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John OLVER AM MBBS MD FAFRM (RACP)

Director Rehabilitation Epworth HealthcareProfessor Rehabilitation MedicineDepartment of Medicine Monash University

The Development of Rehabilitation Services in the Australasian Region

The Asia-Oceania Region

Grouping of countries holding 60% of the world’s population (>4.5 billion)

The region hosts a diversity of cultures, political environments, socio-economic development, religions and population sizes

There has been a gradual evolution of Rehabilitation Medicine and associated programs and facilities throughout the Asia-Oceania region

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sThe Australian Association of Physical Medicine was formed

The Australasian Faculty of Rehabilitation Medicine (AFRM) of the Royal Australasian College of Physicians was formed

Followed by China, India, Indonesia, Korea, Taiwan, Thailand

First Asian National organisations formed (Philippines and Japan)

Followed by Vietnam, Hong Kong and Laos

At a later stage, organisations were also formed in Malaysia, Singapore and Mongolia

Asia-Oceania RegionThe Commencement of Rehabilitation Medicine

Han, 2007

Rehabilitation is still in the initial phase of development in some countries. In others, there are well established programs, research projects and advances in technology that are instigating changes for the discipline and projecting it beyond its current boundaries

Country or

Administrative Region

PMR Association Year of

Establishment

Number of

Physiatrists

PMR Training

(years)

Board Certification

Examination

CME /CPD

Activities

Australia Australasia Faculty of RM a 1993 300 2 + 4 Yes Yes

New Zealand

Bangladesh Bangladesh Association of PRM 1995 25 3 Yes n/a

Brunei n/a - 1 n/a n/a n/a

China Chinese Society of PM&R b 1985 10000 5 In preparation Yes

Chinese Association of RM 1983

Chinese Taipei Taiwan Academy of PM&R 1971 640 4 Yes Yes

Hong Kong SAR Hong Kong Association of RM 1996 39 3 + 3 Yes Yes

India Indian Association of PM&R 1972 416 3 Yes Yes

Indonesia Indonesian Association of PM&R 1987 257 4 Yes Yes

Iran Iranian Association of PRM 1972 250 3 Yes n/a

Japan Japanese Association of RM 1963 1102 5 Yes Yes

Korea Korean Academy of RM 1972 947 4 Yes Yes

Laos Laos National RM Association 2005 4 n/a n/a n/a

Malaysia Malaysian Association of RM 2004 15 2 + 4 Yes Yes

Mongolia Mongolian Society of PRM 2005 130 1 n/a n/a

Philippines Philippine Academy of RM c 1974 300 3 Yes Yes

Singapore Society of RM Singapore 2005 16 3 + 3 Yes Yes

Thailand Royal College of Physiatrists of

Thailand

1998 338 3 Yes Yes

Thai RM Association 1988

Vietnam Vietnam Rehabilitation Association 1991 1400 3 n/a n/a

History of National PMR Societies in Asian Countries

The formation of regional societies has been pivotal for the development of the specialty in Asia and Oceania. It promotes Rehabilitation Medicine and sharing of knowledge across borders. Earliest regional professional meetings:-Thailand (1998), Joint Japan-Korean conference (2002)

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Asia-Oceanian Society of Rehabilitation MedicineThe largest step forward in regional communication (2007)

Formed with the purpose of being a

regional scientific and educational society for practitioners of Physical

and Rehabilitation Medicine

Broader mission: represent physical and

Rehabilitation medicine from the Asian and Oceanian region to international health organisations

Aims to improve the knowledge, skills and

attitudes of physicians in their management – improving

patients quality of life through successful community

reintegration

The conduct of Regional meetings has introduced a global perspective of Rehabilitation (e.g. updates on the Society’s relationship with the WHO and promotion of global concepts e.g. International Classification of Functioning, Disability and Health)

First congress was held in Nanjing, China (in 2008) and since this time, conferences are held on a biennial basis (Taiwan, Bali, Thailand and Philippines)

21 countries have National representatives in the Society including: (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)

Asia-Oceanian Society of Rehabilitation Medicine (AOSPRM)

