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Where does the PM fit in?

Kris-NYKKris-NY Posts: 2,207
edited 06/11/2012 - 8:45 AM in Pain Management
I will admit that I have always been skeptical about PM. In general I am very leary about everything so why should this be different? I'm a NYer .. it's in our blood not to trust.

I found a great PM doc with a very helpful office staff. I'm not to thrilled with my neurologist right now but that's another story. Based on this last MRI and CT it looks like surgery is off the table for now and probably for quite a while.

So here's my question. I have a MRI and a CT which shows some good possibilities of where my pain is coming from. Injections are probably not possible according to the PM doc. So who decides what to do now? Does the PM doc take over my care or is the neurologist still actively involved? Also the PM's office says they can't do the disability paperwork so the neurologists office has been doing this.

I'm a little tired of going to the neurologist and having him go through the same tests and then tell me nothing. And God forbid if he wants to order more tests! But if his office has to do paperwork for disability I guess I have to check in once a month no matter what.

I guess I'm curious to know what everyone else has done. I'm trying to accept this change in plans but it isn't easy. I'm also learning the hard way that there are rules to the game of disability. :(



  • My PM doc deals with all of my meds. What type of doctor is your PM doctor? Mine is a physiatrist, but in general a board certified pain medicine doctor is going to be more well-versed in the research on pain and how to treat it than, say, an orthopedic surgeon, who is going to be more well-versed in how to treat broken bones.

    In the PM office I visit, there are also board certified pain medicine doctors who are anesthesiologists.

    So my PM doctor is the guy I call when I have pain. I don't even have a regular ortho or neuro right now, although I'm seeing a new neurosurgeon tomorrow. Around here (the land of movie stars who use propofol as a sleep aid) many orthos don't prescribe meds at all, so having a PM doctor is very important.
  • I just googled him and it says he is an anesthesiologist, interventional pain management and pain management doctor. Doesn't say if he is board certified but he is part of a large medical group and he practices at the major hospitals in the area. So I am guessing he is. He is also the top pick from both my neurologist and NS.

    Next week I should get a better idea of how this will work. WHen I went to him the first time it was with the recommendation of the neurologist and NS to try injections. He said he can't because the T1/2 is so small to begin with and after surgery there would be too much scar tissue. So now I can find out what he can do about the pain.

    I had a major change of heart today. Up until now I assumed that there would be another surgery to "fix" me. Now I'm realizing that the only surgery that might stop the pain is a multi-level fusion tht would probably be a mistake given that I am only 45. If they can control the pain with meds then why risk that type of surgery? Right now I'm pretty numb. I think the next few days will be very hard for me as reality sinks in. All I can think right now is "why did I get in the car that day?"
  • You can find out if your PM doc is board certified on:


    Also, sounds like you are stuck with the neurologist if is kindly completing your disability forms, which is always a thorn in my side.

    When I decided to have my fusion, it was an act of desparation...I was in overwhelming pain, my left leg was limping, I had back/buttock/hips/groin pain, and bilateral numbness of feet, and bladder issues. This was after 4 blocks, PT, steriods, tens unit. Surgery was imminent.

    Sounds like you want to try a less invasive approach. I hope it work well for you.

    I'm also thinking about getting a PM doctor with invasive skill expertise.

    Let us know how everything goes.

    Good luck,

  • Seriously, I think surgery is in my future as well, because I believe the collapse is causing other problems, and I am in increasing pain. But there is no "fix."

    To me, back surgery is rarely a fix. It's just a kind of a stop-gap measure to try and keep things from getting too much worse.
  • Kris,

    First of all, I really felt for you when I read your sentence about wishing that you "hadn't gotten into the car that day." I have the same feeling of regret, although mine was as stupid as riding a bike on steep hills, i.e. my issue was avoidable. I believe that yours was an accident and so I would hope you can realize that you didn't do anything wrong. I'm convinced that this feeling of guilt contributes to our overall unhappiness. I don't mean to project anything on you -- I'm simply empathizing with what I believe may have happened to you and how you may be feeling about it.

    I've openly discussed my need for a PM doctor with my NS, and both he and his PA as well as his office staff have no issue whatsoever taking care of disability paperwork. They know all too well how unforgiving employers can be and I think they are very happy to do this for their patients. So please don't think twice about continuing to involve your Neurologist or NS (I can't remember which one you have) to take care of disability.

