Physiatry treatments?

[Healthinfo104]

---

Members don't see this ad.

But my question is, are physiatrists trained in forming treatment plans specific to the kind of movements and activities that rehab patients are supposed to do?

not as well as therapists are.

or do PT's come up with the regimen alone and physiatrist just prescribe PT?

You can write a therapy prescription for generic PT, or write the prescription for a specific treatment. Whether or not the therapist does the said treatment depends on the therapist and their own assessment.

And this may be kind of a stupid question, but just like someone who suffers from HFpEF needs different treatments from a pt who suffers from a COPD exacerbation, the regimen for cardio rehab for a heart failure pt should differ from pulmonary rehab for a COPD pt right?

Pulmonary and cardiac rehab are relatively similar. Exercise, increase endurance, time ==> get better.

And will we as future physiatrists be part of designing the regimen for a cardio rehab patient like a cardiologist would design a treatment plan for a heart failure pt?

There are specific cardiac and pulmonary rehab centers and pretty standard treatments. Start slow and increase endurance until they can do the rehab themselves at home or fail.

So a physiatrist can't/ doesn't do the therapy like a physical therapost does?

 

[Kissmyabjj]

A lot of people get physiatrist and PT confused. I understand the differences, and I think it has been talked about ALOOOOOTTT on some of these forums. One of the comments on a thread was saying that it is a "waste" of resource for a physiatrist to do a PT's work and physiatrists are not properly trained to do what PTs do. First of all, PT, OT, ST, and other therapists have my utmost respect for what they do. But my question is, are physiatrists trained in forming treatment plans specific to the kind of movements and activities that rehab patients are supposed to do? or do PT's come up with the regimen alone and physiatrist just prescribe PT? And this may be kind of a stupid question, but just like someone who suffers from HFpEF needs different treatments from a pt who suffers from a COPD exacerbation, the regimen for cardio rehab for a heart failure pt should differ from pulmonary rehab for a COPD pt right? And will we as future physiatrists be part of designing the regimen for a cardio rehab patient like a cardiologist would design a treatment plan for a heart failure pt? Thanks for reading this long-winded comment.

I can really only speak about MSK-related issues in regard to your question.

Unfortunately, most physiatrists just prescribe PT and leave it to the therapist to come up with the treatment plan. I am not saying this is unfortunate because I don't think therapists can do a great job designing treatment plans. They absolutely can and do. It is unfortunate because this style of practice prevents a physiatrist from having to think critically beyond ruling out red flags and finding targets for injections. I really like trying to come up with therapeutic treatment regimens because it forces me to pay more attention to things like gait, balance, and movement quality, and a patient's level of kinesthetic awareness. For example, it may only take 2 minutes for me to teach a 35 year-old Crossfitter with discogenic low back pain how to lift an object from the ground in a spine-sparing manner. On the other hand, teaching a similar maneuver to an obese deconditioned 60 year-old will likely take more time than I have available in clinic and depending on how poor his movement awareness and how weak his glutes and quads are, he may not be able to perform the maneuver initially at all. This is when you could write a recommendation in your therapy prescription that says something like "please work with patient on developing single leg balance necessary for golfer's pick-up as a strategy for spine-sparing lifting."

 

[DMBandFan86]

So a physiatrist can't/ doesn't do the therapy like a physical therapost does?

No that's why there are different professions working together as a team.

Does an ENT doctor know how to do an audiology exam? Is a hospitalist an expert in nursing care? I'm sure either of those doctors could do those things, however they have bigger fish to fry.

PM&R doctors have clinics just like any other doctor. You get 15-30 minutes to take care of a patient's complex medical problems and concerns. Often times our patients have complex social lives as well due to their disabilities. You can teach a few exercises and give some hand outs, but other than that our patients need dedicated hands on time to get therapy. Thats why there is a whole field of people who only do therapy. The therapist don't do the medicine part.

