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 Table of Contents  
CHAPTER 3: PHYSICAL AND REHABILITATION MEDICINE (PRM) - CLINICAL SCOPE
Year : 2019  |  Volume : 2  |  Issue : 2  |  Page : 41-46

3.4 Physical and rehabilitation medicine – Clinical scope: Physical and rehabilitation medicine interventions


Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA

Date of Web Publication11-Jun-2019

Correspondence Address:
Prof. Andrew J Haig
Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisprm.jisprm_12_19

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How to cite this article:
Haig AJ. 3.4 Physical and rehabilitation medicine – Clinical scope: Physical and rehabilitation medicine interventions. J Int Soc Phys Rehabil Med 2019;2, Suppl S1:41-6

How to cite this URL:
Haig AJ. 3.4 Physical and rehabilitation medicine – Clinical scope: Physical and rehabilitation medicine interventions. J Int Soc Phys Rehabil Med [serial online] 2019 [cited 2019 Aug 20];2, Suppl S1:41-6. Available from: http://www.jisprm.org/text.asp?2019/2/2/41/259338




  Introduction Top


What does a specialty that owns no organ system actually do? And what does it do that is uniquely within the specialty?

The specialty of physical and rehabilitation medicine (PRM) has a unique role in health care around the world. Where other chapters in this book focus on the picture of how PRM fits into medicine and society, and the previous chapter discusses important diagnostic competencies, this chapter focuses on interventions that PRM clinicians use to help people who seek their care.

Intervention is the bottom line of all of medicine. Discussions about theory, science, social constructs, organizational structure, economics, education, and diagnostic procedures outlined in the rest of this book mean nothing if these do not lead to interventions and if those interventions do not improve the health and quality of life of persons with disability.

The idea of “interventions” requires some organization. PRM interventions can be placed into 3 large categories:

  • Coordination of care
  • Procedural, medical, and physical interventions that are relatively unique to PRM specialists
  • More general medical management skills that are used in treating diseases of people who seek PRM services.


After discussing the methods this chapter used to explore the scope of PRM interventions, we will address the scope of intervention within these 3 areas.


  Investigating the Interventions Top


An understanding of the scope of interventions in rehabilitation can be gleaned from personal experience, the literature on interventions within the field, and more specific literature that documents expected PRM training and competencies in interventions.

A literature search was performed, using Medline to combine the topic of “PRM” with “competency” and with “curriculum.” Various English language websites of national professional and credentialing agencies were reviewed. Although many were sampled, this review relies heavily on examples provided in the seminal White Book on PRM in Europe,[1] the curriculum of the Australasian Faculty of Rehabilitation Medicine,[2] a descriptor of treatments and procedures PRM physicians perform from the American Academy of Physical and Rehabilitation Medicine,[3] the detailed curriculum of a sophisticated Bangladesh training program at Bangabandhu Sheikh Mujib Medical University,[4] and a survey of PRM training in Pakistan.[5] A more informal look at websites for national organizations in Japan, China, Austria, Malaysia, Mexico, Cuba, and Portugal and international groups including the International Society for PRM, the Association of Academic Physiatrists, and the Asociación Médica Latinoamericana de Rehabilitación largely conformed to the findings in the primary English speaking documents. The European White Book provides a good initial overview of the subject although it is necessarily centered around European practice [Table 1].
Table 1: Essential interventions from the European White Book (Gutenbrunner)

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One early article on the scope of the field was written by Fenderson in 1969.[6] Much more recently, a number of articles have described methods to assess competencies of PRM trainees[7],[8],[9],[10] and medical students in PRM experiences,[11] and these articles or the framework behind them also inform our understanding of the scope of the field.

This chapter excludes important diagnostic competencies such as electrodiagnosis and the diagnostic use of ultrasound, as these are discussed elsewhere. It is not intended to be a systematic review. Rather, it is an informed sensemaking based on personal experience and the literature.


  Coordination of Care Top


Surgeons use knives and internists use pills, but PRM physicians use teams.

The most unique aspect of PRM is also its least concrete one, at least in terms of the medical model. While the rest of medicine has begun to understand the value of working together, expertise in the leadership of teams has been a core PRM intervention for more than half a century. In 1976, long before teams were mentioned in other areas of medicine, Halstead[12] performed a review of research on teams in rehabilitation in the prior quarter century. His conclusion that team rehabilitation was more effective than other processes was highly influential, causing many governments and payers to require PRM-lead team meetings on inpatients.

