Introduction to Physical Medicine and Rehabilitation/PMR

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Introduction to PMR

• Dr. Rambeer Ghuleliya, PhysiatristM.B.B.S., DNB
  (PMR), FIPM (AIIMS, New Delhi), EULAR (Certified
  MSK USG), CCEPC (IAPC, AIIMS, New
  Delhi)Assistant Professor and in-chargeDept. of
  PMRHimalayan Institute of Medical Sciences
• Jolly Grant, Dehradun

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Why CME on PMR?

• Identity crisis
• among medical professionals
• among pts and in the society
• Inadequate representation in MBBS Curriculum
• Lack of PMR faculty/specialist
• Lack of support
• Under-resourced
• Under-developed
• Under-advertised
• Under-utilized
• Referral systems are still not in place

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Physical Medicine Rehabilitation/Physical
Rehabilitation Medicine /Rehabilitation
Medicine / Physiatry
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Contents

• History
• Definition
• Rehabilitation team
• Patient population
• Treatment modalities
• Scope of PMR
• Services

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How did PMR get started?

• Around early of 20th century, a major shift in
  thinking among health care providers began to
  take place
• Holistic, Comprehensive, team-oriented care for
  PWDs
• This powerful philosophy sparked a burgeoning
  interest among health care providers to treat PWDs

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• Dr. Frank Krusen- Founder of Physical Medicine
• Coined the term Physiatrist
• 1928- first dep. Of Physical medicine at temple
  hospital
• 1936- first residency training program at Mayo
  Clinic
• first comprehensive rehabilitation textbook

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• Howard Rusk- Nickname Dr. Live-Again
• Father of Comprehensive Rehabilitation
• Rusk Institute of Rehabilitation Medicine- 1950
• Pioneer physicians in the field helped to plant
  the seeds for an exciting new specialty that
  cared for the whole person, not just the disease

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When did PMR become recognized as a specialty?

• American Academy of Physical Medicine and
  Rehabilitation- 1938
• American Board of PMR (ABPMR)- 1947-
  official medical specialties
• 1st PMR Institute- 1955- AIIPMR, Mumbai
• 1st PMR Department in Medical College- 1963, CMC,
  Vellore

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• 1st MD Course- 1979- School of PMR, IPGMER, SSKM
  Kolkata
• MCI (1999)- Gives directives to all medical
  colleges to establish PMR deptt- implemented
  Negligibly
• Now NMC (from 2022 ) had made PMR Department
  mandatory in all medical Colleges across India

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Why there is need of PMR

• Life expectancy d/t increased quality of
  medical care
• Elderly population
• Chronic disease, non- Communicable disease
• Sedentary lifestyle

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Physical Medicine Rehabilitation

• Physical
• Pertaining to our Physical ness (Body)
• Pertaining to Physical Activity (Exercises)
• Use of Physical Agents Heat, Light, Sound,
  Cold, Electricity etc.

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Physical Medicine Rehabilitation

• Medicine
• That is chikitsa (???????? ) medical care
  including surgeries (???? ????????)
• Medication
• Non Surgical Surgical interventions

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• 2001

• WHO-1997

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WHO Health Indicators-

• Mortality
• Morbidity
• Functioning

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• Almost a third of the worlds population lives
  with limitations in functioning
• Rehabilitation is the key health strategy for
  optimizing functioning

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Physical Medicine Rehabilitation

• Rehabilitation
• Process of transforming a person with functional
  limitations to a person with maximal ability
  through the application of medical treatment,
  therapy, and adaptive equipment
• American Congress of Rehabilitation Medicine
• to restore to a condition of good health
  ability to work, or the like (dictionary.com)
  i.e. restoration to pre-morbid state
• Practically to maximum level of functioning
  thats possible in consideration of medical
  condition vis-à-vis environmental factors

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Physical Medicine Rehabilitation

• Defined
• Rehabilitation of people with disabilities is a
  process aimed at enabling them to reach and
  maintain their optimal physical, sensory,
  intellectual, psychological and social functional
  levels
• Rehabilitation provides people with disabilities,
  the tools they need to attain independence and
  self-determination.
• World Health Organization

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Physical Medicine Rehabilitation

• Defined
• is a medical specialty that emphasizes
  prevention, diagnosis, and treatment of disorders
  particularly related to nerves, muscles and bones
  that may produce temporary or permanent
  impairment
• American Academy of PMR
• With Physiatry intervention Life can always be
  Made better thats Adding Life to Years, while
  in most of other branches of Medicine, Years are
  added to Life

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Physical Medicine Rehabilitation

• Defined
• One of most comprehensive and multifaceted modes
  of tt (amongst all disciplines of medical
  sciences), where focus is on function of patient
  rather than disease

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Physical Medicine Rehabilitation

• Hence,
• PMR can also be described as Cementing Medical
  Specialty that employs all available modes of
  treatment
• Medication (Chemical)
• Physical Agents
• Minimally invasive Interventional procedures
• Surgical (Rehabilitation)
• Compliments almost all clinical departments

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Steps in the Process of Rehabilitation

• Disablement Re-ablement Resettlement
• Retraining Reconditioning Readjustment
• Treating Mentally Tampering Teaching
  Training
• Resource Burner Resource Earner

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Is Rehabilitation is everyones business???

