The Philosophical Foundations of Physical Medicine and Rehabilitation

Author(s): M. Elizabeth Sandel, MD

Originally published:11/03/2012

Last updated:09/15/2019

Introduction

The American Board of Physical Medicine and Rehabilitation (ABPM&R) defines a Physical Medicine and Rehabilitation (PM&R) physician (physiatrist) as “a doctor with training in treating disorders or disability of the muscles, bones, and nervous system.” The ABPM&R goes on to say that conditions treated by a physiatrist may include amputation, arthritis, back and neck pain, brain injury including concussion, chronic pain, complex wounds, congenital disorders, industrial and work injuries, muscle and nerve disorders, spinal cord injury, sports injury, and stroke.1

Board-certified physiatrists have many opportunities for primary and subspecialty certification. The ABPM&R’s seven subspecialty certification areas are helpful for further defining physiatric training, practice, and research. These subspecialty areas are brain injury medicine, hospice and palliative care medicine, neuromuscular medicine, pain medicine, pediatric rehabilitation medicine, spinal cord injury medicine, and sports medicine.2

The broad scope of these areas of subspecialty make PM&R an exciting field. At the same time, PM&R’s lack of focus on one organ or system, and the field’s integration of primary and specialty aspects of practice, present challenges for defining it. Most patients are unfamiliar with PM&R until they encounter a physiatrist and learn what care physiatry can provide. Because there are relatively few practicing physiatrists in the United States and across the world compared with the numbers of practitioners in other medical specialties, public education has fallen short. Nevertheless, the number of trained physiatrists has been steadily rising over the last few decades to meet the patient need. As a consequence, awareness of the specialty is growing.

Diverse Practice Settings and Patients   

As medicine evolved toward subspecialization in the late 20th century, physiatric practice opportunities for adults and children expanded across many diagnostic groups and practice settings. Many physiatrists practice in outpatient settings, and others work as attending physicians in rehabilitation hospitals or rehabilitation units within hospitals. Physiatrists may also provide consultations in acute care and trauma hospitals, and long-term care and skilled nursing facilities.

Physiatrists provide treatment and interventions for a diverse group of adult and pediatric patients. A pain medicine physiatrist treats a patient with a painful condition of the spine using facet joint injections and a pain management program. A pediatric physiatrist prescribes respiratory therapy and a seating system for a child with muscular dystrophy. A physiatrist practicing in a cancer hospital develops a pain management and exercise plan for an woman with metastatic breast cancer and prescribes physical therapy treatments for her lymphedema. A brain injury medicine physiatrist orders a neuropsychological evaluation for a high school athlete with a history of concussion and attention deficit hyperactivity disorder and prescribes a cognitive rehabilitation program. An attending physiatrist coordinates an inpatient program for a stroke patient, prescribing medications to treat a bladder infection and incontinence.

Examples abound to help explain the diverse care that physiatrists provide. However, the logical next questions are: What makes physiatrists alike? And what makes them different from other physicians? Physiatrists are grounded in multifaceted beliefs, concepts, attitudes, and guiding principles, that is, “philosophies,” that underpin the practice of PM&R, its research priorities, training approaches, and advocacy for patients and the specialty.

Patient Evaluation and Treatment Approaches

Physiatrists evaluate their patients using a model based on the traditional medical history and physical examination. However, physiatric evaluations go beyond these conventions. Physiatrists take into account the biopsychosocial and ecological (environmental) factors that affect function and quality of life.3,4 Approaches in physiatry are patient-centered, humanistic, and compassionate. Beyond initially focusing on diagnosis, the physiatrist considers the impact of the diagnosis and related impairments (due to pain, weakness, or other symptoms or conditions) on the patient’s day-to-day activities.

Patients receiving ongoing care from physiatrists often see them as similar to “old-fashioned family physicians”. They take a genuine interest in and become knowledgeable about their patients’ physical, mental, and cognitive health history, current functioning, family supports, occupational circumstances, and recreational activities. PM&R is a complex field in terms of how its clinicians gather and interpret data. Physiatrists seek out medical, social, psychological, vocational, and avocational information to create and formulate a comprehensive treatment plan based on a holistic understanding of the patient.

The concepts of human performance and quality of life that form the basis for the World Health Organization’s International Classification of Function (ICF) are reflected in and contribute to the philosophical foundation of PM&R.5  Physiatrists see patients as individuals who live in social contexts, have values, perspectives, a cultural heritage, life experiences, relationships, and specific functional or other goals for their treatment. Physiatrists understand the patient’s activity limitations and participation restrictions associated with one or more diseases or disorders, and those that impact social roles (for example, student, employee, spouse or partner, parent, member of a faith community, or athlete). They take into account attitudinal and environmental barriers that impact people with disabilities when developing treatment plans.

Physiatrists list rehabilitation and disability management as the top priority areas of treatment across all PM&R subspecialty areas. Offering palliative care and symptom management, including pain treatment, and preventing related disability, are always priorities as well. Physiatrists focus less often on disease management and curative medicine in their practices than other physicians. Rather, they emphasize maximizing a patient’s function and quality of life. Nevertheless, physiatric treatment plans include aspects of disease management and curative medicine, especially during hospital rehabilitation of patients with central nervous system disorders and medical diseases and complications.

