Should You See a Physiatrist for Your Back Pain?

"Seventy to eighty percent of adults will have back pain at some point in their lives," Dr. Deborah A. Venesy, staff physician at the Cleveland Clinic's Center for Spine Health, says.

"Some common reasons for back pain include mechanical low back pain (due to the daily things we do, repetitive bending, twisting, and lifting), muscle strain/sprain, herniated discs, and vertebral compression fracture as a result of osteoporosis," she explains.

Other rare causes include "infection, inflammatory arthritis, cancer, or other non-spine related causes like kidney stones, endometriosis, and stomach issues like stomach or peptic ulcer."

Salvador Portugal, DO (doctor of osteopathic medicine), a physiatrist and medical director of sports medicine rehabilitation at the NYU Grossman School of Medicine in New York City, stresses that "low back pain is more common than neck pain or midback pain."

Even though back pain is familiar, the exact cause is unknown, and while many people will visit their primary care physician if they have back pain, seeing a physiatrist is also an option.

Physiatrists treat back and neck pain, hip and knee arthritis, sports injuries, and other musculoskeletal conditions and injuries. While many people haven't heard of physiatrists, they may have heard of sports medicine doctors.

"Both physiatrists and sports medicine physicians treat similar conditions related to musculoskeletal injuries. However, sports medicine specialists have additional training after residency in sports-related injury management, and many physiatrists are sports medicine physicians," Venesy explains. Likewise, sports medicine physicians may have a background in family medicine or physical medicine and rehabilitation.

Elizabeth Santos, 49, who lives in New York City, developed lower back pain in the summer this year. She says she'd never had back pain before but is pretty sure the cause was lifting a heavy cinder block. She took over-the-counter pain medicine, visited a chiropractor for six weeks, and went for some massages, but nothing helped.

She called NYU Langone Health in Manhattan for help finding a doctor and was referred to a physiatrist. "I'd never heard of a physiatrist before," she says.

"The doctor did some tests, including x-rays, and recommended an MRI, but my health insurance would not approve an MRI until I received six weeks of physical therapy," Santos says. Unfortunately, the PT didn't relieve the pain, and she is scheduled for an MRI.

The physiatrist prescribed anti-inflammatory medicine and a muscle relaxer, which she said hasn't helped with the pain. Once she gets the results of the MRI, she will revisit the doctor so he can make a diagnosis and treatment plan. In the meantime, she takes her meds and alternates between using ice and heat.

"We are a very team-oriented specialty," Venesy says. Physiatrists work with orthopedists, neurologists, neurosurgeons, and primary care physicians (family practice and internal medicine doctors). Physiatrists do not perform surgery but can refer their patients to orthopedic doctors if surgery is indicated.

Physiatrists work in private practice, inpatient rehab centers, hospitals, skilled nursing facilities, pediatric and cancer hospitals, and multi-specialty groups, among other places.

The first visit to a physiatrist is much the same as the first visit to any doctor, Venesy says. After the doctor gets the patient's medical history and the reason for the visit, they ask how the problem affects the patient at home or work. 

Next, the physiatrist will review the patient's medications and electronic health record, any imaging reports, perform a physical examination, and provide a diagnosis and a care plan.

"We may order additional tests such as advanced imaging (MRI, x-rays, CT scan), lab work, or EMG (electromyography)," Venesy explains. A physiatrist may also suggest exercises, prescribe medications, and refer the patient for PT (physical therapy), OT (occupational therapy), speech therapy, or acupuncture. They may also prescribe spine PT and aquatic physical therapy for back pain.

During an office visit, tell the doctor your primary concern and bring a list of questions. It's helpful to get any imaging on a CD so the doctor can review it with you.

"Work with your doctor and be involved," Portugal stresses. "Partnering with a physiatrist and playing an active role in treatment greatly reduces a patient's risk of developing chronic low back pain and may reduce the risk of needing surgical intervention in some cases."

The discs (mainly water) between the vertebra dry out as we get older, and we can develop arthritis of the small joints that help us bend forward and backward (lumbar facet joints). Moreover, patients over 70 or 80 may develop stenosis (narrowing of the canal where the nerves travel), known as lumbar canal stenosis. 

"Folks present leg pain, numbness, or heaviness in the legs when walking for some time (not so much back pain), and these symptoms resolve with sitting," Venesy explains. Another issue is that older women have a higher risk for compression fractures related to osteoporosis.

Regarding prevention, it is necessary to address "modifiable risk factors through eating a healthy diet, living an active lifestyle, avoiding smoking, and seeking a mental health professional if one is experiencing symptoms of anxiety and depression," Portugal says. "A sedentary lifestyle, obesity, smoking, depression, and anxiety are associated with a higher risk of chronic low back pain."

Further, the American College of Sports Medicine recommends at least 150 minutes of moderate-intensity exercise each week, which may reduce the risk of developing many chronic medical conditions, including low back pain," Portugal adds.

Venesy recommends cardio exercise (walking, cycling, elliptical, water aerobics, jogging, dance, etc.), core strengthening, and stretching. "Core strengthening is the most important so that our spine can tolerate the things we do daily (like slouching on a couch or sitting hunched over a computer)."

"We are made to move, and I love to tell patients, "motion is lotion!" Venesy says. "Get up and move – if you are sitting at your desk and on the computer, get up every hour or so. Exercise is key."

Portugal reports that radiofrequency ablation (RFA) is a non-operative technique that can reduce lower back pain "in well-selected patients with confirmed facet joint-mediated pain." Likewise, orthobiologics, including platelet-rich plasma, "may have a role in addressing lower back pain due to degenerative or age-related changes in the spine," he adds.

Venesy says that along with "exercise, exercise, exercise," guided imagery and meditation for chronic pain management can be helpful, as well as spine injections for facet arthritis.