378 Letter to the Editor

Letter to the Editor

International Journal of Rehabilitation Research 2012, 35:378381

How specific is a medical speciality? A

semiserious game to test your understanding
of physical and rehabilitation medicine
Luigi Tesio, Department of Physical and Rehabilitation Medicine, Department
of Biomedical Sciences for Health, Universita` degli Studi and Department
of Neuroehabilitation Sciences, Istituto Auxologico Italiano, IRCCS, Milan, Italy
Correspondence to Luigi Tesio, Istituto Auxologico Italiano, via Mercalli,
32, 21021 Milan, Italy
Tel: + 39 2 58218150; fax + 39 2 58218152; e-mail: luigi.tesio@unimi.it
Received 12 September 2012 Accepted 18 October 2012

In a letter published in 2007 (Tesio and Franchignoni,

2007) my coauthor and I highlighted how the word
rehabilitation as applied to healthcare is still contended
by multiple concepts. Its proposed semantic domains
extend from medical treatments limited to the application of physical energies to the comprehensive care of the
disabled person, by whichever means (e.g. medical
assistance, social support, legal protection and the like).
If one looks at national legislations and scientific journals,
definitions may be thought of as being aligned along a
gradient spanning from physical therapy to physical
medicine and rehabilitation (PMR), physical and
rehabilitation medicine (PRM) and finally to rehabilitation, tout court (Fig. 1).
The WHO now uses the word disability as an umbrella
term to refer to a complex interplay of impairments
(body/organ dysfunctions), activity limitations (at the
whole-person level) and participation restrictions (at the
personsociety interface), all of which are conditioned by
personal and environmental factors (WHO, 2001).

Narrower

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Fig. 1

Wider

PMR domain width.

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0342-5282

At a European level, strong efforts have been made to

provide a description, if not a definition, of the specific
medical speciality [now PRM in Europe and PMR in the
USA] consistent with the ICF model (Stucki and Melvin,
2007; Gutenbrunner et al., 2011). In a previous paper, I
advanced the hypothesis that the ICF model, claiming to
be a classification system, is actually a dictionary with
non-mutually exclusive code words (Tesio, 2011). One
can freely draw words from the dictionary and build an
infinite number of different sentences. The ICF is an
excellent philosophical guideline but I do not think that
it will ever work as a rigid template to forge technical
standard definitions of medical specialities.
Unsurprisingly, a 317-word conceptual description not
yet a definition is the best available ICF-consistent
product (Gutenbrunner et al., 2011). In fact, an accurate
definition of PRM would imply deciding not only what
PRM is but also what it is not.
While awaiting a clearer conceptualization of the speciality, it
may be difficult for policy-makers and academic authorities
to decide which diagnostic and therapeutic procedures are
specific to the field. The quiz game proposed here may
assist them in making such decisions.
In the aforecited letter, I explained why the term
physical should be preserved, and PRM adopted, when
defining the corresponding medical speciality. Physical
describes any therapeutic or diagnostic means practised
from the outer world on the person as a whole, and thus
it may include speech therapy as well as motor exercise
and electrotherapies. Rehabilitation is the goal of
allowing a person to achieve the greatest possible success
in functioning. Curiously enough, the ICF and the huge
related literature do not provide an explicit definition of
function. By this term, I mean the exchange of energy or
information: biological functioning applies to individual
parts within the body (no matter if they are organs or
molecules), whereas person functioning applies to the
interactions between the individual person and the outer
environment (Tesio and Franchignoni, 2007; Tesio, 2007).
In this latter sense, achieving independence in walking
and obtaining sheltered employment are both functional, rehabilitation goals.
Let me now propose a user-friendly sequel to the previous letter, in the form of a quiz game highlighting the
specificity of PRM, or, in other words, what PRM is and
what PRM is not. The game is based on the concept that
neither physical methods nor the rehabilitation goal,
DOI: 10.1097/MRR.0b013e32835ba60d

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The game of PRM specificity Tesio 379

whereas ability is the way a whole-person (not any of his/

her parts) interacts (i.e. it exchanges energy or information) with the physis.

taken individually, are unique to PRM: it is their

interaction that generates specificity.
First, one must acknowledge that the less-to-more continuum depicted in Fig. 1 is not really unidimensional.
Actually, the gradient line mixes up to what extent physical should be the means adopted and how rehabilitative the goals should be. Rather than a line, a twodimensional domain should be proposed. In the following
quiz physis means, according to its Greek etymology,
nature, the outer world (inclusive of other persons),

The game
In Fig. 2a and b, the y-axis represents the less-to-more
gradient of physicality of means, ranging from treatment from inside the body, on body parts to treatment
from outside the body, on a person. Although some of the
latter treatments may well appear to address only body

Fig. 2

E
I

From inside
the body

Physical means

From outside
the body

(a)

J
C

Rehabilitation goal

Biological functioning
within the body

Whole person functioning

in the outer world

From inside
the body

b
h

Physical means

From outside
the body

(b)

Biological functioning
within the body

Rehabilitation goal

+
Whole person functioning
in the outer world

(a) Chart of therapeutic procedures. (b) Chart of diagnostic procedures.

