What Is Physiatry?
Steven J. Farrell, MD
Associate Professor and Chief
Physical Medicine and Rehabilitation
University of Toledo College of
Medicine
Who The Heck Gets Into
Rehab?
Disclaimer
I am married to Dr. Gottwald
I know nothing about skin disease
I cannot get you a derm appointment
sooner
Objectives
Give a basic overview of PM&R
Discuss the principles of inpatient
rehabilitation
Discuss admission criteria for inpatient
rehab facilities (IRF)
Physiatrist
Practices in the field of Physical Medicine
and Rehabilitation
Works with patients who posses functional
disabilities
History of PM&R
Comes from physikos
(physical) and iatreia (art
of healing)
Principles started during
World War I
Physiotherapy and
reconstruction hospitals to
treat war vets
History of PM&R
1936 first program founded at the Mayo
Clinic with the support of the War Dept and
US Navy
1941 World War II broadens the scope of
the field
1945 section of PM&R established in the
AMA
History of PM&R
1946 twenty five residencies established
1952 nearly 58,000 cases of polio become
a prime focus of treatment
President Franklin Roosevelt brings
spotlight disabled Americans
1965 Medicare and Medicaid established
1972 Medicare expands coverage to
include disabled and inpatient
rehabilitation
PM&R Now
78 training programs
Over 1300 positions of training (350 per
year)
Over 8000 Board Certified Physiatrists
Estimated significant need upcoming due
to longer lifespan, more active elderly
population, baby boomers entering the mid
60’s
Toledo and PM&R
Accredited residency program
21-27 bed rehab unit
6 total residents in training
50% of training slots filled by UT COM
graduates
75% of practicing physiatrists graduates of
UT PM&R Residency Program
UT COM is in top 20 medical schools in
training Board Certified Physiatrists
But What Do We Do?
Inpatient Rehabilitation
Physiatrist is part of a team of health care
professionals that work to reintegrate the
disabled patient into the home and
community environments
Multidisciplinary approach can be very
effective
The Team
Physical therapist
Occupational therapist
Speech and language therapist
Counselor
Nursing
Therapeutic recreation specialist
Social worker
Physiatrist
Physical Therapist
Works on tasks
– Mobility
– Transfers
– Gait
– Car skills
– Pain control
– Education
Exercise, modalities
Occupational Therapist
Works on tasks of upper extremities
– Activities of daily living
– Functional transfers
– Splinting
– Modalities and motor control tasks
May specialize in hand therapy
Speech/Language Therapists
Speech and language assessment and
treatment
Cognitive evals and treatment
Swallowing assessment and treatment
– Bedside
– Modified barium swallow testing
Counselor
May be social worker, psychologist
Adaptation to disability
Nursing
Different than acute care floor
Patients are mobile and active
Education
Bladder and bowel programs
Decubutis care
Social Worker
Discharge planning
Procure equipment
Follow up arrangements
Therapeutic Recreation Specialists
Works with avocational tasks
Hobbies and interests
Field trips
Physiatrist
Follow patient’s medical and rehabilitation
needs
Try NOT to call medicine unless really
necessary because they are our friends
Medical/Rehabilitation Issues
We Encounter
Pulmonary
Very important in cases of tetraplegia
Teach respiratory techniques
Wean trachs
Some IRF will take vents; we do not due to
staff training issues
Bowel
Neurogenic bowel very common and
important to treat
Can inhibit rehab and social progress
Will start with the 3-2-1 program
– Colace 100 mg TID
– Senna two tabs at noon
– Dulcolax suppository at night
Bladder
Neurogenic
– Unhibited bladder
Stroke
Babies
– Spastic
TBI or SCI
– Flaccid
Cauda equina syndrome
– Dysynergic
Higher level SCI
Bladder Programs
Timed voids
– CVA
– Brain injury
Intermittent straight caths
– SCI
Suprapubic catheter
Avoid long term foley unless absolutely
necessary
– Reason to keep a foley???
Skin/Pressure Ulcers
Direct pressure
Friction
Shearing
Moisture
Malnutrition
Anemia
Spasticity
Can help or hurt functional recovery
Treatments
– Therapy
– Modalities: cold
– Medication: baclofen, zanaflex
– Botox
– Baclofen pumps
– Surgical tendon release: messy and avoided if
possible
Who Is Eligible?
Ability to participate in therapy 3 hours per day in
meaningful way
– Medically and motivation wise
Home goal
– Should have good home support or be reasonably sure they can
go home alone; judgment call by the PM&R consult team
INSURANCE
– IRF is not the same as an acute care hospital; elective
admission
– Each insurance company can have their own criteria
– Can take away our decision making
– Until they pass health care reform then who knows? Likely not
even congress
Medicare Funding
PPS: prospective payer system
75% rule (now 60%)
Not cheap: $1000/ day
60% Rule
60 % of our patient are required to have
one of the following diagnosis
60 % Rule
CVA
SCI
Congenital deformity
Amputation
Hip fracture
Brain injury
Neurological
disorders
– Parkinson's, MS
Burns
Active RA, psoriatic
arthritis
Seronegative
spondyloarthropathies
Systemic vasculitis
active
60 % Rule
Joint replacement
– BMI > 50
– Active weight bearing polyarthritis
– Bilateral joint replacements
– Age > 85
Physical Medicine
Works with patients that have
musculoskeletal injuries
– Sports injuries
– Occupational injuries
– Spine
– Pain
Electrodiagnosis
Non-operative treatment
Musculoskeletal Injuries
Shoulder: tendonitis
Elbow: tennis elbow
Hand and wrist: CTS
Hip: bursitis
Knee: cartilage or ligament injury
Ankle: Sprains
Back/Neck: strains, disc injury, nerve root
Fields of Overlap
Orthopedics
Internal medicine
Neurology
Neurosurgery
Rheumatology
Case Quiz
82 year old with significant dementia lives
with family with new onset CVA
Left hemiplegia and dysphagia
Otherwise in good health
Acute care therapists note difficulty with
patient in carryover with teaching tasks
Are they a good IRF candidate?
Case Quiz
66 year old female with new onset major
MI; workup leads to CABG
Post op patient develops pneumonia
requiring IV abx
Are they a good rehab candidate?
Case Quiz
72 year old patient with Parkinson's
Disease admitted to Med I with pneumonia
and UTI
On admission notes that tremors have
greatly worsened and neurology
consulted; they change meds but tremors
are slow to respond and you are
concerned about safety
Are they a good rehab candidate??
Questions?