So... what do PM&R docs do? Yes I researched it .. but I can still ask no?

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[runfastnow]

Stroke, SCI, TBI, amputees (new and old), and medically complex patients are the typical patients that you will see on an inpatient rehab unit.

These same patient populations will be seen as outpatients with focus on functional sequelae of the insult (ex: PM&R typically doesn't work up causes of CVA in acute setting, but works on functional deficits after the injury). Ex: wheelchair management for SCI, spasticity management for SCI/TBI/CVA, prosthetic management for amputees. Physiatrists also do non-op sports medicine, pain medicine (ex: spine injections, opioid management), and EMGs.

You will have heave involvement in neurologic and MSK medicine along with management of TBI. Physical exam (especially very specific neuromuscular exam) is key in PM&R.

 

[PMRboy]

My understanding is that physiatry (PM&R) comes in two flavors--inpatient and outpatient.

Outpatient physiatry - Currently, the more popularly practiced PM&R is the outpatient version. Outpatient physiatry concerns itself with musculoskeletal disorders that are not rheumatologic in nature. This means nerve entrapment, osteoarthritis, muscle strain, tendinopathies, axial pain, and sports injuries. Treatment usually involves some form of medical management, minimally invasive procedure or a combination of the two. Whereas a rheumatologist would treat rheumatoid arthritis with some immunosuppressant a physiatrist would treat a patient with osteoarthritis of the knee with an ultrasound guided cortisone injection, PT and or med management.

The physiatrist uses ultrasound to diagnose nerve entrapments, tendinitis (i.e. plantar fasciitis), shoulder cuff tears, and more. Ultrasound can also be used to inject cortisone, platelet rich plasma and other regenerative treatments like bone marrow aspirate concentrate. Regenerative medicine is still an area of research and results are mixed. Physiatrists have been a part of the development of the tenex procedure at Mayo as well, which can be used for microinvasive and surgical debridement of diseased tendons--think refractory plantar fasciitis, tennis elbow, golfers elbow, and more (google 'tenex dr. oz').

Physiatrists are also pioneering technology for carpal tunnel release under ultrasound guidance (google 'sonex carpal tunnel release'). The techniques and possibilities using musculoskeletal ultrasound are rapidly expanding thanks to many physiatrists.

Physiatrists also perform various pain procedures (with and without fellowship depending on residency exposure) for axial pain such as epidural steroid injections, radiofrequency ablation of nerves, medial branch blocks, nerve blocks, kyphoplasty etc. With a pain fellowship, physiatrists can do minor surgical procedures such as spinal cord stimulator and dorsal root ganglion stimulator implantation for chronic pain and other conditions like complex reflex dystrophy syndrome.

Physiatrists also perform botox injections of the muscles for spasticity management in patients with stroke, cerebral palsy or dystonia. All physiatrists learn electromyography (EMG) is residency so they are competent in using EMG and nerve conduction studies to identify radiculopathies and nerve entrapments to assist neurosurgeons and orthopedic surgeons in identifying pathologic nerves that they can go after during operation. EMG can also be used to assist in the diagnose of ALS and other neuromusculoskeletal disorders. Lastly, PM&R docs are knowledgeable in various orthotics, prosthetics and other assistive devices to help patients regain function despite a disability.

Inpatient physiatry - This is currently a less popularly practiced form of PM&R, but those that do practice inpatient PM&R generally enjoy it very much. Following a stroke, for example, patients suffer from many new neurologic sequelae that affect their ability to return to their activities of daily living. A stroke can result in problems communicating, swallowing, walking, sleeping, depression, issues with urinating, and more. Rather than shipping out patients with fresh strokes or spinal cord injuries, a PM&R doctor will admit them to an inpatient floor which can be an attachment to the main hospital or a free-standing facility. The PM&R doctor will manage their medical conditions to ensure they don't develop pneumonia, UTI, CHF, fall, re-stroke etc. during their inpatient stay. The patient will undergo intensive PT, OT, and speech pathology for 3 hours each day. It has been shown that stroke patients that receive inpatient rehabilitation treatment rather than return home or go to a SNF decreases morbidity and mortality as well as reduces government costs in the long run. This type of work can be monotonous for some people because the patients are relatively stable compared to a patient that acutely presents with a new onset stroke, for example. Nonetheless, these patients are still sick and can quickly deteriorate. Patients may stay on the inpatient floor under the supervision of a PM&R doc for days or weeks depending on the severity of their condition. PM&R doctors usually take call for their patients in the inpatient setting from home. Because the acuity of these patients is generally less than that of patients that arrive to the ED acutely, they usually have less emergent issues. In the private sector, many PM&R doctors take second call and have a hospitalist cover acute issues overnight.

Independent medical examinations - Physiatrists often supplement their income doing independent medical examinations due to their extensive knowledge of brain and spinal cord injury, neurorehabilitation, and musculoskeletal disorders. This work is akin to what an occupational physician would do.