 

[DMBandFan86]

There are plenty of research articles about therapy. There are plenty of people doing research into therapy. Why do you think insurance companies pay for inpatient rehab (it is extremely expensive) or any rehab at all. I mean they are even doing research into unconventional therapy methods as well. You can get involved in a research topic any time you want.

Before you come down on PM&R too hard, just remember that everything in medicine needs to be "focused, efficient, and effective." You can hear a lot about "the lack of research" in every field of medicine. It's not just this part of PM&R.

Sure it would be nice to have a follow up appointment with a brain injury patient and only talk about therapy and try to fine-tune an exercise regiment. But I can tell you the patients and families would be pretty upset that you failed to treat all there other problems and co-morbidities at the office visit. For physicians, the main question that most often comes up in outpatient follow up appointments, is the patient improving with therapy or not. Is it justified to continue doing therapy at this point in time. Are they continuously improving or have they plateaued for some reason. It's the physicians job to figure out why they are not improving enough and what to do about it. Sometimes people are so disabled that we want to give them a good shot for improvement, but that doesn't always happen.

There is no goal to have a patient continuously enrolled in a formal therapy program. Most often therapy referrals are single visits for exercise training (simple problems: rotator cuff, OA, back pain) or for a few weeks of therapy (balance issues, mild strokes, mild TBI's). The goal is to have the patient progress and continue doing treatment at home. BTW it is hard for many people to do formal therapy due to logistical issues (ie transportation 2-3 days per week in the middle of the day, etc.)

Finally, PT's don't necessarily share this view that the physiatrist is at the top of the therapy ladder and should be making therapy treatment decisions and detailed regimens. I have seen some PM&R doctors try to tell therapists to do things differently and it doesn't always go so well. I personally give autonomy to the therapists I work with and brainstorm as a team how to make the best progress. I try to suggest things that I think would be helpful to try. But I don't try to tell them how to do their job. They are doctors as well after all.

 

[DMBandFan86]

possibility that future physiatrists like me will be able to prescribe more targeted therapy for patients based on their condition instead of just "prescribe physical therapy"

You can prescribe whatever therapy you want. Just because you heard some doctors do one thing doesn't mean you have to do the same thing. You can go out today and start writing detailed and evidence based therapy prescriptions for you patients.

I just think you are not understanding what a PM&R physician does. For example you get a new consult to your office for gait abnormality. You have a 30 minute consult. The patient hasn't done any formal therapy recently and you plan to send them to therapy. But our job isn't as simple as writing therapy prescriptions, we are diagnosticians. The family doctor who referred the patient to you wants you to determine an etiology and prognosis. You have to determine if there is a medical reason for their gait abnormality. This means a detailed history, physical exam, revmedical diagnosis and then decide what tests are needed (labs, imaging, EDX). Is it a central or peripheral nervous system issue, neurological disease, metabolic or nutritional issue, polypharmacy, MSK, pain, etc. In my opinion you would be a bad physiatrist if you simply said lets do therapy and then track the patient's progress, make an exercise plan, and determine adjustments if they don't get better.

We don't just tell the nurses "pt X needs drug" and let the nurses figure out what dose and which drug to give.

sending people to therapy isn't usually a life or death situation...

but it seems like physiatrist's relationship with PT is write order that "pt X needs therapy" and let the PT have complete autonomy to give whatever therapy for however long that they think is best? Is my understanding correct?

No, you can either write for a specific therapy prescription or write for a generic therapy prescription. Whether or not a therapist does exactly what you write for is on the therapist (they have their own licenses and medical boards). When you write a prescription you usually put a time frame on the prescription (i.e. 2-3 days per week, 5-6weeks). However in order for the insurance to continue to pay for therapy the PT has to document progress and need for continued therapy. If the patient gets better quicker, plateaus or gets worse then the therapist will likely discharge ahead of time.

Don't worry, you will have plenty of contact with the therapist, especially in IPR. They will let you know all the barriers they are having and want you to fix the medical reasons so they progress faster.