1.1.1

Professional practice of the specialist of physical and rehabilitation medicine

As mentioned above professional practice of the specialist in PRM depends on the pathologies to be treated, the limitations in functioning of the respective person as well as on the phase of the disease, the setting he or she is working in and the personal factors of the patient (e.g., age, gender, comorbidities, coping strategies and others). It includes diagnosis and staging of the underlying pathology, the prescription and/or application of a wide range of interventions and the PRM programme management. Additional skills of the PRM specialists include PRM team cooperation, research in the field as well as quality control and management .

PRM specialists have a number of skills ( Table 2 ). Their basic medical training gives them competencies, which are enhanced by knowledge and experience acquired during their core training in other specialties (internal medicine, surgery, psychiatry, etc.). The core specialty competencies of PRM are provided during their specialist training and these are further enhanced by knowledge and experience of subspecialty work . As in other medical fields, PRM specialists have a comprehensive education as defined in the European Board Curriculum ( www.euro-prm.org ). However, during professional practice in different settings and the clinical work with patients with specific health conditions specific knowledge, skills and attitudes will be acquired by the PRM specialist (see Chapter 2 and Fig. 1 below)

Structure of education and training system in physical and rehabilitation medicine. Given points are examples only. For more information see text.

The field of competence will refer to the three main classifications of the World Health Organisation being:

• •
  

  the International Classification of Diseases (ICD) ;

  
  
• •
  

  the International Classification of Functioning, Disabilities and Health (ICF) and;

  
  
• •
  

  the International Classification of Health Interventions (ICHI) .

1.1.2

Pathologies treated by the specialist of physical and rehabilitation medicine (ICD)

The classification referred to is the ICD .

Diseases in which the specialist of PRM can be involved, can be classified relating to their causal mechanism (for example, traumatic or not), to the system or organ concerned, or to the age . Examples are listed in Table 3 .

PRM specialists are mainly involved in promoting functioning and in reducing functional consequences of these conditions. They are involved in the long-term follow-up of patients with long-term conditions in the aim of preserving autonomy, social integration and quality of life.

1.1.3

Functioning and disabilities managed by the specialist of physical and rehabilitation medicine (ICF)

The management of functioning and disabilities of the Specialist in PRM is based on the comprehensive model of functioning, as described in the ICF. The classification referred to is the ICF too .

The management of functioning and disability by a specialist for PRM includes the treatment of the underlying pathology as well as the improvement of body structures and functions, activities and participation as well as to modify the contextual factors (including contextual and personal factors). These dimensions are defined as follows:

• •
  

  a health condition is an umbrella term for disease, disorder, injury or trauma and may also include other circumstances, such as ageing, stress, congenital anomaly, or genetic predisposition. It may also include information about pathogenesis and/or aetiology. There are possible interactions with all components of functioning, body functions and structures, activity and participation;

  
  
• •
  

  body functions are defined as the physiological functions of body systems, including mental, cognitive and psychological functions. Body structures are the anatomical parts of the body, such as organs, limbs and their components. Abnormalities of function, as well as abnormalities of structure, are referred to as impairments, which are defined as a significant deviation or loss (e.g. deformity) of structures (e.g. joints) or/and functions (e.g. reduced range of motion, muscle weakness, pain and fatigue);

  
  
• •
  

  activity is the execution of a task or action by an individual and represents the individual perspective of functioning. Difficulties at the activity level are referred to as activity limitation (e.g. limitations in mobility such as walking, climbing steps, grasping or carrying);

  
  
• •
  

  participation refers to the involvement of an individual in a life situation and represents the societal perspective of functioning. Problems an individual may experience in his/her involvement in life situations are denoted as participation restriction (e.g. restrictions in community life, recreation and leisure, but may be in walking too, if walking is an aspect of participation in terms of life situation);

  
  
• •
  

  environmental factors represent the complete background of an individual’s life and living situation. Within the contextual factors, the environmental factors make up the physical, social and attitudinal environment, in which people live and conduct their lives. These factors are external to individuals and can have a positive or negative influence, i.e., they can represent a facilitator or a barrier for the individual;

  
  
• •
  

  personal factors are the particular background of an individual’s life and living situation and comprise features that are not part of a health condition, i.e. gender, age, race, fitness, lifestyle, habits, and social background;

  
  
• •
  

  assessing the biography of patients is useful, particularly their personal, social, vocational and recreational history. Personal goals are also important to record, e.g. what are the wishes of the patients, what is important for their quality of life?

