History of Physiatry
Past, Present, Future
Andrew L Sherman, MD, MS
Associate Professor
Department of Rehabilitation Medicine
University of Miami Miller School of
Medicine
Disclosure statement

No conflicts to declare relevant to this talk
History of Physiatry

Since the beginning of time,
people have used physical
means for treatment of illness
and injury.


Water, heat, cold, massage, light,
exercise and electricity
Written accounts of physical
techniques for healing can be
traced as far back as the writings
of Hippocrates in 400 B.C
AMSA statement

“For medical students with little exposure to
the field, physiatry is just a game-winning
Scrabble word. In fact, it’s one of the fastest
growing and diverse medical specialties of
the 21st century”
AMSA statement

“One aspect of the specialty that
practitioners love is its variety. Today,
physiatrists treat an extensive range of
conditions, including arthritis, stroke,
neurological disorders, musculoskeletal
conditions, traumatic injuries—including
brain and spinal cord injuries—chronic pain,
work and sports injuries, and chronic
diseases.”
AMSA statement

“Those having some familiarity with the
specialty may write it off as simply advanced
physical therapy. In fact, we are the team
captains, coordinating occupational
therapists, physical therapists, social
workers, psychologists and everyone else
involved in the care of a patient in rehab.
When a patient has problems urinating and
his therapist doesn’t know what to do, we
are the go-to guys.”
History of Physiatry


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.
History of Physiatry


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.
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
History of Physiatry – 1930’s



Frank Krusen, MD, established
the Physical Medicine Program
at the Mayo Clinic in 1936 and
initiated the first three-year
residency in Physical Medicine
He is recognized as the "Father
of Physical Medicine.”
Krusen and Coulter established
the American Academy of
PM&R in 1938
History of Physiatry – 1940’s


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.
History of Physiatry – 1940’s

Howard Rusk, MD:
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 throughout the military
services.

1940’s

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
History of Physiatry – 1940’s

By 1946, medical residencies or fellowships
in PM&R had been established at 25
hospitals as a result of funding from the
Baruch Committee.

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."

85 positions for residents or fellows in
Physical Medicine and Rehabilitation
Certification



Occurred in 1947
At that time there were 91 physiatrists
practicing in the USA
by 1975, there were 1,164. In only ten years,
that number doubled, reaching 2,377 in 1985.
It more than doubled again in the next
decade. In 1995, there were nearly 5,000
board-certified physiatrists. Now there are
nearly 10,000
History of Physiatry – 1950’s


WWII over – Korean conflict
looming, cold war occuring
Polio epidemic – 58,000 cases

Created an increased demand for
physicians trained in a
comprehensive approach to
rehabilitation, including the
physical, mental, emotional,
vocational and social aspects.
History of Physiatry – 1950’s


Mary Switzer, director of the Office of
Vocational Rehabilitation (OVR) brought
about the economic opportunity for the
great expansion of PM&R.
She was totally committed to the
improvement of the quality of life for people
with disabilities. She became convinced
PM&R directed by physiatrists could
provide the greatest benefits for people with
disabilities.
History of Physiatry – 1950’s


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.
During her administration, the concept of regional
rehabilitation research and training centers was
adopted and funded by Congress.
History of Physiatry – 1950’s



The 1950's brought an increase in the
numbers of rehabilitation professionals
More cohesive union between the fields
of Physical Medicine, Rehabilitation
Medicine, and Electromyography.
(EMG) was desired and obtained.
Electromyography (EMG) was
introduced into Physiatry as a
profoundly important method for the
evaluation of problems of the
neuromuscular system, which
constitutes a major part of the work of
the physiatrist.
History of Physiatry – 1960’s


Clinical and educational opportunities
multiplied
Interest in physiatric research multiplied
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 mission is concerned with issues such
as support for academic departments,
improving the quality of teaching programs and
encouraging the development of physiatric
research

History of Physiatry – 1960’s Florida

Organizational meeting of the group that
would become the Florida Society of
Physical Medicine and Rehabilitation in
Miami. Seven physiatrists attended: Drs.
Pedro Arroyo, Norman Borkin, George
Cunningham (Palm Beach), William
Fleming, Arthur Pasach ( Tampa), Stansky
(or Nixon) (Bay Pines VA) and Bruce Sutton
(Coral Gables VA).
History of Physiatry – 1960’s Florida

