Physiatry Progressions: PM&R as First Step for Back Pain

By Chirag Kalola, MD
back pain
Lower back pain is the most common musculoskeletal complaint. It affects up to 30 percent of all Americans at any time and 85 percent of individuals at least once in their lives.  Chronic back pain can have a profound impact on individuals' physical, psychological and emotional health. Chronic back pain is often cited as a reason for giving up exercise, activities of daily life and sexual intercourse.

From their primary care physician’s office, patients with chronic back pain often are referred for evaluation by orthopedics or neurosurgery. However, an overwhelming body of evidence suggests that in the absence of clear surgical indications, such as bowel or bladder dysfunction orprogressive or severe sensory or motor neurologic deficit, the vast majority of these patients have functional pain that cannot be treated with surgery.

Studies evaluating the utility of imaging studies in these patients indicate that structural spine changes are typically non-diagnostic, only weakly associated with outcome and do not impact treatment. Further, imaging abnormalities are often non-specific, and herniated discs and degenerative joint disease are frequent incidental findings in individuals without pain.  Consequently, in nearly all presentations, muscular and ligamentous sources of pain are more likely than surgically treatable structural lesions. Such functional pain cannot be diagnosed on imaging studies and may be more appropriately assessed and treated by an early referral to a physical medicine and rehabilitation physician (PM&R).

For a PM&R specialist, the primary goal is to provide every patient with comprehensive and effective non-operative treatment of pain aimed at restoring optimal function. Physiatry-based approaches to chronic back pain treatment begin with a thorough physical examination, including musculoskeletal assessment of the patient’s posture, passive and active range of motion, evaluation for physical deformity and neurologic testing, including nerve conduction studies (NCS) and electromyography (EMG) when appropriate.

Next, the rehabilitation specialist will recommend a targeted treatment plan aimed at achieving analgesia, improving psychosocial function, reintegration of recreational pursuits and restoring optimal function.  Typically, this involves a multimodal approach that combines physical and occupational therapy, exercise training, movement and activity modification, adaptive equipment and assistive devices, along with local and systemic medications.

PM&R physicians strive to address pain issues on multiple levels and emphasize a multidisciplinary approach involving team members of diverse expertise, including psychologists and physical and occupational therapists. The physician specialist is the primary provider and ensures that care is properly coordinated.

Studies of similar team-based approaches to pain management have demonstrated superior long-term outcomes over conventional treatments including less work disability, fewer diagnostic tests and fewer surgical procedures. In this manner the physiatrist can provide optimal outcomes by ensuring that patients are properly evaluated and receive complete therapy, while addressing the physical, psychological and emotional aspects ofchronic back pain.

Chirag Kalola, MD, is Medical Director of The Spine & Joint Center at Good Shepherd in Allentown, PA, where he provides specialized outpatient care for musculoskeletal and orthopedic pain. He provides fluoroscopy-guided spininjections and EMGs. Dr. Kalola is board certified in physical medicine and rehabilitation and pain management.