Evidence-based position paper on Physical and Rehabilitation Medicine (PRM) professional practice on telerehabilitation. The European PRM position (UEMS PRM Section).

INTRODUCTION: The evidence on the utility and effectiveness of rehabilitation interventions delivered via telerehabilitation is growing rapidly. Telerehabilitation is expected to have a key role in rehabilitation in the future. AIM: The aim of this evidence-based position paper (EBPP) is to improve PRM physicians' professional practice in telerehabilitation to be delivered to improve functioning and to reduce activity limitations and/or participation restrictions in individuals with a variety of disabling health conditions. METHODS: To produce recommendations for PRM physicians on telerehabilitation, a systematic review of the literature and a consensus procedure by means of a Delphi process have been performed involving the delegates of all European countries represented in the UEMS PRM Section. RESULTS: The systematic literature review is reported together with the 32 recommendations resulting from the Delphi procedure. CONCLUSIONS: It is recommended that PRM physicians deliver rehabilitation services remotely, via digital means or using communication technologies to eligible individuals, whenever required and feasible in a variety of health conditions in favor of the patient and his/her family, based on evidence of effectiveness and in compliance with relevant regulations. This EBPP represents the official position of the European Union through the UEMS PRM Section and designates the professional role of PRM physicians in telerehabilitation.

The Medical Community's Role in Communication Strategies during Health Crises-Perspective from European Union of Medical Specialists (UEMS).

The COVID-19 pandemic was complicated by the spread of false information leading to what became widely called an "infodemic". The present opinion paper was written by an ad hoc international team united under the European Union of Medical Specialists (UEMS) umbrella and reflects the organizations' effort to contribute to the resolution of these issues, by highlighting and reflecting on them and by suggesting the medical community's necessary activities resulting in the formulation of effective future communication strategies. The importance of physicians' and other health workers' role and mission as educators and leaders in communities in critical situations should be reassessed and upgraded. We need to equip future doctors with strong and sustainable leadership and communication skills through relevant undergraduate and postgraduate education programs, in order that compliance with preventive medical advice is increased. To avoid possible politically and otherwise biased communication in health crises of the future, European nations should establish independent advisory bodies providing evidence-based advice and participate in communication campaigns. Medical and other health professional organizations should build organizational and personal capacities of their members to enable them to reliably inform and adequately educate governments, populations, civic society, employers' and employees' organizations, schools and universities, and other stakeholders.

Development of simple descriptions of the ICF Generic-30 Set in different languages: laying the foundation for an ICF-based clinical tool for Europe.

BACKGROUND: Functioning is considered a third indicator of health and a key outcome in rehabilitation. A universal practical tool for collecting functioning information is essential. This tool would be ideally based on the International Classification of Functioning, Disability and Health. AIM: To report the results of the development of country/language-specific versions of an ICF-based clinical tool in six European countries. DESIGN: Consensus process. SETTING: Expert conferences. POPULATION: Multi-professional group of rehabilitation professionals in six European countries. METHODS: 1) Developed an initial proposal by translating the published English-language version of the simple descriptions into the targeted language; 2) conducted a multi-stage consensus conference to finalize the descriptions; 3) employed a three-stage multi-professional expert panel translation back to English. The consensus conference model was modified for geographically large countries. RESULTS: Croatian, Flemish/Dutch, Greek, Polish, and Turkish versions were produced. CONCLUSIONS: The creation of the country/language-specific simple descriptions is a significant part of the "system-wide implementation of the ICF" initiative that will pave the way for the implementation of the ICF in national health systems. CLINICAL REHABILITATION IMPACT: The practical ICF-based clinical tool with country/language specific versions for standardized reporting of functioning will serve as a means of integrating functioning information in national health systems and additionally for monitoring the effects of rehabilitation interventions.

Evidence-based position paper on physical and rehabilitation medicine professional practice for persons with COVID-19, including post COVID-19 condition: the European PRM position (UEMS PRM Section).

Although multiple factors still pose challenges to inpatient/outpatient rehabilitation for survivors of COVID-19, rehabilitation plays a key role for this patient population. This study aimed to improve Physical and Rehabilitation Medicine (PRM) physician's professional practice for persons with COVID-19-related functioning limitations, to promote functional recovery and reduce activity limitations and/or participation restrictions. A systematic review of the scientific literature was performed from December 2019 to August 2022, followed by production of recommendations through 5 Delphi rounds, by consensus among the delegates of all European countries represented in the Union of European Medical Specialists PRM Section. The systematic literature review is reported together with thirty-two recommendations resulting from the Delphi procedure. The PRM physician's role for persons with COVID-19-related limitations of functioning is to develop, foster, and monitor the implementation of an individual rehabilitation project tailored to the patient's age, previous medical and functional status, current comorbidities and complications, activity limitations and participation restrictions and personal and environmental factors. This is done by applying the concept of a multi-specialty integrated service model with multi-professional/interdisciplinary teams, providing care at all stages of COVID-19 illness. This evidence-based position paper represents the official position of the European Union through the UEMS PRM Section.

