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In the context of the White Book of Physical and Rehabilitation Medicine (PRM) in Europe, this paper deals with the history of the PRM medical specialty. The specialty evolved in different European countries, and sometimes also into the single countries, from different medical streams that finally joined. These included among others: balneology, gymnastic, use of physical agents (water, heat, cold, massage, joint manipulations, physical exercise, etc.). Another important role has been played by the increasing number of people experiencing or likely to experience disability due to improvement of medicine and consequent survivals from wars, accidents and/or big infective epidemics (like polio) ; these evolutions happened in strict relationship with other specialties like cardiology, neurology, orthopaedics, pneumology, rheumatology, traumatology, creating a knowledge transversal to all of them. Consequently, the PRM specialty has been gradually introduced in the different European countries, however with no uniformity. Subsequently, European Organizations were created for its diffusion and coordination at the level of medical competences and patient care as well as medical teaching and research: The European Federation of Physical Medicine and Rehabilitation - later European Society (ESPRM), The Académie Médicale Européenne de Médecine de Réadaptation (EARME), The PRM Section of the European Union of Medical Specialists and the European College of PRM (served by the UEMS-PRM Board), were created and work today regarding these general aims. Nowadays a uniform definition of the specialty exists in Europe, which is concordant with the internationally accepted description of PRM (based on the ICF-model). Moreover, research in PRM has been mainly improved during recent decades in Europe due to some external as well as internal scientific influences, thus increasing its scientific importance, together with a parallel increase in rehabilitation journals, many of them indexed and some with impact factor (Cr, EJPRM, JRM, among others), as well as a parallel increase in scientific congresses and courses. Last but not least, the recent creation of the Cochrane Rehabilitation field will also give a great boost to this primary medical specialty, as well as the discovery on new physical agents and technologies that diminish activity limitation and participation restriction of disable persons.

In the context of the White Book on Physical and Rehabilitation Medicine (PRM) in Europe this paper deals with the scope and competencies of PRM starting from its definition as the “medicine of functioning.” PRM uses the rehabilitative health strategy as its core strategy together with the curative strategy. According to the complexity of disabling health conditions, PRM also refers to prevention and maintenance and provides information to the patients and other caregivers. The rehabilitation process according to the so- called rehabilitation cycle including an assessment and definition of the (individual) rehabilitation goals, assignment to the rehabilitation program evaluation of individual outcomes. PRM physicians treat a wide spectrum of diseases and take a transversal across most of the medical specialties. They also focus on many functional problems such as immobilization, spasticity, pain syndromes, communication disorders, and others. The diagnosis in PRM is the interaction between the medical diagnosis and a PRM-specific functional assessment. The latter is based on the ICF conceptual framework, and obtained through functional evaluations and scales: these are classified according to their main focus on impairments, activity limitations or participation restrictions ; environmental and personal factors are included as barriers or facilitators. Interventions in PRM are either provided directly by PRM physicians or within the PRM team. They include a wide range of treatments, including medicines, physical therapies, exercises, education and many others. Standardized PRM programs are available for many diseases and functional problems. In most cases rehabilitation is performed in multi-professional teams working in a collaborative way, as well as with other disciplines under the leadership of a PRM physician and it is a patient-centered approach. Outcomes of PRM interventions and programs, showed reduction of impairments in body functions, activity limitations, and impacting on participation restrictions, and also reduction in costs as well as decrease in mortality for certain groups of patients.

In the context of the White Book of Physical and Rehabilitation Medicine (PRM), this paper deals with Research, the future of PRM. PRM students and specialists are mainly involved in biomedical research, investigating the biological processes, the causes of diseases, their medical diagnosis, the evaluation of their consequences on functioning, disability and health and the effects of health interventions at an individual and a societal level. Most of the current PRM research, often interdisciplinary, originates from applied research which, using existing knowledge, is directed towards specific goals. Translational medical research, research and development, implementation research and clinical impact research are in this field. PRM physicians, mainly master or PhD students, are nowadays increasing their participation in basic research and in pre- clinical trials. PRM physicians are involved in primary research, which is an original first hand research, but also in secondary research, which is the analysis and interpretation of primary research publications in a field, with a specific methodology. Secondary research remains an important activity of the UEMS PRM section and it will be the field of the new created Cochrane Rehabilitation. Secondary research with interest for persons with disabilities, will be developed world wide on the basis of evidence based medicine, with the participation of PRM physicians and of all other health and social professionals involved in rehabilitation. The development of research activities with interest for PRM in Europe is a challenge for the future, which has to be faced now. The European PRM schools, the European master and PhD program with their supporting research and clinical facilities, the European PRM organizations with their websites, the PRM scientific journals and European congresses are a strong basis to develop research activities, together with the development of Cochrane Rehabilitation field and of our cooperation with European high level research facilities, European and international scientific societies in different fields. PRM will be a leader in this field of research.

