When the pain in your hip or your knee from that old sports injury is getting worse, you might worry that the doctor will recommend surgery. But many people don’t realize that most often musculoskeletal pain can be treated without surgery. In fact, the best specialist to see may be a physiatrist, a physician who specializes in nonsurgical musculoskeletal care.
Physiatrists, also known as physical medicine and rehabilitation (PM&R) specialists, are doctors who have completed many years of advanced training including medical school, residency, and, frequently, fellowship training—to specialize in areas such as interventional spine and sports medicine. Treating the person, not just the problem, is central to the care they provide. So, in addition to asking about your particular problem, a physiatrist may ask about your related medical, daily lifestyle, and occupational needs, and ergonomics.
“Physiatry is an extensive multifaceted field with many sub-specialties, but really the end goal is all the same—it’s to promote independence, maximize function, and enhance quality of life,” says Eric K. Holder, MD, a physiatrist who specializes in musculoskeletal medicine and spine care.
“I see patients in all age ranges from the young adult years well into the geriatric years," Dr. Holder says. "Our goal is to provide evidence-based, comprehensive nonsurgical musculoskeletal care. To do this, we listen to our patients’ stories and functional goals, as well as perform thorough examinations in order to make an appropriate diagnosis. Then, we partner with our patients to formulate treat plans to help them reach their goals.”
What is physiatry?
Physiatry has been a medical specialty for almost 100 years. It grew in demand after World Wars I and II, when veterans returning home from war with a variety of medical conditions sought care to restore as much of their function and quality of life as possible.
Today, physiatrists complete four years of medical school, as well as a one-year internship and three years of hospital residency, to develop important clinical skills. Physiatrists have extensive training in caring for the musculoskeletal and neurological systems. Many pursue additional training in such subspecialty areas as traumatic brain injury, neuromuscular medicine, pain medicine, pediatric rehabilitation, spinal cord injury, interventional spine, and sports medicine.
Physiatrists may treat both children and adults, and they help some patients manage conditions throughout their entire lives. They work closely with primary care physicians, and sometimes work alongside additional specialists including neurologists, orthopedic surgeons, and other providers.
What conditions does a physiatrist treat?
A physiatrist can manage a variety of conditions that impact a person’s ability to function. The conditions they treat are typically ones that affect the bones, joints, and muscles, as well as the central and peripheral nervous system.
The conditions a physiatrist may be able to help treat include (but are not limited to) the following:
- Back pain
- Neck pain
- Sports injuries
- Carpal tunnel syndrome
In addition to providing physiatry care for patients in doctor’s offices, Yale Medicine physiatrists also provide services in the hospital at Yale New Health’s Yale New Haven and Saint Raphael campuses for people with spinal cord injury, brain injury, brain hemorrhage, stroke, trauma, and fractures, as well as other neurological and medical conditions.
What can I expect from my first visit with a physiatrist?
A physiatrist will listen to your description of the medical problem that brought you in for treatment, and ask questions about your overall health and your medical history. “Most often what the patient tells us provides the biggest clues to determining the root of his or her medical problem,” says Dr. Holder.
A physiatrist performs a comprehensive examination—looking not just at the area that’s painful, but also at the surrounding joints and body parts, all of which may contribute to symptoms elsewhere in the musculoskeletal system.
Musculoskeletal pain can be deceptive, since a problem in one part of the body can cause pain elsewhere. A patient may come in with lower back pain asking to see a spine surgeon, and it turns out the hip is really the source of the pain. Often a physiatrist can figure this out without unnecessary imaging tests or injections, and this can keep medical expenses down.
Physiatrists may also perform a variety of tests, depending on the problem, and the patient’s situation and needs. One commonly used procedure is electrodiagnostic testing, which can measure electrical activity in the nerves by nerve conduction studies and in the muscles by needle electromyography. These tests can help identify nerve and muscle conditions that may be causing pain and weakness, and lead to problems that cause physical impairment.
They may also perform gait analysis, which looks at the way a person’s body and muscles move while they are walking.
What diagnosis and treatment methods will a physiatrist provide?
Physiatrists often recommend physical therapy. They also prescribe medicine, including anti-inflammatory medicines or muscle relaxants, among other treatments. In some cases, they may treat a problem with an ultrasound-guided or fluoroscopy-guided injection, which is a way to deliver pain medication to an injured or damaged area with accuracy and precision.
Some physiatrists are skilled in using platelet-rich plasma (PRP), a treatment that is growing in popularity, to enhance healing. For a PRP treatment, the doctor takes the patient’s own blood products, spins them in a centrifuge to create a highly concentrated growth factor, then injects that into the site of the injury to stimulate healing. They may collaborate with other specialists who can provide other types of regenerative treatments.
“Sometimes, it's just a matter of making small changes,” Dr. Holder says. “We pay attention to the details because making small adjustments, such as recognizing muscle imbalances and providing an exercise program to address a weak muscle, can greatly improve a person’s function and pain,” he says.
Do physiatrists perform or recommend surgery in some cases?
Physiatrists specialize in nonsurgical treatments, but if it becomes clear that you need surgery, a physiatrist will talk to an appropriate surgeon on your care team who can recommend the most minimally invasive approach available. The physiatrist can also support you through recovery.
Can a physiatrist provide assistive devices to patients who need them?
Yes, physiatrists can often provide appropriate supportive devices and items that will help you and with mobility issues that can arise with a disability. Examples include braces, canes, crutches, lifts, walkers, and wheelchairs.
How is Yale Medicine unique in its approach to physiatry?
Our physiatrists provide the most efficient care as they work side-by-side with rheumatology, orthopedics, neurology, surgery, radiology, and physical therapy, among other specialties. If you do need surgery, a physiatrist has quick access to orthopedic surgeons, who will determine the most minimally invasive approach.
“Our focus is to provide patients with support and care that will maximize their chances of leading active and healthy lifestyles,” Dr. Holder says. “As physiatrists, we know the importance of team-based care to equip our patients with every tool possible to succeed in reaching their functional goals. Often, we do this through working closely with physical therapists, behavioral health therapists, as well as our physician colleagues in other specialties, both nonsurgical and surgical, to provide comprehensive care,” he adds.