|CHAPTER 7: THE ORGANIZATIONS OF PHYSICAL AND REHABILITATION MEDICINE IN THE WORLD
|Year : 2019 | Volume
| Issue : 2 | Page : 134-138
7.2 The organization of physical and rehabilitation medicine in the world: Physical and rehabilitation medicine in the Asia-Oceania region
John Olver1, Leonard S W Li2
1 Epworth HealthCare, Melbourne; Monash University, Melbourne, VIC, Australia
2 Department of Medicine, Division of Rehabilitation, Neurological Rehabilitation Centre, University of Hong Kong, Hong Kong SAR, China
|Date of Web Publication||11-Jun-2019|
Prof. John Olver
Epworth HealthCare, Melbourne, VIC
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Olver J, Li LS. 7.2 The organization of physical and rehabilitation medicine in the world: Physical and rehabilitation medicine in the Asia-Oceania region. J Int Soc Phys Rehabil Med 2019;2, Suppl S1:134-8
|How to cite this URL:|
Olver J, Li LS. 7.2 The organization of physical and rehabilitation medicine in the world: Physical and rehabilitation medicine in the Asia-Oceania region. J Int Soc Phys Rehabil Med [serial online] 2019 [cited 2019 Aug 20];2, Suppl S1:134-8. Available from: http://www.jisprm.org/text.asp?2019/2/2/134/259357
| Introduction|| |
The Asia-Oceania region consists of a grouping of countries holding about 60% of the world's population. The region has a diversity of cultures, political environments, socioeconomic development, and religions. A detailed outline of all of the rehabilitation programs available in each country within the region is beyond the scope of this chapter. However, the development of rehabilitation and the challenges faced will be outlined with reference to countries selected to illustrate points of similarity or difference. Even the overall philosophy of rehabilitation medicine and the understanding of the goals of therapy intervention (which are generally accepted as improving activity and participation in society of individuals with impairment and consequent disability) can be interpreted quite differently in Asia and Oceania due to the influence of the cultural diversity in the region. For example, Xiao et al. in a perspective on integrated medical rehabilitation delivery in China noted that culturally, rehabilitation has the same connotation as recovery and is a natural outcome of the disease rather than an active process addressing disability.
Other regional differences lie in the stage of development of rehabilitation programs. In some countries, rehabilitation is still in the initial phase of development whereas in other countries, there are well-established programs, research projects, and advances in technology that are instigating innovative changes for the discipline and projecting it beyond its current boundaries.
Han and Bang 2007 in a paper outlining an Asian perspective in rehabilitation medicine noted that the first national organizations in Asian countries were formed in the 1960s (Philippines and Japan), with China, India, Indonesia, Korea, Taiwan, and Thailand to follow suit in the 1970s, and in the 1990s, Vietnam, Hong Kong, and Laos. At a later stage, national organizations were also established in Malaysia, Singapore, and Mongolia. Similar bodies in Europe and America preceded the commencement of these Asia-Oceania-specific organizations of rehabilitation medicine. The Australian Association of Physical Medicine was formed in 1948 and eventually led to the formation of the Australian College of Rehabilitation Medicine in 1979 and the current Australasian Faculty of Rehabilitation Medicine of the Royal Australasian College of Physicians (RACP) in 1993.
The formation of regional societies promoting rehabilitation medicine and sharing knowledge across borders has been pivotal for the development of the specialty in Asia and Oceania [Refer to [Table 1]. Han and Bang references the earliest regional professional meetings including the first regional congress of the Asian Rehabilitation Medicine Association (held in 1998 in Chiang Mai, Thailand), an Asian Symposium on Rehabilitation Medicine (held in Tokyo in 2001), and a biennial joint conference between the Japanese Association of Rehabilitation Medicine (JARM) and the Korean Academy (held in 2002). The largest step forward in regional communication came in 2007 with the formation of the Asia-Oceanian Society of Physical and Rehabilitation Medicine (AOSPRM).
|Table 1: History of National Physical Medicine and Rehabilitation Societies in Asian Countries|
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| Asia-Oceanian Society of Rehabilitation Medicine|| |
The AOSPRM was formed with the purpose of being a regional scientific and educational society, for practitioners of physical and rehabilitation medicine. The society's central aim was to improve the knowledge, skills, and attitudes of physicians in their management of individuals with injury-related impairments and the consequent limitations it places on activity and participation in society. Consequently, this was aimed at improving the quality of life for these people through successful community reintegration.
