‘Getting people back to their lives’ — How physical medicine and rehabilitation are evolving in U.S. health care

There are numerous elements of medicine that involve patients’ physical health.

There’s also a specialty that focuses specifically on the interactions of the physical systems, from brain to bone to muscles, that are affected when patients suffer losses of function due to injuries and illness.

John C. Cianca, MD, FAAPMR, of Houston, Texas, is president of the American Academy of Physical Medicine and Rehabilitation (AAPM&R). He has worked as a private practice operator and medical instructor in academia. An accomplished runner himself, he served 23 years as medical director of the Houston Marathon and is co-founder of the International Institute for Race Medicine, which has become part of the World Academy for Endurance Medicine.

The specialty physiatry has existed for decades. During and after the COVID-19 pandemic, AAPM&R gained new attention by becoming a leading compiler of medical information about Long COVID and the patients seeking relief from symptoms that were slow — sometimes painfully slow — to heal.

Cianca spoke with Medical Economics about the state of the profession and what primary care physicians should know about physical medicine and rehabilitation. This transcript has been edited for length and clarity.

Medical Economics: What's the biggest challenge facing the specialty right now?

John C. Cianca, MD, FAAPMR: Well, physical medicine is a broad specialty. We take care of kids to senior adults, and we do so across the spectrum of medicine, insofar as we take care of people that have acute injuries that are catastrophic in nature, to more longstanding issues that are day-to-day. My end of the field is less in the catastrophic realm, and more in the day-to-day musculoskeletal injuries that slow people down but don't necessarily leave them disabled, at least not permanently. My colleagues, on the other hand, take care of people that are impaired permanently, usually brain injury, amputees, effects of stroke. Internally, one of our challenges is appealing to everybody in the field in a way that's common to everyone. Reaching everybody across their varied practices can be a little bit of a challenge internally, insofar as being able to be on message for everyone.

Externally, it's a longstanding issue that rehab is sometimes an afterthought. There's acute care medicine. Everybody thinks in terms of, OK, what are we going to do right now? How are we going to treat these people? Can we keep them alive?

But what are you going to do after that? And that's where we come in. And so sometimes that's overlooked or not appreciated till the wheels are already should be in motion. I would say recognition of what we do, how we fit into the picture of medicine as a whole, and getting us involved early enough that we can make a difference sooner and more efficiently. Basically getting people back to their lives.

Medical Economics: What misconceptions do you encounter about physical medicine and rehabilitation among primary care physicians, and what would you like PCPs to better understand about the scope and value of your specialty?

John C. Cianca, MD, FAAPMR: I would say many of the misconceptions have cleared during my career. I mean, early on, we were looked at as inpatient doctors, and then my generation of physicians started doing outpatient and that early on was construed as chronic pain only, or back pain only. Over the course of my career now, we've been recognized more and more as experts in musculoskeletal care, from acute to chronic, post-surgical to nonsurgical. I think a lot of those misconceptions have waned. But not everybody thinks of physiatry, physical medicine, first. They often still kind of default to orthopedics, and orthopedics certainly welcomes those kinds of cases. But if they're nonoperative, why would you send to an orthopedist? Because they're not going to be as interested in in the long-term care of such an issue as we would. So physiatry is really a specialty that helps people across a spectrum of time, not just for an incident, and letting people know that, specialists or patients themselves, is still a bit of a challenge. You know, our ability to maintain a relationship with somebody beyond just an incident is still probably not top of mind for a lot of people.

Medical Economics: When you mentioned about inpatient, would that be a physician who might respond to a person with an acute injury and trying to help them regain certain health while they're still perhaps hospitalized?

John C. Cianca, MD, FAAPMR: Historically, our field has dealt primarily what dealt a lot with people that come to hospital with a major problem — they lost a limb in the war, they've had a head injury for whatever reason, they've had a stroke. They have had any sort of illness, injury, that puts them in the hospital and requires an extended stay, which, almost by necessity, would include some rehabilitation so they could exit the hospital. And of course, that's where we came in, and we did. We still do that, and that was our entree into the house of medicine, per se. And it really arose because people started surviving these things. We invented, or we discovered, antibiotics, which kept people alive. They didn't die from infections now. They lived, but they had no limb, or they had an impaired the left side, or they had a brain that wasn't as sharp as it used to be. So what are you going to do now? That's where we came in. We helped these people accommodate to their new situation, maybe overcome it, and certainly adapt to it. And in that setting, we were working in the hospitals. The sooner that we got involved is always better, and that happens variably, depending on the environment you're in, but it's the best way for us to be involved. But certainly, as their stay progresses, we become involved, and then we stay involved after their discharge. So that's the hospital-based end of our field and how it arose and how it's changing. I think more and more people realize that sooner is better with respect to beginning, at least the footings, of rehabilitation, even if it's not full on early on in the course.

Medical Economics: The Academy was really a leading medical organization that began documenting numbers of patients dealing with Long COVID and their health conditions. Why was Long COVID so important to the Academy?

John C. Cianca, MD, FAAPMR: Well, we recognized early that it was going to be an ongoing problem. People did survive. Unfortunately, many did not. But those that did survive had and do have a host of problems that became obvious to us that were going to need attention. And we've had history with this kind of situation. Polio, for instance. Polio affected people broadly in a number of ways. We were front and center to helping those people deal with the aftereffects. We recognized there's probably going to be a need here as well. We got involved in the post-COVID infection environment very early and I think we made a big difference in helping the public in general, and maybe even the government, recognize that this isn't just a one-off virus, it either kills you or you survive. Many people still are dealing with effects of COVID in some form. I've seen people recently that said, you know, I had COVID three years ago, and I've never been quite the same, either for something like their endurance or their ability to tolerate things that they normally did or previously did without any thought, and now they have to prepare or they have to recover. So, to our credit I think, we saw what was going to happen, and we got to it. And I think many of my colleagues, were very adept at recognizing it and then coalescing people to help present this to the world as a thing, something that we're going to have to deal with.

Medical Economics: How would you describe the current state of care, so to speak, for patient, for those patients who are dealing with Long COVID in the U.S. health care system?

John C. Cianca, MD, FAAPMR: Well, I'd have to say this is more of an estimate, because I am not really on the front line there, but what I've gathered is it's actually probably somewhat harder, because people have forgotten about it, and I say that meaning the people that didn't have COVID, the people that are responsible for supporting health care in that setting. We're having to remind people, look, this is a this is something that happened. Yes, it killed millions of people, but it also affected millions and millions more, and there's fallout from that. We have to remember, we have to keep the edge, so to speak, on care and recognition of these potential problems and what it amounts to. And in particular, with respect to the people that we had already treated, the disabled, in large part, it affected them even more, or could have affected them even more. So, it's an ongoing issue, and I would say, not necessarily easier than it was in terms of the peripherals to getting care and accessing care.