The Five-Finger Approach to Restoring Patient Function
This is male clinic Toksay curated weekly podcast for physicians and healthcare providers. I'm your host Daryl chapter a general internist. At mayo clinic in Rochester, Minnesota, physical medicine and rehabilitation is a medical specialty that aims to improve and restore and individuals functional abilities and quality of life in those with musculoskeletal pain, physical impairments or disabilities yet physical medicine can do so much more. And we'll learn more about the specialty today from Dr Jeff bro, a physiologist in the department of physical medicine and rehabilitation at mayo clinic, Dr Brose specializes in hand in spine issues. Jeff thank you for being here today, Dr chart ca thank you for inviting me, let's start by just kind of a broad question. I think the the the specialty of physical medicine is probably one of the least understood by practising physician. And so what are the goals of physical medicine? The goal of physical medicine is just to restore patience function. We're specialty that doesn't have an organ system, and all we don't have a heart such as cardiologists or central nervous system like neurologist or or the peaks with musculoskeletal we're pretty much wrapped around the patient's function and restoring that. Functional ability of the patient. So you are a physician trained in physical medicine yet. I suspect many of my colleagues, especially in rural areas work, primarily with physical, therapists. When should we be specifically, referring patient to a tryst rather than to therapist? Typically, if a physician has a question about the diagnosis, they're not secure in their diagnostic ability. Referring to a physical therapist typically needs a diagnosis. So if you're looking for a diagnosis physiologist is a good avenue, or if someone is not improving in the timeline that you would end -ticipant for of specific problem. Like, let's say someone has low back pain most low back pain patients improve within two to three weeks sometimes up to three months, and if they're not showing progression that may be a time to refer to physiologist. So you work with physical, therapists. Are you team is a team model that you use? It's very much a team approach again as I said, we're we're kind of the physician at restoring function. We use multiple different professionals in that team. We have physical therapist is one ocupation therapist in some settings. We use nursing recreational. Serviced any profession that helps restoring the function were kind of the team leaders of that speech therapy fits in their fifth in there. And in a lot of institutions outside of male speech therapy is also part of the medicine rehabilitation group. All right. I know you see a wide variety of patients, but what are some of the more common referrals? You get for physical therapy. Well, where I live in the hand in spine center, see predominantly, those individuals, but outside of of mail physiologist, see as you said a quite of quite a breath of patients, including stroke, spinal cord injury patients amputees anyone who's had something happen to them that decreases their functional level design interest have seen and they work with that team that we talked about improve the function of of the patient in. A lot of times people think were the pain doctors, and we're not really pain doctors. We we are much more interested in an improving function. And sometimes pain is the limiting factor that we have to to work around. But our goal is to increase function that always decrease pain. Okay. Now Jeff over thirty plus years of being here. I have sent I don't know how many patients of mind to physical medicine, and that one has come back and said dot they got nothing. There's nothing they can do. They had no therapy. That was going to help my problem. So do you have a therapy or treatment for anything? We send over there. You guys make stuff up once in a while. No one. Yes. There are as you know, there are a lot of patients who have conditions that are not going to improve the there. Sometimes degenerative museum example of a patient with LS or Lou Gehrig's disease in two thousand nineteen. We don't have a cure. So we know their function is going to decline. So the goal is just maintaining what they can maintain for as long as they can maintain it and. Kind of putting the life back in the years years into the lighten? So we want to improve what they're doing their enjoyment of life. The beauty of our is we have a team. So by utilizing the team we typically can find something to help the patient restore function not always getting rid of pain but restoring function. Well, I have to say it's reassuring to know that there is a department out there that will take my patients and work with them and give them something when I've can send them else play other places, and they say sorry, I just got nothing to to help us Beijing. But you always seem to have something. That's good to hear. I've been reading about physical medicine and came across the statement that physical therapy can help patients void surgery. What are some examples of how that happens a lot of times with the and I'll just use an example with the degenerative process, like let's say knee pain patients have fairly significant rightous or even minimal threats and have a great deal of pain. And you know, one of the be it. Be it a friend or, you know, another provider says, oh, you need surgery. It's it's degenerative. A lot of times we can avoid surgery with other things, you know, as I talked to my patients, personally, I always give them my five fingers talk about what's the