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Introduction to Physical Medicine and Rehabilitation (PMR)- 2023 1.pptx
- 1. Introduction to PMR Dr.Rambeer Ghuleliya, Physiatrist M.B.B.S., DNB (PMR), FIPM (AIIMS, New Delhi), EULAR (Certified MSK USG), CCEPC (IAPC, AIIMS, New Delhi) Assistant Professor and in-charge Dept. of PMR Himalayan Institute of Medical Sciences Jolly Grant, Dehradun
- 2. Why CME onPMR? • Identity crisis – among medical professionals – among pts and in the society • Inadequate representation in MBBS Curriculum Curriculum • Lack of PMR faculty/specialist • Lack of support • Under-resourced • Under-developed • Under-advertised • Under-utilized • Referral systems are still not in place
- 3. Physical Medicine &Rehabilitation/ Physical & Rehabilitation Medicine / Rehabilitation Medicine / Physiatry
- 4. Contents • History • Definition •Rehabilitation team • Patient population • Treatment modalities • Scope of PMR • Services
- 5. How did PM&Rget started? • Around early of 20th century, a major shift in thinking among health care providers began to take place • Holistic, Comprehensive, team-oriented PWDs • This powerful philosophy sparked a burgeoning interest among health care providers to treat PWDs
- 6. • Dr. FrankKrusen- Founder of Physical Medicine • Coined the term Physiatrist • 1928- first dep. Of Physical medicine at temple temple hospital • 1936- first residency training program at Mayo Mayo Clinic – first comprehensive rehabilitation textbook
- 7. • 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 the seeds for an exciting new specialty that cared for cared for the whole person, not just the disease
- 8. When did PM&Rbecome recognized as a specialty? • American Academy of Physical Medicine and Rehabilitation- 1938 • American Board of PM&R (ABPM&R)- 1947- ‘‘official’’ medical specialties • 1st PMR Institute- 1955- AIIPMR, Mumbai • 1st PMR Department in Medical College- 1963, CMC, Vellore
- 9. • 1st MDCourse- 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
- 10. Why there isneed of PMR • Life expectancy d/t increased quality of medical care • Elderly population Chronic disease, non- Communicable disease Sedentary lifestyle
- 11. 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.
- 12. Physical Medicine &Rehabilitation Medicine • That is chikitsa (चिचित्सा ) – medical care including surgeries (शल्य चिचित्सा) • Medication • Non – Surgical & Surgical interventions
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- 15. • Almost athird of the world’s population lives with limitations in functioning • Rehabilitation is the key health strategy for optimizing functioning
- 16. 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 that’s possible in consideration of medical condition vis-à-vis environmental factors
- 17. 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
- 18. 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 – that’s Adding Life to Years, while in most of other branches of Medicine, Years are
- 19. 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
- 20. 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
- 21. Steps in theProcess of Rehabilitation • Disablement Re-ablement Resettlement • Retraining Reconditioning Readjustment • Treating Mentally Tampering Teaching Training • Resource Burner Resource Earner
- 22. Is Rehabilitation iseveryone’s business??? NO • Only a trained and skilled person do proper and better rehab • Rehab is not a single man’s business • Rehab is a team work
- 23. Physical Medicine &Rehabilitation Rehabilitation Team • Physiatrist – physician specialist in PMR Team Leader, overall Responsible & Accountable • Physical Therapist • Occupational Therapist • Prosthetist & Orthotist • Speech Language pathologist • Clinical/Rehabilitation Psychologist • Medical/Rehabilitation Social Worker
- 24. Physical Medicine &Rehabilitation Rehabilitation Team contd. • Physiatrist – physician specialist in PMR • Vocational Councilor • Remedial Gymnast • Play/Recreational Therapist • Rehabilitation Nurse
- 25. 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
- 26. 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.
