Is there much overlap between PT and PM&R?

[neoevolution]

I was thinking about fields with mid-levels who have a pretty large scope, like CRNAs or optometrists. Is PT similar, or is it just that the two fields work together but have different capabilities?

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[SpinALL]

Neo, these careers are different. A short example...

In the inpatient setting a physiatrist may work with spinal cord injuries, traumatic brain injuries, strokes and many other various neurological diseases. While they are inpatient each day the patient may see physical therapy, occupational therapy, speech therapy, or some combination determined by their needs. (So PT does have a large role in the patients daily rehab.) The PM&R physician manages the medical conditions the patient has, any medical issues that arise during their stay in the rehab hospital, and addresses any barriers to achieving the best functional outcome they can during their time with the each specialist (like PT).

PM&R physicians often also specialize in sports medicine, sports and spine, pain medicine, outpatient MSK, orthotics and prosthetics, etc. A nurse practitioner or PA would be the midlevel you are asking about. Hopefully you will spend some time discovering what a great field it is!

 

[Fiveoboy11]

Where to start...

"May see physical therapy"....
No. They may see a PT, a PTA, a OT, a COTA or a SLP. You individualize your own group but deindividualize the others. And this is done multiple times in your response. That is like someone calling you "PM&R" (literally, not a physiatrist, and not by your name), and anyone who does a job remotely similar to yours (PM&R PA or NP) being called PM&R.

"Or a combination depending on needs"...
No. It's not determined by need at all. It's determined by everyone but those qualified to make the determination (insurance, physician, administration).

"And addresses any barriers"...
I'd bet the vast majority of barriers that a physiatrist can and should "deal with" are not, and too many that a physiatrist can't or shouldn't are. Example of the former that I've seen relentlessly would be poor communication with rehab professionals re managing the patient medically and addressing the concerns of the patient and therapy staff re the medical concerns (in a timely manner). Example of the latter would be "PT to work on strengthening" (or any similar
worthless variation) which I've seen a sickening amount (thousands of times). Re communication, "Talked with the nurse about it" doesn't count and writing a quickie note doesn't either. Consider how much is lost in translation with this nurse or "rehab director" (often not a physical therapist and not anyone seeing or who knows the patient) middle man method.

I doubt there is much overlap between what a physical therapist REALLY does and what a physiatrist does. The biggest similarity is they most often "work together" in the inpatient acute setting, they often see similar patients (functionally limited, disabled, impaired, in pain) and there is some overlap between entry level training for a PT and some parts of PM&R residency. A PM&R physician by far comes out of residency with the best "understaning" (they really don't) of physical therapy than any other physician specialty but still lame and pitiful.

 

[Jitter Bug]

Sounds like you hate your job. Sorry, but don't take it out on the person responding to the OP.

There is actually very little overlap between PT and an MD of any specialty. I can't do their job, and they can't do mine. We want the same things, which is a happy patient making progress to solve a functional goal. But the training, focus of evaluations, and day to day duties are very different.

 

[Fiveoboy11]

More like I love my profession but hate incompetents screwing it up.

 

[jadedphysiotherapist]

1. I was thinking about fields with mid-levels who have a pretty large scope, like CRNAs or optometrists. Is PT similar, or is it just that the two fields work together but have different capabilities?

CRNAs have the same job for gas and do the same treatment with oversight. PAs and NPs (if not a first assist in surgery or an extra pair of hands) have the same job as primary care and do the same treatment with restricted legal scope under the attendings license.

Optometrists treat differently than ophthalmologists....one is surgical and does meds, the other prescribes glasses and contacts etc. Psychologists use psychotherapy and counseling primarily while psychiatrists focus on psychopharmacology

Therapists use therex, modalities that don't enter the skin, and manual therapy (or graded physical stress) as treatment for functional impairments following disease or injury and help facilitate healing. Usually progressing from passive to active treatment. Physiatrists do high level procedure or pharmacological intervention for patients primarily but have crossover with fitting orthotics and prosthetics etc. depending on the work and collab model. Both will treat the same patients generally but use different approaches.

Inpatient is the most collaborative. Physiatry does the medical management for serious trauma or neuro cases, treats, and coordinates the rehab plan with speech therapy, occupational, and physical. Followups with aquatic therapy etc. are reported and monitored and the physician adjusts things.

