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About Physical Medicine & Rehabilitation (PM&R)
History of PM&R

The History of PM&R:
An Overview

Physical means of healing have been practiced since prehistoric times, but Physiatry did not become recognized as a separate medical specialty until 1947. Most widely known as the field of Physical Medicine and Rehabilitation, the medical specialty of modern-day Physiatry comprises the related disciplines of Physical Medicine, Rehabilitation Medicine and Electromyography.

Since the beginning of time, people have used physical means for treatment of illness and injury. Such physical agents for healing have included water, heat, cold, massage, light, exercise and electricity. Throughout history, water has functioned as a primary means of physical healing. Written accounts of physical techniques for healing can be traced as far back as the writings of Hippocrates in 400 B.C.

Rehabilitation involves the restoration of a diseased or disabled person to optimal physical, psychological and social functioning.

During and after World War I, empirical trials indicated that various physical methods were useful to augment medical care and convalescence of patients. Physicians began practicing "physiotherapy" in "reconstruction hospitals" to rehabilitate injured and disabled soldiers. Therapeutic tools and methods were developed or improved to apply heat, massage, exercise, electrical stimulation, heliotherapy and diathermy. Physicians pioneered new medical applications of electrotherapeutics and x-rays. Functional activities of occupational therapy to provide exercise, retraining of coordination and reassurance that useful performance could be regained, were extensively practiced in Army Hospitals.

Beginning in the 1920's, medical organizations such as the AMA Council on Physical Therapy and the American Society of Physical Therapy Physicians were formed. These organizations later were changed and renamed a number of times to reflect the evolving specialties of physical medicine, physical therapy, electrotherapeutics, radiology, and rehabilitation. The major organizations for physicians in the field of physiatry today include the American Academy of Physical Medicine and Rehabilitation (AAPM&R), the Association of Academic Physiatrists (AAP), the American Board of Physical Medicine and Rehabilitation (ABRM&R), the International Rehabilitation Medicine Association (IRMA), and the American Congress of Rehabilitation Medicine (ACRM). These organizations represent seven decades of development of the field of physiatry. Two major medical journals have evolved to publish research in the field of Physiatry. The Archives of Physical Medicine and Rehabilitation is published by the AAPM&R and the ACRM, and the American Journal of Physical Medicine and Rehabilitation is published by the AAP.

Formal education for Physiatry had its beginning in 1926 when, after service in the U.S. Army during World War I, Dr. John Stanley Coulter joined the faculty of Northwestern University Medical School as the first full-time academic physician in physical medicine. He became the leader of the educational development of the practice of physical medicine over the next two decades. He initiated the first continuing teaching program in physical medicine, consisting of short courses of three to six month's duration, later extended to one year for physicians in practice. Prior to that time, training in Physical Medicine had been by short preceptorship with a practitioner of some aspect of physical medicine. During that period, Dr. Coulter gained recognition as the leader of the developing organizations for physical medicine physicians.

The decade of the 1930's brought further organization and purpose to the field of rehabilitation. Only a few training programs for physical therapy technicians existed, but these were standardized by the formation of The American Registry of Physical Therapists. Likewise additional opportunities for training physicians began to develop, and groups began to form to represent specific interests within Physical Medicine and Rehabilitation. Frank Krusen, MD, established the Physical Medicine Program at the Mayo Clinic in 1936 and initiated the first three-year residency in Physical Medicine. Drs. Coulter and Krusen led the organization of the American Academy of Physical Medicine in 1938, and Dr. Coulter is credited with being its Organizational President. In that year, Dr. Krusen coined the word "Physiatrist" to describe the small group of physicians who were dedicated to the approach of adding physical medicine to medical therapeutics to treat neurological and musculoskeletal disorders. Krusen wrote the first widely used textbook on Physical Medicine in 1941. He is recognized as the "Father of Physical Medicine." In 1946, the AMA Council on Physical Medicine voted to sponsor the term "physiatrist" (fizz-ee-at'-trist) and physiatry (fizz-ee-at'-tree) with the accent on the third syllable. This is how the pronunciation appears in most American dictionaries.

It was not until after World War II, however, that society began to understand the necessity for more advanced treatment and rehabilitation for the disabled. The public became more aware of the rehabilitation effort due to the substantial numbers of debilitating war injuries plus the thousands of individuals disabled by a poliomyelitis epidemic that sent fear into every American home. The influence of radio, movie newsreels, and later television brought home the reality of polio in the person of President Franklin D. Roosevelt, who had regained his capacity to return to public life after physical therapy at Georgia Warm Springs.