Research opportunities - If you are interested in research then PM&R offers many opportunities looking at long term outcomes of stroke patients, spinal cord and brain injury patients etc. There are also research opportunities in regenerative medicine, pain medicine, and sports medicine. Areas of research in this spectrum have gained popularity especially with recent advancements in ultrasound. If you are interested in product development there are also opportunities to work as an engineer or with engineers in developing new assistive devices for patients. There is clinical research in practically anything you can think of related to musculoskeletal disorders and disability.

There is quite a bit of heterogeneity with regards to how a PM&R doc chooses to practice. The way a physiatrist practices can be dependent on the niche they create within their community or academic center. If you work in the private outpatient setting practice you would mostly work as a sports-pain hybrid physician. Inpatient physician you are doing what is described above and leading an interdisciplinary team for patients that have undergone stroke, brain or spinal cord injury. Some physiatrists practice both inpatient and outpatient physiatry.

 

[Slowpoke]

I agree with PMRboy and runfastnow. The one liner is that we help patients achieve maximal function from disabling conditions involving the muscles, nerves (including brain) and bone.

 

[Eilat87]

My understanding is that physiatry (PM&R) comes in two flavors--inpatient and outpatient.

Outpatient physiatry - Currently, the more popularly practiced PM&R is the outpatient version. Outpatient physiatry concerns itself with musculoskeletal disorders that are not rheumatologic in nature. This means nerve entrapment, osteoarthritis, muscle strain, tendinopathies, axial pain, and sports injuries. Treatment usually involves some form of medical management, minimally invasive procedure or a combination of the two. Whereas a rheumatologist would treat rheumatoid arthritis with some immunosuppressant a physiatrist would treat a patient with osteoarthritis of the knee with an ultrasound guided cortisone injection, PT and or med management.

The physiatrist uses ultrasound to diagnose nerve entrapments, tendinitis (i.e. plantar fasciitis), shoulder cuff tears, and more. Ultrasound can also be used to inject cortisone, platelet rich plasma and other regenerative treatments like bone marrow aspirate concentrate. Regenerative medicine is still an area of research and results are mixed. Physiatrists have been a part of the development of the tenex procedure at Mayo as well, which can be used for microinvasive and surgical debridement of diseased tendons--think refractory plantar fasciitis, tennis elbow, golfers elbow, and more (google 'tenex dr. oz').

Physiatrists are also pioneering technology for carpal tunnel release under ultrasound guidance (google 'sonex carpal tunnel release'). The techniques and possibilities using musculoskeletal ultrasound are rapidly expanding thanks to many physiatrists.

Physiatrists also perform various pain procedures (with and without fellowship depending on residency exposure) for axial pain such as epidural steroid injections, radiofrequency ablation of nerves, medial branch blocks, nerve blocks, kyphoplasty etc. With a pain fellowship, physiatrists can do minor surgical procedures such as spinal cord stimulator and dorsal root ganglion stimulator implantation for chronic pain and other conditions like complex reflex dystrophy syndrome.

Physiatrists also perform botox injections of the muscles for spasticity management in patients with stroke, cerebral palsy or dystonia. All physiatrists learn electromyography (EMG) is residency so they are competent in using EMG and nerve conduction studies to identify radiculopathies and nerve entrapments to assist neurosurgeons and orthopedic surgeons in identifying pathologic nerves that they can go after during operation. EMG can also be used to assist in the diagnose of ALS and other neuromusculoskeletal disorders. Lastly, PM&R docs are knowledgeable in various orthotics, prosthetics and other assistive devices to help patients regain function despite a disability.

Inpatient physiatry - This is currently a less popularly practiced form of PM&R, but those that do practice inpatient PM&R generally enjoy it very much. Following a stroke, for example, patients suffer from many new neurologic sequelae that affect their ability to return to their activities of daily living. A stroke can result in problems communicating, swallowing, walking, sleeping, depression, issues with urinating, and more. Rather than shipping out patients with fresh strokes or spinal cord injuries, a PM&R doctor will admit them to an inpatient floor which can be an attachment to the main hospital or a free-standing facility. The PM&R doctor will manage their medical conditions to ensure they don't develop pneumonia, UTI, CHF, fall, re-stroke etc. during their inpatient stay. The patient will undergo intensive PT, OT, and speech pathology for 3 hours each day. It has been shown that stroke patients that receive inpatient rehabilitation treatment rather than return home or go to a SNF decreases morbidity and mortality as well as reduces government costs in the long run. This type of work can be monotonous for some people because the patients are relatively stable compared to a patient that acutely presents with a new onset stroke, for example. Nonetheless, these patients are still sick and can quickly deteriorate. Patients may stay on the inpatient floor under the supervision of a PM&R doc for days or weeks depending on the severity of their condition. PM&R doctors usually take call for their patients in the inpatient setting from home. Because the acuity of these patients is generally less than that of patients that arrive to the ED acutely, they usually have less emergent issues. In the private sector, many PM&R doctors take second call and have a hospitalist cover acute issues overnight.