Evidence-based position paper of the UEMS PRM on the role of Physical and Rehabilitation Medicine (PRM) physician in the management of children and adults with spinal dysraphism.

Spinal dysraphism (SD) or spina bifida (SB) is a congenital deformity that results from embryonic neural tube closure failure during fetal development. This evidence-based position paper represents the official position of the European Union through the UEMS PRM Section. This paper aims to evaluate the role of the physical and rehabilitation medicine (PRM) physician and PRM practice for children and adults with spinal dysraphism. A systematic literature review and a consensus procedure involved all European countries delegates represented in the UEMS PRM section through a Delphi process. The systematic literature review is reported together with thirty-two recommendations resulting from the Delphi procedure. The professional role of the PRM physician requires specific expertise in the treatment of patients with SD to plan, lead and monitor the rehabilitation process in an interdisciplinary setting and to participate in the assessment of the needs of these patients in the transitional phase from childhood to adulthood, with particular attention to the activity limitation and participation restriction.

Extending Thrombolysis in Acute Ischemic Stroke to Primary Care: Early Experiences with a Network-Based Teleneurology Approach.

Background and Purpose-Systemic thrombolysis represents the main proven therapy for acute ischemic stroke, but safe treatment is reported only in well-established stroke units. To extend the use of tissue plasminogen activator (tPA) treatment in primary care hospitals on isolated areas through telemedic was the purpose of specific initiatives in southern Umbria, Italy. Methods-The stroke center of Foligno established a telestroke network to provide consultations for three local hospitals in southern Umbria. The telemedic system consists of a digital network that includes a two-way video conference system and imaging sharing. The main network hospital established specialized stroke wards/teams in which qualified teams treat acute stroke patients. Physicians in these hospitals are able to contact the stroke centers 24 h per day. Quality data are available to support the safe implementation of the stroke procedures. Those available from governmental authorities and local datasets are volume of hospitalization, in-hospital mortality, 30-days mortality, and discharge setting. Objective of the study was to assess the annual hospitalization volume in both the hub and spoke hospitals for ischemic stroke and appraise the performance of the network after the introduction of the telestroke system. Results-A total of 225 systemic thrombolyses were performed in time period indicated above all hospitals. In the main spoke hospital, 41 procedures were performed after teleconsultations were made available. The thrombolysis rate in the hub hospital ranged between 10% in 2016 and 20% in 2019, while in the spoke hospital was below 5% in 2016 and raised to 15% in 2019. The statistically significant difference, in the number of procedures, between hub and spoke in the beginning of the observation time disappeared after introduction of the telestroke network. No increase of the mortality was found. Conclusions-The present data suggest that systemic thrombolysis indicated via stroke experts in the setting of teleconsultation shows similar complication rates to those reported in the National Institute of Neurological Disorders and Stroke trial. Therefore, tPA treatment is also safe in this context and can be extended to primary hospitals.

The Individual Rehabilitation Project as the core of person-centered rehabilitation: the Physical and Rehabilitation Medicine Section and Board of the European Union of Medical Specialists Framework for Rehabilitation in Europe.

To facilitate the interaction between the health professional and the patient, a framework to guide the rehabilitation process is needed. This framework would encompass three interwoven aspects: the rehabilitation management plan, Individual Rehabilitation Project (IRP), and rehabilitation cycle(s). All three framework aspects focus on the patient and on the aim of rehabilitation, i.e. to optimize a person's functioning across the continuum of care. An IRP is a multi-element, person-centered rehabilitation management scheme, in which rehabilitation is generally provided by a multiprofessional team under the leadership of a physical and rehabilitation medicine (PRM) physician, working in an interdisciplinary manner and together with the patient (or proxy). A reference system for operationalizing functioning and standardizing the process is the International Classification of Functioning, Disability and Health (ICF) - for assessing functioning needs, defining rehabilitation goals and outcomes. The objective of this paper is to present the IRP as a framework for rehabilitation in Europe (EUR-IRP). The specific aims are: 1) to introduce the IRP; and 2) to describe the framework components, elements and variables of the IRP. Demonstration projects (case studies) using the EUR-IRP will be conducted. The present paper presents the efforts to date for developing the EUR-IRP, a key part of the action plan of the PRM Section and Board of the European Union of Medical Specialists to implement the ICF systemwide across the care continuum. This paper serves as another step to bring together practice, science and governance in calling for contribution from rehabilitation clinicians and researchers and professional societies in PRM and beyond.

