Physiatry: The Medical Rehabilitation Specialty

Physical medicine and rehabilitation (PM&R) "is often called the 'quality-of-life' profession because its aim is to restore optimal patient functioning. 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 American Academy of Physical Medicine & Rehabilitation (AAPM&R) Charles Levy, MD Physical medicine and rehabilitation (PM&R) "focuses on how the whole person functions," says Charles Levy, MD , chief, Physical Medicine & Rehabilitation Service, North Florida/South Georgia Veterans Health System, Gainesville, Florida. "Each specialist on the rehab team has his perspective, but we physiatrists have the responsibility of seeing the entire picture--that's part of our training." The "whole-patient" view encompasses treatment or referral for medical conditions, pain management, making sure the patient receives needed physical or occupational therapy, and prosthetic or orthotic devices and training in their use, Levy explains. Often psychological, vocational, and funding issues also must be addressed. "We try to make sure that everything patients need to get on with their lives--not just heal their wounds--is in place," says Clay Kelly, MD , director, Amputee Clinic, MetroHealth System, Cleveland, Ohio. Team Model Physiatry emphasizes the team model, with the physiatrist as the leader, coordinating treatment. The physiatrist is charged with overseeing the process and assuring that the other team members are working in concordance. This is similar to putting the pieces of a puzzle together. "A major theory of physical medicine is that the patient is managed by a team--we're not alone," says Kelly. Ideally, key members of the team will see the patient together and develop a treatment plan. If consultation is needed to reach consensus, the team may adjourn to a separate room for discussion, then return to the patient. Clay Kelly, MD The patient thus benefits from the best thinking of several professionals who can interact with one another and the patient on the spot. Besides physiatrists, teams may include orthotists/prosthetists, physical or occupational therapists, orthopedists, rehabilitation nurses, residents, and others. Harry Webster, MD , Pediatric Division chief, New England Medical Center Department of Physical Medicine & Rehabilitation, Boston, Massachusetts, points out that the patient "gets the best of our thinking," when the team meets together at the same time. "I don't consider myself the ultimate authority; I'm looking for that synthesis to give the patient the best prescription. That doesn't happen if I write the prescription and two weeks later, the patient and family go to an orthotist I've never seen." The physiatrist takes the lead in evaluating symptoms and making appropriate diagnoses. The rest of the team then knows the medical issues and can also anticipate medical complications that could interfere with rehab. However, the physiatrist also needs to listen closely to other team members, since they have in-depth experience in their specialties and can contribute information to help the physician make good decisions, says Walter Davis, MD , director of education, Center for Biomedical Ethics, Department of Physical Medicine & Rehabilitation, University of Virginia, Richmond. "This is not the typical medical model, in which the doctor takes the history of the patient, performs an examination, makes a diagnosis, and prescribes treatments," explains Davis. "The rehab model is more complicated; the physician should be checking in with members of the rehab team to get their experience and thoughts." The patient also enjoys the convenience of "one-stop shopping." Walter Davis, MD "When an orthotist comes to our clinic, we provide a service to families that is outstanding," says Webster. "Not only can we do the casting on that same visit, thus saving the family time, parking expenses, etc., but we can put our heads together for the best solution and appliance for that patient." "Patients don't like having to see the doctor, then wait to see the prosthetist, then wait again to see the physical therapist," says Davis. "When patients come to our clinic and we see them together, they feel they've gotten the best interaction from the clinical team--a meeting of the minds, rather than three different people saying three different things." Vikki Stefans, MD, associate professor, University of Arkansas for Medical Sciences Department of Pediatrics and Physical Medicine & Rehabilitation, Little Rock, often coordinates overall medical care for inpatients, rather like a primary care physician. However, the primary care physician generally coordinates outpatient care, while she works with him/her on rehabilitation-related treatment and makes appropriate referrals for O&P care. Stefans appreciates the team approach: "By working together, we can come up with a plan. One might think of something the others didn't." Webster gives much credit to his pediatric patients' families as vital team members: "They are really doing the everyday work to help these children achieve their maximum potential. We are privileged to help them; we try to do this by achieving the best coordination and service possible." Vikki Stefans, MD Academic medical centers are usually necessary for a true team approach, notes Davis. Reimbursement issues and simple logistics make it much more difficult for physiatrists with separate, independent practices to utilize a true team approach, which