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Introduction

The specialty of Physical Medicine and Rehabilitation (PM&R), also called physiatry, has its historical origins in the early 20th century, decades before its recognition by the medical establishment and medical organizations in the United States (US) and abroad. A continuing series of articles in the American Academy of Physical Medicine and Rehabilitation’s official journal, PM&R, and historian Richard Verville’s book, War, Politics and Philanthropy: The History of Rehabilitation Medicine document the specialty’s history and its first practitioners (called physical therapy physicians). Another Knowledge Now online resource, A Celebration of AAPM&R’s 75 Years, provides a timeline that places major milestones for the specialty in the context of national and world events. Readers are directed to these and other resources in their reference lists for more detailed accounts.

The Earliest Leaders: McKensie, Coulter, and Krusen

Early 20th-century physical therapy physicians were a diverse group who had training in other fields of medicine and surgery. They found themselves with distinct interests and concerns related to those of physical therapy technicians, the term for physical therapists at that time, and also of radiologists, who used various physical agents to treat medical conditions.

One of the first physical therapy physicians to hold an academic appointment in the US, R. Tait McKenzie, was appointed a professor of physical education and physical therapy at the University of Pennsylvania in 1904. McKenzie taught medical students the fundamentals of exercise, massage, hydrotherapy, and other modalities. He also wrote a textbook called The Handbook of Physical Therapy that was used by the British, Canadian, and US Armed Forces during World War I. One of McKenzie’s students, John Stanley Coulter, an internist and tropical disease specialist, played a major role in establishing the specialty of PM&R. Coulter directed the first overseas rehabilitation hospital (in France) during World War I, and he later practiced in industrial (occupational) and physical medicine in Chicago and taught at Northwestern Medical School, which was later affiliated with the Rehabilitation Institute of Chicago.

Frank Krusen trained as a physician and surgeon at Jefferson Medical College in Philadelphia, and he found the physical treatments he received for tuberculosis very effective. Krusen began a program of physical therapy at Temple University and opened the first inpatient rehabilitation unit at the Temple hospital in 1929. In the 1930s, Krusen left his position as assistant dean at Temple for the Mayo Clinic, where he developed a department of physical medicine and the first three-year residency PM&R program in the US.

Coulter and Krusen emerged as the scientific leaders of physical therapy technicians and physicians. In the 1920s, the AMA created the Council on Physical Therapy to address questions surrounding what physical treatments benefited patients, and what methods did not. During this time, there was controversy about this young medical field that held promise but had produced little research to back its claims. Coulter chaired the Council from 1932 until his death in 1949. A small group of other physical therapy physicians joined Coulter and Krusen to push for developing physical medicine as a distinct medical field with a scientific basis. The AMA’s Advisory Council on Medical Specialties (the forerunner of the American Board of Medical Specialties or ABMS) did not initially favor creating a separate board for the field.

To achieve AMA board status, the field needed to create a professional society of at least 100 members dedicated primarily to physical medicine. In 1938, at the annual meeting of the American Congress of Physical Therapy (now the American Congress of Rehabilitation Medicine, or ACRM), Krusen and Coulter founded the American Society of Physical Therapy Physicians with 40 charter members. Membership in the Society was limited to physicians with at least five years in full-time physical therapy practice and with a teaching appointment at a medical school or directorship of a department. Krusen proposed the term “physiatrist” to identify physicians specializing in physical medicine. The group elected Coulter its first president and Walter Zeiter, a graduate of the Mayo Clinic residency program, its first executive director, a position Zeiter held for twenty-two years.

After many meetings and countless letters written by this first generation of physiatrists, support came from the AMA, the ABMS, and other medical specialty boards for PM&R to become a distinct medical specialty. In 1944, the American Society of Physical Medicine Physicians dropped the membership limitation, and in 1951, the words “and Rehabilitation” were added. The current name, the American Academy of Physical Medicine and Rehabilitation (AAPM&R), became official in 1955. In 1959, the AAPM&R established a separate scientific program from the ACRM for its annual meeting, assuming responsibility for continuing medical education (CME) for members. Over the decades that followed, the two organizations became fully independent, with separate annual meetings and each with its own journal – The Archives of Physical Medicine and Rehabilitation (ACRM) and PM&R (AAPM&R).

Initially, the American Board of Medical Specialties (ABMS) recommended that physical medicine affiliate with the American Board of Internal Medicine (ABIM), but the ABIM declined and suggested a separate board for certifying physical medicine physicians. In 1947, the ABMS accepted a plan presented by Drs. Krusen, Coulter, and Zeiter for organizing and financing a separate board. The American Board of Physical Medicine was established, with Krusen named its first chairman. Thirty physical medicine physicians received certification without having to take the examinations (a written exam on the first day and an oral exam on the second day) and 91 physiatrists were approved as charter diplomates. In 1949, the board was renamed the American Board of Physical Medicine and Rehabilitation (ABPM&R).