This congress also formed the focus of Rehabilitation in China (Disaster Relief) as it occurred just after the Sichuan earthquake whereby Chinese delegates were in disaster relief roles

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Asia Oceania Region – Regional Differences Examples

General, accepted understanding Alternative understanding

Overall philosophy of rehabilitation medicine

Improving activity and participation in society in individuals with impairment and consequent disability

Rehabilitation has the same connotation as recovery and is a natural outcome of the disease rather than an active process addressing it (China)

Definition In Asia-Oceania, it ranges from RM, PRM or PM&R (Han 2007)

Stage of Development

For most Western countries (including Australia), Rehabilitation Medicine started after World War II to provide medical service and rehabilitation for veterans with spinal cord injuries or amputations. It started much later in Asia than in Europe or the United States

Han, 2007

1955 –1948

Ministry of Post-War reconstruction became the Commonwealth Rehabilitation Service

Transitioned previous serving servicemen back into the workforce (through Vocational Rehabilitation). No focus on improving personal independence. Services available in most States – at the time little rehabilitation existed in state run public hospital systems

Australian State Run Rehabilitation programs

emerged within dedicated Rehabilitation Centres

1970 1977

Bruce Ford described the concepts of team-based, multi-disciplinary programs which extended beyond medical impairment and encompassed physical, psychological and social assessment of patients

Diploma in Physical and Rehabilitation Medicine commenced (1970) to recruit doctors into the

specialty. The National Specialist Advisory committee formally recognised Rehabilitation as

a principal specialty (1977)

1996

Rehabilitation in Australia

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Royal Australasian College of Physicians (RACP)

The College introduced a Fellowship Training Program in Rehabilitation Medicine which grants doctors the right to practice as Specialists in Australia

New Zealand adopted the same training program, initiating their own country branch of the college (holding its first meeting in 1989)

In 1991, the College joined with the Royal Australasian College of Physicians (RACP) and became one of its faculties

Post graduate education is modelled on the Royal College System from the UK rather than a University based qualification

Module 1

Written Assessment

Module 3

Clinical Research/ Research Project

Module 5

Health Services Administration and

Evaluation

Module 2

Clinical Assessment

Module 4

Clinical Neuropsychology

Module 6

Behavioural Sciences

Rehabilitation Training Curriculum

Formalised curriculum for training

48 month program (at 2nd or 3rd

year post graduate level)

6 modules to be completed during training

Post Fellowship education is presently run by a newly formed Rehabilitation Medicine Society of Australia and New Zealand (RMSANZ)

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Proportion of Rehabilitation Physicians in Australasia

567 rehabilitation physicians across Australasia

214 trainees

67 retired Fellows

14 honorary Fellows

AROC is the national rehabilitation medicine clinical registry of Australia and New Zealand (established in 2002 as a not-for-profit centre)

The Australasian Faculty of Rehabilitation Medicine (AFRM) is the auspice body and data custodian

Australian Health Services Research Institute at the University of Wollongong manages AROC on its behalf and undertakes the day to day management of AROC

AROC collects data from >96% of Rehabilitation Facilities in Australia and New Zealand for every episode of care on admission and discharge

Australasian Rehabilitation Outcomes Centre (AROC)

https://ahsri.uow.edu.au/aroc/whatisaroc/index.html

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Rehabilitation physicians in our

role as educators:

To produce information on the efficacy of interventions through the systematic collection of outcomes information in both the inpatient and ambulatory settings

It provides an audit tool to allow for internal evaluation and comparison with national benchmark data for all impairment groups

A set of benchmarking reports are prepared for individual facilities and payer organisations every 6 months that summarise the Australasian data against the submitting facility

Develop clinical and management information reports based on functional outcomes, impairment groupings and other relevant variables

Purpose and Aims of AROC

https://ahsri.uow.edu.au/aroc/whatisaroc/index.html

19631920s

The Japanese Association of Rehabilitation Medicine (JARM) was established

Rehabilitation practice preceded its formal establishment. In the 1920’s, it was focused on “crippled children”

1980 1982

A certification system in

Rehabilitation was started

Rehabilitation in Japan

2003

Guidelines for post graduate training were created and the “Fundamental Principles for Education of Rehabilitation Medicine” were developed

Following the certification system, this developed into a new organisation of Board-certified Physiatrists

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Rehabilitation Curriculum in Japan

Curriculum in Japan had similar objectives to the Australian model. Institutes were certified for education in Rehabilitation Medicine

and courses developed by JARM

Electrodiagnosis was a key skill for physiatrists.