is a hallmark of what makes the PM&R specialty unique, he explains. "The team approach is also alive and well in the Veterans Health System," adds Levy. Many physiatrists in private practice focus on sports medicine and pain disorders such as back pain, rather than treating amputations, stroke, cerebral palsy and other largely pediatric conditions, and brain and spinal cord injuries, Webster notes. "They are generally procedure-oriented, using interventions such as steroid injections; then sending the patient to a therapist in another facility. It is a challenge to do a true team approach." Pain Management Pain management is a vital part of the physiatrist's responsibility. "If pain is not being controlled, the rest of the rehab doesn't go anywhere," says Davis. For example, when the physician sees the patient in his morning rounds, he may not gain accurate information on how well pain medicines are working. However, by working with the patient later in the day, the therapist can note problems and report them to the physician. For instance, the patient may still be in too much pain for effective therapy or be so over-medicated that he or she is practically asleep. Orthotists/Prosthetists What do physiatrists look for in orthotist/prosthetist team members? Clay M. Kelly, MD,; Sharon L. Kelly, CP; Joyce Acord, LPT, instructing John Lee, MD, a PM&R resident at MetroHealth "Someone who likes being part of a team and coming up with solutions together," answers Stefans. Being willing to be flexible and modify a brace or prosthesis to meet a particular patient's or family's needs is vital too, she adds, citing an example of a brace that was simply too stiff for the family to put on the child. The orthotist modified the brace to make it more pliable and easier to don and wear. Kelly, who specializes in amputee care, looks for a prosthetist who is talented, ethical, and up-to-date, since technology is advancing rapidly. "Fitting a prosthesis is an ongoing dynamic process," he explains. "I tell patients that, due to adjustments and follow-up, they'll see the prosthetist more often than they will me. Prosthetists really need to pay attention to patient satisfaction," he adds. When possible, Levy likes to have orthotists/prosthetists from about three different companies as part of the team evaluating the patient. He sees several advantages to this procedure: 1) it's educational, since the orthotists/prosthetists learn more about medical and physical-therapy related considerations, and physicians and other specialists learn more about prosthetics and orthotics; 2) the device recommendations and reimbursement required are community standards and not "overblown;" and 3) in this setting, the prosthetists/orthotists often are more willing to share thinking to come up with good solutions, even if they are competitors. Surgeons and Rehab Noting that MetroHealth operates one of the largest and busiest trauma centers in the country, Kelly says that the team approach is being used more often for amputations. "More surgeons are beginning to understand that a beautiful residual limb is a work of art and makes everything down the line easier for the amputee to regain function." Surgeons and PM&R physicians have a complementary relationship at MetroHealth, with the orthopedic, vascular, and plastic surgeons sending Kelly practically all their amputee patients once the patients are past the acute phase. "However, that is not true in all places," he adds. "Sometimes the orthopedists want their residents to have experience with amputees." Some surgeons are open to input from the rehab team and some are not, says Davis. "Some--and I work with one like this--will actually involve the rehab team before surgery. This is a great idea, but often underutilized. It's what we should aim for in amputee rehabilitation: to have input from the whole team--surgeon, physiatrist, prosthetist, physical therapist, and nurses. This is time-consuming, but provides the best patient care. It's not simple, but it's worth tenfold to the patient." Stefans says that she often coordinates care after surgery and sometimes helps in preparation for surgery, especially if surgery will change the patient's function. "Orthopedic and functional goals may be different or may coordinate exactly." However, if the orthopedist is concerned about fracture healing, wound protection, and similar issues, "we don't want to interfere with that in any way." Orthopedic surgeons are often responsive to the need to prepare the limb for a prosthesis, since by the nature of their work they are more oriented toward function, it was noted. "They are more likely to see success as a more functional person, rather than a well-healed residual limb," says Davis. However, vascular surgeons often look only at the limb, with the goal to salvage it or at least save as much tissue as possible, he said. "The goal is to cut as little as possible to get to where there is circulation. But if the goal is simply to save a limb and function is not considered, it's doomed." He cites partial foot amputations as an example: "The patient may never be able to walk on that foot, due to pain and skin breakdown." A higher-level amputation in the beginning may obviate the need for later amputations and get the patient mobile right away, he explains. "If the patient can't walk right away, he may suffer contractures, deconditioning, depression over spending time in a wheelchair and wondering if later surgery