What can PM&R do for patients with musculoskeletal injuries?

Discussion in 'PM&R' started by 253, Dec 4, 2008.

  1. 253

    253

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    I'm interested in MSK medicine, but I don't see that it is actually capable of accomplishing much in terms of intervention. I'm not impressed with palliative treatments like analgesics; anybody can go to the store and purchase a bottle of naproxen. I also disapprove of the widespread use of orthoses in podiatry (I feel that they are often prescribed to people who don't need them), so if this is a feature of MSK medicine, count that among the things I don't want to participate in. Apart from NSAIDs, steroid injections, and orthoses, what is PM&R capable of doing for someone with a musculoskeletal injury? If the answer is administering rehab, what is the value of a physiatrist over a physical therapist? Not trying to disrespect the field of PM&R or its practitioners in any way, just seeking insight, and trying to determine whether it's right for me. Thanks in advance.
     
    #1 253, Dec 4, 2008
    Last edited: Dec 4, 2008
  2. Disciple

    Disciple Senior Member
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    A good musculoskeletal Physiatrist should be an expert diagnostician. Without a complete diagnosis, you can’t treat successfully.

    The interventional spine approach to diagnosis typically involves injecting different structures and blocking various nerves.

    The PT approach involves teasing out subtle muscle imbalances, hyper/hypomobility and biomechanical abnormalities.

    Surgeons look for anatomic lesions that are surgically correctable.

    A Physiatrist should be able to see the big picture utilizing all these approaches, thereby arriving at a complete diagnosis.

    Without good diagnostic skills, the patient may get the wrong (or too many or too few) injections, the wrong therapy, and worst of all the wrong surgery.

    Many patients never get a diagnosis for their chronic painful musculoskeletal condition, and end up on inappropriate opiates.

    As you know, options for treatment typically include medication management, modalities, various forms of therapy/bracing, interventional procedures, or surgery.

    As a Physiatrist you so be able to personally manage medications and perform procedures, and should be able to identify when (and which) modalities, surgery or other forms of therapy would be appropriate. You should also be able to mix and match various treatment options to achieve the best possible outcome for your patient.

    One more point--There is a lot more to palliating pain with medications than telling patients to “pick up a bottle of Naproxen”.
     
  3. PMR 4 MSK

    PMR 4 MSK Large Member
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    Most acute MSK injury are going to resolve themselves over time, usually days to a few weeks. Reassurance, RICE and a little TLC will take care of most of these. Pain meds simply buy the patient time to heal with lessor symptoms. Judicious use of NSAIDs may decrease inflammation, which may or may not be beneficial.

    If after 2-3 weeks, a patient is still having significant problems, a better Hx and PE needs to be done to elicit what is causing the pain, rather than just calling it a "Strain" or "Sprain." This is where a good MSK physician is needed, be they PM&R, Ortho, FP or whatever.

    Accurate Dx, as Disciple says, is the key, and many of the prolonged cases are due to inadequate diagnose reulting in the wrong treatment. Where PM&R excels is at making the correct diagnosis and implimenting specific treatments, be they medications, PT or HEP, injections, electrotheraeutics, or referal to another field such as ortho for surgical repair.

    For many of these injuries, ortho doesn't want to treat unless it's surgical, FPs and other specialties often don't have adequate training to correctly diagnose and many docs don't know when to use PT vs injections, vs meds.

    PTs want direct patient access so they can be front line therapy. However, beyond modalities such as heat, US and massage, as well as teaching the patient stretching and strengthening, and some manual therapy techniques like STYM ansd ASTYM, they can neither advise nor impliment other treatments or testing. They cannot order and interpret an MRI, EMG or even an Xray, and had better know when to refer for these.

    I tell people all the time that most of what I am doing is buying them time to allow the body to heal, if it doesn't heal, which is rare, they may need surgery.
     
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  4. ampaphb

    ampaphb Interventional Spine
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    Tying our hands behind our backs and then asking us to defend our field is unreasonable. The concept of "disapproving" the use of anti-inflammatories, administered either orally or via injection, seems akin to asking an oncologist to justify his practice without allowing him to use chemotherapy, or telling a spine surgeon he is worthless 'cause you don't believe in intradiscal procedures like decompressions or fusions, so what else does he have to offer.

