Physical Medicine & Rehabilitation: The Unknown Specialty

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As a family physician in private practice, our Editor in Chief, Linda Girgis, MD, understands what it means to practice in a vast area of medicine. While physicians will always juggle the challenges of their specialty, many are unfamiliar with a resource that can provide support for countless medical conditions: physical medicine and rehabilitation (PM&R). Recently, Dr. Girgis introduced us to Mahmud M. Ibrahim, MD, who is double board certified in sports medicine and PM&R.

In a Q&A with Dr. Girgis, Dr. Ibrahim explains the often unknown value of his specialty. And we’ve found he is just as passionate about his specialty as his specialty is valuable to the medical community:

Q: Many of my patients and colleagues aren’t familiar with your specialty. What is the goal of PM&R?
A: As one of the youngest specialties, PM&R is not well known. Many medical schools do not offer rotations in PM&R, but the field is becoming more popular, and residency spots more competitive, as the demand for physiatry increases. PM&R is all about restoring function through non-surgical treatments. While physiatrists treat a wide variety of conditions in all patients, from infants to the elderly—including spinal cord injury, traumatic brain injury, and pediatric developmental issues—they primarily treat musculoskeletal injuries.

Q: What procedures do you perform?
A: Physiatrists are trained to perform electrodiagnostic studies to aid in the diagnosis of issues with the nervous system. We can perform injections from the base of the skull to the coccyx, epidural steroid injections, facet injections, radiofrequency ablations, spinal cord stimulator trials and implants, and disc procedures. With regard to the peripheral joints, injections can be performed in almost every joint/tendon/bursa. I usually use ultrasound or fluoroscopic guidance to perform my injections

Q: Many of my colleagues refer patients to pain medicine physicians. How are physiatrists different?
A: Many patients and physicians think of pain management specialists as those who will prescribe pills to “cover up” pain. Physiatrists work directly with physical and occupational therapists to help patients regain strength, flexibility, and balance. Our focus is to restore the patient’s functioning. Yes, pain management is a part of that, but pain management does not necessarily mean pills.

Q: When should I refer a patient to a PM&R doctor as opposed to an orthopedist?
A: I’ve had patients who were seeing me for one issue and mentioned that their PCP had sent them to an orthopedic surgeon for their shoulder issue. If they had mentioned to me that their shoulder hurt, I could have treated that too.

Q: I’ve had many patients addicted to opioids. At what point should I refer them to a physiatrist or rehab facility?
A: Depending on the setting, with time, nearly anyone prescribed opioids develops some sort of addiction. If it’s just an issue that the patient likes taking their opioids, but otherwise does not display any aberrant behavior, a referral to a pain management physician is appropriate. If a patient is blatantly misusing their opioids and/or abusing other substances, a referral to detox is appropriate.

Q: I’ve found that many patients and physicians believe that the success of treatment is determined by the elimination of pain, a dangerous misconception that can impact treatment adherence and the potential for drug addiction. What should both physicians and patients keep in mind?
A: It’s important to set realistic expectations with patients. With some simple issues, it’s easy to achieve 100% pain relief, but it may not be possible with more chronic issues. The goal should always be to get patients back to their prior level of functioning. If that can be accomplished and the patient is pain free, that’s great. If the patient still has some pain, but it’s not functionally limiting, that’s ok too.

It’s a balance of function and pain relief to improve quality of life. Dr. Ibrahim reiterates that every situation is different—the issue, its duration, and the patient’s expectations. But one thing is for sure: PCPs and PM&R specialists should network and develop a relationship with one another to help patients navigate murky waters where specialists, conditions, and treatments can overlap, in order to establish optimal outcomes for patients.

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