The broader mission of the society was to represent physical and rehabilitation medicine from the Asian and Oceanian region to international health organizations.
The first congress was held in 2008 in Nanjing China which incidentally was just after the Sichuan earthquake whereby a number of the Chinese delegates were diverted into disaster relief roles. Disaster relief has since been one focus of rehabilitation medicine in China. Since this time, conferences have been held on a biennial basis in Taipei – Taiwan, Bali – Indonesia, Bangkok – Thailand, Cebu – Philippines, and Auckland – New Zealand.
Twenty-one countries currently have nominated national representatives in the society. These include Australia, Bangladesh, Brunei Darussalam, China, Chinese Taipei, Hong Kong, India, Indonesia, Iran, Japan, Korea, Laos, Malaysia, Mongolia, Myanmar, New Zealand, Pakistan, Philippines, Singapore, Thailand, and Vietnam.
In 2014, the AOSPRM signed a memorandum of understanding with the International Society of Physical and Rehabilitation Medicine (ISPRM).
In addition, the annual ISPRM scientific meetings have been held within the region in recent years including Seoul Korea (2007), Beijing China (2013,) and in Kuala Lumpur Malaysia (2016). As well as their scientific content, these meetings promote global concepts such as the use of the International Classification of Functioning and Disability and Health in rehabilitation settings. The meetings also report on the ISPRM's relationship with the World Health Organization (WHO).
| Examples of How Rehabilitation Medicine Training Developed – Australia, New Zealand, Japan|| |
Malaysia and China
There has been a gradual evolution of rehabilitation medicine and associated programs and facilities throughout the Asia-Oceania region. Similarities and differences can best be illustrated by references to 5 country-specific approaches to the discipline which reflects differing cultures, population sizes, and economies.
Australia and New Zealand
In Australia, there is a notion that rehabilitation commenced in the 1930s with physical programs offered to patients with polio. Rather, rehabilitation programs for individuals in the general population emerged from the services designated for the rehabilitation of injured servicemen. The Ministry of Post-War reconstruction in 1946 became the Commonwealth Rehabilitation Service in 1948. Its main focus was to transition previously serving servicemen from invalid or disability pensions and back into the workforce through vocational rehabilitation (rather than improving independence in personal or domestic activities of daily living). These services were set up by the commonwealth in most states of Australia where little rehabilitation existed in the public hospital system which at the time was state run.
In the mid-1950s and beyond, Australian state runs rehabilitation programs emerged within dedicated rehabilitation centers. The concepts of team-based, multidisciplinary programs which extended beyond medical impairment care and encompassed physical, psychological, and social assessment of patients by doctors, nurses, and allied health staff were well described by Bruce Ford in his book “The Wounded Warrior and Rehabilitation.”
In 1970, a Diploma in Physical and Rehabilitation Medicine course commenced to recruit doctors into the specialty, and in 1977, the National Specialist Advisory Committee formally recognized rehabilitation as a principal specialty. The college started a training program in rehabilitation medicine, and on gaining a fellowship of the college, this granted doctors the right to practice as specialists in rehabilitation medicine in Australia. New Zealand adopted the same training program and initiated their own country branch of the college which held their first branch meeting in February 1989. Thus, in two countries, clinical governance of rehabilitation was combined under one college structure. In 1991, the college joined with the much larger RACP and became one of its faculties. Postgraduate education in rehabilitation was therefore modeled on the Royal College System from the United Kingdom rather than being a university-based qualification.