  
  
• •
  

  risk factors could thus be described in both personal factors (e.g. lifestyle, genetic make-up) and environmental factors (e.g. architectural barriers, living and work conditions). Risk factors are not only associated with the onset, but interact with the disabling process at each stage.

1.1.4

Diagnosis and assessment (ICHI)

The classification referred to is the ICHI .

PRM doctors recognise the need for a (or several) definitive diagnosis prior to treatment and problem-orientated PRM programme. In addition, they are concerned with aspects of functioning and participation that contribute to the full evaluation of the patient in determining the treatment goals . Diagnosis and assessment in PRM comprise all dimensions of body functions and structures, activities and participation issues relevant for the rehabilitation process . Additionally relevant contextual factors are assessed.

History taking in PRM includes analysing problems in all the ICF dimensions. In order to obtain a diagnosis of structural deficits relevant to the disease and the PRM-programme.

Standard investigations and techniques are used in addition to clinical examination. These include laboratory analysis of blood samples, imaging, etc.

Clinical evaluation and measurement of functional restrictions and functional potential with respect to the PRM-programme constitute a major part of diagnostics in PRM. These include the clinical evaluation of muscle power, range of motion, circulatory and respiratory functions.

Qualitative and quantitative assessment of body functions based on technical equipment. These measurements may include muscle testing (strength, electrical activity and others), testing of circulatory functions (blood pressure, heart frequency, EMG while resting and under strain), lung function, balance and gait, hand grip, swallowing function and others. PRM specialists use specialised technical assessments of performance such as gait and movement analysis, isokinetic muscle testing and other movement functions.

In PRM-programs of patients with certain conditions specialised diagnostic measures will be required, e.g. dysphagia evaluation in patients with stroke, urodynamic measurements in patients with spinal cord injury, or executive function analysis in patients with brain injury.

Patients’ activities can be assessed in many ways. Examples of two important methods are standardised activities of single functions performed by the patient (e.g., walking test, grip tests or handling of instruments, performance in standardised occupational settings) and assessments of more complex activities, such as the activities of daily living (washing oneself, dressing, toileting and others) and performance in day-to-day living (walking, sitting, etc.)

Numerous scales are used to assess patients’ activities in PRM assessment questionnaires

Socioeconomic parameters (e.g., days of sick leave) are used in order to evaluate social or occupational participation problems. Many assessment instruments in PRM combine parameters of body functions, activities and participation.

The relevant contextual factors with respect to the social and physical environment are evaluated by interviews or standardised ICF-based checklists. For the identification of personal factors, for example, standardised questionnaires may be used to assess coping strategies.

1.1.5

Treatments and Interventions (ICHI)

Also here the classification referred to is the International Classification of Health Interventions of the WHO (ICHI) .

PRM specialists perform and/or prescribe medical and physical interventions and provide information and education programs for patients and their families. Many of the PRM interventions listed below are performed by therapists (physiotherapists, occupational therapists, speech and language therapists, rehabilitation nurses and others) and appropriately coordinated in a multi-professional patient-centred team. Of course other professionals such as psychologists, social workers, prosthesits and others will contribute to team-integrated care.

The classification referred to is the International Classification of Health Interventions (ICHI) PRM specialists use diverse interventions. They develop an intervention plan based on the diagnosis of lesions, the evaluation of impairments, activities limitations, participation restrictions and the functional performance of the patient .

This PRM programme is explained and proposed to the patients, their families and the confident persons (e.g., relatives, friends) they wish.

As diagnosis and assessment in PRM cover a wide range of methods other team members will contribute to this process. In many cases, the task of diagnosis of the pathology falls to the PRM specialists, however, in some cases other medical specialists will be involved too (e.g., neuroradiologists for lesions of the central nervous system). The evaluation of functions and activities can be performed also by PRM specialists, however, frequently other team members, such as occupational therapists, physiotherapist, speech and language therapist will perform functional assessements. The evaluation of participation can be performed by the PRM specialists, but also other health professionals (social workers, psychologists, and others).

Family and relatives should be consulted in order to build a clearer picture of activity limitations and participation restrictions. Patients may underestimate their need for support (particularly following acquired brain injury). The estimation of dependency level is of high value in order to define the number of hours and the type of health and social, professional need by a patient. It has high economical consequences. There are several useful instruments. One straightforward validated instrument for day-to-day clinical use is the Northwick Park Dependency Scale .

Thereafter, the PRM-specialist either performs the intervention aiming at solving the given problems or other team members may do so. Alternatively or additionally the PRM specialists will prescribe the therapy that then will be performed by other therapists (e.g. Physiotherapists, Occupational Therapists, Speech and Language Therapists, and others. Practical procedures include injections and other techniques of drug administration. Assessment and review of medical interventions and prognostication are part of practice of PRM specialists too.

