NOTE: This Message was originally addressed to Tom Mckeever
      from Lewhite@usa.pipeline.com and was forwarded to you by Tom Mckeever
                           --------------------
From: lewhite@usa.pipeline.com (Larry)
To: Tom Mckeeever 
Date: Tue, 3 Sep 1996 20:01:55 GMT
Subject: WHAT ARE PHYSIATRISTS (pronounced fiss-ee-at-trists)
 
Hi Tom; 
 
Here is the information you requested. 
 
Larry White  lewhite@usa.pipeline.com 
 
WHAT ARE PHYSIATRISTS (pronounced fiss-ee-at-trists) 
 
Physiatrists are physicians who specialize in physical medicine and 
rehabilitation, a medical specialty that deals with the evaluation and 
treatment of patients whose functional abilities have been impaired. 
The disabilities and impairments may result from injuries or diseases 
such as stroke, neuromuscular disorders, musculoskeletal disorders, 
cardiopulmonary diseases, arthritis, peripheral vascular disease, 
cerebral palsy and others. The physiatrist can help to improve a 
person's functional capabilities by medical treatment and organizing 
and integrating a program of rehabilitation therapy such as physical, 
occupational, and speech therapies, psychological, social nursing, 
prosthetic, orthotic, engineering and vocational services. 
 
THE HISTORY OF PHYSIATRY 
 
                                                  AN OVERVIEW 
 
Physical means of healing have been practiced since prehistoric 
times, but Physiatry did not become recognized as a separate 
medical specialty until 1947. Most widely known as the field of 
Physical Medicine and Rehabilitation, the medical specialty of 
modern-day Physiatry comprises the related disciplines of Physical 
Medicine, Rehabilitation Medicine and Electromyography. 
 
The term Physiatry derives from the Greek words physikos (physical) 
and iatreia (art of healing).  A Physiatrist is a physician who creatively 
employs physical agents as well as other medical therapeutics to 
help in the healing and rehabilitation of a patient. Treatment involves 
the whole person and addresses the physical, emotional and social 
needs that must be satisfied to successfully restore the patient's 
quality of life to its maximum potential. 
 
Since the beginning of time, people have used physical means for 
treatment of illness and injury.  Such physical agents for healing have 
included water, heat, cold, massage, light, exercise and electricity. 
Throughout history, water has functioned as a primary means of 
physical healing. Written accounts of physical techniques for healing 
can be traced as far back as the writings of Hippocrates in 400 B.C. 
 
Rehabilitation involves the restoration of a diseased or disabled 
person to optimal physical, psychological and social functioning. 
 
During and after World War I, empirical trials indicated that various 
physical methods were useful to augment medical care and 
onvalescence of patients. Physicians began practicing 
physiotherapy" in "reconstruction hospitals" to rehabilitate injured 
and disabled soldiers. Therapeutic tools and methods were 
eveloped or improved to apply heat, massage, exercise, electrical 
stimulation, heliotherapy and diathermy. Physicians pioneered new 
medical applications of electrotherapeutics and x-rays. Functional 
activities of occupational therapy to provide exercise, retraining of 
coordination and reassurance that useful performance could be 
regained, were extensively practiced in Army Hospitals. 
 
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. These organizations later were 
changed and renamed a number of times to reflect the evolving 
specialties of physical medicine, physical therapy, 
lectrotherapeutics, radiology, and rehabilitation. The major 
organizations for physicians in the field of physiatry today include the 
American Academy of Physical Medicine and Rehabilitation 
(AAPM&R), the Association of Academic Physiatrists (AAP), the 
American Board of Physical Medicine and Rehabilitation (ABRM&R), 
the International Rehabilitation Medicine Association (IRMA), and the 
American Congress of Rehabilitation Medicine (ACRM). These 
organizations represent seven decades of development of the field 
of physiatry. Two major medical journals have evolved to publish 
research in the field of Physiatry. The Archives of Physical Medicine 
and Rehabilitation is published by the AAPM&R and the ACRM, and 
the American Journal of Physical Medicine and Rehabilitation is 
published by the AAP. 
 
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. He became 
the leader of the educational development of the practice of physical 
medicine over the next two decades. He initiated the first continuing 
teaching program in physical medicine, consisting of short courses of 
three to six month's duration, later extended to one year for 
physicians in practice. Prior to that time, training in Physical Medicine 
had been by short preceptorship with a practitioner of some aspect of 
physical medicine. During that period, Dr. Coulter gained recognition 
as the leader of the developing organizations for physical medicine 
physicians. 
 
