Thursday, February 6, 2014

What cool stuff do physiatrists do?

People are always asking me exactly what physiatrists (PM&R docs) do. Well, here's a list of some of the cool stuff we get to do:

1) EMGs

I've done EMGs to diagnose everything from carpal tunnel to ALS.

2) Fluoroscopic injections for pain

We get to go into the fluoro lab and do steroid injections to the back, hip, neck, etc. They're fun to do AND they make you glow in the dark!

3) Botox/Phenol blocks

We do botulinum toxin injections in muscles to reduce spasticity. And if they're a little left over, we might do your forehead too.

4) Musculoskeletal ultrasound

OK, this is a new one and not that many physiatrists do it yet, but we're getting there. Msk US can be used to diagnose rotator cuff tears, carpal tunnel, and guide injections. And after we're done with that, we can put the probe on your belly and see if there's a reason you've been throwing up every morning.

5) Steroid injections, et al. (Or Synvisc, PRP, etc)

We inject pretty much everything in the office. I'm most comfortable with knees and shoulders, but we do elbows, trigger fingers, IT bands, you name it. If I can find it in my injection handbook, I'll do it!

13 comments:

  1. I love your blog and your book!

    I need an EMG to test for carpal tunnel. Your comment about the Msk US sounds so much more pleasant. Is that a common diagnostic tool for carpal tunnel? If I ask my ortho for one and he won't/can't do one is it okay to get one elsewhere then go back to him with the results and still ask him to do the surgery, or would that be "offensive"?

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    1. Not many people are yet skilled enough to do the study though.

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  2. Oooh, MSK u/s--way better than trying to hold still for an MRI! Can't wait until that becomes more mainstream.

    Thinking about your specialty and sports medicine...why would one specialist be preferable over the other for athletes? I refer a fair number of my teen athletes to sports medicine, but maybe PM&R is another option? What do you think?

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    1. Lots of physiatrists do sports fellowships. They're probably good options.

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  3. Can musculoskeletal ultrasound assist in dxing RA?

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  4. Yes, ultrasound can diagnose carpal tunnel -- measure the area of the median nerve in cross section, and volar displacement of the retinaculum. Lots of diagnostic imaging specialists are good at dx'ing carpal tunnel.
    Ultrasound is very good at diagnosing RA, can see early stages long before radiography. Also can see synovial thickening that cannot be seen on x-ray
    I suggest you leave ultrasound to sonographers and sonologists, or go do a fellowhship in diagnostic imaging.

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    1. Fizzy said that ultrasound can be used to diagnose carpal tunnel syndrome. The problem is, not many people are properly trained to perform the study and interpretation is difficult, as opposed to EMG. So not all hand surgeons will accept the findings.
      And whereas U/S can be used to diagnose RA, RA is primarily a lab diagnosis. Synovial thickening in the absence of +RF, ANA, etc is definitely not diagnostic of RA since that's a nonspecific symptom common to both inflammatory and seronegative arthropathies.

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    2. Thanks for clarifying. I don't do msk us but I know a guy who teaches it and he's honest about the fact that not many people are good at it yet. The possibilities are endless but the reality currently limited.

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    3. "RA is primarily a lab diagnosis." Except it apparently isn't, in up to 30% of RA patients, according to two of my rheumatologists. Not trying to be difficult, but I would just note that there are a ton of people out there who are and may forever be seronegative. I only note this so that people are aware of the high number of RA sufferers who may never have bloodwork that "proves" the diagnosis. Because their labs show nothing specific, many of these patients will not be diagnosed until long after they are already suffering from bone erosions due to disease activity. I was lucky and properly diagnosed before any permanent joint damage, but it took me years to get help because every physician I saw stopped looking for answers after my bloodwork came back with nothing other than a high ANA titer. 5 years after the onset of my initial symptoms, I remain RF negative, sed rate is still always normal, etc.

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  5. In what way would physiatrists work with prosthetics? To clarify, how often/common is this? Or do certain types of physiatrists work with these patients? Or not at all!?

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    1. It's not uncommon and is actually something I do. I work with prosthetists to get patients appropriate prosthetics. But I don't consider it particularly cool.

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    2. Emily McMedStudentFebruary 9, 2014 at 3:17 PM

      Fair enough! well if you have a minute and are interested in the past of medicine that looks widely non-evidence based, check out some of these old prosthetics that were used. *shiver*

      http://www.ebaumsworld.com/pictures/view/83858344/

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