Good Overview Articles on PM&R

PHYSIATRISTS SEEK TO GET PATIENTS BACK TO NORMAL


BY ELIZABETH LARGE
The 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.

"Physical medicine" refers not to sports medicine, but to the physi-cal methods used, such as 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. 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.

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 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.

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 says. 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 Gloth's office at Union Memorial Hospital in Baltimore.

"I was amazed at the number of options he had for me," says 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 quite precise instructions.

"It takes out the guessing game," 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.

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."

While the emphasis is on alternatives to surgery, these specialists also work with post-operative 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.

PHYSIATRY SHUNS SHORT TERM FIXES

Specialty unites physical medicine and rehabilitation
Maximizing ability to live, work and play is the goal


BARBARA TURNBULL
LIFE WRITER
TORONTO STAR NEWSPAPER


Leslie Bolt knew it was risky.

That's why she had put off for years the operation to correct the tangled web of arteries and veins in her brain, a condition, arteriovenous malformation (AVM), caused by abnormal development of blood vessels.

She suffered through seizures in high school, but a bleed in her 20s led to a recommendation that she have surgery, despite the risk it posed. During the procedure, a vascular hemorrhage caused Bolt to become paralyzed on one side.

She spent six months in an acute care hospital, a year in the Toronto Rehabilitation Institute (TRI), six months as an out-patient and, two years later, continues with physiotherapy three times a week.

It could have been worse: no major cognitive damage was done and, despite some permanent impairment, her physical abilities will likely continue to improve, albeit only with continual hard work.

Ask Bolt who she counts on the most of the myriad of professionals she has dealt with and the answer is unequivocal: her physiatrist at TRI, Dr. Mark Bayley.

Physiatry is the specialty of physical medicine and rehabilitation. The word is new to many people, but the specialty has been around since the 1940s, when advances in antibiotics and surgical techniques meant many war veterans were surviving with multiple and complex needs. They had combinations of musculoskeletal issues (involving bones, joints and muscles) and neurological problems (nervous system, brain, spinal cord and peripheral nervous injuries), while also requiring specialized rehabilitation.

Physiatry ? which is pronounced fiz-i-a-try ? is often confused with psychiatry.

Who would see a physiatrist? A wide spectrum, from people who have suffered amputation, a stroke, brain or spinal injury, were born with a neurological disorder or are simply affected by chronic pain or sports injuries. Even those with repetitive strain injuries may apply.

It is often the last hope for patients who can't or don't want to be helped by surgery.

Unlike traditional medicine, which typically zeroes in on diagnosing a problem and its initial treatment, physiatry focuses on the resulting disability and how it affects that person's life, explains Tim Doherty, vice-president of the Canadian Association of Physical Medicine and Rehabilitation. The ultimate goal is to maximize each person's ability to live, work and play.

Physiatry takes a team-based approach, adopted by a growing number of medical specialties, but pioneered in physiatry's developing days. A physiatrist heads a team that's unique for each case: it may contain surgeons, specialized nurses, various therapists, psychologists, social workers, prosthetists and other physicians.

It also includes the patient as an equal partner, Doherty says. "Rehabilitation, as a concept, isn't done to somebody, they participate in it."

A physiatrist takes into account the individual factors that come into play outside the main medical problem: an individual's coping mechanisms, social and financial support structures, psychological makeup and personality. "Working within a team, you can get expertise brought to the table that helps deal with as many of those things as possible," Doherty says. "The physiatrist's job within that realm of our work is really in being somebody who sees the big picture from the beginning to the point that people have reached their rehabilitation goals."

That big picture means a lot to someone like Bolt, who checks in with her team leader at least four times a year ? that's when things are going well. "The neat thing about physiatry as a practice is that because they're really out for the goal of the wellness of you, it just really shows through in the way they care about you," she says.

In the general hospital, Bolt found answers and attitudes to be more inflexible. She even came to rely on that, entering rehab with a similar attitude, but quickly learning that things can be much grayer. "The good news about it being more gray is that there's always opportunities, there's still hope in different corners," she says.

Physiatry is a broad specialty because it deals with people with such a variety of problems, from sports injuries to complex brain and spinal cord injuries. As a result, even physiatrists become specialized, with practices often devoted to nerve and muscle disease, chronic pain or musculoskeletal problems.

Another aspect unique to physiatry is that it follows people for very long periods of time. "As opposed to seeing someone once and providing a diagnosis, people are followed for months or years as they progress through the different stages of trying to maximize what they can functionally do," Doherty says.

Eventually that follow-up happens intermittently, but it's still important, because there are issues that, for example, a family physician might not have the expertise to deal with and a specialist might not focus on because it's something that can only be managed, not cured.

"Despite advances in drugs and (medical research), we still have areas of medicine that provide problems that we can't fix," Doherty says. "Attempting to minimize complications and maximize the individual's function is really where we're at with a lot of things still."

As opposed to a quick fix, rehabilitation is a set of principles that looks at a person's quality of life and how it can be maximized ? no matter how long it takes.

Someone who's always been an active, hard-working person and develops a back problem may have to completely change the way he functions as an employee, a spouse and a parent.

"Appropriately, patients don't accept, `This is the way you are. Live with it,'" Doherty says. "There's a process that has to go on. Some of it is helping with the underlying problem and some of it is, `Here's what you can and can't do.'" The physiatrist even goes one step further by including any medical professionals who can help the patient achieve the goals.

"It's a skill set that a lot of physicians don't have, because they have not been taught how to deal with chronic problems and chronic disability," Doherty says. For things not fixable, the traditional medical model mostly hopes that a person can cope, but "it's facilitating that coping and minimizing other problems that come from it that is really the hallmark of trying to rehabilitate somebody and how to make the most of what they have," he says.

Ga?tan Tardif, director of physiatry at the University of Toronto and vice-president of medicine and physician-in-chief at the Toronto Rehabilitation Institute, notes that, compared to the U.S. on a per capita basis, Canada has less than one-third the number of physiatrists. Yet physiatrists are among the specialists Americans try to recruit, he says.

There are always openings, although that's common for most medical specialties. Toronto could absorb every graduate from this year and still have positions unfilled, Tardif says.

"One of the interesting things about physiatry is that people either know us a lot or they don't know us at all," Tardif says.

But that's likely to change as the population ages and the need grows.

