A physiatrist is also known as a Physical Medicine and Rehabilitation (PM&R) physician. They treat a wide variety of medical conditions affecting the brain, spinal cord, nerves, bones, joints, ligaments, muscles and tendons (AAPMR, 2016). A physiatrist specializes in physical medicine, rehabilitation and pain medicine and management.
Physiatrists may focus on a sub-specialty of the field, such as Brain Injury Medicine, Hospice and Palliative Medicine, Neuromuscular Medicine, Pain Medicine, Pediatric Rehabilitation Medicine, Spinal Cord Injury Medicine, and/or Sports Medicine (AAPMR, 2016).
A physiatrist treats patients of all ages, and they focus on treatment and function of the patient’s injury. They diagnose and treat pain as a result of an injury, illness, or disabling condition. Physiatrists have a broad medical expertise that allows them to treat disabling conditions throughout a person’s lifetime (AAPMR, 2016).
Physiatry is an aggressive, non-surgical approach to treating musculoskeletal disease and injury, including different types of pain (Brzusek, 2017). Like other types of spine specialists, physiatrists take the patient's medical history, perform a physical and neurological examination, order X-rays or other imaging studies, prescribe medications, and perform spinal injections.
What Does a Physiatrist Do?
A physiatrist will examine the patient’s injury and determine and lead a treatment and/or prevention plan. These medical professionals work with other specialists, such as physical therapists, occupational therapists, and physician extenders to optimize patient care. They may also work with other physicians, which may include primary care physicians, neurologists, orthopedic surgeons, and many others.
Depending on the injury, illness, or disabling condition, some PM&R physicians may treat their patients using the following procedures/services (AAPRM, 2016):
EMG/Nerve Conduction Studies, Ultrasound guided procedures, Fluoroscopy guided procedures, Injections of spine , Discography, Disc Decompression and Vertebroplasty/Kyphoplasty, Nerve Stimulators, Blocks and Ablation procedures—Peripheral and Spinal, Injections of joints, Prolotherapy, Spasticity Treatment (Phenol and Botulinum toxin injections, intrathecal baclofen pump trial and implants), Nerve and Muscle Biopsy, Manual Medicine/Osteopathic Treatment, Prosthetics and Orthotics, Complementary-alternative medicine (i.e. acupuncture, etc.), Disability/impairment assessment and Medicolegal consulting.
Physiatrists maximize the patient’s functions and assist the patient in adapting to what he or she cannot do. A physiatrist should be consulted when pain, weakness, or disability is preventing a patient from achieving their desired level of independence (AAPRM, 2016). These physicians work in a variety of environments including hospitals, clinical centers and private practices. In addition to management used in general medical practice, physiatrists prescribe therapeutic exercise, prosthetics / orthotics, and adaptive devices to treat patients of all ages.
Physiatrists facilitate physiologic adaptation to disability to prevent complications or deterioration secondary to disabling conditions (AAPRM, 2016). The goal of the physiatrist is to provide medical care to patients with pain, weakness, numbness, flaccidity, spasticity and loss of function so that they can maximize their physical, biological, psychological, social, and vocational potential. As people survive conditions that once would have been fatal, the field of physiatry is moving to the forefront of medicine. The specialty serves all age groups and treats problems that touch upon all major systems of the body.
Physiatrists look to restore the physical function in patients with bone, muscle or nerve injuries or diseases – everything from strokes and brain injuries to low back pain and knee stiffness (LVHN, 2017). This medical profession is different from others in that physiatrists focus on the entire body rather than just one organ, and this head-to-toe approach can be particularly helpful for hard-to-diagnose problems like spine pain, which may be caused by anything from muscle strain to osteoarthritis (LVHN, 2017).
A physiatrist does not perform surgery. Instead, they prescribe nonsurgical treatments such as pain medications, steroid injections, strengthening exercises, stretching and assistive devices (for example, a wheelchair or braces). Physiatrists work with patients before and after surgery to help with recovery and physical rehabilitation.
The Difference Between Physiatrists and Physical Therapists
Physiatrists are often confused with physical therapists. Although they may work together, they do have different duties. Physiatrists and physical therapists treat patients with the same types of conditions. However, physiatrists are physicians who have completed medical school plus four years of residency training, and a physical therapist only needs to complete an undergraduate degree.