The decade of the 1930's brought further organization and purpose to 
the field of rehabilitation.  Only a few training programs for physical 
therapy technicians existed, but these were standardized by the 
formation of The American Registry of Physical Therapists. Likewise 
additional opportunities for training physicians began to develop, and 
groups began to form to represent specific interests within Physical 
Medicine and Rehabilitation. Frank Krusen, MD, established the 
Physical Medicine Program at the Mayo Clinic in 1936 and initiated 
the first three-year residency in Physical Medicine.  Drs. Coulter and 
Krusen led the organization of the American Academy of Physical 
Medicine in 1938, and Dr. Coulter is credited with being its 
Organizational President. In that year, Dr. Krusen coined the word 
"Physiatrist" to describe the small group of physicians who were 
dedicated to the approach of adding physical medicine to medical 
therapeutics to treat neurological and musculoskeletal disorders. 
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. 
 
It was not until after World War II, however, that society began to 
understand the necessity for more advanced treatment and 
rehabilitation for the disabled. The public became more aware of the 
rehabilitation effort due to the substantial numbers of debilitating war 
injuries plus the thousands of individuals disabled by a poliomyelitis 
epidemic that sent fear into every American home. The influence of 
radio, movie newsreels, and later television brought home the reality 
of polio in the person of President Franklin D. Roosevelt, who had 
regained his capacity to return to public life after physical therapy at 
Georgia Warm Springs. 
 
These events created an increased demand for physicians trained in 
a comprehensive approach to rehabilitation, including the physical, 
mental, emotional, vocational and social aspects. With the cases of 
polio reaching nearly 58,000 in 1952, physiatrists were called upon to 
treat the "whole patient" and direct the restoration of the disabled and 
their return to functional roles in their communities. 
 
>From quite a different origin, as a result of his experience in the Army 
Air Corps Convalescent and Rehabilitation Services at Jefferson 
Barracks in World War II, Howard A. Rusk, MD, an internist, saw and 
recognized that passive, inactive, non-physical convalescence 
resulted in both physical and emotional deterioration of soldiers 
recovering from accident or illness. As a result, these soldiers were 
often classified as unfit to return to duty. Although Rusk faced passive 
resistance from medical officialdom, he was able to 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 to all of its hospitals, and shortly thereafter, it was 
extended throughout the military services. The Medical War 
Manpower Board recognized the great value of active rehabilitation 
and introduced it into civilian medical practice. 
 
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. During those years, Rusk had a profound influence on 
present-day physiatry.  He established the Institute of Rehabilitation 
Medicine at the New York University Medical Center and helped to 
found The World Rehabilitation Fund, which has trained hundreds of 
rehabilitation specialists and physicians representing dozens of 
countries. 
 
Rusk advocated the aggressive approach to rehabilitation medicine, 
which he had begun in the Army Hospitals and which is practiced 
widely today.  He insisted that patients should not remain inactive 
during convalescence but should be involved in early ambulation, 
aggressive physical therapy, recreational and sports activities of 
progressive intensity and programs involving emotional and 
psychological support. Rusk's endeavors earned him recognition as 
"the Father of Rehabilitation Medicine." 
 
The Veterans Administration, through its experience in caring for 
thousands of injured and disabled soldiers over many decades, has 
been a primary influence in the development of Physical Medicine 
and Rehabilitation. After World War II, under the directorship of A.B.C. 
Knudson, MD, the modern-day Physical Medicine and Rehabilitation 
Service was established.  Since that time, the VA has become an 
important partner to university PM&R residency programs in providing 
training facilities, faculty and patients. Physical Medicine and 
Rehabilitation is currently practiced in each of the 171 VA Medical 
Centers throughout the United States and Puerto Rico. 
 