Evidence-based position paper on Physical and Rehabilitation Medicine practice for people with amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) is a progressive motor neuron disease that affects both upper and lower motor neurons and is fatal in its course. This evidence-based position paper represents the official position of the UEMS PRM Section. The aim of the paper is to define the role of the physical and rehabilitation medicine (PRM) physician and PRM professional practice for people with ALS. A systematic review of the literature and a consensus procedure by means of a Delphi process have been performed involving the delegates of all European countries represented in the UEMS PRM Section. The systematic literature review is reported together with thirty-two recommendations resulting from the Delphi procedure. The responsibility of the PRM physician is functional assessment of persons with ALS and delivering the optimal and most effective PRM program of care. The rehabilitation program of patients with ALS should be delivered and monitored by the multiprofessional team, with the PRM physician as principal coordinator.

European expert consensus on improving patient selection for the management of disabling spasticity with intrathecal baclofen and/or botulinum toxin type A.

OBJECTIVE: To develop an algorithm for the selection of adults with disabling spasticity for treatment with intrathecal baclofen (ITB) and/or botulinum toxin type A (BoNT A). METHODS: A European Advisory Board of 4 neurologists and 4 rehabilitation specialists performed a literature review on ITB and BoNT A treatment for disabling spasticity. An online survey was sent to 125 physicians and 13 non-physician spasticity experts. Information on their current clinical practice and level of agreement on proposed selection criteria was used to inform algorithm design. Consensus was considered reached when ≥75% of respondents agreed or were neutral. RESULTS: A total of 79 experts from 17 countries completed the on-line survey (57%). Agreement was reached that patients with multi-segmental or generalized disabling spasticity refractory to oral drugs are the best candidates for ITB (96.1% consensus), while those with focal/segmental disabling spasticity are ideal candidates for BoNT A (98.7% consensus). In addition the following are good candidates for ITB (% consensus): bilateral disabling spasticity affecting lower limbs only (97.4%), bilateral (100%) or unilateral (90.9%) disabling spasticity affecting lower limbs and trunk, and unilateral or bilateral disabling spasticity affecting upper and lower extremities (96.1%). CONCLUSION: This algorithm will support the management of adult patients with disabling spasticity by aiding patient selection for ITB and/or BoNT A treatments.

Evidence based position paper on Physical and Rehabilitation Medicine practice for people with muscular dystrophies.

Muscular dystrophies present a group of inherited degenerative disorder that are characterized by progressive muscular weakness. This evidence-based position paper represents the official position of the European Union through the UEMS PRM Section. The aim of the paper is to evaluate the role of the physical and rehabilitation medicine (PRM) physician and PRM practice for people with muscular dystrophies. A systematic review of the literature and a consensus procedure by means of a Delphi process have been performed involving the delegates of all European countries represented in the UEMS PRM Section. The systematic literature review is reported together with thirty-three recommendations resulting from the Delphi procedure. The role of the PRM physician is to assess the functional status of persons with muscular dystrophy and to plan, monitor and lead PRM program in an interdisciplinary setting within a multiprofessional team.

Treatment with Delta-9-tetrahydrocannabinol/cannabidiol in Multiple Sclerosis: Influence on the Autonomy Profile according to the International Classification of Functioning, Disability and Health.

Multiple sclerosis (MS) is the most common cause of non-traumatic neurological disability in young adults. It has effects at different levels: physical, emotional, psychological, cognitive and social, with a great variety of signs and symptoms. In particular, spasticity contributes to reducing the motor performance of patients with MS, causing pain, reduction in distance walked and limitations in social life. We present the case of a 39-year-old woman with MS. She was treated with delta-9-tetrahydrocannabinol/cannabidiol and the outcome was assessed with the International Classification of Functioning Disability and Health core set framework. LEARNING POINTS: The clinical presentation of multiple sclerosis (MS) is heterogeneous but very often lower limb spasticity leads to severe disability.The use of nabiximols improved spasticity control and motor performance in walking, and also had a larger effect in improving activity and participation in personal relationships.Appropriate assessment of MS cases, through the ICF framework, may demonstrate further effects of nabiximols on patient capacity and performance.

Evidence-based position paper on the professional practice of Physical and Rehabilitation Medicine for persons with cerebral palsy. The European PRM position (UEMS PRM section).

