PHYSIATRY Getting physical to heal

A rise in sports injuries is lending new prominence to the specialty.
By ELIZABETH LARGE
BALTIMORE SUN
When Dr. Mark Gloth is asked what he does for a living, he usually says he's a "rehab doc." If he explains he's a physiatrist, he gets a puzzled look.
A psychiatrist?
Nope, although the two are sometimes confused. Pronounced "physi-AT-ry," this little-known specialty is often the last hope for patients who can't or don't want to be helped by surgery -- anyone from a stroke victim to someone suffering from carpal tunnel syndrome to a weekend warrior with a chronic knee problem.
Call it conservative care medicine.
A physiatrist is a physician who specializes in physical medicine and rehabilitation after four years of medical school. The four-year postdoctoral training includes, among other specialties, orthopedics, neurology and rheumatology. He or she may go into pediatrics or treat adults.
One reason physiatry is getting more publicity now is the number of sports-related injuries and musculoskeletal problems. With more than 35 million musculoskeletal injuries in the United States each year, according to the Web site Physiatry.com, there are enough patients to keep as many physiatrists busy as medical schools can turn out. The aging of the American population contributes to the demand, too.
Techniques
"Physical medicine" refers not to sports medicine, but to the physical methods used, like physical therapy and heat. Rehabilitation describes perhaps the most important part of the specialty -- helping people with serious disabilities (such as Parkinson's disease or an amputation) function better.
Dr. Jeffrey Palmer, a professor and director of research in the department of physical medicine and rehabilitation at Johns Hopkins, calls rehabilitation "an approach and a philosophy," pointing out that a person with a catastrophic injury, like actor Christopher Reeve, might formerly have been put in a nursing home to die. No longer. And physiatry deals with problems that you might not expect. Dr. Palmer is a specialist in swallowing disorders.
These physicians do what it takes to get their patients back to their normal lives. That could be making a difficult diagnosis, prescribing drugs (although exercise is prescribed more than medicine), applying a heating pad in the office or teaching stretching techniques. It's not unheard of for a physiatrist to be trained in acupuncture.
Surprisingly, given how few people know about it, the specialty has been around almost 60 years. During World War I, soldiers started surviving serious injuries because of advances in medicine. Doctors treated the disabled with physical techniques such as heat and exercise. This was the beginning of physiatry, but it wasn't recognized as a separate medical specialty until 1947 (gaining importance again with the treatment of injured and disabled soldiers). Until recently, the emphasis was on rehabilitation, but these days medical students are likely to specialize in the sports-medicine side.
Growth in the field
In 1994, there were 4,642 board-certified physiatrists in the United States; now there are 7,460, according to the American Board of Physical Medicine and Rehabilitation. That doesn't mean they are as common as, say, orthopedic surgeons. When Dr. Palmer first arrived in 1987, he was the only physiatrist at Hopkins. The number has grown to 12.
Treatments have changed as well. Twenty years ago, if you had a herniated disk, you'd have a back operation. These days, surgery isn't usually performed. Instead, you might go to a physiatrist, who because of his or her training will take a holistic approach to the problem. In an age of specialists, a physiatrist is more of a generalist. He or she will look at your whole body during the physical exam and in taking your medical history.
Patient's report
When Julie Elrod, owner of the American Academy of Martial Arts in Columbia, Md., hurt her thumb sparring with a student last December, she thought it was a minor injury.
"It should have been nothing, but it turned into chronic pain," she said. It radiated all the way up to her shoulder. "On a scale of 1 to 10, it was a 14. I've never felt anything like it."
After seeing a host of specialists, she ended up in Dr. Gloth's office at Union Memorial Hospital in Baltimore.
"I was amazed at the number of options he had for me," said Elrod, 37. The treatment they settled on started with taping her hand a certain way to pull the skin away from the nerve and putting her on a steroid medicine. It continued with physical therapy. An orthopedic surgeon's prescription for physical therapy may say something like "evaluate and treat," leaving the details up to the therapist. A physiatrist will give precise instructions.
"It takes out the guessing game," Dr. Gloth says.
Within a month of her first appointment, Elrod says, the pain was down to a 4. She's back teaching martial arts five hours a day, six days a week.
Boosting independence
Dr. Gloth, the new head of physical medicine and rehabilitation at Union Memorial, sees his job as improving his patients' "functional independence."
"Physiatrists focus on the quality rather than the quantity of life," he says. "It's not acute-care medicine. [We deal with] the recovery level."
Although the emphasis is on alternatives to surgery, these specialists also work with postoperative patients. Large orthopedic practices sometimes include a physiatrist. Surgery isn't ruled out as the solution to the patient's problem. It's simply the last resort.