What Is Physiatry?What Is Physiatry?

Steven J. Farrell, MDSteven J. Farrell, MDAssociate Professor and ChiefAssociate Professor and Chief

Physical Medicine and RehabilitationPhysical Medicine and RehabilitationUniversity of Toledo College of University of Toledo College of

MedicineMedicine

Who The Heck Gets Into Who The Heck Gets Into Rehab?Rehab?

DisclaimerDisclaimer

I am married to Dr. GottwaldI am married to Dr. Gottwald

I know nothing about skin diseaseI know nothing about skin disease

I cannot get you a derm appointment I cannot get you a derm appointment soonersooner

ObjectivesObjectives

Give a basic overview of PM&RGive a basic overview of PM&R

Discuss the principles of inpatient Discuss the principles of inpatient rehabilitationrehabilitation

Discuss admission criteria for inpatient Discuss admission criteria for inpatient rehab facilities (IRF)rehab facilities (IRF)

PhysiatristPhysiatrist

Practices in the field of Physical Medicine Practices in the field of Physical Medicine and Rehabilitationand Rehabilitation

Works with patients who posses functional Works with patients who posses functional disabilitiesdisabilities

History of PM&RHistory of PM&R

Comes from Comes from physikosphysikos (physical) and (physical) and iatreiaiatreia (art (art of healing)of healing)

Principles started during Principles started during World War IWorld War I

Physiotherapy and Physiotherapy and reconstruction hospitals to reconstruction hospitals to treat war vetstreat war vets

History of PM&RHistory of PM&R

1936 first program founded at the Mayo 1936 first program founded at the Mayo Clinic with the support of the War Dept Clinic with the support of the War Dept and US Navyand US Navy

1941 World War II broadens the scope of 1941 World War II broadens the scope of the fieldthe field

1945 section of PM&R established in the 1945 section of PM&R established in the AMAAMA

History of PM&RHistory of PM&R

1946 twenty five residencies established1946 twenty five residencies established1952 nearly 58,000 cases of polio become 1952 nearly 58,000 cases of polio become a prime focus of treatmenta prime focus of treatmentPresident Franklin Roosevelt brings President Franklin Roosevelt brings spotlight disabled Americansspotlight disabled Americans1965 Medicare and Medicaid established1965 Medicare and Medicaid established1972 Medicare expands coverage to 1972 Medicare expands coverage to include disabled and inpatient include disabled and inpatient rehabilitationrehabilitation

PM&R NowPM&R Now

78 training programs 78 training programs

Over 1300 positions of training (350 per Over 1300 positions of training (350 per year)year)

Over 8000 Board Certified Physiatrists Over 8000 Board Certified Physiatrists

Estimated significant need upcoming due Estimated significant need upcoming due to longer lifespan, more active elderly to longer lifespan, more active elderly population, baby boomers entering the mid population, baby boomers entering the mid 60’s60’s

Toledo and PM&RToledo and PM&R

Accredited residency programAccredited residency program21-27 bed rehab unit21-27 bed rehab unit6 total residents in training6 total residents in training50% of training slots filled by UT COM 50% of training slots filled by UT COM graduatesgraduates75% of practicing physiatrists graduates of 75% of practicing physiatrists graduates of UT PM&R Residency ProgramUT PM&R Residency ProgramUT COM is in top 20 medical schools in UT COM is in top 20 medical schools in training Board Certified Physiatriststraining Board Certified Physiatrists

But What Do We Do?But What Do We Do?

Inpatient RehabilitationInpatient Rehabilitation

Physiatrist is part of a team of health care Physiatrist is part of a team of health care professionals that work to reintegrate the professionals that work to reintegrate the disabled patient into the home and disabled patient into the home and community environmentscommunity environments

Multidisciplinary approach can be very Multidisciplinary approach can be very effectiveeffective

The TeamThe Team

Physical therapistPhysical therapistOccupational therapistOccupational therapistSpeech and language therapistSpeech and language therapistCounselorCounselorNursingNursingTherapeutic recreation specialistTherapeutic recreation specialistSocial workerSocial workerPhysiatristPhysiatrist