Other Key Figures: Howard Rusk and Bernard Baruch

Beginning in World War I and expanding during World War II after the US entry in 1941, the US military had offered support for physiatry as a medical specialty. As injured soldiers returned home for treatment, physiatrists promoted a comprehensive approach to restoring a soldier’s capabilities. This aspect of the field – rehabilitation medicine – received further development under the leadership of Howard Rusk, an internist and graduate of the University of Pennsylvania. In 1941, Rusk enlisted in the Army, leaving a successful St Louis practice, and joined the Jefferson Barracks in Missouri, a 1000-bed hospital. Rusk designed simple activities to challenge soldiers both physically and mentally during their convalescence, and the program’s success led the military to ask him to set up a similar program for the Army Air Corps. Estimates are that Rusk’s “Convalescent Training Program” saved over five million man-hours during World War II and gave countless veterans with disabilities hope and a sense of purpose.

A prominent Columbia University physician and public health advocate, Simon Baruch, promoted hydrotherapy and other physical medicine approaches while serving as head of New York’s Department of Health in the early 20th century. To honor his father, Simon’s son Bernard Baruch, a Wall Street financier and philanthropist, pressed for further developing the field of physical medicine, and provided funding to promote it. A friend of both Krusen and Rusk, Baruch served in both the Woodrow Wilson and Franklin Delano Roosevelt (FDR) White Houses, and he lent critical support for the next stage of the field’s development.

In 1943, the Baruch Committee, chaired by Ray Lyman Wilbur, Stanford University Provost (and later President and Chancellor), with Krusen as its executive director, conducted a review of the field of physical medicine. The Baruch Committee recommended that the specialty establish fellowships, residency programs, medical school training in PM&R, funding of basic/clinical research and promotion of wartime and post-war rehabilitation and also set up a certifying board. Research funding and training programs through Bernard Baruch’s generosity at Columbia, NYU, the Medical College of Virginia, Harvard, and other institutions across the US launched a new generation of departments and physiatry leaders. In 1945, the AMA established a section on PM&R. The next year, the AMA’s Council on Physical Medicine voted to sponsor the term “physiatrist” as the designation for physicians specializing in physical medicine. By this time, 25 hospitals had established residency and fellowship training programs.

In 1945, the Veterans Administration (VA) Hospital systems appointed Rusk and Krusen as consultants to work in establishing rehabilitation services. In 1950, Rusk established the Institute of Physical Medicine and Rehabilitation in New York, now the Rusk Institute at New York University (NYU), which became a major center for research, training, and expanding rehabilitation medicine’s role in treating many different medical and surgical conditions. Rusk made “rehabilitation” a household word through his public speaking and weekly columns in The New York Times.

The Polio Epidemic and FDR

The polio epidemic, beginning with an outbreak in New York City in 1916, served as another key historical development that propelled the field . Almost 58,000 cases of polio were reported in the US by 1952, the peak of the epidemic. The epidemic dominated the attention of PM&R physicians for decades after because of the disabling aspects of polio for the disease’s survivors. FDR had contracted the disease in 1921; as part of his approach to living with the effects of polio, he purchased the Georgia Warm Springs facility in 1926 and developed it into a rehabilitation program for polio survivors. Through the help he received from Warm Springs physiatrist Robert Bennett, FDR learned about and gained appreciation for the field of PM&R. Bennett was, like Walter Zeiter, in the first graduating class of the Mayo PM&R residency program.

In 1935, FDR signed the Social Security Act, establishing federal assistance to adults with disabilities and extending existing vocational rehabilitation programs. Title V of this legislation also established the Maternal and Child Health Program and the Crippled Children’s Program. The National Foundation for Infantile Paralysis, formed in 1938 by FDR, raised donations for research to prevent polio and to fund training grants for PM&R departments and schools of physical therapy. It also funded the treatment and rehabilitation of polio patients.

Continuing Governmental Support

In the early 20th century, the public gained an increasing awareness of the problems caused by the activities of large corporations, and by urban blight such as slums and worker injuries caused by increased industrialization. The public response was based on a belief that government should play a role in addressing these problems. One consequence was the establishment of worker’s compensation programs. By 1918, such programs existed in Wisconsin, Oregon, California, North Dakota, and New Jersey, and the AMA called for the development of more such programs.

In 1920, President Woodrow Wilson signed the original Vocational Rehabilitation Act, which for the first time established  nationwide rehabilitation services for civilians with disabilities. In 1943, the LaFollette-Barden Vocational Rehabilitation Act added physical rehabilitation to the goals of federally funded vocational rehabilitation programs and certain medical rehabilitation programs for civilians. The same year, the Office of Vocational Rehabilitation moved out of the Department of Education and gained independent status within the Federal Security Agency, and the Veterans Administration became responsible for medical and rehabilitation services for veterans, less than a decade before the US entered the Korean War in 1950.

