What Is Physiatry? Steven J. Farrell, MD Associate Professor and Chief Physical Medicine and...
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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
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Who The Heck Gets Into Who The Heck Gets Into Rehab?Rehab?
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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
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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)
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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
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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
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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
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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
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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
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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
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But What Do We Do?But What Do We Do?
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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
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The TeamThe Team
Physical therapistPhysical therapistOccupational therapistOccupational therapistSpeech and language therapistSpeech and language therapistCounselorCounselorNursingNursingTherapeutic recreation specialistTherapeutic recreation specialistSocial workerSocial workerPhysiatristPhysiatrist
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Physical TherapistPhysical Therapist
Works on tasks Works on tasks – MobilityMobility– TransfersTransfers– GaitGait– Car skillsCar skills– Pain controlPain control– EducationEducation
Exercise, modalitiesExercise, modalities
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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
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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
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CounselorCounselor
May be social worker, psychologistMay be social worker, psychologist
Adaptation to disabilityAdaptation to disability
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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
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Social WorkerSocial Worker
Discharge planning Discharge planning
Procure equipmentProcure equipment
Follow up arrangementsFollow up arrangements
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Therapeutic Recreation SpecialistsTherapeutic Recreation Specialists
Works with avocational tasksWorks with avocational tasks
Hobbies and interestsHobbies and interests
Field tripsField trips
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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
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Medical/Rehabilitation Issues Medical/Rehabilitation Issues We EncounterWe Encounter
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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
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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
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BladderBladder
NeurogenicNeurogenic– Unhibited bladderUnhibited bladder
StrokeStrokeBabiesBabies
– SpasticSpasticTBI or SCITBI or SCI
– FlaccidFlaccidCauda equina syndromeCauda equina syndrome
– Dysynergic Dysynergic Higher level SCIHigher level SCI
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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???
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Skin/Pressure UlcersSkin/Pressure Ulcers
Direct pressureDirect pressure
FrictionFriction
ShearingShearing
MoistureMoisture
MalnutritionMalnutrition
AnemiaAnemia
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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
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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
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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
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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
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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
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60 % Rule60 % Rule
Joint replacementJoint replacement– BMI > 50BMI > 50– Active weight bearing polyarthritisActive weight bearing polyarthritis– Bilateral joint replacementsBilateral joint replacements– Age > 85Age > 85
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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
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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
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Fields of OverlapFields of Overlap
OrthopedicsOrthopedics
Internal medicineInternal medicine
NeurologyNeurology
NeurosurgeryNeurosurgery
Rheumatology Rheumatology
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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?
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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?
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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??
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Questions?Questions?