possibilities. Well, the five fingers include surgery, we could all you know, we could send you to someone to have surgery. We have medications we have a lot of medications for different conditions, particularly degenerative, we I think last count we had sixty three different kinds of anti inflammatories. Some pain medications though, were decreasing their use for obvious reasons. Injections is number three steroid injection seem to help with some degenerative changes to at least get rid of symptoms were also starting to inject PRP in stem cells. And I know one of our physicians have been on this program to talk about that. The fourth thing we have is therapies, which I include physical therapy, occupational therapy of as the, you know, the some of the top two, and then we also have manipulation there's you know physicians. Chiropractors osteopaths doing manipulation, acupunctures is another variable that sometimes people use and then our final treatment number five is living with, you know, some people just need to adapt. The way that they live with it or change their functional -bility to live with a problem. You know, we we kinda run up that ladder. You know, the safest thing sometimes changing what you do and living with it. And folks specially with degenerative changes of joint ten fluctuation in their symptoms. They have good and bad days. Good and bad weeks bed years. So if we can utilize therapy to restore kind of the muscle function around joint sometimes we can avoid surgery so special. In the patient to may have multiple Comber abilities and be maybe significant risk for surgery. If they were given some help in cheating some activities that they want to accomplish. But can't at the present time, they might be happy in maybe decide maybe surgeries that needed. And that's one of the things that sometimes can be difficult as establishing a goal. You know, what is our goal of our intervention? And if the goal is one hundred percent pain relief, there aren't too many interventions we can do to achieve that. But if you're goal is like to walk to the mailbox to get your mail. Those those are goals that we can attain may you have pain doing sure. But if that's goal we can work towards. Come to mayo clinic in lovely Rochester. Minnesota for the geriatric update for the primary care providers. Held November fourteenth of two thousand nineteen catch all the latest updates in innovative practice models for evaluating managing and caring for your geriatric. Patients. Registration for this popular course fills up quickly. Visit C E dot mayo dot EDU for more information. Join us weekly here. At mayo clinic toxins, we discuss best practices and burning questions. Subscribe today, using itunes or your favorite podcasting app. I had a patient this morning who has pretty vast generous Rytas in one of his knees. And he's finally come to the decision that he's going to have a knee replacement in the near future would he benefit from seeing somebody in physical medicine prior to his surgery instead of afterwards. Yes. In that case too. You know, frequently what happens when people don't use a joint as the muscles around atrophy. So by seeing desire tree and physical therapy. And even occupational therapy. Sometimes in that case, we can build the muscles up around the joint that's going to be replaced pre-operative lead to give them, but her success post operative Lii, one of the most common things we see regarding musculoskeletal pain is low back pain. You must see a lot of that. When should we consider furring patient to physical medicine, physical therapy for low back pain again? Diagnostic confirmation sometimes. Individuals. Primary care physicians are looking for reassurance or confirmation that they're their diagnosis is appropriate. And that that's. Great referral, or if someone has red flags, including leg pain, leg weakness, loss of bowler, bladder symptomology, or they're falling because of the leg pain. That's a good time to refer those individual time. I have found significant benefit from sending a patient PM is a personal has recurrent, low back pain and even sending them over between episodes giving them some exercises that they can do to help prevent their recurrences. It's been very successful. And that sometimes the most difficult time when a person is in pain. There are a lot of things I can have them do exercise wise and activity wise to try to regain their function. But when they're not experiencing pain, sometimes it's hard to say, well, these exercises would help. So a lot of our our job is to establish that recurrent exercise program and kind of build it into their life. So they continue with, you know, with the low back pain just walking, you know, it doesn't have to be an elaborate exercise walking seems to be fairly effective in decreasing the frequency of those episodes of recurrent, low back pain as well as the intensity. So this is sort of a related question. Is there sort of preventive physical therapy evaluation. You ever get patients in for for maintaining the future, you know, like no livelihood prevention. We do we we get folks who, you know. I'm starting to notice like us walking to the mailbox that I'm having more and more difficulty getting to the end of my driveway and the mailbox and sometimes it's just performing some very simple exercises, even in chair or in bed that can, you know, keep you and maintain your ability to do those functional things that you wanna do. So sure you mentioned some other areas of physical medicine. What are some of the other broad categories that that you deal with in the field of physical medicine other than just musculoskeletal pain? Vast? You