|CHAPTER 7: THE ORGANIZATIONS OF PHYSICAL AND REHABILITATION MEDICINE IN
|Year : 2019 | Volume
| Issue : 2 | Page : 148-155
7.5 The organizations of physical and rehabilitation medicine in the world: The scope of physical and rehabilitation medicine in the Middle East and North Africa
Maher Saad Benjadid
Department of Rehabilitation Medicine, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
|Date of Web Publication||11-Jun-2019|
Prof. Maher Saad Benjadid
Department of Rehabilitation Medicine, Prince Sultan Military Medical City, Riyadh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Benjadid MS. 7.5 The organizations of physical and rehabilitation medicine in the world: The scope of physical and rehabilitation medicine in the Middle East and North Africa. J Int Soc Phys Rehabil Med 2019;2, Suppl S1:148-55
|How to cite this URL:|
Benjadid MS. 7.5 The organizations of physical and rehabilitation medicine in the world: The scope of physical and rehabilitation medicine in the Middle East and North Africa. J Int Soc Phys Rehabil Med [serial online] 2019 [cited 2019 Aug 20];2, Suppl S1:148-55. Available from: http://www.jisprm.org/text.asp?2019/2/2/148/259360
| Introduction: Disability and the Specialty of Physical Medicine and Rehabilitation|| |
According to the World Health Organization (WHO), rehabilitation is “the use of all means aimed at decreasing the impact of disabling and handicapping conditions and at enabling people with disabilities to achieve optimal social integration.”, The American Board of Physical Medicine and Rehabilitation (PMR) defines the PMR specialist as one who is an expert in nerve, muscle, and bone, who gives treatment for injuries or illnesses that affect body movement, who diagnoses and treats pain, who restores to the maximum any function that has deteriorated or been lost due to injury, illness or disabling conditions, who treats the entire person and not simply the affected area, who leads a team of medical professionals, offering non-surgical treatments, and who clearly outlines the patient's medical conditions and a suitable strategy of treatment/prevention. Physiatry or PMR deals with the prevention, diagnostics, and treatment of disabling diseases, disorders, and injuries, by using physical methods (such as electrotherapy, therapeutic exercise, or pharmaceutical pain control). This medical discipline helps patients in regaining the ability to accomplish their lives through re-established body function. Therefore, PMR offers treatment to patients with traumatic injury, postsurgery or those affected by diseases that induce impairments through disorders of the musculoskeletal or nervous systems, chronic pain, or restricted movement.,,, Treatments usually involve physical therapeutics, medications, and/or noninvasive or marginally invasive techniques. The chief focus in PMR is to enable the individuals to function optimally within the limitations they experience. The PMR is also practiced in certain countries as rehabilitation medicine. There has been some notion to call PMR physical and rehabilitation medicine (PRM). There is a dearth of true statistics about persons with disability in the Middle East and North African (MENA) region. These trends along with other factors such as the presence of social stigma, which may discourage people from reporting disabilities, may help to explain the remarkably low reported disability prevalence found in the MENA region. Disability prevalence ranges from 0.4% in Qatar to 4.9% in Sudan. Of the 18 countries for which data are available, 15 countries reported the prevalence of disability to be under 3% and half reported rates under 2%. Such data do not go with those of other regions with similar socioeconomic status as well as with global averages. For example, in Latin America and the Caribbean regions, the average disability prevalence is estimated at 12.4% and 5.4%, respectively, whereas the WHO and World Bank estimate that approximately 15% of the world population lives with disability. Moreover, disability prevalence in MENA countries is remarkably lower than reality, knowing the abundance of risk factors and causes of disability, including consanguinity, communicable and chronic diseases, road traffic accidents, and wars.
| Role of Physical and Rehabilitation Medicine Specialists|| |
Medical rehabilitation is practiced through interdisciplinary team with its spirit. Although many specialists including physical, occupational therapists, speech therapists, recreationalists, rehabilitation nurses, psychologists, and social workers are involved in the treatment of patients in rehabilitation medicine, PMR consultants undertake leadership roles in treatment groups., While the focus of the team is not on comprehensive restoration to the premorbid level of function, optimization of the quality of life is the goal for those unable to reach a complete level of restoration., Physiatrists also provide patients the practical evidence and not just medical knowledge. PRM patients usually need practical information, such as where they can purchase cheap walking aids, how they can have their house remodeled to accommodate handicapped individuals, and how they can obtain a welfare card for the handicapped. As PRM deals with diseases in subacute to chronic stages, communication with physicians in other departments (such as neurology, neurosurgery, orthopedics, and cardiology) who treat the same patients during acute stage is essential for effective rehabilitation strategies.
