THE PAST

One might inquire what a history and philosophical chapter is doing in an evidence-based clinical textbook. Interventional spine procedures by physiatrists at first glance seem simply to be an outgrowth of physical medicine, a clinical right turn justified by new information similar to other changes in medical practice such as interventional cardiology. But the role of the practitioner is so fundamentally changed from previous roles that a deeper inquiry is invited. How do such striking ‘about-faces’ occur in medicine? What and who promotes these changes and how are they accomplished? After all, a hospital-based practitioner can’t simply announce one day that he or she is going to have entry to a surgical suite or intervention room and do new procedures. The author is grateful to the many early members of the Physiatric Association of Spine Sport and Occupational Rehabilitation (PASSOR) who were willing to e-mail to the author their observations regarding how they became involved is this movement, who influenced them, and in which directions they believe we are evolving.

Most of organized medicine, including its Boards, Academies and educational hierarchy, justify their existence by including words such as ‘in the public interest …’ in their constitution or bylaws preamble. None should believe that such baser needs such as ego, power, control, and economic well-being and keeping a practice away from ‘the other guy’ do not play a role as well. The trick to good organizational management and maintenance of the voluntary system of medical accreditation is to be sure the balance favors public good a great deal more than the practitioner benefit.

The development of interventional physiatry represents a model study of how change is reasonably brought about in medical practice. If one reviews the history of the practice of medicine in the United States since Flexner’s report,¹ the complex story of organized medicine is found to be the string in the supersaturated sugar solution (the great mix of knowledge, attitudes, and practices) allowing the formation of rock candy (the roles of the various medical and surgical specialties). An approach through organized medical channels is the ‘way’ to get desired changes. Change does not occur quickly, nor particularly smoothly; however, the system seems to work. Perseverance pays. Such has been the case for interventional physiatry.

Osler in medicine, and Halstead and others in surgery are names known by every internist and surgeon. These pioneers opined that 4 years of matriculation through even the best medical school curriculum was inadequate to teach the volume and complexity of knowledge, skills, and behaviors required to properly care for patients with significant illness. Postgraduate medical education at the bedside was required, and the development of a capacity for life-long professional learning.

During the first 20 years of the twentieth century there was no such thing as a physical medicine and rehabilitation doctor. World War One, however, produced sufficient casualties, many with musculoskeletal injuries, that would become chronic and which seemed to improve when treated with physical modalities including hydrotherapy and therapeutic exercise and newly harnessed portions of the electromagnetic spectrum. With the lead of the American Medical Association in the 1915–21 time frame, a group of physical modality experts were called together to see how more physicians might learn about and put to use these procedures. The AMA Board of Trustees approved this group, called the American Congress of Physical Therapy, in September 1921. It was not to be the start of a new specialty, but rather a task force to enhance knowledge and skills. It consisted of physicians from medicine, most of whom were attached to academic centers and who had studied and advocated for these methods. The AMA had previously and subsequently stimulated and assisted the creation of the American College of Surgeons (ACS) and the American College of Physicians (ACP) and several surgical and medical specialty organizations. With the American Association of Medical Colleges (AAMC) and the Association of Teaching Hospitals, the AMA, ACP, and ACS, the idea of credentialing individuals who were willing to subject themselves to additional postgraduate education, training, and experience and who were willing to put their knowledge and skills to a test, thereby identifying properly trained ‘specialists’ for the public. The medical schools came under the supervision of the Liaison Council for Medical Education (LCME), the residencies under residency review committees (RRCs) appointed jointly by the AMA section councils and specialty societies and supervised by the Accreditation Council on Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS), continuing education led by the Council on Medical Specialty Societies (CMSS). The various liaison groups had representation from practitioners, academicians, hospitals, boards, and medical and surgical academies. When federal dollars became prominent in support of medical education and practice, government representatives were added, but control was always in the hands of physician volunteers who were either elected by or appointed by their peers to represent them.

In its earliest days practitioners of physical medicine often shared an interest in the newly developed area of ionizing radiation. In 1923, the American College of Radiology and Physiotherapy became the first physical medicine society. As radiology established itself as a separate discipline, the organization’s name was changed to drop radiology; however, the first journal was titled the Archives of Physical Therapy, X-ray and Radium. In 1930, the organization became the American Congress of Physical Therapy and in 1945, as the practice of physical therapy became its own discipline, the name changed to the American Congress of Physical Medicine. By 1954, the World War Two-developed team concept of care, espoused by Howard Rusk and George Deaver, caused another name change to Physical Medicine and Rehabilitation. By 1967, the ‘team concept of rehabilitation’ devotees were of sufficient number to cause the name to change to the American Congress of Rehabilitation Medicine. Their journal became the Archives of Physical Medicine and Rehabilitation. Upon action from an AMA advisory council on medical specialties, on June 6, 1947, eleven physiatrists became the first American Board of Physical Medicine with Krusen as its first chairman and Zeiter as vice-chairman. A few physiatrists were ‘grandfathered’ and a total of 103 became the first listed Board Diplomats. In 1949 the board name was changed to the American Board of Physical Medicine and Rehabilitation following the trend towards rehabilitation.

