The field of competence of the specialist in physical and rehabilitation medicine (PRM).

Abstract

The Field of Competence (FOC) of specialists in Physical and Rehabilitation Medicine (PRM) in Europe follows uniform basic principles described in the White Book of PRM in Europe. An agreed basis of the field of competence is the European Board curriculum for the PRM-specialist certification. However, due to national traditions, different health systems and other factors, PRM practice varies between regions and countries in Europe. Even within a country the professional practice of the individual doctor may vary because of the specific setting he or she is working in. For that reason this paper aims at a comprehensive description of the FOC in PRM. PRM specialists deal with/intervene in a wide range of diseases and functional deficits. Their interventions include, prevention of diseases and their complications, diagnosis of diseases, functional assessment, information and education of patients, families and professionals, treatments (physical modalities, drugs and other interventions). PRM interventions are often organized within PRM programmes of care. PRM interventions benefit from the involvement of PRM specialists in research. PRM specialists have knowledge of the rehabilitation process, team working, medical and physical treatments, rehabilitation technology, prevention and management of complications and methodology of research in the field. PRM specialists are involved in reducing functional consequences of many health conditions and manage functioning and disability in the respective patients. Diagnostic skills include all dimensions of body functions and structures, activities and participation issues relevant for the rehabilitation process. Additionally relevant contextual factors are assessed. PRM interventions range from medication, physical treatments, psychosocial interventions and rehabilitation technology. As PRM is based on the principles of evidence-based medicine PRM specialist are involved in research too. Quality management programs for PRM interventions are established at national and European levels. PRM specialists are practising in various settings along a continuum of care, including acute settings, post acute and long term rehabilitation programs. The latter include community based activities and intermittent in- or out-patient programs. Within all PRM practice, Continuous Medical Education (CME) and Continuous Professional Development (CPD) are part of the comprehensive educational system.

Full text

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Professional practices and recommendations / Pratiques professionnelles et recommandations
The field of competence of the specialist in physical and rehabilitation
medicine (PRM)
Champ de compétence du spécialiste en médecine physique et de réadaptation
C. Gutenbrunnera,*, F. Lemoineb, A. Yelnikc, P.-A. Josephd,
G. de Korvine, V. Neumannf, A. Delarqueg
aDepartment for Rehabilitation Medicine Carl-Neuberg-Str. 1, Hannover Medical School, 30625 Hannover, Germany
bCentre He ´lio-Marin, Ugecam - Paca et corse, voie Julia, 06223 Vallauris, France
cService de Me ´decine Physique et de Re ´adaptation, GH Lariboisie `re F. Widal, 200, rue du Faubourg-Saint-Denis, 75010 Paris, France
dService de Me ´decine Physique et de Re ´adaptation Fe ´de ´ration de Neurosciences Cliniques, Universite ´ Victor-Segalen Bordeaux 2, CHU, 33076 Bordeaux, France
eCentre Hospitalier, Prive ´ Saint-Gre ´goire, 6, boulevard de la Boutie `re, 35768 Saint-Gre ´goire, France
fAcademic Department of Rehabilitation Medicine, Faculty of Medicine and Health, University of Leeds, Great-George Street, Leeds LS1 3EX, UK
gPo ˆle Me ´dical Intersites de Me ´decine Physique et de Re ´adaptation-Me ´decine du Sport (PMPR), Faculte ´ de Me ´decine, Universite ´ de la Me ´diterrane ´e,
CHU Timone, AP–HM, 13385 Marseille, France
Received 23 November 2010; accepted 6 May 2011
Abstract
The Field of Competence (FOC) of specialists in Physical and Rehabilitation Medicine (PRM) in Europe follows uniform basic principles
described in the White Book of PRM in Europe. An agreed basis of the field of competence is the European Board curriculum for the PRM-
specialist certification. However, due to national traditions, different health systems and other factors, PRM practice varies between regions and
countries in Europe. Even within a country the professional practice of the individual doctor may vary because of the specific setting he or she is
workingin.ForthatreasonthispaperaimsatacomprehensivedescriptionoftheFOCinPRM.PRMspecialistsdealwith/interveneinawiderange
of diseases and functional deficits. Their interventions include, prevention of diseases and their complications, diagnosis of diseases, functional
assessment, information and education of patients, families and professionals, treatments (physical modalities, drugs and other interventions).