Dr. Pasach remembers that Dr. Fleming put
together the first set of By-Laws, and that
they met around a poker table and
adjourned after the meeting for BBQ ribs
and corn at Shorty’s. Dr. Pasach, who had
come to Tampa in 1958, was elected the first
President, Dr Cunningham the Secretary.
Meetings were very collegial, consisting of a
scientific case reports and discussion of
mutual problems.
History of Physiatry – 1960’s Florida

Dr Pedro Arroyo was elected President. He had arrived in
Miami in 1959 as the Medical Director of the Rehabilitation
Center for Crippled Children and Adults ( Easter Seal) and
found the local reputation of PMR to be very poor, as
rehabilitation was seen to be the province of Orthopedics.
Serving as consultant to the VA and the School of
Medicine, he continued to pioneer the specialty, writing for
the Journal of the Florida Medical Association and securing
a grant from Vocational Rehabilitation for a yearly course
in Principles of Rehabilitation for non-physiatrists.
History of Physiatry – 1970’s


In 1974, the Commission on Rehabilitation
Medicine published a bulletin: Physical
Medicine, Need, Supply and Demand, 19721987
Severe shortage of physiatrists predicted


Joel Delisa, MD – Archives of PMR, Kessler
Expansion of residency positions begins
History of Physiatry – 1970’s Florida

New Constitution and By-Laws adopted.
The qualifications for Active membership
now specified board certification. Associate
membership granted to board-eligible
candidates and Affiliate membership to
residents in training.
History of Physiatry – 1980’s



In the 1980's, there is recognition by the American
public that medical rehabilitation decreased
dependency and increased the quality of life for
handicapped persons.
PPS was invented – Rehabilitation beds exempt
Resulted in the development of many community
rehabilitation centers and created a demand for
many more physiatrists to direct these medical
programs.
 Indeed a shortage of physiatrists materialized
 Increased residency slots, increased physiatrists
History of Physiatry – 1980’s


Studies by the Saul Brothers and Weber
indicated that non-operative care of lower
back problems and herniated discs should
be largely non-surgical
Use of rehabilitation programs, medications,
and spinal injections opened new
opportunities for physiatrists interested in
sports and musculoskeletal medicine.
History of Physiatry – 1980’s Florida



During Dr. Pasach¹s term as President, the
Neurologic Injury Compensation Association
(NICA) was enacted, and a significant focus of
Society attention was the push toward tort reform.
1988: Officers installed: President Dr Dorothea
Glass, VP Dr David Lipkin, Secretary-Treasurer Dr
Enrique Monasterio
May, annual meeting Safety Harbor 15 members
attended. Society has 37 members. Dues increased
to $50 (From 25$).
History of Physiatry – 1990’s



In 1994, the American Board of PM&R
reported 1313 residency positions were
offered and 1277 (97 percent) of those
positions were filled – 85% by American
graduates
Total number of Board Certified Physiatrists
grew to 4642 (1994), with 2561 of those
certified between 1984-94
The average age of a physiatrist is now
under 40 and still decreasing
1996 workforce study


At the 1994-95 level of residency capacity, the
supply of physiatrists would nearly double in
20 years. The specialty would be challenged
to absorb this growth in supply as market
conditions changed in the managed care
environment.
The South appears to be the region with
greatest growth potential for physiatrists,
while the Northeast and states adjoining the
Great Lakes are areas that are more likely to
have excess numbers of physiatrists.
P F Hogan, A Dobson, B Haynie, J A DeLisa, B Gans, M Grabois, M M LaBan, J L
Melvin, N E WalshPhysical medicine and rehabilitation workforce study: the
supply of and demand for physiatristsArchives of physical medicine and
rehabilitation. 02/1996; 77(1):95-9.
History of Physiatry – 1990’s




Seizmic shift in PM&R
The MSK area is growing – a few becoming
highly procedural – to some harsh criticism
from peers.
Inpatient programs on west coast shrinking
- Feeling inpatient rehab = neurorehab
Subacute programs growing – (grwothe
temporarily slowed by reduction in SAR
reimbursement in 1997)
History of Physiatry – 1990’s Florida





October incorporated as 501 (c) (6) non-profit corporation
(business league professional association)
Concerns of the Society include proposed P.T. practice act
which permitted treatment without physician prescription
Of 147 physiatrists in Florida, 92 are FSPMR members
Society agrees to contract with Executive Director (Lorry
Davis)
Education Committee reports 1) One month rotation at
Mayo Clinic Jacksonville (Thorsteinsson) 2) Site visit for
Miami program scheduled. 9Ultimately not funded due to
hurricane Andrew)
History of Physiatry – 1990’s Florida