| Needs of Physical Medicine and Rehabilitation in Middle East and North Africa|| |
MENA is an acronym which refers to the Middle East and North Africa. Algeria, Bahrain, Djibouti, Egypt, Iran (Islamic Republic of Iran), Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Qatar, Saudi Arabia, the State of Palestine, Sudan, the Syrian Arab Republic, Tunisia, the United Arab Emirates (UAE), and Yemen are the countries which are in the MENA region. They share much in common in terms of religion, language, culture, and customs. At the same time, there are a range of diversity and subtle differences between the countries in the region economically, socially, politically, and geographically, all of which have effects on social and political movements, including human rights and disability issues.
| Current Situation of Physical Medicine and Rehabilitation in Middle East and North African Region|| |
Health-care system in most of the MENA countries is public with some optional health insurance programs. As known, medical rehabilitation can prevent permanent disability and decrease the disability consequences, give chance for recovery, avoid expected complications, improve the quality of life, and reintegrate persons to their community and society whenever possible. At the same time, rehabilitation for persons with disability could be expensive, and this could be a reason for some countries not being able to develop PMR services.
The PMR started unsuccessfully in many countries, because of lack of understanding of the services provided by the specialists and as a result of underestimation by colleagues. As in some other developed countries, some PMR specialists in the late 1970s changed their career from one of the medical specialties to PMR for one reason or another. PMR lately is becoming highly competitive specialty mainly in countries which run postgraduate medical training to obtain board/fellowship certificates.
As the population within the MENA have increased and aged, disability has also risen, with greater numbers of systemic, congenital diseases and traumatic injuries (i.e., vehicular). In addition to these reasons, consanguinity is also common with the increased chance of genetic diseases and may be disabilities. Such factors have created an increased demand for PMR services and a concordant need for higher levels of awareness for PMR in the MENA.,,, Medical rehabilitation is not available in all countries, and even if available, not in each district, region, or city. There are some countries with advance health-care services, but the number of rehabilitation services whether inpatients or outpatients is deficient. In other countries, medical rehabilitation is not known except through the provision of limited physical therapy and may be speech therapy, but no medical rehabilitation centers/wards or hospitals. Even when there is some exposure to medical rehabilitation, there is lack of full team members, lack of disability-related equipment, and no possibility to home modification to ease accessibility for persons with disabilities (mainly for physical disability). Economy is stringent in most of the MENA countries, and health budget is directed mainly for emergency medicine and acute medical and surgical issues. Over the past two decades, several rehabilitative services for persons with disabilities and other residents have been set up by throughout the MENA countries; however, most of these programs provide physical, occupational, speech, and hearing therapy only. Recently, studies have reported an increasing need for more rehabilitation centers, physicians trained in rehabilitation medicine, and teams of rehabilitation professionals in MENA.
Wars in some MENA countries have resulted in many fatalities and disabilities. Because of war and shortage of budget allocation for health care, persons with disabilities suffering have increased with noticeable reduction of the life expectancy. In the better income countries including the Gulf Cooperation Council, there was some improvement in health care, social development, and rehabilitation for their nation, but some other issues arose including road traffic accidents and sedentary life practice which led to diseases/disabilities. They enjoyed the comforts of economic prosperity for many years, making social change less of a priority until very recently. Civil society and nongovernmental organizations in those countries have not yet established full independence from the State in terms of outlook and point of view.
The medical specialty of PMR is well known in many developed countries, but this is not the case in many developing countries. Few MENA countries have an organized residency program in PMR. Egypt may be the first to introduce rehabilitation since the 1940s (used to be called rheumatology and rehabilitation). In others, it was till the 80s of the last century when the field of PMR was introduced in the Arab countries. Some countries like Jordan, Kuwait, and Saudi Arabia have a recognized board in PMR.
The situation in Saudi Arabia and may be in some MENA countries is as follows: in the early 80s of the last century, they launched rehabilitation hospitals/centers, mainly in the armed forces hospitals. Others opened department of PMR within tertiary referral hospitals. The major reason, there were lack of physiatrists in this region, hence the physicians, consultants, and specialists, including rheumatologists, neurologists, neurosurgeons, family medicine, pediatricians and urologists taking care the patients under the rehabilitation services. Others are certified PMR specialists recruited from North America or Europe. Still, some countries do not have PMR specialty registered at their licensing bodies compared to other medical specialties. The growth of health-care system and the increasing number of hospital beds have led to more understanding of medical rehabilitation. Most of the inpatients who are staying longer than recommended within the hospitals are having some type of disability, so the concept of introducing medical rehabilitation service was accepted to reduce the effect of disability, increase patient turnover, and for better bed utilization. Consequently, PMR was approved as a medical specialty that can run the service. The above discussion applies also to other MENA countries with similar economy.
