by Maurice G. Sholas, M.D., Ph.D.
From ATLANTA Medicine Vol. 84, No. 4
Many of us fell in love with our profession while watching famous TV Doctors. Serious portrayals, like those on “Grey’s Anatomy” or “ER”, bring to life the real drama of helping patients cope with life altering health issues. Comedic portrayals, like those on “Scrubs”, shine light on the ironic aspects of the patient-doctor relationship. No matter the approach, all remind the viewer that doctors help patients on their journey through life.
As medicine has advanced, physicians and surgeons have become better able to provide more advanced treatment options for a variety of children and adolescents with catastrophic diagnoses. As a result, previously terminal findings have become more chronic conditions. Similarly, patients previously considered a success to simply be alive have the opportunity to seek out a better quality of life.
That evolving reality lead to the creation of the specialty of Pediatric Rehabilitation Medicine — officially recognized by the American Board of Medical Specialties in 2005. Specialists in Pediatric Physical Medicine and Rehabilitation (PM&R), called Pediatric Physiatrists, are specially trained to diagnose, manage and treat acquired or congenital physical disabilities in children. Most commonly, this includes injuries and the sequela of diseases of the musculoskeletal and neuromuscular systems.
Pediatric physiatrists are tertiary care sub-specialists who generally practice out of hospitals, private clinics or rehabilitation centers. They offer comprehensive, non- surgical treatment programs that help address the needs of the whole patient from a context of maximizing function. This approach of maximizing function can be applied to the non-disabled population as well through sports medicine.
The crux of Physiatry is the promotion of teamwork to address the functional concerns of a patient in a manner that is appropriate to their family, community and life context. As such, physiatrists coordinate a team consisting of: nurses, physical therapists, occupational therapists, speech-language pathologists, psychologists, neuropsychologists, prosthetists, orthotists, child life specialists, social workers and case managers. Pediatric physiatrists can serve as a very useful referral for primary care pediatricians and other specialists who provide care to children with special healthcare needs who have congenital or acquire physical disabilities.
Examples of congenital diagnoses that are treated by Pediatric Physiatrists include: cerebral palsy, spina bifida, brachial plexus lesions, muscular dystrophy and torticollis. The goal of the physiatrist is to manage the consequences of the patient’s disability. Thus, if a patient’s condition causes them to have muscle spasticity, the physiatrist uses medications like baclofen, botulinum toxin injections or specialized permanent nerve blocks to ameliorate these symptoms and promote easier care and comfort or better functional independence.
Another opportunity for physiatry management comes in using technology to maximize function. Physiatrists are experts at matching children with appropriate communication devices, braces (orthoses), prosthetic devices, wheelchairs, mobility devices or durable medical equipment essential in addressing caregiver or patient needs unique to this vulnerable population. Pediatric physiatrists blend non-operative musculoskeletal medicine with applied neurology to optimize the life trajectory for children born with physical disabilities.
Acquired conditions that are treated by pediatric physiatrists include: traumatic brain injuries, encephalitis, spinal cord injuries, pediatric burns, strokes and limb deficiency. In addition, they treat children who are deconditioned after oncological diagnoses (cancer rehab), cardiac anomalies (cardiac rehab) and those following complex musculoskeletal surgery.
Once the trauma team or the primary treating physicians stabilize the patient, the physiatrist works in a coordinated manner to restore function and optimize independence in patients as varied as those with brain tumors and others post complex spine and limb surgery. What makes the pediatric physiatry input unique is that it incorporates evidence-based medical care with functional optimization via therapy. Ultimately, this manages the child’s discoordination, poor endurance, altered cognitive status and altered functional independence following life-threatening insults. Pediatric physiatrists are critical in assisting patients and families to redefine and restore their definition of normal following a physical impairment.
In addition to working with a team of nurses, therapists and para-medical professionals, pediatric physiatrists work with primary care doctors, neurologists, neurosurgeons, orthopedic surgeons, oncologists, rheumatologists and many other specialists. The patients of focus often are medically complex and require input across the spectrum of medical specialties – thus care coordination and “big picture” planning are of high value.
Two prime examples of physiatrist-led collaboration are pediatric cardiac rehabilitation and spasticity management. Cardiopulmonary rehabilitation involves optimizing function in those affected with heart or lung disease. Considerable efforts are made to manage a cardiac patients’ disease process under the direction of a cardiologist or cardiothoracic surgeon. Once that acute process is optimized, the physiatrist crafts a program that makes the child functional in spite of the limitation of their cardiopulmonary system – allowing them to rise from the proverbial couch and re-enter school, vocational interests and avocational activities.
Spasticity is a neurological finding resulting from damage to the central nervous system. Using medication, modalities, manual medicine and physical interventions, physiatrists participate in the care of children with these neuromuscular conditions to decrease this type of hypertonicity. Depending on the case, PM&R physicians may prescribe physical therapy to relax the muscles and improve strength.
For decades, adults who require rehabilitation have had access to Medical specialists who help them focus on function. Now that level of expertise is available to children and adolescents. Rehabilitation, the recovery of previously mastered skills, in addition to habilitation, the acquisition of new skills not previously mastered, are cornerstone concepts in pediatric physiatry.
In addition to understanding the disease process leading to disability, physiatrists appreciate the context under which interventions have to exist to be successful. These medical sub-specialists provide care in a collaborative manner that emphasizes practicality and teamwork. Practice models include inpatient and outpatient management as well as consultation.
Physiatrists can assist with studies that help identify a diagnosis, like when they perform electromyography or nerve conduction studies, but more often they focus on patient management for those children with the most complex diagnoses. Interventions can be medication optimization or procedural of coordination of care. Children with special healthcare needs are well-served by having a pediatric physiatrist among the specialists providing care for them.
For more information on physiatry and its subspecialty areas like pediatric rehabilitation medicine, go to The American Academy of Physical Medicine and Rehabilitation.
Maurice Sholas, M.D., Ph.D., is the Medical & Practice Director for Rehabilitation Services at Children’s Healthcare of Atlanta. He is one of 191 board-certified Pediatric Rehabilitation Medicine specialists in America. His professional focus is providing care to children with acquired or congenital physical disabilities. Dr. Sholas received an M.D. and Ph.D. from Harvard Medical School. He completed his residency training at the University of Texas HSC – San Antonio and fellowship training at the Rehabilitation Institute of Chicago. Dr. Sholas is active with Leadership Atlanta and the Medical Association of Atlanta.