The group that was to become the American Academy of Physical Medicine and Rehabilitation (PM&R) began in 1938–39 as an invitation-only membership of 42 physical therapy physicians with an intent of limiting membership to 100 physicians. After 1952, all Diplomats of the American Board of Physical Medicine and Rehabilitation were invited to become members. In 1957, a conference was held to determine the proper roles of the Academy versus the American Congress. The Congress was to control the journal, to provide interdisciplinary rehabilitation education, and to reach out to nonphysiatrist physicians interested in the field. The Academy was to bring their member physiatrists into closer collaboration with other physician peers and concentrate on physiatric education and policy. The Academy was to represent the field in the AMA House of Delegates. Later, after considerable negotiation, the Archives of PM&R ownership were split by the Congress with the Academy for a purchase price of ‘$1.00 and considerations.’ Editorial Boards represented each organization under an editor-in-chief. As the Academy grew, and as the various allied professions became more independent with policy interests different at times from physicians, physiatric membership in the Congress declined. Several attempts were made to work out ways to stay allied and share a common central office but a split was inevitable. The Congress now is independent of the Academy, smaller in membership and has refocused itself to interdisciplinary rehabilitation research. The Council of Academic Societies (CAS) of the Association of American Medical Colleges in 1967 rejected the American Academy of Physical Medicine and Rehabilitation as too broadly based to be a constituent member but at the same time recognized the newly formed Association of Academic Physiatrists (AAP) to represent undergraduate and graduate medical education interests and academic policy.

The history of the specialty of Physical Medicine and Rehabilitation is covered in detail elsewhere and should be reviewed for a more complete story.^2–6 Elkins, Knapp, Bennett, Bierman, Kovacs, Molander, Coulter, Zeiter, Krusen Ewerhardt and others were among the originators of the field followed by Rusk, Deaver, Johnson, Lehman, Kottke, Stillwell and many more than can be mentioned here. Review will be rewarding to observe how a small group of dedicated physicians gave much volunteer time and attention to the multiple facets necessary for growth of a medical specialty.

One should appreciate that what began as a ‘physical medicine’-oriented body of knowledge transitioned to a medical rehabilitation orientation over time. Physical medicine was never ‘lost;’ it was simply less visible with the overriding mass appeal of rehabilitation as popularized by Rusk.⁷ New York philanthropist Bernard Baruch played a major role in stimulating development of 12 departments that matriculated nearly 60 early physiatric pioneers. Baruch convinced President Truman of the field’s contribution to the war and postwar effort. The President ordered military medical authorities to embrace the field. Civilian interest followed. Large infusions of federal dollars from the Medicare program followed. During the DeBakey era, heart disease and stroke held the top-tiered research support position. This funding resulted in increased medical rehabilitation demands and funding at a time of virtual nonfunding for musculoskeletal disorders and research. These currents influenced the practitioners and their representatives in the American Academy of Physical Medicine and Rehabilitation. Those physicians with a more physical medicine orientation often complained of inadequate attention and resource sharing in the Academy. In general, the physical medicine oriented physiatrists gravitated towards care of more acute neuro-musculo-skeletal disorders including ever more ubiquitous spine related pain. In the military, the training programs focused on physical medicine, with rehabilitation to occur in the Veterans Administration system. In this setting, and in the growing private musculoskeletal practice setting, the physiatrist saw acute patients and often provided full diagnostic and therapeutic care, referring to other specialties as was appropriate. This conflicted with the rehabilitation model in which practitioners were describing their domain as ‘the third phase of medicine after preventive medicine and acute care.’ In the latter paradigm, the physiatrist did not have access to the patient except upon referral from a physician or surgeon who were the primary practitioners.