PRM interventions are often organized within PRM programmes of care. PRM interventions benefit from the involvement of PRM specialists in
research. PRM specialists have knowledge of the rehabilitation process, team working, medical and physical treatments, rehabilitation technology,
prevention and management of complications and methodology of research in the field. PRM specialists are involved in reducing functional
consequences of many health conditions and manage functioning and disability in the respective patients. Diagnostic skills include all dimensions
of body functions and structures, activities and participation issues relevant for the rehabilitation process. Additionally relevant contextual factors
are assessed. PRM interventions range from medication, physical treatments, psychosocial interventions and rehabilitation technology. As PRM is
based on the principles of evidence-based medicine PRM specialist are involved in research too. Quality management programs for PRM
interventions are established at national and European levels. PRM specialists are practising in various settings along a continuum of care,
includingacutesettings,postacuteandlongtermrehabilitationprograms.Thelatterincludecommunitybasedactivitiesandintermittentin-orout-
patient programs. Within all PRM practice, Continuous Medical Education (CME) and Continuous Professional Development (CPD) are part of
the comprehensive educational system.
# 2011 Elsevier Masson SAS. All rights reserved.
Keywords: Physical and rehabilitation medicine (PRM); Field of competence; Professional practice; PRM-interventions; Diagnostic and assessment in PRM
Re ´sume ´
Le champ de compe ´tences (CC) du spe ´cialiste en me ´decine physique et re ´adaptation (MPR) en Europe repose sur des principes de base de ´crits
dans le Livre blanc de MPR en Europe. Un socle consensuel du champ de compe ´tences est le cursus e ´tabli par le Board europe ´en pour la
Annals of Physical and Rehabilitation Medicine 54 (2011) 298–318
* Corresponding author.
E-mail address: gutenbrunner.christoph@mh-hannover.de (C. Gutenbrunner).
1877-0657/$ – see front matter # 2011 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.rehab.2011.05.001
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certification desspe ´cialistes enMPR. Cependant, du fait detraditions nationales, des diffe ´rents syste `mes desante ´ et d’autres facteurs,l’exercice de
la MPR varie suivant les re ´gions et les pays d’Europe. Au sein d’un pays donne ´, la pratique professionnelle d’un me ´decin peut changer selon ses
conditions de travail spe ´cifique. Le butde cet article est de donner une description du CC en MPR. Les spe ´cialistes de MPR sont concerne ´s par une
grande varie ´te ´ de maladies et d’incapacite ´s. Ils interviennent dans la pre ´vention des maladies et de leurs complications, dans le diagnostic, dans
l’e ´valuation fonctionnelle, dans l’information et l’e ´ducation des patients, des familles et des professionnels de sante ´, dans le traitement (the ´rapie
physique, me ´dicaments et autres interventions the ´rapeutiques) et dans la recherche. Les actes de MPR sont souvent organise ´s en programmes. Les
spe ´cialistes en MPR ont la connaissance de la conduite de la re ´e ´ducation, du travail en e ´quipe, des traitements me ´dicaux et physiques, de la
technologie au service de la re ´e ´ducation, de la pre ´vention, de la prise en charge des complications et de la me ´thodologie en matie `re de recherche
dans leur domaine. Les spe ´cialistes en MPR sont implique ´s dans la re ´duction des conse ´quences fonctionnelles de nombreuses affections et
s’occupent des incapacite ´s et du fonctionnement pour chaque patient. Les aptitudes diagnostiques et d’e ´valuation comprennent toutes les grandes
fonctions et les structures du corps, les activite ´s, les actes de participation en rapport avec le plan de re ´e ´ducation. Les activite ´s de MPR
comprennent les prescriptions me ´dicamenteuses, les traitements physiques, les interventions psychosociales, la re ´e ´ducation. La MPR est fonde ´e
sur les principes de la me ´decine par la preuve, le spe ´cialiste en MPR est implique ´ dans la recherche. Des programmes qualite ´ pour les activite ´s de
MPR sont e ´tablis a ` un niveau national et europe ´en. Les spe ´cialistes en MPR travaillent dans des conditions varie ´es a ` chaque e ´tape de la filie `re de
soins dans les e ´tablissements de soins aigus, les soins de suite et le suivi a ` long terme. Ce dernier secteur comprend les activite ´s en milieu ordinaire
de vie et les prises en charge en e ´tablissements de soins de longue dure ´e, que ce soit en hospitalisation comple `te ou de jour. Pour toutes ces
pratiques, la formation me ´dicale continue (FMC) et l’e ´valuation des pratiques professionnelles (EPP) font partie inte ´grante du syste `me e ´ducatif
global.
# 2011 Elsevier Masson SAS. Tous droits re ´serve ´s.
Mots cle ´s : Me ´decine physique et re ´adaptation (MPR) ; Champ de compe ´tences ; Pratique professionnelle ; Interventions en MPR ; Diagnostic et e ´valuation en
MPR
1. English version
1.1. Introduction
Physical and rehabilitation medicine (PRM) is an indepen-
dent specialty, member of the Union of European Medical
Specialists (Union europe ´enne des me ´decins spe ´cialistes
[UEMS]) with a PRM Section and Board. The field of
competence of PRM and the teaching and training programmes
organized at national and European levels aim to respond to:
? population health needs. Improvement in acute care and life
expectancy has led to an increase in the number of people
with activity limitation and participation restriction;
? individual patient’s goals. PRM specialists set up and
coordinate individual care pathways.