Research methodology and interdisciplinary team management was also

encouraged

An additional focus at present is

leading the development of

robotics in physical rehabilitation

Rehabilitation in Malaysia

Training program and development of Rehabilitation Medicine was championed by Professor Datuk Dr Zaliha Omar

Training formally commenced in 1997 – a four year post-graduate Masters course (University of Malaya). <2004 trainees spent 6 months training in Melbourne

Examinations were conducted with external examiners (from USA, Europe, Australia)

Rehabilitation has evolved over recent years with new facilities containing dedicated Rehabilitation beds

First Malaysian Association of Rehabilitation Medicine Conference held in December 2004

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Evolution Modern

PolicyEstimates

The evolution of Rehabilitation has embraced Traditional Chinese practices (massage, (acupuncture, herbal medicine) and Western

medicine. This integration is particularly applied in stroke/chronic pain

1980s: Modern rehabilitation was introduced to the Chinese

health system. System needs restructure and increased

financial input (as disassociation between the different grades of

hospitals e.g. acute, subacute)

85 million disabled people (with 90% having Rehabilitation needs). Many cannot access a Rehabilitation program. In response, pilot programs of integrated Rehabilitation were introduced in 2010 (46 cities and 14 provinces)

With the recent National Policy on Health China

(2030) and economic growth, Rehabilitation is an important aspect of healthy

living and aging. There are now training facilities for doctors,

therapists and nurses and partnerships to create new rehabilitation facilities

Rehabilitation in China

Challenges in Delivering Rehabilitation Services

Referral between tiers of

management

Rehabilitation medicine is often not well understood by the general public and other doctors. People who would benefit from rehabilitation are not being referred to the services

Team-Based Specialty

Rehabilitation operates most efficiently with good team communication – rather than the delivery of individual therapy services. The treating Rehabilitation physician is best placed to take a leadership role in the coordination of treatment

Locality

Service gap exists between city and rural services. Rural services are under resourced. Difficult to access services in countries such as Australia with vast distances

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Rural Rehabilitation Services

2009 Thailand study: 8.9% of the population had disabilities and majority lived in rural areas. No more than 2% were involved in Institution based Rehabilitation. Community-based Rehabilitation was introduced to address this service gap (1970 - early 80s)

Therapists require alternative training for roles - need to be aware of cultural, economic and religious differences of clients and be flexible in their approach and goal setting

In China, there was a shortage of Rehabilitation resources which were unevenly distributed between rural, urban areas and in different regions

Challenges in Delivering Rehabilitation Services (cont.)

Aging population

Specialty focuses on minimising the effects of disability on activity and participation in society – so will need to meet this demographic challenge. In Japan, 22% of the 128 million population are >65 years. In Singapore, by 2030, 20% of the population will be >65 years

Prevention

Preventative role in all phases of rehabilitation treatment (from acute to community) to oppose the “vicious circle of immobility.” Involves preventing further impairment after injury due to immobilization and sedentary lifestyles

Resources

Disability has been related to a high risk of poverty – with some prejudice noted against people with disability. In Indonesia, 1.8% of the population have extreme problems and 19.5% have problems with daily living tasks. Across the region, the financial resources and available personnel to deliver services are low compared to the existing needs

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It is hoped this report will provide a template to influence Governments in this region to allocate more resources to Rehabilitation – to ensure the dignity of people with disability and help change the perception of them to “active and equal citizens”

Epworth Monash Rehabilitation Medicine Unit Research Team

Thank you

Email: john.olver@epworth.org.au