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