Public administrator Mary Switzer became Director of the U.S. Office of Vocational Rehabilitation in 1950. She emphasized independent living for people with disabilities as a quality of life issue. Along with Howard Rusk, Mary Switzer led successful efforts to pass the 1958 Vocational Rehabilitation Act, which granted research and training funding for PM&R. The same year, President Truman appointed Rusk to chair the National Security Resources Board’s Health Resources Advisory Committee. The Committee recommended employing people with disabilities to assist at home in the war effort, replacing those who had volunteered or been drafted for military service.

The Social Security Act of 1935, drafted during FDR’s first term and passed by Congress as part of the New Deal, was a response to the Great Depression and its disproportionate effects on the elderly, the unemployed, widows, and fatherless children. In the 1970s, Social Security Amendments established Supplemental Security Income (SSI) for the elderly and the disabled poor and Social Security Disability Insurance (SSDI). Whereas SSI pays benefits based on financial need, SSDI pays people with disabilities, and sometimes family members, if they have an entitlement to a Social Security benefit, meaning that they worked long enough and paid Social Security taxes.

The Hill-Burton Act of 1946 (also known as the Hospital Survey and Construction Act) authorized federal grants to states for constructing hospitals, public health centers, and health facilities, but Hill-Burton did not fund rehabilitation facilities or hospitals. In 1954, Congress passed amendments to the Hill-Burton Act, at the urging of Switzer and Rusk, that increased funding for constructing rehabilitation facilities.

Congress enacted Medicare and Medicaid in 1965, and in 1972 Medicare coverage expanded to include disability services and inpatient rehabilitation. In 1990, George H.W. Bush signed the Americans with Disabilities Act (ADA). Closely modeled after the Civil Rights Act of 1964 and Section 504 of the Rehabilitation Act of 1973, the landmark ADA represents the most sweeping disability rights legislation in US history. It mandates that local, state, and federal governments and programs be accessible; that businesses with more than 15 employees make “reasonable accommodations” for disabled workers; and that public accommodations such as restaurants and stores make “reasonable modifications” to ensure access for disabled members of the public. The ADA, amended in 2008, also mandates access to public transportation, communication, and other areas of public accommodation.

Congress passed the Education for All Handicapped Children Act in 1975; it became the Individuals with Disabilities Education Act (IDEA) in 1997 and was reauthorized in 2004. That law mandates individualized educational plans (IEPs) providing for students with disabilities up to the age of 22 to receive a “free and appropriate public education” in the “least restrictive environment” and promotes research and technology.

Broadening the Scope of the Specialty

During the 1980s and for several decades thereafter, inpatient rehabilitation programs (called inpatient rehabilitation facilities by the Centers for Medicare and Medicaid Services [CMS], formerly the Health Care Financing Administration [HCFA]) expanded across the US. The Medicare Inpatient Rehabilitation Facilities Prospective Payment System (PPS) became effective in 2001. Further changes in reimbursements for inpatient rehabilitation followed over the next two decades. The World Health Organization (WHO) Health Assembly endorsed the International Classification of Functioning, Disability and Health (ICF) in the 1990s. The ICD coding system, used by hospitals, outpatient facilities, and researchers, now includes not only diagnosis categories, but also functioning and disability elements. These developments led to more physiatrists in hospital-based settings practicing rehabilitation medicine and providing care to patients with complex diseases and catastrophic injuries.

In the 1990s, physical medicine practices expanded to include pain, spine, sports and occupational medicine. The ABPM&R now offers physiatrists opportunities to become board certified in seven diverse subspecialties: brain injury medicine, hospice and palliative care, neuromuscular medicine, pain medicine, pediatric rehabilitation, spinal cord injury medicine, and sports medicine. Expansion into these subspecialty areas represents the state of the field in the late 20th and early 21st century. Today there are more than 9,000 Board-certified physiatrists practicing in the US, evidence that the early leaders in the specialty laid a solid foundation.

The author acknowledges the assistance of Richard Verville and John F. Ditunno, Jr., MD in the writing of this article.

REFERENCES

  1. Sandel, M.E., Conway, R.R., Gerber, N.L., A Celebration of AAPM&R’s 75th Anniversary, AAPM&R, 2015.
  2. Verville, R. War, Politics and Philanthropy: The History of Rehabilitation Medicine. University Press of America, 2009.
  3. A collection of history articles, with their references, in PM&R: The Journal of Injury, Function, and Rehabilitation: https://onlinelibrary.wiley.com/doi/toc/10.1016/(ISSN)1934-1563.history-collection

Original Version of the Topic

AAPM&R History Preservation Committee. The History of the Specialty of Physical Medicine and Rehabilitation. Original Publication Date: 11/03/2012

Author Disclosure

Elizabeth Sandel, MD
Nothing to Disclose