Department of Physiatry

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.

1. Directly. A person calls or books online directly with a specific physician or surgeon of their choosing.
2. 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.
3. 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

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

• Lutz C, Cheng J, Prysak M, Zukofsky T, Rothman R, Lutz G. Clinical outcomes following intradiscal injections of higher-concentration platelet-rich plasma in patients with chronic lumbar discogenic pain. Int Orthop. 2022 Mar 28.
• Kirschner J, Cheng J, Creighton A, Santiago K, Hurwitz N, Dundas M, Beatty N, Kingsbury D, Konin G, Abutalib Z, Chang R. Efficacy of ultrasound-guided glenohumeral joint injections of leukocyte-poor platelet-rich plasma versus hyaluronic acid in the treatment of glenohumeral osteoarthritis: a randomized, double-blind controlled trial. Clin J Sport Med. 2022 Mar 17. 
• Tan ET, Serrano KC, Bhatti P, Pishgar F, Vanderbeek AM, Milani CJ, Sneag DB. Quantitative MRI differentiates electromyography severity grades of denervated muscle in neuropathy of the brachial plexus. J Magn Reson Imaging. 2022 Feb 23.
• Marmor W, McElheny K, Lingor R, Shetty T, Lin E, Casey E, Ling D. Disparities in concussion diagnoses compared to ankle injuries. PM&R. 2022 Feb 1.
• Robinson P, Williamson T, Creighton A, Cheng J, Murray A, Prather H, Dines J, Gulotta L, Su E, Press J, Hawkes R, Clement N. The rate and timing of return to golf after hip, knee, or shoulder arthroplasty: a systematic review and meta-analysis. Amer J Sports Med. 2022 Jan 12.
• Cheng A, Ring D, McDuffie J, Schuelke M, Calfee R, Prather H, Colditz G. How should be measure social deprivation in orthopaedic patients? Clin Orthop Relat Res. 2022 Feb 1;480(2):325-339.
• Queler S, Towbin A, Milani C, Whang J, Sneag D. Parsonage-Turner Syndrome following COVID-19 vaccination: magnetic resonance neurography. Radiology. 2022;302:84-87.
• Cheng AL, Collis RW, McCullough AB, Bui M, Brady BK, Schuelke MJ, Clohisy JC, Colditz GA, Prather H. Rate of continued conservative management versus progression to surgery at minimum 1-year follow-up in patients with pre-arthritic hip pain. PM&R. 2021 Dec 11.
• Kirschner J, Cheng J, Hurwitz N, Santiago K, Lin E, Beatty N, Kingsbury D, Wendel I, Milani C. Ultrasound-guided percutaneous needle tenotomy (PNT) alone vs. PNT plus platelet-rich plasma injection for the treatment of chronic tendinosis: a randomized controlled trial. PM&R. 2021 Dec;13(12):1340-1349.
• Prysak MH, Kyriakides CP, Zukofsky TA, Reutter SE, Cheng J, Lutz GE. A retrospective analysis of a commercially available platelet-rich plasma kit during clinical use. PM&R. 2021 Dec;13(12):1410-1417.
• Cheng J, Santiago KA, Abutalib Z, Temme KE, Hulme A, Goolsby MA, Esopenko CL, Casey EK. Menstrual irregularity, hormonal contraceptive use, and bone stress injuries in collegiate female athletes in the United States. PM&R. 2021 Nov;13(11):1207-1215.
• LeBrun DG, Sneag DB, Feinberg JH, McCarthy MM, Gulotta LV, Lee SK, Wolfe SW. Surgical treatment of iatrogenic nerve injury following arthroscopic capsulolabral repair. J Hand Surg. 2021 Dec;46(12):1121.e1-1121.e11.
• Sweeney EA, Howell DR, Seehusen CN, Tilley D, Casey E. Health outcomes among former female collegiate gymnasts: the influence of sport specialization, concussion, and disordered eating. Phys Sportsmed. 2021 Nov;49(4):438-444.
• Leopold M, Santiago K, Cheng J, Keller L, Abutalib Z, Bonder J, Sharma G, Tenforde A, Casey E. Efficacy of an online core strengthening program for diastasis rectus abdominis in postpartum women: A prospective observational study. J Women’s Health Phys Ther. 2021 Oct/Dec;45(4):147-163.
• Prather H, Fogarty AE, Cheng AL, Wahl G, Hong B, Hunt D. Feasibility of an intensive interprofessional lifestyle medicine program for patients with musculoskeletal conditions in the setting of lifestyle-related chronic disease. PM&R. 2021 Oct 28.
• Ferber A, Howell D, Tilley D, Casey E, Sweeney E. Intersection of surgical injuries and pain interference among former female collegiate gymnasts. PM&R. 2021 Sep 9.
• Ammerman B, Cheng J, Ling D, Casey E. Type of oral contraceptive pills in patients with complete ACL tears: a retrospective study. Penn State J Med. 2021; 2.

Recent Abstracts Accepted or Presented at Conferences

• Malik GR, Cheng J, Rothman R, Casey E, Kirschner J, Milani C, Sokunbi G, Sandhu H, Prather H. Comparison of baseline PROMIS-10 scores of mental and physical health of low back pain patients evaluated by physiatrists and orthopedic spine surgeons. Accepted for poster presentation at AAP 2022.
• Malik GR, Goldsmith C, Wyss J, Moley PJ. Anteromedial acetabular fracture evaluation and treatment with non-operative approach: a case report. Accepted for poster presentation at AAP 2022.
• Chen H, Cheng J, Tsai J, Wyss J. Correlation between aspiration of calcific rotator cuff tendinopathy and morphology on imaging. Accepted for poster presentation at AAP 2022.
• Tsai J, Cheng J, Barcavage C, Wyss J. A case of bilateral rapidly progressive osteoarthritis of the hip. Accepted for poster presentation at AAP 2022.
• Chen H, Cheng J, Wyss J, Tsai J. Correlation between aspiration of calcific rotator cuff tendinopathy and morphology on imaging. Accepted for poster presentation at AAPM&R 2021.
• Batka R, Quirolgico K. Platelet-rich plasma (PRP) into the 1st metatarsalphalangeal (MTP) joint of a dancer with medial hallux sesamoid fracture/stress reaction and joint capsule sprain. Accepted for poster presentation at IADMS 2021.
• Fryar C, Howell DR, Seehusen CN, Tilley D, Casey E, Sweeney EA. Time loss injuries among former collegiate gymnasts: the influence of female athlete triad symptoms. Presented at PRiSM 2021.
• Bui M, Collis R, McCullough AB, Brady B, Ng C, Clohisy JC, Prather H, Colditz G, Cheng A. Clinical and radiographic predictors of conservative versus surgical management in patients with pre-arthritic hip disorders. Presented at AAP 2021.
• McCullough AB, Prasad N, Arbanas J, Prather H, Hunt D, Cheng A. Diagnostic hip injections and satisfaction with surgical versus conservative management in adolescents and young adults with hip pain. Presented at AAP 2021.
• Cheng A, Bradley EC, Brady B, Waller L, Calfee R, Colditz G, Prather H. Opioid use and social disadvantage in patients with chronic musculoskeletal pain. Presented at AAP 2021.
• Fogarty A, Cheng A, Prather H. The Living Well Center: a pilot study of a lifestyle medicine program in patients with musculoskeletal disorders. Presented at AAP 2021.