Outpatient Physiatry does more primary care and sports medicine utilizing injections to my understanding. Spine and trauma go with it for pain medicine as well for fellowships I believe. In some setups, Physiatry will refer patients and send imaging to the Ortho or sports therapists who create a rehab plan after the initial visit.

In other settings, particularly with surgeons and therapists only, the therapist just does differential dx for low level pathology themself and creates the rehab plan or progresses patients from post op back to withstanding high physical stresses.

So it's much more similar to the optom/optho and psychology/psychiatry field dynamics. Treatments differ and complexity of patients may need more physician management or not. The treatment is adaptation, habituation, compensation, and substitution which work with disease form/function deficits or facilitating neuroplasticity for neuromusculoskeletal issues as opposed to procedure and pharmaceutical interventions for the same problems when necessary. Other physician collaborations include:

-Neurological outpatient following neurosurg or neurology
-ENT collab with vestibular and dizziness issues
-Hospitalist collab with acute/subacute positioning and secondary/tertiary complication prevention (this is the most general hospital work)
-Ob/gyn collab for pelvic floor dysfunction and retraining or pain during the pregnancy process or birth
-Oncology for lymphedema management using manual techniques and sleeves for drainage
-Pediatric developmental delay with PCPs to facilitate strength and motor control for activities for developmental milestones
-HH and snf for basic independence or palliative care with internal medicine

 

[pmrmd]

The question is there overlap? Sure there is. I spend quite a bit of time discussing and demonstrating an exercise program that is specific to the patient. Certain modalities are better than others and can be helpful in hastening the patient's recovery.

In the real world you will see P.T.s who think they know more than they actually do providing more "treatment" than they actually should. Take the obvious reply above as an example.

 

[jadedphysiotherapist]

The question is there overlap? Sure there is. I spend quite a bit of time discussing and demonstrating an exercise program that is specific to the patient. Certain modalities are better than others and can be helpful in hastening the patient's recovery.

In the real world you will see P.T.s who think they know more than they actually do providing more "treatment" than they actually should. Take the obvious reply above as an example.

This was directed at my input?

My commentary is rather spot on for interdisciplinary collabs, referral sources, business models, and independent Tx or Rx separated by legalities among the fields in a rather informative, diplomatic, and educational set of paragraphs to be quite honest.

Wouldn't classify commenting on those practice patterns as knowing "more than I than actually do"....but maybe I should refrain from cross posting interdisciplinary education of practice patterns to other specialties if that is the response elicited.

Unless the comment was directed elsewhere at more inflammatory commentary in the thread. Then no problem and my apologies for misinterpretation

 

[pmrmd]

This was directed at my input?

Sorry, not at all. You were right on the money. More toward a certain late December poster.

Let me be more specific to the student O.P. In the inpatient world there is daily collaboration, as there should be. I believe the therapists play an invaluable role and help people tremendously. I have nothing bad to say about that aspect.

Its the outpatient world is where we see the trend I mentioned.
Does every patient with a pain need dry needling? Because they get it, even with obvious exam findings of radiculopathy.
Does every patient with a pain need hot packs and cold packs on the same visit? Because they get it.
Does every patient need electrical stimulation as a part of their regimen? Because they get it.
Does every patient need neuromuscular retraining exercises? Because they get it. And since the whole premise behind this and result of this are debatable, let's leave that for another time.
Does every patient need core strengthening? Because they get it, even though there is no way to accurately and precisely measure baseline levels and gains.

Traction is still a great modality. Rarely do people get it. Because it doesn't work? No. Because its time intensive and requires a 1:1 therapist to patient ratio rather than the passive modalities that seem to allow a better income stream.

Do I really need to send my patient for three months of the above bull**** when there is an obvious facet pain by history, examination, and imaging? Yes, because the P.T. lobby has done well with the government bureaucrats it seems. Is the above treatment regimen more expensive than a facet block x 2 and RF? Absolutely.

There are quite a few basic questions that seem to be unanswered and overlooked every day.

 

[jadedphysiotherapist]

Sorry, not at all. You were right on the money. More toward a certain late December poster.

