The document provides an overview of the history and concepts of physical medicine and rehabilitation (PM&R), also known as physiatry. It discusses how rehabilitation therapies have evolved over thousands of years across various cultures to treat injuries and functional limitations. The document also defines key terms used in rehabilitation such as impairment, disability, and handicap according to the World Health Organization's international classification system. It emphasizes that the overall goal of rehabilitation is to minimize disability and handicap so individuals can lead productive lives.

1. BY
DR MOHD SHOEB PT

2. • Physical medicine and rehabilitation (PM&R), or
physiatry, is a medical specialty focused on prevention,
diagnosis, rehabilitation, and therapy for patients who
experience functional limitations resulting from injury,
disease, or malformation.
• The history of Physical Medicine & Rehabilitation crosses
many cultures and geographic boundaries.
• The word “therapy” comes from the ancient Hebrew
word refua which means (healing). Rehabilitation therapy,
an essential component of the PM&R treatment
approach, has a long history.

3. • Thousands of years ago the ancient Chinese employed Cong
Fu, a movement therapy, to relieve pain.
• The Roman physician Galen described interventions to
rehabilitate military injuries in the second century.
• The Greek physician Herodicus described an elaborate
system of gymnastic exercises for the prevention and
treatment of disease in the fifth century.
• During the Middle Ages, the philosopher-physician
Maimonides emphasized principles of healthy exercise
habits, as well as diet, as preventive medicine in Medical
Aphorisms, published between 1187-1190.

4. • In the eighteenth century, Niels Stenson explored the
biomechanics of human motion and Joseph Clement
Tissot’s 1780 Medical and Surgical Gymnastics promoted
the value of movement as an alternative to bed rest for
patients recovering from surgery, facing neurological
conditions, and recuperating after strokes.
• In the nineteenth century, the concept of neuromuscular
re-education was proposed by Fulgence Raymond
(1844-1910).

5. • According to various estimate about 5-10 percent of the
world population is affected by one or more disabiliies.
• In our country the national sample survey estimated nearly
about two percent of population, who experience difficulty in
walking or suffer from visual, hearing and mental
impairement.

6. • The incidence of disabiility is reported to be just over two
percent in rural areas and 1.6 percent in urban areas.
• In modern society acting independently is of supreme
importance – be it in the area of personal care, day to
day activities, cooking, studies or anything that requires
human persuit. It is these areas that a disabled person
suffer most; socially, economically, psychologically and
emotionally.

7. • Due to physical or medical handicap a disabled person
cannot act independently in many spheres of life and
hence faces many problems in his social adjustment.
• His incapacity generates emotional problems like apathy,
self pity and he tends to isolate himself from society.
• It is the collective responsibility of the abled body to
rehabilitate these handicapped individuals.
• The role of rehabilitation is to minimize disability and
handicap, and help a handicapped person lead a useful
life within his limitation.
• In other words to make a disabled person into a
“differently abled” person.

8. • Rehabilitation is the utilization of the existing capacities of
the handicapped person, by the combined and co-
ordinated use of medical, social, educational and
vocational measures to the optimum level of his
functional ability.
• It makes his life more meaningful, more productive and
therefore worthwhile living.
• It is the third phase of medical care; after preventive and
curative phase.

9. • Rehabilitation must be started at the earliest possible
time in order to ensure the best results. It is administered
in conjunction with specific medical and surgical
treatment of disease.
• Rehabilitation may be medical or sociovocational.
• Medical rehabilitation is the utilization of medical and
paramedical skills to help treat the patient.
• The role of medical rehabilitation is to limit disability.

10. • Socio-vocational rehabilitation follows, or sometimes is
delivered simultaneously along with medical
rehabilitation.
• It is a team effort, which aims at providing the disabled a
vocation and reducing his handicap and empower the
person not just economically but in a more basic and
meaningful sense.
• It makes a person stand on his own legs.
• It does not bind him to a job, it sets him free.

11. • The word epidemiology is derived from greek word
epidemios; meaning “among the people”.
• In the early 20th century Stallybross defined epidemiology
as “the science which considers infectious disease – their
course, propagation and prevention”.
• The fundamental purpose of epidemiology is the
prevention and eradication of disease through a better
understanding of its causation.

12. • If complete prevention or total eradication is not possible,
containment is the second choice.
• W H Welch defined epidemiology as “the study of the
natural history of disease”.
• Lillienfeld described it as the study of “the distribution of a
disease or condition in a population and of the factors
that influence this distribution”.

13. • The definition of health put out by the WHO as follows :
“a state of complete physical, mental and social wellbeing
and not merely the absence of disease or infirmity”.
• The fundamental goals of medical science is not to
produce an immortal being but to maintain him in
optimum health as long as possible, ideally until death.
• The fundamental goal of rehabilitation is to “ add life to
years, not years to life”.

14. The world health organisation’s international classification
of impairement, disability and handicap (ICIDH 1980)
defines these terms as follows :

15. Any loss or abnormality of psychological, physiological or
anatomical structure or function, e.g. loss of finger, loss of
conduction of impulses in the heart, or loss of certain
chemicals in the brain leading to parkinsonism.
Not all impairement lead to disability; for example the loss
of the pinna of the ear would not lead to loss of hearing but
merely result in a cosmetic deficiency.

16. Any restriction or lack of ability to perform an activity in the
manner or within the range considered normal for a human
being resulting from an impairement, e.g. difficulty in
walking after lower limb amputation. It must be noted here
that strenous or rarely indulged in feats like rock climbing or
wind surfing are not included in activities to be considered
for disability. To be considered disabled a person should
not be able to perform day to day activities considered
normal for his age, sex or physique.

