Department of Physiatry
The physiatrists at Hospital for Special Surgery perform non-operative treatment procedures on patients who have spinal and sports-related injuries as well as other musculoskeletal problems. These procedures are combined with medically supervised exercise therapies to restore mobility and function in patients who might otherwise require surgery.
Several members of the Department of Physiatry also perform electrodiagnostic studies such as nerve conduction and electromyography. These diagnostic studies help to determine whether patients may have nerve or muscular disorders such as lumbar or cervical radiculopathy, carpal tunnel syndrome, and other debilitating conditions.
The Department is not only involved with the development of new non-invasive procedures, it also employs innovative research techniques to better understand and validate many non-operative or minimally invasive interventional procedures to treat spinal and sports-related injuries.
What is physiatry?
Physiatry – also known as physical medicine and rehabilitation (PM&R) – is a medical specialty focused on the nonsurgical treatment of musculoskeletal conditions that cause pain and/or physical weakness. Physiatry first emerged as a medical specialty shortly after World War II, when veterans returned with spinal cord injuries, traumatic brain injuries, loss of limbs and other musculoskeletal impairments. The specialists who emerged from this specialty are called physiatrists and they combine their knowledge of anatomy and biomechanics with the goal of restoring function to individuals with these types of injuries.
When should I see a physiatrist?
Many people who experience pain or dysfunction in their bones, joints or soft tissues are confused about which type of medical specialist is appropriate for them. The trend in medicine toward specialization had made this an increasingly difficult task. People wonder, “Do I have a serious condition that requires surgery or will simple rest and exercise can fix the problem?” In many cases, especially when a spine injury is suspected, a physiatrist is the appropriate doctor who can help treat or determine the appropriate level of care.
Regardless of which type of practitioner you consult first, people who think they may have a bone or joint injury of any kind should find a doctor at an institution that emphasizes collaboration among disciplines and which specializes in every aspect of musculoskeletal treatment and recovery. Patients with a musculoskeletal injury can be assured that at HSS, non-operative care is provided whenever possible and appropriate.
How do I find the right specialist?
Not everyone necessarily needs to see a physician or a surgeon for their first visit. Although HSS is well-known for orthopedic surgery, the majority of our outpatient visits result in nonsurgical, medical and rehabilitative care. All medical and surgical departments at HSS share the goal for each patients to see the right practitioner for the right treatment at the right time.
The Department of Physiatry places a strong emphasis on triage – a process in which the severity of a condition and the urgency of treatment is assessed – and on facilitating access to appropriate care. With proper assessment by a nurse practitioner or a physical therapist, the patient can often get the attention he or she needs promptly. This is also the best way to avoid progression to a chronic problem or one that is more difficult to treat.
To illustrate how HSS determines the right path of care, these are three hypothetical scenarios in which a person might contact the Hospital to seek treatment for back pain.
- Directly. A person calls or books online directly with a specific physician or surgeon of their choosing.
- Referral. An individual is referred by a health care provider (physical therapist, nurse clinician or primary care doctor) who believes that they should see a a specialist or require surgery.
- Unsure. A person has just experienced the acute onset of back pain or sustained a back injury and does not know what kind of treatment they require from a spine specialist.
HSS has many ways to help the unsure person get immediate care by booking online or speaking to one of our physician referral specialists. Depending on the nature and severity of the injury, a spine specialist will then determine if the patient needs immediate referral to a physiatrist or to a different specialist.
HSS Direct Access for patients
Another option is the Direct Access Physical Therapy program. Experienced physical therapists, who have already passed rigorous qualifying tests for certification, can diagnose and treat a patient without a doctor’s prescription.If needed, they can escalate the care to a physiatrist or other appropriate specialist.
Regardless of the path, once treated, the patient's progress is tracked continually by the spine specialist. If the patient achieves relief, then the focus of treatment turns to prevention. If not, then the spine specialist ensures that the patient receives the next level of care as appropriate for the injury or disorder. After the patient has recovered, HSS specialists provide direction on maintaining wellness.
Integrated Care and Research
At HSS, collaboration between physiatry and other orthopedic specialties is easier because oftentimes, they are under the same roof. If a physiatrist believes a patient is in need of surgery, a simple referral to one of the surgeon's at the same location can be made, and vice versa. This arrangement allows for an easy transition for patients and improved communication among physicians.
In addition to acting as partners with other specialists in the delivery of care, HSS physiatrists take an active role in collaborative research, such as conducting surveys to clearly identify patient expectations and goals of care. Areas of study include regenerative medicine, a discipline in which platelet-rich plasma, bone morphogenic proteins and/or stem cells may be used to repair and restore damaged and diseased musculoskeletal tissue.
HSS research teams include members of multiple departments in order to bring together different points of view, which then increases the understanding of what the research shows and which patients may potentially benefit from it.
The Department provides over 30,000 ambulatory care visits a year, including approximately 3,900 minimally invasive procedures and 1,100 EMG/NCV studies, attending over 17,500 returning patients and 7,500 new patients each year.