PRM interventions of course have to be adapted to the needs
ofindividual patients and will be different in different phases of
the diseases and functional recovery [26,59,8,25,22,29].
Epidemiological studies on disabled persons within the
European Union (EU) show an increased number of people
with disabilities [26]. The population prevalence amounts to
10% [58,14,7,15].
Several factors have led to increased demand:
? the improvement of acute care, the life expectancy
lengthening thanks to the progress of public health in
developed countries [50];
? people with disabilities and user organisations are more
aware of the medical and social new opportunities available
to improve their quality of life;
? thanks to improvements in communication (patients ´ reviews,
websites with accurate information) patients and families
have greater awareness of available treatments.
Patients’ needs may differ with respect to the phases of the
evolution of their pathology: acute phase, post-acute phase,
steady state with sequels. Table 1 will give an overview on
patients needs during acute, post acute and long-term phases as
well as in prevention.
This paper intends to describe the field of competence of the
specialist of PRM starting from professional practice and
clinical work with the patients [29]. It is based on the definition
of the field as given by the UEMS (‘‘PRM is an independent
medical specialty’ concerned with the promotion of physical
and cognitive functioning, activities [including behaviour],
participation [including quality of life] and modifying personal
and environmental factors. It is thus responsible for the
prevention, diagnosis, treatments and rehabilitation manage-
ment of people with disabling medical conditions and co-
morbidity across all ages’’) and the descriptions made in the
WhiteBookonPRMinEurope[26].Additionally,itreflectsthe
discussion about an ICF-based conceptual description of PRM
[50].
1.1.1. Professional practice of the specialist of physical
and rehabilitation medicine
As mentioned aboveprofessional practice of the specialistin
PRMdependsonthepathologiestobetreated,thelimitationsin
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 [52].
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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
[26,24,13,51,40]. 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 knowl-
edge, skills and attitudes will be acquiredby the PRM specialist
(see Chapter 2 and Fig. 1 below)
The field of competence will refer to the three main
classifications of the World Health Organisation being:
? the International Classification of Diseases (ICD) [60];
? the International Classification of Functioning, Disabilities
and Health (ICF) [61] and;
? the International Classification of Health Interventions
(ICHI) [62].
1.1.2. Pathologies treated by the specialist of physical and
rehabilitation medicine (ICD)
The classification referred to is the ICD [60].
DiseasesinwhichthespecialistofPRMcanbeinvolved,can
be classified relating to their causal mechanism (for example,
traumatic or not), to the system or organ concerned, or to the
age [26]. 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
Table 1
Patients needs during acute, post acute and long term phases of rehabilitation as well as in prevention.
Patients’ needs
during acute
phase [59,8,25]
Diagnostic and assessment of functional loss
Prevention of usual complications, these complications have to be anticipated and recognised by the PRM specialist
(deconditioning and malnutrition, pressure ulcers, thromboses, joint contractures, spasticity, mood disturbances)
Preservation or restoration of their main functions, capacities, participation
Orientation and integration as soon as possible towards a specific PRM programme adapted to the patients and
their needs and wishes
Presentation and explanation of these programmes, their milestones to the patients and their families along with the
referent professionals for them, for example their general practitioners, their nurses or physical therapists
Adaptation of these programmes to the particularities of each patient and family
Planning discharge from hospital
Patients needs during
post acute phase
within dedicated
PRM facilities
[32,6,17,10,35,45,46]
Diagnostic and treatment of complications linked to the initial pathology and of complications
Evaluation based on ICF, definition, presentation, coordination of the PRM programme with the expected targets,
the tools and methods which will be used to assess the results, definition in collaboration with patients and their
families of the treatment targets, the phases and the
assessments to be set up
Patients needs during
steady state [33]
Assessment of long-term disabilities, activity limitations and participation restrictions as well as of rehabilitation potential
Long-term follow-up of people with disabilities including adaptation of treatments to the progress or decrease
of the patients functional capacity and progress of therapies and technologies
Analysis of contextual factors influencing the patients’ functioning
Setting-up a long-term PRM-plan
Prescribing PRM-interventions including technical aids and coordination of multi-Professional team work
Education of patient and relatives
Supporting participation including return to work and leisure activities and social support
Prevention
[21,39,5,31,56,20,19,30,36]
Teaching and applying primary prevention measures such as management of risk factors (e.g., hypertension for stroke),
physical activity and healthy food
Teaching health promoting behaviour both in healthy people and persons with chronic conditions (e.g., lifting &
handling techniques, back schools, physical training, and others) with a long-term perspective
Prevention of complications after acute trauma or disease as well as in the post-acute rehabilitation phase (see above)
Table 2
Competencies of PRM specialists.