In preparation of this chapter, a call was sent to founding PASSOR members to identify the influences upon them to become members. Perhaps the most frequently cited was the desire to become a primary practitioner for musculoskeletal patients. They were influenced by orthopedists such as James Cyriax, Arthur White, John Fromoyer, Malcolm Pope, W.H. Kirkaldy-Willis, and Alf Nachemson and sometimes encouraged to become ‘nonoperative orthopedists’ in lieu of physiatrists. They were also influenced by independent minded physiatrists whose credentials in physical medicine were rich and who were expert in use of modalities and therapeutic exercise, clinical kinesiology, and the newly developing field of electrodiagnostic medicine such as V. Lieberson, Carl Granger, Justus Lehman, Ernest Johnson, Myron Laban, Erwin Gonzalez, Ian MacLean, Joe Honet and others. Henry Betts was identified as a facilitator sympathetic to growth in this arena. Newer generations of PASSOR members were greatly influenced by Jeffrey and Joel Saal and their associate Stan Herring. These physiatrists were often themselves sportsmen whose interests gravitated in this direction. To this group add those physiatrists whose practices included large numbers of injured workmen. Many of these patients suffered spine-related pain disorders. The musculoskeletal physiatrists included also those who followed the work of Janet Travell and Dave Simons in dealing with the clinical entity of myofascial pain syndrome and those whose interests gravitated to arthritis and related disorders. Many of these physicians tended to feel that the Archives of Physical Medicine and Rehabilitation, especially those issues sponsored by the American Congress of Rehabilitation Medicine, did not adequately represent their spine and musculoskeletal interests and did not believe the Archives was well regarded by spine and sports peers in medicine. The policy issues facing the main field of rehabilitation, which were primarily government regulatory-related, were of little concern to the physical medicine practitioner who was not practicing in rehabilitation facilities but was more often office or clinic based. Furthermore, the educational offerings of the Academy were felt to slight the need for both basic and advanced material from the musculoskeletal area, especially spine and sport, and not to pay adequate attention to the office practice needs of these physiatrists. The earliest and common practice model, which continues today, was for the physiatrist to associate with an orthopedist or orthopedic group practice, becoming the member who did not perform surgery, but attended to diagnostics and postoperative care. Government and insurance bodies tended to ‘bundle’ preoperative care, surgery, and limited postoperative care into one standard surgical fee. The surgeon now had a financial incentive to pass on care to another specialist. Furthermoe, additional members in a group practice made investment in practice-owned diagnostic imaging equipment and laboratories inviting and increased the frequency of use of the equipment. As physiatrists became competent in interventional spine procedures, more struck out on their own or became part of single-specialty (physiatric spine medicine) practice groups. Several academic programs became involved. Orthopedists and family practitioners laid claim to sports medicine, although several physiatrists have become professional and school team physicians and are highly regarded for their work. Physiatrists have become increasingly attractive to insurers and re-insurers as the physicians of choice for industrial musculoskeletal injuries and post-trauma soft tissue injuries. These physicians offer thorough history and physical examination, astute diagnostic capabilities, nonsurgical (read less expensive) remediative and rehabilitative care, ability to collaborate when surgery is indicated, and disability evaluation and management all in one place. The capacity to perform electromyography and diagnostic and therapeutic blocks in carefully selected patients was an added benefit.

During the 1980s the Academy of PM&R attempted to address these musculoskeletal and related issues by permitting the development of special interest groups (SIGs) which became responsible for developing education appropriate to their interest and promoting policy concerns to Academy Board attention. During the annual meeting, the Academy met the first part of a week, the Congress the second part, with the middle weekday for supposed integrated blend. Time and organizational collaboration was inadequate to meet the needs of either party and disenchantment grew. There was even consideration of development of a new group outside of the Academy of PM&R to represent the interests of these musculoskeletal-oriented physiatrists.

At the same time, the Academy Board, and in fact much of organized medicine, was involved in a great debate regarding subspecialization and the credentialing of subspecialists. To the degree that groups identified special added competence, the issues of territoriality appeared, i.e. limitation to one kind of practitioner or open to members of vorious Boards of Specialty. Added to this were issues of curriculum content definition and development of a critical mass of expert educators and clinical facilities to achieve the educational standards. Would specialization prevent the general Diplomat from practice in the defined area? Would that in effect drive out competition and be inflationary? Would subspecialty educational offerings be available to all (generally making the offerings entry level) or be at advanced level, good for the specialist but beyond benefit to the generalist? Would an added credential become a requirement for hospitals and certifying organizations to allow privileges or access to practitioners or for courts to recognize expertise? The Academy (and medicine) resolved these issues differently in various areas such as pediatric rehabilitation, electrodiagnostic medicine, spinal cord injury, and head injury rehabilitation.

There was waxing and waning of support for the musculoskeletal specialization at the Academy Board level depending on the relative representation of rehabilitation primary versus physical medicine primary practitioners on the Board. Quick fixes allowing SIGs greater access to program content met with resistance from program committee members who felt their control and ability to meet their responsibilities challenged. At the same time, division over ownership and editorial control of the Archives of PM&R raged on at a time when the two organizations were growing ever more apart in their aspirations and needs.

In 1983, the Richard and Hinda Rosenthal Foundation indicated its wish to identify physiatrists less than 50 years of age who would be outstanding leaders in the clinical nonoperative care of low back pain. An AAPM&R Rosenthal Lectureship was created with Myron M. LaBan, MD, as the first recipient and Jeffery A Saal, MD, as the second. Both of these physiatrists were strongly identified with the movement to enhance the place of spine, sports and occupational rehabilitation in the field. The Rosenthal award served not only to recognize outstanding and innovative practitioners such as the two mentioned and those Rosenthal awardees who followed, but indicated real interest on the part of the many physiatrists who overflowed the meeting rooms to hear these lectures. The Academy leadership had to be impressed with the quality of the presentations and the professionalism of those who were listening. This was not simply some start-up group of malcontents, but rather a real wave of practitioners with like clinical interests.