Another group of great importance to Physiatry was the Baruch 
Committee, which left a lasting legacy for the development of 
university research and training programs in the field of physiatry. 
The committee, which served from 1943-52, was appointed by 
philanthropist Bernard Baruch in memory of his father, Dr. Simon 
Baruch, who was a leading proponent of hydrotherapy as a faculty 
member at Columbia University's College of Physicians and 
Surgeons. The committee awarded grants to hospitals and medical 
schools to establish PM&R teaching and research programs.  By 
1946, medical residencies or fellowships in PM&R had been 
established at 25 hospitals as a result of funding from the Baruch 
Committee.  Although the grants provided the basis for the expansion 
of training and research, the propelling influence for the expansion of 
the field of physiatry was the recognition by the public that 
rehabilitation worked. Hundreds of wounded soldiers and injured 
civilians were being rehabilitated and returned to be productive, 
tax-paying members of society. This was the testimony before 
Congress and to the public at large that ensured the future of the field 
physiatry. 
 
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." For 
the first time, the specialty of physical medicine and the specialty of 
rehabilitation medicine were under one governing board. At that time, 
university hospitals were offering a total of 85 positions for residents 
or fellows in Physical Medicine and Rehabilitation. 
 
In the 1950's, a major collaborator with Howard Rusk, Mary Switzer, 
director of the Office of Vocational Rehabilitation (OVR) brought about 
the economic opportunity for the great expansion of Physical 
Medicine and Rehabilitation.  Mary Switzer was totally committed to 
the improvement of the quality of life for people with disabilities. She 
became convinced by Howard Rusk that physical medicine and 
rehabilitation under the direction of physiatrists could provide the 
greatest benefits for people with disabilities. 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 in medical 
rehabilitation. During her administration, the concept of regional 
rehabilitation research and training centers was adopted and funded 
by Congress. These centers remained the major resources 
available to physiatrists for rehabilitation research and research 
training until 1990, when the National Center for Medical Rehabilitation 
Research was established at the National Institutes of Health. 
 
The 1950's brought an increase in the numbers of rehabilitation 
professionals and a more cohesive union between the fields of 
Physical Medicine, Rehabilitation Medicine, and Electromyography. 
Electromyography (EMG) was introduced into Physiatry as a 
profoundly important electrodiagnostic method for the evaluation of 
problems of the neuromuscular system, which constitutes a major 
part of the work of the physiatrist. Through EMG, it is possible to 
localize and evaluate significant pathology of both the muscular and 
sensory components of the nervous system. The general acceptance 
of this diagnostic tool created a significant niche for the growing 
specialty of PM&R.  On the therapeutic side, many rehabilitation 
centers were born because the value of medical rehabilitation was 
recognized by the general public, who demanded that these services 
be made available in every large community. 
 
Along with the expansion of education and training opportunities in 
physical medicine and rehabilitation, interest in physiatric research 
multiplied during the 1960's. 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 is the only major PM&R organization 
that at the present uses "physiatrist" in its name. The primary purpose 
of the AAP is to promote methods of undergraduate and graduate 
teaching of the art and science of PM&R. From 1968 to 1992, the 
AAP grew to more than 1,000 members. 
 
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.  Although 
many new physicians graduated from PM&R residency programs in 
the 1970's, the increase in the number of new physiatrists was far 
slower than the increased demand for physiatric services. 
 
In 1974, the Commission on Rehabilitation Medicine, a group with 
representatives from the American Board of Physical Medicine and 
Rehabilitation, the American Academy of Physical Medicine and 
Rehabilitation and the Association of Academic Physiatrists, 
published a bulletin
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NOTE: This message was originally in conference "INTERNET - E-MAIL AREA"
      and was copied here by Tom Mckeever.
From: Alan Mitchell 
To: Multiple recipients of list POLIO 
Date:         Mon, 16 Sep 1996 09:49:54 GMT
Subject:      APPA News 13 Special Report from the Internet (*)
Organization: MindSpring Enterprises, Inc.
 
The following is an excerpt from an article by Dr. Richard L. Bruno,
called  The Knife Is Not So Rough If..... .
 
Dr. Bruno put this article on the Internet and asked that it be shared
with polio survivors
 