"People are demanding more and more rehabilitation services," Doherty says. "It's a growth industry because of the way people perceive what the health care system should bring to them and there's demand. That really has produced a very significant need for rehabilitation physicians or physiatrists."

PHYSIATRY: THE MEDICAL REHABILITATION SPECIALTY

By Miki Fairley
THE O&P EDGE

Physical medicine and rehabilitation (PM&R) "is often called the 'quality-of-life' profession because its aim is to restore optimal patient functioning. The focus is not on one part of the body, but instead on the development of a comprehensive program for putting the pieces of a person's life back together--medically, socially, emotionally, and vocationally--after injury or disease

Physical medicine and rehabilitation (PM&R) "focuses on how the whole person functions," says Charles Levy, MD, chief, Physical Medicine & Rehabilitation Service, North Florida/South Georgia Veterans Health System, Gainesville, Florida. "Each specialist on the rehab team has his perspective, but we physiatrists have the responsibility of seeing the entire picture--that's part of our training." The "whole-patient" view encompasses treatment or referral for medical conditions, pain management, making sure the patient receives needed physical or occupational therapy, and prosthetic or orthotic devices and training in their use, Levy explains. Often psychological, vocational, and funding issues also must be addressed.

"We try to make sure that everything patients need to get on with their lives--not just heal their wounds--is in place," says Clay Kelly, MD, director, Amputee Clinic, MetroHealth System, Cleveland, Ohio.


Team Model

Physiatry emphasizes the team model, with the physiatrist as the leader, coordinating treatment. The physiatrist is charged with overseeing the process and assuring that the other team members are working in concordance. This is similar to putting the pieces of a puzzle together.

"A major theory of physical medicine is that the patient is managed by a team--we're not alone," says Kelly.

Ideally, key members of the team will see the patient together and develop a treatment plan. If consultation is needed to reach consensus, the team may adjourn to a separate room for discussion, then return to the patient.

The patient thus benefits from the best thinking of several professionals who can interact with one another and the patient on the spot. Besides physiatrists, teams may include orthotists/prosthetists, physical or occupational therapists, orthopedists, rehabilitation nurses, residents, and others.

Harry Webster, MD, Pediatric Division chief, New England Medical Center Department of Physical Medicine & Rehabilitation, Boston, Massachusetts, points out that the patient "gets the best of our thinking," when the team meets together at the same time. "I don't consider myself the ultimate authority; I'm looking for that synthesis to give the patient the best prescription. That doesn't happen if I write the prescription and two weeks later, the patient and family go to an orthotist I've never seen."

The physiatrist takes the lead in evaluating symptoms and making appropriate diagnoses. The rest of the team then knows the medical issues and can also anticipate medical complications that could interfere with rehab. However, the physiatrist also needs to listen closely to other team members, since they have in-depth experience in their specialties and can contribute information to help the physician make good decisions, says Walter Davis, MD, director of education, Center for Biomedical Ethics, Department of Physical Medicine & Rehabilitation, University of Virginia, Richmond.

"This is not the typical medical model, in which the doctor takes the history of the patient, performs an examination, makes a diagnosis, and prescribes treatments," explains Davis. "The rehab model is more complicated; the physician should be checking in with members of the rehab team to get their experience and thoughts."

"When an orthotist comes to our clinic, we provide a service to families that is outstanding," says Webster. "Not only can we do the casting on that same visit, thus saving the family time, parking expenses, etc., but we can put our heads together for the best solution and appliance for that patient."

"Patients don't like having to see the doctor, then wait to see the prosthetist, then wait again to see the physical therapist," says Davis. "When patients come to our clinic and we see them together, they feel they've gotten the best interaction from the clinical team--a meeting of the minds, rather than three different people saying three different things."

Academic medical centers are usually necessary for a true team approach, notes Davis. Reimbursement issues and simple logistics make it much more difficult for physiatrists with separate, independent practices to utilize a true team approach, which is a hallmark of what makes the PM&R specialty unique, he explains.

"The team approach is also alive and well in the Veterans Health System," adds Levy.

Many physiatrists in private practice focus on sports medicine and pain disorders such as back pain, rather than treating amputations, stroke, cerebral palsy and other largely pediatric conditions, and brain and spinal cord injuries, Webster notes. "They are generally procedure-oriented, using interventions such as steroid injections; then sending the patient to a therapist in another facility. It is a challenge to do a true team approach."


Pain Management

Pain management is a vital part of the physiatrist's responsibility. "If pain is not being controlled, the rest of the rehab doesn't go anywhere," says Davis. For example, when the physician sees the patient in his morning rounds, he may not gain accurate information on how well pain medicines are working. However, by working with the patient later in the day, the therapist can note problems and report them to the physician. For instance, the patient may still be in too much pain for effective therapy or be so over-medicated that he or she is practically asleep.


What draws physicians to this specialty?

Sometimes it's a longstanding interest in the field. Kelly has had an interest in amputee care since he was young, and he is even married to a prosthetist: Sharon Kelly, CP, who works for Hanger Prosthetics & Orthotics, Euclid, Ohio. Kelly says he would be delighted if their three sons follow their parents into a medically related field, "but that's up to them."

Working with children with disabilities and special needs in a summer camp as a volunteer hooked Stefans into deciding on a career as a pediatric physiatrist.

When Davis was in medical school, he attended a yearly medical student association conference in Washington, DC. Among the exhibits was one from the Walter Reed Hospital rehabilitation physicians. "Before that, I didn't realize this was a separate specialty," he remembers. Davis had already had experience in working with disabled children and adults before entering medical school, and PM&R "enables me to combine medicine with my interest in working with disability."

Levy's first interest was in neurology, but PM&R was more appealing. In some aspects of medicine, once the diagnosis is made, the recipe for care is basically always the same, Levy notes. "But with physical medicine and rehabilitation, you have to look at the whole person. You can't get the answers out of a book." For example, to help one person psychologically through rehab, the physiatrist might have to be a cheerleader, for another patient, being a sympathetic listener might be best. Some benefit from support groups or joining an online listserv, others don't want to talk about their problems. Some are motivated by their desire to return to work or accomplish some skill. "You have to understand that person and what helps him get up and what knocks him down," says Levy. Matching the person to the solution also extends to such practical matters as prosthetic component selection: for instance, an extremely active patient needs a rugged prosthesis, while another patient may be a milder user.