Jeff Saal, MD, became the first physician at Stanford University to begin facet and image-guided epidural spinal injections. By 1987, he, together with his brother Joel and associate Stanley Herring, MD, began to teach two-day spinal injection courses which attracted a larger number of applicants than could be accommodated. This type of course was integrated into Academy offerings. Short courses were recognized to be inadequate to gain competency but served as an introduction and facilitated the need for curricular design and Fellowship development. In 1989, the Saal brothers again made a major contribution to understanding the rationale for antiinflammatory use in disc disease by describing disc disease treatment with epidural steroids and stabilization exercises and elaborating on the inflammatory enzymes involved (PLA2). This attracted great additional interest in interventional physiatry. The new data were particularly welcome in an era of ‘low back losers’ and Nachemsen’s articles regarding the great divergence of surgical rates between the United States and Sweden and describing the long-term natural course of disc disease. By now the journal Spine was becoming well recognized as a place to publish spine-related material.

From 1983, a succession of Academy of PM&R Presidents (Grant, Kraft, LaBan, Materson, Gonzalez, MacLean) were particularly impressed with the need to reach out to their colleagues, pressing this movement, and were themselves interested in musculoskeletal medicine practice. Drs Opitz, de Lateur, Christopher, and Demopoulos were interspersed with these others and, while personally more rehabilitation medicine oriented or balanced, paved the way for ascendancy of this area from a SIG to a higher-level entity within the Academy.

THE PRESENT

With the urging of LaBan, Honet and Gonzalez, Saal and others, the concept of making this group an official body of the Academy with the ability to raise dues, put on educational offerings, and self-govern became real with the official creation of the Physiatric Association of Spine, Sports and Industrial Rehabilitation (PASSOR) in 1993 with Jeff Saal, MD, as its first president. A three-year probationary period for new councils was defined in the Academy Bylaws. PASSOR Founding members and Charter members are listed in Table 1.1 and Table 1.2. The Founding members in particular all played important roles in getting the organization established, supported the educational programs and special courses as organizers and faculty, took leadership in the definition of a Fellowship curriculum, contributed to definitions for proper billing and procedure codes for this subspecialty, and represented the subspecialty to outside organizations and journals. They also contributed to the writing of the PASSOR Constitution and Bylaws. Worried that feisty PASSOR leaders might lead a movement to ‘jump ship’ from the Academy if their needs were not immediately met, the then Academy president appointed Joe Honet and Dick Materson, former Academy presidents, to an Advisory Board for PASSOR and Myron LaBan as a Board Liaison. Their job was to see that ‘cooler heads’ prevailed and that PASSOR was given good information on the best strategies to assure its needs were met. As an attendee at a majority of the subsequent board meetings, this author will testify as to the maturity, wisdom, professionalism, and dedication of the founding officers and those leaders who have followed to this date.

Table 1.1 PASSOR Founding Members

Jeffrey A. Saal, MD, Founding Chairman

Richard P. Bonfiglio, MD

Robert S. Gamburg, MD

Steve R. Geiringer, MD

Erwin G. Gonzalez, MD

Peter A. Grant, MD

Andrew J. Haig, MD

Stanley A. Herring, MD

Gerald P. Keane, MD

Francis P. Lagattuta, MD

Edward R. Laskowski, MD

Joel M. Press, MD

Joel S. Saal, MD

Curtis W. Slipman, MD

Barry S. Smith, MD

Table 1.2 PASSOR Charter Members

Terence P. Braden, III, DO

Mark Steven Carducci, DO

James P. Foydel, MD

Michael Fredericson, MD

Kenneth W. Gentilezza, MD

Michael C. Geraci, Jr., MD

Jerel H. Glassman, MPH, DO

Richard A. Goldberg, DO

Robert S. Gotlin, DO

Robert Iskowitz, MD

John Keun-Sang Lee, MD

Aaron M. Levine, MD

Howard I. Levy, MD

Donald Liss, MD

Howard Liss, MD

William James Pesce, DO

Bernard M. Portner, MD

Stephen R. Ribaudo, MD

Robert D. Rondinelli, MD, PhD

Sridhar V. Vasudevan, MD

John C. Vidoloff, MD

With Jeff Saal, MD, as Founding President of PASSOR and Erwin Gonzalez his successor, administration of PASSOR and its transition to a fully functioning academic organization proceeded at a remarkable pace, withstanding the trials and tribulations of meeting the individual desires of its well ego-defined Board personalities. A dues structure was necessary in order to put on programs, develop and disseminate academic and marketing materials, enhance membership, promote research, and reward visiting faculty for contributions. An initial dues of US$300 per member per annum was agreed upon to which would be added the revenues from the successful and oversubscribed cadaver courses on injection techniques (now named the PASSOR Spinal Procedures Workshop Series) and annual meetings fees. Disputes regarding the size of the economic commitment of membership and its effect on both PASSOR membership and Academy membership numbers, and access of PASSOR materials and educational events to non-PASSOR Academy members caused animated debate but were resolved. AAPM&R Bylaws stated Councils could self-govern; however, all policy and procedure were required to be consistent with Academy policy and subject to their overall approval. The PASSOR Board controlled finances, but dues were collected and finances reviewed and approved at Academy Board levels.

