The inaugural dinner meeting of the Canadian Association of Physical Medicine and Rehabilitation was held at the King Edward Hotel, Toronto, on the evening of 30 May 1952. Thirteen specialists in physical medicine were present. Three of these, William Gardiner, Guy Fisk and T.H. Coffey had been certified by the Royal College under the ‘grandfather’ clause. One of them, Andrew Zinovieff, was recognized by the Royal College as a qualified specialist without examination. The first successful candidate for the certification in physical medicine and rehabilitation had been awarded to Harold Cranfield in 1947. The other eight members were G.A. Lawson, Harry Silverstein, Bruce Young, John Fowler, Gustave Gingras, Maurice Delage, A.T. Jousse and Joseph Berkeley.
The events leading up to this inaugural dinner began in 1945 when the Council of the Royal College, on the advice of the committee on training of internal medicine, chaired by Duncan Graham, Professor of Medicine at the University of Toronto, agreed to the proposed training requirements in the specialty of physical medicine. This was the seventh specialty so identified if one includes pathology, bacteriology and two discontinued combinations namely, diagnostic and therapeutic radiology and neurology and psychiatry. Outside forces in all likelihood helped to spur the committee to action at this time. In 1944, when the invasion of Europe against Nazi Germany was already in progress, Colonel Harry Botterell, Chief of Neurosurgery at the No. 1 Canadian Neurological and Plastic Surgical Hospital at Basingstoke, England, was dealing with spinal cord injured war casualties. Botterell recognized the need for a multidisciplined team approach to the care not only of the military, but also of the spinal cord injured civilian population. On the west coast G.F. Strong, a prominent cardiologist who subsequently became president of the Canadian Medical Association, converted his perception of rehabilitation into action by forming a rehabilitation centre in Vancouver with funds provided entirely by voluntary donations. After his untimely death the centre was renamed the G.F. Strong Rehabilitation Centre.
As far back as 1928 Duncan Graham had foreseen the need for a teacher of physical medicine at the Toronto General Hospital and had appointed William Gardiner. Gardiner was the first well-trained specialist in physical medicine to occupy a university post. He subsequently held a position of influence with the Royal Canadian Air Force and probably persuaded two younger air force officers, Harold Cranfield and G.A. Lawson, to take training in the subject.
Although he was never a member of this Association, Robert Tait McKenzie (1867-1938) was an ardent protagonist for exercise therapy. During World War I he was intrigued with the therapeutic potentials of electricity. During his undergraduate years at McGill he became an instructor in gymnastics. He graduated from medicine in 1892 and, following a two year battle with a severe attack of typhoid fever, he was appointed medical director of physical training at McGiIl, a post which was the first in a Canadian university. From 1904 to 1930 he was the director of physical education at the University of Pennsylvania during which time he wrote a textbook entitled ‘Exercise and Education in Medicine’ (W.B. Saunders Co.). He is, however, best known as a sculptor. The Mill of Kintail, near Almonte, Ontario, his birthplace, houses a museum of many of his most famous sculptures. His career as an artist was almost exclusively dedicated to the facial expressions and the body motions of athletes. The biography by Jean McGill, The Joy of Effort, pays lasting tribute to a Canadian artist whose works were commemorated by the International Olympic Committee, King Gustave of Sweden, the British monarchy and the United States presidency. Two commemorative postage stamps, of one and two dollars, were issued by Canada Post in 1975 to commemorate the 1976 Montreal Olympic Games. They show two of McKenzie’s bronzes: a runner on his mark and a swimmer poised for the starting gun.
There were three other notable ‘grandfathers’: Harold Storms, Guy Fisk and T.H. Coffey.
Storms graduated in medicine from Toronto in 1915 to practise surgery with his father in Hamilton. However, he had become interested in physiotherapy and shortly thereafter joined the Workmen’s Compensation Board of Ontario where he combined physical and occupational therapy with vocational rehabilitation and earlier return to work for injured workmen. Storms assisted in drafting the legislation of the WCBO in which settlements are made without outside legal intervention; this became the model for workers’ compensation in Canada and the envy of other countries. One of his students was Herman Flax from Puerto Rico, who later became the director of rehabilitation for veterans in that US protectorate. Flax used his influence with a state insurance fund which enabled him to invite Storms to Puerto Rico in 1951 to develop a school of physical and occupational therapy. Storms continued as director until his death at the age of 66.