Medical assessment in determining the underlying diagnosis
Assessment of functional capacity and the potential for change
Assessment of activity and participation as well as contextual factors (personal
characteristics and environment)
Knowledge of core rehabilitation processes and their evidence base
Knowledge on the competencies of all team members involved in rehabilitation
programs [17]
Devising a PRM intervention plan
Knowledge, experience and application of medical and physical treatments
(including physical modalities, natural factors and others)
Evaluation and measurement of outcome
Prevention and management of complications
Prognostication of disease/condition and rehabilitation outcomes
Knowledge of rehabilitations technology (orthotics, prosthetics, technical aids
and others)
Team dynamics and leadership skills
Teaching skills (patients, carer, tem members and others)
Knowledge of social system and legislation on disablement including
educational and vocational aspects and compensation
Basic knowledge of economic (and financial) aspects of rehabilitation
Methodology of research in the field of biomedical rehabilitation sciences and
engineering
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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 [50,61].
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
pathogenesisand/oraetiology.Therearepossibleinteractions
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.
Table 3
Conditions treated by PRM specialists.
Traumatic diseases: brain injury, spinal cord injury, multiple trauma, peripheral nervous lesions, sports trauma, trauma during long-term disabling disease, work-
related trauma
Non traumatic diseases of the nervous system: stroke, degenerative disease (Parkinsonism, Alzheimer’s disease and others) multiple sclerosis, infection or abscess of
the central nervous system, tumour of the CNS, spinal cord paralysis whatever the cause, complex consequences of neurosurgery, muscular dystrophy and
neuromuscular disorders, peripheral neuropathies (among them Guillain Barre polyradiculopathy), nervous compression, congenital diseases (cerebral palsy, spina
bifida, and others), metabolic or biochemic genetical diseases
Acute or chronic pain from various causes such as amputation, post surgical care, critical illness polyneuropathy
Complex status of various and multiple cause: bed rest syndrome, effort deconditioning, multisystem failure
Non traumatic diseases of the musculo-skeletal system: spinal column (chronic and acute low back pain, cervical or thoracic pain), infectious, degenerative and
inflammatory arthropathies (mono and poly arthritis), vascular amputation, soft tissues disorder including fibromyalgia, complex disorders of the extremities (hands,
feet), osteoporosis, work-related chronic pain syndrome, chronic fatigue syndrome
Cardiovascular diseases: ischaemic heart diseases, cardiac failure, valve diseases, lower limb atherosclerosis, myocarditis, high blood pressure, heart transplant
Diseases of the lymphatic system
Diseases of the respiratory system: asthma, chronic obstructive pulmonary disease, pulmonary fibrosis, pneumoconiosis, asbestosis
Endocrine and metabolic diseases: diabetic complications, complications of the metabolic syndrome, obesity
Diseases of the genito-urinary system: chronic renal failure, vesico-sphincterian disorders, genito-sexual disorders
Infectious and immunologic diseases: consequences of the HIV infection, transplant of the bone marrow
Cancer, its treatments and their functional consequences
Age-related disorders
Other diseases in children: scoliosis, congenital malformations
[(Fig._ 1)TD$FIG]
PRM
Curri-
culum
Specific training in PRM e.g.:
assessment of functional capacities and activities
specific knowledge on therapies (physical therapies, medication)
coordination of PRM-teamwork
influencing contextual factors and participation in society
Basic medical education
diagnosing the underlying pathology
principles of medical treatment
evaluation of treatment results
and others
PRM
Programs
PRM in
people
after
stroke
PRM in
musculo-
skeletal
conditions
PRM in
the
elderly
and
others
Fig. 1. Structure of education and training system in physical and rehabilitation medicine. Given points are examples only. For more information see text.
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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 thebiography ofpatientsisuseful,particularlytheir
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 [60,62].
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
[3]. Diagnosis and assessment in PRM comprise all dimensions
of body functions and structures, activities and participation
issues relevant for the rehabilitation process [51]. 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 restric-
tions 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. dyspha-
gia evaluation in patients with stroke, urodynamic measure-
ments 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.) [4]
Numerous scales are used to assess patients’ activities in
PRM assessment questionnaires [2]
Socioeconomicparameters (e.g., daysofsickleave)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 standar-
dised 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) [62].
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 Classifica-
tion ofHealth Interventions (ICHI) [62,23] 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 func-
tional performance of the patient [52].
C. Gutenbrunner et al./Annals of Physical and Rehabilitation Medicine 54 (2011) 298–318302
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