These events created an increased demand for physicians trained in a comprehensive approach to rehabilitation, including the physical, mental, emotional, vocational and social aspects. With the cases of polio reaching nearly 58,000 in 1952, physiatrists were called upon to treat the "whole patient" and direct the restoration of the disabled and their return to functional roles in their communities.

From quite a different origin, as a result of his experience in the Army Air Corps Convalescent and Rehabilitation Services at Jefferson Barracks in World War II, Howard A. Rusk, MD, an internist, saw and recognized that passive, inactive, non-physical convalescence resulted in both physical and emotional deterioration of soldiers recovering from accident or illness. As a result, these soldiers were often classified as unfit to return to duty. Although Rusk faced passive resistance from medical officialdom, he was able to set up a controlled experiment in one barracks in which active rehabilitation was carried out while a control barracks continued the passive program of convalescence. The dramatic demonstration of the more rapid recovery of strength and endurance and the much more rapid return to active duty due to the benefits of planned aggressive rehabilitation were so remarkable that the Army Air Corps extended the program to all of its hospitals, and shortly thereafter, it was extended throughout the military services. The Medical War Manpower Board recognized the great value of active rehabilitation and introduced it into civilian medical practice.

After the war, Rusk left his medical practice in Missouri and went to New York's Bellevue Hospital where he began his 30-year campaign to train physicians and establish rehabilitation programs to treat the whole patient. During those years, Rusk had a profound influence on present-day physiatry. He established the Institute of Rehabilitation Medicine at the New York University Medical Center and helped to found The World Rehabilitation Fund, which has trained hundreds of rehabilitation specialists and physicians representing dozens of countries.

Rusk advocated the aggressive approach to rehabilitation medicine, which he had begun in the Army Hospitals and which is practiced widely today. He insisted that patients should not remain inactive during convalescence but should be involved in early ambulation, aggressive physical therapy, recreational and sports activities of progressive intensity and programs involving emotional and psychological support. Rusk's endeavors earned him recognition as "the Father of Rehabilitation Medicine."

The Veterans Administration, through its experience in caring for thousands of injured and disabled soldiers over many decades, has been a primary influence in the development of Physical Medicine and Rehabilitation. After World War II, under the directorship of A.B.C. Knudson, MD, the modern-day Physical Medicine and Rehabilitation Service was established. Since that time, the VA has become an important partner to university PM&R residency programs in providing training facilities, faculty and patients. Physical Medicine and Rehabilitation is currently practiced in each of the 171 VA Medical Centers throughout the United States and Puerto Rico.

Another group of great importance to Physiatry was the Baruch Committee, which left a lasting legacy for the development of university research and training programs in the field of physiatry. The committee, which served from 1943-52, was appointed by philanthropist Bernard Baruch in memory of his father, Dr. Simon Baruch, who was a leading proponent of hydrotherapy as a faculty member at Columbia University's College of Physicians and Surgeons. The committee awarded grants to hospitals and medical schools to establish PM&R teaching and research programs. By 1946, medical residencies or fellowships in PM&R had been established at 25 hospitals as a result of funding from the Baruch Committee. Although the grants provided the basis for the expansion of training and research, the propelling influence for the expansion of the field of physiatry was the recognition by the public that rehabilitation worked. Hundreds of wounded soldiers and injured civilians were being rehabilitated and returned to be productive, tax-paying members of society. This was the testimony before Congress and to the public at large that ensured the future of the field physiatry.

In January 1947, the Advisory Board of Medical Specialties (now the American Board of Medical Specialties) formally recognized the American Board of Physical Medicine. Two years later, at the urging of Dr. Rusk, the name was changed to include "Rehabilitation." For the first time, the specialty of physical medicine and the specialty of rehabilitation medicine were under one governing board. At that time, university hospitals were offering a total of 85 positions for residents or fellows in Physical Medicine and Rehabilitation.

In the 1950's, a major collaborator with Howard Rusk, Mary Switzer, director of the Office of Vocational Rehabilitation (OVR) brought about the economic opportunity for the great expansion of Physical Medicine and Rehabilitation. Mary Switzer was totally committed to the improvement of the quality of life for people with disabilities. She became convinced by Howard Rusk that physical medicine and rehabilitation under the direction of physiatrists could provide the greatest benefits for people with disabilities. Her effectiveness as an administrator and advocate for the disabled before Congress resulted in greatly increased budgets not only to provide rehabilitation services, but also to support physiatric training programs, physiatric fellowships, and support for research in medical rehabilitation. During her administration, the concept of regional rehabilitation research and training centers was adopted and funded by Congress. These centers remained the major resources available to physiatrists for rehabilitation research and research training until 1990, when the National Center for Medical Rehabilitation Research was established at the National Institutes of Health.