If you have to  go under the knife,  the innocent ignorance of your
surgeon  can lead to unnecessary emotional discomfort, excessive
physical pain and, occasionally, serious complications.
        So read the article and give a copy to each member of the surgical
team and the nurses on the hospital floor where you will be staying.
Discuss the article with your doctor and ask that a copy be put in you
 
medical chart.
        Medical professionals need to be familiar with the neurological 
amage
done by the original polio infection.
        POST-OPERATIVE PREPARATION This is the most important period, since
this is their period when you must establish communication with the
surgical tea.  After a second opinion, meet with the surgeon and the
anesthesiologist to discuss in detail your complete polio and general
medical histories and any problems that might arise before and during
surgery, in the recovery room and on the nursing floor.
        LUNGS.  It is recommended that all polio survivors have pulmonary
function studies as part of your preoperative testing..  This will
help the surgical team evaluate the proper type of anesthesia for you
and will help eliminate any unpleasant surprises coming off  a
respirator at the end of surgery.
        PHYSICAL ASSISTANCE X-ray and examining tables are built at heights
that are convenient for the professional, not the patient.  Many polio
survivors cannot step on a stool to get on a high table.  Polio
survivors must ask for help in transferring.
        Since most polio survivors are not good at asking for help , they 
eed
to find a phrase with which they are comfortable that will communicate
their needs.  If you run into someone that does not want to help or
work with you, ask for someone else to help or ask to speak to their
supervisor.
        GENERAL ANESTHETICS Polio survivors are exquisitely sensitive to
anesthetic.  A little anesthetic goes a long way and lasts a long time
due to the damage of the brain stem - called the reticular activating
system. Polio survivors have been known to sleep for days after
surgery.
 
For polio survivors we use the   RULES OF 2  - for surgery.
 
ANESTHETIC RULE OF 2 Polio survivors need the typical dose of
anesthetic divided by 2.  This is merely to remind anesthesiologists
that polio survivors need much less anesthetic than do other patients.
 
        Also, polio survivors can be sensitive to atropine-like drugs used
during surgery.
 
POSITIONING One overlooked problem is the positioning of the
post-polio patient on the operating table. Muscle atrophy, scoliosis
and spinal fusion  may make certain positions problematic.  It would
be advisable for the patient to be awake during positioning on the
table to prevent post-op complications..
POST-OPERATIVE CARE Cold. Polio survivors are extremely sensitive to
cold because they have difficulty regulating their body temperature.
        No polio survivor should have same-day surgery for any reason except
for the most simple procedure that requires a local anesthetic.
POST-ANESTHETIC RULE OF 2 Polio survivors require 2 times as long to
recover from the effects of any anesthetics.
BLOOD AND GUTS   Polio survivors with muscle atrophy, will have a
smaller blood volume that would be expected for their weight and
height.  Therefore bleeding during surgery may be more of a problem
        Polio survivors cannot control the size of their blood vessels, since
the nerves that make the smooth muscle around veins and capillaries
contract were paralyzed by poliovirus. Therefore, polio survivors
blood vessels open under anesthetic and dump the heat of their warm
blood into the cold recovery room.  Polio survivors must be kept warm.
 
VOMITING   Another post-op problem related to brain stem damage is
vomiting.  Polio survivors are more apt to faint (have vasovagal
syncope and even brief asystoles) when they attempt to vomit.  It is
important that post-op emetic control be discussed with the
anesthesiologist and administered before going to the recovery room.
CHOKING   Polio survivors who are aware of having swallowing problems,
and sometimes in those  without apparent swallowing difficulty, cannot
clear secretions and may choke  when they are lying on their
backs.  Polio survivors secretions need to be monitored in the
recovery room and they should be positioned on their side if possible
so that secretions can  drain.
PAIN   The single most  troublesome problem after surgery is pain
control. Under-medication is a serious problem for the post-polio
patient since two research studies have shown that polio survivors are
twice as sensitive to pain as those who didn t have polio.
RULE OF 2 FOR PAIN   Polio survivors need 2 times the dose of pain
medication for 2 times as long.
RECOVERY Polio survivors need more bed rest than most patients,
because of autonomic nervous system damage. Polio survivors are the
best judges of when they can move, stand and walk safely.
RULE OF 2 FOR RECOVERY   Polio survivors should stay in  bed 2 times
longer than other patients.
RULE OF 2 FOR LENGTH OF STAY   Polio survivors need to stay in the
hospital 2 times longer than other patients.
RULE OF 2 FOR WORK   Polio survivors need 2 times the number of days
of rest at home before they return to work or household duties.
RULE OF 2 FOR FEELING BETTER   Polio survivors need 2 times longer to
feel  back to normal  again.
CONCLUSION   All of the  Rules of 2  are suggestions for polio
survivors and the surgical team; they are not a substitute for
specific  information about the individual patient and communication
among all members of the treatment team, including the patient.
 
Linda Sutherland
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