The following is a partial list of procedures performed by physiatrists at HSS:
- IntraDiscal Electrothermal Therapy (IDET) is a minimally invasive procedure that offers an important treatment option to individuals with lower back pain caused by lumbar disc disease. The physician then passes a thermal catheter through the needle and into the injured disc in the specific area of the annulus tear. The catheter heats the collagen of the disc to shrink the protruded material and destroy the pain fibers
- Epidural steroid injection is an umbrella term applying to a variety of techniques performed to deliver a corticosteroid preparation around a nerve exiting the spinal cord in an epidural space. This procedure decreases inflammation of the nerve roots, thereby reducing pain for several months and hopefully aiding the healing process as well.
- Nucleoplasty uses radiofrequency energy to treat patients with low back pain from contained, or mildly herniated, discs. Guided by X-ray imaging, a wand-like instrument is inserted through a needle into the disc to create a channel that allows inner disc material to be removed. The wand then heats and shrinks the tissue, sealing the disc wall. Several channels are made, depending on how much disc material needs to be removed.
- Radiofrequency ablation/lesioning uses high-frequency alternating current flow to generate heat and destroy pain sensing nerves. A narrow electrode is introduced to the affected nerve. Precisely controlled generator heat is generated to destroy the nerve.
- Nerve conduction/electromyography testing, or EMG testing, is a two-part electrodiagnostic test that is used to study nerve and muscle function, and it can provide your doctor with specific information about the extent of nerve and/or muscle injury. The test consists of a nerve conduction study and a needle exam for muscle testing. The nerve conduction study entails stimulating the nerves at different points with small electric shocks, artificially activating them so their function can be measured. The needle exam involves inserting very fine needles into several muscles with determine normal and abnormal electrical signals given off by the muscles. EMG testing usually takes anywhere from 30 to 90 minutes, depending on the condition being tested and findings of the study.
- Joint lavage procedures are arthroscopic techniques essentially meant to wash loose tissue debris and inflammatory agents away from the interior of a major joint, such as the knee. Although the lavage procedure is a short-term solution, it may assist in relieving the symptoms of those suffering from osteoarthritis for a number of years. Joint injections are performed for diagnostic and therapeutic purposes, and they can be used in two ways - for aspiration, which involves removing fluid for testing or drainage, and fluid injection, whereby medications such as corticosteroids are injected into a joint to medicate areas affected by inflammatory arthritis.
Video: Regenerative Treatments for Lumbar Disc Disease
Condition & Treatment Highlights
- Carpal Tunnel Syndrome: Electrodiagnostic Testing for a Proper Diagnosis
- A Brief Overview of Physiatry, Electrodiagnostics, and Injections
- Epidural Injections: Frequently Asked Questions
- Disc Herniations in the Lumbar Spine: Frequently Asked Questions
- Cervical Radiculopathy: Non-operative Treatments and Cervical Epidural Steroid Injection
- Patient’s Guide to EMG Testing
- Complete article index
Affiliated Centers and Service
Fellowship Training
The Department provides a one-year Spine and Sports Medicine Fellowship, with two fellows accepted each year. This fellowship program focuses on the improvement of skills in the areas of diagnosis and treatment using a comprehensive approach, including including interventional spine procedures (cervical and lumbar), diagnostic and interventional ultrasound, electrodiagnostics, regenerative medicine and concussion management.
The Department also takes part in the training of Columbia University and Cornell University's residents from NewYork-Presbyterian Hospital's Physical Medicine and Rehabilitation residency program, and is involved in the education of medical students from Weill Cornell Medicine.
Recent Publications
- Dave U, Shetty T, Emami K, Jivanelli B, Cheng J, Ling D. A systematic review and meta-analysis of sex-based differences in recurrent concussion incidence across sports. J Womens Sports Med. 2022 Dec.
- Hunt D, Prather H, Park P, Hong B, Brady B, Downs D, Cheng A. Interpretation of PROMIS depression and anxiety measures compared to DSM-5 diagnostic criteria in musculoskeletal patients. Accepted for publication in JBJS Open Access on Dec 1, 2022.
- Madrazo-Ibarra A, Kolin DA, Hunter T, Ogyaadu JA, Duah HO, Tutu HO, Bandoh A, Nutsuklo P, Boachie-Adjei K, Carroll K, Vad A, Zhao E, Vad VB. Carboplasty, a minimally invasive procedure for knee osteoarthritis: surgical technique and clinical evidence. Tech Orthop. 2022 Nov 28.
- Lutz GE. Intradiscal leukocyte-rich platelet-rich plasma for degenerative disc disease. Phys Med Rehabil Clin N Am. 2022 Oct 18.
- Cheng A, Snider E, Prather H, Dougherty N, Wilcher-Roberts M, Hunt D. Provider-perceived value of interprofessional team meetings as a core element of a lifestyle medicine program: a mixed-methods analysis of one center’s experience. Am J Lifestyle Med. 2022 Oct 25.