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380 International Journal of Rehabilitation Research 2012, Vol 35 No 4

parts (e.g. strengthening a muscle group), therapists are

dealing nonetheless with a unique person, a self with
unpredictable behaviours and perceptions (Tesio, 2003).
A person can say ouch, thats enough for me and apply
more or less force when required to make maximum
effort. No body parts can do that.
The x-axis represents the rehabilitative nature of the
goal, ranging from restoring biological functioning within
the body to restoring whole person functioning in the
outer world. Circles encase 10 distinct therapeutic
(Fig. 2a) and diagnostic procedures (Fig. 2b), labelled A
to J and a to j, respectively. The plane is divided into four
equal-area quadrants: procedures specific to PRM (in that
they combine physical means and rehabilitative goals)
should fall within the top-right quadrant. In the other three
quadrants, either the goal is not rehabilitative enough (top
left) or the means are not physical enough (bottom right),
or both (bottom left).
The reader is now invited to match the labels with the
procedures listed in random order in Table 1.
You need to select the correct quadrant to score a point.
The cumulative scores may range from 0 to 20. The higher
the score, the sounder the readers concept of PRM. The
solution is given, as in any reputable tabloid quiz, upside
down in the Appendix. Table 2 gives an interpretation of

the cumulative score, according to arbitrary and unsafe

(Franchignoni et al., 2012) cutoff levels.

A cautionary note
(1) The 10 therapeutic and 10 diagnostic procedures
selected are just examples of a countless number of
procedures that might fall within the same quadrants.
(2) The proposed coordinates of the circles are clearly
semiquantitative and largely questionable. For example, within the top-left quadrant of Fig. 1a, two
therapeutic procedures may be equally physical but
one may be considered more rehabilitative than the
other if the former is expected to be more directly
related, compared with the latter, to an improvement
in persons behaviour. The same holds for the
diagnostic procedures in Fig. 1b, if one procedure is
expected to test more behavioural, less organ-bound
functions than the other. Of course, there may be
procedures that straddle several quadrants. Both the
coordinates and the match between circles and
procedures only reflect the authors opinion.
(3) The specific top-right procedures are not the only
ones in which PRM professionals are competent; the
same procedures may well be practised by other
specialists. Specificity is not an all-or-nothing attribute; yet this is not a good reason to not seek a
clearer discrimination.
Conclusion

List of procedures (in random order) labelled in Fig. 2a

and b (left and right column, respectively)
Table 1

Therapeutic procedure chart

Diagnostic procedure chart

Botulinum toxin injection for spasticity or dystonia

Antihypertensive drugs
Muscle strengthening exercise
Myopic laser corneal ablation
Shock waves for delayed union of fractures
Speech therapy

Brain fMRI (functional MRI)

Bicycle stress ECG
Gait analysis
Handgrip force testing
Spatial neglect testing
Basal metabolic rate
measurement
Tendon transfer in tetraplegia
Needle electromyography
Antidepressant drugs
Surface dynamic
electromyography
t-DCS (transcranic direct-current brain stimulation) Videofluoroscopy for
swallowing
Tibial nerve electrical stimulation (SANS) for
Urodynamics
bladder incontinence

Table 2 The physical and rehabilitation medicine understanding:

cutoff scores for clinical interpretation
Score

Value judgment

Typical specialist (examples only)

05
610
1114
1418

Unacceptable
Insufficient, improvement unlikely
Sufficient, might improve
Good, can understand
PRM language

1920

Excellent, he/she understands

what is specific to PRM

Pathologist
Surgeon Anaesthesiologist
Internist Neurologist
Gerontologist specialist in sports
medicine specialist in Industrial/
Occupational Medicine
Psychiatrist Physiatrist

PRM, physical and rehabilitation medicine.

With these limitations in mind, one should consider that

once a procedure is placed within the top right-hand
quadrant it can be deemed a stronger candidate, compared
with procedures falling within the other quadrants, to join
PRM services and, on the teaching side of healthcare, to
enter the core curriculum of PRM professionals.

Take-home points

(1) PRM is a specific medical discipline, not any kind of

support for disabled people.
(2) Physical means are any diagnostic or therapeutic
procedures applied from the outside to a person as a
whole (e.g. motor and cognitive assessments, motor
exercise or speech therapy).
(3) Rehabilitation is the goal of leading a whole person to
the highest possible successful interaction with the
outer environment, inclusive of other persons.
(4) Only the use of physical means aimed at rehabilitation goals (not means or goals separately) generates
specificity of PMR.

