What is a Physiatrist?
A physiatrist (pronounced “fizz ee AT trist”) is a physician specializing in physical medicine and rehabilitation. As the American population ages, as people survive conditions that once would have been fatal, and as quality of life is an increasing concern, the field of physiatry is moving to the forefront of medicine. The specialty serves all age groups and treats problems that touch upon all major body systems.
How did the specialty develop?
The field of physical medicine and rehabilitation (PM&R) began in the 1930s to address musculoskeletal and neurological problems, but broadened its scope considerably after World War II. As thousands of veterans came back to the United States with serious disabilities, the task of helping to restore them to productive lives became a new direction for the field. The Advisory Board of Medical Specialties granted PM&R its approval as a specialty of medicine in 1947.
What types of conditions does a physiatrist treat?
Physiatrists are physicians who treat a wide range of problems -- from sore shoulders to spinal cord injuries. The focus of the specialty is on restoring function to people. Physiatrists treat acute and chronic pain and musculoskeletal disorders. They may see a person who lifts a heavy object at work and experiences back pain, a basketball player who sprains an ankle and needs rehabilitation to play again, or a knitter who has carpal tunnel syndrome. Physiatrists’ patients also include people with arthritis, tendonitis, any kind of back pain, and work- and sports-related injuries.
Physiatrists treat very serious disorders of the musculoskeletal system that result in severe functional limitations as well. They would treat a baby with a birth defect, someone injured in a bad car accident, or an older adult with a broken hip. Physiatrists also treat people with spinal cord injuries, brain injuries, strokes, amputations, cancer, and multiple sclerosis. All require a long-term rehabilitation process.
What is the physiatrist’s role in treatment?
A physiatrist may treat patients directly, lead an interdisciplinary team, or act as a consultant. Here are some scenarios that illustrate the varied roles of a physiatrist:
• A carpenter is lifting some heavy wood when he feels pain in his lower back and down his leg. He sees a physiatrist who does a thorough history and physical examination and performs all the testing needed to make the diagnosis: a herniated disc. The physiatrist develops an appropriate treatment program, monitoring and adjusting it as needed. With this treatment and rehabilitation program, the patient does not need surgery.
• A woman in a diving accident has a spinal cord injury and is paralyzed below the waist. The physiatrist assesses her injury and, with the patient and a team of health care professionals, determines the course of her rehabilitation. The physiatrist treats the array of medical issues that occur as a result of the spinal cord injury, and also leads the interdisciplinary team to enable the woman to reach the highest possible level of functioning. The team varies in composition depending on the needs of the patient. In addition to other physicians, the team may include healthcare professionals such as nurses, physical therapists, occupational therapists, social workers, neuropsychologists, and vocational counselors.
• A baby is born with cerebral palsy. The physiatrist is called in as the expert who advises on the correct treatment and rehabilitation that can affect the rest of the child’s life.
How do physiatrists diagnose?
Physiatrists’ diagnostic tools are the same as those used by other physicians, with the addition of special techniques in electrodiagnostic medicine, such as electromyography (EMG), nerve conduction studies, and somatosensory evoked potentials. These techniques help the physiatrist to diagnose conditions that cause pain, weakness, and numbness.
What kinds of treatments do physiatrists offer?
Physiatrists offer a broad spectrum of medical services. They do not perform surgery. Physiatrists may prescribe drugs or assistive devices, such as a brace or artificial limb. They also use diverse therapies such as heat and cold, electrotherapies, massage, biofeedback, traction, and therapeutic exercise.
Where do physiatrists practice?
Physiatrists practice in rehabilitation centers, hospitals, and in private offices. They often have broad practices, but some concentrate on one area such as pediatrics, sports medicine, geriatric medicine, brain injury, and many other special interests.
What kinds of differences do physiatrists make?
Because it is the concern of physiatrists to restore patients to maximum function, the difference they make can be dramatic. In the case of the herniated disc, the physiatrist not only takes care of the acute problem, but also treats the patient until he returns to optimal functioning, usually without surgery. The physiatrist also teaches the patient how to prevent the injury in the future. Another example is that of a broken hip in an older adult. Physiatrists can provide aggressive rehabilitation so the person can walk and even exercise again. And because the physiatrist is concerned with all areas of rehabilitation–social, vocational, and medical–the quality of life is significantly increased for patients.
What is Lower Back Pain?
Low back pain (LBP) is often described as sudden, sharp, persistent, or dull pain felt below the waist. LBP is very common and affects most people at some time during their life.
Low back pain is most commonly caused by muscle strain associated with heavy physical work, lifting or forceful movement, bending or twisting, awkward positions, or standing in one position for too long. Any of these movements can exacerbate a prior or existing back disorder.
Other conditions that can cause low back pain include spinal stenosis, arthritis (osteoarthritis), spinal infection (osteomyelitis), spinal tumors (benign and malignant), spondylolisthesis, and vertebral fractures (e.g., burst fracture).