The 1950's brought an increase in the numbers of rehabilitation professionals and a more cohesive union between the fields of Physical Medicine, Rehabilitation Medicine, and Electromyography. Electromyography (EMG) was introduced into Physiatry as a profoundly important electrodiagnostic method for the evaluation of problems of the neuromuscular system, which constitutes a major part of the work of the physiatrist. Through EMG, it is possible to localize and evaluate significant pathology of both the muscular and sensory components of the nervous system. The general acceptance of this diagnostic tool created a significant niche for the growing specialty of PM&R.

On the therapeutic side, many rehabilitation centers were born because the value of medical rehabilitation was recognized by the general public, who demanded that these services be made available in every large community.

Along with the expansion of education and training opportunities in physical medicine and rehabilitation, interest in physiatric research multiplied during the 1960's. The Association of Academic Physiatrists (AAP) was formed in 1967 by a small group of dedicated physiatric educators with Ernest W. Johnson, MD, considered the "founding father". The AAP is the only major PM&R organization that at the present uses "physiatrist" in its name. The primary purpose of the AAP is to promote methods of undergraduate and graduate teaching of the art and science of PM&R. From 1968 to 1992, the AAP grew to more than 1,000 members.

The AAP mission is concerned with issues such as support for academic departments, improving the quality of teaching programs and encouraging the development of physiatric research. Although many new physicians graduated from PM&R residency programs in the 1970's, the increase in the number of new physiatrists was far slower than the increased demand for physiatric services.

In 1974, the Commission on Rehabilitation Medicine, a group with representatives from the American Board of Physical Medicine and Rehabilitation, the American Academy of Physical Medicine and Rehabilitation and the Association of Academic Physiatrists, published a bulletin: Physical Medicine, Need, Supply and Demand, 1972-1987. These estimates predicted that only with significantly increased productivity of new physiatrists would the supply reach the lower limit of demand for 4000 physiatrists in 1990. The upper limit of demand could not be predicted because it was recognized that as physiatry became more available, there would be an increased demand for the rehabilitation of persons with disabilities who were "out of the circuit" and living in passive dependency.

In the 1980's, the recognition by the American public that medical rehabilitation decreased dependency and increased the quality of life for handicapped persons resulted in the development of many community rehabilitation centers and created a demand for many more physiatrists to direct these medical programs, which was in accord with the projections made by the Commission on PM&R in 1974. A severe shortage of physiatrists developed, and American medical students began to discover the field as a promising career. By 1982, the number of residents climbed to 500 and the positions were more competitive. The rate of training of young physiatrists did increase, but not up to the rate predicted as necessary to meet the lower limit of demand in 1990.

In 1994, the ABPMR reported 1313 residency positions were offered and 1277 (97 percent) of those positions were filled. American medical school graduates account for 84 percent of those residents. The Seventh Edition of the Residency Training Program Directory published in 1995 by the Association of Academic Physiatrists listed 79 accredited residency training programs.

As of 1994, the total number of Board Certified Physiatrists grew to 4642, with 2561 of those certified between 1984-94. The current decade promises continued growth in the number of physiatrists. As a result of so many newly graduated physiatrists entering the field, the average age of a physiatrist is now under 40 and still decreasing. Some areas of the country have an adequate supply of physiatrists, while other areas continue to have a shortage of rehabilitation services and/or physiatrists. As is true for other medical specialties, there is a geographic maldistribution of physiatrists and in certain geographic areas, no physiatric services are available. The greatest unmet need in physiatry, however, is the need to increase the number of academic physiatrists trained for research and teaching. PM&R Residency Programs continue to experience a shortage of academic talent to fill chairperson and faculty positions.

The next century promises many medical advancements and with them new challenges to maintain a high level of medical ethics and a high standard of medical care with the resources and services that are available. Advancements in medical technology will save more lives and therefore multiply the number of persons needing rehabilitation services. Society will continue to grapple with controversies and conflicts of policy and practice stemming from medical, social and economic issues that match selfishness, convenience and conspicuous consumption for some against the presence or absence of the quality of life available for others. The ensuing struggle promises to shake the foundations of the Hippocratic Oath. Quality of life throughout the time of survival, and the cost of each medical service in relation to the benefit to the quality and duration of life which it provides will be a central issue. Physiatrists will be challenged to stand firm in the battle to add quality of life to years and duration of years to that quality of life for all patients.

Special thanks to Physiatrists of Asian Indian Origin for Research (PAIR) for helping to sponsor this publication

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