Acknowledgements
Conflicts of interest

There are no conflict of interest.

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The game of PRM specificity Tesio 381

References
Franchignoni F, Salaffi F, Tesio L (2012). How should we use the visual analogue
scale (VAS) in rehabilitation outcomes? I: how much of what? The seductive
VAS numbers are not true measures. J Rehabil Med 44:798799.
Gutenbrunner C, Meyer T, Melvin J, Stucki G (2011). Towards a conceptual description of physical and rehabilitation medicine. J Rehabil Med 43:
760764.
Stucki G, Melvin J (2007). The international classification of functioning, disability
and health: a unifying model for the conceptual description of physical and
rehabilitation medicine. J Rehabil Med 39:286292.

Tesio L (2003). Measuring persons behaviours and perceptions: rasch analysis

as a tool for rehabilitation research. J Rehabil Med 35:111.
Tesio L (2007). Functional assessment in rehabilitative medicine: principles and
methods. Eura Medicophys 43:515523.
Tesio L (2011). From codes to language: is the ICF a classification system or a
dictionary? BMC Public Health 11:S2.
Tesio L, Franchignoni F (2007). Dont touch the physical in physical and
rehabilitation medicine. J Rehabil Med 39:662663.
WHO (2001). International classification of functioning, disability and health.
Geneva: World Health Organization.

Appendix The solution

Botulinum toxin injection for spasticity or dystonia
Antihypertensive drugs
Muscle strengthening exercise
Myopic laser corneal ablation
Shock waves for delayed union of fractures
Speech therapy
Tendon transfer in tetraplegia
Antidepressant drugs
t-DCS (transcranic direct-current brain stimulation)
Tibial nerve electrical stimulation (SANS) for bladder incontinence
Therapeutic procedure chart

C
J
F
I
E
B
G
H
D
A

Brain fMRI (functional MRI)

Bicycle stress ECG
Gait analysis
Handgrip force testing
Spatial neglect testing
Basal metabolic rate measurement
Needle electromyography
Surface dynamic electromyography
Videofluoroscopy for swallowing
Urodynamics
Diagnostic procedure chart

Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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b
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Letter to the Editor 91

Letter to the Editor

International Journal of Rehabilitation Research 2013, 36:9192

Specialization in medicine
Lajos Kullmann, Gusztav Barczi Faculty of Special Education, Eotvos Lorand
University of Sciences, Budapest, Hungary
Correspondence to Lajos Kullmann, Gusztav Barczi Faculty of Special Education,
Eotvos Lorand University of Sciences, Ecseri ut 3, 1097 Budapest, Hungary
Tel: + 36 30 962 3314; fax: + 36 1 348 3187;
e-mail: lajos.kullmann@barczi.elte.hu.
Received 9 January 2013 Accepted 12 January 2013

It was stimulating to read Luigi Tesios Letter to the

Editor on the specificity of the profession of physical and
rehabilitation medicine (Tesio, 2012). Without arguing
with what has been written in the letter, consideration of
the speciality may be viewed from other viewpoints as
well.
Separation of medical disciplines occurred over different
historical times on different bases. Back in historical
times, the basis for separation was the nature of activity,
and medicine was separated from surgery, the latter
performed not by medical doctors but by barbers. This is
clearly stated in the Hippocratic Oath: I will not cut,
even for stone, but I will leave such procedures to the
practitioners of that craft (Margotta, 1968). This
difference is still considered while addressing physicians
and surgeons in Britain.
Through the centuries, a large number of new medical
specialities have been developed parallely, mainly on two
different grounds: the age of the patient and diseased
organs. These have been the basis of establishment of
paediatrics and geriatrics on one hand and, for example,
gynaecology, neurology, rheumatology or urology on the
other. This process went on to create further subspecializations such as addictology or paediatric orthopaedics.
A third line, also formed in parallel, led to the development
of new diagnostic disciplines such as audiology, clinical
laboratory diagnostics or radiology, mainly on the basis
of technical developments.
In recent times, a brand new basis for specializations has
emerged. The ground for differentiating a new discipline
became its consideration as a specific health condition.
This era saw the emergence of emergency medicine for
life-threatening conditions, palliative care for the end-oflife health state, and rehabilitation medicine for disability
as a specific health condition as new specialities. See also
the definition of the speciality in the White book on
physical and rehabilitation medicine: It is thus responsible forypeople with disabling medical conditions and
co-morbidity across all ages (Gutenbrunner et al., 2006).
c 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
0342-5282