    As we have discussed before, I don't think that any NS or Neurologist is in the best position to manage the overall pain management picture. Hence, we are both actively searching for a good PM doctor. I guess I'm just suggesting that you should also hang on to your relationship with your NS/Neurologist to support your disability, but also in the event that surgery does become an option.

    I hope I'm making sense. I haven't been sleeping much lately and I don't know if my brain is working very well any more. :(

    As you know, these are just my opinions. I know that you have the wisdom and common sense to do what's best for you based upon your own particular needs.

    Best wishes,
  • Kris,
    Ideally both of these practitioners should work together and PM is now introduced sooner in the treatment process, even as some of the invasive aspects are still ongoing. PM is possibility the next best option and the sooner the better when surgery is not recommended. At our PM residential some patients were omitted from the program based on initial assessment and I was always concerned that they had not been supported as they should. Some people are more resistant to change and that in itself may improve over time and experience, we need to be resilient.

    That marking-time element that Kris mentions, is always difficult and we seem to be going from one place to another with making any progress and perhaps if that process is not working for us, we should change strategy.

    We have to have confidence that the less invasive approach will have some benefit and trying to match our expectations with reality is never easy, some success will be how we as patients approach PM and it is as successful as we make it. If we constantly think that surgery is the answer no amount of PM will be effective, although my own fusion failed, once I was told that no future surgery would help then it made the option of PM seem more appropriate, we have to believe that this is the right route for us and embrace it the best we can.

    The concept in the NHS does differ and although many of these doctors do work together they are separate, the NS may recommend PM on the basis that surgery is not an option andthey can do no more and indentifying the origin of our symptom is a long way from repairing it. On the basis that PM is usually less invasive you could have the NS/PM process simultaneously and that overlapping is sometimes part of change. As you say if surgery is off the table now, maybe this is the time for change and see if the PM process would help.

    I am interested to know is it PM as a concept that you think will not help or just certain elements.

    Melzack and Wall 1983, in Challenging Pain suggest that the “simultaneous collective” approach of PM is the best option for managing pain in using all possibilities at the same time.

    Take care and good luck.


  • One thing I have noticed is the perception that pain management = injections. True, PM docs offer a wide variety of injections, this is just *one* small aspect of overall pain management. I think some PM docs pass themselves off as just injections because their interest lies in procedures rather than patient care (very similar to surgeons). One thing I always look for in pain management is a balanced approach, where maybe 50% of my treatment is injections, but the other 50% is office visit type care. I kind of thought that was the norm for PM, but reading from others on this site it sounds like there are certainly PM docs that aren't great with patient care and are only interested in the procedure side of the specialty.

    So, with that being said I think PM has a lot to offer when surgery is not on the table. I think pain management docs take a much broader approach and can appreciate the scope of overall function rather than narrowly focusing on one little defect. I've heard it said that the farther out you get from an insighting incident the less the specifics of your condition matter- at some point chronic pain is chronic pain, and when a "fix" is not in the mix sometimes it makes sense to simply treat the pain. A PM doc can offer you this treatment even if he can't specifically fix the problem.

    As far as the roll of PM in overall care: I think of it as my PM doc is the "primary" doctor on my case- if I need an opinion from another specialty he directs me. He is also very good to say "as a PM doc this is what i have to offer, but if you went to a NS they may be able to offer you this..." So, I know my options are open. My PM doc is basically like the GP of my spine care. I can go to him with anything involving my back and 99% of the time he can handle it and help me, and that other 1% he knows exactly where to tell me to go. I think ideally you should ask your PM to come up with the solution regarding the neurologist- I'd tell him that you basically aren't needing the neurologist anymore because you are shifting into PM, but that you need someone to do your disability paperwork. That gives him the option of helping you with the paperwork (if possible), and if not it lets him know that you will still be seeing a neurologist. Ideally, he would work with the neurologist, but that may or may not happen.

    While epidurals or nerve root blocks may not be in the mix, there should still be other PM options for you to try- I had a very hard time when my orthopedist told me "there's nothing else I can do...You need to go to pain management." It felt like being given up on, and like I was being shipped out to a hopeless place where pain was inevitable. The idea of needing pain management rather than a doctor in a "pain fixing" specialty was hard to hear. But, it ended up being a great decision, and I found the attitude and care I received from my PM doc was *so* different than the care I was getting with docs in other specialities- rather than looking at me with confusion, frustration, etc. I finally found a doctor who I felt was going to find a way to help me and would not give up on me. It also felt really good to finally get to a doctor with a plan for me.