Describing the specialty's appeal, which likely applies to many other PM&R physicians, Levy says, "In rehabilitation, you almost always can improve patients' lives in some way, even if they are not totally restored. I like to be able to think creatively and come up with solutions."


Physiatry: Focusing on Function

Physiatrists focus on restoring function, notes the American Academy of Physical Medicine & Rehabilitation (AAPM&R). Physiatry is one of the 24 medical specialties certified by the American Board of Medical Specialties. Currently there are 80 accredited residency programs in the US and more than 6,700 practicing physiatrists.

Although physical means of healing have been practiced for thousands of years, PM&R began in earnest in the 1930s with the physical treatment of musculoskeletal and neurological conditions. The field broadened its scope after World War II when thousands of veterans returned home with catastrophic injuries. In 1947, the Advisory Board of Medical Specialties recognized physiatry as a medical specialty.

Physiatrists treat a broad range of conditions, including acute and chronic pain and musculoskeletal disorders. They coordinate long-term rehabilitation for patients with spinal cord injuries, cancer, stroke and other neurological disorders, brain injuries, multiple
sclerosis, and amputations. Physiatrists treat about 50,000 new amputees each year, according to AAPM&R.

Physiatrists practice in rehabilitation centers, hospitals, and private offices. Often they have broad practices, but some concentrate on one area, such as pediatrics, sports medicine, geriatric medicine, or brain injury. In recent years, the field has seen an increased focus on musculoskeletal and industrial medicine, pain management, sports medicine, and electromyography.

NATIONAL INSTITUTES OF HEALTH AWARDS GRANTS TO MOTION ANALYSIS LABORATORY AT SPAULDING REHABILITATION HOSPITAL

BOSTON, Nov. 17 (AScribe Newswire) --

Led by Paolo Bonato, PhD, director, Motion Analysis Laboratory at Spaulding Rehabilitation Hospital Network (SRHN), researchers at the hospital will contribute to two cross-institutional studies that examine motor control during functional tasks.

A team of researchers including Bonato; Sara Salles, DO; and David Standaert, MD, PhD; will embark on a four-year project to study motor fluctuations, or changes in the body's ability to move, in individuals with Parkinson's Disease (PD). The grant, funded by the National Institutes of Health, includes a subcontract with Metin Akay, PhD, Dartmouth College.

According to Bonato, the team will rely on Delsey Sherrill, MS, who recently joined the Motion Analysis Laboratory, to develop data mining and artificial intelligence systems to recognize the presence and severity of motor fluctuations in individuals with PD. "Data mining allows us to use current information to predict future behavior and outcomes. Because of this, our findings will benefit clinical management of patients as well as aid those who conduct medical trials on treatments for Parkinson's Disease," explains Bonato.

One phase of the study will explore motor patterns associated with the various motor tasks in individuals with PD. Typically, individuals with PD experience slowness of movement, rigidity in the limbs, and tremors. While there are several medications to treat these symptoms, the dose period for each varies differently from person to person, resulting in "on" and "off" phases. During the "off phase," the individual's medication may not be working, usually because it is later in the dose period. In the "on phase," the medication is working, and the individual may have normal to near-normal voluntary movement. However, individuals may still experience dyskinesia, rigidity, akinesia, and dystonia in the "on phase."

Since clinical assessments rely on motor tests such as the Stand-Walk-Sit test, Pronation-Supination test, and "Hand Arm Movement Between Two Points" test, similar motor tasks will be examined in this study. Bonato states, "At present, we hypothesize that movement disorders that accompany late-stage Parkinson's Disease will present with identifiable and predictable features that can be derived from surface electromyographic (EMG) and accelerometer (ACC) signals recorded during a standardized set of motor assessment tasks."

The research team will analyze data collected in the Motion Analysis Laboratory at Spaulding Rehabilitation Hospital, and also from portable technology that records the participants' movements outside of the laboratory. Bonato explains that the study "meshes with the work we are doing in the field of wearable technology. At present, portable technology is bulky and inconvenient, so we are developing better sensors and systems that allow us to gather more data in a less intrusive way."

He continues, "Although this project focuses on a specific clinical application, the approach can be generalized to numerous applications in which data mining and other methods developed in this project can be used to analyze large data sets recorded using wearable sensors."

At Dartmouth College, Akay will focus on the assessment of motor functions in PD using nonlinear dynamical analysis including fractal and chaos analysis. According to Akay, nonlinear dynamical analysis will provide an insight about the underlying mechanism and help researchers to determine the complexity of motor fluctuations in PD patients before, during, and after medication. Akay states, "These complexity measures can be further used to assess the effectiveness of the prescribed treatments and therapies."

The second research study, in coordination with Gerald Gottlieb, PhD, at Boston University and Daniel Corcos, PhD, at the University of Illinois at Chicago, will study motor control mechanisms in lower limb movement. The researchers hope to achieve a deeper understanding of how the brain interacts with the environment to produce a coordinated voluntary movement.

Jennifer Lelas, MS, a member of Bonato's team in the Motion Analysis Laboratory, will organize the study at Spaulding Rehabilitation Hospital. Lelas states, "We believe that the central nervous system plans movements in terms of learned patterns of muscle activation that, through trial and error, have been found to generate the forces within a joint that produce acceptable movements. This contradicts the widely held theory that voluntary movement emerges from some form of explicit kinematic planning, namely that the brain is programmed according to desired trajectories of body segments."

She continues, "In this study we will examine how forces within a joint, or joint torque patterns, and associated muscle EMG patterns vary across a range of tasks and subject populations."

At completion of the study, the researchers hope to learn how forces in a joint adapt to perform different movement tasks. A component of the study will measure individuals who have had strokes to shed light on principles that affect gait changes in that population.

About the Spaulding Rehabilitation Hospital Network The Spaulding Rehabilitation Hospital Network, home to Harvard Medical School's Department of Physical Medicine and Rehabilitation, has built a national reputation for excellent clinical care, advanced research, and innovative programs in rehabilitation. A member of Partners HealthCare, the Spaulding Network includes its main campus, a 296-bed facility located in Boston, Mass., and seven outpatient sites throughout the Greater Boston area.

