Most often, a patient is referred to my practice by their primary care physician (PCP) or spine surgeon. When a PCP or surgeon believes their patient may benefit from a second tier of medical care—that is, nonsurgical treatment—the patient is sent to me for further evaluation and conservative therapy. — Nayan R. Patel, MD

SpineUniverse: How is a physiatrist’s assessment of a patient’s neck or back pain different—or is it the same as a PCP or spine surgeon?

Dr. Patel:
Although the PCP or spine surgeon has performed a thorough physical and neurological examination, I too will evaluate the patient in a similar manner. Of course, if the referring doctor has current x-rays, CT scans, and/or MRI studies, those will be sent to me, so there is no need to repeat imaging studies—although, sometimes a radiographic or other imaging study is necessary.

Physiatrists are trained in electrodiagnostic medicine, which are tests that measure the efficiency of nerve and muscle functions. The names of these tests are electromyography (EMG) and nerve conduction studies. These studies can help me determine the origin or cause of pain. Of course, just because I perform these tests, does not mean that every patient requires electrodiagnostic testing.

SpineUniverse: If the referring doctor has already performed a physical and neurological examination, why do you perform one too?

Dr. Patel:
There are many reasons I perform my own physical and neurological exams. First, the patient is new to me, and although the referring doctor has sent me the patient’s records, I benefit by making my own observations—which, ultimately benefits the patient too. Second, the patient’s condition may have changed (eg, worsened) since they saw their referring doctor. The result of a comprehensive physical and neurological examination is critical to making an accurate diagnosis.

For example, I saw a very pleasant lady today who was complaining of numbness in both hands and both feet. She thought it might be related to her spine. Typically, those symptoms don’t indicate a spinal condition, but I still needed to rule that out. I found no pinched nerve in her neck or lower back. For this patient, I needed to look further and maybe rule out a generalized neuropathy (nerve damage) or some other reason for her symptoms. I “tailor” the examination by listening to the patient, carefully applying what I learned while taking their medical history, and applying my expertise.

SpineUniverse:  Do physiatrists perform spinal injections?

Dr. Patel:  
Physiatrists perform many different types spinal procedures—from the neck (cervical spine) to the tailbone (sacrum).  This includes facet joint blocks, epidural injections, selective nerve root injections, and medial branch blocks. Physical medicine and rehabilitation physicians (PM&R, physiatrists) also perform second-tier procedures, such as rhizotomies. A rhizotomy can help block pain nerve pain. A spinal cord stimulator is a third-tier treatment to help patients manage chronic pain.

SpineUniverse: Typically, what type of treatment do you prescribe?

Dr. Patel:
A patient’s treatment plan may include medications, passive physical therapy (eg, massage, transcutaneous electrical stimulation [TENS], heat/cold), spinal injections, and active therapeutic exercise. My goal is to help patients become more functional/physically active while minimizing pain.

As physiatrists, we can offer many different treatment options. Although we strive to avoid invasive therapies, sometimes spinal injections, which are considered interventional, help patients manage their pain. Unfortunately, despite our best efforts—mine and the patient’s, spine surgery may be recommended.

SpineUniverse: What might a new patient expect?

Dr. Patel:
During the first visit with a new patient, I explain the treatment goal—which is to try to restore the patient’s functional level without relying on medications to minimize pain.  An appropriate exercise program—designed to fit the patient’s current physical abilities—is important to increase physical function and reduce pain. Other therapies, such as those I mentioned earlier, augment therapeutic exercise. Medication may be recommended to help manage pain flare-ups. However, opiates are not a long-term solution for all types of pain. Of course, there are factors that override that statement, but few of my patients strictly use medications.

SpineUniverse: Does the physiatrist take over the patient’s care from the referring doctor?

Dr. Patel:
The patient can always see their referring doctor. Again, my job is triage—carefully evaluate the patient and their diagnosis (if a diagnosis was given), and formulate a treatment plan to alleviate pain and/or other symptoms (eg, numbness, weakness). Following a course of treatment, when the patient’s condition is improved or stable, they follow-up with their PCP or other doctor.

If the patient’s pain or related symptoms recur, they may return directly to me for additional assessment and further treatment. It’s about half and half depending on how quickly the patient can get into see either me or their primary care physician.