Objective: To assess the efficiency of knee-ankle-foot orthoses for treating painful genu recurvatum, and to determine users’ tolerance and satisfaction. Patients: Patients included in the study had a genu recurvatum during the stance phase, confirmed by a medical doctor on physical examination. A total of 27 patients with 31 knee-ankle-foot orthoses were included. Methods: The main outcome was scored on a verbal numerical rating scale (VNRS) before and at least 3 months after a knee-ankle-foot orthosis was fitted, and scored on a verbal numerical pain rating scale (VRS). Secondary outcomes were rated with the Quebec User Evaluation of Satisfaction with assistive Technology (QUEST). Results: After fitting the knee-ankle-foot orthosis, the median VNRS pain score decreased from 85/100 to 25/100 (p ≤ 0.001) and the description of pain on the VRS decreased from “extreme” to “mild” (p ≤ 0.001). The QUEST total score was 4.0. Conclusion: Treating a painful genu recurvatum with a knee-ankle-foot orthosis reduced the pain efficiently whatever the patients’ diagnosis, and high scores were obtained for patients’ satisfaction.

In the context of the White Book of Physical and Rehabilitation Medicine (PRM), this paper deals with the education of PRM physicians in Europe. To acquire the wide field of competence needed, specialists in Physical and Rehabilitation Medicine have to undergo a well organised and appropriately structured training of adequate duration. In fact they are required to develop not only medical knowledge, but also competence in patient care, specific procedural skills, and attitudes towards interpersonal relationship and communication, profound understanding of the main principles of medical ethics and public health, ability to apply policies of care and prevention for disabled people, capacity to master strategies for reintegration of disabled people into society, apply principles of quality assurance and promote a practice-based continuous professional development. This paper provides updated detailed information about the education and training of specialists, delivers recommendations concerning the standards required at a European level, in agreement with the UEMS rules of creating a Common Training Framework, that consists of a common set of knowledge, skills and competencies for postgraduate training. The role of the European PRM Board is highlighted as a body aimed at ensuring the highest standards of medical training and health care across Europe and the harmonization of PRM physicians’ qualifications. To this scope, the theoretical knowledge necessary for the practice of PRM specialty and the core competencies (training outcomes) to be achieved at the end of training have been established and the postgraduate PRM core curriculum has been added. Undergraduate training of medical students is also focused, being considered a mandatory element for the growth of both PRM specialty and the medical community as a whole, mainly in front of the future challenges of the ageing population and the increase of disability in our continent. Finally, the problems of continuing professional development and medical education are faced in a PRM European perspective, and the role of the European Accreditation Council of Continuous Medical Education (EACCME) of UEMS is outlined.

In the context of the White Book of Physical and Rehabilitation Medicine (PRM) in Europe, this paper describes the background to the context of PRM services and comprises the following: - Epidemiological Aspects of Functioning and Disability - Ethical Aspects and Human Rights - Rehabilitation and Health Systems - Economic Burden of Disability - Effects of Lack of Rehabilitation Health care service planning accounts for the burden of disability among society and the chapter describes the justification for specialist rehabilitation, the background of PRM and why making a functional diagnosis and a management plan based on function is its core competence. The chapter describes the increasing burden of disability due to conditions seen in PRM practice rather than on all those diseases contributing to physical disablement and does not include mental illness, learning disabilities, etc. Ten percent of Western Europe’s population have a disability and are surviving longer, resulting in higher costs for health and social care and a greater impact of co-morbidities. The chapter also describes the impact and increased costs in the absence of rehabilitation. Not only is money spent on rehabilitation recovered with five to nine-fold savings (e.g. in return to work), but rehabilitation is effective in all phases of health conditions. Specialized rehabilitation (as delivered by PRM services) is highly cost- efficient for all neurological conditions, producing substantial savings in ongoing care costs, especially in high-dependency patients. Disability discrimination has been outlawed and the text describes the legal context and status of a person living in Europe with a disability. The second part highlights the United Nations Conventions on human rights, confirmed in the World Report on Disability, but also on the principles of ethical practice among PRM physicians. The third part addresses the variability of access to and funding of rehabilitation services across countries. The chapter also distinguishes highly specialist interventions (such as those provided by a PRM physician) from specialized therapies, (such as pressure ulcer management) and generic therapies (e.g. after an uncomplicated limb fracture). It will be important for healthcare authorities, public health organizations, payers, providers, healthcare professionals, consumers and the community. The economic and social burden of disability on society is considerable and will get worse, although this is difficult to quantify. Direct costs are variable and include disabled persons’ additional costs for daily living and state disability benefits. Rehabilitation has a pivotal role in reducing these costs through promoting personal recovery and increasing function through altering environmental factors. This part describes cost savings studies through rehabilitation for persons with severe disabilities.

