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Melanie Cole (Host): Welcome to Back To Health, your source for the latest in heath, wellness and medical care; Keeping you informed so you can make informed health care choices for yourself and your whole family. Back to Health features conversations about trending health topics, and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine. I am Melanie Cole and today we are discussing rehabilitation medicine and how it can help you. My guests today are Dr. Joel Stein, he's a Physiatrist-in-Chief and Chairman in the Department of Rehabilitation Medicine at Weill Cornell Medicine, and Dr. Michael O'Dell. He's the Vice Chairman of Clinical Services in Rehabilitation Medicine at New York Presbyterian Weill Cornell Medicine. Welcome to the show gentlemen. Dr. O'Dell, I'd like to start with you. What is rehabilitation medicine, and how is it defined in the health care sector?

Dr. Michael O’Dell, MD (Guest): I like to think of rehabilitation medicine as the specialty that maximizes human performance. We deal with an amazingly wide variety of patients in rehab from those with muscular skeletal injuries to neurologic rehab to cancer rehab, and so it's difficult to define this on the basis of a diagnosis. But regardless of the populations that we are treating, and regardless of whether you're using medications, or injections, or exercise, our end point is always how a patient performs, whether it's taking care of themselves, mobility, work or play, performance is always the end point of our intervention.

Melanie: Dr. Stein, how would you define rehab medicine to patients? How do you explain it to them?

Dr. Joel Stein, MD (Guest): I often focus on the disorders that we treat, because I think that's how many people think about selecting a physician. So we deal with of course a variety of neurologic disorders, as Dr. O'Dell mentioned, including stroke, brain injuries, injuries to the spinal cord, multiple sclerosis, and our focus there is on finding ways to help people function better, to manage their limitations from the neurologic disease better, and to live life to its fullest.

The other group- large group of disorders that we treat are those affecting the musculoskeletal system, and these include back pain, neck pain, various sports injuries, overuse injuries, anything that hurts essentially is another major area where we can provide non-surgical management, diagnosis, treatment of these disorders, and help return people to the activities that they love, and whenever possible avoid the need for surgery.

Melanie: Dr. Stein, I'm sticking with you for a second. As you mentioned physicians, what kind of physicians and healthcare providers practice rehab medicine? What draws them into the field?

Dr. Stein: Our colleagues in the field have been drawn to it by generally speaking a holistic perspective, a desire to look at the whole person rather than just focus narrowly on a particular aspect of health or disease. They are by and large a very pragmatic group, really trying to figure out what are the practical ways they can help people achieve their goals? We certainly spend time with diagnosis, with treatment and cure in many cases, but oftentimes cures are not possible, and we are a specialty that excels in figuring out how to get people feeling better and more active, even if a cure is not in the cards.

Melanie: So Dr. O'Dell, what kinds of modalities are involved? As long as you're discussing occupational therapy, people have heard about physical therapy, but what does that really mean? And what kind of modalities do you use to help people?

Dr. O’Dell: So exercise is the primary modality. Anyone who goes into rehab medicine as a physician or as a therapist provider really is heading in that direction as their career because exercise is important to them and that's what they want to learn about. So we use a variety of exercises to treat weakness, to treat walking difficulties, to treat muscle stiffness, and that can be combined with - from a physician standpoint - medications or injection therapy to treat pain or other problems. And from a therapist standpoint can involve the use of ultrasound, can involve the use of electrical stimulation to help control pain and movement, it can involve types of massage and soft tissue mobilization that occupational and physical therapists are well-trained in.

It's important to make the distinction between the role of a therapist in rehabilitation medicine and that of a physiatrist. As a physician, I'm involved with making a diagnosis and helping manage the symptoms of a given neurologic or non-neurologic disease process. A physical and occupational therapist will be involved in the actual provision of a variety of exercises, and as you said, sometimes modalities in addition to the physician to really help control those symptoms and get somebody back to a level of performance that they're interested in.

Melanie: So how do the physical therapists work with the actual doctors? How do you work together with your team, Doctor?

Dr. O’Dell: We work very closely with our physical and occupational therapists, both in terms of the inpatient rehabilitation unit that we have here at Weill Cornell, and also on the outpatient setting as well. So for example, there are any number of medications that may be required in the setting of neurologic or musculoskeletal rehabilitation.

Oftentimes it's the therapist or sometimes the nurses who actually identify the need for that particular medication, because quite frankly, they spend a lot more time with the patients than we do as physicians. As a physician, I will ultimately make the decision on what medication if any may be appropriate, and it's that feedback back to me as a physician from my therapists and nurses as to whether that intervention has worked or not. So it really works very smoothly as a team with the therapists serving as my eyes and ears to a certain extent to take the very best care of that patient as I possibly can.