Other problem – Medicare not paying!
February FSPMR invited to participate in
CPAC ( Carrier Physician Advisory Council)
for establishing Medicare B benefits. (Drs
Villalobos, Vaughen)
As AAPMR Liaison Councilor Dr Mitch
Freed spearheads FSPMR member
assignments to discuss basic benefit
packages with members of Florida HouseSenate Healthcare Committee
History of Physiatry – 1990’s Florida


May 31 Meeting Bal Harbour with FMA. 121
members. Program Practicing PMR in the
Subacute Setting including definition,
accreditation, contracting and use of
physician-extenders
Reports: Exec. Dir. Davis presented
FSPMR¹s WC Gatekeeper initiative to the
Council of State PMR Presidents.
History of Physiatry – 1990’s Florida


FSPMR votes to form PLAC (Physiatric
Legislative Action Committee) to establish
lobbying activity through a Trust. Drs.
Freed, Haddock, Imfeld, Hunter explore
locating lobbyist (Staver Group) contracted
at $ 26,500/yr. Membership assessment is
initiated.
Only physiatrists to review cases involving
PMR practice
History of Physiatry – 2000’s




The landscape changed
Explosive growth has
continued – most so in the
areas of pain medicine,
sports medicine, disability
medicine, medical legal
work.
“Interventional physiatrist”
Inpatient rehab is under fire
from CMS 13
CMS 13
Medicare states that 75% of an
inpatient rehab unit must be made up
of patients with one of 13 diagnosis
 Overall goal from Medicare is to reduce
inpatient rehabilitation costs – divert
patients with primarily medical and
simple joint replacement diagnoses to
less intensive care

CMS 13



For the individual physiatrist,
this will result in increased
requirements to justify the
need for intensive inpatient
rehabilitation services to
outside surveyors
Increased education of nonrehab physicians and allied
health personnel
Ultimately increased
utilization of SNF’s
Pain Management






4th vital sign
Demand increasing
Many specialties participating
New requirements from
fellowships mandate
multidisciplinary training
Interventional option
Subspecialty boards
Research

REHABILITATION MEDICINE SUMMIT -Building
Research Capacity – 2005


Rehabilitation Medicine Scientist Training Program
(RMSTP)


http://www.physiatry.org/research/k12info.html
Research Enrichment Program for Physiatrists. Missouri
Arthritis Rehabilitation Research and Training Center


http://www.foundationforpmr.org/summit/bibliography.html
http://www.muhealth.org/~rep/
Department of Veterans Affairs Rehabilitation
Research & Development Service

http://www1.va.gov/resdev/

http://www1.va.gov/resdev/about/rehab.cfm
History of Physiatry – 2000’s



Despite the changes, the need for a physician
to provide holistic medical care to patients
with disabilities should continue and
increase.
Advances in technology should fuel further
demand for physiatrist’s services.
Continuing research will lead to advances
that will ultimately benefit our patients and
help physiatrists provide state of the art care.
History of Physiatry – 2000’s




2005 – Start of first residency at University of
Central FL/Tampa VAHS – Jeff Scott, MD
program director
2005 – Start of SCI fellowships at TAMPA
VA and JMH/Miami VA/Univ of Miami
2006 Start of PMR residency at
JMH/University of Miami Miller School of
Medicine – Andrew Sherman, MD Program
director
Now up to 18 residents – 19 graduates so far.
JMH Rehabilitation Residency
Mission :
To provide a each resident with the
opportunity to achieve competence in
ALL aspects of PM&R by facilitating a
positive educational and work
environment that allows for an open
exchange of ideas, so that upon
graduation, each resident can function
independently as an excellent medical
provider in any setting – academic or
private practice - with the highest
degree of confidence and proficiency.
Results



19 graduates
2 took jobs as academic attending –
inpatient/outpatient/EMG
3 went directly onto private practice
1 impatient/consultation
 1 Joined a group - inpatient/outpatient/EMG
 1 in solo practice outpatient/EMG/accupuncture

Results

14 went for fellowships (about 2/3)
2 SCI
 12 MSK/Sports/Spine/Pain
 1 SCI fellow went then for pain fellowship
 13/19 – 70%

New Decade 2011 and beyond


Pendulum swinging back for inpatient rehab
– improvements lead to opportunities.
Outpatient landscape changing –
Challenges from insurance limits on procedures
 New opportunities from

Biologics
 MSK ultrasound
 Stimulation
 Alternative treatments

Questions?