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.
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.