Physical Medicine and Rehabilitation: Diversity in a Profession

"Physiatrists offer patients understanding and insight about their condition and its effects on their daily lives that few other specialists can."

An Introduction

A 30-year-old man is hit by a car and is in a coma for two weeks. A physician who specializes in disability assembles a team of other health care specialists to address the patient s mobility, muscle tone, bowel and bladder dysfunction, and his need for environmental stimulation. When the young man regains consciousness – lethargic, disoriented, and barely able to move – he is transferred to a rehabilitation unit. A neuropsychologist, rehabilitation nurses, and other allied health professionals are added to the team. The physician attends not only to the medical, but also the social, emotional and vocational concerns the patient faces as a result of his accident. As improvement continues, the physician implements new programs to respond to the young man's changing needs. A year later, he lives at home and functions fairly independently.

A 12-year-old girl is the star of her softball team. Sliding into second base, she twists her ankle, feeling intense pain. Her physician confirms a bad sprain; preliminary treatment with icing, immobilization and pressure is followed by a range of motion program that restores ankle mobility. In the next phase, the physician begins aggressive reconditioning of her ankle, all the while supporting the conditioning of the rest of her body. In five weeks, she s playing ball again in better shape than when she had the accident.

A 70-year-old woman has had a right hemisphere stroke with left hemiplegia and left-sided neglect. She has a history of osteoarthritis and coronary artery disease, experiences emotional lability, and has the range of problems normally associated with stroke. Her physician gives her comprehensive care, right down to addressing the risk of overstressing her heart during rehabilitation. The doctor actually uses the patient s spasticity as a functional aid in regaining mobility.

"The important part of some other specialties is diagnosis. Our greatest challenge is to restore the patient to optimal functioning."

Diversity in a Specialty

Physical medicine and rehabilitation physicians can have general practices or they can pursue special interests. They treat the complete range of disabilities including newborns with congenital birth defects, the elderly who have pain, and people of all ages with traumatic injuries. Society benefits from rehabilitation, too; a recent study indicates that for every $1 spent on rehabilitation, the public saves $11 in long-term disability costs. PM&R physicians report great professional satisfaction based on a high degree of involvement with patients that can continue for a lifetime.

These are just a few examples of the medical specialty called physical medicine and rehabilitation (PM&R), also called physiatry. Pronounced fizz ee at' tree or fizz eye' uh tree, this specialty focuses on the restoration of function to people with problems ranging from simple physical mobility issues to those with complex cognitive involvement.

Physiatry began in the 1930s with the physical treatment of musculoskeletal and neurological conditions, and broadened its scope during World War II when thousands of veterans came home with catastrophic disabilities. The goal of restoring veterans to productive lives triggered expansion of the field into a specialty that deals with all functional aspects of people with disabilities.

Today, physiatry is a diverse specialty. Physiatrists practice in major rehabilitation centers, in acute care hospitals, and in outpatient settings. Their approach to patients requires listening and observing, but also employs state-of-the-art technological support to assist in the healing process.

Physiatry allows physicians to pursue special interests, touches on a wide variety of other specialties, and has as its goal the fullest possible recovery for patients through a truly interdisciplinary, team approach to medicine.

The PM&R Specialty

As medicine becomes more sophisticated, and as life expectancy for Americans increases, the goal of good health has spawned a new theme: quality of life. Physiatry is often called the quality of life profession because its aim is to restore optimal patient functioning. In only a few decades, the thinking that rest will cure everything has become outmoded, replaced by the idea that mobilization and aggressive rehabilitation affords a patient the opportunity to live a full life.

A physiatrist may treat an elderly man with a hip fracture to ensure proper healing of his bones; but more than that, the physiatrist's goal is to see the patient walk without pain.

The job of a physiatrist is to treat any disability resulting from disease or injury involving any organ system. The focus is not on one part of the body, but instead on the development of a comprehensive program for putting the pieces of a person s life back together --medically, socially, emotionally, and vocationally -- after injury or disease. The problems that physiatrists manage span the entire spectrum, from the most complicated multiple trauma to injury prevention for athletes. Physiatrists can function as specialists or as primary care physicians. As America ages, and as the public and the medical community become better educated about the physiatrist s place on the health care continuum, the demand for the specialty will continue to grow.

