PM&R, Physical Therapy, and Imaging

[engmedpt]

I already ghosted the threads from 07, 08 , and 10. 2 were productive, 1 was useless.

Basic understanding.....

There is large overlap in the fields.

Obvious training differences:
8 PM&R (learn medical model 2 yr didactic, 2 yr rotations +match 4 yr residency)

DPT 3+optional residency (learn rehab and movement dysfunction didactic ~1.5-2 yr clinical rotations ~1-1.5 yr + optional (as of now) residency)

Specifics:
1. PM&R works much more as a supervisor in areas that operate as a team with SLP, OT, and PT and obviously, can prescribe medication. They can pass patients off to therapists but lack the actual full exercise knowledge base scope and are trained to find medical complications. Also, more responsibility and liable to malpractice.

2. DPT sees referred patients and develops modified plans of care if not given many explicit directions. If direct access patient and not referred, then full msk evals and preventative, non invasive treatments and mobilizations for patient. Screen out for things out of scope from basic pharmacology and differential diagnosis coursework. This is to "recognize" things that are needed for referral since physical therapists lack the knowledge base to and don't diagnose. Less liable to malpractice and no prescribing.

Questions:
Can someone provide different work scenarios and what the roles of PM&R and DPTs are and how the workplace collaboration would work dependent on setting?

Is this statement correct? PM&R is much more administrative and concerned with the diagnosis part while DPT is more conservative patient work and soft skills.

What are complications DPTs can miss when patients come directly to them due to pain?

What are the laws and workplace procedures for who usually does and who can order imaging, work with imaging, and interpret imaging in regards to both PM&R and DPT? What about in an area without a medical professional that is strictly allied healthcare professional?

^Take the above and insert "MRI." Does this change anything?

Which is more hands on?

During referrals, would potential disease complications go to PM&R or a different physician? During referrals, potential breaks and fractures will always go to the ortho, correct?

Have interactions between PM&R and DPTs changed at all in the last 7-10 years or so in the workplace or in regards to current laws?

@ptisfun2
@jblil
@Azimuthal
@NewDPT31
@jesspt
@truthseeker

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[engmedpt]

I just threw a truck at people with this post, but if there's something someone notices that could help even with one question then that would be awesome. I think knowing the distinctions is really important. Tagging physicians might be a good idea as well....I just didn't know references. It's not a widely talked about specialty.

 

[Azimuthal]

Outside of what you have mentioned, PM&R docs work with chronic pain patients. Patients that other docs avoid and are not envious of undertaking.

In Acute Rehab, a PM&R doc makes the decision on admitting patients. After that, the therapists take over and everyone conducts "rounds" every week to update goals and assess patient progress. It's also pretty handy to have the doc around when we suspect changes that warrant diagnostic tests ASAP. But you're correct, when it comes to the actual rehab portion, the docs are hands off. That's because as a team, we respect each other's area of expertise.

Quite honestly, we use the same screening techniques when it comes to physical exams (pain, dysfunction, etc.), the big difference is the tools available and the training used to interpret such tools. You will notice that most imaging are referred out to a radiologist (usually required by the institution) for their impressions. Usually, both PM&R and PT go off what the radiologist reports and consult the findings with each other.

In a setting without a diagnostician, you would refer out if you suspect that your patient needs it. This is either back to their primary, or if direct access, to a physician of the patient's choice. You may make recommendations in that case.

PT's do not order imaging, and may not in my state by law. The military is a different story. That is because imaging is considered a "diagnostic" tool required for a medical diagnosis. We only make PT diagnosis. Some PT's use diagnostic ultrasound to view possible lesions, etc., but must send the imaging to the primary or radiologist for a medical diagnosis. I don't even know where to begin with billing for that procedure. The women's health PT's have much more experience with that. You can ask one about pelvic floor dysfunctions, biofeedback, etc. Like peds, I don't go there. The same goes for PT's who are qualified and perform neuro conduction tests and electromyography. The results must be sent to a diagnostician for a medical diagnosis unless within the scope of referral, i.e., perform electromyography at xxx, eval and treat. Regardless, results should always be sent to the physician. My state also has a disclaimer that we must send along with the results.

Nothing new that I know of in terms of current laws.

 

[jesspt]

"What are complications DPTs can miss when patients come directly to them due to pain?"

Cancer, fracture, MS, DVT, upper motor neuron involvement, cervical myelopathy, any of the typical "ortho" injuries that a PCP may not have picked up (meniscus tear, ACL Tear, cuff tear, etc.), rhuematic conditions (RA, Ankylosing Spondylitis, Lupus), depression, anxiety, infection. For starters.

"During referrals, would potential disease complications go to PM&R or a different physician? During referrals, potential breaks and fractures will always go to the ortho, correct?"