• NO
• Only a trained and skilled person do proper and
  better rehab
• Rehab is not a single mans business
• Rehab is a team work

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Physical Medicine Rehabilitation

• Rehabilitation Team
• Physiatrist physician specialist in PMRTeam
  Leader, overall Responsible Accountable
• Physical Therapist
• Occupational Therapist
• Prosthetist Orthotist
• Speech Language pathologist
• Clinical/Rehabilitation Psychologist
• Medical/Rehabilitation Social Worker

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Physical Medicine Rehabilitation

• Rehabilitation Team contd.
• Physiatrist physician specialist in PMR
• Vocational Councilor
• Remedial Gymnast
• Play/Recreational Therapist
• Rehabilitation Nurse

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Physical Medicine Rehabilitation

• Rehabilitation Team west.
• Physiatrist physician specialist in PMR
• Chaplain
• Insurance Company
• Employer/School Teachers
• Home Health Agency
• Rehabilitation Engineer
• Durable Medical Equipment Vendor

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Physical Medicine Rehabilitation

• Rehabilitation Team spl. con.
• Physiatrist physician specialist in PMR
• Other Physicians
• Orthopedics
• Internist/Physician
• Pediatrician/Pediatric Surgeon
• Neuro-Surgeon/Neurologist
• Plastic Surgeon, etc.

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Physical Medicine Rehabilitation

• Rehabilitation Team
• the Most Important Member
• The Patient his/herFamily

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Physical Medicine Rehabilitation
Rehabilitation Team
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Physical Medicine Rehabilitation

• Defined
• Rehabilitation Physicians are nerve, muscles and
  bone experts who treat injuries or illnesses that
  affect how you move.
• American Academy of PMR

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Physical Medicine Rehabilitation

• Rehabilitation TeamPhysiatrist
• A physician who specializes, thats MD/DNB, in
  the field of Physical Medicine and Rehabilitation
• Psychiatrist vs Psychologist
• Anesthesiologist vs Anesthetist
• Physiatrist vs Physiotherapist

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Physical Medicine Rehabilitation

• Rehabilitation TeamPhysiatrists Role
• Clinical
• Managerial
• Academics Research
• Leadership

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Physical Medicine Rehabilitation

• Rehabilitation TeamPhysiatrists Role
• Leadership to Rehabilitation Team 1st Patient
  Contact - Clinical Work-up
• Diagnosis Medical Rehabilitation
• Medical Minimally invasive procedure management
• Rehabilitation Planning, Implementation
  Monitoring through the team be
  responsible/accountable for the same
• Team Coordination Communication
• Communication with Patient Family other
  Physicians, Agencies (Govt./NGOs/Donors)

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Physical Medicine Rehabilitation

• Condition treated
• Experts at diagnosing treating Pain and various
  disabling conditions
• Treat whole person not just problem area
• Restore maximum function lost through
  injury/Paralysis and/or
• Deformity

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Patient population
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Conditions treated

• Neuromuscular disorders/injuries-
• Radiculopathy/Neuropathy/plexus/nerve
  injury/Bells palsy
• SCI, TBI, MS, MD, MND etc.
• Developmental delays, CP, MMC etc
• Musculoskeletal disorders/injuries-
• bone/muscles/joints/nerve etc pain
• Arthritis/rheumatological disorders

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• Work related injuries/Sports injuries
• Vascular/Ischemic pain/Cancer pain
• Lymphedema
• Deformities/Amputations/after arthroplasty,
  fracture, surgery
• Cardiovascular/Pulmonary disease- MI etc
• Vertigo

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What Diagnostic tools are used in PMR?

• Include those used by other physicians
• Medical H P,
• Lab studies, medical imaging- X ray, CT scan,
  MRI, etc..
• Musculoskeletal Ultrasound- Stethoscope of a
  Physiatrist
• EMG/NCV
• Foot Pressure analysis etc.

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Treatments

• Medicine-
• NSAIDS/Opioids
• Neuropathic Pain medications- Gabapentinoids,
  TCA, SNRI etc
• Muscle Relaxants
• Anti-spasticity medications- Baclofen, tizanidine
• Medicines for Neurogenic bladder- Tolterodine etc
• Casting- Serial casting, Total Contact Casting,
  etc
• Various types of dressing and offloading
  braces/shoe modifications

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Treatments

• Minimally Invasive Pain and spine Procedures
  (MIPSI)-
• USG/Fluoroscopic/nerve stimulator guided
• Regenerative therapy-
• PRP, Dextrose Prolotherapy
• Steroids, Hyaluronic acid etc
• Intra-articular/Trigger point/Myofascial plane
  blocks
• Bursa/tendon sheath/lig- PRP etc

