Rehab Sunnybrook Magazine – Fall 2016

Physiatrists: on the front-lines of rehab

Michael Kennedy. His leg was crushed in a motor vehicle collision.

Michael Kennedy’s leg was crushed in a motor vehicle collision (left). Sunnybrook’s team, including physiatrist Dr. Matthew Godleski, helped him through the rehabilitation process. (Photography by Tim Fraser)

Physiatrists are the unsung heroes of recovery, specialists who help seriously injured patients get their body and soul back together – no matter how long it takes.

After his serious motor-vehicle crash, it fell to surgeons to put Michael Kennedy’s bones back together and a team of specialists to start rebuilding his life.

Michael, a 26-year-old contractor from Halifax, was airlifted to Sunnybrook from Florida after the right side of his body was crushed. He was the passenger in a truck that collided with another vehicle on the highway. After arriving at Sunnybrook and undergoing countless surgeries, Michael met physiatrist Dr. Matthew Godleski. “Matt,” as Michael calls him, was there to figure out what happens next.

Physiatry emerged as a field to help Second World War veterans returning from the battlefield. Physiatrists are medical doctors who have completed training in the specialty of physical medicine and rehabilitation. They prescribe therapies and manage the patient’s rehabilitation and recovery to help seriously injured patients not only heal, but also regain function. They do that by treating the whole person.

“These patients not only have shattered bones,” says Sunnybrook physiatrist Dr. Ed Hanada, “but their lives in an instant are changed.” It takes a team of rehab specialists – including occupational therapists, physiotherapists, social workers and nurses – to help rebuild these lives. Dr. Hanada also invites the clergy to weekly meetings.

Michael Kennedy

Michael Kennedy’s leg was crushed in a motor vehicle accident. (Photography by Tim Fraser)

Sunnybrook recently shifted the start of the rehab process to begin as early as possible after a trauma patient enters the hospital. Sunnybrook’s St. John’s Rehab physiatrists are involved at the acute care stage in the Intensive Care Unit and trauma wards.

“Traditional practice had been to treat trauma patients in the acute care program, and after they were deemed ready, send them to the rehabilitation centre,” says Dr. Larry Robinson, chief of rehabilitation services and St. John’s Rehab program at Sunnybrook. But evidence shows starting the process in acute care creates a better chance for long-term healing and more fulsome function.

“The physiatrists are starting the rehab process early and proactively, by asking questions such as: ‘What does a patient’s mobility and function look like? What will their activities of daily living look like when they get home? What does their physical home environment look like? How might it need to be adjusted?’”

Improving function requires a comprehensive assessment that addresses more than an isolated task like picking up a pen and writing. Physiatrists want their patients fully active in their communities as quickly as possible. As Dr. Robinson puts it, “I want my patients to do more than survive – I want them to succeed.”

That’s why Dr. Robinson, along with Drs. Hanada and Godleski, are evaluating how early intervention impacts patient outcomes. They are gathering data on how long patients stay in hospital, their ability to function and how complications are prevented. The doctors’ interest lies not only in how patients are doing during their treatment, but also their quality of life in the future.

When Michael woke up in the hospital, he started thinking about just that.

He describes himself as an active guy before the crash, so it’s no surprise that his mind quickly turned to getting his life back. For him, that meant saving his leg.

“Someone who has an amputation may think they’ll never walk again,” says Dr. Robinson. A physiatrist in acute care educates patients about what is possible and helps them cope with their fears. Of course, the opposite response can also happen. “A patient may expect to put on a prosthesis and walk out the door, and we need to help them understand what’s realistic,” he says.

Fortunately for Michael, his leg was saved. Now at home, he continues to work on regaining function.

How physiatry works

Physiatrists focus on assessing patient function, which includes things like mobility (ranging from moving in bed to walking), bladder and bowel function and future ability to do activities of daily living (ranging from dressing to cooking). Next, they take comprehensive histories: physical, family and functional. Physically, they’re monitoring heart and lungs, muscle and skeletal systems, plus range of motion, strength and sensation. Finally, they work with the healthcare team to determine a course of action, whether it’s physiotherapy, speech therapy, assistive devices or medication.

“I want my patients to do more than survive – I want them to succeed.”
– Dr. Larry Robinson, chief of rehabilitation services and St. John’s Rehab program

The assessment also helps physiatrists identify other issues. Complications like pressure sores and contractures (tightening of the muscles or tendons that can lead to a restriction of movement) and tightness in the joints can arise in acute care. For example, Dr. Hanada says they keep an eye on the Achilles tendon, “making sure the foot isn’t pointed downward and forcing a patient to walk on their tiptoes.” Attention from a physiatrist at this stage is crucial because patients may be too unwell to recognize additional injury.

Once a patient is stable enough to make the move to rehab, the physiatrist continues with their care, acting as a critical link across different treatment sites. Physiatrists understand their patients can be at their most vulnerable at the points of transitions in care, when moving from acute care to rehab, rehab to outpatient and from the outpatient clinic to home.

For Michael, knowing that his physiatrist was in charge of his care plan from start to finish gave him the peace of mind he needed to accept his situation and focus on recovery. “Time and energy are pretty serious when you’re trying to heal,” he says. “The smallest, littlest things take so much energy and time out of your day.” Having to coordinate his care in addition to rehab would have been “too much.”

