Stroke Rehab

Physical medicine and rehabilitation (PM&R) is a relatively young specialty that developed during the 20th century, with significant growth and development stimulated by two World Wars and by increasingly severe epidemics of paralytic poliomyelitis during the first half of the 20th century (1-4). During and after each of the World Wars, many soldiers returned with serious injuries and severe disabilities, and physicians and therapists were needed to treat and manage their chronic disabling conditions. This was particularly true after World War II, when the availability of antibiotics and improved surgical techniques allowed more injured soldiers to survive, albeit with significant disabilities. Similarly, over the same time period, increasingly severe epidemics of polio, frequent industrial accidents, and escalating motor vehicle accidents as a result of the increased availability of automobiles and higher-speed roadways added greatly to the burden of impairment and disability among the civilian population. Thus, events in the first half of the 20th century necessitated the development of new restorative treatment programs incorporating new physical and rehabilitative techniques, and the establishment of training programs for physicians and therapists to administer the treatments.

Nevertheless, with the exception of a relatively few scattered physical medicine physicians, it was not until the second half of the 20th century that specialists in rehabilitation medicine could profitably direct their energies exclusively, or even preferentially, to rehabilitation outside of the unprecedented and unsustainable circumstances of wartime military programs. Also largely missing until the second half of the 20th century were separate departments in academic and nonacademic medical centers devoted to the specialty, established training programs in PM&R, a sufficient number of PM&R practitioners, separate dedicated facilities for provision of rehabilitation services (e.g., dedicated wards in hospitals or separate rehabilitation centers), forums for the interchange of ideas (e.g., texts, journals, and professional societies), recognition by professional colleagues and the public that rehabilitation medicine specialists provided a needed service, and supportive legislation that would provide financial mechanisms to develop and provide such resources (5).

WORLD WAR AND ITS AFTERMATH: BEGINNINGS OF PHYSICAL MEDCINE AND WOCATIONAL REHABILITATION

During much of the 19th century, physicians who employed physical modalities or advocated treatment with fresh air, water, exercise, and dietary modification were at risk of being labeled quacks by other members of the medical profession. However, near the turn of the century, orthopedic surgeons, in particular, began using selected physical treatments-massage, exercise, hydrotherapy-as part of special programs to augment medical care and convalescence within hospitals under physician supervision. During World War I (1914-1918), physical and occupational therapy became increasingly important adjuncts to surgical practice, particularly in the treatment of orthopedic casualties, because surgeons realized that surgery alone was insufficient to achieve maximum return of function, and because empirical experience indicated that physical methods were useful adjuncts in the medical care and convalescence of wounded and disabled soldiers (1,4). In particular, with active U.S. involvement in the war beginning in 1917, Colonel Joel Ernst Goldthwait, MD (1866-1961), chief surgeon in the Orthopedic Medical Corp of the American Expeditionary Forces, and Colonel Elliott G. Brackett, MD, in the Home Service, also an orthopedic surgeon, enthusiastically supported a role for physical therapists in the rehabilitation of orthopedic casualties (67). Late in 1917, a program of Women's Auxiliary Medical Aides was established in the Surgeon General's Office, but by April 1918, this was transferred to the Division of Physical Reconstruction and renamed "Reconstruction Aides" (Figure 1.1)(6). Major (later Lieutenant Colonel) Frank B. Granger, MD (1875-1928), was named director of the Physiotherapy Service of the Reconstruction Division for the Army, and under his command the reconstruction aid program was directed by Chief Aide Marquerite Sanderson (formerly from Dr. Goldthwait's office in Boston) (6.8). Training programs for the reconstruction aides were established at Walter Reed General Hospital, headed by therapist Mary McMillan; later at Reed College in Portland, Oregon (where McMillan also initially taught during a leave of absence from Walter Reed); and eventually at 13 other programs across the country (6,9,10).