17. • Disabilities that are direct consequences of a disease or
condition are called primary disability. Paraplegia
following spinal cord injury, inability to walk following hip
fracture are example of primary disability.
• On the other hand, disabilities that did not exist at the
onset of the primary disability but develop subsequently
are called secondary disability. Secondary disability is
indirectly related to the disease or condition that is
responsible for the primary disability. Example are joint
contracture in poliomyelitis, subluxation of shoulder joint
in hemiplegia and pressure sores in paraplegia

18. • Elderly people and those who have had a primary
disability for an extended period are most susceptible to
a secondary disability.
• Further, when pain or spasticity accompanies the disease
or condition causing the primary disability, the prevalence
of secondary disability increases.
• Negligence or ignorance on the part of paramedical
personnel or family members results in placing the
person with disability in positions that promote secondary
disability.

19. • Any attempts to halt a person‘s slide down the slope of
the health status scale is termed as prevention.
• And any attempt to push it up towards the peak, i.e.
optimum health is called therapeutic health care.
• This total spectrum is classified into three levels of
prevention by WORLD HEALTH ORGANISATION.
• Primary prevention
• Secondary prevention
• Tertiary prevention

20. • Primary prevention : it is explained as a measure
taken prior to the onset of any disease. E.g.
immunization against childhood infection or
chlorination of drinking water. It is designed to
promote general health and improve the quality
of life. This is the first phase of medicine, i.e.
preventive medicine.
• Secondary prevention : it is explained as a
measure taken to arrest the development of a
disease while it is still in the early asymptomatic
stage of the disease. It involves early diagnosis
and immediate treatment. E.g. ergonomic
intervention to prevent clinical symptoms in a
patient with spondylosis. This is the second
phase or curative aspect of medicine

21. • Tertiary prevention :- it is explained as a measure taken
to minimize the consequences of a disease or injury once
it has become clinically manifested, e.g. prevention of
pressure sores by turning the patient over regularly. This
is the third phase or rehabilitation medicine.

22. • Prevention of disability does not start only at birth, at the
onset of disease or after a primary disability occurs.
• Sometimes it may be done even before the child is born,
by anticipating disability due to genetic defects and can
be prevented by means of genetic counselling.
• Current population growth, particularly aged, naturally
would result in a sharp rise in people with disability in the
near future. Because of tremendous strides that medical
science taken, the number of patients surviving a
potentially fatal condition like brain injury is much more.
• Therefore it follows that with a fall in mortality level there
is a rise in morbidity level.

23. • Rehabilitation deals with morbidity; it deals with quality of
life.
• Unless more effective method of prevention are
developed to protect the population from primary
disability in the future, the newly detected person with
disability will face a critical situation.
• The shortage of health manpower will cause them to be
without benefit of rehabilitation services and
superimposed secondary disabilities will render them
totally dependent on society for everything.

24. • This will result not only in personal tragedy, but will create
infinite economical problems for families, community and
nation.
• The medical community must act to prevent epidemics of
disability in much the same manner that we are now able
to prevent communicable disease.

25. • All specialities in therapeutic medicine require early and
precise diagnosis in order to institute the most effective
treatment.
• The same logic applies to rehabilitation and the disabled
should be given early evaluation and intensive treatment
to prevent permanent disability.
• The total person physically, emotionally, vocationally and
socially must be considered in the diagnosis.
• The Patient is evaluated as a human being and not as a
case.

26. • Diagnosis of disability may be expressed either in terms
of the amount of disability or in terms of the amount of
remaining function.
• The expression of disability evaluation or functional
diagnosis varies according to the method used.

27. The functional diagnosis should be :
• Simple enough, so that rapid evaluation is possible.
• Reproduced, so that constancy may be maintained.
• Objective, using measurable factors so that the results
are statistically more reliable.
• Descriptive, so that the actual situation is accurately
reflected.
• Comprehensive, so that the diagnosis is complete and
specifically utilized in the direct care of the patient.

28. An example would be in the diagnosis of cerebral palsy.
While the diagnosis of cerebral palsy, conveys very little or
no meaning, it would be ideal to functionally diagnose a
child so that following question are answered :
• How many limbs are affected – i.e. diplegic or
quadriplegic ?
• Type of CP – spastic or some other ?
• Mental abnormality – present ?
• Communication impairement – present ?
• Hearing and visual impairement – present ?

29. • A disadvantage for a given individual in his or her social
context resulting from an impairement or a disability that
limits or prevent the fulfillment of a role that is normal
(depending on age, sex, social and cultural factors) for
that individual.
• Many socio-economic factors like family background,
skills achieved and financial stability come into play while
determining handicap.

30. • The WHO has identified six handicaps :
1. Locomotor (which forms 60 % of all handicaps)
2. Visual
3. Hearing and speech
4. Cardiopulmonary
5. Intellectually challenged
6. Emotionally disturbed
• The person with locomotor disability are the largest in
number (60-70%) followed by those with hearing and
speech and visual impairement.

31. • Many patient suffer from multiple handicaps, which
include combinations of any of the six given above.
• Above 12 % of individuals with disability suffer from more
than one type of disability.
• For example, a child with cerebral palsy, would probably
have, in addition to the delayed milestones and motor
problem, damage of the part of the brain responsible for
sight and hearing.

32. Such handicapped individuals have problems with :
• Orientation
• Physical independence
• Mobility
• Occupational integration
• Social integration and
• Economic self sufficiency
No person is said to be fully rehabilitated unless all the
above criteria have been looked into.