Interventions are shown in Table 4 .

1.1.6

PRM programmes of care management (ICF, ICHI)

The specialists in PRM plays a complex role, which starts with a medical diagnosis, a functional and social assessment and continues with the definition of the different goals to achieve, according to the patient needs, the set up of a comprehensive strategy, the achievement of personal intervention including prescription of medication, physical therapies (including physical modalities, physiotherapy, occupational therapy and other) and rehabilitation technology, and the supervision of team or network cooperation. It ends after a final assessment of the overall process.

This process can be named a PRM programme of care . It refers to all three classifications of WHO (ICD, ICF and ICIH). The UEMS accreditation of PRM programs follows the following pattern:

• •
  

  general basis: pathological and impairment considerations, functioning and disability issues, social and economic consequences, main principles of the programmes;

  
  
• •
  

  aims and goals: target population, goals of the programme, targets in terms of ICF;

  
  
• •
  

  content: assessment (diagnosis, impairment, activity and participation, environmental factor), intervention (timeframe of the programme, PRM specialist’s intervention, team intervention), follow-up and outcome, discharge planning and long-term follow-up;

  
  
• •
  

  environment and organization: clinical setting, clinical programmes, clinical approach, facility, safety and patient rights, advocacy. PRM Specialists in the programme and team management;

  
  
• •
  

  information management: patient records, management information, programme monitoring and outcome;

  
  
• •
  

  quality improvement: strong and weak points of the programme, action plan to improve the programme;

  
  
• •
  

  references: scientific references and guidelines cited in the above description, details about national documents.

PRM programmes of care adapt general principles to any local need and condition. For instance, PRM early intervention in an acute care hospital will comprise a different programe of interventions for brain-injured people from that of a community-based unit dealing with people suffering from brain damage. A Posture and Movement Assessment Unit will provide a third kind of additional assessment and advisory program. In big cities, specialised PRM programmes may accept referrals from a large catchment area and address the needs of a very specific population. Other programmes will be designed to respond to more common health conditions with less technology and specialized resources but with a more personal relationship.

PRM programmes of care should address one special issue, rather than describe the overall activity of a PRM Department. The main entrance to the programme may be:

• •
  

  an impairment (pathology): spinal cord injury, knee ligament reconstruction, stroke, low back pain;

  
  
• •
  

  an activity and participation limitation: walking disability, aphasia;

  
  
• •
  

  a vocational goal: independent living for brain-injured people, professional activities for people with chronic low back pain;

  
  
• •
  

  a period of life, with some specific features: children with cerebral palsies, sportsmen/women with musculoskeletal injuries, manual workers with low back pain, elderly people with falling hazards.

PRM programmes of care are the basis for a quality approach. This issue will be further developed below in Chapter 1.6 .

1.1.7

Quality control and management (ICHI)

Achieving the best quality of care as possible is an ethical obligation for any physician. However, beyond the personal commitment, some pioneers have started to express the quality approach in a more formal way, e.g. the Mayo brothers, whose precepts remain up to date.

On the legal ground, the Council of Europe issued in 1997 the Recommendation No R(97)17 about the development and implementation of quality improvement systems (QIS) in health care. The UEMS started to address this issue very early and adopted, as soon as 1996 a first European Charter on Quality Insurance in Specialized Medical Practice.

In European countries, certification and accreditation mandatory procedures are focused either on physicians or on facilities. In France, accreditation of facilities contains some special features adapted to post-acute settings (Services de suite et de réadaptation [SSR]), but the recent merging of the different kinds of settings into a single ensemble has led to confusion, so this cannot be given as an example for PRM projects.

However, the French PRM organizations (SYFMER, SOFMER, FEDMER) have issued a series of papers addressing the organizational aspects of PRM Practice:

• •
  

  charter on Quality in PRM (1997);

  
  
• •
  

  recommendations for the equipment of outpatient PRM facilities (2002);

  
  
• •
  

  inclusion criteria of patients into PRM facilities (2008).

In this perspective, the concept of PRM Programme of Care (PRM-PC), has quickly emerged as the best basis for developing a European approach of Quality of Care. The PRM Specialist, who is the responsible person for a PRM-PC, has to describe his/her programmes with respect to the definition given in chapter E.