Furthermore, Spaulding provides clinical and management consulting services to the following: Berkshire Medical Center, Pittsfield, Mass.; Burbank Rehabilitation Center/HealthAlliance, Fitchburg, Mass.; Park View Specialty Hospital, Springfield, Mass.; Rehabilitation Hospital of the Cape and Islands, East Sandwich, Mass.; Rehabilitation Hospital of Rhode Island, North Smithfield, R.I.; and St. Joseph Hospital, Nashua, N.H. Among the 10 best rehabilitation hospitals in the nation, Spaulding is the only rehabilitation facility in New England ranked since 1995 by U.S. News and World Report in its Best Hospitals survey. For more information, please visit www.spauldingrehab.org.

WHEN WE HURT GETTING MOVING CAN HELP

By MOLLY MARTIN

The Seattle Times

The aching and swelling in the joints are gone for now, but the bottoms of my feet still burn, pretty much all the time. The tendinitis in my right forearm seems to be fading, but the back of the left knee has swollen, mysteriously, into a big, smooth lump. A nagging left wrist tenderness, from my body-surfing stupidity two years ago, did eventually calm down. But the upper arm that needed a metal rod and nine screws to repair the break that day hasn't been the same since. I have finally healed up from the Achilles, knee, back and wrist injuries I had at the end of my last go-round with basketball - nearly four years ago.

But as I write these words, my neck has seized up.

Perhaps I've gone a little overboard on research for this story.


Chronic, acute pain

I'm not complaining, just taking stock. Considering the estimated 50 million Americans living with chronic pain and 25 million more each year with acute pain from injury or surgery, I'm fairly well-off.

As many of those millions well know, although the research, understanding and treatment of pain have advanced considerably in recent decades, that doesn't always translate into an ability to reduce or relieve pain, even among those who specialize in that field.

"The research data on the biochemistry of nerve function and the physiology of pain really is impressive," says J. David Sinclair, a Seattle-area M.D. and independent consultant for the management of chronic pain. "It's so impressive that if we're not careful, we can convince ourselves we know what we're treating. We know an enormous amount more than we did 30 years ago, yet we really need to keep in sight that we know very little about what we're treating, namely the extremely complicated phenomenon of the experience of pain - and most of us know very little about who we're treating."


A powerful tool

Fortunately, one of the most powerful tools for dealing with pain - whether from exercise, injury, surgery or some more mysterious source - is also cheap and accessible, if not always easy:

Movement.

At first, it may seem counterintuitive, for when we hurt, we often feel like staying still, lying low until the pain is gone. Or we use pain as an excuse to not exercise (as I'm doing with this stiff neck). But regular, moderate movement often can help soreness dissipate more quickly and injuries heal faster, as well as help us manage ongoing pain and keep it from running our lives.

"Pain is not a valid reason for not being fit," Sinclair says. "In fact, fitness is a major contributor to the modulation of pain in a way that helps people be more comfortable."

Obviously, pain can't be counted on as the only indicator of trouble. When diagnosed with breast cancer more than 10 years ago, I had no pain whatsoever, until surgery and then chemotherapy, which were well worth living through.

Also, movement clearly isn't the solution to all pain. Certain medical conditions, such as migraine headaches, aren't necessarily helped by increased physical activity.

Often, though, there's a compromise. When I was 9, my mother knew I wasn't faking knee pain when I actually lagged behind during trick-or-treating. We learned I had a disease of the hip, and I was instructed not to put weight on that leg while the ailment ran its course, which turned out to be 2 1/2 years. But as kids tend to do, I adapted, reluctantly doing prescribed leg-lift exercises but eagerly learning crutch kickball, crutch-running (crutch, hop-hop, crutch, hop-hop) and crutch-walking (moving without touching the ground with my good foot, quite a good upper-body workout). I remember once sprinting with one crutch while preparing to launch the other, javelin-style, at some boys during recess, incurring a different sort of pain: a trip to the principal's office.

Though there may be many kinds of pain, doctors generally distinguish between two overall categories: acute and chronic.

Acute pain is useful, biologically speaking, and crucial to protect life and health. It's the pain that tells me to take my hand away from the fire so I won't get burned.

For the most part, acute pain isn't very mysterious: Doctors understand how the signals are sent and received, and it's fairly clear which treatments help. Anti-inflammatory and narcotic medications, for example, often work well.

Acute pain also carries an expectation of resolution, that the wounded part will get better. So pain or discomfort from exercise can be considered a type of acute pain.

Chest pain, a severe injury or pain that persists during a workout should get immediate attention, of course. But when working to develop the heart, lungs and muscles, some discomfort can be expected, and is in fact needed to improve fitness.

Being able to differentiate training discomfort from acute pain can be a matter of listening to the body, knowing the risks of the sport or activity, or consulting with someone who understands one or both. Each year as the sun rises earlier and the weather warms up, I resume jogging along the downtown Seattle waterfront and climbing the stairs at one of the piers, a nice interval workout with a view of Mount Rainier. I know the burning in my lungs will lessen if I persist with these workouts, and the soreness in my thighs and calves will be worse two days after my initial outing and not too bothersome after that. But I also know, from more experience than I'd like to admit, that if I continue to run after feeling an aching in my shins, I'm likely to wind up with shin splints that can dog me for months.

One guideline says it's often OK to keep exercising with dull, temporary discomfort in the muscles but not when pain is sharp or in or near the joints. Stiffness that lasts 24 to 48 hours after exercise is normal, as muscles rebuild themselves stronger than before. Ongoing soreness, constant fatigue and a fast pulse upon waking can be signs of injury or overtraining.

Icing is the first line of treatment for many injuries, and immobility is used less and less. After reconstructive surgery more than 20 years ago, my knee was immobilized for eight weeks and in a hinged cast for another three. If I were to have that same surgery today, I might begin bending my knee (with some prompting) the very next day, to help reduce stiffness and retain range of motion and muscle tone, all enhancing recovery.

Even if the injured part needs rest, often the other parts of the body can keep moving: stationary bicycling while an arm mends, swimming during knee rehab.

"The quickest way to get over any injury is to use it," says Thomas Williamson-Kirkland, an M.D. in physical medicine and rehabilitation at Virginia Mason Medical Center in Seattle. "Use it to stretch it, use it to get stronger, then use it to get endurance back up. Injuries will heal themselves, mostly. You keep stretching and flexibility up, and it works best if you stress it moderately while it's healing."

