Physical Medicine & Rehabilitation
Physical medicine and rehabilitation (PM&R), or physiatry, is a branch of medicine that aims to enhance and restore functional ability and quality of life to those with physical impairments or disabilities.1
Physiatrists evaluate and treat both adults and children with acute and chronic pain, including those with short- or long-term physical and/or cognitive impairments and disabilities that result from musculoskeletal conditions (neck or back pain, or sports or work injuries), neurological conditions (stroke, brain injury, or spinal cord injury) or other medical conditions (fibromyalgia). The goal of physiatrists is to decrease pain and enhance performance without surgery.2
History of PM&R
The Society of Physical Therapy Physicians was founded on September 12, 1938, during the annual meeting of the American Congress of Physical Medicine at the Palmer House in Chicago. The group elected Walter Zeiter, MD, as executive director, a position he held for 22 years. John S. Coulter, MD was elected as the first president.2
In the early years of the society, membership was limited to physicians with at least 5 years’ experience in the practice of physical therapy. According to the American Academy of Physical Medicine and Rehabilitation, “membership was by invitation only and was limited (until 1944) to 100 doctors. Dues for the newly formed organization were $5 a year, a rate that continued until 1956.” In 1939, the Society was formalized in New York and had 40 charter members.
The name of the organization continually evolved over the years. What began as the American Society of Physical Therapy Physicians in 1938 became the American Society of Physical Medicine in 1944. In 1951, the words “and Rehabilitation” were added. The present name, The American Academy of Physical Medicine and Rehabilitation, was adopted in 1955. By 1958, the group assumed the responsibility for continuing medical education (CME) for members. Today, over 8,000 physicians are members of AAPMR.
Chronic Pain Management
There are several modalities physiatrists employ to treat pain, including exercise, physical therapy, medication management, and interventional pain treatments. At times, a physiatrist may also be a member of an interdisciplinary team involving physicians, psychologists, nurses, and pharmacists when indicated.3 According to AAPMR, the goal of the PM&R specialty is to “effectively manage complex clinical, functional, and psychosocial issues associated with chronic pain management, and to restore function by minimizing pain. To that end, the society recognizes the critical balance needed in the medication management of chronic pain.2
Rehabilitation of Low Back Pain
This article will focus on treatment of low back pain. Rehabilitation, specifically for lumbar radiculopathy, occurs in 3 phases: physiatrists make a specific diagnosis, develop a treatment plan, and offer treatment options; flexibility and strength are developed to get the body parts into their proper positions; and a total body fitness program is designed to maintain body mechanics and increase endurance.
Back pain has been estimated to account for 45% of all physiatry visits and is one of the most expensive injuries to treat. The prevalence of lumbar radiculopathy is higher in men than women, occurring in 2% to 5% of men and 1% to 3% of women.4 Risk factors for low back pain include long-haul driving occupations, frequent lifting (especially with twisting), heavy industry work, back trauma, being tall, smoking, being overweight,5 having a sedentary lifestyle, multiple pregnancies in women, history of back pain, and chronic cough. Environmental factors account for most cases of sciatica, although family history of herniated disks is also a risk factor.6
During a PM&R visit, a physical exam will be performed to assess the intensity and exacerbating/alleviating factors as well as strength, reflexes, sensation, walking ability, hip range of motion, and presence of other disease symptoms. The patient’s disability may also be assessed using common questionnaires. X-rays can be used to screen for other problems, such as fractures. Magnetic resonance imaging (MRI) and CT scans are used primarily to confirm a diagnosis or in cases where rehabilitation is unhelpful. Electromyography can be used to record the electrical activity of the muscles, and diagnostic injections of medications can also be used (Table 1).4
The majority of patients (70% to 80%) experience improvement in pain and disability within 4 to 6 weeks with relative rest and activity modification, and only 1% to 10% of patients will require surgery.2 Rehabilitation management emphasizes return to activity. Heat, ice, electrical stimulation, and medications are often used. Epidural injections of steroids or surgery are used in cases where other treatments have failed. Chronic pain also can be treated with complementary and alternative modalities, such as acupuncture, massage therapy, and spinal manipulation.2
Education in body mechanics, stretching, strengthening, and aerobic exercises are among the most common treatment preferences.7 Exercise training to stabilize the trunk, as well as upper and lower body strengthening and increased flexibility, are extremely useful. Previous studies have found that a back hygiene program that included aggressive training in body mechanics increased proper movements that minimized or prevented further impairment and reduced the cost associated with back injury.8
How Do Proper Body Mechanics Affect Pain?
“Proper body mechanics” is a term used to describe the ways one moves throughout the day. It includes how one holds the body when lifting, standing/walking, driving, sitting, and sleeping (Table 2). Poor body mechanics are often the cause of back problems. When one moves incorrectly and not safely, the spine is subjected to abnormal stresses that, over time, can lead to degeneration of spinal structures like discs and joints, injury, and unnecessary wear and tear. That is why it is so important to learn about proper body mechanics.
Proper body mechanics maintain the natural curve of the spine. The spine normally curves at the neck, the torso, and the lower back area; this positions the head over the pelvis naturally. The curves also work as shock absorbers, distributing the stress that occurs during movement. When the spine curves too far inward, the condition is called swayback. Good posture means the spine is in a “neutral” position.
But what does good posture look like? You can instruct patients by using the following 5 steps:
- Stand with the feet apart
- Tuck the tailbone in and tilt the pelvic bone slightly forward
- Pull the shoulders back and lift the chest
- Lift the chin until it is on a horizontal plane
- Relax the jaw and mouth.
Below are some additional pointers for proper body mechanics for several daily activities.9