Position paper on PRM and persons with long term disabilities.

In the current population we observe a rise of chronic health problems often with multiple characteristics. This results in a growing number of people who are experiencing long-term disabilities or difficulties in functioning because of disability. These conditions require a complex response over an extended period of time, that involves coordinated inputs from a wide range of health professionals. This paper argues the central role and benefit of rehabilitation and describes the rehabilitation as an integral component in the management of people with chronic disabilities. It also presents the most important related definitions: long-term care, rehabilitation for chronic disease and disability, the aim of physical and rehabilitation medicine (PRM). An interdisciplinary team is ideal for an effective implementation of rehabilitation for chronic disease and disability. However, the article mainly focuses on defining the role and contribution of the PRM physician in the rehabilitation of persons with long-term disabilities. The article includes: descriptions of his/her key role and competencies, particularly with regard to medical and functional status and prognosis, of the ability to comprehensively define the rehabilitation needs of the patient/person with respect to ICD-WHO classification domains, of the cooperation with other medical specialists and health professionals, of determining the rehabilitation potential, of developing the rehabilitation plan tailored to specific needs, as well as of the contribution of PRM physician in the follow-up care pathways.