Subsequent PASSOR presidents (see Table 1.3, PASSOR past presidents) each identified major areas of emphasis for their presidential years. As frequently happens in similar organizations, discussion began to consider lengthening the presidential term to 2 years to allow task completion, as presidents discovered the tasks were great and the time short. (A single-year term prevailed, encouraging presidential efficiency). As PASSOR members demonstrated their ability to plan and conduct highly valued educational offerings for the annual AAPM&R session, they were allocated additional program time and responsibility, evolving towards greater control of all musculoskeletal offerings. Aside from standard lectures and symposia, clinical demonstrations were scheduled and some (such as joint examination) videotaped for future use. Topics were purposefully varied so that sports medicine and industrial medicine topics could be interspersed with those dealing with the spine (which was always highlighted by the Rosenthal Lecture presentation).

Table 1.3 PASSOR Past Presidents

Jeffrey A. Saal, MD	1993–1994
Erwin G. Gonzalez, MD	1994–1995
Joel S. Saal, MD	1995–1996
Joel M. Press, MD	1996–1997
Robert E. Windsor, MD	1997–1998
Andrew J. Cole, MD	1998–1999
Barry S. Smith, MD	1999–2000
Gerard A. Malanga, MD	2000–2001
William F. Micheo, MD	2001–2002
Bruce E. Becker, MD	2002–2003

Typical of similar organizations, a committee structure was seen as desirable. Committees dealing with Constitution and Bylaws; Nominations and Membership were first, followed by Education and Program, Research, Marketing and Communication, Medical Practice, and Information Systems. Unlike too many other organizational committees, PASSOR members served faithfully and enthusiastically, with appropriate and timely reports requiring careful management of board meetings to remain on course and on time. The presidents rose to the occasion so that motions were acted upon, either being approved, disapproved, or tabled, and with meaningful but limited debate encouraged. This was carried out efficiently and with good humor, with a minimum of bruised egos, which can be a part of such undertakings. A review of the board meeting minutes, minutes of telephone conferences, annual meetings, and reports to members demonstrate a continued thread of progress of important PASSOR business. This was facilitated by outstanding administrative support in the person of Dawn M. Levreau, staff liaison assigned by Academy Executive Director Ronald A. Henrichs, CAE. Ms. Levreau was an Illinois State University graduate with a BS in economics and a minor in Speech Communication who began work at the Academy in April, 1994. Her educational background, and 12 years of experience in association management, made her an invaluable contributor to PASSOR growth. Those who serve in volunteer medical organization roles recognize just how important good staffing is to an organization’s success. Board and Committee and Task Force packets were prepared in orderly fashion, agendas planned, meetings, speakers, meeting and exhibit space planned and carried out with flexibility and positive attitude. The Academy board, other councils, committees, and staff developed a pride in their work with PASSOR and sparked member enthusiasm with benefits. Rarely do members speak up when things go well in organizations; rather, their loud protests are heard if someone is perceived to ‘muck up.’ In PASSOR’s history, praise for leadership and staff assistance has been a constant.

PASSOR members became interested in defining a model musculoskeletal curriculum and muscuoskeletal physical examination competencies for use in Fellowships and generally in postgraduate PM&R training programs. Evidence of a generally unsatisfactory low level of history taking and physical examination skills observed at Fellowship entry has propelled this into a major project. Plans to educate the instructors, identified in collaboration with the Association for Academic Physiatrists, were seen as a precursor to organizing curricula and instructional materials. A traveling Fellowship was proposed and is being explored so that a Fellow might gain from the varied strengths of more than one teaching program. So as not to tread on prerogatives of credentialing bodies, RRC, and Boards, these materials were seen as approaches or guidelines rather than requirements for certification.

Since fellowships were not formally defined, Dr. Slipman, in his capacity of Chair of the Education Committee of PASSOR, developed the concept that a single credible reference source was necessary for residents who wished to seek elective fellowships of value. Together with committee member Terry Sawchuk he produced the first resident’s Fellowship Guide. Rob Windsor subsequently recognized the need to differentiate between Fellowships PASSOR recognized and those which it did not. Modest criteria for PASSOR recognition were set but the idea was set in motion that all Fellowships were not created equal. More recently, Jason Lipetz, in his role as Education Committee Chair, further raised the bar, as the entry requirement includes scholarly criteria (publications and scientific presentations). These materials were developed and disseminated and have become a valuable resource for trainees. PASSOR promulgated its criteria for Fellowship Directors and model curricular content of fellowships. Programs could voluntarily supply information for the guide but PASSOR found itself incapable of policing the accuracy of the data even if it were desirable to do this. Nevertheless, the guide has been highly valued by residents exploring such programs and informal truth-telling networks developed by resident’s ‘circuits’ complemented the guides. Issues of practice privileges at hospitals and institutions began to develop, with some physiatrists denied privileges. This spurred investigation of formal subspecialization credentials through the RRCs, the Boards, and the ABMS. Subspecialization is a complex issue as previously alluded to in this chapter dealing with curriculum, capacity, means of credentialing, and its effect on others and the public. Further pursuit by PASSOR members is active, especially in the sports medicine arena.