Dr. Stein: If I could add something, I'll give a concrete example for a patient with back pain. So someone has back pain that's causing them to really be impaired, they can't go about their daily activities. The primary care physician sent them to one of our physicians to get a specialty evaluation. We might decide that they need imaging to determine if they have a pinched nerve that might be contributing to the pain, and then perhaps put them on medication and have them work with a physical therapist for exercise therapy. After that works for several weeks, maybe the patient is better, but perhaps not, in which case we might consider say an injection if that might be the next action for this patient. And then again, probably some more exercise therapy with the physical therapist.

So it's very much a team process where the physician is managing the diagnostic and the medical treatment, the injections if needed, and the physical therapist really provides the hands-on exercise training.

Melanie: Dr. O'Dell, since rehab is so comprehensive and multidisciplinary, how does rehab medicine integrate with and enhance other specialties?

Dr. O’Dell: So rehabilitation medicine can be looked at as a value added to almost any other medical specialty, whether that's neurology, neurosurgery, even obstetrics, gynecology, pain management. As Dr. Stein had mentioned, the holistic view that we can bring to the care and management of the patient, I think is really a very- is a different philosophy than what many other specialties can provide. So yes, we do make diagnosis, but primarily what we're involved in is managing the symptoms that a patient presents with.

And so working in our team with physical therapists, occupational therapists, speech language pathologists, many times orthopists and prosthetists that are making artificial limbs, we can serve as the captain of the ship, the coordinator of therapy, and sometimes physicians of varying expertise with varying skillsets, and be able to really coordinate and provide the symptom management and the mobilization and the achievement of hopefully the very best quality of life and the performance for a patient as we possibly can.

That's something that we're uniquely trained for in rehabilitation medicine. We are really quite expert at managing healthcare teams, and given the number of individuals that may be required in taking care of complex disease, by doing that we are really providing a value added on a variety of patient diagnosis above and beyond what their primary physician might add.

Melanie: Dr. O'Dell, so many people in this country suffer from back pain. What kinds of treatments are available other than surgery for those many people that are suffering from back pain that can keep them from doing the daily activities they enjoy?

Dr. O’Dell: Physiatrists and other professionals in rehabilitation medicine are really able to provide a variety of interventions, non-surgical interventions, for our patients with low back pain or neck pain. In addition to exercise, and this could be provided by a physical therapist- and by the way, there are very good, very well-researched strategies and types of exercises that a physical therapist can use to ameliorate particular types of back pain.

Having a rehabilitation medicine physician or physiatrist involved allows oral medications to be explored, as well as other interventional local injections into the back. There are also procedures that can identify a pain generating nerve, and that nerve can be temporarily inactivated, leading to pain relief. If not, there are other implantable devices that can be used to help control back pain as well.

The reality is that in the vast majority of cases, back pain can be managed and minimized without surgery, and there's relatively few individuals who eventually require back surgery to control their pain and improve their quality of life.

Melanie: Dr. Stein, rehab medicine can help so many people. Tell us how it can help women, and also tell us how it can help children, and how do you work with children doing rehab?

Dr. Stein: So women have unique health needs that are overlapping of course with those of men but have some distinct areas. Certainly for example we know that women are predisposed to certain types of injures such as ACL, anterior cruciate ligament injuries, that's a well-known predisposition. There are also specific issues related to pregnancy. Pregnancy-related back pain is extremely common and often under-recognized and under-treated, and this sort of thing we actually can help with.

There are also some women who struggle with longer term pelvic pain sometimes after childbirth, sometimes unrelated to that, and they may have muscular spasm that's affecting the pelvis, and there are rehabilitation therapies for that as well. We are fortunate to have specific expertise in women's rehabilitation needs and someone who specializes particularly in pelvis muscle pain disorders. We are fortunate to have special expertise within our department. We have physicians with a focus on these issues and who can help people be on sort of just general rehabilitation, really have a specialty focused on this.

In terms of children, children can have a variety of different disabling or potentially disabling illnesses. At the more severe end, that could include neurologic disorders. Cerebral palsy is the most common problem that we see, and we have a lot of experience dealing with the needs of children with this problem. Exercise therapies of course, PT, OT, oftentimes speech therapies are part of that. Spasticity management is frequently a problem in children with cerebral palsy, and that's an area where we have expertise as well. There are other issues that can affect children. We have a program where we treat musculoskeletal disorders in children. For example, among dancers or athletes or musicians, even at a young age can develop pain from overuse, sometimes from bad form if they're not using the instrument correctly for example, or they are pushing their bodies too hard, and we have expertise in those sports medicine issues affecting children as well.

Melanie: Gentlemen, I'm going to ask you please to each describe a patient case study where maybe the patient had tried other specialties and treatments before coming to see a physiatrist, and how you were able to help them in a way that another specialty might not have been able to. So Dr. Stein, I'd like to start with you.