Identifying and treating acute pain is also important because left unaddressed, pain itself can slow healing or, what's worse, lead to much murkier territory.

--CON'T FROM ABOVE ABOVE--

WHEN WE HURT GETTING MOVING CAN HELP

By MOLLY MARTIN

The Seattle Times


Chronic pain, by contrast, is defined as being, well, more poorly defined. It's not biologically useful-hurt does not necessarily mean harm.

Some kinds of ongoing pain, such as arthritis of the hip, have an identifiable source and tend to respond to anti-inflammatory medications. But often, where tissue has been injured in the past, the body continues to produce a perception of pain, even though the injury is no longer active. Anti-inflammatories aren't as effective in relieving such "centralized" pain, but anti-depressants can be, even in patients who aren't depressed.

"With chronic pain, it's more difficult," says Williamson-Kirkland. "If you look at injuries, there is a gradual weeding out of people who get healed. In six weeks, 90 percent will be back functioning. Within six months, it's 95 percent. So you're left with 5 percent of the most difficult problems."

Those 5 percent are a big reason why more than 1,300 doctors in this country specialize in pain management and why pain causes up to an estimated $100 billion each year in medical costs and lost work.

Treatment of chronic pain begins with getting a reliable diagnosis and ruling out causes that might be life-threatening, such as cancer. After that, the palette of treatments can be as wide-ranging as the pain is stubborn. What helps in many cases is a combination of approaches, including medications, stress management, diet, health habits and, often, some sort of movement.

Sinclair differentiates between things that comfort, such as massage and hot tubs, and those that help. "The list of things that comfort is a mile long. The list of things that help is a line long - and most have to do with being fit."

His short list for helping with pain starts with a life of some consistency: getting up at a given time, getting washed and dressed, going to bed at a regular time. "Structure is the underpinning of an active life, and it's good for a person's mental state to be living a reasonably structured life." Also within that structure: staying active physically and mentally, using medications appropriately, and paying attention to diet.

"You wouldn't have had to tell anybody this 50 years ago," when physical activity was a natural part of daily life, Sinclair points out.

Movement stimulates the sense of where our body is in space, not only lubricating joints, improving aerobic capacity of muscle and giving psychological benefits, but also helping derail pain signals.

Pain specialists advise patients to get moving again gradually, to prevent re-injury and excessive soreness and create small successes that encourage more activity. Some start with as little as a minute at a time, repeated many times a day and adding a minute each day. Others increase activity only after three successful bouts at the previous level, or commit at first to only 20 minutes, three times a week. Another rule for patience and persistence is "one day down, two days to rehab," meaning if the period of inactivity has been a month, it could take two months to regain the previous level of function; if sedentary a year, then two years to recover it.

Along the way, another crucial and equally cheap and accessible tool comes into play: the brain.

Bringing up the role of the brain to people in pain can be tricky. Many are extremely sensitive to hearing, "It's all in your head."

"I tell people, 'You do have real pain, even if you may not have anything to see on the X-ray. But that pain can be modified by the brain,' " says Gordon Irving, an M.D. and medical director of the Pain Management Center at Swedish Medical Center in Seattle. "You have to train your brain to dampen down those pain signals."

It also helps some people to realize this: "All our conscious experiences are in our head," says David Tauben, an M.D. in internal and pain medicine at Minor & James Medical in Seattle. "That's where our biology has placed our pain perception. So pain is always in your head, just like laughter, memory, poetry, thought."

Some pain specialists describe acute pain as one part the sensation of pain and three parts anxiety. "That is as it should be," Tauben says. "We ought to be anxious that we have, say, a thorn in our leg, and be worried enough to do something about it."

With chronic pain, when there is no discernible thorn, just knowing the hurt is not doing harm can be a step toward reducing that natural anxiety and managing pain.

Years ago I pulled a groin muscle while stretching. Weeks and months went by and it never seemed to heal. Sometimes I'd start limping after just 10 minutes of jogging or playing tennis. I went to see, in succession, an orthopedic surgeon (and was given cortisone pills), physical therapist (exercises), chiropractor (multiple spinal adjustments), podiatrist (orthotics) and acupuncturist (needles). Some treatments helped for a while, but the pain always came back.

After a few years, I saw another orthopedic specialist. He concluded the pain was not a chronic groin pull but instead was related to that hip disease of my childhood. It wasn't likely to get worse, he said, but there was nothing to make it better, either, unless I wanted to go to a particular surgeon in Italy to try an operation that would remove a slice from the thigh bone, changing its angle and, perhaps, easing the strain on the malformed joint. I briefly considered the trip and the surgery, then decided against it. Knowing the pain wasn't a sign of a worsening problem, I stopped worrying about the hip. And after a month or two, the pain went away. Though the tightness is still there, it hasn't really bothered me since.

But what about pain that doesn't go away?

"Patients may expect the problem to be totally cured. That, at least at this point, is not a realistic expectation for people with chronic pain," says James Robinson, an M.D. at the University of Washington's pioneering Multidisciplinary Pain Center. "But there's a monumental difference between pain that dominates a person's attention, produces severe emotional distress, leads them to stop living, disrupts all their plans, versus pain that they'd much rather not have but they've put some boundaries down, put it in the background, and gone on with their lives."

That can require a shift in thinking.

"Much of their suffering is related to the changes the pain has drawn onto the map they were following in life," says Sinclair. "There are rivers and hills, bridges and roadblocks where none existed before. Their map of life has changed enormously, and they don't know where to go. At this point they can be 'lost' forever or they can orienteer the new territory to find old satisfactions using a new map."

It might even be possible to tone down the inevitable.

"The best thing you can do for back pain is to be happy," says Stan Herring, an M.D. with Puget Sound Sports and Spine Physicians in Seattle and team physician for the Seattle Seahawks. "Because if you're happy, whatever injury or illness comes your way, you're going to handle it better."

This seems increasingly relevant, at least for me, midway through my 45th year, or what I'm beginning to think of as my "Year of Prednisone." The steroid medication took care of that joint swelling from an apparent auto-immune problem, which has curtailed my activity though not, unfortunately, my ability to gain weight.

With all this in mind, then, I might pick the subject of next year's fitness issue a little more carefully. Perhaps "Getting in the Best Shape of One's Life" or "Making Every Day a Spa Experience."