On this basis, a European Accreditation of PRM-PC has been set up on the web-site www.euro-prm.org . The main criteria for acceptance are:

• •
  

  the responsible person of the programme is PRM Board certificated doctor;

  
  
• •
  

  the programme is clearly structured and described;

  
  
• •
  

  the programme demonstrates evidence of using the ICF concept;

  
  
• •
  

  quantified data about the target population are given, goals must be consistent and should be expressed in terms of ICF categories;

  
  
• •
  

  environment and organization of the programme is clearly defined, PRM Specialists participating in the programme should be listed, staff competencies should be adequate, adequate continuing vocational training for physicians and staff must be organized;

  
  
• •
  

  clear definitions of admission and discharge criteria should be given, the programme should include properly organized patient records;

  
  
• •
  

  the references are cited within the description of the programme, there should be evidence that the references cited are relevant and incorporated into PRM practice.

The criteria for refusal are:

• •
  

  the Programme of Care submitted is not run by a PRM Board Certified Specialist;

  
  
• •
  

  or there is a combination of the following negative aspects:

  
  
• •
  

  no provision is made for vocational training on the PRM health care programme;

  
  
• •
  

  no follow-up is being carried out on the outcomes of the programme;

  
  
• •
  

  the scientific bases of the programme have not been specified.

Operating PRM program quality management doesn’t require an extensive assessment of numerous parameters, which may become incompatible with a normal daily practice. Here, it is useful to make a difference between a Clinical Research Programme and the Assessment of a PRM-PC. Whereas the general goal of clinical research is to give the most definite answer to a simple and concise question, a programme of care, aims at performing an efficient intervention onto the widest population as possible, only defined by the same issues to deal with, the same goal to reach and a potential compliance to the scheduled intervention. For instance, a follow-up programme of patients after anterior cruciate ligament reconstruction can also be applied, subject to some special adaptations, to reconstruction of the posterior cruciate ligament or to complex knee damage. Of course, it will be necessary to adjust the goals and the calendar, to detail precautions and specific measures to take for each sub-group.

Routine assessment in daily clinical practice can address a limited number of parameters only, which should be chosen as significant indicators of the progress or the difficulties of the patient and on the programme efficiency. Working within team cooperation may help to share the tasks, especially those related with more or less sophisticated and time consuming tests. Nevertheless, the cost of this operation has to be considered and maintained under a reasonable level, without prejudice for the concrete care of the patient.

The choice of criteria and methods of assessments therefore results from a compromise between the assessments goals and the available means. This choice may move with time where some parameters appear to be redundant, always get the same score at the same stage of the programme or prove to have no practical significance, whereas other parameters can reveal a dysfunction or a good enough level of performance to allow the starting of the next programme stage. All these concerns should be expressed within the care programme description.

1.1.8

Team work

Effective team working plays a crucial role in PRM. As part of its role of optimizing and harmonizing clinical practice across Europe, the Professional Practice Committee of UEMS, PRM Section has reviewed patterns of team working and debated recommendations for good practice .

Effective team working produces better patient outcomes (including better survival rates) in a range of disorders, notably following stroke (for an overview see 26). There is limited published evidence concerning what constitute the key components of successful teams in PRM programmes. However, the theoretical basis for good team-working has been well-described in other settings and includes agreed aims, agreement and understanding on how best to achieve these, a multi-professional team with an appropriate range of knowledge and skills, mutual trust and respect, willingness to share knowledge and expertise and to speak openly. A central element of this are regular team meetings.

PRM specialists have an essential role to play in interdisciplinary teams; their training and specific expertise enables them to diagnose and assess severity of health problems, a prerequisite for safe intervention as well as taking team leadership. Their broad training also means they are able to take holistic view of an individual patient’s care, and are therefore well-placed to coordinate PRM programmes and develop and evaluate new management strategies.

Additionally to multi-professional teamwork networking out of PRM facilities from acute care to long term facilities or community-based services is crucial to PRM practice. This includes communication and counselling with other specialists for the underlying pathology, with the general practitioner (especially in long term PRM-programs) as well as to social network including social services and employers. PRM provides continuous education of the patient, his or her family and the PRM team. Of course, the exchange of information must follow the strict data-protection rules and must be agreed by the patient.

PRM have to know the competencies of the professionals involved in the PRM team. When they create these teams they have to know the professionals with whom they will to cooperate best. This is dependent on the patients they welcome to the PRM facilities they coordinate, the stage of the evolution of these patients. PRM specialists have to take lead of the team. This includes asking the team members relevant questions to be answered in a comprehensive way.