In the context of the White Book of Physical and Rehabilitation Medicine (PRM) in Europe, this paper deals with the definitions and concepts relevant for PRM. Physical and Rehabilitation Medicine is the primary medical specialty responsible for the prevention, medical diagnosis, treatment and rehabilitation management of persons of all ages with disabling health conditions and their co-morbidities, specifically addressing their impairments and activity limitations in order to facilitate their physical and cognitive functioning (including behavior), participation (including quality of life) and modifying personal and environmental factors. To arrive to this PRM definition we need to consider a conceptual description of it. Several fundamental aspects must be observed namely functioning, disability and rehabilitation. These definitions include and are presented in this chapter: - Functioning: all that human bodies do and the actions that people perform. In the International Classification of Functioning, Disability and Health (ICF), functioning is operationalized in terms of functioning domains, and these domains are partitioned into the dimensions of Body Functions and Structures, Activities and Participation ; - Disability: the problem a person has performing the actions that he or she needs and wants to do, because of how an underlying health condition - a disease, injury or even ageing - affects his or her performance in his or her actual environment ; - Rehabilitation: a set of measures that assist individuals, who experience or are likely to experience disability, to achieve and maintain optimum functioning in interaction with their environments. The ICF definition of disability clearly distinguishes between problems that result entirely from the underlying health condition (capacity) from problems arising from the interaction between capacity and the environment and personal factors (performance). This paper approaches all these concepts that are essential to the understanding of the PRM strategy to evaluate disability and implement interventions that may lead to the improvement of functioning and health.

In the context of the White Book of Physical and Rehabilitation Medicine (PRM) in Europe, this paper deals with the future perspectives of PRM in Europe according to the actual vision of the European Bodies. All Chapters stress the big changes that Europe is facing in terms of demography, life expectancy, survival rates, disability burden, increasing prevalence of long- term health conditions, progress in technology, but also health costs and society changes in terms of requirements of wellness and quality of life together with health. All these challenges combined with the specificities of PRM, that is the medical specialty focusing on the whole person and its functioning in the various health conditions, with the aim to guarantee the best possible participation through improvement of activities and reduction of impairments. The possible consequences of these changes in the future evolution of PRM clinical practice, services, education, research are presented ; moreover, the vision on the progress to harmonization of the development of PRM across Europe, and the possible contribution of PRM to policy planning are presented.

In the context of the White Book of Physical and Rehabilitation Medicine (PRM) in Europe, this paper deals with the core concepts at the base of the PRM specialty. These are the essential constituents that make PRM a primary medical specialty, different from all the other medical specialties, and PRM physician the primary medical specialist among the rehabilitation professionals. The core concepts that will be discussed in this Section include: - PRM is a person/functioning oriented specialty, and this makes the specialty different from the organ/disease oriented, or treatment/age specific medical specialties. - PRM physicians have medical responsibilities, like all the other medical specialists, but with an additional specificity of making a functional assessment. - Like the other specialists, PRM physicians provide direct treatments, but they also work leading the multi-professional rehabilitation team, that works in a collaborative way with other professionals and medical specialists. - Due to its function oriented approach, PRM has a multimodal approach including a wide variety of treatment tools (frequently provided by other rehabilitation professionals) and manages all persons’ morbidities (health conditions), since it focuses on decreasing impairments and activity limitations to allow the best possible participation of patients. - As PRM bases its work on functioning, it has a transversal role to other specialties: it overlaps with several of them, sharing part of their knowledge, but it is also totally independent from all of them, since it is based on a different and transversal body of knowledge. - PRM is focused on the person and neither on the disease nor on the setting ; in fact, PRM is not only transversal to specialties, but also to the settings of care, and PRM physicians should know these different realities: persons with disabilities and those with long-term health conditions in fact move inside the national health systems between various facilities to obtain the best possible functioning and participation through an appropriate rehabilitation process.