    P.S. I'm sure you've heard the joke about neurology: it's the one specialty that can diagnose everything and fix nothing. My neurologist told me that :)
  • I can't wait to go next week. That's pretty funny since when I went last time I was so defensive. I did not want injections and I remember sitting in the waiting room telling myself to keep an open mind. I was so shocked that he said no injection since I was ready to fight with him - lol.

    This time I am going in with the opposite idea. I am hoping that they will take the role as "primary" in my care. I'm even hoping they will have a neurologist in their group that they will recommend.

    This morning my back is hurting and my right eye is very blurry. It's time to accept that this is a long slow road.
  • Nice to see I am not the only one here because of being stupid enough to ride a bike on a steep slope!

    Kris, walking into ANY professional office with a predetermined mindset will usually leave you baffled by the whole experience! Typically the doctor will throw something you never thought of or 360* away from the last visit. When that happens to me I am usually in the car in the parking lot going WTF? then thinking all the questions I should have asked!

    That's when it is very helpful to have questions written down and someone on your side in the room.

    I could tell you where I'd like to fit my PM, but it would get edited by the mods =))

    I have only ever seen three and one is the PA of my current PM. The one that impressed me the most my wife talked me out of seeing due to travel headaches/distance. I really, really wish I had followed my gut instinct and not my wife as she never met the guy.

    In the end, it really is our choice of who to continue seeing and why.
  • And another thing- around here, nobody but PM uses long-acting opiods. Here's to feeling better.

    It must be harder for those of you for whom the accident wasn't doing something you love. I never wished I didn't get on my horse. Now that he's for sale I still wish I didn't have to sell him. And when I put him on the market, my friends suggested a fund to keep him because he had changed me for the better- despite the broken back.

    Maybe you should take up parasailing and try getting injured that way instead?

  • Oh man. Selling my bike is NOT like selling a horse! I have a brand new road bike that I paid $1300 for and I got all of 200 miles on it (which is nothing). Every time I look at it I'm sad that that part of my life is probably over. That's just a stupid bike. I can't imagine the feeling associated with having to give up a horse. I would imagine that's almost like losing a family member.

    HappyMom, so far all of the PM docs I've talked to DON'T prescribe narcotics, they just do injections. They must have figured out their little niche where they can make a lot of money and not deal with all of the narcotic regulation hassles.

    I do think I found someone who will manage the whole picture, including narcotics if necessary, so I'm a little more hopeful that I could have him take over my entire treatment plan.

    Anyhow, back to Kris, good luck with your PM appointment. Please don't shy away from injections!
    They may very well help you.

    Take Care,
  • dilaurodilauro ConnecticutPosts: 9,839
    You will see that many people use these terms interchangeable. I know I have, probably because I always had trouble spelling physiatrist.

    Dealing with Spinal Issues, I see these following medical professions and their roles:

    Might just be the first doctor you saw after visiting your Primary Care Physician. The Neurologist might be the one to start setting up the initial diagnostic testing. They do not perform any surgery

    Are the ones that will actually do the spinal surgery, many times accompanied by an Orthopedic surgeon.

    Pain Management
    Are the doctors that generally perform the various set of Spinal Injections, EMG testing, etc

    Like the captain of a team. They should be coordinating everything about your situation.
    Prescribing medications, setting up diagnostic tests, making recommendations to see other specialists, etc.

    For me, my physiatrist has total control of my medical , physical and emotional condition. I've been seeing her for over three years and it was only after seeing her for a while and getting the various treatments required, did I start to show signs of improvement.
    Ron DiLauro Spine-Health System Administrator
    I am not a medical professional. I comment on personal experiences
    You can email me at: rdilauro@veritashealth.com
  • I'm lauging Ron, not at you, mind you, but with you. I can never spell Physiatrist either. Thank goodness you had it right there for me to copy and paste.

    Kris, I'm glad you are giving this PM a try. Just like the many nero's you have seen sometimes you may have to see more than one before you find one that works for you.

    I use my Physiatrist for my PM and he is wonderful. He coordinates all my spinal issues, refers me to surgeons when necessary collects their notes, we talk about it and he recommends from there. Sometimes I listen. Sometimes I don't. He also manages all my meds. I am currently working with a surgeon but still see my Physiatrist regularly.

    Everyone has spelled out their experience with their PM well so I've really no need to add to this thread except to say this about the disability forms.

    I provide my disability company with the names of all doctors I have been seeing. They then contact them and collect the medical records and request updates on my condition, usually including those ridiculous functions and abilities forms.