My feet still burn. But hey - my neck is feeling a bit better.

BABY BOOMERS EXPECT TO BEAT THE ODDS WITH MORE ACTIVE, LONGER LIVES


CHICAGO--(BUSINESS WIRE)--Dec. 23, 2003--At the stroke of midnight, January 1, 2004, the youngest of the Baby Boomers will begin marking their 40th birthdays and the official entrance to "middle age." Baby Boomers - those born between 1946 and 1964 -- have, for the entirety of their lives, been fixated on health, vitality and youth. The Rehabilitation Institute of Chicago (RIC), today announced the results of a survey of Baby Boomers that showed they are perhaps the first generation to not only expect, but also demand to live longer than the average life expectancy and to remain active until the end. The survey also revealed shifting attitudes toward the type of medical care Boomer's would seek to help maintain their youthful vigor.

The Baby Boom generation has seen the most dramatic leaps in medical science and life expectancy of any other generation in history, with the average for men now at 74.1 years and for women, 79.5 years. "No one wants to admit they are going to slow down as they age, but the Baby Boomers surveyed have unbridled optimism about life, with 50 percent planning to make it beyond age 80 without serious limitation on their activities," said Dr. James Sliwa, medical director of the General Rehabilitation Program at RIC. "An overwhelming 79 percent feel they will not experience serious limitation until beyond age 70. We are delighted to know that Boomers have such high hopes, but they need to take decisive action now to turn those hopes into reality."

Adopting a healthy, active life style is the number one New Year's resolution for most of the U.S. population. However, Baby Boomers, are no strangers to asking medical science to assist with managing the big and small challenges of growing up and growing old. They were the first generation to have braces in large numbers and the first to come of age with birth control pills. Over 75% of them have turned to medical science to enhance the quality of their lives. Yet the survey indicates that many Boomers are choosing physical rehabilitation over other treatments including prescription medication, surgery, chiropractic and acupuncture, for "getting well." Of the respondents, 84 percent would choose physical therapy in conjunction with another treatment to get well.

Physical medicine and rehabilitation, once thought of only for complex conditions and sports injuries, is taking center stage in the prevention and treatment of conditions that typically begin in middle age, like arthritis and back pain. "We know now that proper physical activity is imperative to keep bodies functioning, helping prevent injuries and minimizing the progress of degenerative conditions, in addition to lowering the risk for heart disease and stroke. The Baby Boomers' demand for physical rehabilitation will reshape America's medical landscape in the coming decades," said Sliwa. "The Rehabilitation Institute of Chicago is already a leader in this area, with centers devoted to the treatment of arthritis, chronic pain, and back and sports injuries. This survey has shown us that Boomers intend to be on the golf course or tennis court until the end. And we will help them achieve this."

The survey, administered to 1000 respondents nationwide - 518 women and 482 men between the ages of 43 and 57.

Experts from RIC can shed light on these survey findings and explain the potential for alternative medicine to keep Boomers healthier than any generation in human history.

Rehabilitation Institute of Chicago is dedicated to helping people with all levels and types of physical rehabilitation needs regain or improve their physical functions and empowers them to participate more fully in family, social, vocational and leisure time pursuits. U.S. News & World Report has ranked the Rehabilitation Institute of Chicago "The Best Rehabilitation Hospital in America" for 13 consecutive years and a "Best Hospital" in rheumatology. RIC provides healing and hope through its renowned flagship hospital, and extensive network of Outpatient Centers, including specialized centers for Arthritis, Chronic Pain Care and Spine and Sports Rehabilitation. RIC is also home to the largest rehabilitation research program in the world, with more than 250 scientific studies underway.

Here's a link to a good overview article on PM&R published in the Canadian Medical Association Journal. There are also a couple links to articles on common inpatient PM&R issues such as dysphagia and autonomic dysreflexia.

Canadian Rehabilitation Medicine Series

Not directly related to PM&R, but discusses trends in residency preferences including "controllable lifestyles."

PM&R is typically considered a "lifestyle specialty" along with fields such as dermatology, anesthesia, radiology, radiation oncology, and preventive medicine.


Young Doctors and Wish Lists: No Weekend Calls, No Beepers

By MATT RICHTEL

New York Times
Published: January 7, 2004


Jennifer C. Boldrick lights up when the topic turns to blisters, eczema and skin cancer. She is also a big fan of getting a full night of sleep. And the combination of these interests has led Dr. Boldrick to become part of a marked shift in the medical profession.

Dr. Boldrick, 31, a graduate of Stanford University Medical School, is training to become a dermatologist. Dermatology has become one of the most competitive fields for new doctors, with a 40 percent increase in students pursuing the profession over the last five years, compared with a 40 percent drop in those interested in family practice.

The field may have acquired its newfound chic from television shows like "Nip/Tuck" and the vogue for cosmetic treatments like Botox, but for young doctors it satisfies another longing. Today's medical residents, half of them women, are choosing specialties with what experts call a "controllable lifestyle." Dermatologists typically do not work nights or weekends, have decent control over their time and are often paid out of pocket, rather than dealing with the inconveniences of insurance.

"The surgery lifestyle is so much worse," said Dr. Boldrick, who rejected a career in plastic surgery. "I want to have a family. And when you work 80 or 90 hours a week, you can't even take care of yourself."

Other specialties also enjoying a surge in popularity are radiology, anesthesiology and even emergency-room medicine, which despite their differences all allow doctors to put work behind them when their shifts end, and make medicine less all-encompassing, more like a 9-to-5 job.

What young doctors say they want is that "when they finish their shift, they don't carry a beeper; they're done," said Dr. Gregory W. Rutecki, chairman of medical education at Evanston Northwestern Healthcare, a community hospital affiliated with the Feinberg School of Medicine at Northwestern University.

Lifestyle considerations accounted for 55 percent of a doctor's choice of specialty in 2002, according to a paper in the Journal of the American Medical Association in September by Dr. Rutecki and two co-authors. That factor far outweighs income, which accounted for only 9 percent of the weight prospective residents gave in selecting a specialty.

Many of the brightest students vie for several hundred dermatology residency spots. The National Residency Matching Program, which matches medical school graduates to residency openings, reported that in 2002, 338 medical school seniors were interested in dermatology, up from 244 in 1997 ?though the 2002 figure still represented only 2.3 percent of the potential doctor pool.

