizenship.” The committee of four invited the Società Italiana di Medicina Fisica e Rehabilitazioni to hold the first world congress (IRMA I) in Milan on September 20, 1970. During its life, IRMA focused not only on scientific matters but also on communication. IRMA fostered liaisons with other rehabilitation organizations, adopted the Journal of Disability and Rehabilitation, and produced several monographs to achieve its mission of broadening the professional competence of its members.

International Society of Physical and Rehabilitation Medicine

Since the creation of IRMA in 1968, there always was some liaison between it and the already existing IFPM&R.¹⁷ During a meeting in Dresden in 1992, it was resolved to explore the possibility of merging the two societies. As noted above, an international task force was created, including John Melvin (United States), Robert Oakeshott (Australia), and Jose Jimenez (Canada) representing IFPM&R and Martin Grabois (United States), Satoshi Ueda (Japan), and Ashok Muzumdar (Canada) representing IRMA. John Melvin was elected Chair. This group worked out an agreement that included:

1. Preliminary acceptance of the name of International Society of Physical Medicine and Rehabilitation to designate the new organization

2. Designation of Amsterdam as the site of the First World Congress of ISPRM in 2001, to be organized and sponsored by the Netherlands Association of Physical Medicine and Rehabilitation.

Dr. John Melvin was installed in 1999 as the first president of the ISPRM. The mission of the ISPRM was and continues to be as outlined in Box 61-1.

ISPRM offers two categories of active membership: (1) “National Societies of PM&R—recognized as such in their own country; and whose membership is primarily composed of qualified physicians,” and (2) “All physicians and surgeons qualified to practice in their own country or retired from practice five years or less, who are interested in and/or concerned with the care of people with impairments and disabilities.” Associate and corporate memberships are also available. It was decided to have a permanent and professional secretariat, and after evaluation of several proposals and applicants, Medicongress Service N.V. from Assenede, Belgium was selected.

ISPRM continues to maintain contact with other regional and rehabilitation-related organizations such as the Latin American Medical Association of Rehabilitation, European Society of Physical and Rehabilitation Medicine, Asian-Oceanian Society of Physical and Rehabilitation Medicine, Mediterranean Forum of Physical and Rehabilitation Medicine, Spinal Cord Injury Data Set, Rehabilitation International, sub-Saharan Africa interest groups, Bone and Joint, and the recently created Baltic & North Sea Forum on Physical and Rehabilitation Medicine. ISPRM continues to grow, and by 2009, there were 2054 individual members and 24 paid-up national societies.

The activities of the ISPRM in its short 10-year history have increased greatly. Congress attendance has averaged more than 1500 registrants, with plenary sessions, courses, workshops, meetings with the experts, daily poster sessions, and six to eight simultaneous free paper presentations. News and Views is now published monthly; there is online availability of the Journal of Rehabilitation Medicine; and there is an ongoing relationship with the Journal of Disability. The ISPRM website (www.isprm.org) now provides visitors with a detailed history and evolution of ISPRM, as well as continuing coverage of its activities. ISPRM has also facilitated an increasing exchange of experts and education with WHO Committees.

Education in Physical Medicine and Rehabilitation: International Perspectives—Challenges and Opportunities for Mutual Growth

Maintaining an international joint effort to promote excellence in teaching and training of professionals in the field of PRM with wide geographic representation is an ambitious task. There has been a continuous growth of initiatives to expand the collaboration among active members of ISPRM to achieve this goal. The Education Committee of ISPRM is charged with preparing, maintaining, and assuring access to systematic reviews about the effects of treatments in the field of PRM. It is also charged with helping physiatrists in the decision-making process based on quality information in rehabilitation care, creating undergraduate and postgraduate minimum curricula that can be used at an international level, facilitating access to the best levels of education in PRM, facilitating access to research data and activities in the field, and disseminating information on PRM education.

Members of the Physical and Rehabilitation Medicine Section of the Board of the European Union of Medical Specialists (UEMS) have created the European standards of competence in PRM. The White Book on Physical and Rehabilitation Medicine in Europe contains a clear and detailed list of the topics that should be covered as a minimum requirement for any education and training program in the specialty within the European countries affiliated with the European Union.¹³ The White Book is a unique and realistic attempt to promote standards of education for practitioners of different backgrounds, languages, and cultures. The program content is divided into 15 chapters, under two major sections. The first section has four chapters, including the fundamentals of PRM, physiology and basic physiopathology, clinical and functional assessment in PRM, and therapies in PRM. The second section includes topics relating to the application of PRM to specific pathologies and health conditions: the immobile patient; adult locomotor system; sports, nervous system, respiratory, cardiovascular, pediatric, urologic, and sexual problems; geriatrics; oncologic rehabilitation; and reintegration and maintenance of disabled and elderly people at home.¹³ The standardized training course is described in detail to facilitate the development of common standards of training. Despite different laws and national traditions, physicians certified in PRM by their national training authorities are eligible to be recognized by the European Board of PRM.

Once certified these specialists have the ability to move freely across UEMS member states and practice PRM in different countries. The White Book also includes a list of national delegates from each country.¹³ The unified education program under the UEMS provides a mechanism responsible for recognition of teachers and training institutions, as well as monitoring and guaranteeing quality assurance of the training sites. Another important step is the recognition of a single annual written certifying examination given throughout Europe, as well as standard rules for the accreditation of trainees and for the process of certification.

A unified continuing medical education (CME) system also consolidates the revalidation of practitioner certification into 10 yearly intervals. CME credits are provided for participation in scientific events, presentation of scientific work, publications, academic, and self-education activities. An extraordinary effort is made to promote the accreditation of international congresses and events in Europe. The program was developed based on the mutual agreement signed between the UEMS European Accreditation Council of CME and the UEMS-PRM Section and Board. A special committee is responsible for continuing programs within the specialty, for the accreditation of the several scientific events in Europe, and for the scientific status of board-certified PRM specialists.¹³

Specialized medical knowledge is only part of the core competencies required for residency programs by the Accreditation Council on Graduate Medical Education (the governing body that accredits residency programs in the United States). A competent specialized physician should demonstrate the six core competencies as outlined in Box 61-2. The main goals of the core competencies are for practitioners to develop the ability to care for patients and to work effectively in health care delivery systems.⁴⁸ The curricula developed by the American Board of Physical Medicine and Rehabilitation (a constituent member of the American Board of Medical Specialties) are implemented in all American programs, including those in Puerto Rico. Residency programs of all specialties are now required to develop and implement education strategies to meet these six core competencies.