Physiatric assessments and treatment approaches are often integrated with other rehabilitation professionals, and physiatrists believe in the importance of team coordination for delivering optimal care. PM&R was among the first specialties to base care on team models, and to study teams through research. Inpatient rehabilitation teams include other rehabilitation professionals (such as physical/occupational/speech and language therapists, neuropsychologists, rehabilitation nurses and social workers, and prosthetists/orthotists) on inpatient teams. Today, rehabilitation teams extend into outpatient and post-acute/residential programs as well.

Physiatrists are also skilled at communicating with and coordinating care with physicians in other fields such as cardiology, critical care and hospital medicine, neurology, neurosurgery, and orthopedics. This skill requires respect for and knowledge of these other medical specialties. For example, a spinal cord injury physiatrist must understand decompression and fusion of the cervical spine in order to integrate care delivery with the nurses, therapists and other staff in the intensive care unit.

The field also embraces pragmatic and conservative treatment, and physiatrists have the knowledge and skills to provide non-surgical treatments, many of which are low risk and potentially highly beneficial. Essential to physiatric practice are patient and social support system/caregiver education about diagnosis, prognosis, treatment options, and strategies to decrease pain, improve function, and decrease the burden of care on caregivers. Physiatrists believe in the power of education, especially for self-care and self-management of symptoms, but also for training caregivers, including family members.

Physiatrists provide interventions aimed at decreasing symptoms and improving function, even when the treatment or intervention may not influence or cure the disease or condition itself. Physiatrists measure the benefits of interventions in terms of improved function in everyday life, not just improvements in symptoms such as pain or weakness. Ultimately, the broader goal is to improve quality of life so that the patient can live not in isolation but within a relational social context.

Physiatrists predict function in relation to the natural history of disease, injury, and recovery trajectories. They tend, however, to use caution when asked to  provide a definitive functional prognosis for the long-term. Physiatrists believe in people’s resilience and adaptability, and in the capacity of biological systems to respond and modify. This philosophy likely derives from clinical experience with individual patients whose functional outcomes defy statistics. Longitudinal investigations of the patient populations physiatrists treat have also allowed for more optimistic predictions in some cases. Neuroscience translational research that demonstrates the potential for neural recovery after injury and disease has helped to confirm this tendency to avoid definitive predictions.

Research

Physiatric research is as diverse as physiatric practice. One researcher studies the improvements in low back pain and function using a core strengthening exercise program. Another investigates the benefits of a cognitive enhancing medication for a patient with a severe traumatic brain injury. A pediatric physiatry researcher uses longitudinal databases to investigate functional outcomes for children with spinal cord injuries. Yet another researcher studies the effectiveness of an antidepressant on outcomes in patients who have a history of stroke.

A Blue-Ribbon Panel on Rehabilitation Research of the National Institutes of Health (NIH) selected this definition of rehabilitation research: “the study of mechanisms and interventions that prevent, improve, restore or replace lost, underdeveloped or deteriorating function.”6  Physiatric research aims to understand the mechanisms of diseases and disorders represented by the wide range of patient populations physiatrists treat. The goals of this research may be to find effective interventions that palliate specific symptoms, enhance function and human performance, and/or improve quality of life.

PM&R research is primarily translational and often team-based, and its researchers may be basic scientists, bioengineers, assistive technologists, or outcomes specialists. Opportunities abound for studying the effectiveness of pragmatic, non-operative, multi-modality interventions (for example, using physical therapeutics and pharmacologic agents) that characterize physiatric practice, although this is methodologically challenging research.

Advocacy

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 or assisting in a patient’s academic or vocational integration or re-integration. Physiatrists also assume responsibility for influencing the environment in which patients receive health care, advocating to remove barriers and promote participation in the communities in which they live, attend school, play, and work.

Forces operating inside and outside the specialty from PM&R’s historic beginnings to the present have influenced its evolution.The field’s belief in the need to identify and fill gaps in care, particularly for underserved populations, has fostered this evolution. Such advocacy has its foundation in the work of early leaders such as internist and physiatrist 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

Over the decades since the Rusk era, many physatrists have used administrative roles to address the unmet needs of adult and pediatric patients by building programs, clinics, and hospitals to serve them. That advocacy and action continues in the early 21st century.

REFERENCES

  1. ABPM&R: https://www.abpmr.org/About. Accessed July 17, 2019.
  2. ABPM&R: https://www.abpmr.org/Subspecialties. Accessed July 17, 2019.
  3. Engel GL. The need for a new medical model: A challenge for biomedicine. Science. 1977; 196:129–136.
  4. Stineman MG, Streim JE. The biopsycho-ecological paradigm: a foundational theory for medicine. PM&R. 2010;2(11):1035–1045.
  5. World Health Organization: https://www.who.int/classifications/en/. Accessed July 17, 2019.
  6. NICHD/NIH: https://www.nichd.nih.gov/sites/default/files/about/advisory/nachhd/Documents/Blue_Ribbon_Panel_201205.pdf. Accessed July 17, 2019.
  7. Knowledge Now: Early History of Physical Medicine and Rehabilitation in the United States. (also being updated)
  8. Rusk HA. Preventive medicine, curative medicine – then rehabilitation. New Phys. 1964; 13:165-167.

The author thanks Dr. John F. Ditunno, Jr. for his review and recommendations for this article.

Original Version of the Topic

M. Elizabeth Sandel, MD. The Philosophical Foundations of Physical Medicine and Rehabilitation. Original Publication Date: 11/03/2012

Author Disclosure

M. Elizabeth Sandel, MD
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