Justin Liu, MD
Point Of View
In today's world of immediate gratification, individuals with physical or emotional ailments often seek medical attention with the expectation that a doctor will be able to provide them with a magical pill or medical procedure that will miraculously alleviate all their symptoms instantly. To approach medical treatment with this mentality is usually not realistic or fruitful. As advanced as modern medicine has become, successful treatment of more complicated functionally-impairing conditions requires careful planning and effort by both the physician and the patient.
Regardless of whether an individual has sustained a loss of function due to deconditioning from inactivity or a physical injury from an accident, any loss of function that disrupts a person's ability to participate in the usual daily activities is highly traumatic to the body and mind. Because of this, it is vital to acknowledge the global effect mental illness and physical injury can have on a person's overall well-being. Prolonged physical debility can lead directly to negatively affecting a person's self-image and mood. Conversely, poor mental health can severely impact a person's ability to properly heal and regain lost function.
With the close tie between a person's physical and mental health, it quickly becomes evident that physicians must not make the mistake of treating the mind and body as two separate entities. A successful approach to an individual's global well-being requires that a plan of care be developed with the deeper understanding that the treatment plan's objective is to ultimately promote physical and mental health simultaneously.
Integration With Team
A medical doctor specializing in Physical Medicine & Rehabilitation (PM&R) will play an important role in the recovery process for an individual who has lost the ability to perform his or her activities of daily living. The PM&R physician will help individuals develop a custom-tailored activity program. Often times, the PM&R Physician will design a comprehensive program that ties in specialists from various other fields. Physical Therapists, Occupational Therapists, Recreational Therapists, Nutritionists, and Fitness coaches are often some of the key disciplines that a PM&R Physician will incorporate into the personalized treatment plan for a specific individual. The PM&R Physician will ultimately help guide and direct what activities these specific specialties should focus on with a patient. Specific body biomechanical guidelines are prescribed by the PM&R Physician to help prevent physical injury to the patient.
Assessment Process
Before a physical activity program is started, a PM&R Physician should perform a thorough pre-exercise assessment. As part of this process, a comprehensive History & Physical examination should be done. Key elements that should be detailed during this exam will include an in-depth look at the individual's prior medical history and uncovering the acute physical issues as well as the subacute chronic issues that are impacting the patient. Family medical history and assessment of the patient's substance use history (i.e. nicotine, alcohol, prescription/non-prescription drugs) are also important variables to consider. A thorough physical examination with focus on musculoskeletal and neurological testing must be completed. A baseline set of blood tests and an electrocardiogram may also be obtained to ensure that the patient does not have other underlying medical conditions that could limit activity. Such conditions like anemia, electrolyte disturbances, dehydration, or arrhythmias must be adequately addressed before an individual can safely embark on a program of regimented physical activity.
Another essential part of the assessment process will be the functional evaluation. The PM&R Physician should accurately determine what the patient's current functional status is. The individual's physical endurance and ability to perform basic activities of daily living should be looked at in detail. In tailoring a program for a patient, it is imperative to see how much function a patient has lost over a recent interim of time. This information will be useful in deciding how to set appropriate and useful goals for the patient.
Goal Setting
Once an accurate assessment of an individual's current physical condition has been done, the PM&R Physician can help design an activity program specific to the patient's strengths and weaknesses. The idea is to design a therapeutic exercise regimen that is neither too easy nor too difficult for the patient. The program must also provide an appropriate challenge to the patient from both a physical and cognitive standpoint. Another vital factor is to create a routine that is dynamic and entertaining for the individual. No one likes performing activities that are repetitive or dull. Various therapy modalities should therefore be used to help keep things from becoming monotonous. Unless it is medically contraindicated, I feel it is beneficial to have patients participate in a variety of activities: from isometric weight-training activities to isodynamic aerobic-type activities to more alternative use of interactive gaming technologies like the Nintendo Wii. The key is to be creative while never losing sight of the primary objective of assisting the patient to regain a sense of physical and mental well-being through a structured program of progressively increasing physical activity.
When designing the exercise regimen, it is important to check in at regular intervals with the patient and his or her Rehab Therapist or Fitness Coach to see how a patient is doing in reaching a specific goal. It is crucial that the goals set for an individual are realistic and actually attainable. Functional goals should not be rigid. Depending on progress, new goals can always be set. It is paramount to always remember that goals, like the individuals themselves, need to always evolve and not remain static.
Treatment
As the individual continues on his regimen of therapeutic exercises, the PM&R Physician will need to constantly maintain lines of communication with the patient. Feedback on how the patient feels physically and emotionally should be assessed at regular intervals. To ensure that the patient does not develop a physical barrier to hinder his or her progress with the program, it is critical that the PM&R Physician assess the patient's overall pain levels and provide appropriate treatment in an efficient manner. In an effective therapy program, there are often noticeable physiologic and emotional changes that occur. Blood pressure and blood sugars often improve with weight loss and improved overall fitness. Patients who struggle with insomnia start to have improved sleep-wake cycles with a structured exercise routine. Individuals who are on psychotropic medications for depression and mania begin to notice improvement of their overall mood, self-image, and energy levels. As the PM&R Physician who is checking in and monitoring all of these positive changes, appropriate medical management must concurrently be provided. Necessary coordination and discussion with the patient's Primary Care Physician, Psychiatrist, and other treating specialist physicians must be done to ensure that the patient's various medications are appropriately lowered or tapered off based on the noted physical and emotional changes.
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