In 2002, 944 seniors wanted to pursue anesthesiology, compared with 243 five years earlier ?while the interest in radiology almost doubled, to 903 from 463, according to the matching program's figures.

Numerous medical educators noted that the growth of interest in these fields coincided with a drop in students drawn to more traditional ?and all-consuming ?fields. In 2002, the number of students interested in general surgery dropped to 1,123 from 1,437, for example.

And that has many doctors and educators concerned. "There's a brain drain to dermatology, radiology and anesthesia," Dr. Rutecki said. He said that students who are not selected for residencies in these lifestyle-friendly specialties are choosing internal medicine by default.

"Not only are we getting interest from people lower in the class, but we're getting a number of them because they have nowhere else to go," Dr. Rutecki said.

This notion of a "brain drain" to subspecialties from the bread and butter fields of medicine is not new. But in recent years it has come to be associated with a flight to more lucrative fields. What is new, say medical educators, is an emphasis on way of life. In some cases, it even means doctors are willing to take lower-paying jobs ?say, in emergency room medicine ?or work part time. In other fields, like dermatology and radiology, doctors can enjoy both more control over their time and a relatively hefty paycheck.

According to the American Medical Association, a dermatologist averages $221,000 annually for 45.5 hours of work per week. That's more lucrative ?and less time-consuming ?than internal medicine or pediatrics, where doctors earn around $135,000 and spend more than 50 hours a week at work. A general surgeon averages $238,000 for a 60-hour week, while an orthopedist makes $323,000 for a 58-hour week. The number of dermatology residencies has been steadily growing. The American Academy of Dermatology says there are 343 dermatology residents in their third year, 377 in their second year, and 392 in their first.

The trend comes as the medical profession is already struggling to balance the demands of patient care with the strain put on doctors from overwork. Since last year, new rules have limited a resident's hours to 80 hours a week.

Some medical careers, like radiology, entail working long hours but not responding to patient emergencies on nights and weekends.

Educators point to a number of factors to explain the newfound emphasis on lifestyle. Dr. Elliott Wolfe, director of professional development for medical students at Stanford, cites the growing proportion of medical students who are women; in the 2002-3 year they made up 49.1 percent of entering students, according to the American Medical Association. Dermatology offers more control and income than, say, pediatrics and family medicine, which have traditionally drawn women.

Lee Ann Michelson, director of premedical and health care advising at Harvard University, said undergraduates considering a future in medicine are extremely concerned about whether they can have a life outside of medicine. She said she talks to numerous children of physicians who are concerned they will be as absent in the lives of their children, as their parents were.

The symbol for "controllable lifestyle" is dermatology. And when residents graduate they can count on plenty of faces and bodies to heal and reconstruct, thanks to an aging, and affluent, population. One-stop dermatology spas seem to open weekly in Manhattan, offering lunchtime visitors quick-fix lip fillers, laser procedures and face peels. It's not fast food, it's fast facial.

"You make your own hours. You can see 15 patients a day, or 10 patients a day. There are very few emergencies. It's not an acute situation, ever," said Dr. Dennis Gross, a Manhattan dermatologist. Plus, he said the procedures dermatologists perform can be lucrative; a 12-minute Botox treatment can cost a patient $400, with the doctor keeping half, for instance.

And the procedures often are elective, meaning that patients pay out of their own pockets. "It's cash, check or credit card," said Dr. Wolfe of Stanford.

The difference in lives is well illustrated by the experience of Z. Paul Lorenc and Marek M. Lorenc, 48-year-old twin brothers who chose careers on different ends of the spectrum.

Marek is a dermatologist in Santa Rosa, Calif., north of San Francisco. He gets into work at 8 a.m., leaves at 6 p.m., and is rarely called to the hospital at night, giving him ample time to spend with his wife and two children. "When I'm done," he said, "I'm a husband and a father. I go to soccer games. I coach soccer games."

His brother is a plastic surgeon in Manhattan. He arrives at work before 7, kissing his two sleeping children before he leaves the house. He performs face lifts, breast augmentations, brow lifts and liposuction, intensive surgical procedures that demand round-the-clock availability at the hospital. He often does not get home until after 9 p.m., and he goes into the office on Saturday. He doesn't see his children nearly as much as he would like, but he said that is what the pursuit of excellence in his specialty requires.

He is bothered by what he sees as a lack of devotion by today's medical students. A faculty member at New York University's medical school, he said the interest in way of life is across the board.

"When residents come looking for jobs, they ask, `How often do I have to take night call,' " he said. "There's less intensity, less determination and less devotion."

But Dr. Boldrick said she is not trying to avoid hard work. While she intends to have two children, she still plans to work full time.

What she wants to avoid is chaos and uncertainty and the lack of control that comes with other specialties. "I see people around me who like to do those things, and I think, `Thank God,' " said Dr. Boldrick, who added that she feels she can make a contribution without taking on the meat and potatoes of say, internal medicine. "If I force myself to do something that didn't make me happy in order to pay a debt to society, that wouldn't do anyone any good," she said.

The reasoning resonates with Dr. Clara Choi, 32, a resident in radiation oncology at Stanford. Dr. Choi finds her field fascinating but pointed out that it also demands few unexpected calls to the hospital.

Married, she plans to have a family. "I'd have to get someone to take care of the baby if I spent every third or fourth night in the hospital," Dr. Choi said.

Dr. Rutecki says he completely understands, having missed out on a lot in the lives of his own two children.

"I missed a lot because I was on call three to five days a week," he said. "Rather than take this data as an opportunity to criticize, I think we recognize that this is the way medicine is moving."

50 years of healing at Rehabilitation Institute

October 3, 2004

BY JIM RITTER Health Reporter Advertisement


After returning home from a routine errand, ParraLee Bridge didn't feel well, so she collapsed on the couch. She couldn't get back up.

Bridge, 78, was suffering a stroke that would severely disable her right side. Bridge couldn't raise her right arm, or write her name, or even make an X. She was unable to walk or to stand up. "This is the end," she remembers thinking.

Fortunately, she was mistaken. It was just the beginning. Bridge was about to enter the world of the Rehabilitation Institute of Chicago.