Independent medical examinations - Physiatrists often supplement their income doing independent medical examinations due to their extensive knowledge of brain and spinal cord injury, neurorehabilitation, and musculoskeletal disorders. This work is akin to what an occupational physician would do.

Research opportunities - If you are interested in research then PM&R offers many opportunities looking at long term outcomes of stroke patients, spinal cord and brain injury patients etc. There are also research opportunities in regenerative medicine, pain medicine, and sports medicine. Areas of research in this spectrum have gained popularity especially with recent advancements in ultrasound. If you are interested in product development there are also opportunities to work as an engineer or with engineers in developing new assistive devices for patients. There is clinical research in practically anything you can think of related to musculoskeletal disorders and disability.

There is quite a bit of heterogeneity with regards to how a PM&R doc chooses to practice. The way a physiatrist practices can be dependent on the niche they create within their community or academic center. If you work in the private outpatient setting practice you would mostly work as a sports-pain hybrid physician. Inpatient physician you are doing what is described above and leading an interdisciplinary team for patients that have undergone stroke, brain or spinal cord injury. Some physiatrists practice both inpatient and outpatient physiatry.

What a great summary.

 

[PMRboy]

I agree, but do you have an actual answer.. or not?

Specific differences between neurologists and pm&r I think is what you are looking for...

PM&R performs nerve blocks, ablations, injects joints, soft tissue, and spine, which neurologists do not do (unless fellowship trained in pain)

PM&R does diagnostic musculoskeletal and ultrasound guided procedures for various injuries, which neurologists don’t do

PM&R does EMG/NCV studies in order to identify nerve entrapments, brachial plexopathies, radiculopathies (usually MSK focus), which neurologists generally don't do (unless fellowship trained in neuromuscular medicine).

PM&R does botox injections for spasticity management in patients with spinal cord injury, cerebral palsy and stroke, which neurologists may or may not do depending on their training (they usually need a fellowship in neuromuscular medicine because residency doesn’t usually focus on this type of neurorehabilitation medicine)

PM&R admits and discharges patients to their own rehabilitation facility for rehabilitation services and manages their medical issues while they receive therapy (a neurologist does not do this but can be consulted if the patient has another stroke or has a seizure). A spinal cord injury patient can develop things like neurogenic bladder, autonomic dysreflexia, have respiratory issues, etc. depending on the location of their trauma. A physiatrist (more specifically a SCI fellowship trained physiatrist) would be an expert in medically managing these issues.

Neurologists diagnose brain disorders. They treat epilepsy, headache, acute stroke, and more with medications. They also perform EEGs (when fellowship trained) and can identify pathology on CT/MRI etc. So, if a patient is seizing uncontrollably in the hospital you would call a neurologist not a physiatrist to help with med management and evaluate why the patient is seizing with an EEG. If a patient comes in with a stroke in the middle of the night you will be calling your neurologist to evaluate this patient’s need for TPA--you would not call your physiatrist.

Once the patient is stabilized from their stroke, the physiatrist would be called to evaluate what physical disabilities the patient may developed as a result of their stroke and admit them to their rehab unit. The recovering stroke patient would receive SLP, OT, and PT according to the physiatrist’s recommendation before the patient is sent home. Following the patient’s discharge, the patient could return to their neurologist or PCP to be placed on a statin. The patient may also return to their physiatrist as an outpatient to assist in improving whatever functional deficits they have due to their stroke (i.e. spasticity management, pain control, orthotic evaluation, quality of life issues, etc.)

A neurologist is on the front line in terms of medical management of a patient with seizure or stroke. Residency training for neurologists really focuses on this aspect of care, as this is primarily what they do after graduating. Realize that being on the front line for acute ischemic events of the brain is akin to being on the front line for acute ischemic events of the heart (think cardiologist). Stroke patients can arrive at all hours of the night and day so the lifestyle of a neurologist will be similar to that of a cardiologist on call. Outpatient neurologists follow up with patients that have different types of seizure disorders, MS, etc. and adjust their medications accordingly.

When the dust settles, the PM&R doc may follow up with this same stroke patient and try to find ways to maximize their functionality as they return back to society. How has the patient's function decreased due to the stroke and how can we improve it through anti-spasticity medications, injections, orthotics, physical therapy, etc?

PM&R and neurologists may see the same patient but offer different modalities of treatment and have a different outlook. PM&R also works with neuro and orthopedic surgeons in a different way a neurologist does. PM&R collaborates with neuro and orthopedic surgeons by helping diagnose and identify painful anatomy using ultrasound, EMG, physical exam, and nerve blocks. For example, if an orthopedic surgeron isn't sure what nerve in the foot is causing a patient pain they can refer to their PM&R colleague. A PM&R doctor can use ultrasound to identify the pathologic nerve and block the nerve with lidocaine. If the patient’s pain subsides from this nerve block then the ortho doc now knows what nerve he can remove under the knife. As another example, a PM&R doctor can perform discography to identify a damaged disc before a neurosurgeon replaces this damaged disc with an artificial one.

I hope this helps.