Perhaps, PRM is the only specialty in medicine where a major aspect of training is in team dynamics and team leadership. An important goal is for the specialist to advance the team from individual skills used in parallel play, to interdisciplinary discussion, to high functioning, coordinated, and creative transdisciplinary teams. The quality of teamwork – and by implication the quality of team leader – correlates with improved outcome.[13]

The complexity of rehabilitation teams still surpasses that of most other areas of medicine. Inpatient rehabilitation especially requires routine reliance on collaboration between clinicians with vastly divergent areas of expertise, ranging from social to mechanical. Teams typically include occupational therapists, speech language pathologists, physiotherapists, social workers, rehabilitation nurses, vocational rehabilitation experts, psychologists, orthotists, recreational therapists, and prosthetists among others.

Outside of the hospital, the need for teamwork varies considerably. For persons with severe physical disabilities, programs of comprehensive outpatient rehabilitation very much parallel the inpatient model. When pain syndromes including back pain disable people from work or lifestyle for more than a few months, it is quite clear that a highly structured team approach led by an expert physician is superior to individual therapies.

The value of teams in outpatient settings team is equally well established. Numerous studies in chronic pain have shown the superiority of a physician-led team in returning patients to full functioning, with less pain, mental health stress, fewer medications, less surgery, and better quality of life.[14] In a randomized trial, even a single visit with a PRM-lead multidisciplinary team has been shown to be more effective than traditional care in terms of number of ideas, compliance, function, satisfaction with care, and quality of life (Haig 2015).[15]

The role of PRM specialists in coordinating outpatient care for more straightforward medical problems may vary. Simple musculoskeletal injuries may do well with physiotherapy alone. As physiotherapy training becomes more advanced, the argument that PRM supervision is required for all cases involving physiotherapy becomes less valid. Still, important limitations on the competency of allied health professionals are likely to remain regardless of training.

Back pain is an example. While most acute back pain gets better and may require no treatment, physiotherapy is an effective intervention. However, the most devastating and costly aspects of back pain are medical diagnoses such as cancer or infection and the psychiatric disorders that impede recovery. Allied health professional training in these areas is not zero. However, along the course of care, there comes a point where years of medical school along with many more years of specialist training is required for optimal care.

There are soft boundaries, defined by training and experience of the individual allied health professionals involved, where counselors need physician help; occupational therapists need a medical understanding of impairments and contraindications to activity, etc. There are specific PRM skills as noted in this chapter that become most appropriate at some point. Even where the treatment is completely and appropriately within the scope of an allied health professional, payers and policymakers may require PRM physician oversight to control costs and quality.

Another type of teamwork important in rehabilitation is the PRM physician's role in relation to other physician specialists. Inside hospitals, the impact of PRM physician consultation services goes beyond advice and collaboration with specialists because one important impact is more coordinated discharge planning and shorter hospital length of stay. In many countries, the partnership between PRM and spine surgeons is a popular one. We have coined the term “controlling the midfield” to describe an analogy in which PRM receives referrals from primary care, manages diagnostics and treatment, then forwards the relatively small number of well-organized cases with high chance of surgical success to the surgeons; after surgery, or if surgery is not elected, patients are again managed by PRM (Haig 2015).[16] Similar, though less, common models exist for other musculoskeletal conditions. PRM is also often part of teams that care for patients typically seen by neurology, oncology, rheumatology, and other specialists.


  Procedural, Medical, and Physical Interventions That Are Relatively Unique to Prm Specialists Top


Most PRM specialists receive training in a large number of treatments that are relatively specific to the populations seen by PRM. They range from procedures bordering on surgery to the use of everyday resources such as ice packs.