Let me be more specific to the student O.P. In the inpatient world there is daily collaboration, as there should be. I believe the therapists play an invaluable role and help people tremendously. I have nothing bad to say about that aspect.

Its the outpatient world is where we see the trend I mentioned.
Does every patient with a pain need dry needling? Because they get it, even with obvious exam findings of radiculopathy.
Does every patient with a pain need hot packs and cold packs on the same visit? Because they get it.
Does every patient need electrical stimulation as a part of their regimen? Because they get it.
Does every patient need neuromuscular retraining exercises? Because they get it. And since the whole premise behind this and result of this are debatable, let's leave that for another time.
Does every patient need core strengthening? Because they get it, even though there is no way to accurately and precisely measure baseline levels and gains.

Traction is still a great modality. Rarely do people get it. Because it doesn't work? No. Because its time intensive and requires a 1:1 therapist to patient ratio rather than the passive modalities that seem to allow a better income stream.

Do I really need to send my patient for three months of the above bull**** when there is an obvious facet pain by history, examination, and imaging? Yes, because the P.T. lobby has done well with the government bureaucrats it seems. Is the above treatment regimen more expensive than a facet block x 2 and RF? Absolutely.

There are quite a few basic questions that seem to be unanswered and overlooked every day.

Passive to active progression with exercise of low stress with the modalities usually is the way to go. Definitely agree on PT mills. Hot and cold aren't reimbursed anymore. Idk why dry needling is really even used

 

[jesspt]

Sorry, not at all. You were right on the money. More toward a certain late December poster.

Let me be more specific to the student O.P. In the inpatient world there is daily collaboration, as there should be. I believe the therapists play an invaluable role and help people tremendously. I have nothing bad to say about that aspect.

Its the outpatient world is where we see the trend I mentioned.
Does every patient with a pain need dry needling? Because they get it, even with obvious exam findings of radiculopathy.
Does every patient with a pain need hot packs and cold packs on the same visit? Because they get it.
Does every patient need electrical stimulation as a part of their regimen? Because they get it.
Does every patient need neuromuscular retraining exercises? Because they get it. And since the whole premise behind this and result of this are debatable, let's leave that for another time.
Does every patient need core strengthening? Because they get it, even though there is no way to accurately and precisely measure baseline levels and gains.

Traction is still a great modality. Rarely do people get it. Because it doesn't work? No. Because its time intensive and requires a 1:1 therapist to patient ratio rather than the passive modalities that seem to allow a better income stream.

Do I really need to send my patient for three months of the above bull**** when there is an obvious facet pain by history, examination, and imaging? Yes, because the P.T. lobby has done well with the government bureaucrats it seems. Is the above treatment regimen more expensive than a facet block x 2 and RF? Absolutely.

There are quite a few basic questions that seem to be unanswered and overlooked every day.

I'm not sure our lobbying body has anything to do with this. They aren't exactly known to have a lot of influence.

 

[jadedphysiotherapist]

I'm not sure our lobbying body has anything to do with this. They aren't exactly known to have a lot of influence.

Our lobbying body is to puppies as the AMA is to dogs as the Nursing group is to two headed werewolves

 

[Fiveoboy11]

Sorry, not at all. You were right on the money. More toward a certain late December poster.

Let me be more specific to the student O.P. In the inpatient world there is daily collaboration, as there should be. I believe the therapists play an invaluable role and help people tremendously. I have nothing bad to say about that aspect.

Its the outpatient world is where we see the trend I mentioned.
Does every patient with a pain need dry needling? Because they get it, even with obvious exam findings of radiculopathy.
Does every patient with a pain need hot packs and cold packs on the same visit? Because they get it.
Does every patient need electrical stimulation as a part of their regimen? Because they get it.
Does every patient need neuromuscular retraining exercises? Because they get it. And since the whole premise behind this and result of this are debatable, let's leave that for another time.
Does every patient need core strengthening? Because they get it, even though there is no way to accurately and precisely measure baseline levels and gains.

Traction is still a great modality. Rarely do people get it. Because it doesn't work? No. Because its time intensive and requires a 1:1 therapist to patient ratio rather than the passive modalities that seem to allow a better income stream.