"In the hospital-based program I direct, we always need more physiatrists than we have."

What Do Physiatrists Treat?

Musculoskeletal injuries
Amputations
Spinal cord injuries
Multiple trauma
Brain injuries
Stroke
Cardiac disorders
Sports injuries
Cancer
Pulmonary disorders
Burns
Industrial injuries
Arthritis
Neuropathies
Back Pain
Neck Pain

Physical Medicine and Rehabilitation

Physical medicine and rehabilitation describes the spectrum of care that physiatrists provide. Physiatry s primary goal for the patient is attainment of maximum functioning, not only medically, but psychologically, vocationally, and socially as well.

Their diagnostic tools include those used by other physicians --medical histories and physical examinations, X-rays and laboratory studies. However, physiatrists also use special techniques like electromyography, nerve conduction studies and evoked potentials.

Like all physicians, physiatrists are skilled in the administration of traditional drug therapies. In addition, they prescribe treatment modalities such as heat, cold, electrotherapies, massage, biofeedback, traction, and therapeutic exercise.

The diversity of the profession is reflected in the wide variety of roles a physiatrist plays and the broad range of patients physiatrists treat. They deal with the prevention, diagnosis and treatment of acute and chronic pain and musculoskeletal disorders, such as arthritis, tendonitis, low back pain, or sports or work-related injuries.

Physiatry also encompasses the treatment of patients with severe congenital or acquired pathology of the musculoskeletal systems resulting in functional limitations. Examples of these disorders include spinal cord injuries, cerebral vascular accidents, amputations, traumatic brain injuries, cancer, multiple sclerosis and spina bifida.

When treating patients with severe physical problems, the physiatrist serves as the leader of an interdisciplinary team. The team may include medical professionals such as neurologists, psychiatrists, orthopaedic surgeons, and urologists, and non-physician health professionals such as physical therapists, occupational therapists, speech pathologists, vocational counselors, psychologists and social workers. The team is different for each patient, and the team s composition changes during treatment to match the patient s shifting needs.

"Because we are a part of a long process with many of our patients, we have the privilege to get involved in all facets of their lives."

How the Field Grew

In 1947, when PM&R became a board-certified specialty, there were 91 board-certified physiatrists; by 1975, there were 1,164. In only ten years, that number doubled, reaching 2,377 in 1985. It more than doubled again in the next decade. In 1995, there were nearly 5,000 board-certified physiatrists.

Technical Innovations

Electrodiagnosis is used so extensively in the field that physical medicine and rehabilitation actually requires training in electrodiagnostic medicine during residency. Electrodiagnostic medicine procedures can be used in the diagnosis of numbness, weakness, fatigue, cramps and abnormal sensations. The two procedures used most commonly are the electromyographic examination (EMG) and nerve conduction studies.

During electrodiagnostic medicine examinations, physiatrists assess electrical activity in muscles by inserting fine electrodes into them. The electrical activity can be both observed and heard. Nerve conduction studies evaluate the presence of nerve damage by applying electrical stimulation to portions of nerves. A third procedure, called evoked potentials, also is routinely used in physical medicine and rehabilitation to evaluate sensory impulses in the nerves, spinal cord and brain.
The specialty is growing at such a fast rate that the creation of new, cutting-edge technologies is common. In spinal cord injury, functional electrical stimulation (FES) is being used to stimulate and strengthen muscles; EMG Biofeedback is used to measure muscle activity, even in paralyzed patients.

Advances in computer-aided design and manufacturing have brought many new options to people needing prosthetics and orthotics. Examples of the field s technical strides are energy storing prosthetic feet, and highly sensitive, myoelectric hands that allow patients to move their prostheses at variable speeds with little effort.

A Shortage Specialty

A Workforce Study concluded in 1994 indicates that if the 1994-95 level of residency capacity is maintained, the supply of physiatrists will continue to grow, roughly doubling over the next 20 years. Since managed care penetration will continue to grow as well, it is crucial that the profession is successful in informing managed care organizations, the medical community and the public about its value and cost effectiveness. If the level of residency capacity remains the same and physiatry can inform the market about itself, excess supply of physiatrists is not likely to emerge through 2015.

