Physical and rehabilitation medicine for outpatients

European Journal of Physical and Rehabilitation Medicine 2025 February;61(1):4-8

Iuly TREGER ^{1, 2} *, Aydan ORAL ³, Alessandro GIUSTINI ⁴, Nicolas CHRISTODOULOU ⁵, Maria G. CERAVOLO ⁶, Mauro ZAMPOLINI ⁷

The need for medical rehabilitation is growing rapidly, including functional assessment and rehabilitation management of outpatients. The wide diversity of the out of the hospital PRM programs leads to define the basic principles and the role of the PRM specialist in the field. The aim of this article is to outline the core professional principles of the PRM for outpatient care, according to the Physical and Rehabilitation Medicine Section of the European Union of Medical Specialists. A Working Group (WG) on “Physical and Rehabilitation Medicine for Outpatients” was formed in March 2023. The final version was unanimously approved at the General Assembly on September 13^th, 2024. The principal aspects of PRM management of outpatients, according to the UEMS PRM Section, are reported. It is essential that PRM programs for outpatients are planned, developed, and implemented according to the professional principles of Physical and Rehabilitation Medicine in appropriate settings. They must be conducted by a multiprofessional team led by a PRM physician. These efforts aim to maximize functional outcomes and enhance the quality of life for individuals at risk of disability and chronic conditions.

Key words: Outpatients; Physical and rehabilitation medicine; Consensus.

The Physical and Rehabilitation Medicine (PRM) Section of the European Union of Medical Specialists (UEMS) is developing Position Papers highlighting the critical roles of PRM physicians in managing various health conditions and addressing topics pertinent to PRM. This effort is led by the UEMS PRM Section, the official European body comprising delegates from national PRM scientific societies representing medical rehabilitation specialists across the European Union.¹

The Declaration of Alma-Ata defines primary care as: “the first level of contact for the population with the health care system, bringing health care as close as possible to where people live and work. It should address the main problems in the community, providing preventive, curative, and rehabilitation services.”² Medical rehabilitation is an essential strategy in primary healthcare, with medical specialists in Physical and Rehabilitation Medicine playing a pivotal role. Our discipline, due to its peculiarity of addressing the care of the Person to cope with the various types of Disability, is particularly trained and competent to integrate bio-medical clinical problems with social, relational and life context problems in the Community.

Physical and Rehabilitation Medicine (PRM) is experiencing rapid advancements worldwide, driven by several key factors.³ The ageing population, alongside improvements in medical care outcomes and a heightened understanding of the critical role of rehabilitation medicine, are among the primary catalysts.⁴ PRM is a specialized medical field committed to enhancing physical and cognitive abilities, encompassing engagement in activities, including behavioral aspects, active participation, which encompasses overall quality of life, and managing personal, social and environmental factors. Therefore, PRM plays a pivotal role in the prevention, diagnosis, therapeutic intervention, and long-term care of diverse debilitating health conditions and concurrent comorbidities across all age groups, spanning acute and chronic stages.⁵

Outpatient medical care, commonly known as ambulatory care, entails services provided to patients without needing admission to an inpatient hospital or for stays lasting less than 24 hours. Significant strides have been made in advancing comprehensive outpatient rehabilitation diagnostic approaches and treatments. These processes offer a viable substitute for hospitalization for acute and chronic patients and serve as a professional intervention following early discharge from inpatient programs. In medical rehabilitation, terminology such as outpatient rehabilitation, ambulatory rehabilitation, and rehabilitation in primary care denote non-inpatient services.⁶

Community-based medical rehabilitation encompasses a variety of programs tailored to meet diverse needs. While the fundamental principles of inpatient rehabilitation are generally consistent across many countries, outpatient programs often exhibit considerable diversity. These programs are influenced by factors such as the healthcare model, local environmental conditions, economic considerations, and resource availability. Community and outpatient rehabilitation programs offer significant advantages, including greater capacity, variety of interventions and cost-effectiveness compared to inpatient programs,⁷ high patient satisfaction rates, and the ability to alleviate the demand for inpatient rehabilitation beds.⁸ Therefore, there is an urgent need to establish minimum standards for these programs and carefully plan their implementation and support. The primary objective of this Position Statement is to outline the core professional principles of the PRM for outpatient care, according to the Physical and Rehabilitation Medicine Section of the European Union of Medical Specialists (UEMS PRM Section).