Confusion over the meaning of, pronunciation of, and marketing usefulness of the term physiatrist has come up recurrently. A ‘naming’ organization was hired to study the issue and present choices for new name consideration and adoption. Observations of member’s practices and member interviews and polls were carried out with no real consensus. Older members preferred to stay with ‘physiatrist,’ younger members wished a name change. ‘Externist,’ ‘orthomyologist,’ ‘orthologist’ and others were discussed. The name was to apply to muscuolskeletal-interested physiatrists, not replace ‘physiatrist.’ The PASSOR board agreed that 90% of the members should favor a change and polls were taken. Response was never adequate to be determinative, and in the interim, marketing could not be delayed. With time and exposure, more members seemed to be comfortable with ‘physiatrist.’

The AAPM&R Board decided to dip into reserves and launch a major marketing program for the field. After considerable discussion the PASSOR Board decided also to invade reserves and make a major financial and creativity contribution to the effort. The Academy Marketing and Communication staff was geared up for the effort and PASSOR members made outstanding contributions to brochure development, newspaper inserts, speaker bureaus, and development of desktop office marketing materials aimed at patients, medical colleagues, insurance companies, and adjusters. A USA Today insert was highly regarded. The program was a remarkable success. The PASSOR goal was to identify the physiatrist as the physician of choice (experts) for functional musculoskeletal rehabilitation. Drs K Ragnarsson and Joel Press played major roles.

Education has always been a mainstay of PASSOR. Officers and members generously gave of their time to produce AAPM&R annual meeting muscuoskeletal programs and demonstrations. Mid-year advanced-level courses were offered with varied success in attracting attendance despite the high order of materials and lecturers. An exception was the PASSOR Spinal Procedures Workshops Series that was sufficiently popular to be offered at or about the time of the Annual AAPM&R meeting and at mid-year on a regional basis.

Joel Press started the idea of a special bibliography with a sports topic while he chaired the first education committee. The work continued through Curtis Slipman’s chair of the committee and the two served as the editors of the final product. Following Brian A Casazza, MD, and Jason Lipetz and others, the medical education committee saw to the development of bibliographies regarding major musculoskeletal topics including Lower Extremity, Lumbar Spine, and Cervical Spine as the initial three. All Fellowship Chairs are to review and contribute to these documents. The bibliographies were placed in the PASSOR website as the new millennium brought PASSOR to the cyber-education age. Musculoskeletal and EMG case studies were added after the pioneering contributions of Ian C. MacLean, MD, to make the EMG case studies available for this methodology. These continue to be contributed by Jason Lipetz, MD, and his medical education committee members who have also attempted to add a cyber journal club to the offerings. The Fellowship Guide and other references were also made available online.

Informally, PASSOR members contributed to the Academy’s cyclic Study Guide sections promulgated through the Academy of PM&R’s Medical Education Committee (MEC). They also contributed to the Resident and Practitioner Self-Assessment materials published by the Academy’s MEC subcommittee on self-assessment (SAE-R and SAE-P). Earlier, some papers authored by PASSOR members were developed and distributed as educational mini-monographs; however, this has been discontinued. PASSOR Educational Guidelines for the Performance of Spinal Injection Procedures was produced and additional education guides are planned. Promulgation of ‘practice guidelines’ was considered and rejected for a myriad of reasons including copyright and legal issues as well as an inability to keep such papers current. Collaboration with the information steering function of the Agency for Health Care Research and Quality (AHRQ – formally the Agency for Health Care Policy Research [AHCPR] of the Department of Health and Human Services) and other organizations such as the American Association of Electrodiagnostic Medicine and The American Academy of Neurology was considered more appropriate for practice guidelines. Several coalitions of spine and musculoskeletal societies developed including the National Association of Spine Societies (NASS), the Council of Spine Societies (COSS), and the Joint Commission on Sports Medicine. PASSOR members regularly contributed in ever increasing numbers to the peer-reviewed medical literature in the Archives of Physical Medicine and Rehabilitation and other journals. After considerable investigation and debate a formal affiliation with and sponsorship of the Clinical Journal of Sports Medicine began with Stuart Weinstein, MD, as Senior Editor. However this affiliation was dropped at the end of the first contract term in 2003. PASSOR paid the subscription price for its members during the contract.