A formalized curriculum for training has been established which encompasses key areas of rehabilitation medicine. Typically, doctors enter the 48-month program at the 2nd or 3rd year postgraduate level. There are 6 modules to be completed during training including assignments on research, neuropsychology, administration, and behavioral sciences. In year 3 or 4 of training, rehabilitation trainees are required to sit an exit examination consisting of a multiple choice paper, a modified short answer paper, and a clinical objective-structured clinical examination.
Postfellowship education is presently run by a newly formed Rehabilitation Medicine Society of Australia and New Zealand. There is an annual maintenance of professional standards programs for all faculty fellows.
Currently, there are 214 trainees, 567 active fellows, 67 retired fellows, and 14 honorary fellows for a population of 24.5 million (Australia).
The Australasian Rehabilitation Outcomes Centre commenced in 2002 at the University of Wollongong (New South Wales, Australia) and established a minimum data set for rehabilitation. It collects date from over 96 percent of rehabilitation facilities in Australia and New Zealand for every episode of care on admission and discharge. The data set contains demographic data and core indicators of rehabilitation medicine (namely, length of stay and functional status measured by the functional independence measure on patient admission and discharge from rehabilitation). These data provide each individual rehabilitation unit with an audit tool which allows for internal evaluation and comparison with national benchmarking data for all impairment programs.
The JARM was established in 1963. A paper by Izumi celebrating the 50th Anniversary of JARM notes however that the practice preceded its establishment whereby in the 1920s, rehabilitation was focused on “crippled” children. A certification system in rehabilitation medicine was started in 1980 and developed into a new organization of board-certified physiatrists in 2003. Guidelines for postgraduate training were created in1982, and after revisions, the “Fundamental Principles for Education of Rehabilitation Medicine” were developed. The curriculum had similar objectives to the Australian model outlined above. Institutes were certified for education in rehabilitation medicine and courses were developed by the JARM. The Izumi article emphasizes that electrodiagnosis was a key skill for Japanese physiatrists, and that research methodology and interdisciplinary team management were encouraged as part of the curriculum. An additional focus at present is the leadership in the development of robotics in physical rehabilitation.
The training program and development of rehabilitation medicine in Malaysia was championed by Professor Datuk Dr. Zaliha Omar. The training which formally commenced in 1997 is a 4-year postgraduate masters course in rehabilitation medicine conducted at the University of Malaya. In the early days and up until 2004, candidates spent 6-month training in Melbourne Australia. Examinations were conducted with external examiners from the USA, Europe, and Australia. Initially, trainees worked in hospitals without designated rehabilitation beds. This has evolved over recent years with new facilities containing dedicated rehabilitation beds that are well-equipped and well-designed for management. The first Malaysian Association of Rehabilitation Medicine Conference was held in December 2004.
In line with other medical specialties in China, the evolution of rehabilitation has embraced both traditional Chinese practices (namely, acupuncture, Chinese massage, and herbal medicine) and Western medicine. The integration of both medical modalities has been particularly applied in stroke rehabilitation and the treatment of chronic pain. Modern rehabilitation was introduced into the Chinese health system in the 1980s.
Zhang and Shen in a review of the problems and challenges in the rehabilitation medical system in China recognized the presence of a three-tier rehabilitation medical service (acute, subacute, and community), however, felt there was a dissociation between the different grades of hospitals. Zhang and Shen highlighted that the system needed reconstruction and increased financial input. There was a shortage of rehabilitation resources which were unevenly distributed between rural, urban areas, and in different regions.
Current estimates are that China had over 85 million disabled people (with 90% having rehabilitation needs). Many of these individuals did not have access to a rehabilitation program. Zhang and Shen reported that pilot programs of integrated rehabilitative care were introduced into 46 cities and 14 provinces in 2010 to overcome some of the problems cited.