Not to be confused with the word “intervention” in the title of this chapter, “Interventional PRM” is a term often used to describe the practice of using invasive procedures, mostly for pain management. Twenty-five years ago, almost no PRM physician performed epidural injections, facet injections, radiofrequency ablations, or other spinal procedures. However, as PRM grew, the number of PRM physicians managing outpatients instead of inpatients grew, and thus a desire to more completely manage patients with spinal and musculoskeletal disorders. Competency in relevant anatomy and injection procedures became important.[17],[18]

In the United States, an organization called the Physiatric Association for Sports, Spine, and Musculoskeletal Rehabilitation (PASSOR) was formed and eventually included about one-third of all PRM specialists. At a time when almost all training occurred in hospitals, PASSOR advocated for musculoskeletal medicine and spinal procedures as a core component of PRM training succeeded in its mission then dissolved itself, turning its resources over to the American Academy. Interventional physiatry continued to grow rapidly in countries where it paid well and is now a core competency in many of the regions of the world. PRM pain specialists may also train in more esoteric nerve procedures such as sympathetic blockades. In this area, PRM often competes with anesthesiologists, radiologists, and others who have training in the use of fluoroscopy for spinal procedures.

Other needle procedures for pain routinely performed by most PRM specialists include peripheral joint injections, tendon, ligament, and bursa injections, trigger point injections, and injections of sites of nerve compression such as the carpal tunnel.[19] Ultrasound guidance has become an important adjunct, and although definitive proof that ultrasound improves outcome in all procedures is not established, ultrasound is becoming a standard skill for PRM injection trainees.[20],[21],[22] Commonly, but not ubiquitously, PRM specialists perform acupuncture,[23] use prolotherapy, and perform other invasive procedures. In India, PRM specialists have a strong surgical background, and many perform tendon releases, minor plastic procedures such as wound closure, and other surgical treatments. Elsewhere, individual PRM specialists may pick up specific surgical techniques such as the Ponseti method of dealing with club foot or the placement of spinal stimulators and pumps.

The management of spasticity bridges the gap between interventional physiatry and medication management.[24] Some highly specialized PRM physicians will implant or manage baclofen pumps. Commonly PRM specialists will use ablation procedures such as phenol blocks or botulinum toxin injections. Management of spasticity with medications, exercise, and modalities are core competencies for all PRM physicians.

In addition to spasticity drugs, PRM specialists have special expertise in medication management of a number of problems common in the population served. Pain medications are commonly prescribed by PRM, as are antidepressants and anxiolytics. Psychologically active medications are often prescribed by PRM for persons with brain injury and other disorders of consciousness and commonly prescribed by pediatric PRM specialists for children with attention deficit and other problems. PRM physicians often manage seizure disorders as well, and pediatric PRM specialty has a number of child-specific interventions.[25]

Bowel, bladder, and sexual function and the medications and techniques used to manage them fall between the roles of nurses, gastroenterologists, urologists, gynecologists and others. As a result, in persons with physical disability, PRM specialists are most commonly the ones who provide medication and other means of managing these issues.

The term “Physical Medicine” has expanded from the initial implication of the use of physical agents (heat, cold, ultrasound, diathermy, electrical stimulation, and others) to the use of exercise, bracing, and other interventions that are neither medication nor surgery. The physical interventions provided by PRM often do intersect directly with the practice of allied health professionals.

PRM physician specialists receive training in the management of contractures with serial casting or bracing; some actually perform these while others leave them to team members. PRM specialists usually do not fit braces or prosthetic limbs but are critically involved in decisions about prescribing these, as the specific device used often depending on surgical, medical, psychosocial, and physical factors.

Many PRM specialists are expert in a variety of physical interventions designed to decrease pain. Manual medicine is a common competency, though the specific techniques taught and used may vary highly from standard osteopathic and chiropractic manipulation to esoteric treatments. Some but not all PRM specialists train in acupuncture and use that modality. Again, these are areas where other health professionals may focus an entire career. PRM physicians may variably emulate that career, or dabble in simple interventions, or simply be knowledgeable enough to guide treatment.

Exercise, diet, and counseling are other areas where PRM physicians have substantial competencies. Advice in these areas are also are typically provided by others, but instruction in these areas unavoidably becomes part of the intervention provided directly by PRM in the office.

Information may be the most important PRM intervention. PRM specialists provide essentially two types of information: patient education and assessment of disability.

The authoritative advice from a physician on diagnosis, prognosis, treatment choices, risks, and benefits is inherent in other specialties, but arguably more important in the population of persons recently diagnosed with disabling disorders.