- 27. Physical Medicine &Rehabilitation Rehabilitation Team – the Most Important Member The Patient & his/her Family
- 28. Physical Medicine &Rehabilitation Rehabilitation Team
- 29. Physical Medicine &Rehabilitation Defined: “Rehabilitation Physicians are nerve, muscles and bone experts who treat injuries or illnesses that affect how you you move.” American Academy of PMR
- 30. Physical Medicine &Rehabilitation Rehabilitation Team Physiatrist A physician who specializes, that’s MD/DNB, in the field of Physical Medicine and Rehabilitation Psychiatrist vs Psychologist Anesthesiologist vs Anesthetist Physiatrist vs Physiotherapist
- 31. Physical Medicine &Rehabilitation Rehabilitation Team Physiatrist’s Role • Clinical • Managerial • Academics & Research • Leadership
- 32. Physical Medicine &Rehabilitation Rehabilitation Team Physiatrist’s 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)
- 33. 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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- 35. Conditions treated… • Neuromusculardisorders/injuries- –Radiculopathy/Neuropathy/plexus/nerve injury/Bell’s palsy –SCI, TBI, MS, MD, MND etc. –Developmental delays, CP, MMC etc – Musculoskeletal disorders/injuries- –bone/muscles/joints/nerve etc pain –Arthritis/rheumatological disorders
- 36. • Work relatedinjuries/Sports injuries • Vascular/Ischemic pain/Cancer pain • Lymphedema • Deformities/Amputations/after arthroplasty, fracture, surgery • Cardiovascular/Pulmonary disease- MI etc • Vertigo
- 37. What Diagnostic toolsare 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.
- 38. Treatments • Medicine- NSAIDS/Opioids Neuropathic Painmedications- 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
- 39. Treatments • Minimally InvasivePain 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
- 40. • Lumbar Epiduralsteroid/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
- 41. 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
- 42. PMR department islike a Mall Collaborate with all, Rehabilitate all (सबिा साथ, सबिा पुनर्ाास)
- 43. Referring Patients toPMR?? • Competitor to Collaborator • Type of referral we are getting are like- • Referred to PMR dept. for Physiotherapy • exercises or • Dept of Physiotherapy for PMR
- 44. • But referralshould be like- • Pt Referred to PMR Dept for • Stroke /neurological rehabilitation etc • Pain management • further management/opinion/opinion on rehabilitation management etc.
- 45. • Please refrainfrom 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
- 46. 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
- 50. Is Physiatry arecognized 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
- 51. • WHO Rehabilitation2030 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
- 52. Specialty/Subspecialty courses inIndia • 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
- 53. Abroad Subspecialty/Fellowships • Americanboard 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)
- 54. My Vision andMission • 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
- 55. • Establishing astate 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
- 56. Services provided byPMR at our Institute • OPD services • Pain management • Neurorehabilitation • Cancer rehabilitation • Prosthetic and orthotic • Disability evaluation
- 57. 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
- 58. • Each bodyis different “Therefore each rehabilitation must be different” • Standard and universal referral for rehabilitation is probably the essential policy to be implemented
- 59. Physical Medicine &Rehabilitation Live with dignity rather than live for long is the motto today Please collaborate Queries/Comments Thanks very much!
Editor's Notes
- #2 Pts, residents and other physicians often struggle with our identity. Which result in their poor empathy towards disabled population.
- #3 Lack of PMR faculty in most medical colleges may turn out to be a hindrance in implementing this curriculum. Due to Inadequate funding/resources this specialty is underdeveloped. Lack of prioritization of rehabilitation services. Under utilization and delayed referral to rehab physician will leads to under treatment and mismanagement of disabled patients
- #4 So I can say that Medical illiteracy rate is very high among medical professionals about this specialty. This prompted me that why not should I present this topic as my first lecture in this meet
- #6 This powerful philosophy sparked great interest among…… word “holistic” simply means addressing the whole person. This includes a person's physical, emotional, mental, social, spiritual, and financial health. Social determinants of health such as poverty, unequal access to health care, lack of education, stigma, and racism
- #7 year 1936 was a banner year for physiatry. Improvements in acute medical care (e.g., penicillin) during World War II saved the lives of many soldiers with disabilities who returned home in dire need of rehabilitative care. Krusen was a surgeon.
- #8 AIIMS New Delhi PMR department was developed in his guidance. Rusk was internal medicine specialist and serve USA Air force. Dr. Rusk's passionate concern was, as he put it in a 1982 interview, ''what happens to severely disabled people after the stitches are out and the fever is down.'' Then, he said, the crucial task was to ''take them back into the best lives they can live with what they have left.''Howard Rusk, 88, Dies; Medical Pioneer Retraining, reconditioning and psychological readjustment
- #9 ABPM&R was approved in 1947 by the Advisory Board of Medical Specialties as one of twenty-four
- #11 India is the most populus country in the world. Demand for holistic care is growing.
- #12 So we are treating physical with physical activity and physical and chemical agents. Physical medicine: Diagnosis and treatment of neuromusculoskeletal disorders with the use of medications, modalities, procedures, and exercise
- #13 What concepts are reflected in the name physical medicine and rehabilitation? It is not enough to know why people die, and what illnesses they have. Perhaps what matters even more is to know how they live… to understand how health conditions play out in their day‑to‑day life.”