PRM specialists have links with the acute facilities wishing to send patients. They have to define the criteria for admission defining the medical and social profile of the patients they admit. PRM specialists have links with long-term facilities (either PRM coordinated or not) and ambulatory facilities (either PRM coordinated or not). The criterion for discharge to long term facilities or to return to home, without or with a support such a medical and social service (PRM run or not) have to be defined. PRM specialists have to develop out of the PRM facilities they coordinate, a network of persons, mainly health and social Professional but also public or private organizations which can facilitate integration, avoid or solve problems encountered by patients (e.g. TBI with mood disturbance) and maintain health.

1.2.1

Undergraduate education in the field

As any patient may require rehabilitation and physical therapies, all physicians need to achieve basic knowledge of PRM. A motion has been agreed by the UEMS Council that undergraduate education in all the EU Medical Schools should include a teaching programme on disability issues . Models have been developed to systematically include PRM in undergraduate teaching programmes .

1.3.1

Continuous medical education, continuous professional development

CME and CPD are an integral part of medical specialists’ professional practice and PRM specialists need (either on a mandatory or ethical basis) to demonstrate their continued competence like all other doctors. CPD covers all aspects of updating medical practitioners, of which CME is one component. The PRM specialty has set up various congresses, teaching and training programmes across Europe, which serve to educate PRM specialists and their colleagues in PRM teams. These cover basic science and clinical teaching topics, as well as investigational, technical and management programmes .

At EU level the accreditation of PRM congresses is under supervision of the UEMS European Accreditation Council of CME (EACCME). The UEMS PRM Board on the basis of an agreement signed with the EACCME is the referent body to evaluate the quality of PRM congresses.

A CME and CPD program is organised on European level for accreditation of international PRM congresses and events. The programme is based on the provisions of the mutual agreement signed between the UEMS European Accreditation Council of CME (EACCME) and the UEMS-PRM Section and Board. The European provisions are the same for all specialities. The PRM Board has created the CPD/CME Committee, which is responsible for the relevant continuing programs within our speciality, for the accreditation of the several scientific events on European level and the scientific status of the Board Certified PRM specialists.

EACCME is responsible for coordinating this activity for all medical specialties and the UEMS website gives details of the CME requirements for all specialists in Europe ( www.uems.org ). Each Board-recognised PRM specialist is required to gain 250 educational credits over a five-year period for the purposes of reaccreditation ( www.euro-prm.org ). Medical doctors are required to fulfil their CME requirements before they can be accreditated and this is becoming an essential part of national as well as European life. Obligatory CPD/CME is established in certain countries of Europe and is becoming increasingly required in medical practice.

2.1.1

Exercice professionnel du spécialiste de médecine physique et réadaptation

L’exercice professionnel du spécialiste en MPR dépend des pathologies à traiter, de leurs stades évolutifs, des incapacités et des limitations de participation de la personne ainsi que de son lieu de vie, de ses conditions de travail, de facteurs individuels tels que l’âge, le sexe, les comorbidités, la façon dont la personne fait face à la maladie. L’exercice professionnel comprend le diagnostic, l’évaluation de la sévérité de la pathologie sous-jacente, la prescription ou la réalisation personnelle d’un grand nombre d’actes et la direction d’un programme de MPR, ce qui implique la coopération avec l’équipe de MPR, le contrôle de la qualité des soins et la recherche dans ce domaine.

Les spécialistes en MPR ont de nombreuses capacités d’intervention ( Tableau 2 ). Leur formation médicale de base leur donne des compétences qui sont améliorées par les connaissances et l’expérience acquise durant leurs stages dans d’autres spécialités (médecine interne, chirurgie, psychiatrie, etc.). Ces compétences dans des spécialités ciblées dans le cadre de la MPR sont acquises pendant la formation mais sont plus tard renforcées dans le cadre d’une sur-spécialisation . Comme dans les autres domaines médicaux, les spécialistes en MPR ont une formation globale définie dans l’ European Board Curriculum ( www.euro-prm.org ). Cependant, pendant leur exercice professionnel, dans différentes conditions et pendant leur travail clinique avec les patients présentant des problèmes de santé particuliers, des connaissances spécifiques, des compétences et des comportements seront acquis par le spécialiste en MPR (cf. Chapitre 2 et Fig. 1 ci-dessous).

Tableau 2

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

De l’indexation bibliométrique au financement et à l’évaluation de la recherche, un enjeu pour les Annales de médecine physique et de réadaptation? Peroneus quartus and functional ankle instability New rehabilitation program for intermittent claudication: Interval training with active recovery. Pilot study Haematoma of pectineus muscle after total hip arthroplasty Education in the management of low back pain. Literature review and recall of key recommendations for practice Diagnosis and Treatment of Cervical Radiculopathy and Myelopathy

Stay updated, free articles. Join our Telegram channel

Join