International audience; Objective: The therapeutic effects of intramuscular injections of botulinum toxin-type A on spasticity can largely be explained by its blocking action at the neuromuscular junction. Botulinum toxin-type A is also thought to have a central action on the functional organization of the central nervous system. This study assessed the action of botulinum toxin-type A on spinal motor networks by investigating post-activation depression of the soleus H-reflex in post-stroke patients. Post-activation depression, a presynaptic mechanism controlling the synaptic efficacy of Ia-motoneuron transmission , is involved in the pathophysiology of spasticity. Patients: Eight patients with chronic hemiplegia post-stroke presenting with lower limb spasticity and requiring botuli-num toxin-type A injection in the ankle extensor muscle. Methods: Post-activation depression of soleus H-reflex assessed as frequency-related depression of H-reflex was investigated before and 3, 6 and 12 weeks after botulinum toxin-type A injections in the triceps surae. Post-activation depression was quantified as the ratio between H-reflex amplitude at 0.5 and 0.1 Hz. Results: Post-activation depression of soleus H-reflex, which is reduced on the paretic leg, was affected 3 weeks after botulinum toxin-type A injection. Depending on the residual motor capacity of the post-stroke patients, post-activation depression was either restored in patients with preserved voluntary motor control or further reduced in patients with no residual voluntary control. Conclusion: Botulinum toxin treatment induces synaptic plasticity at the Ia-motoneuron synapse in post-stroke pa-retic patients, which suggests that the effectiveness of bot-ulinum toxin-type A in post-stroke rehabilitation might be partly due to its central effects.

International audience; Access to the college cycle for students with disabilities and their employability have become a priority for universities. The Handicap Mission manages it within the Aix-Marseille University (AMU). Few studies have focused on the students with disabilities' insertion/integration within the universities and on the compensations. The objective of this study is to analyze within the AMU the students with disabilities census and characteristics, and the Handicap Mission's operating. The census was conducted using a self-administered questionnaire (Handi need card: university curriculum, deficiencies, technical and social help, adjustments appealed for at the university). It was performed by the staff at the AMU's Mission Handicap Department/Office. If supporting measures seem to be necessary, the interdisciplinary team (comprised of representatives of the University teaching, Administrative and Technical staff, Mission Handicap staff, Preventive Medicine staff, and partners from associations involved in assisting people with disabilities) then defines and sets up suitable means of assistance. The Handicap Mission improves students with disabilities insertion, defines necessary adjustments, and promotes research on disability. A total of 551 students with disabilities were identified, 304 in law and human sciences. In all, 141 deficiencies encountered related to language disorders, among which 105 were not defined by the students ('Other' in the questionnaire). In all, 519 SWD benefited from extra time when sitting exams and 40 were helped to take notes by others students. Compensations and Handicap Mission improve the monitoring and the link between high school and university for the students with disabilities, promote their exam success, and support them in their working life.

Accreditation europeenne des programmes de soin en medecine physique et de readaptation. Objectifs, phase pilote, nouvelle procedure G. De Korvin *, M. Quittan , A. Juocevicius , T. Lejeune , J. Lains , J. McElligott , V. Mikova , F. Nollet , A. Delarque i a Centre hospitalier prive Saint-Gregoire, CS 56816, 35768 Rennes, France b Kaiser Franz Joseph Hospital, Vienna, Austria c Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania d Cliniques universitaires Saint-Luc, UCL, Brussels, Belgium e Hospital Rovisco Pais, Tocha, Portugal f National Rehabilitation Hospital, Dublin, Ireland g Hospital Tabor, Tabor, Czech Republic h Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands i Universite de la Mediterranee, CHU La Timone, 13385 Marseille, France

To determine the effects of an attentional task on hemiplegic patients' postural control performances.Retrospective study.Department of physical and rehabilitation medicine at a university hospital.Twenty-three hemiplegic patients and 23 healthy age- and sex-matched control subjects.Not applicable.Sway area and sway path of the center of pressure were measured during 30 seconds in standing subjects and patients under 3 conditions: eyes open (EO), EO while performing a simple arithmetic task (EO-AT), and eyes closed (EC).In the hemiplegic patients, the body sway area increased significantly with EC (P.001) and during the EO-AT task (P.017) in comparison with EO. Sway area with EO-AT remained, however, significantly smaller than with EC (P.014). In the healthy subjects, the body sway did not differ significantly between the EO-AT and EO tasks (P.42). The increase observed in the sway area and path in the hemiplegic population during the EO-AT task correlated significantly with age.The postural performances of hemiplegic patients decreased during both the arithmetic task and the EC task. The cognitive task had no effect on healthy subjects' postural performances. This study is the first to show the combined effects of age and dual task on the postural performances of hemiplegic subjects.