- #14 Before going to the definition of Rehabilitation first we have to understand concept of what is impairment, activity and participation
- #15 Functioning, WHO’s third health indicator alongside mortality and morbidity, is gaining importance in public health and health policy planning. Functioning is the outcome of the interaction between a person with a health condition, and their environment. Rehabilitation interventions target people’s health conditions and their environment
- #16 Living a healthy life includes being independent, able to fulfill meaningful life roles, and participating in work and education. It is about optimal functioning in everyday life, including the ability to think, see, hear, move, communicate, work and create relationships
- #17 Vis-à-vis- in relation to; with regard to.
- #18 Can rehab always improve the condition???
- #19 pts who experience limitations in function resulting from any disease process, injury, or symptom
- #20 This specialty provides….
- #22 By utilizing medications, injections, physical modalities, exercise, and education individualized to the pt’s needs. PM&R specialists provide care for pts with neuromusculoskeletal disorders who have acute and chronic disabilities requiring rehabilitation services. Teaching the pts to take care of themselves and train them for a new job
- #30 PMR Practitioners known by various name like Physiatrist, Rehabilitation Physicians, PMR Specialist
- #31 Anesthesiologist is a physician who specializes in anesthesiology and administer anesthesia. Anesthetist- refer to a nurse anesthetist or a medical specialist who administers anesthetics (other than the doctor), provide basic care before, after and during procedures
- #33 Makes the short term and long term rehab goals, implement them and monitor these goals through
- #35 Diverse patient population and disparity in the PMR Practice. So, it can be argued that every pt require some form of rehab while discharging from hospital
- #36 We are the doctors of nerves, muscles and bones/joints
- #38 differs from a medical or surgical (med/surg) H&P because of its focus on functional status, social supports, disposition, and goals. The physiatric H&P also identifies those systems not affected that might be used for compensation
- #39 toe walking problems or other gait abnormalities like in-toeing or out-toeing, spasticity
- #40 MIPSI- Minimally Invasive Pain and Spine interventions
- #42 The process of rehabilitation is not restricted to a hospital. Recommending appropriate home modifications to provide a user friendly environment for the pt is also a part of the lengthy but satisfying process of comprehensively rehabilitating a disabled individual
- #43 All rehabilitation services under one roof under the supervision of single physician.so that disabled patient can enjoy all facets of rehabilitation under the responsibility of one single department, where otherwise his or her care would be fragmented around many different hospital departments and non-hospital services
- #44 With relatively low number of PM&R specialists and the diversity of our practice there can often be confusion regarding how pts and physicians refer to us. Because of the overlap of this branch, there may be competition from other specialties and reluctance to refer patients to the PMR
- #45 There is speciality beyond exercises. PMR physicians are also looked down by other branches and recognized as an underrated field. Say go to the PMR department, they will assess you and give further rehab management and continue my medication and follow-up with me
- #46 .
- #49 Sudha Chandran-classical dancer, Arunima Sinha-1st female amputee to climb Mount Everest, Avani Lakhera- Gold medal Tokyo olympic
- #51 physiatry has achieved an unprecedented high level of popularity throughout the world. Physician compensation and satisfaction data are not available in India. PMR specialists was placed at the 17th place amongst more than 30 clinical specialties. 85% of the PM and R doctors mentioned that they would like to choose PM and R as their career option again if given an opportunity.
- #52 because of the aging population internationally and the focus on functional restoration
- #53 PM and R is a varied and vast subject and requires subspecialty training. This will not only improve patient care but also boost interest in young aspirants.
- #55 Production of PM and R specialists is far less compared to the demand. Future of this branch is very bright. Almost fixed working hour so Can spare time for family/hobbies/recreational activities
- #56 To prevent unnecessary suffering PWDs, To restore the dignity of PWDs
- #59 PMR is not linked to one specific organ or body system, rather our field takes a global view of how a dz or impairment affects a pt’s function. Physiatrists seldom work alone:- part of an interdisciplinary team. Physiatrists make possible the synergistic efforts that pt and rehabilitation team, by working together, can use to maximize each other’s potential
- #60 Hospitals social responsibility should not be restricted to medical services only
- #61 So we can provide better outcome for the patients. Lack of medical insurance. Although there are many challenges and problems, PMR specialty is growing slowly day–by‑day in this country