Dr. Stein: Certainly. So it's not uncommon for me to see people with stroke, who have come to me perhaps sometime after having been in the hospital, and having for whatever reason, sort of been lost to rehabilitation follow-up. They just haven't really had a close follow-up from whatever reason that they've transitioned from one phase to another, and their needs have been ignored. And the sorts of things that I often address in these individuals are, first of all, improving their walking. Many of them are able to further improve their ability to get around, perhaps getting rid of a large cane and using a more modest one, or getting rid of a cane altogether to walk more independently. Oftentimes physical therapy is a part of that, sometimes people need braces that they've not been provided, and we can help them with that.

Another common issue is muscle spasticity. This abnormal increase in muscle activity that's not under the person's control, and that tends actually occur some months after a stroke. So it may not have been recognized initially, it may not have been present, and then has become a problem gradually over time. That's the sort of situation where injections are often helpful in alleviating discomfort, and often improving function to some degree.

Sometimes I help people get back to driving. People that don't realize that despite the fact that they have some residual disability, they can in fact resume driving with appropriate modifications and preparation. And we see a lot of depression that's not been recognized, and part of our job is to point that out, and make sure that that gets treated. Depression is very common after a stroke, and yet often attributed to just kind of the consequences of disability. Who wouldn't be depressed if you were feeling like that sort of thing? But the fact of the matter is that depression is a highly common and very treatable condition after stroke, and part of our job is to make sure that it gets the attention it needs.

Melanie: Dr. O'Dell, your turn. Tell us about a patient's story where you've helped someone with back pain or something that couldn't get help anywhere else.

Dr. O’Dell: So I think the case that I would choose is a woman in her mid-fifties with multiple sclerosis who I saw several years ago. And there are three things that distinguish physiatry, the training that we receive in physiatry, again our focus on performance, the fact that we're able to work and lead healthcare teams so well, but the third point is that we're very well trained in both neurology and musculoskeletal medicine. And there's a huge overlap in those medical disciplines.

Again, this patient that I cared for a few years ago came to me with stiffness in both her legs. Now as Dr. Stein had mentioned, spasticity is a very common cause of stiffness. And she had seen several physicians, she had actually received botulinum toxin injections in the past, but it didn't seem to be helping her symptoms. So she reported to my outpatient clinic and I noticed on exam that she had very, very little range of motion of her hips, but her knees and her ankles looked pretty good. This would be very unusual in a neurologic setting, and after checking x-rays it turned out that she had very severe arthritis of both of her hips, a musculoskeletal, not a neurologic reason for her walking problems, despite the fact that she had MS. Eventually after trying some conservative measures, she eventually required hip replacement surgery on both sides. She actually came to us in our inpatient rehab unit after that to help out with her mobilization. And about six or eight months after I initially saw her, she was back to a normal level of walking, and a substantial improvement in her mobility and her quality of life.

Again, I think this is partly due to the fact that we're able to see both the neurologic and the musculoskeletal complications that may come with multiple sclerosis. Again, a very unique aspect of training and rehabilitation medicine.

Melanie: Dr. Stein, to wrap up in summary, what else would you like patients to know about the field of rehab medicine, and tell us about your team at Weill Cornell.

Dr. Stein: I think what really is remarkable in the experiences of the patients who I've spoken to, who've provided me feedback, has been the sense that when they come to see one of our physicians, we really hear them, we really listen to them in a way that perhaps is becoming a bit of a lost art in medicine. I've had my own family members receive care from colleagues within the department and have been really gratified by the attention to taking a thoughtful and detailed history, understanding where the problem came from, what activities or injuries might have led to it, and working out a treatment plan that is not based on a preconceived notion how to fix the problem. It really is tailored to the individual goals and aspirations of the specific patient. These are just a great group of people we have in our department, and really among the most humanistic physicians I've ever worked with. They're technically skilled, but have not lost the ability to really listen, and hear what people are needing help with, and provide them both the emotional and the technical expertise that they need.

Melanie: Dr. O'Dell, last word to you. Give us your best advice for keeping healthy, active, and hopefully pain-free. What do you tell your patients every single day? We've talked about how important exercise is. Give us your best advice.

Dr. O’Dell: I would say that exercise in any quantity is going to be beneficial. We often think of exercise as running a marathon, or seeing the types of activities that athletes are involved in when the Olympics are on TV. Exercise can be quite as simple as walking around the block at a slow pace within one's ability, both from a cardiovascular standpoint and a musculoskeletal standpoint, staying as active as you can for as long as you can is probably the most important advice that could be given.

And even after an injury, neurologic or musculoskeletal, even if it causes and is associated with small amounts of pain, figure out how to minimize that pain, and rather than doing nothing, try to do your very best to get up within your limitation and be as active as you can.

Melanie: Absolutely great advice. Thank you gentlemen so much for being with us today, really for sharing your expertise, such important information.  This concludes today's episode of Back To Heath. We’d like to thank our listeners and invite our audience to download, subscribe, rate and review Back To Health on Apple Podcast, Spotify, and Google Play Music. For more health tips go to weillcornell.org and search podcasts. Parents – don’t forget to check out Kids Health Cast!