The Philosophical Foundations of Physical Medicine and Rehabilitation

Author(s): M. Elizabeth Sandel, MD

Originally published:11/03/2012

Last updated:11/03/2012

Introduction

Physical medicine and rehabilitation (PM&R) can be viewed as incomprehensively diverse, lacking focus and misunderstood. This is likely the result of the field’s integration of primary and specialty aspects of practice, its expanding scope of practice, the relatively small number of practicing physiatrists, and an inadequate representation in many geographic areas across the world.

Patients receiving ongoing care from physiatrists often see them as similar to the “old-fashioned family physicians”, genuinely interested in and knowledgeable about, their physical and mental health history, current functioning in everyday life, family, occupation, and recreational interests.

As other fields of medicine have evolved toward subspecialization, physiatric practice has greatly expanded for both children and adults, across many diagnostic groups and practice settings. Its lack of focus on one organ or system has led to a unique and ongoing pattern of subspecialization, with many diverse opportunities for practice. But these opportunities have also presented as a yet unmet challenge: how to explain the field to colleagues, policymakers, and the public at large.

One physiatrist treats patients with conditions of the spine and does interventions such as facet joint injections. Another treats children with neuromuscular conditions. Another physiatrist treats children and adults with cancer, managing the complications produced either by the cancers and/or their treatments. Yet another treats patients with mild traumatic brain injury, frequently presenting with concurrent psychological disorders. One physiatric researcher studies the effects of exercise on the intervertebral disc. Another investigates the use of upper limb electrical stimulation to decrease pain in stroke patients. Yet another invents robotic devices to enhance function for people with disabling neurologic conditions. Another uses longitudinal databases to investigate functional outcomes of pediatric patients with spinal cord injury.

These physicians are all colleagues in our field. The largest physiatric practices may represent the entire scope of practice; an individual physiatrist practices only a portion of the field’s scope. So what makes physiatrists alike? And what makes us different from other physicians and medical researchers?

Physiatrists are grounded in multifaceted beliefs, concepts, attitudes, and guiding principles, that is, “philosophies”, that underpin the practice of PM&R, its research priorities and training approaches, and the advocacy for our patients and our specialty. This discussion encompasses defining the distinguishing characteristics of physiatrists regarding how we approach patient care, research and advocacy during our everyday lives as physicians.

Patient Evaluation and Treatment Approaches

Physiatric evaluations are modeled after the traditional history and physical examination. However, physiatric training goes beyond these conventions once a diagnosis is established. Post-diagnostic approaches in physiatry are patient-centered, humanistic, and compassionate. Beyond the initial focus on diagnostic considerations, the physiatrist considers the impact of the diagnosis on the patient’s function and quality of life, as defined one’s day-to-day activities and/or the painful conditions or other symptoms that affect health and well-being. We evaluate patients and design treatment plans by taking into account the bio-psycho-social and ecological factors that affect function and quality of life.

The concepts of human performance and quality of life that form the basis for the World Health Organization’s International Classification of Function (ICF) contributes to the conceptual foundation of PM&R.1 We do not see a patient only as a diagnosis, but as an individual who lives in a social context, has values, perspectives, a cultural heritage, experiences, relationships, views of the past, present, and future, and specific functional or other goals of treatment that are practical and realistic. By the conclusion of our evaluation, we understand our patient’s activity limitations and participation restrictions, that are associated with one or more disorders, and that impact social roles such as student, employee, spouse or partner, parent, member of a particular faith community, or athlete.

