Physiatrists Help Patients Manage Neck and Back Pain
An Interview with Nayan R. Patel, MD
SpineUniverse: What is the typical education and training to become a physiatrist?
Both academic and clinical training are required to become a physiatrist. For myself, following medical school, I completed one year in a general internal medicine internship followed by three years in a Physical Medicine and Rehabilitation (PM&R) residency at University of Texas, Southwestern. This gave me a breadth of experience in outpatient rehabilitation, musculoskeletal disorders, and electromyography (EMG) testing. I also received experience in inpatient treatment of neurological disorders, including stroke and spinal cord injuries, as well as orthopedic conditions such as hip replacements, knee replacements, fractures, and fracture management.
Some physiatrists have a subspecialty in pain management or musculoskeletal disorders. They may also complete a six-month or one-year fellowship in traumatic brain injury, spinal cord injury, geriatrics, or other subspecialty. Within a spine specialty group — such as Texas Back Institute, where I work — physiatrists typically receive their training through either a musculoskeletal fellowship or a pain management fellowship.
SpineUniverse: Do physiatrists typically practice in specialty groups?
Physiatrists started to be integrated into orthopedic and surgical practices about 20 years ago. I was the second or third physiatrist here at TBI. At that time, it was starting to become accepted practice to have a physiatrist within an orthopedic or surgical practice.
SpineUniverse: What is a physiatrist’s role in caring for patients with neck and low back pain?
My role is to triage patients who come in with acute or chronic neck or low back pain. I establish up a plan to evaluate each patient individually to determine the cause of their pain. I then assess appropriate non-operative treatment options, which are effective for the majority of patients.
My goal is to alleviate the patient’s pain without any invasive procedures. I help the patient achieve functional restoration as opposed to just masking the pain by prescribing medication. This may involve a referral for physical therapy, chiropractic treatments, and/or short-term treatment with medication. I want to see if the patient’s condition can be improved with these types of conservative therapies before considering an invasive intervention, such as spinal injections.
SpineUniverse: Do physiatrists only treat neck or back pain?
No. In my practice, my specialty and focus is spine care. Here, at TBI, the role of the physiatrist is to evaluate and treat spine-related musculoskeletal problems, which may include the extremities (eg, arms, legs). However, a physiatrist may practice in a multi-orthopedic group where he (or she) treats hands, shoulders, knees, and ankles — any musculoskeletal problem.
If I see a patient with shoulder pain who needs further intervention, I’ll refer him to an orthopedist. Physiatrists endeavor to manage pain without surgery.
SpineUniverse: Is a physiatrist different from a pain medicine specialist?
Yes. A physiatrist may have a subspecialty in pain medicine, but all physiatrists are not pain medicine specialists. When I started at TBI, very few physiatrists specialized in pain medicine management. That has changed over the last 15 years. Now, there is a fellowship program for physiatrists and anesthesiologists to become pain medicine specialists.
SpineUniverse: How are physiatrists involved with pain medications?
I try to explain from the first visit that our goal is nonreliance on pain medications, although some patients may need a pain drug, especially during the acute phase of treatment. We teach patients how to manage their pain symptoms with exercise and other techniques. Pain medications can be used intermittently to manage flare-ups, but I don’t usually use opiates as a long-term solution for pain management, unless there are overriding factors that require their use.
When patients are sent back to me, it’s not typically for pain management; it’s to make sure that we follow the patients. If they need an exercise-based program, we gear them up for that. But I try not to get involved in their medication management.