Residency

The opportunity to have a high degree of patient contact is available even in residency because the emphasis on communication and involvement with patients begins in training.

There are currently 80 accredited residency programs in physical medicine and rehabilitation. Physiatry requires four years of training, including three years of training in the specialty, and one year of fundamental clinical skills, obtained separately or as a part of the PM&R residency.

Fellowships are available for specialized study in such areas as pediatrics, traumatic brain injury, spinal cord injury, and sports medicine.

The American Board of Physical Medicine and Rehabilitation also has agreements with each of the boards of pediatrics, internal medicine, and neurology to allow special training programs leading to certification in both specialties.

"Physiatry is at the forefront of where all medicine is headed. We take a total approach to the patient through our work with the interdisciplinary team."

Changing Demographics

The number of PM&R residents has grown dramatically in a decade, from 795 in 1982 to 1293 in 1995. The percentage of women in that same time period has increased as well, from 27% to 35% of all PM&R residents. Because of the phenomenal growth of the specialty, more than 60% of physiatrists are 40 years old or younger.

Special Interests

Some areas of special interest are:

AIDS/HIV
Arts Medicine
Brain Injury
Burn Injury
Cancer Rehabilitation
Cardiopulmonary
Geriatric Rehabilitation
Industrial Rehabilitation
Manual Medicine
Medical Hydrology
Medical Informatics
Myofascial Pain
Neurophysiology
Osteoporosis
Pain Rehabilitation
Pediatric Rehabilitation
Prosthetic, Orthotic, Wheelchair and Assistive Technology
Rheumatologic Rehabilitation
Spinal Cord Injury
Sports Medicine
Stroke and Neurologic Disease Rehabilitation
Thermography

The field of physical medicine and rehabilitation is growing so quickly and is so diverse that the American Academy of Physical Medicine and Rehabilitation has responded by creating special interest groups. The American Board of Physical Medicine and Rehabilitation is currently examining development of a certificate of special qualifications in spinal cord injury medicine, a process which seeks to accredit fellowships leading to subspecialization. Other areas of subspecialization are in earlier stages of development.

Some physiatrists have broad-based practices that encompass many different types of patients. Others pursue special interests and focus on specific groups or problems. Sports medicine is one special interest that has grown in popularity over the last decade, reflecting America s fitness trend. Physiatrists who focus on sports medicine treat sports-related injuries, develop programs to help athletes avoid injury, and do research in the field.

Pediatrics is another special interest area. A physiatrist s evaluation and treatment of, for example, premature infants or children with catastrophic injuries, results in lifetime benefits to those patients and their families.

Research

The opportunity for research in PM&R is growing and has been significantly advanced by the creation of the National Center for Medical Rehabil-itation Research within the National Institutes of Health.

Funding is available from public and private sources for clinical and applied research, research training and for basic sciences which are relevant to rehabilitation medicine. Subjects of research are wide ranging from neuroscience and cardiopulmonary research to applied research topics like prosthetic and orthotic design and outcomes measurement. A pressing need exists in the field for highly skilled researchers.

"Our rewards are through patient success. Our patients regain self respect and functional independence."

Conclusion

The opportunities available for physiatrists are myriad and diverse. From research to clinical medicine, physical medicine and rehabilitation is a specialty that makes a difference both to its patients and to society.
Beyond that, PM&R is a specialty for the future. In this new era of health care reform, specifically managed care, PM&R can demonstrate its own value in terms of team orientation, cost effectiveness and efficiency. It has in the past, and will continue to respond to the needs of a changing world.

Information Resources

American Academy of Physical Medicine and Rehabilitation
330 North Wabash, Suite 2500
Chicago, Illinois 60611-7617
312.464.9700

American Board of Physical Medicine and Rehabilitation
Norwest Center, Suite 674
21 First Street, SW
Rochester, Minnesota 55902-3009
507.282.1776

Association of Academic Physiatrists
7100 Lakewood Building, Suite 112
5987 East 71st Street
Indianapolis, Indiana 46220
317.845.4200

"Quality of life has long been the goal of physiatry. We strive to achieve that goal by looking at the multiple problems of patients, minimizing those problems and optimizing function."

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