    Just because podiatrists overuse orthoses, it does not follow that that has any bearing on how physiatrists use technology, and would be analogous to criticizing the way chiropractors utilize physical therapy, and then extending your criticism to orthopaedists.

    So feel free to tell my chronic pain patients you're "not impressed" with palliative care for their symptoms - how quickly do you think they will tell you to get lost?

    Would you care to share RCT data to bolster why you don't believe, and aren't impressed with, what we do? 'Cause if not, your views are just as illegitimate as the snake oil salesmen who used to take care of pain patients before we tried to use real science to justify what we do. You can "believe" whatever you like. But if you really want to take on an entire field of medicine, you'd be far better off coming to the table with facts, rather than mere personal opinion.
     
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    #4 ampaphb, Dec 6, 2008
    Last edited: Dec 7, 2008
  5. Bleurberry

    5+ Year Member

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    I just read your work here to a trippy techno beat (at work in a gym) and I have to say, there's elements of poetry here.
     
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  6. caedmon

    caedmon Member
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    I'm not sure of your level of training, but it seems you have been misguided on a number of issues.

    1. I wouldn't consider the use of NSAIDs as palliative. That implies that you would be giving up on treating the actual problem and just covering symptoms. Use of NSAIDS and other pain medications in PM&R are typically an adjunctive treatment to aid in recovery by other means such as PT. Actually, the use of NSAIDS in certain acute injuries are thought to inhibit the healing process and are avoided at times. That being said, Rx dose NSAIDS can be powerful pain relievers that allow someone to proceed with a therapy program possibly cure thier problem.

    2. I agree somewhat in principle with you that the "widespread use of orthoses... in people who don't need them" shouldn't be done. A properly trained physiatrist should be an expert in understanding the kinetic chain (look it up if you don't know what it is) and therefore wouldn't prescribe orthotics to someone who doesn't need them. If you understand how ground reaction forces can affect the body, you will know who deserves at least a trial of orthotics. Althought the literature may not be vast, orthotics have been shown to reduce symptoms in those with intrinsic foot deformities, repetitive stress, and can aid in pain and reduction of forces in knee OA.

    3. The use of MSK ultrasound is rapidly becoming a integral tool to the practice of physiatry. Some are using it for diagnoses and others more for guidance for certain interventions. It is a nice tool for the physiatrist as it extends the physical exam (much like an EMG) and gives you real time feedback to MSK dysfunction (unlike CT or MRI). Some of the most promising interventions that are being done include percutaneous tenotomy for tendonopathy as well as administration of pro-inflammatory agents such as PRP or autologus blood.

    4. I wouldn't say a physiatrist has value "over a physical therapist". We serve different roles. As already mentioned, a physiatrist has expertise in diagnosis of MSK (and neuro) pathology and understands the pathophysiology of MSK problems. This understanding is critical in guiding a therapy program in terms of use of proper modalities and even implementation of appropriate exercises at a given time in the recovery process. Take the rotator cuff for example- If you're the PT or referring provider who says "evaluate and treat" you don't know what you're going to get. Good PT's may start with scapular stabilization or correction of other biomechanical insufficienies, but some will start with rotator cuff exercises without addressing the core issues. Often times, certain providers ma may overlook an appropriate rehabilitaiton program altogether. For example, a severe ankle sprains are often just treated with "RICE" therapy and care is done when pain resolves. Without appropriate rehabilitation these patients are susceptible recurrent ankle injuires, improper biomechanics and more proximal injuries. For cases such as this, rotator cuff problems and a host of other MSK issues, I think physiatrists should be the primary provider for MSK problems. Unfortunately, this doesn't happen often enought and we end up seeing the results of poor management.

    I think MSK medicine is an exciting field and growing quickly. We're learning more about medical and other therapeutic interventions. Many of these fit into our niche well as PCP's may not feel comfortable managing more complex cases and the surgeons don't necessarily have the time to add additional office based medicine or procedures.
     
  7. Ludicolo

    Ludicolo Fib Hunter
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    :thumbup: Agree with all of the above. Don't know about the techno thing though.
     
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