In general, physical therapists are trained in the clinical features of common musculoskeletal pathology, musculoskeletal examination, developing a treatment plan and exercise regimen, and physical modalities (including heat, cold, TENS) (AAPMR, 2016). Physiatrists, on the other hand, make and manage medical diagnoses and prescribe the therapies that physical therapists will subsequently perform, so they don’t directly perform the treatment.
The role of the physiatrist is to manage a patient’s medical issues as they navigate the rehabilitation process. A physiatrist will assess the patient and assure that the patient is medically stable to participate in therapies the physical therapist is performing. Medical issues specific to rehabilitation include pain management, neurogenic bowel and bladder, autonomic dysreflexia, dysphagia, gait and movement ataxia, spasticity management, and disease education (AAPMR, 2016). A physiatrist may also manage other co-morbid conditions (e.g., hypertension, diabetes, CAD, COPD, etc.) to prevent further medical complications (AAPMR, 2016).
The History of Physiatry
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 (Atanelov et al, 2015). This is a relatively new specialty compared to other medical specialties, although they all have the same ancient medial origins.
The Beginning of Rehabilitation Therapy
Rehabilitation therapy has been around for thousands of years, dating back to ancient China. An ancient Chinese movement therapy known as Cong Fu was used to relive pain in various parts of the body. Herodicus, a Greek physician, described an elaborate system of gymnastic exercises for the prevention and treatment of disease in the fifth century BCE, and the Roman physician Galen described interventions to rehabilitate military injuries in the second century CE (Atanelov et al, 2015).
During the Middle Ages, Talmudic principles were introduced by Maimonides. These principles emphasized healthy diet and exercise as forms of preventative medicine. Maimonides published his findings in a book titled Medical Aphorisms, which was published in between 1187 and 1190 (Atanelov et al, 2015). In 1569, Mercurialis emphasizes gymnastics for preventative and rehabilitative medicine in his publication The Art of Gymnastics.
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 (Atanelov et al, 2015).
The History of Physiatry in the United States
The polio epidemic in addition to the World Wars led to significant medical advances in the United States in the 1900s. The development of physiatry in the US has origins both in comprehensive rehabilitative programs for polio survivors and veterans and in academic departments and medical centers (Atanelov et al, 2015).
The First Rehabilitation Center
In 1921, Franklin Delano Roosevelt developed a high fever and lower extremity paralysis from a polio virus infection (Atanelov et al, 2015). He went through rehabilitation in Georgia that involved therapeutic swimming in the sun which helped him regain his leg strength and endurance. Roosevelt then bought this rehabilitation center and included services such as heliotherapy, swimming, exercise, training in orthotic use, muscle re-education, massage, and occupational and recreational therapy (Atanelov et al, 2015). This is thought to be the first comprehensive rehabilitation center.
Physiatry in Academic Institutions
The first academic physiatry department was founded by Dr. Frank Krusen at Temple University Medical School in 1929 (Atanelov et al, 2015). Dr. Krusen was one of the first American physicians to acknowledge the importance of physical medicine, which came after he had a bout with tuberculosis. He had a prolonged stay in the hospital, where he recognized that bed-ridden patients faced intense deconditioning and functional deterioration.
Dr. Krusen was dedicated to developing the field of physiatry and demonstrated the importance of physical therapy to the human body. In 1935, he became the department chair of the physical medicine department at the Mayo Clinic in Rochester, Minnesota. Here, he studied the effects of therapeutic exercise and physical modalities like short-wave diathermy and ultraviolet radiation on patients with military-related disabilities, back pain, and postsurgical musculoskeletal complications (Atanelov et al, 2015). Dr. Krusen is known as the first in the US to use the term “physiatrist”.
In 1942, Dr. Howard A. Rusk worked with the United States Army to develop a comprehensive rehabilitative training program that included physical, neuro-physical and occupational therapy. He then founded the world’s first university-affiliated comprehensive rehabilitation center at New York University in 1951.
Contemporary support for physiatry’s establishment as a medical specialty came from philanthropist Bernard Baruch, who sought to advance the research of his physician father, Simon Baruch, on the use of hydrotherapy for patients with chronic diseases (Atanelov et al, 2015).