Physical TherapistPhysical Therapist

Works on tasks Works on tasks – MobilityMobility– TransfersTransfers– GaitGait– Car skillsCar skills– Pain controlPain control– EducationEducation

Exercise, modalitiesExercise, modalities

Occupational TherapistOccupational Therapist

Works on tasks of upper extremitiesWorks on tasks of upper extremities– Activities of daily livingActivities of daily living– Functional transfersFunctional transfers– SplintingSplinting– Modalities and motor control tasksModalities and motor control tasks

May specialize in hand therapyMay specialize in hand therapy

Speech/Language TherapistsSpeech/Language Therapists

Speech and language assessment and Speech and language assessment and treatmenttreatment

Cognitive evals and treatmentCognitive evals and treatment

Swallowing assessment and treatmentSwallowing assessment and treatment– BedsideBedside– Modified barium swallow testingModified barium swallow testing

CounselorCounselor

May be social worker, psychologistMay be social worker, psychologist

Adaptation to disabilityAdaptation to disability

NursingNursing

Different than acute care floorDifferent than acute care floor

Patients are mobile and activePatients are mobile and active

EducationEducation

Bladder and bowel programsBladder and bowel programs

Decubutis careDecubutis care

Social WorkerSocial Worker

Discharge planning Discharge planning

Procure equipmentProcure equipment

Follow up arrangementsFollow up arrangements

Therapeutic Recreation SpecialistsTherapeutic Recreation Specialists

Works with avocational tasksWorks with avocational tasks

Hobbies and interestsHobbies and interests

Field tripsField trips

PhysiatristPhysiatrist

Follow patient’s medical and rehabilitation Follow patient’s medical and rehabilitation needsneeds

Try NOT to call medicine unless really Try NOT to call medicine unless really necessary because they are our friendsnecessary because they are our friends

Medical/Rehabilitation Issues Medical/Rehabilitation Issues We EncounterWe Encounter

PulmonaryPulmonary

Very important in cases of tetraplegiaVery important in cases of tetraplegia

Teach respiratory techniquesTeach respiratory techniques

Wean trachsWean trachs

Some IRF will take vents; we do not due to Some IRF will take vents; we do not due to staff training issuesstaff training issues

BowelBowel

Neurogenic bowel very common and Neurogenic bowel very common and important to treatimportant to treat

Can inhibit rehab and social progressCan inhibit rehab and social progress

Will start with the 3-2-1 programWill start with the 3-2-1 program– Colace 100 mg TIDColace 100 mg TID– Senna two tabs at noonSenna two tabs at noon– Dulcolax suppository at nightDulcolax suppository at night

BladderBladder

NeurogenicNeurogenic– Unhibited bladderUnhibited bladder

StrokeStrokeBabiesBabies

– SpasticSpasticTBI or SCITBI or SCI

– FlaccidFlaccidCauda equina syndromeCauda equina syndrome

– Dysynergic Dysynergic Higher level SCIHigher level SCI

Bladder ProgramsBladder Programs

Timed voidsTimed voids– CVACVA– Brain injuryBrain injury

Intermittent straight cathsIntermittent straight caths– SCISCI

Suprapubic catheterSuprapubic catheterAvoid long term foley unless absolutely Avoid long term foley unless absolutely necessarynecessary– Reason to keep a foley???Reason to keep a foley???

Skin/Pressure UlcersSkin/Pressure Ulcers

Direct pressureDirect pressure

FrictionFriction

ShearingShearing

MoistureMoisture

MalnutritionMalnutrition

AnemiaAnemia

SpasticitySpasticity

Can help or hurt functional recoveryCan help or hurt functional recoveryTreatmentsTreatments– TherapyTherapy– Modalities: coldModalities: cold– Medication: baclofen, zanaflexMedication: baclofen, zanaflex– BotoxBotox– Baclofen pumpsBaclofen pumps– Surgical tendon release: messy and avoided if Surgical tendon release: messy and avoided if

possiblepossible

Who Is Eligible?Who Is Eligible?

