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
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
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
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&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
• 1st PMR Institute- 1955- AIIPMR, Mumbai
• 1st PMR Department in Medical College- 1963, CMC,
Vellore

9. • 1st 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 (चिचित्सा ) – medical
care including surgeries (शल्य चिचित्सा)
• 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 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 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
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

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 (सबिा साथ,
सबिा पुनर्ाास)

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

50. 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
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 Rehabilitation 2030 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 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

53. 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)

54. 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

55. • 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

56. Services provided by PMR 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 body is 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!