A recent article presented a thoughtful distinction between functional outcomes and underlying physiological mechanisms. However, drawing a rigid border between biomechanical function and cellular mechanisms creates an artificial divide that limits the natural evolution of our specialty.
Rather than viewing "functional medicine" as an outside entity attempting to appropriate physiatry's domain, we should recognize it as the natural, modern expansion of what physiatrists have always done. We do not need a separate specialty or a new residency pipeline; physiatrists are uniquely positioned to own, brand, and lead this space.
Medical specialties do not remain static — they adapt to shifting disease burdens by moving upstream into underlying mechanisms.
Consider the trajectory of cardiology. Decades ago, cardiology was almost purely an acute, reactive specialty. Physicians managed post-infarction damage, end-stage heart failure, and acute structural defects. Had early cardiologists drawn a hard line in the sand and stated, "We are physicians of heart failure and structural defects, not preventive biochemistry," cardiology would have remained locked in a reactive silo. Insteasd, the specialty adapted. Modern cardiologists spend immense clinical effort managing endothelial function, lipid sub-fractions, systemic inflammation, and metabolic drivers decades before structural heart failure occurs.
Cardiology didn't lose its identity by expanding into cellular and metabolic mechanism. It expanded its brand and became far more effective. Physiatry faces the same evolutionary crossroads.
Physiatry has spent decades building its reputation around restoring functional capacity, mobility, and physical independence. But physical rehabilitation is inextricably linked to underlying metabolic, mitochondrial, and physiological health.
When a patient suffers from chronic fatigue, metabolic dysfunction, or systemic inflammation, their physical function suffers directly. Declaring that PM&R only treats the outcome while ignoring the underlying cellular mechanisms artificially constrains our scope.
We do not need to create a new board certification or build stand-alone functional medicine residencies. Physiatry already possesses the ideal framework: We are holistic, systems-based, outcome-driven physicians.
Instead of defending legacy territorial lines against the phrase "functional medicine," PM&R should actively integrate metabolic health, clinical nutrition, environmental physiology, and root-cause biochemistry directly into our existing residency tracks and clinical practice.
The chronic disease landscape in the U.S. demands physicians who understand function at every level — from the cell, to the joint, to whole-body performance. Physiatrists are already the physicians of function. It is time we expand our brand to encompass the full spectrum of what that truly means.
