# Physical medicine and rehabilitation

Physical medicine and rehabilitation (PM&R), also known as physiatry, is a branch of medicine that aims to enhance and restore functional ability and quality of life to people with physical impairments or disabilities. This can include conditions such as spinal cord injury, brain injury, musculoskeletal injury, stroke, pain and spasticity from muscle, ligament, or nerve damage. PM&R physicians lead rehabilitation teams and are trained in medication management, electrodiagnosis, and targeted injections. A physician having completed training in this field may be referred to as a physiatrist.

## Scope of the field

Physical medicine and rehabilitation encompasses a variety of clinical locations in both the inpatient and outpatient settings. Physiatrists can also oversee patient care in subacute settings (IPR, LTAC, SNF). A major goal of Physiatry is to optimize function. Thus, the scope of the field is broad in terms of patient populations and conditions that are managed.
In hospital settings, physiatrists commonly treat patients who have had a spinal cord injury, stroke, traumatic brain injury, amputation, or other debilitating condition requiring acute rehabilitation care. In treating these patients, physiatrists lead a team of physical, occupational, respiratory, and speech therapists, as well as nurses, psychologists, and social workers who work in tandem to facilitate patient care..
In the outpatient setting, physiatrists can see to the long-term care of patients with disabling conditions and management of the sequelae associated with those conditions. For example, a physiatrist could manage the bowel and bladder regimen for a SCI patient. In addition, patients can be evaluated and treated for muscle and joint injuries, pain syndromes, non-healing wounds, and other disabling conditions.
Physiatrists are trained to perform injections into joints or muscle as a pain treatment option. Physiatrists are also trained in ultrasound, nerve conduction studies, and electromyography.

## History

During the first half of the 20th century, two unofficial specialties, physical medicine and rehabilitation medicine, developed separately, but in practice both treated similar patient populations consisting of those with disabling injuries. Frank H. Krusen was a pioneer of physical medicine, which emphasized the use of physical agents, such as hydrotherapy and hyperbaric oxygen. His work began at Temple University and was continued at Mayo Clinic where he coined the term 'physiatry' in 1938. Rehabilitation medicine gained prominence during both World Wars in the treatment of injured soldiers and laborers. Howard A. Rusk, an internal medicine physician from Missouri, became a pioneer of rehabilitation medicine after being appointed to rehabilitate airmen during World War II. In 1944, the Baruch Committee, commissioned by philanthropist Bernard Baruch, defined the specialty as a combination of the two fields and laid the framework for its acceptance as an official medical specialty. The committee also distributed funds to establish training and research programs across the nation. The specialty that came to be known as physical medicine and rehabilitation in the United States was officially established in 1947, when an independent Board of Physical Medicine was established under the authority of the American Board of Medical Specialties. In 1949, at the insistence of Rusk and others, the specialty incorporated rehabilitation medicine and changed its name to Physical Medicine and Rehabilitation.
PM&R has played an important role in several epidemics, including management of the long-term complications of the poliovirus. Prior to its official creation as a specialty in the Unites States, many modern PM&R concepts were developed following President Franklin D. Roosevelt's time at Warm Springs Resort, a hot springs spa in Georgia. He attended the facility in 1924 to assist in his recovery from paralysis secondary to the poliovirus. Due to improvements in his own condition, Roosevelt later purchased the resort in 1926 and transformed it into a medical rehabilitation center. He continued to fundraise money for the facility throughout his presidential years in the 1930s. The improvements to the facility allowed for budding physiatrists, including Dr. Robert L Bennett, to research and enhance the field of PM&R. Many of the techniques that Bennett developed at Warm Springs continue to be utilized by physiatrists today, including the refinement of manual muscle testing and the creation of several prosthetic devices.

## Treatment

The major goal of physical medicine and rehabilitation treatment is to help a person reach optimal functionality within the limitations placed upon them by a disabling impairment or disease process for which there is no known cure. The emphasis is not on the full restoration to the premorbid level of function, but rather the optimization of the quality of life for those not able to achieve full restoration. A team approach to chronic conditions is emphasized to coordinate care of patients. Comprehensive rehabilitation is provided by specialists in this field, who act as facilitators, team leaders, and medical experts for rehabilitation.
In rehabilitation, goal setting is often used by the clinical care team to provide the team and the person undergoing rehabilitation for an acquired disability a direction to work towards. Very low quality evidence indicates that goal setting may lead to a higher quality of life for the person with the disability, and it not clear if goal setting used in this context reduces or increases re-hospitalization or death.
Not only must a physiatrist have medical knowledge regarding a patient's condition, but they also need to have practical knowledge regarding it as well. This involves issues such as: what type of wheelchair best suits the patient, what type of prosthetic would fit best, will the patient's current house layout accommodate their handicap well, and other every day complications that their patients might have.

## Training

In the United States, residency training for physical medicine and rehabilitation is four years (PGY1-4) long, including an intern year of general medical training. There are 112 ACGME accredited PM&R residency training programs in the United States. In addition, there are 4 ACGME accredited pediatric PM&R residency training programs.
Specifics of training differs from program to program but all residents must obtain the same fundamental skills. Residents are trained in the inpatient setting to take care of multiple types of rehabilitation including: spinal cord injury, traumatic brain injury, stroke, orthopedic injuries, cancer, cerebral palsy, burn, pediatric rehab, and other disabling injuries. The residents are also trained in the outpatient setting to know how to take care of the chronic conditions patients have following their inpatient stay. During training, residents are instructed on how to properly perform several diagnostic procedures which include electromyography, nerve conduction studies and also procedures such as joint injections and trigger point injections.

### Subspecialties

Seven accredited sub-specializations are recognized in the United States:
* Neuromuscular medicine
* Pain medicine
* Pediatric rehabilitation medicine
* Spinal cord injury
* Sports medicine
* Brain damage
* Hospice and palliative medicine
Fellowship training for other unaccredited subspecialties within the field include the following:
* Musculoskeletal/Spine
* Stroke
* Multiple sclerosis
* Neurorehabilitation
* Electrodiagnostic medicine
* Cancer rehabilitation
* Occupational and environmental medicine