PMR in MENA countries, with established postgraduate training programs, covers all age group from pediatrics rehabilitation, through adolescence to adults and geriatrics. Most residents are trained to manage all sorts of disabilities including, but limited to, spinal cord injuries, traumatic brain injuries, stroke, pediatrics, neurorehabilitation, prostheses and orthoses, cardiopulmonary rehabilitation, chronic nonsurgical musculoskeletal pain, intervention procedures related to pain and spasticity, and others. PMR is practiced both in public and private hospitals; private health insurance covers some medical rehabilitation with limitations, including coverage of only outpatient services and limited sessions of physical and occupation therapy (usually only six, extendable by justifying medical report from PMR specialists).
| Scientific Meetings|| |
Since the late 1990s, there have been many PMR conferences/symposia, at least one annually and sometimes even twice a year. At least, three regional meetings of the International Society of Physical and Rehabilitation Medicine (ISPRM) were organized. The Pan Arab Society of Physical Medicine and Rehabilitation in cooperation with some national societies organizes too, if not annually, once every 2 years, a scientific meeting. Speakers from MENA region with international quality experts discussed many topics, including PMR research. There are also some invited speakers from medical fields related to PMR such as rheumatology, spinal, neurosurgery, orthopedics, plastics, and urology. Workshops are arranged in parallel such as spasticity management; interventional procedures in chronic pain, using some evaluation tools; pediatrics rehabilitation; and others. The most active countries in this regard are Egypt, Jordan, Saudi Arabia, Kuwait, and the UAE.
| Scientific Publications|| |
There is no journal specific for PMR in MENA countries, but most of the rehabilitation topics are published in local cited medical journals or international ones. The Saudi Medical Journal is one of the important journals which published many rehabilitation related researches. There are some authorities which provide counseling, materials, equipment, and grants for researches in the field of all types of disabilities in some MENA region countries. An example of them is King Salman Center for Disability Research, based in Riyadh, Saudi Arabia.
| Recent Statistics of Physical Medicine and Rehabilitation in Middle East and North Africa Region|| |
The current situations of PMR among the different countries from MENA region are shown in [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]. The clear statistics are available with few countries such as Tunisia, the UAE, Saudi Arabia, Palestine, and Oman.
|Table 1: Current situation of physical medicine and rehabilitation in Tunisia, the United Arab Emirates, and Egypt|
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|Table 2: Current situation of physical medicine and rehabilitation in Bahrain, Saudi Arabia, and Morocco|
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|Table 3: Current situation of physical medicine and rehabilitation in Iraq, Lebanon, and Kuwait|
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|Table 4: Current situation of physical medicine and rehabilitation in Yemen, Palestine, and Oman|
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|Table 5: Current situation of physical medicine and rehabilitation in Sudan and Algeria|
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According to our recent survey, most of the countries from the MENA region reported that trauma and chronic diseases are the leading causes of disability [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]. It is well documented that chronic illnesses affecting older adults and, to a lesser degree, middle-aged people are the main source of disability and physical impairment. On the other hand, major trauma in any type of injury has the potential to cause prolonged disability or death. There are many causes of major trauma, mainly blunt, penetrating, falls, traffic accidents, stabbing wounds, and gunshot wounds.
Service delivery is an important component of health systems. To capture availability, access, and distribution of health services delivery, a series of indicators or a composite indicator is required. Currently, there are no such data available for the majority of countries. In-patient bed density is one of the few accessible indicators on a component level of health service delivery. As per our survey findings, in terms of hospital beads, except Tunisia, the number of beds in most countries is in the range of 1.5–104/10,000 populations. However, the number of beds in some countries in MENA are below the rate of some middle-income countries like China and Brazil.
Available statistics show that over 45% of the WHO member states report to have <1 physician per 1000 population. In MENA region except Bahrain, Lebanon, and Algeria, most of the MENA region countries have PMR-certified physicians and residents. A high number of PMR-certified physicians and residents are available in Egypt, Algeria, and Iraq. The countries like Morocco (0.6/1000) and (Yemen (0.3/1000) have lesser number of physicians [Table 1] and [Table 4]. In the MENA region, the PMR services are delegated as outpatient and inpatient services except that in Yemen and Sudan. It should be noted here that, in Sudan, the rehabilitation services have been provided under the umbrella of neurology division.
The PMR, in particular, is one of the specialties that have become more popular, and therefore more competitive, among medical students in recent years around the world. However, there is no much exposure to PMR in MENA region's medical schools in most of the countries. Further, countries like Bahrain, the UAE, Saudi Arabia, Iraq, Kuwait, Yemen, and Sudan do not have the facility to train PRM during the medical school, whereas other countries from the MENA region including Tunisia, Egypt, Morocco, Lebanon, Palestine, Oman, and Algeria have the provision to trained PRM specialists in the medical schools. We also found that majority of the countries the PMR physician providing the courses mainly during 4th and 5th years of the medical school. A total of 9 countries out of 14 included have a recognized training program in PMR internally, and some have affiliation with European countries (split program), with duration between 4 and 5 years; no country offers post board subspecialty training.