Guy Fisk (1908-1987) graduated from McGill in 1933. In 1935 and 1936 he carried out frontier medicine in Newfoundland and spent the next three years abroad studying and working in tropical medicine in Nigeria, then in physical medicine in London, Copenhagen and Lund, Sweden. Although he developed a department of physical medicine at the Montreal General Hospital, no funding for a new department was available from his alma mater. Even after laying the groundwork for new schools of physical and occupational therapy his appointment at the university was nominal. There appeared to be less pressure on this privately endowed university to develop teaching units in physical medicine than in the publicly funded universities throughout the country. During his professional lifetime he worked not only as professor and director of a department, but also as a busy general practitioner with particular concern for disabled workers in Montreal and vicinity. He retired at the age of 70 to continue his interests in photography and botany.
Theodore H. Coffey (1905-1961) was a maritimer who took up physical education before he graduated in medicine from Queen’s in 1939. In the Canadian Army Overseas he served in convalescent depots in England and was finally discharged with the rank of Lieutenant-Colonel and the title ‘Director of Physical Rehabilitation, Canadian Army Overseas’. As officer commanding the Roman Way Convalescent Hospital he was responsible for changing the concept of passive convalescence to active rehabilitation and was able to discharge wounded soldiers in better physical shape and in a shorter time than was previously the case. His work was noticed by the British authorities. Several pieces of apparatus were designed by him and are still used, with local modifications, in most physical therapy departments. In Canada he held several administrative posts in the Department of Veterans’ Affairs, including Director of Rehabilitation for Eastern Canada. London, Ontario, was attractive to him partly because of the opening of a new Veterans’ hospital where both acute and chronic cases were treated. In that year, 1947, the University of Western Ontario medical school expanded and several department heads were being recruited from the ranks of the military. He became the first professor in an autonomous department of physical medicine and rehabilitation in Canada. He established a full course in physical medicine for undergraduate medical students and, virtually single-handed, looked after the needs of disabled children as well as adults, both veteran and civilian. He was the medical director of Woodeden Camp for Crippled Children and was honoured by the Crippled Children’s Treatment Centre which named its medical clinic after him.
From the beginning the Association had decided on the addition of the term ‘Rehabilitation’ to the previously designated title Physical Medicine. The Royal College officially changed the name of the specialty to Physical Medicine and Rehabilitation on 1 June 1955. This action shaped the course and training requirements of future physiatrists for at least thirty years.
Gustave Gingras received two years of training in the RCAMC in England with Harry Botterell (who was awarded the OBE and, later, Officer, Order of Canada) where he found numerous challenges in the treatment of spinal cord injured soldiers. He returned to Montreal where Wilder Penfield encouraged him to pursue the course which he had set for himself. Gingras became the medical director of the physical medicine department of the Queen Mary Veterans Hospital and immediately transferred to it the spinal cord injured veterans from the chronic care pavilion of Ste. Anne de Bellevue Hospital. At the same time he saw the need for formal rehabilitation of civilians in the francophone population and began the development of the Montreal Rehabilitation Centre in a church basement. In 1949, the new Rehabilitation Institute of Montreal was opened, divided into program categories such as amputees, spinal cord injured, strokes, children, both amputees and cerebral palsy, etc. much as the G.F. Strong Centre, also opened in 1949, was developing. Gingras did not rest on his laurels but, under the auspices of l’Université de Montréal, organized the first francophone schools of physical and occupational therapy. In 1950-1953 the Institute was swamped with convalescing acute poliomyelitis cases. In 1959 the thalidomide tragedy made its appearance, primarily in Germany but also in Canada and in the USSR. It was the Russians who were first able to produce an interface between muscle contraction and the driving of a prosthetic limb by an electric motor. Gingras brought back the ‘Russian Arm’ along with its copyright to his engineering colleagues. The invention of the transistor allowed him to develop a miniaturized version of the device.