know, someone once said our profession is mile wide. But only an inch deep because we treat a plethora of of conditions, including stroke, traumatic brain injury cardio-vascular rehabilitation amputee. Neurological conditions like proven, rob Pathy. Sports medicine. I mean, we're in a whole host of of different areas, but all centered around restoring the patient's function I used to work in the incontinence clinic here for a while. And I even found benefits any patients to physical therapy for pelvic floor exercises. They have biofeedback and all kinds of interesting ways of teaching patients how to do good pelvic floor exercises, and that's actually run by public floor, nurses. So that part of part of the team our nursing team. I imagine another fast growing area in physical medicine is at a sports medicine. Are you getting involved in not only professional teams but high school as well? I'm not one of the sports medicine members here at the clinic, and they are here. But we're more involved in the community. Some of the areas were looking at that I'm involved with is with individuals with disability. I have a stepdaughter who has C P and she plays sled hockey. She does dapper of climbing at one of the local climbing walls, and we travel throughout the mid west links lead hockey. So there are physicians and residents who are helping with that. So not just sports medicine, the elite athletes, but the weekend warriors and and kids at your softball teams. Baseball teams all the way up there. Elite athletes so sports medicine kind of mental here, but other institutions treat all the whole gamut of athletes a little bit about some of the devices that you have available to us. I want said some very weird ridiculous pain and other. They gave me a tens unit which had not really used before. But I found it, quite helpful. Are there some other devices that you use to improve function and reduced pain? So talking little bit before physical medicine, the physical medicine component of physical medicine rehabilitation actually began here at mail under the to each of Dr Frank cruise who's kind of one of the fathers of our profession and his his background was in physical therapeutics. So not only tens unit we use Heaton is ultra sound sometimes which is a deep form heat and people hear about sound injections. We also use ultrasound to visually. Is sometimes if we're doing injection therapy. But again, all of it is to reduce pain. So we can increase function in some way. But then there's there's many therapeutics that have come and gone. Like, dia Thermie was one that came out of here that was used for pelvic floor pain for a long time, and they found better ways to do it. So there there are many physical therapeutics interventions that we allies you just reminded me of something back when I was a medical student week tour of the physical medicine floor and had these paraffin baths. They'll still around. Yes. They are. In fact, use a quite frequently in the hand. And the reason is the hand has had a very interesting shape. You you can't put heat on it or cold on it with uniformity by dipping it into wax. You can actually heat up all the tissues uniformly. And it's caught on quite extensively. I mean, you can go to a local retailer now pick up a pair of bath to be able to do it at home. So we use it in in the hand clinic. I am quite frequently. Will you mentioned working hand clinic? What are some of the common hand in problem at UC? Personally, a lot of degenerative changes, particularly the thumb base, which is can be quite functionally. Limiting we see a lot of carpal tunnel. We feel out attendant at these and being a tertiary institution. We also see a lot of kind of interesting cases of complex regional pain syndrome or break, your plex up these break, yo plexus injuries things like that. Finally, one more question in your field. What would you like to have known by primary care providers? In terms of what your specialty can do either. From what you've seen inappropriate referrals or referrals that you'd like to see sooner or anything you would like to tell primary care providers. How to better utilize your services? I'd have to say, we're not chronic pain specialist that our job is if you have someone who has a functional decline that knee has goals to work on the sooner. We can see him better. If pain is a component. That's fine. But seeing patients who have chronic pain that have had chronic pain sometimes needed different intervention, and we're not always the best specialty to see them. Is it a rewarding specialty, Amen. Yes. It is. All areas, and I realized now I'm in kind of a musculoskeletal area. But I also were competing after IX. So to see some of these kids. As they age as you help them develop and with their exercises and their ability to walk and doing certain interventions like botulism, toxin injections and things like that very rewarding or having a stroke patient come into the rehab unit. Unable to get out of bed and by the time they walk out. You're like at a part of that. Yeah. Yeah. I know I've given some presentations to physical medicine, physical therapy audiences and the always seem very happy. It's always a pleasure. Speaking to them. Appreciate that. We've been talking with Dr Jeff bro, a male clinic physician in the department of physical medicine and rehabilitation, Jeff thank you so much for being here and sharing your expertise with us. Thanks for having. If even -joyed mayo clinic talks podcasts. Please. Subscribe mayo clinic delivers more CME offerings nationwide than any other medical education provider. 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