Any need for treatment outside of the scope of PT practice should go through the referral source. Even if my patients have a PPO plan that does not require referal for a specialist visit, I make sure I let the PCP know that the patient wishes to go to ortho for work-up.

 

[engmedpt]

PT's do not order imaging, and may not in my state by law.

This is where I see an issue. How are you supposed to screen out if you can't order imaging?

 

[engmedpt]

Cancer, fracture, MS, DVT, upper motor neuron involvement, cervical myelopathy, any of the typical "ortho" injuries that a PCP may not have picked up (meniscus tear, ACL Tear, cuff tear, etc.), rhuematic conditions (RA, Ankylosing Spondylitis, Lupus), depression, anxiety, infection. For starters.

PCP referral source can find this though or send to specialist if PT doesn't think pain is musculoskeletal and makes a referral in the first place though right?

 

[Azimuthal]

This is where I see an issue. How are you supposed to screen out if you can't order imaging?

I'm a little confused here. If you feel that the patient requires imaging to screen something out, then you probably found something in your examination to warrant a referral back to the PCP or ortho for imaging. We have a lot of screening tools. Too many to explain. You're probably jumping ahead of yourself.

Do not fall into the realm of over relying on imaging.

Look at the Ottawa Ankle Rule as an example.

 

[engmedpt]

I'm a little confused here. If you feel that the patient requires imaging to screen something out, then you probably found something in your examination to warrant a referral back to the PCP or ortho for imaging. We have a lot of screening tools. Too many to explain. You're probably jumping ahead of yourself.

Do not fall into the realm of over relying on imaging.

Look at the Ottawa Ankle Rule as an example.

I am. This makes sense now.

 

[jesspt]

PCP referral source can find this though or send to specialist if PT doesn't think pain is musculoskeletal and makes a referral in the first place though right?

I'm not entirely sure what you're asking.

Are you asking that if a PT picks up somthing suspicious during their assessment and refers the patient back to their PCP, can that PCP order appropriate imaging to rule out the suspected condition? If so, the answer is "Of course.".

 

[engmedpt]

I'm not entirely sure what you're asking.

Are you asking that if a PT picks up somthing suspicious during their assessment and refers the patient back to their PCP, can that PCP order appropriate imaging to rule out the suspected condition? If so, the answer is "Of course.".

It was a stupid question.

 

[Baritonebass]

Physical medicine and rehab simplified

Physical medicine(out patients):
Diagnosis g and treating MSK ailment treating with medication, injections, life style modification patient education and referrals to PT/OT.
I'm not a micromanager so I only provide parameters for the treating therapist for formulate their treatment plan(precaution, modalities) and special instruction.

Rehabiliation(inpatient and outpatient follow
Management of medical complications related stroke, TBI, SCI, MS. Our daily work there is focus on medical optimization and secondary prevention.

Again we rely on the expertise of therapist and in general have a good working relationship with the them. We do get quite an extensive education in biomechanics and the exercise Medicine but as that is not the primary thing we do those that don't prescribe prosthetic and orthotics can get rusty

 

[engmedpt]

Physical medicine and rehab simplified

Physical medicine(out patients):
Diagnosis g and treating MSK ailment treating with medication, injections, life style modification patient education and referrals to PT/OT.
I'm not a micromanager so I only provide parameters for the treating therapist for formulate their treatment plan(precaution, modalities) and special instruction.

Rehabiliation(inpatient and outpatient follow
Management of medical complications related stroke, TBI, SCI, MS. Our daily work there is focus on medical optimization and secondary prevention.

Again we rely on the expertise of therapist and in general have a good working relationship with the them. We do get quite an extensive education in biomechanics and the exercise Medicine but as that is not the primary thing we do those that don't prescribe prosthetic and orthotics can get rusty

Much appreciated. Thanks for coming over here.

 

[engmedpt]

We do get quite an extensive education in biomechanics and the exercise Medicine but as that is not the primary thing we do those that don't prescribe prosthetic and orthotics can get rusty

This makes sense. Knowledge that isn't the day to day will dull over time.

 

[Schland]

I work in an inpatient rehab hospital. The PM&R admits the pt and follows the pt. the PT/OT (and SLP if necessary) see the pt every day. One a week we have a team conference where we discuss pt progress, goals, barriers to d/c, and typically set the d/c date. The doc and the social worker then go room to room to discuss with the pt and family. The doc obviously is the one who orders the images, consults, and changes meds. I will say though the doc I am paired with trusts my decision and frequently asks me questions about why or why not something is happening with a pt. let's face it the PT spends way more time and sees more of the pt so sometimes we catch things the doctors miss. after d/c the pt only follows up with the PM&R