The establishment of traumatology and oncology could be

classified into this third line, considering injuries and
malignancy, respectively, as specific health conditions.
Coming back to rehabilitation medicine, the roots of its
development show rather large variance in different parts
of the world. The speciality grew out of orthopaedics,
rheumatology, neurology and other disciplines when
doctors realized the gap between their daily practice
from inside the body and biological functioning within
the body at Tesio and their patients needs from
outside the body and whole person functioning in the
outer world (Tesio, 2012). Most probably, Ludwig
Guttmanns pioneering work helped several British
neurologists to take the lead in developing rehabilitation
medicine, whereas in central Europe balneologists and
orthopaedic surgeons had contributed a great deal (Silver,
2005; Eldar et al., 2008).
Taking the general picture of specialization in medicine
into consideration may perhaps add to a better understanding of the specificities of single disciplines.
In addition to diagnostic and therapeutic interventions,
a new concept of prevention has emerged in rehabilitation medicine the prevention of secondary conditions.
Prevention of secondary conditions was the key element
of Guttmanns activities at the introduction of successful
rehabilitation of people with spinal cord injuries (Silver,
2005). It is also true that this topic did not emerge to an
awareness-raising level in the scientific literature until
about the early 1990s (Marincek, 2007b).
Secondary conditions are direct or indirect but not
obligatory consequences of the primary disabling condition or of its severity; as a consequence, they are
preventable. Their development is largely influenced by
both personal (e.g. autonomy, lifestyle or motivation) and
environmental factors (such as access to care or the social
support system). Secondary conditions comprise not only
impairments but also activity limitation and participation
restriction and usually deteriorate the quality of life.
Secondary conditions may also have a backward effect
(repercussions) on the patient and on his or her
environment (Marincek, 2007a; Moharic and Marincek,
2007; Rimmer and Rowland, 2008; Pershouse et al., 2012).
For these reasons prevention of secondary conditions
is also regarded as an important part of our discipline.
This statement does not mean that physicians involved
in primary interventions and people with disabilities
DOI: 10.1097/MRR.0b013e32835eea31

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92 International Journal of Rehabilitation Research 2013, Vol 36 No 1

themselves would not have important chances or

responsibilities in this prevention process.
It is also important to mention that present knowledge on
the epidemiology, on the most frequent causal factors, on
the nature and on the possibilities of effective prevention
of secondary conditions is still not sufficient; therefore,
these topics should be the priority in rehabilitation
research. Although the number of publications on the
topic is increasing rapidly, because of different research
goals, plans, noncomparable study samples and methods,
finding evidence is still rather difficult (Marincek,
2007b; Kullmann, 2012).
The use of ICF for description, systematization and study
of secondary conditions and their causal factors may
improve the methodology and help obtain comparable
and many-sided outcomes of research.

Acknowledgements
Conflicts of interest

There are no conflicts of interest.

References

Eldar R, Kullmann L, Marincek C, Sekelj-Kauzlaric K, Svestkova O, Palat M

(2008). Rehabilitation medicine in countries of Central/Eastern Europe.
Disabil Rehabil 30:134141.
Gutenbrunner C, Ward AB, Chamberlain MA. (Eds) White book on physical and
rehabilitation medicine in Europe. Eur J Phys Rehabil Med 2006;
42:292332. J Rehabil Med 2007; Suppl 45:150.
Kullmann L (2012). Importance of secondary conditions in rehabilitation medicine
[in Hungarian]. Hungarian Med J 153:19371947.
Margotta R (1968). An illustrated history of medicine. Feltham, Middlesex:
Hamlyn Publications; p. 64.
Marincek C (2007a). Secondary conditions late sequelae of chronic diseases
or injury. Ljubljana: Ministry of Health of Sloveniapp. 163166.
Marincek C (2007b). Secondary conditions whose responsibility? Int J Rehabil
Res 30 (Suppl 1):22.
Moharic M, Marincek C (2007). Prevention of secondary conditions [in Slovenian].
Proceedings, Chamber of physiotherapists of Slovenia, 29th November - 1st
December 2007; pp. 3438.
Pershouse KJ, Barker RN, Kendall MB, Buettner PG, Kuipers P, Schuurs SB,
Amsters DI (2012). Investigating changes in quality of life and function along
lifespan for people with spinal cord injury. Arch Phys Med Rehabil 93:413419.
Rimmer JH, Rowland JR (2008). Health promotion for people with disabilities:
implications for empowering the person and promoting disability-free
environment. Am J Lifestyle Med 2:409420.
Silver JR (2005). History of the treatment of spinal injuries. Postgrad Med J 81:
108114, Available at: http://pmj.bmj.com/content/81/952/108.full.pdf + html.
Tesio L (2012). How specific is a medical speciality? A semiserious game to test
your understanding of physical and rehabilitation medicine. Int J Rehabil Res
35:378381.

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