Ability to participate in therapy 3 hours per day in Ability to participate in therapy 3 hours per day in meaningful waymeaningful way– Medically and motivation wiseMedically and motivation wise

Home goalHome goal– Should have good home support or be reasonably sure they can Should have good home support or be reasonably sure they can

go home alone; judgment call by the PM&R consult teamgo home alone; judgment call by the PM&R consult team

INSURANCEINSURANCE– IRF is not the same as an acute care hospital; elective IRF is not the same as an acute care hospital; elective

admission admission – Each insurance company can have their own criteriaEach insurance company can have their own criteria– Can take away our decision makingCan take away our decision making– Until they pass health care reform then who knows? Likely not Until they pass health care reform then who knows? Likely not

even congresseven congress

Medicare FundingMedicare Funding

PPS: prospective payer systemPPS: prospective payer system

75% rule (now 60%)75% rule (now 60%)

Not cheap: $1000/ dayNot cheap: $1000/ day

60% Rule60% Rule

60 % of our patient are required to have 60 % of our patient are required to have one of the following diagnosisone of the following diagnosis

60 % Rule60 % Rule

CVACVA

SCISCI

Congenital deformityCongenital deformity

AmputationAmputation

Hip fractureHip fracture

Brain injury Brain injury

Neurological Neurological disordersdisorders– Parkinson's, MSParkinson's, MS

BurnsBurns

Active RA, psoriatic Active RA, psoriatic arthritisarthritis

Seronegative Seronegative spondyloarthropathiesspondyloarthropathies

Systemic vasculitis Systemic vasculitis activeactive

60 % Rule60 % Rule

Joint replacementJoint replacement– BMI > 50BMI > 50– Active weight bearing polyarthritisActive weight bearing polyarthritis– Bilateral joint replacementsBilateral joint replacements– Age > 85Age > 85

Physical MedicinePhysical Medicine

Works with patients that have Works with patients that have musculoskeletal injuriesmusculoskeletal injuries– Sports injuriesSports injuries– Occupational injuriesOccupational injuries– SpineSpine– PainPain

Electrodiagnosis Electrodiagnosis

Non-operative treatmentNon-operative treatment

Musculoskeletal InjuriesMusculoskeletal Injuries

Shoulder: tendonitisShoulder: tendonitis

Elbow: tennis elbowElbow: tennis elbow

Hand and wrist: CTSHand and wrist: CTS

Hip: bursitisHip: bursitis

Knee: cartilage or ligament injuryKnee: cartilage or ligament injury

Ankle: SprainsAnkle: Sprains

Back/Neck: strains, disc injury, nerve rootBack/Neck: strains, disc injury, nerve root

Fields of OverlapFields of Overlap

OrthopedicsOrthopedics

Internal medicineInternal medicine

NeurologyNeurology

NeurosurgeryNeurosurgery

Rheumatology Rheumatology

Case QuizCase Quiz

82 year old with significant dementia lives 82 year old with significant dementia lives with family with new onset CVAwith family with new onset CVA

Left hemiplegia and dysphagiaLeft hemiplegia and dysphagia

Otherwise in good healthOtherwise in good health

Acute care therapists note difficulty with Acute care therapists note difficulty with patient in carryover with teaching taskspatient in carryover with teaching tasks

Are they a good IRF candidate?Are they a good IRF candidate?

Case QuizCase Quiz

66 year old female with new onset major 66 year old female with new onset major MI; workup leads to CABGMI; workup leads to CABG

Post op patient develops pneumonia Post op patient develops pneumonia requiring IV abxrequiring IV abx

Are they a good rehab candidate?Are they a good rehab candidate?

Case QuizCase Quiz

72 year old patient with Parkinson's 72 year old patient with Parkinson's Disease admitted to Med I with pneumonia Disease admitted to Med I with pneumonia and UTIand UTIOn admission notes that tremors have On admission notes that tremors have greatly worsened and neurology greatly worsened and neurology consulted; they change meds but tremors consulted; they change meds but tremors are slow to respond and you are are slow to respond and you are concerned about safetyconcerned about safetyAre they a good rehab candidate??Are they a good rehab candidate??

Questions?Questions?