Physiatrists predict function in relation to natural history of disease and/or recovery; we tend to be cautious in providing functional prognoses over the long-term. Physiatrists believe in the resilience and adaptability of people, and the capacity of biological systems to adapt and change. This philosophy likely derives from clinical experience and longitudinal investigation of the patient populations who physiatrists treat over many years, whose functional outcomes defy statistics. Recent basic neuroscience translational research has confirmed this experience, typified by the concept of neuroplasticity.2

Physiatric evaluation and treatment approaches are integrative and cross interdisciplinary boundaries; we are not limited to one organ or system. We seek out and obtain medical, social, psychological, vocational, and avocational information to create and formulate a comprehensive evaluation, to understand the whole patient. At its foundation, PM&R is both complex in the gathering and interpretation of data, and holistic in our understanding of patients. Physiatry attracts a diverse group of individuals because it integrates aspects of primary and specialty care, and opportunities for subspecialization, across broad practice settings.3

The field also embraces the concepts of pragmatic and conservative treatment, giving physiatrists the knowledge and skills to provide non-surgical treatments, many of which are low risk and potentially highly beneficial. Patient and social support system/caregiver education about diagnosis, prognosis, treatment options, and strategies to improve function and decrease the burden of care, is essential to our practice. Physiatrists believe in empowering patients and their social supports and caregivers through knowledge.

In addition, physiatrists provide interventions aimed at improving function, even when the treatment or intervention may not improve the disease or condition itself. We measure the benefits of physiatric interventions in terms of improved function in everyday life, and improvements in symptoms, most often pain, and therefore, ultimately, improvements in quality of life for the patient who is not isolated but lives in a social context.

Physiatrists believe in the importance of teams for the delivery of care. Historically, the rehabilitation team included primarily other rehabilitation non-medical professionals (physical/occupational/speech and language therapists), but today the team extends into other fields of medicine as represented in hospital-based, post-acute, and ambulatory models of care. PM&R was among the first specialties to base care on team models, and to study teams through research.4

Contrasting Physiatric Practice with other Medical Specialties

Physiatrists list rehabilitation and disability management as the top priority areas of treatment across all subspecialty areas of PM&R. Palliative care and symptom management, including treatment of pain, and prevention, most often secondary, are priorities as well. Physiatrists focus less often on disease management and curative medicine in their practices, although physiatric treatment plans include aspects of both, especially during rehabilitation of patients with central nervous system disorders and systemic medical diseases.

Physiatry serves diverse patient populations and offers a wide scope of practice. Before 2009, the proliferation of Special Interest Groups over 30 years within the American Academy of PM&R exemplifies this diversity (Table 1). The Membership Council structure within this organization, created in 2009, represents a consolidation of the areas of practice into five groups, with considerable overlap (Table 2).

Research

The philosophical approaches of PM&R underpin physiatric research which includes basic science, bioengineering and assistive technology, and population-based health services and outcomes research. Physiatric research is primarily translational and often team-based. Opportunities abound for the study of comparative effectiveness of pragmatic, non-operative, and relatively low risk approaches that define the field. Physiatric research aims to understand the mechanisms of diseases represented by a wide-range of patient populations, and link this explicitly to providing scientific bases for interventions that palliate specific symptoms, enhance function and human performance, and improve quality of life. The definition of rehabilitation research selected recently by the Blue Ribbon Panel on Rehabilitation Research of the National Institutes of Health is “the study of mechanisms and interventions that prevent, improve, restore or replace lost, underdeveloped or deteriorating function.”5

Training and Certification

The Accreditation Council for Graduate Medical Education (ACGME) Program Requirements for PM&R includes the following statements, which illustrates its philosophy:

“Physical medicine and rehabilitation (PM&R), also referred to as physiatry, is a medical specialty concerned with diagnosis, evaluation, and management of persons of all ages with physical and/or cognitive impairments and disability. This specialty involves diagnosis and treatment of patients with painful or functionally limiting conditions, the management of comorbidities and coimpairments, diagnostic and therapeutic injection procedures, electrodiagnostic medicine and emphasis on the prevention of complications of disability from secondary conditions. Physiatrists are trained in the diagnosis and management of impairments of the neurologic, musculoskeletal (including sports and occupational aspects) and other organ systems and the long-term management of patients with disabling conditions. Physiatrists provide leadership to multidisciplinary teams concerned with maximal restoration or development of physical, psychological, social, occupational and vocational functions in persons whose abilities have been limited by disease, trauma, congenital disorders or pain.”6