Do I really need to send my patient for three months of the above bull**** when there is an obvious facet pain by history, examination, and imaging? Yes, because the P.T. lobby has done well with the government bureaucrats it seems. Is the above treatment regimen more expensive than a facet block x 2 and RF? Absolutely.

There are quite a few basic questions that seem to be unanswered and overlooked every day.

Thought I would jump in since pmrmd likes me so much

I don't practice the way you describe and neither do many PT's out there, but too many do. Something to keep in mind is that the useless modalities that are often used that you talk about (more so in the past though) are forced by clinic owners. It's standard procedure by techs trained to do so by the owners and there's nothing the PT's that work in these clinics often can do besides get a new job or educate patients re the uselessness and to refuse it. Lots of doctors order that crap btw, I got a call from one years ago complaining that I wasn't doing hot packs as ordered. I'd bet PT clinic owners can write off the loss of using all that garbage (I.e. Non reimbursed 50 dollar hot pack) that equates to a huge savings for them.

The "plan" you read about in a PT eval does not necessarily mean they're guaranteed to get it as treatment, I hope that makes sense. It's just a laundry list that get checked.

In my view the problems in the physical therapist world are not due to a lack of collaboration between a PT and a physician (aka physician trying to dictate the POC), it's due to the lack of power PT's have, lack of patient accountability to the PT, bogus false patient beliefs about what physical therapy is and what they need, and non PT control over physical therapy. I think that on average this leads to diminished effort on the part of the PT and diminished professional development of the PT. Not to mention exploitation of physical therapy by non PT's and false sense of expertese re physical therapy by non PT's.

Dry needling is just reaching by many PT's to get satisfaction in their work, it's not good enough to just do "PT." Why is that?

 

[Kissmyabjj]

Right on the money

Sorry, not at all. You were right on the money. More toward a certain late December poster.

Let me be more specific to the student O.P. In the inpatient world there is daily collaboration, as there should be. I believe the therapists play an invaluable role and help people tremendously. I have nothing bad to say about that aspect.

Its the outpatient world is where we see the trend I mentioned.
Does every patient with a pain need dry needling? Because they get it, even with obvious exam findings of radiculopathy.
Does every patient with a pain need hot packs and cold packs on the same visit? Because they get it.
Does every patient need electrical stimulation as a part of their regimen? Because they get it.
Does every patient need neuromuscular retraining exercises? Because they get it. And since the whole premise behind this and result of this are debatable, let's leave that for another time.
Does every patient need core strengthening? Because they get it, even though there is no way to accurately and precisely measure baseline levels and gains.

Traction is still a great modality. Rarely do people get it. Because it doesn't work? No. Because its time intensive and requires a 1:1 therapist to patient ratio rather than the passive modalities that seem to allow a better income stream.

Do I really need to send my patient for three months of the above bull**** when there is an obvious facet pain by history, examination, and imaging? Yes, because the P.T. lobby has done well with the government bureaucrats it seems. Is the above treatment regimen more expensive than a facet block x 2 and RF? Absolutely.

There are quite a few basic questions that seem to be unanswered and overlooked every day.

 

[Baron Samedi]

Where to start...

"May see physical therapy"....
No. They may see a PT, a PTA, a OT, a COTA or a SLP. You individualize your own group but deindividualize the others. And this is done multiple times in your response. That is like someone calling you "PM&R" (literally, not a physiatrist, and not by your name), and anyone who does a job remotely similar to yours (PM&R PA or NP) being called PM&R.

"Or a combination depending on needs"...
No. It's not determined by need at all. It's determined by everyone but those qualified to make the determination (insurance, physician, administration).

"And addresses any barriers"...
I'd bet the vast majority of barriers that a physiatrist can and should "deal with" are not, and too many that a physiatrist can't or shouldn't are. Example of the former that I've seen relentlessly would be poor communication with rehab professionals re managing the patient medically and addressing the concerns of the patient and therapy staff re the medical concerns (in a timely manner). Example of the latter would be "PT to work on strengthening" (or any similar
worthless variation) which I've seen a sickening amount (thousands of times). Re communication, "Talked with the nurse about it" doesn't count and writing a quickie note doesn't either. Consider how much is lost in translation with this nurse or "rehab director" (often not a physical therapist and not anyone seeing or who knows the patient) middle man method.