The PASSOR Spinal Procedure Workshop Series and the musculoskeletal and sports education courses were the paradigm of PASSOR members giving extraordinarily generously of their time and personal expertise to take learners through a well-devised curriculum and practical clinical demonstrations and experience. These courses were organized and carried out by PASSOR members with the capable assistance of Academy staff. Professional meetings companies expert in the delicate arrangements for such courses helped arrange the cadaver courses. Space does not permit listing all of these outstanding educators; however, a few are mentioned here: Curtis Slipman, Jeff and Joel Saal, Robert Windsor, Andrew Haig, Andrew Cole, Gerard Malanga, William Micheo, Francis Lagattuta, Paul Dreyfuss, Jeffrey Young, Stanley Herring, Stuart Weinstein, Scott Nadler, Heidi Prather, Jeff Pavell, Anthony Cucuzzella, Bruce Becker, Joel Press, Michael Furman, David Bagnall, Jay Smith, Sheila Dugan, Barry Smith, Ann Zeni, Venu Akuthota, Lori Wasserburger, Kurt Hoppe, Susan Dreyer, Terry Sawchuk, Frederick McAdam, Erwin Gonzalez, Jerrold Rosenberg, Krystal Chambers, Christopher Huston, Edward Rachlin, James Atchison, and Joseph Feinberg.

Research was recognized as the key to successful incorporation of this subspecialty into accepted practice. This needed to be evidence-based, primarily clinical, research. PASSOR elected to support the newly reformatted Foundation for Physical Medicine with a significant donation from reserves and personal commitment to a challenge grant by all Board members. PASSOR tightened its criteria for award of the Rosenthal Awardees (Table 1.4 – Rosenthal Lecturers). Recently, the Saal Family Foundation has announced its sponsorship of spine research. A PASSOR Research Grant Award for US$10 000 ‘seed money’ Research Award was created. (See Table 1.5 for awardees and topics.)

Table 1.4 Richard and Hinda Rosenthal Foundation Lecturers

The Richard and Hinda Rosenthal Foundation Lecture is presented by a young physiatrist who has demonstrated noteworthy advancement in the nonsurgical care of low back pain. This prestigious lectureship was established through the generosity of the Richard and Hinda Rosenthal Foundation.

Lecturer	Year	Rosenthal Lecture Title
Scott F. Nadler, DO	2003	Core Strength: What is it all about?
Stuart M. Weinstein, MD	2001	The 21st Century Physiatrist: Seasoned Veteran or Rookie Sensation. Cancelled due to 9/11

Joseph D. Fortin, DO 2000 Interventional Physiatry: The ‘Cardiology’ Approach to Musculoskeletal Medicine Curtis W. Slipman, MD 1999 Controlling Our Future: Managing the Dilemmas Facing Physiatry Susan J. Dreyer, MD 1998 The Forgotten Spinal Epidemics: Osteoporosis Andrew J. Cole, MD 1997 Education and Mentoring: Physiatric Core Values Paul H. Dreyfuss, MD 1996 Diagnosis Driven Spine Care in the 21st Century Joel M. Press, MD 1995 The Future of Physiatric Low Back Care Andrew J. Haig, MD 1994 New Job for an Old Test: Needle Electromyography of the Paraspinal Muscles James Rainville, MD 1993 Uncoupling Pain and Impairment – Maximizing the Potential of Chronic Low Back Pain in Patients Maury Ellenberg, MD 1992 Radiculopathy Secondary to Disc Herniation: Does it Require Surgery? Nicolas E. Walsh, MD 1991 Research Design in Low Back Pain Joel S. Saal, MD 1990 The Biochemistry and Pathophysiology of Lumbar Degenerative Disc Disease: A Rationale for Non-Operative Care Stanley A. Herring, MD 1989 Stanley A. Herring, MD The Physiatrist as the Primary Spine Care Specialist, Implications for Training and Education Avital Fast, MD 1988 Low Back Pain in Pregnancy Irina Barkan, MD 1987 Lumbar Outlet Syndrome and Myofascial Back Syndrome: Diagnosis and Treatment Patricia E. Wongsam, MD 1986 Biomechanics of the Lumbar Spine: Some Recent Advances Jeffery A. Saal, MD 1985 Advances in Conservative Care in the Lumbar Spine: Correlation of SNR Block and Clinical EMG Findings Myron M. LaBan, MD 1983 Vesper’s Curse’ Night Pain – The Bank of Hypnosis

Note that Dr. Nadler passed away in December 2004.

Table 1.5 PASSOR Research Grant Recipients

2004	Jay Smith, MD	Electromyographic Activity in the Immobilized Shoulder Girdle Musculature during Ipsilateral and Contralateral Upper Limb Motions
2003	Julie Lin, MD	Functional Impact of the Posture Training Support in Elderly Osteoporotic Patients
2002	Michael Fredericson, MD	The Effect of Running on Bone Density and Bone Structure in Elite Athletes
2001	Heidi Prather, DO	Vertebral Compression Fractures Related to Cancer Patients and Treatment with Vertebroplasty
2000	Anne I. Zeni, DO PT	Does Athletic Amenorrhea Induce Cardiovascular Changes?
1999	Gregory E. Lutz, MD	The Biomechanical and Histological Analysis of Intradisc Electrothermal Therapy on Interventional Discs
1998	Thierry H.M. Dahan, MD	Double blind randomized clinical trial examining the efficacy of modified Bupivacaine suprascapular nerve blocks in the treatment of chronic refractory painful subacromial impingement syndrome

Organizations Awards highlight PASSOR values. Aside from the Presidential awards, Research Grant Award, and Rosenthal Lectureships, the PASSOR Board created the PASSOR Distinguished Clinician Award to honor members who have achieved distinction on the basis of their outstanding performance in musculoskeletal patient care, their scholarly level of teaching, and who have contributed significantly to the advancement of the specialty through participation in PASSOR activities (see Table 1.6 – Distinguished Clinician Awardees). A Distinguished PASSOR Member Award was also created to honor PASSOR members who have provided invaluable services to the specialty through participation in PASSOR activities (see Table 1.7). These awards were to be directed to members who were not serving on the Board in the three years prior to the award.