Gingras took in trainees from other countries, one from Venezuela. He was subsequently invited to Venezuela to set up schools of occupational and physical therapy. He had also established connections with the International Red Cross and with the Canadian International Development Agency. Both these agencies were involved when ten thousand Moroccans were poisoned by contaminated cooking oil. He and another Canadian, Charles M. Godfrey, CM, went to Morocco and taught the local authorities to develop simple orthotic devices for weakened muscles and unstable limbs. Dr. Gingras also attended the First International Congress of Physical Medicine and Rehabilitation in Great Britain in 1953 and subsequently served on its educational council. He was president for four years immediately following the successful Fifth Congress held in Montréal in 1968. We believe this was the first time an eastern bloc country (USSR) had attended an international congress of the specialty.
During the Vietnam conflict the Canadian government elected to establish a rehabilitation centre run by civilians for Vietnamese children. Gingras persuaded an English-born pediatrician from Canada, who had become certified in physical medicine and rehabilitation, to take a team of experts in therapies as well as prosthetics and orthotics to a relatively quiet area in South Vietnam near a sanatorium and an orphanage. A.F. (Peter) Huston was instructed to train Vietnamese physicians, nurses, and therapists to develop their own expertise, both medical and engineering, to deal with the expected war casualties. He found, however, that the ravages of poliomyelitis far exceeded those of enemy bombs.
Doctor Gingras received, amongst many honours and awards, the Companion of the Order of Canada and Knight of the Order of Saint John.
Albin Jousse, OC, received his certification in 1949 and was asked, also by Dr. Botterell, to start up a new rehabilitation institution in Toronto to look after spinal cord injured veterans and, later, civilians. One of the early veteran paraplegics, John Counsell, was wounded in 1942 at Dieppe and was the last Canadian to leave the infamous beach alive. He became the first president of the Canadian Paraplegic Association, an organization which had no counterpart in Britain or the United States at that early time. Jousse, unable to join his classmates in the Canadian Forces because of a physical disability, made his extensive contribution to Canada’s war effort by freeing up able medical personnel from a huge mental institution in Toronto known locally as 999 Queen Street West. With, the support of John Counsell and the CPA he was the ideal person to start a new program in Toronto. He subsequently became professor and head of the division of Physical Medicine and Rehabilitation at the University of Toronto, responsible not only for residency training, but also the training of occupational and physical therapists. He patterned his program on that of Sir Ludwig Guttman at Stoke-Mandeville in England.
After his service in Morocco, Godfrey joined MEDICO which later became part of CARE of Canada. As its medical director for many years he has been instrumental in directing health care measures to numerous Third World countries.
Michel Dupuis, OC, is chairman of the department of physical medicine at the University of Montreal, director of the schools of physical and occupational therapy in Montreal, physiatrist-in-chief at Notre Dame Hospital, author of three books on various aspects of rehabilitation medicine, and a man who has been responsible for the excellence of the trainees in physical medicine and rehabilitation in Quebec.
Early in its history the Association acknowledged that the training and examinations of the Quebec Association of Physiatrists were the equivalent of the Royal College examinations for purposes of membership in the Association, and a large number also joined the CAPM&R. The Association has recently changed its constitution to include as members non-medical scientists associated with universities. Other qualified physicians of a related specialty may join the Association as associate members on payment of reduced annual dues.
The specialty committee of the CAPM&R to the Royal College, with Jose Jimenez as chairman, invited all program directors and chief examiners to be corresponding members of the committee instead of merely ex-officio members, as had been the custom. The education committee has offered to judge the best essay, usually a review, submitted by a first or second year resident. The successful candidate is asked to give his paper at the society’s regular retreat preceding the annual general meeting, with expenses paid and the presentation of a suitable plaque and small cash award. A similar competition with the same rewards is open to senior residents who have carried out independent research. The Association, through its education committee has established limited funding towards ‘visiting professorships’ to either university departments or private groups. Two or three such visits have been made each year to departments across the country. Evaluations have been enthusiastic. The Association believes the program has been largely successful and should be expanded.