A smooth transfer of care also made a world of difference to Patricia Prenger, 52, one of Dr. Hanada’s patients. Patricia, a high school teacher from Bowmanville, Ont., was driving to school on a Monday morning when she was hit by another car. She doesn’t recall being cut from her vehicle, or the names of the countless people who circulated past her hospital bed. But she is acutely aware of how rehab helped prepare her to go home from day one.

Patricia, former rehab patient

“Everyone – therapists, nurses and Dr. Hanada – make you feel like you’re a player on the team” – Patricia Prenger, car crash survivor (Photography by Tim Fraser)

“Everyone – therapists, nurses and Dr. Hanada – make you feel like you’re a player on the team, and they have strong expectations for you. It really does feel like you’re central to your own progress,” Patricia says.

After setting recovery goals, the ongoing respect and consistent collaboration with her health-care team kept Patricia going – from more than a month in a wheelchair, to her first steps on a cane, and finally, home. She describes Dr. Hanada as an engaged presence and a “fluid partner,” the glue of the team. And this kind of seamless care doesn’t only happen from one site to another, but also within the walls of the rehab centre itself. Having access to therapy rooms on the weekend got her home that much quicker.

The patient connection & rehab

The one thing physiatrists can’t fix is the anxiety many patients experience between therapy sessions. That’s where other patients come in. Patients frequently form bonds that create a sense of camaraderie and an environment where they can work together through loss. They console each other when there is failure and celebrate successes big and small. Those emotional connections are critical to healing.

Patricia and her fellow patients also shared  another key ingredient to recovery: laughter. “Sometimes we would joke about ‘meeting at the bar,’” she says. But not that kind of bar − the parallel bars used for exercise therapy. Patricia also counted on the “rollicking laughs” from a couple of therapists. A sense of humour can be crucial to recovery.

Several of Dr. Godleski’s patients also found each other at rehab.

Kyle Rowe, 25, a contractor from Scarborough, Ont., was in shock after being admitted in November 2015 for reconstructive surgery on his leg. At St. John’s Rehab he found a pal in 33-year-old Richard Deathe. Richard, a farmer, suffered significant burns in a kitchen fire. The pair became a trio when Michael Kennedy arrived after surviving a car collision in Florida.

“It makes days go by faster, makes the process a lot less depressing,” Kyle says.

The three friends are now home and stay in touch, but their journey through the healthcare system hasn’t ended. In fact, the final transition from the safety net of rehab can be the biggest challenge.

“Reality sets in more when they’re at home,” says Dr. Hanada. “It’s not uncommon for patients to go home still using crutches or a wheelchair. Since patients may think they’re harming themselves by bearing weight on their injured limb, and then feel reluctant to do it, it’s a difficult line to walk: they need to tolerate some pain to recover, but also know when to pull back.”

Enter Sunnybrook Research Institute scientist Sara McEwen, who is also trained as a physiotherapist. Her research focuses on teaching patients how to solve problems that can arise in the real world. Instead of just showing a patient how to move from a bed to a chair, she helps the patient figure out how to move from one surface to another in different situations. Showing patients how to problem-solve their way home is one tool Dr. Robinson believes will help achieve the long-term success he wants for his patients.

Dr. Hanada, for his part, says his job isn’t done until he carries the news of his patients’ recoveries back to the people who saved their lives in the first place in acute care.

“It’s the best part of my job.”

A special approach to burn patients

Patients with burn injuries especially need early attention from a physiatrist.

Dr. Matthew Godleski is one of only a handful of physiatrists in North America specializing in burn rehabilitation. He is well-versed in both the physical and social aspects of recovery.

 Dr. Matthew Godleski

Dr. Matthew Godleski (Photography by Doug Nicholson)

His research has taken on a common physical complication for burn injuries: soft tissue contractures (when muscles or tendons tighten and constrict movement). The American Burn Association is paying attention and recognized his work in May. They selected a recent study of his, as one of six top abstracts for their annual conference.

The study documented the severity and patterns of contractures in burn patients from 1994 to 2003, which helps provide a baseline for future contracture prevention and treatment efforts. Dr. Godleski also understands that tending to patients’ emotional well-being and mental health is crucial.

“Scars can have a huge impact on how people feel with friends, family and that five-year-old on the bus with mom who asks, ‘What happened to you?’” he says.

Despite the challenges people with burn injuries face, Dr. Godleski says his patients often accomplish more than they expect. He says even patients with severe burns can regain quality of life with effective rehab.

Proof of concept

Evidence has long shown that patients seen by a physiatrist in acute care have better outcomes later on. A 1992 study published in the Archives of Physical Medicine and Rehabilitation looked at in-patient rehab patients with a traumatic brain injury (TBI).

Those who received a physiatry consult and multidisciplinary rehab while in acute care had a shorter stint in rehab than those who didn’t. TBI patients who received the intensive rehab also had a higher cognitive level on discharge and were more often discharged home than to an extended care facility.

Similarly, a 2003 study published in the American Journal of Physical Medicine and Rehabilitation also found positive outcomes. It reviewed 1,866 TBI patients, finding that a physiatry consult less than 48 hours after admission improved patients’ ability to move and shortened their stay in acute care.

More recently, a 2016 study published in the American Journal of Medicine and Rehabilitation reviewed the literature on acute care physiatry consults. It concluded that “Studies in this area have all demonstrated improvements in outcome measures with early physiatry consultation within each study’s select population; presumably, health-care and societal costs would also be reduced in these populations as well.”

About the author


Paula Last