***

The Rehab Institute is where thousands of patients come each year to rehab from disabilities ranging from tennis elbow to neck-down paralysis.
Year after year, it's the nation's No. 1 rehab hospital in U.S. News and World Report's hospital rankings. And on Tuesday, the institute will have something new to celebrate -- its 50th anniversary. It's planning a big birthday party at which Mayor Daley will get an award and paralyzed actor Christopher Reeve will speak.

Since it opened in a converted warehouse in 1954, the Rehab Institute has been in the forefront of the revolutionary changes that have transformed rehabilitative medicine.

Fifty years ago, disabled people were virtually imprisoned in their homes or shuttled off to nursing homes with names such as "Home for the Incurables," recalls former CEO Dr. Henry Betts, who has worked at the institute for 41 years.

"The attitude was highly negative," Betts said. "In some cases, families were embarrassed to have a 'crippled' family member around," Betts said.

Disabled people, Betts continued, "didn't have jobs or entertainment. They didn't go to movies or make love or even go to the window to see the sunset. We've come a long way from that."

The Rehab Institute was the inspiration of a strong-willed, blunt-spoken orthopedic surgeon named Dr. Paul Magnuson.

Magnuson became an innovator in rehabilitative medicine while serving as medical director of the Veterans Administration. He instituted a team approach that brought together doctors and therapists in the rehabilitation of wounded World War II vets.

After leaving the VA, Magnuson founded the Rehabilitation Institute to give civilians the same type of team care. He raised $250,000 from wealthy donors and opened an outpatient clinic at 401 E. Ohio. The clinic was in an old warehouse that had once been a printing plant.

The institute began admitting patients in 1958. It was an unusual hospital because it didn't have operating rooms or surgeons.

As hospital administrator John Perkins explained to the Chicago Sun-Times in a 1962 interview, "We take the patient after the initial wound is healed."

Patients often say their biggest problem isn't their disability, but society's intolerant attitude toward the disabled. Responding to that need, the institute founded a legal clinic for the disabled and an organization that promotes independent living for people with disabilities, Access Living of Metropolitan Chicago.

The institute also has pushed new technology. Doctors and therapists helped develop a motorized wheelchair that a quadriplegic can operate by sipping and puffing a straw. They helped introduce an iBot wheelchair that can climb stairs and raise users to eye level. And they tested a walking machine called Lokomat that uses a computerized robotic device to move a paralyzed patient's legs over a treadmill.

Institute researchers are among the leaders in a field called neural engineering. Their goal is to enable a patient to operate a device, such as a bionic arm, just by thinking. For example, a computer would translate nerve impulses into arm movements.

"We think of ourselves as both high tech and high touch," said the institute's medical director, Dr. Elliot Roth.

The Rehab Institute is nonprofit. If a patient doesn't have insurance, the institute's Free Care Fund will pay the bill.

The hospital still doesn't do surgery. Patients are admitted after completing their acute care elsewhere. They stay at the Rehab Institute for as long as two months, although the typical stay is two or three weeks.

More than 50 million Americans have a disability. And the number will increase as the population ages and improvements in emergency care enable more people to survive traumas such as car accidents and gunshot wounds.

"Most families have some experience with disability," Betts said.

Seventy percent to 80 percent of Rehab Institute patients return home; the rest go to nursing homes. Roth said he hopes to increase the percentage who go home.

Fifty years ago, the field of physical medicine and rehabilitation, known as physiatry, was one of the least-prestigious specialties in medicine.

In medical school, Betts recalled, "It was implied that it would not be interesting and we wouldn't amount to much."

The specialty gets more respect today, thanks in large part to changes in the field the Rehab Institute has helped bring about.

Nevertheless, Roth said, he often gets asked: Isn't it depressing to work at a place where people can't speak or can't walk or can't hold a fork?

"But it's the exact opposite," Roth said. "This is one of the most upbeat and dynamic places because you see people improving."

***

ParraLee Bridge came to the Rehab Institute on Sept. 7, two weeks after her stroke. She has cheerfully completed up to six hours of therapy a day, five days a week, plus two hours on Saturday. Not once, her therapists say, has Bridge begged off.

"I was determined to help myself," she said. "If you help yourself, you can achieve a lot of things."

Still, Bridge never dreamed she would make so much progress. She has risen from her wheelchair and now can walk fast enough to cross a street. She can write her name, too. It's not very neat, but at least she can write it.

"I feel it's a blessing I've come this far," she said.

On Monday, she's going home.





REHABILITATION INSTITUTE AT A GLANCE


Doctors: 55 attending, 154 consulting, 40 residents.

Total employees: 1,238

Beds: 286*

Inpatients, 2003: 5,121

Average length of stay: 17 days

Satellite facilities in metropolitan Chicago and southern Illinois: 32

Outpatient visits, 2003: 276,000*

Sports program: About 2,300 disabled people participate, at no charge, in 18 sports and recreational activities, including swimming, sled hockey, sit volleyball and wheelchair baseball, football and basketball.

Services: arthritis, assistive technology, asthma, brain injury, cancer rehab, cerebral palsy, day rehab, driver rehab, general rehab, joint replacement rehab, limb deficiency management, multiple sclerosis, musculoskeletal rehab, occupational rehab, pain management, pediatrics and adolescents, performing arts medicine, prosthetics and orthotics, pulmonary rehab, rehabilitation engineers, spinal cord injury, sports and spine rehab, stroke rehab, transplant rehab, vocational rehab.

* All sites

REHAB INSTITUTE MILESTONES




1954. Converts old warehouse at 401 E. Ohio into outpatient rehab clinic.

1958. Opens inpatient unit.

1963. RIC has 75 beds but only 15 inpatients.

1965. All 75 beds are filled.

1974. Opens flagship hospital at 345 E. Superior. It's the largest free-standing structure of its kind.

1979. Founds Access Living of Metropolitan Chicago, a pioneering independent-living center.

1981. Establishes competitive and recreational sports program for people with disabilities.

1983. Founds a legal clinic for the disabled.

1991. U.S. News and World Report names RIC the nation's best rehab hospital, a title it has kept ever since.

1995. Establishes Center for the Study of Disability Ethics.

1997. Forms partnership with Loyola University Health System and Southern Illinois Healthcare System.

2000. Launches Arthritis Center.

2002. At the Winter Paralympics, RIC's downhill skier wins two bronze medals, while eight hockey players share a gold medal.

2004. Celebrates its 50th anniversary.