- Vad VB, Madrazo-Ibarra A, Estrin D, Pollak JP, Carroll KM, Vojta D, Vad A, Trapness C. Back Rx, a personalized mobile phone application for discogenic chronic low back pain: a prospective pilot study. BMC Musculoskelet Disord. 2022 Oct;23(1):923.
- Patel TS, Faustin Marcia, Katz NB, Kruse DW, Tilley D, Laird J, Casey E. Monitoring Training Load in Artistic Gymnastics: Benefits, Challenges, and Future Directions. BJSM Blog. 2022 Sep 30.
- Tang C, Sookochoff M, Rhea L, Carrier J, Prather H, Guan L. An audit of structure-based medical acupuncture by a single provider in patients with musculoskeletal pain using PROMIS scores as the outcome. Acupunct Med. 2022 Sep 13.
- Sanguino R, Cheng J, Wyss J. Tropical Achilles tendinopathy: sea urchin spine injury. J Am Podiatr Med Assoc. 2022 Jul-Aug;112(4):21-007.
- Milani C, Vyas K, Malik G. Evidence-based diagnosis and treatments of posterior tibialis tendinopathy. Curr Phys Med Rehabil Rep. 2022 Aug 12.
- Creighton A, Cheng J, Press J. Upper body injuries in golfers. Curr Rev Musculoskelet Med. 2022 Aug 5.
- Casey E, Bonanno J, Cheng J, Abutalib Z, Kranz K, Kruse D, Thomas C, Faustin M. Return to sport in elite gymnastics: unprecedented training interruptions provide lessons for the future. PM&R. 2022 Aug 2.
- Goldsmith C, Cheng J, Halpert J, Moley P. Long-term outcomes following non-operative treatment of pre-arthritic or extra-articular hip pain in women. Women’s Health Reports. 2022 Aug;3(1).
- Goldsmith C, Cheng J, Mintz D, Moley P. Correlation of femoral version measurements between computed tomography and magnetic resonance imaging studies in patients presenting with a femoroacetabular impingement-related complaint. J Hip Preserv Surg. 2022 Jul 27.
- Bonanno J, Cheng J, Tilley D, Abutalib Z, Casey E. Factors associated with Achilles tendon rupture in women’s collegiate gymnastics. Sports Health. 2022 May-Jun;14(3):358-368.
- Sanguino R, Sood V, Santiago K, Cheng J, Casey E, Mintz D, Wyss J. Prevalence of rapidly progressive osteoarthritis of the hip following intra-articular steroid injections. PM&R. 2022 May 20.
- Cheng AL, Carbonell KV, Prather H, Hong BA, Downs DL, Metzler JP, Hunt DM. Unique characteristics of patients who choose an intensive lifestyle medicine program to address chronic musculoskeletal pain. PM&R. 2022 May 14.
- Charnoff J, Rothman R, Andres Bergos J, Rodeo S, Casey E, Cheng J. Variability in patient-incurred costs and protocols of regenerative medicine procedures for musculoskeletal conditions in the United States. HSS J. 2022 Jul 2.
Recent Abstracts Accepted or Presented at Conferences
- Prather H, Cheng A, Dwivedi M, Hong B, Taverna-Trani A, Hunt D. Building a lifestyle medicine program to address painful musculoskeletal conditions. Presented at ACLM 2022.
- Cheng J, Casey E, Cheng A, Leupold O, Rau O, Prather H. Prevalence of lifestyle-related comorbidities and patient-reported physical and mental health in low back pain patients. Presented at ACLM 2022.
- Cheng A, Brady B, Prather H, Downs D, Hong B, Hunt D. PROMIS mental health screening in lifestyle medicine. Presented at ACLM 2022.
- Hunt D, Cheng A, Snider E, Prather H, Jacobsen H. Provider-perceived value of interprofessional team meetings. Presented at ACLM 2022.
- Cheng J, Casey E, Cheng A, Leupold O, Rau O, Prather H. Prevalence of lifestyle-related comorbidities and patient-reported physical and mental health in low back pain patients. Presented at NYP Rehabilitation Research Day 2022.
- Vyas K, Leupold O, Cheng J, Quirolgico K. Patient outcomes on treatment of Achilles tendinopathy with extracorporeal shockwave therapy: a retrospective study. Presented at NYP Rehabilitation Research Day 2022.
- Charnoff J, Rothman R, Andres Bergos J, Rodeo S, Casey E, Cheng J. Variability in patient-incurred costs and protocols of regenerative medicine procedures for musculoskeletal conditions in the United States. Presented at NYP Rehabilitation Research Day 2022.
- Tsai J, Cheng J, Barcavage C, Wyss J. A case of bilateral rapidly progressive osteoarthritis of the hip. Presented at NYP Rehabilitation Research Day 2022.
- Vyas K, Quirolgico K. Patient outcomes on treatment of insertional Achilles tendinopathy with extracorporeal shockwave therapy: a retrospective study. Presented at AOFAS Annual Meeting 2022.