The Baruch Committee on Physical Medicine was formed in 1943 to promote physical medicine and rehabilitation. The goal of this established was to offer effective properties of light, heat, cold, water, electricity, massage, manipulation, exercise and mechanical devices for physical and occupational therapy in the diagnosis or treatment of disease, in addition to rehabilitation of people handicapped by disease, injury, or malformation to a normal physical and mental state (or as close as possible) to address the needs of the estimated four million disabled people in 1940 and the expected surge of World War II veterans with disabilities (Atanelov et al, 2015).
The Polio Epidemic and World War II
Poliomyelitis, known as polio, is an acute viral disease usually affecting children and young adults, caused by any of three polioviruses, characterized by inflammation of the moto neurons of the brain stem and spinal cord, and resulting in motor paralysis, followed by muscular atrophy and often permanent deformities (Evolution, 2017).
The polio virus continued to epidemic proportions in the 1930s. World War II began around 1939 and it led to an increase in the need for physiatrists due to advances in medicine – more soldiers with injuries survived, and physical therapists were needed to treat those with war disabilities. Wounded veterans who returned home with amputations, burns, cold injuries, wounds, fractures, and nerve and spinal cord injuries required attention of physiatrists in the first half of the 1940s during the peak of World War II.
The field of physiatry continued to evolve and develop as more soldiers survived previously fatal injuries. The Korean War began in 1950. The Korean war presented even more soldiers with war disabilities who required treatment in addition to polio patients. In the early 1960s, the Salk vaccine for polio was introduced, so physiatrists gradually moved their focus from polio-related injuries to soldier injuries. Polio was eradicated in the early 1960s, although those with the disease continued to need treatment.
Modern Day Physiatry
Today, the American Board of Physical Medicine and Rehabilitation defines physiatrists as nerve, muscle, and bone experts who treat injuries or illnesses that affect how you move…diagnose and treat pain, restore maximum function lost through injury, illness or disabling conditions, treat the whole person, not just the problem area, lead a team of medical professionals, provide non-surgical treatments, [and] explain your medical problems and treatment/prevention plan (Atanelov et al, 2015).
While many physicians focus on specialty areas for the management and stabilization of pathologic conditions, the physiatrist will treat the whole patient and include social circumstances in addition to physical ones. Physiatrists customize treatments to for each patient that may include medication, therapeutic exercise, injections, physical modalities and education (Atanelov et al, 2015).
As team leaders, physiatrists champion the rights and autonomy of their patients by maximizing function and optimizing their living situations so that they can contribute to the community in the least restrictive setting (Atanelov et al, 2015). By emphasizing prevention, diagnosis, and treatment of patients’ functional limitations resulting from many different medical conditions, physiatry helps to maintain and restore optimal function for patients in many spheres of life including the social, emotional, medical, and vocational (Atanelov et al, 2015). Physiatrists focus on improving their patient’s overall quality of life.
Physiatry and Ethics
Throughout the growth and evolution of the physiatry profession, multiple ethical and moral issues have emerged for this and other medical fields. Some of these issues include health care reimbursement changes, patient or family conflicts, and assessing patients’ decision-making capacity.
Physiatrists are typically the leaders of a multi-disciplinary medical team, so they must be careful that they are making ethically sound decisions. They may interact with the ethics committee of the hospital or medical center where they are employed. At times, members of the medical team may disagree, so the physiatrist must ensure the patient’s treatment plan is providing the best possible care.
Because physiatrists deal with many patients who have physical or mental disabilities, they must be advocates for their patients and provide customized care plans that involve a variety of medical specialists. Physiatrists analyze multiple dimensions of their patients’ lives including vocational, emotional and social, along with the medical aspect.
How to Become a Physiatrist
Extensive education and training are required to become a physiatrist. An undergraduate degree, completion of medical school, and a residency program are all required to become a licensed professional in this medical field. The required education and training takes approximately 10 years to complete, as it includes an undergraduate degree, medical school and a residency program. Some may also complete a fellowship. A physiatrist must be licensed to practice medicine by the state they choose to work in.
Undergraduate degree
Undergraduate degrees in pre-medical or other science (biology, chemistry, physics) will help the student prepare for the Medical College Admission Test (MCAT) exam, although there is no specific major required for most medical school programs. Some students may choose to major in humanities or social sciences (sociology, psychology, anthropology, foreign language or literature). A future physiatrist will have to pass the MCAT in order to be accepted into any accredited medical school.