will be needed, plus the risk, expense, and stress of later surgeries if they are needed. "Sometimes it's better for the patient to undergo a higher-level amputation, go through the grieving process, and get on with life," he says. His comments point out a sound reason for bringing the rehab team into the amputation process early. The physiatrists concur that overall, amputation surgery is improving and is being given more consideration than in the past. One physiatrist recalls that as a senior medical student, he was asked to do an amputation. "At the time, I was excited to have the opportunity. But in retrospect, I was shocked. They obviously didn't take it very seriously." Amputees are no doubt glad that times are changing! Why Did They Choose Physiatry? Orthotists and prosthetists interviewed by The O&P EDGE commented on how much they appreciate the time physiatrists spend with their patients. Physiatrists earn kudos for their dedication, even though they may take a hit financially, since a doctor who sees four patients in an hour will receive more remuneration than a doctor who sees only one amputee in that same hour, but addresses the multiple dimensions of care. What draws physicians to this specialty? Sometimes it's a longstanding interest in the field. Kelly has had an interest in amputee care since he was young, and he is even married to a prosthetist: Sharon Kelly, CP, who works for Hanger Prosthetics & Orthotics, Euclid, Ohio. Kelly says he would be delighted if their three sons follow their parents into a medically related field, "but that's up to them." Working with children with disabilities and special needs in a summer camp as a volunteer hooked Stefans into deciding on a career as a pediatric physiatrist. When Davis was in medical school, he attended a yearly medical student association conference in Washington, DC. Among the exhibits was one from the Walter Reed Hospital rehabilitation physicians. "Before that, I didn't realize this was a separate specialty," he remembers. Davis had already had experience in working with disabled children and adults before entering medical school, and PM&R "enables me to combine medicine with my interest in working with disability." Levy's first interest was in neurology, but PM&R was more appealing. In some aspects of medicine, once the diagnosis is made, the recipe for care is basically always the same, Levy notes. "But with physical medicine and rehabilitation, you have to look at the whole person. You can't get the answers out of a book." For example, to help one person psychologically through rehab, the physiatrist might have to be a cheerleader, for another patient, being a sympathetic listener might be best. Some benefit from support groups or joining an online listserv, others don't want to talk about their problems. Some are motivated by their desire to return to work or accomplish some skill. "You have to understand that person and what helps him get up and what knocks him down," says Levy. Matching the person to the solution also extends to such practical matters as prosthetic component selection: for instance, an extremely active patient needs a rugged prosthesis, while another patient may be a milder user. Describing the specialty's appeal, which likely applies to many other PM&R physicians, Levy says, "In rehabilitation, you almost always can improve patients' lives in some way, even if they are not totally restored. I like to be able to think creatively and come up with solutions." Physiatry: Focusing on Function Photo courtesy of Vikki Stefans, MD, pediatric physiatrist at UAMS and Arkansas Children's Hospital. Physiatrists focus on restoring function, notes the American Academy of Physical Medicine & Rehabilitation (AAPM&R). Physiatry is one of the 24 medical specialties certified by the American Board of Medical Specialties. Currently there are 80 accredited residency programs in the US and more than 6,700 practicing physiatrists. Although physical means of healing have been practiced for thousands of years, PM&R began in earnest in the 1930s with the physical treatment of musculoskeletal and neurological conditions. The field broadened its scope after World War II when thousands of veterans returned home with catastrophic injuries. In 1947, the Advisory Board of Medical Specialties recognized physiatry as a medical specialty. Physiatrists treat a broad range of conditions, including acute and chronic pain and musculoskeletal disorders. They coordinate long-term rehabilitation for patients with spinal cord injuries, cancer, stroke and other neurological disorders, brain injuries, multiple sclerosis, and amputations. Physiatrists treat about 50,000 new amputees each year, according to AAPM&R. Physiatrists practice in rehabilitation centers, hospitals, and private offices. Often they have broad practices, but some concentrate on one area, such as pediatrics, sports medicine, geriatric medicine, or brain injury. In recent years, the field has seen an increased focus on musculoskeletal and industrial medicine, pain management, sports medicine, and electromyography. For more information, visit the American Academy of Physical Medicine & Rehabilitation, www.aapmr.org , and the Association of Academic Physiatrists, www.physiatry.org . Watch for an article on physiatrists from the prosthetist/orthotist perspective in an upcoming issue.

Physiatry: The Medical Rehabilitation Specialty

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