I doubt there is much overlap between what a physical therapist REALLY does and what a physiatrist does. The biggest similarity is they most often "work together" in the inpatient acute setting, they often see similar patients (functionally limited, disabled, impaired, in pain) and there is some overlap between entry level training for a PT and some parts of PM&R residency. A PM&R physician by far comes out of residency with the best "understaning" (they really don't) of physical therapy than any other physician specialty but still lame and pitiful.

I bet you're a blast at parties.

 

[truthseeker]

Sorry, not at all.

Traction is still a great modality. Rarely do people get it. Because it doesn't work? No. Because its time intensive and requires a 1:1 therapist to patient ratio rather than the passive modalities that seem to allow a better income stream.

it feels good when its done to some people but it really doesn't have much if any long term effect. A good therapist would address WHY unloading feels good and address those factors that are causing the symptoms, not necessarily only the symptoms themselves. When you get off of the traction machine/device, unless you are on the space station or a professional scuba diver, gravity is still loading you.

 

[jadedphysiotherapist]

it feels good when its done to some people but it really doesn't have much if any long term effect. A good therapist would address WHY unloading feels good and address those factors that are causing the symptoms, not necessarily only the symptoms themselves. When you get off of the traction machine/device, unless you are on the space station or a professional scuba diver, gravity is still loading you.

Wouldn't water aerobic exercise for HEP be a good home transition in that regard then? Manips proceeding that work as well for acute if not contraindicated. It's the activity habits you have to change.

Other than that....heck, I mean you've provided a service for an acute problem in exchange for payment. Some people go on SSRIs for an acute period and then come off (although that period may be a few weeks until the Rx kicks in and they're past a rough emotional period). Probably not the best comparison here, but oh well

 

[truthseeker]

yes, water exercise will reduce the gravity component but again, when you get out of the pool there it is again. I find that most people that have back problems either don't move enough in their hips, or move too much in their spine or both. we need to move where we are built to move. lack of hip movement can cause facets to slap together to often and too vigorously. Over time that results in degenerative changes. also can cause too much sagittal plane movement in the spine which is one thing that can cause disk herniations as well as facet problems. Modalities of any kind are rarely of long term benefit. Kind of like taking a Tylenol. They have some utility in very acute stages of mechanical pain, but rarely get done in my clinic.

The difference between PMR and PT is big but I think of it as areas of expertise. Good PM&R docs realize that the good PTs know more about PT stuff than they do. Good PTs don't try to practice medicine. Unfortunately, not all PM&R docs are good ones and not all PTs are good ones. Too many cookbook followers I fear.

Duh

 

[jadedphysiotherapist]

yes, water exercise will reduce the gravity component but again, when you get out of the pool there it is again. I find that most people that have back problems either don't move enough in their hips, or move too much in their spine or both. we need to move where we are built to move. lack of hip movement can cause facets to slap together to often and too vigorously. Over time that results in degenerative changes. also can cause too much sagittal plane movement in the spine which is one thing that can cause disk herniations as well as facet problems. Modalities of any kind are rarely of long term benefit. Kind of like taking a Tylenol. They have some utility in very acute stages of mechanical pain, but rarely get done in my clinic.

The difference between PMR and PT is big but I think of it as areas of expertise. Good PM&R docs realize that the good PTs know more about PT stuff than they do. Good PTs don't try to practice medicine. Unfortunately, not all PM&R docs are good ones and not all PTs are good ones. Too many cookbook followers I fear.

Duh

Degenerative changes are okay though. That's natural aging, unfortunately cultural freakout over MRI findings of degenerative change leads to excess surgery justification.

Maintenance of a solid BMI, effective strengthening exercises to decrease kyphosis and proper body mechanics (ergonomics nitch) at work with activities etc. help mitigate that.

Sometimes acute pain fixes lead to better HEP compliance. Whether that be injections or a manip could be patient preference. I'll have to read literature on the use of TFESIs and the length of relief. Not within practice scope obviously so never referenced. That could be OP referral sources or conservative competition depending on how people play in the sandbox.

Also.....you said people should move at the hips more

This thread is now off topic