Introduction to Physical Medicine and Rehabilitation (PMR)- 2023 1.pptx

What is the Specialty PMR or Physical Medicine and Rehabilitation or Physiatry or Rehabilitation medicine.

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 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

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&R 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

6. 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

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 seeds for an exciting new specialty that cared for the whole person, not just the disease

8. When did PM&R become recognized as a specialty? American Academy of Physical Medicine and Rehabilitation- 1938 American Board of PM&R (ABPM&R)- 1947- ‘‘official’’ medical specialties 1 st PMR Institute- 1955- AIIPMR, Mumbai 1 st PMR Department in Medical College- 1963, CMC, Vellore

9. 1 st 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

10. Why there is need 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 ( चिकित्सा ) – medical care including surgeries (शल्य चिकित्सा) Medication Non – Surgical & Surgical interventions

13. 2001 WHO- 1997

14. WHO Health Indicators- Mortality Morbidity Functioning

15. Almost a third 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 wit h 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 added to Life

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 the Process of Rehabilitation Disablement Re- ablement Resettlement Retraining Reconditioning Readjustment Treating Mentally Tampering Teaching Training Resource Burner Resource Earner

22. Is Rehabilitation is everyone’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 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 – 1 st 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

34. Patient population

35. Conditions treated… Neuromuscular disorders/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 related injuries/Sports injuries Vascular/Ischemic pain/Cancer pain Lymphedema Deformities/Amputations/after arthroplasty, fracture, surgery Cardiovascular/Pulmonary disease- MI etc Vertigo

37. 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.

38. 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

39. 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

40. 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

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 is like a Mall Collaborate with all, Rehabilitate all ( सबका साथ, सबका पुनर्वास )

43. 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

44. 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.

45. 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

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

47. 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 21 th 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

48. WHO Rehabilitation 2030 initiative “Call fo r action”(2017) - rehab for all and through all stages of life course 2 nd Rehabilitation 2030 meet- July 2019 3 rd Rehabilitation 2030 meet- July 2023

49. 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

50. 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)

51. Pros and cons of PMR Pros Diverse pt population High in demand High or at par salary Emergencies rarely Work life balance Evolving field with newer t/t options Cons Not always rewarding Time consuming and require active pt participation Lack of awareness about specialty Difficulty in explaining role to pt/physicians

52. 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

53. 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

54. Services provided by PMR at our Institute OPD services Pain management Neurorehabilitation Cancer rehabilitation Prosthetic and orthotic Disability evaluation

55. 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

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

57. Physical Medicine & Rehabilitation Live with dignity rather than live for long is the motto today Please collaborate Queries/Comments Thanks very much!