In 1990 the annual general meeting unanimously passed the resolution
that the Association establish the ‘Canadian Physiatrists Research Foundation’. Details of objectives, rules and regulations have not yet been finalized, but its funds will be used to encourage research. The research committee maintains a register of research projects across the country.
In 1988 a new standing committee, subsequently named the committee on electrodiagnostic medicine, was formed. At the Association’s 1990 annual general meeting, a set of guidelines was passed by the membership which approved in principle the establishment of practice standards. These included additional training leading to an examination which could stand on its own or be coordinated with a similar examination proposed by the Canadian Society of Clinical Neurophysiologists. Reciprocity with the American Association of Electrodiagnostic Medicine would be sought in the future.
The health care delivery committee was set up as a resource for the allied health committee of the Canadian Medical Association. The Canadian Physiotherapy Association, through its provincial chapters, was seeking to establish legislation whereby its members could treat patients with musculoskeletal disorders without preliminary medical referral. It sought the help of the Canadian Medical Association. The CMA in turn asked the CAPM&R to appoint a member to the CMA committee. When it became clear such legislation was not acceptable to the CAPM&R, the CMA responded by reorganizing the committee without input from CAPM&R.
The health care delivery committee felt that the Canadian Council on Hospital Accreditation did not have consultants knowledgeable in Physical Medicine and Rehabilitation; after some negotiation it was agreed that consultants from the CAPM&R could serve on its survey teams. Because of the presence of free-standing rehabilitation centres which should be assessed periodically by the CCHA or its counterpart, its membership and core structure were changed to include more medical input, including physiatric. The title of the CCHA has since been changed to the Canadian Council on Accreditation of Health Care Facilities. Aspects related to accreditation are continually reviewed.
The manpower committee has been active both nationally and provincially. Most of the urban centres are fairly adequately supplied, except for a shortage of dedicated teachers and researchers. It has been generally agreed that 1 physiatrist per 75,000 population would be considered satisfactory, but at the moment the figure stands at approximately 1 per 110,000. The specialty is becoming somewhat more popular with the undergraduate students. Most programs have adequate numbers of trainees.
The Association is now 38 years old; its members practice in Canada, the United States, Puerto Rico and Vietnam. The sole Vietnamese physician trained with Dr. Gingras at the Institute of Rehabilitation at Montreal and with the CIDA rehabilitation unit in Quinhon, Vietnam.
As the presence of the physically disabled has become more visible, society, with increasing enthusiasm, has accepted the Independent Living Movement. Many physiatrists are actively assisting community efforts towards the integration of healthy, disabled persons into the mainstream of society. Rehabilitation medicine skills and philosophies have also moved into the functional upgrading of children with congenital disorders such as cerebral palsy. Parents demanded special schools which were soon followed by the training of teachers to work in the existing children’s rehabilitation centres. Some of these programs were initiated or developed by CAPM&R members such as Gustave Gingras in Montreal and Bruce Young in Kingston, Ontario. Rehabilitation centres, in addition to the three already mentioned, have been built and staffed in every medical school in the country, with a couple of notable exceptions.
The Association has always believed that in order to maintain a legitimate position in the academic community, university teachers must involve themselves in research. It has therefore fostered research mindedness in trainees, and has recently laid the groundwork for a research foundation. In this year, 1990, there is still insufficient output from members to sustain a journal. Fortunately, at least two American journals are currently accepting articles from Canadian authors. One of the first resolves as recorded in the minutes of the Association in 1953 was to establish a journal of PM&R in Canada. Unfortunately this item is still on the list of unfinished business, almost forty years later. With fewer than 200 practicing physiatrists in the country, a peer-reviewed specialist journal is not likely to be seen in the near future.
The Canadian Association of Physical Medicine and Rehabilitation. Medical Specialty Societies of Canada Affiliates of the Royal College of Physicians and Surgeons of Canada. Ed. T.P. Morley, FRCSC. Toronto: The Boston Mills Press, 1991.
Article reprinted with the permission of Associated Medical Services, Inc.
Healthcare professionals and students with a focus on physical medicine and rehabilitation may become members of the CAPM&R. Membership is renewed annually.
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Healthcare professionals and students with a focus on physical medicine and rehabilitation may become members of the CAPM&R. Membership is renewed annually.