The specific literature on PRM as a patient educator is compelling in the case of pain. In randomized trials, PRM specialist Aage Indahl's single talk with acute back pain patients resulted in less pain, disability, and surgery years afterward, and in subsequent studies that talk with a minimal therapy program was equivalent in clinical outcome (but not cost) to a lumbar fusion operation.[26],[27],[28] Our group decreased back surgery by 30% across an entire region of the United States by requiring a PRM consultation before insurance would pay for surgery.[29]

Aesculapian authority is a term used for the somewhat mystical power that physicians hold.[30] Aesculapian authority is more than a cultural phenomenon. For better or worse, government and business have also bestowed powers of judgment and prediction on PRM specialists in the area of disability determination. As experts who focus on function and ability PRM specialists are often called on to decide whether a person has a permanent or temporary impairment, exactly what it consists of, and in many cases how this impairment will affect future employment or independence.

This role often challenges the medical and social model that PRM comes from because it stems from either legal proceedings or statutes. The former involves rules that seem foreign to PRM: PRM physicians strive to help people accomplish their goals even if there is a smaller than 50% chance of succeeding. PRM science often relies on evidence that is “P < 0.05” certain. Yet, civil proceedings between two parties must be resolved with fairness to both. Hence, the questions are rather black and white: a person does or does not have an impairment. They can or cannot lift precisely 15.234 kg. Either the problem is lifelong or it is not.

This legal logic applies to many questions posed to PRM physicians that will never end up in court. An insurer may ask about early retirement, an employer may ask about work restrictions, or a family member may ask about placing an elderly relative in a protected living situation, for instance.

In other circumstances, the decisions are arbitrary, and sometimes even more challenging. Government statutes may assign the same certain percentage impairment to a person with an amputated toe, whether she is a typist or a professional footballer, for instance.

Most PRM physicians are trained in a number of specific interventions as reflected in [Table 2]. These skills are fairly consistent across countries but change as technology, financial incentives, and patient populations change.
Table 2: Specific direct interventions performed by physical and rehabilitation medicine physicians

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  General Medical Management Skills That Are Needed to Treat the Diseases of People Who Seek Physical and Rehabilitation Medicine Services Top


PRM physicians have to provide traditional medical care services in addition to rehabilitation interventions. Especially on the hospital wards, the nature of their patient population is so challenging that rehabilitation units have been compared to intensive care units in terms of nursing complexity. The typical inpatient may require management of their admitting diagnosis, whether it be from trauma, neurological insult, orthopedic procedure, cancer, cardiopulmonary disease, or other disorder. Management of breathing and tracheostomies,[31] urinary continence, feeding tubes, bowel control, and other consequences of these disorders is routine. In addition, it is common for PRM physicians to encounter thrombophlebitis, infections (of the urinary tract, lung, skin and others), gastrointestinal disease, bowel and bladder continence issues, nutrition, hydration, electrolyte balance, and respiratory failure, among many other complications and comorbidities.

Internists and the referring specialties may have competency in managing the medical issues of rehabilitation patients. As the subspecialty of hospital medicine grows, these physicians often manage complex patients on medical and surgical wards. They may even be involved on rehabilitation wards. However, it is unavoidable that PRM often ends up as the best expert to manage some of the sickest patients. PRM is most familiar with the presentation and management of problems in the context of disabling illnesses.

Spinal cord injury is an excellent example. Treatment of urinary tract infections, rather straightforward in the ambulatory population, requires consideration of patient learning, fluid balance, catheters, spasticity, urinary tract stones, and epididymitis in in persons with spinal cord injury. The diagnostic workup of any fever takes on substantial complexity when the patient cannot feel important potential sites of infection. Autonomic hyperreflexia, heterotopic ossification, hypercalcemia from recumbency, and other problems that are commonly seen in persons with spinal cord injury are rarities in the general medical population.

This is somewhat true of outpatients as well. Many persons with complex disability see their PRM physicians as their primary care physicians. Routine health screening is different for many rehab populations. Management of obesity, cholesterol, blood pressure, addictions, and other risks may involve different strategies. Management of life events such as sexuality and pregnancy require specialized knowledge. Hence, a final important PRM intervention is the medical management of persons with complex disability.