Low back pain is either acute or chronic. Acute LBP may begin suddenly with intense pain, usually lasting less than 3 months. Chronic pain is persistent long-term pain that sometimes lasts throughout life. Even chronic pain may present episodes of acute pain.
Other symptoms include localized pain in a specific area of the low back, general aching, and/or pain that radiates into the low back, buttocks, and leg(s). Sometimes pain is accompanied by neurologic symptoms such as numbness, tingling, or weakness.
Neurologic symptoms requiring immediate medical attention include bowel or bladder dysfunction, groin or leg weakness or numbness, severe symptoms that do not subside after a few days, or pain that prevents everyday activities.
Diagnosis
Pain felt in the low back does not always indicate a spinal problem. A thorough physical and neurologic assessment may reveal the cause of the low back pain. The physical examination begins with the patient’s current condition and medical history.
Range of Motion
The patient’s range of spinal motion is evaluated while standing straight, bending forward, and bending to the side. Asymmetry, posture, and leg length is noted. Methodical palpation of the spine can reveal muscle spasm, possible bony displacement, and tender points. Abdominal palpation is performed to determine if the cause of low back pain is possibly organ related (e.g., an inflammed pancreas).
Neurologic Assessment
The neurologic assessment evaluates weakness, absence of reflexes, tingling, burning, pain, diminished function, and other signs that may indicate nerve involvement. In some cases, electrodiagnostic studies, such as electromyography (EMG) or nerve conduction studies (NCS) (http://www.totalspine.com/nervetesting.html), are performed to confirm a diagnosis or to localize the site of nerve injury.
Lab Tests
If infection, cancer, fracture, or other risk factors are suspected, routine lab tests may be ordered. These tests may include a complete blood count (CBC), erythrocyte sedimentation rate (ESR), and urinalysis.
Imaging Studies
Plain radiographs (X-rays), CT scan, and/or MRI studies are performed when a fracture or neurologic dysfunction is suspected. An MRI represents the gold standard in imaging today. An MRI renders high-resolution images of spinal tissues such as the spinal cord and intervertebral discs. X-rays are still the imaging methods of choice to study the bony elements in the low back.
The results of the physical and neurologic examinations combined with test results are carefully evaluated to confirm a diagnosis.
Treatment
Most patients with low back pain are treated without surgery. A conventional treatment plan may include bed rest for a day or two combined with medication to reduce inflammation and pain. Medications recommended by the physician are based on the patient’s medical condition, age, other drugs the patient currently takes, and safety.
Medication
The first choice for pain relief is often nonsteroidal anti-inflammatory drugs (NSAIDs). These drugs should be taken with food to prevent stomach upset and stomach bleeding. Muscle relaxants may provide relief from muscle spasm but are actually benign sedatives, which often cause drowsiness. Narcotic pain relievers are prescribed for use during the acute phase.
Physical Therapy
Physical therapy (PT) is started as soon as the patient can tolerate activity. A managed PT program can help build muscle strength, flexibility, improve mobility, coordination, stability, balance, and promote relaxation. Patients who participate in a structured physical therapy program often progress to wellness more rapidly than those who do not. This includes low back maintenance through a home exercise program developed for the patient by the physical therapist.
PT may include ice therapy to slow nerve conduction thereby decreasing inflammation and pain. Heat treatments may be used to accelerate soft tissue repair. Heat increases blood flow and speeds up the metabolic rate to help healing. Heat also helps decreases muscle spasm, pain, and promotes a relaxed feeling. Ultrasound is a treatment used to deliver heat deep into soft tissues. Sometimes a heat treatment is given before a therapeutic exercise session.
Surgery
Seldom is surgery required to treat low back pain. Surgery may be considered if the patient is experiencing bowel or bladder dysfunction, increased nerve impairment, progressive weakness, incapacitating pain, or spinal instability. The surgical procedure depends on the diagnosis or the cause of low back pain.
Recovery
First and foremost, follow the treatment plan outlined by the physician and physical therapist. To enhance recovery from surgery, an episode of low back pain, or to help prevent future worsening of back pain, try to maintain good posture, be consistent with your home exercise program, and eat sensibly to maintain proper body weight.
How can posture affect my symptoms?
Sitting
When sitting, even in the best type of chair, avoid the natural tendency to slump forward as your back muscles become tired. Sit with your lower back against the chair and with your feet flat on the floor. Avoid sitting for long periods. Take breaks to stand up and stretch. Choose a chair that supports the back and allows your knees to be level with your hips. This should help reduce the pressure on your lower back.
Standing
Again, it is important to try to maintain the normal curvature of your lower back when standing. Wear comfortable shoes with good arch support. If you must stand in one place for long times, try to shift positions or rest one foot on a stool. If you are working, try to keep your equipment close to you and at a comfortable height.
Sleeping
When lying on your back, place one or two pillows underneath your knees to support your lower back. When you are lying on your side, place a pillow between your knees. When first getting up from sleeping, roll to your side and push up slowly with your arms until you are sitting on the side of the bed.
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