    My Physiatrist has been the primary doctor to update them on my condition but they have collected records from every doctor I have seen related to my condition. Even if it's just 2nd opinion's (and 3rd and 4th) My guess is if you make them aware you are now seeing a PM they will take it from there.

    They then have ALL of your medical records. This comes in handy if and when it becomes necessary to extend your benefits to LTD if you are eligible and find yourself needing to file for SSD should they require it. (At least it did for me.)

    Take the monkey off your back.

  • I go to the PM tomorrow. I've given up on my neurologist so I am hoping they will have a recommendation. My appt is actually with the nurse practitioner but the PM will be there and available. But I may do better with her since she will know which offices are better to work with for the paper work. I am also going to ask her about a physiatrist. I did a google search but they seem to be chiropractic or PT based offices.

    I just read the independent review of my MRIs. There are several problems around my surgery site involving the facet joints and the costrovertebral joints. Basically what made me better (the surgery) caused all kinds of issues with the connection of the vertebra and the ribs. Nothing that can be fixed without doing a major fusion with all kinds of hardware and there is probably a very small chance that it would work. So it looks like I will be very good friends with the PM group.

    Thank you all for your thoughts and suggestions. I guess I have my answer.... PM will be a very large part of my life.
  • I hope this doesn't mean that you are giving up trying to find a complete answer to all that is going on with you still? My last Neurologist was *cough* a piece of work as you probably remember, but aside from my post retirement doctor break, I am getting back on the 'start over' mode (for a new Neurologist).

    Like I've seen on here with many who were either ignored, or moved to the mystery diagnosis side of the house, most don't give in or give up. From what I've seen of you in the threads, and to PM, you aren't a give up type. Hopefully you're just taking a step back as I have only to mentally and physically regroup! Still keeping positive thoughts heading your way woman!!! *HUG*

    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.
  • Well the visit went fine. I like the nurse practitioner which is a huge plus. She spent most of the time shaking her head about the crazy reports from different doctors.

    Their opinion is that for now the only treatment option is pain management and possibly PT if the physiatrist agrees. So I signed my contract and join the ranks of pain management patients.

    PS Brenda it's not that I am giving up. But the report shows several issues in the facet joints, vertebra and costrovertebral joint which connects to the ribs. There just isn't any way to fix them, not even a fusion. So I can try to strengthen the surrounding muscle and then just treat the pain. I wish there was an answer.
  • Kris,

    I guess I look at it this way based on your appointment today, you are at least getting more detailed answers to what all is going on. I think that was the hope/goal? :)

    Unfortunately I am still a work in progress. I've already been told by 3 neck and back are still on the future 'to do' list. *sigh* Please let us know if the PM side of the house is a 'helper', okay? *HUG*

    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.
  • Most of us have issues with our backs that aren't fixable. So, at least you know you're not alone! DDD in general isn't really a reversible process, so there are many people wandering around with problems nobody can fix :)

    Not that that helps, but what's that saying? A problem shared... something something.

    Hopefully you'll get some steady pain control now, and be able to get back to your life.
  • Kris,

    I'm glad to hear that you are moving forward. I'm meeting with a "real" PM doctor on the 10th, so I have been paying close attention to your thoughts/concerns/hopes in doing so yourself. I was told upfront, though, that this doctor will help manage my whole pain management picture except that he won't prescribe narcotics. Huh???? I asked his receptionist if he only does injections and she said "yes". How is that comprehensive pain management? At that point I didn't move forward. However, I got a call a couple of days later from his nurse and she said that he will indeed take care of everything as long as it is coordinated with my current doctor. Okay, I thought that was a given. I wasn't expecting to get narcotic prescriptions from two different doctors.

    My goal is to get off of narcotics by finding the root cause of my pain and addressing it. Even if he can address it through non-narcotic meds, I would be fine with that. I just thought it was odd that some of the office staff were not on the same page. It seems like a red flag to me, but I cannot find any other comprehensive PM doctor in my state. It's very hard for me to drive more than 30-45 minutes, so going out of state doesn't seem very realistic.

    Anyhow, Kris, I hope my experience goes anywhere near as well as yours.

    Take Care,
  • Yes, when I got out of Kaiser I went through a lot of confusion about who would prescribe my narcotics. I figured it would be my ortho, but they were like... nooooo! OK then. The first PM doc I went to was like "Lose weight and go to physical therapy" (he also ran his fingers down my back and said "I don't see anything wrong there." I have one vertebrae that is basically missing. What a maroon.).

    But the last two PM docs were comprehensive. Both really like their injections, but they do meds as well.
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