  Conclusion Top


This chapter reviews actions taken by PRM physicians to accomplish the mission and duties of the specialty. As the science and practice of medicine changes, specifics of PRM interventions will change. Still, it seems that team coordination, invasive procedures, medication, physical modalities, and instruction, along with medical management of persons with complex disability will always be important roles for PRM physicians.

Financial support and sponsorship

Nil.

Conflicts of interest

Andrew Haig is president of Haig Consulting LLC, an organization that consults in rehabilitation program development, and president of the International Rehabilitation Forum, a not-for-profit organization that builds rehabilitation in low resource countries.



 
  References Top

1.
Gutenbrunner C, Ward AB, Chamberlain MA. White Book on Physical and Rehabilitation Medicine in Europe. Available from: http://www.euro-prm.org/docs/white_book_v_5_2.pdf. [Last accessed on 2017 Dec 10].  Back to cited text no. 1
    
2.
Australasian Faculty of Rehabilitation Medicine. Rehabilitation Medicine Advanced Training Curriculum. 1st ed. Australasian Faculty of Rehabilitation Medicine; 2010. Last Revised in 2013. Available from: https://www.racp.edu.au/docs/default-source/default-document-library/at-afrm-rehabilitation-medicine-curriculum.pdf?sfvrsn=2. [Last accessed on 2017 Dec 10].  Back to cited text no. 2
    
3.
American Academy of Physical Medicine and Rehabilitation. What types of Treatments and Procedures to Physiatrists Perform? Available from: http://www.aapmr.org/career-center/medical-students/a-medical-student's-guide-to-pm-r/what-types-of-treatments-and-procedures-do-physiatrists-perform. [Last accessed on 2017 Dec 10].  Back to cited text no. 3
    
4.
Bangabandhu Sheikh Mujib Medical University. Residency Program, Doctor of Medicine (M.D.) Curriculum (Phase-B), Physical Medicine and Rehabilitation. Bangabandhu Sheikh Mujib Medical University; February, 2014. Available from: http://www.bsmmu.edu.bd/media/residency_curriculum_phase_b/1416289710-14-physical%20medicine%20and%20rehabilitation.pdf. [Last accessed on 2017 Dec 10].  Back to cited text no. 4
    
5.
Rathore FA, Butt AW, Soomro N, Akhtar N. A questionnaire-based survey of physical medicine and rehabilitation residency training in Pakistan. Cureus 2017;9:e1005.  Back to cited text no. 5
    
6.
Fenderson DA. The basis of physical medicine and rehabilitation as a medical specialty. Arch Phys Med Rehabil 1969;50:63-7.  Back to cited text no. 6
    
7.
Willoughby J, Nguyen V, Bockenek WL. Assessing competency in physical medicine and rehabilitation residency: The ACGME milestones initiative. AMA J Ethics 2015;17:515-20.  Back to cited text no. 7
    
8.
Jain SS, DeLisa JA, Campagnolo DI. Methods used in the evaluation of clinical competency of physical medicine and rehabilitation residents. Am J Phys Med Rehabil 1994;73:234-9.  Back to cited text no. 8
    
9.
Mallow M, Baer H, Moroz A, Nguyen VQ. Entrustable professional activities for residency training in physical medicine and rehabilitation. Am J Phys Med Rehabil 2017;96:762-4.  Back to cited text no. 9
    
10.
Kanaar AC. Curriculum development in physical medicine and rehabilitation. New Physician 1963;12:104-6.  Back to cited text no. 10
    
11.
Altschuler EL, Cruz E, Salim SZ, Jani JB, Stitik TP, Foye PM, et al. Efficacy of a checklist as part of a physical medicine and rehabilitation clerkship to teach medical students musculoskeletal physical examination skills: A prospective study. Am J Phys Med Rehabil 2014;93:82-9.  Back to cited text no. 11
    
12.
Halstead LS. Team care in chronic illness: A critical review of the literature of the past 25 years. Arch Phys Med Rehabil 1976;57:507-11.  Back to cited text no. 12
    
13.
Strasser DC, Falconer JA, Herrin JS, Bowen SE, Stevens AB, Uomoto J, et al. Team functioning and patient outcomes in stroke rehabilitation. Arch Phys Med Rehabil 2005;86:403-9.  Back to cited text no. 13
    
