Multi-Specialty Approach

PM&R, also known as physiatry, is a medical specialty that emphasizes prevention,diagnosis, and treatment of patients who experience limitations in function resulting from any disease process, injury, or symptom. Physiatrists utilize medications,injections, physical modalities, exercise, and education individualized to the patient's needs. PM&R specialists provide care for patients with neuromusculoskeletal disorders who have acute and chronic disabilities requiring rehabilitation services. The goal of physiatry is to restore optimal patient function in all spheres of life, including the medical, social, emotional, and vocational dimensions. Physiatry has been aptly branded the quality of life medical specialty and has grown in international recognition because of its commitment to meeting the quality-of-life and nonoperative neuromusculoskeletal needs of an aging society.

Physiatrists work with patients and transdisciplinary teams to achieve patient centered goals by using a broad synergistic variety of biomedical, modality, exercise, prosthetic, orthotic assistive technology, psychological, and educationally based treatments that require full patient participation.

Diagnostic tools include those used by other physicians (medical history, physical examinations, x-rays, and laboratory tests), as well as special techniques in electrodiagnostic medicine such as electromyography (EMG), nerve conduction studies, and somatosensory and motor-evoked potentials. EMG examinations and nerve conduction studies are the most common procedures used. Musculoskeletal ultrasound is a rapidly developing technique that is also performed by many physiatrists.

Treatment options include the use of medications; modalities such as hot packs, cold packs, ultrasound, and electrotherapy; assistive devices, such as a brace or artificial limb; massage; biofeedback; traction; and therapeutic exercise. Surgery is not used. Physiatrists, with added training, also perform injections, interventional procedures, including peripheral articular injections (increasingly guided by ultrasound), spinal blocks, botulinum toxin injections, and acupuncture.

PM&R strives to promote a person's quality of life and functional outcomes through a dynamic team-oriented approach. Often the physiatrist plays a leadership role in this process. Valuable members of the physiatry team include the physical therapist (PT), occupational therapist (OT), speech-language pathologist, respiratory therapist, nursing staff, and others. By blending the best of the traditional medical approach (adding years to life) with the functional model (adding life to years), the PM&R team accomplishes its noble mission.

Like a true friend, a physiatrist must be an optimistic spirit, a team player, and one who gives life to the immortal words of William Arthur Ward, a true friend knows your weakness but shows your strength; feels your fears but fortifies your faith; sees your anxieties but frees your spirit; [most importantly] recognizes your disabilities but emphasizes your possibilities.

The official name of the field reflects the two essential concepts of the specialty:

Physical medicine : Diagnosis and treatment of neuromusculoskeletal disorders with the use of medications, modalities, procedures, and exercise

Rehabilitation : The process of transforming a person with functional limitations to a person with maximal ability through the application of medical treatment, therapy, and adaptive equipment

Physicians choose PM&R for many reasons:

Physiatric practice is collaborative. Physiatrists seldom work alone. They practice as part of an interdisciplinary team. All team members have knowledge and skills that complement those of other team members in meeting patients' needs. The physiatrist is often the team leader, orchestrating the collaborative effort.

Physiatric practice requires an intimate knowledge of the patient's resources and pitfalls as well as the patient's environment. By witnessing the enablement of the patient, the physiatrist becomes more enabled and achieves a profound sense of pride and satisfaction that is shared with patients when they achieve functional recovery. One of the deep satisfactions in physiatry arises from supporting patients as they achieve their goals and sharing successes with the entire rehabilitation treatment team.

The nature of physiatric practice requires skills in interpersonal communication, multisystem diagnostics, mechanical interventions and electrodiagnostics, and therapeutics.

Working individually with patients to design unique life-enhancing solutions is creative and fun for physiatrists. They often follow patients for years and help them solve a variety of problems as they age and engage in new activities. All of these aspects involve the continuing rediscovery of patients and team members and the existing options within their environments. Physiatrists make possible the synergistic efforts that the patient and the rehabilitation team, by working together, can use to maximize each other's potential.