Table 1.6 PASSOR Distinguished Clinician Award Recipients

The PASSOR Distinguished Clinician Award honors PASSOR members who have achieved distinction on the basis of their outstanding performance in musculoskeletal patient care, their scholarly level of teaching, and have contributed significantly to the advancement of the specialty through participation in PASSOR activities.
Robert E. Windsor, MD	2003
Francis P. Lagattuta, MD	2002
Paul H. Dreyfuss, MD	2001
Jeffrey L. Young, MD	2000

Table 1.7 Distinguished PASSOR Member Award Recipients

PASSOR members who have provided invaluable service to the specialty through participation in PASSOR activities.
Erwin G. Gonzalez, MD	2002
Jeffrey A. Saal, MD	2001
Robert E. Windsor, MD	2000

THE FUTURE

PASSOR has had a recent strategic plan which redefines its mission, goals, and objectives and which seeks to reintegrate PASSOR into the mainstream of the Academy of PM&R. This would eliminate distinct dues or meeting fees and necessitate creative ways to maintain funding and momentum. It remains to be seen if this is not simply another change in the flow of organizational makeup and if the good will and resources necessary to meet the needs of all members is present. A number of members have opined that simply being a nonoperative orthopedist eschews the valuable education, training, and experience of general physiatrist rehabilitation training. The proper value of team care and methodologies, and attention to psychosocial, vocational and disablement issues for selected patients must be appreciated and not shunned. Some members opine that there is often no need for ancillary assistance when a skilled physiatrist can ‘provide it all,’ and state that physical therapists, chiropractors, and others do not truly represent competition if physiatrists are good at all that they lay claim to be good at.

This author is in agreement with colleague Bernie Portner, MD,⁸ who observes, ‘… that much of what is done today is way off mark. There is, in the book on the History of Medicine, a chapter entitled ‘blood letting, the four humors, the hypothymic syndrome and other nonsensical, yet commonly held, tomfoolery of days gone by …’ and then gives his personal opinion of some of today’s practices. Each of us could make a list of those things that we do which may not be adequately supported by evidence-based research, or which appear to have greater physician emollient benefit than good patent outcome. Often, procedures are promulgated with much greater enthusiasm than for which evidence of their long-term success exists. Polls of spines surgeons have indicated that financial incentives alone for doing added procedures, not careful medical individualization, have made laminectomy without fusion relatively rare. We must support and utilize evidence-based medical literature, starting with this textbook, and look for carefully done outcomes research. Despite the requirement for resource constraint considerations and cost–benefit analysis, as a profession we must guard against primarily economic-driven clinical decision-making, or the public will demand diminishment of medical autonomy and substitution of creativity-stifling regulation.

To this end, NIH, NIDRR, and other recognized funders of research (including private endowments) must support bona fide musculoskeletal clinical and research models.

Regarding progress in academia, Curtis Slipman founded the first interdisciplinary academic spine program at the university of Pennsylvania in 1992 at a time when physiatrists were being blocked by anesthesia and orthopedics. His program included direct participation of ortho spine, neurosurg spine, and radiology, and all saw patients in the same facility, and created the first academic interventional physiatric fellowship in 1993. Slipman’s emphasis had also been on developing leaders of interventional physiatry that could go on to develop academic programs with top-notch fellowships. He has been able to place a group of incredibly productive young physiatrists in academic centers. These physiatrists include: Zacharia Isaac at Harvard, Omar el Abd at Harvard, Jason Lipetz at Einstein in NY, Michael dePalma at the Medical College of Virginia, Raj Patel at the University of Rochester, David deDanious at the Medical College of Wisconsin, Russell Gilchrist at the University of Pittsburgh, and Amit Bhargavia at the University of Maryland. The University of Michigan program was founded by Andrew Haig, MD, and emphasized the critical importance of research to this field.

Another prediction that has been observed to be coming true is that young women physiatrists who were themselves athletes during their school years have become attracted to this arena and see opportunity in the hands-on approach to interventional spine treatment, and welcome the opportunity to contribute to the medical literature dealing specifically with women’s issues

Physiatry will continue to evolve as science warrants and practitioners are willing. Organizations such as PASSOR, collaborating with organized medicine, will facilitate the needed changes as new young leaders act today to create the history of tomorrow. Congratulations colleagues, you’ve produced an enviable history.