14.
Schonstein E, Kenny DT, Keating J, Koes BW. Work conditioning, work hardening and functional restoration for workers with back and neck pain. Cochrane Database Syst Rev 2003:CD001822. Available from: https://www.ncbi.nlm.nih.gov/pubmed/12535416.  Back to cited text no. 14
    
15.
Haig AJ, Nagy A, LeBreck DB, Stein GL. Outpatient planning for persons with physical disabilities: A randomized prospective trial of physiatrist alone versus a multidisciplinary team. Arch Phys Med Rehabil 1995;76:341-8.  Back to cited text no. 15
    
16.
Haig AJ. Controlling the midfield: Treating patients with chronic pain using alternative payment models. PM R 2015;7:S248-S256.  Back to cited text no. 16
    
17.
Lisk K, Flannery JF, Loh EY, Richardson D, Agur AM, Woods NN, et al. Determination of clinically relevant content for a musculoskeletal anatomy curriculum for physical medicine and rehabilitation residents. Anat Sci Educ 2014;7:135-43.  Back to cited text no. 17
    
18.
Visco CJ, Kennedy DJ, Chimes GP, Rittenberg J, McLean J, Dawson P, et al. Programmatic design for teaching the introductory skills and concepts of lumbar spine procedures to physiatry residents: A prospective multiyear study. Am J Phys Med Rehabil 2013;92:248-57.  Back to cited text no. 18
    
19.
Cuccurullo S, Brown D, Petagna AM, Platt H, Strax TE. Musculoskeletal injection skills competency in physical medicine and rehabilitation residents: A method for development and assessment. Am J Phys Med Rehabil 2004;83:479-85.  Back to cited text no. 19
    
20.
Luz J, Siddiqui I, Jain NB, Kohler MJ, Donovan J, Gerrard P, et al. Resident-perceived benefit of a diagnostic and interventional musculoskeletal ultrasound curriculum: A multifaceted approach using independent study, peer teaching, and interdisciplinary collaboration. Am J Phys Med Rehabil 2015;94:1095-103.  Back to cited text no. 20
    
21.
Siddiqui IJ, Luz J, Borg-Stein J, O'Connor K, Bockbrader M, Rainey H, et al. The current state of musculoskeletal ultrasound education in physical medicine and rehabilitation residency programs. PM R 2016;8:660-6.  Back to cited text no. 21
    
22.
Finnoff JT, Smith J, Nutz DJ, Grogg BE. A musculoskeletal ultrasound course for physical medicine and rehabilitation residents. Am J Phys Med Rehabil 2010;89:56-69.  Back to cited text no. 22
    
23.
Braverman SE. Acupuncture education and integration in the physical medicine and rehabilitation residency. Phys Med Rehabil Clin N Am 1999;10:755-65, xi.  Back to cited text no. 23
    
24.
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25.
Hurvitz EA, Nelson VS. Characteristics of pediatric rehabilitation training offered by physical medicine and rehabilitation residencies. Am J Phys Med Rehabil 1991;70:81-5.  Back to cited text no. 25
    
26.
Indahl A, Velund L, Reikeraas O. Good prognosis for low back pain when left untampered. A randomized clinical trial. Spine (Phila Pa 1976) 1995;20:473-7.  Back to cited text no. 26
    
27.
Fairbank J, Frost H, Wilson-MacDonald J, Yu LM, Barker K, Collins R, et al. Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: The MRC spine stabilisation trial. BMJ 2005;330:1233.  Back to cited text no. 27
    
28.
Brox JI, Sørensen R, Friis A, Nygaard Ø, Indahl A, Keller A, et al. Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine (Phila Pa 1976) 2003;28:1913-21.  Back to cited text no. 28
    
29.
Fox J, Haig AJ, Todey B, Challa S. The effect of required physiatrist consultation on surgery rates for back pain. Spine (Phila Pa 1976) 2013;38:E178-84.  Back to cited text no. 29
    
30.
Kalisch BJ. Of half gods and mortals: Aesculapian authority. Nurs Outlook 1975;23:22-8.  Back to cited text no. 30
    
31.
Khademi A, Cuccurullo SJ, Cerillo LM, Dibling J, Wade C, Liang J, et al. Tracheostomy management skills competency in physical medicine and rehabilitation residents: A method for development and assessment. Am J Phys Med Rehabil 2012;91:65-74.  Back to cited text no. 31
    



 
 
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