With the recent national policy on Health China 2030 and rapid economic growth in China, the concept of rehabilitation service has shifted to an important aspect for healthy living and aging care for the coming 30 years in China, leading the way to achieving increased quality of life and years of healthy life. As part of the progress of rehabilitation in China, there are now training facilities for rehabilitation doctors, therapists, and nurses at Bachelor degree or above. As well, there are private/public partnerships evolving to create new rehabilitation facilities.
| Challenges in Delivering Rehabilitation Services|| |
In the lead up to Malaysia hosting the 2016 ISPRM annual scientific meeting, in local media, Zaliha Omar was able to highlight issues which were of concern to her in Malaysia that are in fact common problems to rehabilitation physicians and programs throughout the Asia-Oceania region.
A core challenge is the referral process between the tiers of management into the specialty. Rehabilitation medicine is often not well understood by the general public and other doctors, and consequently, people who would benefit from rehabilitation are not getting referred to the services. Second, medical rehabilitation is a team-based specialty which operates most efficiently with good team communication and goal setting with the patient compared with the delivery of individual therapy services. In the multidisciplinary team, Zaliha commented that the treating rehabilitation physician is best placed to take a leadership role in the coordination of treatment. Finally, it has been highlighted by many developing programs in the region that a service gap exists between city based and rural services. Rural-based services are generally underresourced compared to the service available in the higher density populations in the cities. Where distances between cities are large (such as in countries like Australia), this service gap is compounded. A study done in Thailand in 2009 reported that 8.9% of the population had disabilities and the majority of these people were living in rural areas. It was estimated that no more than 2% were involved in institution-based rehabilitation, and thus between the 1970s to the early 80s, community-based rehabilitation was introduced into Thailand in response to this service gap. The study of the roles of community therapists recognized that therapists would require alternative training to take on community roles as opposed to center-based therapy. In particular, facilitators would need to be aware of the cultural, economic, and religious differences of their clients and have more flexibility in their approach and goal setting.
The literature has estimated that in Japan in 2013, 22% of the population of 128 million were 65 or over, and in Singapore, by 2030, 20% of the population will be 65 years or older. The aging population provides a challenge for all countries in our region. All areas of medical care will be affected, but in a specialty which focuses on minimizing the effects of disability on activity and participation in society, the rehabilitation programs offered will need to meet this demographic challenge.
In an article looking at the development of rehabilitation medicine in Japan and the board certification system and curriculum development, the point was made that there is a preventative role in rehabilitation treatment relating to what they referred to as the “vicious circle of immobility.” This basically involves all phases of rehabilitation treatment from acute to community and aims at preventing further impairment after the initial illness due to immobilization and sedentary lifestyle.
Kusumastuti et al. also highlighted some of these problems in an analysis of people with disability in Indonesia. He quoted the figures that “1.8% of the Indonesian population have extreme problems and 19.5% have problems in various aspects of their ability to carry out daily living tasks.” The article related disability to a high risk of poverty and noted some prejudice against people with disability which was presumed to be related to their unproductivity and dependence. Like many countries in the region, the financial resources and available personnel to deliver services are low compared to the existing needs.
It is hoped that the WHO World Report on Disability of 2011 will provide the template to influence governments in this region to allocate more resources to rehabilitation and thus ensure the dignity of people with disability and help change the perception of them to “active and equal citizens.”
| Conclusion|| |
The communication between rehabilitation societies, programs, and individuals throughout Asia and Oceania is constantly improving and adding value to the services delivered in all countries. Courses in specialist areas such as ultrasound use and robotics are now offered locally in the region which reduces travel costs and increases participation. Furthermore, internet-based learning is becoming more prevalent. Currently recognized service gaps are being addressed with the implementation of telerehabilitation options for individuals residing in rural areas. We are witnessing unprecedented growth in services in many countries as governments recognize the benefits of increasing activity and participation of the population of people with disabilities.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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