Advocacy

Forces operating inside and outside the specialty have influenced the evolution of PM&R. The field’s belief in the need to identify and fill gaps in care, particularly for underserved populations, has fostered this evolution. Physiatrists often fill administrative roles focused on populations with unmet needs, building programs, clinics, and hospitals to serve these populations.7

Physiatrists advocate for individual patients with a broad range of diseases, conditions, and complications that lead to activity limitations and participation restrictions. Advocacy may include arguing for durable medical equipment and assistive technology on a patient’s behalf, or assisting in a patient’s academic or vocational integration or re-integration. Physiatrists also assume responsibility for influencing the environment in which our patients receive health care, and we promote the removal of barriers to care and to participation in social roles in the diverse communities in which they live, attend school, play and work.

Such advocacy has its foundation in the work of early leaders such as Howard Rusk who wrote in the 1960s: “Rehabilitation of the chronically ill and the chronically disabled is not just a series of restorative techniques; it is a philosophy of medical responsibility. Failure to assume this responsibility means to guarantee the continued deterioration of many less severely disabled persons until they too reach the severely disabled and totally disabled category. The neglect of disability in its early stages is far more costly than an early aggressive program of rehabilitation, which will restore the individual to optimal self-sufficiency and functional performance.”8

Table 1: America Academy of Physical Medicine & Rehabilitation Special Interest Groups Created Before 2009

African American Physiatrists

AIDS/HIV Rehabilitation

Arts Medicine

Brain Injury

Cancer Rehabilitation

Cardiopulmonary Rehabilitation

Geriatric Rehabilitation

Industrial Rehabilitation

Manual Medicine

Medical Acupuncture

Medical Hydrology

Medical Informatics

Myofascial Pain

Neurophysiology

Osteoporosis Rehabilitation

Pain Rehabilitation

Pediatric Rehabilitation

Physicians with Disability

Prosthetics and Orthotics

Primary Care for Persons with Disabilities

Research

Rheumatologic Rehabilitation

Rural Physiatrists

Spinal Cord Injury

Sports Medicine

Stroke Rehabilitation

Thermography

Veterans Affairs (VA) Physiatrists

Women Physiatrists

Wound Care

Table 2: American Academy of Physical Medicine & Rehabilitation Membership Councils Created in 2009

Membership Council Examples: Diseases/Conditions

Central Nervous System Rehabilitation

Brain injury, spinal cord injury, stroke, neurodegenerative diseases, spasticity

Medical Rehabilitation

Amputations, burns, cancer, cardiovascular and pulmonary disorders, geriatrics, obesity

Musculoskeletal Medicine

Spinal disorders, tendinopathy, arthritis, work- and sports-related repetitive overuse injuries

Pain Medicine / Neuromuscular Medicine

Chronic pain, centrally mediated pain, amyotrophic lateral sclerosis, peripheral neuropathy, plexopathy

Pediatric Rehabilitation / Developmental Disabilities

Cerebral palsy, muscular dystrophy, myelomeningocele, Down syndrome

REFERENCES

  1. World Health Organization.International classification of impairments, disabilities, and handicaps: a manual of classification relating to the consequences of disease.Geneva: World Health Organization, 1980.
  2. Warraich BS, Kleim JA.Neural plasticity: the biological substrate for neurorehabilitation. PM&R. 2010;2:S208-S219.
  3. www.abpmr.org/candidates/subspecialties.html; accessed August 10, 2012.
  4. Halstead LS.Team care in chronic illness: a critical review of the literature of the past 25 years.Arch Phys Med Rehabil. 1976;57:507-511.
  5. www.nichd.nih.gov/about/overview/advisory/nachhd/upload/
    Blue_Ribbon_Panel_201205.pdf; accessed August 10, 2012.
  6. www.acgme.org/acWebsite/downloads/RRC_progReq/
    340physicalmedicinerehabilitation07012007.pdf; accessed August 10, 2012.
  7. Sandel, ME.Playback/PM&R: our voices, our vision. PM&R 2011;3:293-295.
  8. Rusk HA. Preventive medicine, curative medicine – then rehabilitation. New Phys. 1964; 13:165-167.

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