There is now a better understanding of the importance of PMR, particularly in major hospitals. More than 220 physiatrists are registered (licensed) by the Saudi Commission for Health Specialties (52 are certified, 42 are residents in the Saudi Board of PMR in four training centers/two cities, and the remaining are service residents or registrars). Ranking of physicians is as follows: intern, resident, specialist “Registrar,” senior registrar, and consultant. There is at least one scientific conference/symposium for medical rehabilitation every year. The Saudi Arabian Society of PMR, one of the members of the International Society of Physical and Rehabilitation Medicine (ISPRM) since the year of 2000. The specialty of PMR is now well recognized and offer many academic degrees including PhDs.
Jordan was one of the early countries in the MENA region which launched PMR board within the Jordan Medical Council since 1984. They have an active national society of PMR, and all physiatrists are officially registered with the Society. The Society organizes monthly lectures for the members and occasionally for other medical societies and weekly journal clubs. The Government has been very supportive of PMR. However, it is important to educate other colleagues in the country to the role of PMR. Other specialists, such as orthopedic surgeons, neurologists, and neurosurgeons, have been very active in rehabilitation.
This country was in war since 1990, with an increasing number of persons with disabilities The specialty of PMR has existed in Iraq for years in major hospitals as well as in the private sector. However, no organized residency training is available. The number of people with disabilities has increased with the recent wars, and appropriate rehabilitation services are not available.
In 2003, they organized the 2nd Regional Meeting for the ISPRM. The specialty of PMR is well recognized, and the specialists are offered an academic title of PhD degree too. The number of physiatrists has increased recently with some nationals undergoing their training in Slovenia, Canada, and other countries. There is a Kuwaiti Board of PMR which was launched in 2011.
The United Arab Emirates
A number of certified physiatrists practice the specialty in different Emirates. A proposal to create an Emirates Club of PMR has been discussed. There are at least ten physiatrists, but no residency training program.
The field of rehabilitation medicine is not well known in Oman. Few orthopedic surgeons and neurologists have become interested in the rehabilitation of people with disabilities.
The specialty of PMR is not practiced in Yemen. It is likely that the current political situation will result in an increase in the number of people with disabilities.
There are many universities which have an established program in PMR. They offer a master's degree and a doctorate degree. The specialty started as rheumatology and rehabilitation as early as the 1940s. Later, some Egyptian universities tended to change the specialty to Rheumatology and a few decades ago, they agreed to unify the specialty named as PMR. The National PMR Society in Egypt used to conduct annual meeting.
| Developing Physical Medicine and Rehabilitation in Middle East and North Africa and May Be Worldwide|| |
Due to the nature of the society mentioned above and the war that is affecting some of the MENA countries, there is a great need for increasing the services of medical rehabilitation and increasing the number of PMR specialists. This should also be combined by improving the quality of PMR. It is proposed that PMR medical doctors are the most responsible physicians for persons with disability and they are the primary health-care providers. They should have an excellent medical knowledge of all health issues related to disabilities. It is difficult to manage medical/surgical conditions by physiatrists, but they can do the clinical diagnosis for the PMR patients and follow them afterwards. As known well, the patients and their families and colleagues in health-care provision will respect a practitioner who adds to health or quality of life. Having a certificate in any specialty with deficient knowledge and practice cannot be respected or appreciated. Although life seems to become increasingly tough for all medical specialties, PRM is a robust specialty with varied activities. This is also part of its weakness, as health-care systems view it under different terms. The plan is, therefore, to describe the specialty at a level for publication in all the member states and to work with health policymakers in ensuring the future of the specialty's role in delivering health care, but also at a MENA governmental role in making the specialty's expertise known for the development of health and social policy.
| Conclusion|| |
Countries in the MENA region share many criteria, namely demographic, geographic, political, and even issues related to disability. There is still a lack of understanding of the medical specialty of PMR or PRM as called by some clinicians. The number of PMR physicians or physiatrists is still insufficient. There are postgraduate training programs with an exit certificate of masters' degree, doctorate degree, or board. Most of the MENA countries have rehabilitation units/wards within their hospitals. Other countries have self-standing rehabilitation hospitals; the services whenever available cover all age groups. Research conducted by PMR specialists is scant. There is no specific medical journal for PMR in the region. The Pan Arab Society of PMR is conducting almost an annual scientific meeting of PMR in addition to some local conferences/symposia. In this article, we discuss the current situation of PMR and its scope in the MENA region and envision the future.
Appreciation to my colleagues in MENA countries who have filled the form and returned it to me. Many thanks to them.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]