Methods

The need to develop a Position Statement (PS) was identified at the UEMS PRM Section meeting on March 31^st, 2023. Consequently, a decision was made to establish a Working Group (WG) on “Physical and Rehabilitation Medicine for Outpatients” to discuss and develop the Statement. The WG comprised 17 delegates from 13 European countries. Through live and virtual discussions, as well as email communications, the WG members collaboratively produced the PS. The final version of the PS was unanimously approved at the General Assembly of the UEMS PRM Section on September 13^th, 2024, during the meeting in Palanga, Lithuania.

General professional principles of the PRM for outpatients

• Professional practice must adhere to the principles of the International Classification of Functioning, Disability, and Health (ICF), clearly defining functional goals.⁹

• Professional activities should follow the model of the Individual Rehabilitation Project (IRP),¹⁰ ensuring a tailored approach to each patient’s needs.

• The professional process should embrace a holistic approach, prioritising patient-centred care and involving the patient’s family.¹¹

• Outpatient programs should be delineated as part of the Rehabilitation Management Plan, building upon previous stages and incorporating plans for subsequent stages.¹¹

• Utilising validated assessment measures to gauge functional improvement is imperative,⁵ ensuring accuracy and reliability in tracking progress.

• The engagement of a PRM physician as the leader of the multiprofessional rehabilitation team is warranted, to ensure a comprehensive and expert oversight of the IRP delivery.¹²

• Embracing an multiprofessional approach to the rehabilitation process, including effective interprofessional communication and regular staff meetings,¹³ fosters collaboration and holistic care delivery.

Types of settings of the PRM for outpatients

The European Union of Medical Specialists - PRM Section has meticulously outlined a systematic approach, engaging representatives from numerous member countries via the Delphi process. Through this collaborative effort, they have curated a comprehensive catalogue of medical rehabilitation modalities seamlessly integrated into the community rehabilitation framework. These encompass diverse systems, from rehabilitation day hospitalization and home-based rehabilitation to treatment administered within specialized rehabilitation clinics and other pertinent settings.¹⁴

The most popular outpatient settings for PRM are delineated as follows:

• day rehabilitation: acknowledged as the pinnacle of outpatient rehabilitation settings, it stands out for its professional rigor, characterized by high intensity multiprofessional treatment akin to inpatient programs.¹⁵ The pivotal role of a PRM physician is indispensable in taking medical responsibility of the patient rehabilitation care and orchestrating these interventions. UEMS PRM Section states, “Patients living in the community and presenting with one or more out of a range of health conditions referred to intensive treatment provided by a facility that can accommodate patients during the day. According to the national health system, patients may come directly or be referred after an acute or post-acute situation or by a physician practicing in the community.” These programs may be general and specialized, operating within rehabilitation departments, autonomous community systems, or specialized centers;

• home-based rehabilitation programs: due to logistical constraints, these programs are typified by a lower treatment intensity. However, they remain valuable, particularly for patients with minor injuries or those facing challenges leaving their residences.¹⁶ While home rehabilitation programs vary widely for patients with significant disabilities, a multiprofessional approach, when necessary, under the guidance of a PRM physician is strongly recommended for optimal outcomes;

• outpatient rehabilitation clinics: as defined by the UEMS PRM Section (Rehabilitation in the Community), “Patients living in the community and presenting with one out of a range of health conditions referred to a community health clinic or private practice offering rehabilitation interventions. Patients are referred after an acute or post-acute situation or an episode of a chronic or recurrent health condition.”¹⁴ Rehabilitation clinics led by a physical and rehabilitation medicine physician offer viable solutions for specific patient profiles. These programs may be operated within rehabilitation departments, autonomous community systems, or specialized centers. PRM physicians, in consultative clinics, proceed to clinical diagnosis, assess patients, administer physical medicine treatments, and collaborate with other professionals to develop comprehensive rehabilitation programs tailored to the patient’s needs within the community.

The leading role of PRM physician in PRM diagnosis and therapy for outpatients

The role of a PRM physician in outpatient diagnosis and therapy is multifaceted and pivotal for ensuring the effectiveness and success of rehabilitation interventions.^{17, 18} PRM physicians are adequately trained and qualified to organize and manage IRP for different types of disabilities within a holistic teamwork approach in acute, post-acute, and community settings.¹⁹ White Book on PRM in Europe states, “Like the other specialists, PRM physicians provide direct treatments, but they also lead the multi-professional rehabilitation team that works collaboratively with other professionals and medical specialists”⁵.

