PM&R: Where We Have Been, Where We Are Heading

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It is with pleasure and pride that I have watched the specialty of physical medicine and rehabilitation advance to where we are today. We are a rich and varied specialty composed of many thousands of unique practices and approaches to managing many different types of neurological and musculoskeletal conditions. I am exceptionally pleased that we will now have our own journal, PM&R, to help us survey the field of physiatry and collect our knowledge, but more on that later. For now, I would like to share some history with you, some personal, but all in the historical context of the evolution of our specialty. What our past has taught us will undoubtedly help us shape our future growth and development.

There have been some great pioneers in our specialty, and I am fortunate to have known them when they were young men, making their way and standing up for what they believed in. I was associated with Drs. Howard Rusk and Frank Krusen, and I trained under Drs. Ralph Worden and Justus Lehmann. These men have influenced the lives of many including my own and my decision to embrace this field. My surprising selection of physical medicine and rehabilitation as a specialty was an unexpected, unplanned, and entirely serendipitous occurrence. Although I had already applied for residency in psychiatry at the University of Indiana College of Medicine, I experienced an awakening during my rotation in psychiatry while completing my internship, which abruptly interrupted my medical career. My month on psychiatry, the specialty I had carefully selected while typing psychiatric social service notes from the outpatient clinic during work/study, was a disaster. Consequently, I worked for a year in general practice and helped cover the local emergency room. One of my first patients was a 19-year-old painter who fell off a scaffold and suffered a C6 complete tetraplegia. I transferred the patient to The Ohio State University (OSU) rehabilitation facility that Dean Charles Doan had recruited Dr. Worden to run. Dr. Worden trained at the Mayo Clinic and had been a staff physician at the Kenny Polio Clinic in Minneapolis. I eventually attended this patient's discharge conference, where Dr. Worden remarked that he remembered me as someone who was interested in physical medicine. He showed me posters from National Foundation for Infantile Paralysis, which proposed 3-year fellowships in physical medicine and rehabilitation. Shortly thereafter I began my residency at OSU in July 1954.

My mentor during my residency was Dr. Lehmann, who taught the residents and faculty as well as senior therapists, many treatment modalities including the principles and application of therapeutic ultrasound. He guided me while I researched the temperature distribution in a pig thigh exposed to ultrasound including identifying hot spots around metallic implants and interfaces of different tissues. Dr. Lehmann also trusted me to treat many of his patients who often traveled from across the United States and Europe for therapeutic ultrasound, “the miracle cure” for arthritis pain.

When Dr. Lehmann left OSU in 1957 to establish a physiatry program at the University of Washington in Seattle, I assumed his position on the faculty. My research then moved into the areas of electrodiagnosis, polio, and child development. In 1963 our division became a separate department, and I was appointed professor and chair. We initiated intensive research in electrodiagnosis emphasizing carpal tunnel syndrome among other clinical diagnostic problems. The patient population gradually changed to a plurality of traumatic brain injury (TBI). Our faculty composition and research interests followed suit.

Physiatric research was once largely centered on the efficacy of deep heating modalities—ultrasound, microwave, and short wave—in a variety of conditions. In the late 1930s and early 1940s, physicians in this area of medicine were called “physical therapy physicians,” which was the impetus that caused Dr. Krusen to coin the word “physiatrist.”

Our specialty's grandfathers, Dr. Krusen and Dr. Rusk, played important roles in the founding of our medical specialty. Dr. Krusen organized one of the first training programs at the Mayo Clinic and focused on treatment of musculoskeletal diseases. Dr. Rusk, an outstanding officer in the Air Force Medical Division, organized a rehabilitation program for injured airmen. Although not a physiatrist by specialty, his reputation resulted in the formation and his heading of the internationally-recognized New York University rehabilitation program. Dr. Krusen was the driving force behind the American Board of Medical Specialties' acceptance of the American Board of Physical Medicine in 1947. He wanted the specialists to be called physiatrists (fiz-ee-á-trists). He became compulsive about the pronunciation and authored half a dozen editorials on the concept. His stance was that this pronunciation eliminated confusion with psychiatrists.

Dr. Rusk was steadfastly opposed to and would not allow any of his students to sit for the board examination unless it became the “rehabilitation medicine” board. After 2 years of negotiations, it was changed to the American Board of Physical Medicine and Rehabilitation. Dr. Rusk then decided to pronounce it fi-zahy-uh-trist. The PM&R physicians who trained in the eastern United States use Rusk's pronunciation. Unfortunately, the tension between Dr. Krusen and Dr. Rusk was evidently, but possibly inadvertently, continued by using different pronunciations of physiatrist. This is still a point of contention in 2008!

As World War II and the Korean conflicts ended, many wounded veterans descended on the medical system. Rehabilitation became a necessity, and experts in the field were recruited and training programs organized. Today, the numbers of disabled veterans are increasing tremendously. We still treat a substantial number of people with posttraumatic stress syndrome and amputations, but the number of soldiers with traumatic brain injuries has really increased in the veterans returning from the Iraq and Afghanistan wars.

Physiatry provides excellent care for people with TBI. The model systems that originated in physiatry have been remarkably effective in planning rehabilitation programs for patients with TBI and spinal cord injuries.

Overall, my career as a physiatrist is representative of the growth and development that the specialty has undergone in the last half century. I have witnessed a variety of changes in managing pain and a sweeping transformation in how we practice. I have watched the specialty adjust to treat veterans disabled in conflicts around the globe, and I have seen residency programs and PM&R practices react to reimbursement issues. When I started in the field, we were referred to as physical therapy physicians. Today, we not only are known as the best physicians to evaluate impairment and disability, but also are experts in the assessment and maximization of function. This apparent dichotomy crosses all aspects of our specialty. Dr. Rusk's rehabilitation component of PM&R emphasized function. We started testing function and measuring how much patients increased their function during and after rehabilitation. This is a tremendously important part of our field, one that both defines us and will sustain us if we can demonstrate its worth through outcomes research.

Even before I was president of AAPM&R in 1977, I was adamant that we needed to publish our own journal. Every medical specialty has at least one journal, which is necessary to guarantee the growth and survival of the specialty. Up until this point, physiatry has had an academic voice through the American Journal of PM&R and an interdisciplinary voice through the Archives of Physical Medicine and Rehabilitation. We merit a journal where we can compile an array of research reports, reviews of novel clinical management techniques, updates of successful outcomes of unusual and difficult rehabilitation problems, and highlight newly validated diagnostic and evaluation techniques. Our new journal, PM&R, is essential to stimulate, guide, distribute, report, and evaluate the vast area of PM&R knowledge.

PM&R will be our voice. PM&R will enable us to have our best clinicians and researchers publishing their best work in their own journal. World events are remarkably similar today as they were in 1940s and 1950s, when physical medicine and rehabilitation experienced its greatest period of growth. Thanks to this new journal, we are now ready for another major phase of growth and development that will sustain us into this new century. And PM&R will be the vehicle to disseminate this new information. Good luck to all!

• ⁎ Disclosure: nothing to disclose