Although many physiatrists view themselves as primary care physicians for people with disabilities (and therefore offer comprehensive care for persons with diverse medical conditions), a growing number of physiatry specialists have elected to focus on specific rehabilitation areas. Common conditions treated by physiatrists include amputations, arthritis, brain injuries, burns, cancer, cardiac disorders, fibromyalgia, industrial injuries, multiple sclerosis, neuromuscular diseases, neuropathies, orthopedic injuries, pain disorders, pediatric disorders, pulmonary disorders, spinal cord injuries, stroke, and trauma. Physiatrists are uniquely suited to treat painful neuromusculoskeletal conditions through a holistic and balanced combination of exercise, medication, and procedures and moral and psychosocial support.

People with disabilities occupy an essential and ever-growing segment of the health care continuum. Physiatrists must always be true to the altruistic roots and traditions of the field and their education by being available to manage the unique needs of persons with disabilities. Whether the task involves readily accepting a consultation on a newly quadriplegic inpatient or rendering assistance to a community-based elderly patient who has had a stroke, the physiatrist by virtue of his/her training can truly make a difference.

Around the middle of the 20th century, a major shift in thinking among health care providers began to take place. Holistic, comprehensive, team-oriented care for people with disabilities began to be recognized as an important societal obligation. This powerful philosophy sparked a burgeoning interest among health care providers to treat people with disabilities. The year 1936 was a banner year for physiatry. Dr. Frank Krusen inaugurated the first residency training program at the Mayo Clinic. Dr. Krusen coined the term physiatrist and is credited as the author of the first comprehensive rehabilitation textbook. Dr. Krusen's monumental work has had a lasting imprint on the field. Improvements in acute medical care (e.g., penicillin) during World War II saved the lives of many soldiers with disabilities who returned home in dire need of rehabilitative care. Pioneer physicians in the field helped to plant the seeds for an exciting new specialty that cared for the whole person, not just the disease.

Although the American Academy of Physical Medicine and Rehabilitation traces its origins to 1938, the American Board of PM&R (ABPM&R) was established in 1947 by members of the academy in response to the urgent need for a certifying authority. The ABPM&R was approved in 1947 by the Advisory Board of Medical Specialties as one of twenty-four official medical specialties.

First, there is medical school (4 years). Then there is an internship (one year of a coordinated program of experience in fundamental clinical skills such as an accredited transitional year or six months or more in accredited training in family practice, internal medicine, obstetrics and gynecology, pediatrics, or surgery, or any combination of these patient care experiences). This 1-year internship is followed by a 3-year residency. For some, there is a fellowship (from 1 to 3 years in disciplines such as spinal cord injury, traumatic brain injury, electromyography, musculoskeletal medicine, or pain medicine). Similar to many medical specialization career paths, the road to becoming a PM&R diplomate is exciting and challenging because the field draws from so many sources of knowledge and practice. At the conclusion of PM&R residency, qualified candidates take a written certification exam (part 1) given by the ABPM&R. When they have completed residency, another exam (oral; part 2) is administered after the first year of practice. Upon successful completion of parts 1 and 2, students can proudly display a numbered board certification sheepskin,recognizing their achievement.

You never stop learning. Recertification is required every 10 years.

With over 75 accredited residency programs in PM&R in the United States, there are ample opportunities for postgraduate education. All accredited programs adhere to program requirements written and administered by the Residency Review Committee for PM&R. This hopefully ensures uniformity in high-quality training experience and exposure to the various programs. As an added bonus, some programs offer opportunities for advanced degrees (MBA, MD, PhD), specialized electives, and research opportunities. A select group of senior residents who become chief residents may have the opportunity to develop additional administrative and leadership skills. Some institutions offer combined programs such as PM&R/neurology,PM&R/pediatrics, and PM&R/internal medicine.

For those who want to specialize in specific areas, subspecialty fellowships accredited by ABPM&R are currently available in Spinal Cord Injury Medicine, Pain, and Pediatrics (2002), Sports Medicine (2006), Hospice and Palliative Medicine (2006), and Neuromuscular Medicine (2006).