Cerebral palsy (CP) is a group of the most common developmental disorders affecting movement and posture of the body, causing activity limitations and participation restrictions. The motor disorders of persons with CP are often accompanied by disturbances of sensation, cognition, communication and perception. The symptoms of CP are very diverse and persons with CP are usually presented with a mixed type of symptoms. The non-progressive disturbances can be attributed to disorders that were developed during pregnancy, birth and/or infant stage. The aim of this study was to improve physicians' professional practice of Physical and Rehabilitation Medicine for persons with cerebral palsy in order to improve their functionality, social and community integration, and to reduce activity limitations and/or participation restrictions. A systematic review of the literature including an 18-year period and consensus procedure by means of a Delphi process was performed and involved the delegates of all European countries represented in the Union of European Medical Specialists Physical and Rehabilitation Medicine (UEMS PRM) Section. As the result of a Consensus Delphi procedure, 74 recommendations are presented together with the systematic literature review. The PRM physician's role for persons with cerebral palsy is to lead and coordinate the multiprofessional team, working in an interdisciplinary way. They should propose and manage the complex but individual PRM program developed in conjunction with other health professionals, medical specialists and importantly in agreement with the patient, their family and care giver. This should be, according to the specific medical diagnosis to improve patients' health, functioning, social and education status, considering all impairments, comorbidities and complications, activity limitations and participation restrictions. This evidence-based position paper is representing the official position of The European Union through the UEMS PRM Section and designates the professional role of PRM physicians in persons with cerebral palsy.

Narrative Medicine to integrate patients', caregivers' and clinicians' migraine experiences: the DRONE multicentre project.

BACKGROUND: Although migraine is widespread and disabling, stigmatisation and poor awareness of the condition still represent barriers to effective care; furthermore, research on migraine individual and social impact must be enhanced to unveil neglected issues, such as caregiving burden. The project investigated the migraine illness experience through Narrative Medicine (NM) to understand daily life, needs and personal resources of migraneurs, their caregivers and clinicians, and to provide insights for clinical practice. METHODS: The project involved 13 Italian headache centres and targeted migraneurs, their caregivers and migraine specialists at these centres. Written narratives, composed by a sociodemographic survey and illness plot or parallel chart, were collected through the project's webpage. Illness plots and parallel charts employed open words to encourage participants' expression. Narratives were analysed through Nvivo software, interpretive coding and NM classifications. RESULTS: One hundred and seven narratives were collected from patients and 26 from caregivers, as well as 45 parallel charts from clinicians. The analysis revealed migraine perception in social, domestic and work life within the care pathway evolution and a bond between chaos narratives and day loss due to migraine; furthermore, narratives suggested the extent of the caregiving burden and a risk of underestimation of migraine burden in patients' and caregivers' life. CONCLUSION: The project represents the first investigation on migraine illness experience through NM simultaneously considering migraneurs', caregivers' and clinicians' perspectives. Comparing narratives and parallel charts allowed to obtain suggestions for clinical practice, while NM emerged as able to foster the pursuing of migraine knowledge and awareness.

Neurofibromatosis Type 1 with Highly Active Relapsing-Remitting Multiple Sclerosis (RRMS).

Neurofibromatosis type 1 (NF1) is an autosomal dominant neurocutaneous disease which confers an increased risk of malignant tumour development. Relapsing remitting multiple sclerosis (RRMS) is an inflammatory demyelinating disease of the central nervous system. The coexistence of multiple sclerosis and NF1 is rare but has been reported. Here, we describe the case of a 31-year-old man with NF1 and subacute walking problems with proximal pain in the lower limbs who was successfully treated with natalizumab. LEARNING POINTS: The coexistence of multiple sclerosis (MS) and neurofibromatosis type 1 (NF1) is very rare but has been described in the literature.Follow-up of patients with NF1 is important as the early detection and management of MS can prevent further disability.Appropriate treatment and physical therapy can improve the patient's activity and social life.

Telemedicine during the Coronavirus Disease (COVID-19) Pandemic: A Multiple Sclerosis (MS) Outpatients Service Perspective.

BACKGROUND: During the COVID-19 pandemic, the need for a broader implementation of telemedicine for many diseases has become apparent. Televisits are one type of telemedicine in which clinical visits are conducted remotely using an audio-visual connection with the patient at home. The use of televisits is more established in Stroke care but was also recently formally evaluated for Multiple Sclerosis (MS). This retrospective case series describes patient characteristics and reasons for televisits in persons with MS during the COVID-19 pandemic outbreak in Italy, which was declared in February 2020. METHODS: Recruitment occurred in a general hospital based MS clinic during Italy's lockdown months period (9 March-18 May). Each subject completed at least one televisit. The baseline data included were demographics and MS history; reasons for the remote house calls were analyzed focusing on COVID-19 related needs. RESULTS: Forty-six participants completed at least one study visit. The patients enrolled were more often females suffering from Relapsing Remitting Multiple Sclerosis (RRMS). Half of the patients had an intermediate level of education and lived within a 60 min drive from the clinic. These patients predominately had a short disease duration and were mostly involved in oral treatment. The main reasons for the call were drug use and counseling on social distancing. In 5 cases, COVID-19 infection was reported. CONCLUSIONS: Televisits during the COVID-19 outbreak demonstrated their utility as a care delivery method for MS. Hence, it is vital to facilitate the implementation of this technology in common practice to both face infectious threats and increase accessibility of the health care system.