Accredited medical school acceptance is extremely competitive. Volunteering at local hospitals or other medical centers during the undergraduate years is recommended in order to obtain hands-on experience in the health care profession. Some aspiring physiatrists may complete a Master’s degree program prior to applying to medical school in order to display additional education and training on their medical school application. A high GPA and test scores will boost a medical school application as well.
Medical School
The first two years of medical school includes coursework in anatomy, biochemistry, medical law and ethics, microbiology, pathology, pharmacology, physiology and psychology. The last two years consist of hands-on experience under the supervision of a licensed physician. Hospital rotations allow students to receive training in a variety of areas including internal medicine, family practice, obstetrics and gynecology, pediatrics, psychiatry and surgery.
Graduates of medical school receive a Doctor of Medicine (M.D.) degree and go on to complete a 1 to 3-year residency, which involves additional training with direct patient interaction. Some aspiring general practitioners complete a 1-year internship prior to residency in order to receive a Doctor of Osteopathic Medicine Degree (Ph.D.).
Residency Program
A physiatrist will need to complete a 3- to 4-year residency program to gain specialized knowledge of the field. Those who do the three-year program typically complete a one-year internship after medical school. Interning can be done in family medicine, pediatrics, general medicine or surgery or osteopathic medicine.
During the residency program, students receive additional training in generalized and rehabilitation medicine, as well as with neurological disorders such as ALS (amyotrophic lateral sclerosis), Multiple Sclerosis (MS), fractures, stroke recovery, brain injury and pediatrics (Doctorly, 2017). Residents will interact with patients directly and practice managing patients who have had a stroke, amputation or spinal cord injuries, among others.
Fellowship Program
After a residency is completed, some physiatrists may choose to receive additional specialized training through a 1- to 2-year fellowship program. Specialized physiatry programs may include neurorehabilitation, pain medicine, musculoskeletal care, sports injuries or sports medicine, post-operative care, pediatrics and specialized rehabilitation. Specialized rehabilitation may include dance therapy or palliative care and involves a variety of treatments and therapies. A physiatrist may also focus on research in a fellowship program.
Licensing and Certification
Although a license is required for a physiatrist to practice in their state of choice, certification is optional. A physiatrist will have to pass a state examination in order to legally treat patients. Requirements for licensing vary by state or region, so it is a good idea to complete the residency and fellowship in the state the physiatrist wishes to practice in.
The certifying organization for physiatrists is the American Board of Physical Medicine (ABPM) and Rehabilitation. To receive board certification, a physiatrist must complete a written and oral examination. Many physiatrists with specialized knowledge obtain certification in their specialty area. The AMPM offers certification in brain injury medicine, hospice and palliative medicine, neuromuscular medicine, pain medicine, pediatric rehabilitation medicine, spinal cord injury medicine and sports medicine.
Job Prospects
The Bureau of Labor Statistics (BLS) projects a growth of 18% for all physicians by the year 2022. This is slightly higher than the average growth for other occupations in the United States. The average annual salary for physiatrists in the US is close to $256,000.
Physiatrists may work in a primary care center, hospital or an outpatient specialty clinic, or in a private practice. Some may choose to work in academic settings or educational centers. Others may work in mental health facilities to assess those with mental and physical diseases or disorders.
Physiatry is a popular field of choice for medical students, as many choose physiatry because it allows them to improve quality of life without surgery. With an increasing aging population, this is a good profession of choice for an aspiring physician. A quote by William Arthur Ward sums up the goal of physiatrists: A true friend knows your weaknesses but shows you your strengths, feels your fears but fortifies your faith; sees your anxieties but frees your spirit; recognizes your disabilities but emphasizes your possibilities (Atanelov et al, 2015).
Levan Atanelov, MD, MS, Steven A. Stiens, MD, MS, and Mark A. Young, MD, MBA. History of Physical Medicine and Rehabilitation and Its Ethical Dimensions. AMA Journal of Ethics. June 2015, Volume 17, Number 6: 568-574.
American Physical Therapy Association (APTA). Today’s Physical Therapist: A Comprehensive Review of a 21st-Century Health Care Profession. January, 2011.
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