Here is an overview of the leading role of a PRM physician in outpatient settings:

• clinical assessment and diagnosis: PRM physicians are trained to conduct clinical diagnoses and comprehensive assessments to evaluate patients’ functional abilities, impairments, rehabilitation needs and prognosis. They use their expertise to diagnose and understand the underlying medical conditions, the complexity of impairments interacting with limitations in activities and restrictions in participation, and psychosocial factors influencing the patient’s rehabilitation journey. They can use electromyography, diagnostic ultrasounds, and other technological tools for assessment and reaching comprehensive clinical and functional diagnosis;

• treatment planning and coordination: based on the assessment findings, PRM physicians implement triage and formulate individualized rehabilitation projects tailored to each patient’s needs, goals, and preferences, including the amount of rehabilitation care needed and the professionals who should be involved.¹¹ They collaborate closely with multiprofessional teams, including physiotherapists, occupational therapists, speech therapists, psychologists, social workers, etc. to coordinate comprehensive care and ensure a holistic approach to rehabilitation based on shared decision principles;

• medical management and intervention: PRM physicians are central in providing medical interventions tailored to alleviate pain, spasticity, and other impediments that could impede the patient’s functional progress. Through precise diagnosis and assessment, they prescribe suitable medications, administer injections, recommend orthoses and prostheses, and advise using assistive devices. Their profound expertise in Physical and Rehabilitation Medicine equips them to address a spectrum of medical and functional challenges patients face in subacute and chronic phases, fostering optimized mobility, independence, and enhanced quality of life;

• supervision and monitoring: PRM physicians supervise the patient’s progress throughout the rehabilitation process, closely monitoring their response to treatment interventions and adjusting the rehabilitation plan as needed. They provide ongoing support, guidance, and encouragement to motivate patients and maximize their potential for improvement. Implementation of standardized digital health records is essential to systematically monitor disability trends in the chronic phase and evaluate the effectiveness of therapeutic interventions. This approach would allow healthcare providers to track functional outcomes over time and analyze the relationship between provided treatments and changes in patient status;

• education and counselling: PRM physicians educate patients and their families about their medical conditions, treatment options, and self-management strategies to promote active participation in the rehabilitation process according personal, social and context conditions. They offer counselling, emotional support, and coping strategies to address the psychosocial challenges and emotional adjustments associated with disability and chronic illness;

• integrating innovative technologies and techniques: PRM specialists play a vital role in introducing and integrating innovative technologies, techniques, and interventions into rehabilitation practice. They stay up to date with the latest research, advancements in assistive devices, robotic rehabilitation systems, virtual reality applications, telerehabilitation²⁰ and other cutting-edge approaches that can enhance patient outcomes such as artificial intelligence.

• advocacy and rehabilitation planning: PRM physicians advocate for their patient’s rights and needs within the healthcare system, ensuring access to appropriate rehabilitation services, community resources, and vocational support.²¹ They collaborate with external stakeholders, such as insurers, employers, and community organizations, to facilitate smooth transitions and continuity of care beyond the outpatient setting aiming to support the better Habilitation in the Community.

The pivotal role of a PRM physician is significantly amplified in outpatient settings compared to inpatient environments, primarily due to the fragmented nature of services within the community. Their professional contribution extends beyond clinical expertise, encompassing multiprofessional collaboration and team coordination, patient-centered care, advocacy, and the seamless continuity of rehabilitation services. These efforts are all directed towards maximizing functional outcomes and enriching the quality of life for individuals grappling with the risk of disability and chronic conditions.

Conclusions

It is essential that PRM programs for outpatients are planned, developed, and implemented according to the professional principles of Physical and Rehabilitation Medicine in appropriate settings. A minimal shared dataset, able to record the outpatient outcome and the treatment provided, could be desirable in order to detect how and if the functional patient’s status change according to the treatment provided. The professional management of patients with various functional problems and at different stages of rehabilitation treatment must be conducted by a multiprofessional team led by a PRM physician. These efforts aim to maximize functional outcomes and enhance the quality of life for individuals at risk of disability and chronic conditions.