Objective: To determine whether fascicular neurotomy has long-lasting effects on spasticity. Design: We present 4 clinical cases and a critical analysis of the literature. Patients: This is a retrospective study on 4 patients referred to our department for spastic equinovarus foot deformity. For all 4, neurotomy was successful not long after surgery, but spasticity reappeared after a few months. Methods: We compared our results with those in the PubMed database. Results: Most publications acknowledge the immediate effectiveness of this surgery, but do not study the long-term effects of neurotomy. No publication proved long-lasting effects of neurotomy for spastic equinovarus foot deformity. The only long-term follow-up with a sufficient population is the one of Berard et al. (Pediatr Orthop B 1998, 7:66), who reported 61% recurrence. Conclusion: There is no study showing that tibial nerve neurotomy has long-lasting effects. The 4 cases reported are an illustration that recurrence of spasticity may occur after neurotomy. These findings have to be taken into account for treatment decision-making and for provision of information to patients.

Objective To assess the kinetic and kinematic characteristics of hemiplegic stroke patients' gait initiation patterns during the various gait initiation phases. Design and subjects Gait initiation was studied in 3 hemiplegic subjects with a spastic equinus varus foot and 3 control subjects. Methods Temporal and kinetic analysis of gait initiation was performed with 2 AMTI force plates, and kinematic analysis of gait initiation with an ELITE optoelectronic system. A one-way ANOVA was performed directly on the phase durations, forces, centre of pressure displacements, stride length, and ankle motion range. Results Duration of the monopodal phase was shorter in hemiplegic patients when the affected leg rather than the sound one was used as the supporting leg. Propulsion forces were exerted by the hemiplegic patients' sound leg during the postural phase. Hemiplegic patients' body weight was supported more by the sound leg than by the affected leg. Knee was lifted higher on the affected side during the swing phase to compensate for the equinus. Initial contact was performed with a flat foot on the affected side. Conclusion Quantitative data obtained on the gait initiation phase suggest that hemiplegic patients develop asymmetrical adaptive posturo-motor strategies to compensate for their impairments.

Lateral leg movement is accompanied by opposite movements of the supporting leg and trunk segments. This kinematic synergy shifts the center of mass (CM) towards the supporting foot and stabilizes its final position, while the leg movement is being performed. The aim of the present study was to provide insight in the behavioral substitution process responsible for the performance of this kinematic synergy. The kinematic synergy was assessed by the principal component analysis (PCA) applied to both hip joints and supporting ankle joint. Patients after unilateral below-knee amputation and control subjects were asked to perform a lateral leg raising. The first principal component (PC(1)) accounted for more than 99% of the total angular variance for all subjects (amputees and controls). PC(1) thus well represents the possibility to describe this complex multi-joint movement as a one degree of freedom movement with fixed ratios between joint angular time course. In control subjects, the time covariation between joints changes holds during all phases of the leg movement (postural phase, ascending and braking phases). In amputees, PC(1) score decreased during the ascending phase of the movement (i.e. when the body weight transfer is completed, while the movement is initiated). We conclude that a feedback mechanism is involved and discuss the hypothesis that this inter-joint coordination in amputees results from a failure in the pre-setting of the inter-joint coupling.

The purpose of this study was to identify changes in equilibrium and movement control strategies in patients with arthritis of the knee. These strategies were expected to be different from those of healthy subjects because of the impairments caused by knee arthritis. The different phases of a side step were studied in patients with severe knee arthritis using a movement analysis system and force-plates. The duration of the postural phase and the intensity of the horizontal ground reaction forces during the postural phase were increased when the pathological limb was the supporting one. The monopodal phase was shortened on the pathological leg. These results show that knee arthritis patients develop new posturomotor strategies mainly aimed at shortening the monopodal phase when the affected leg is the supporting one. This movement analysis method enables quantification of differences that cannot be observed on clinical examination between knee arthritis patients and control subjects, and provides additional information to the usual clinical evaluation scales.