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• Lumbar Epidural steroid/MBB etc
• Sympathetic Ganglion blocks- Stellate/Impar
  ganglion
• Nerve/Plexus block- SSNB/GFN/Splanchnic/CPB etc
• Botulinum toxin injections
• Phenol/alcohol Motor point block or neurolysis
• Radiofrequency ablation/Neuromodulation

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Treatments

• Rehabilitative Sx- Tendon lengthening etc
• May Prescribe rehabilitation programme-
• Physical therapy
• Occupational therapy
• Ergonomic advises
• Prosthesis/Orthosis/shoe modifications
• Assistive technology
• Architectural modifications
• Vocational rehabilitation
• Mental health

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• PMR department is like a Mall
• Collaborate with all, Rehabilitate all (???? ???,
  ???? ????????)

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Referring Patients to PMR??

• Competitor to Collaborator
• Type of referral we are getting are like-
• Referred to PMR dept. for Physiotherapy
• exercises or
• Dept of Physiotherapy for PMR

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• But referral should be like-
• Pt Referred to PMR Dept for
• Stroke /neurological rehabilitation etc
• Pain management
• further management/opinion/opinion on
  rehabilitation management etc.

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• Please refrain from counselling the patient that
  go to PMR department and learn exercises
• SCI, TBI, stroke, etc., need to be compulsorily
  transferred to PMR to
• achieve superior outcomes, after meeting clinical
  stability criteria as soon as possible

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Future of PMR

• Musculoskeletal ultrasound
• Interventional Physiatry
• Gait Motion analysis
• Virtual Rehabilitation
• Robotic Rehabilitation
• 3D Printing for Orthosis/Prosthesis
• Intrathecal baclofen pump
• Spinal Cord Stimulation

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Is Physiatry a recognized specialty in other
countries? Has it achieved international
Prominence?

• Highly popular throughout world
• Average salary of PMR Specialist is placed at
  21th position among 29 specialty in Physician
  Compensation Report-2023 (USA) well above from
  medicine, pediatrics etc.
• This field continues to be a drawing card for
  international doctors

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• WHO Rehabilitation 2030 initiative Call for
  action(2017)-
• rehab for all and through all stages of life
  course
• 2nd Rehabilitation 2030 meet- July 2019
• 3rd Rehabilitation 2030 meet- July 2023

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Specialty/Subspecialty courses in India

• MD/DNB
• DM in Pain Medicine- AIIMS Rishikesh
• Fellowship in Pain Medicine- AIIMS, New Delhi
• Fellowship in Pain and Palliative care- AIIMS,
  Jodhpur
• Fellowship in Pain Medicine- ESIH, SSKM-Kolkata
• Fellowship in Rehabilitation Surgery- AIIPMR,
  Mumbai
• Fellowship in Neurorehabilitation- NIMHANS

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Abroad Subspecialty/Fellowships

• American board of PMR Accredited
• Pain Medicine
• SCI Medicine, Neuromuscular Medicine
• Sports Medicine
• Paediatric rehabilitation
• Hospice and Palliative Medicine
• Electrodiagnostic medicine, Stroke Medicine
• World Institute of Pain
• CIPS (Certified Interventional Pain Sonologist)
• FIPP (Fellowship of Interventional Pain Practice)

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Pros and cons of PMR

• Pros

• Cons

• Diverse pt population
• High in demand
• High or at par salary
• Emergencies rarely
• Work life balance
• Evolving field with
• newer t/t options

• Not always rewarding
• Time consuming and require active pt
  participation
• Lack of awareness about specialty
• Difficulty in explaining role to pt/physicians

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My Vision and Mission

• To promote the field of rehabilitation
• To provide the best possible and affordable
  rehabilitation care
• To improve the quality of care
• To increase the scope
• To increase the capacity

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• Establishing a state of art Physical Medicine and
  Rehabilitation Department equipped with latest
  rehabilitation technology
• Chronic Pain Medicine Unit
• Indoor Based Rehabilitation unit
• Occupational therapy unit
• Paediatric Rehabilitation unit/Early Sensory
  Integration Unit
• Expansion of Physiotherapy unit
• Expansion of Prosthetic/orthotic unit
• Speech and Language and Swallowing disorder unit
• Foot Care unit

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Services provided by PMR at our Institute

• OPD services
• Pain management
• Neurorehabilitation
• Cancer rehabilitation
• Prosthetic and orthotic
• Disability evaluation

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Take Home Message

• Not linked to one specific organ or body system
• Doctors that specialize in function
• Rehab
• Art
• Team work
• Need of the hour
• Should not be taken as stopgap solution
• Holistic, Collaborative and synergistic efforts
• Therapeutic Exercises are part of comprehensive
  rehab process

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• Each body is different Therefore each
  rehabilitation must be different
• Standard and universal referral for
  rehabilitation is probably the essential policy
  to be implemented

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Physical Medicine Rehabilitation

• Live with dignity rather than live for long is
  the motto today
• Please collaborate
• Queries/Comments
• Thanks very much!