SJMHS Physical Medicine Advances 2009

Jon M. Wardner, M.D.

Dr. Wardner is a practicing physician at Associates in Physical Medicine & Rehabilitation.

When Physical Medicine and Rehabilitation (PM&R) was established as a board-certified specialty in 1947, its primary mission was to rehabilitate servicemen injured during World War II. Over the ensuing six decades, the specialty has grown in size and scope, but its focus has remained on restoring function lost through injury, illness or disease. Now in the 21st century, the essence of physiatry is the evaluation, treatment and rehabilitation of nerve, muscle, bone and joint conditions. Some of the more common conditions we see are the various regional pain disorders: back, neck, upper and lower extremity pain; myofascial pain syndrome; fibromyalgia syndrome; tendonitis, bursitis and arthritis; sprains and strains; and athletic, work and auto injuries. Physiatrists routinely treat nerve entrapments such as carpal tunnel syndrome, ulnar neuropathy and footdrop; central nervous system disorders, including stroke, cerebral palsy, multiple sclerosis, traumatic brain injury, encephalopathy and spinal cord injury; neuromuscular conditions such as polio, muscular dystrophies and peripheral neuropathy; and limb amputations.

In recent years, the range of available treatments under PM&R at SJMHS has expanded to include prolotherapy, ultrasound guidance, medical acupuncture, viscosupplementation, botulinum toxin therapy and intrathecal baclofen therapy. This article will outline the highlights of these treatments, which have significantly enhanced our ability to promote healing and improved function in our patients.


This treatment is indicated for lax ligaments, joint capsule and tendons. Irritants—dextrose and saline—are injected into ligament and tendon structures. This creates an inflammatory reaction that stimulates the healing process. New collagen is laid down, strengthening the lax soft tissues, and leading to decreased joint pain and increased functional mobility.

Ultrasound Guidance

The use of ultrasound to guide injections of joint, bursa, tendon sheath, muscle and nerve can greatly enhance the precise placement of cortisone, PRP and other agents in the targeted tissues.

Medical Acupuncture

This ancient Chinese method is used in PM&R to treat chronic pain syndromes and to promote function. Needles are inserted at precise acupuncture sites, and then heat or electrical stimulation is applied. The classical Chinese explanation of acupuncture’s mechanism is the release of obstructions in the energy “meridians” that flow through the body and along its surface. The modern scientific explanation is the stimulation of endorphins, hormones and neurochemicals, resulting in analgesia, emotional well-being and promotion of healing.


This treatment is indicated for mild to moderate osteoarthritis of the knee. It involves the injection of supplemental synovial fluid, which provides lubrication and shock absorption for the joint. A series of 1–5 injections may be required, depending on the patient’s clinical/functional situation and the specific agent. Outcomes include pain score reduction and improved tolerance of daily activities.

Botulinum Toxin Therapy

Although botulinum toxin receives much media coverage for its cosmetic applications, we use this agent in PM&R to manage dystonia and spacticity. Common dystonias include spasmodic torticollis, writer’s cramp and hemifacial spasm. Spasticity is a velocity-dependent increase in muscle tone caused by upper motor neuron disorders such as stroke, cerebral palsy, traumatic brain injury and multiple sclerosis. Botlinum toxin, injected intramuscularly with EMG guidance, binds to motor nerve endings at the neuromuscular junction, inhibiting the release of acetylcholine and thereby decreasing muscle tone. It is a useful adjunct to other spasticity treatments, including oral medications, orthoses and therapeutic exercise. The duration of effect is typically three to four months after each injection.

Motor Point Blocks

Another agent used by physiatrists for decades to treat spasticity is phenol. When injected into motor points or pure motor nerve branches, this alcohol causes demyelination and denervation, resulting in significant and sustained reduction in muscle spasticity.

Intrathecal Baclofen Therapy

For patients with severe muscle spasticity involving multiple muscle groups, ITB therapy is an established treatment approved by the FDA in 1982. Baclofen is a GABA agonist which works at the spinal cord level. The intrathecal route of delivery avoids the sedation and generalized weakness which can be experienced by patients taking oral baclofen. The first step is a one-day ITB trial, consisting of a lumbar puncture and administration of an intrathecal bolus of baclofen, followed by several hours of serial examinations and monitoring. If the trial is successful, the patient is scheduled for ITB pump implantation by Neurosurgery, after which the pump is managed, adjusted and periodically refilled by the PM&R team.

Other Established PM&R Services

Electrodiagnostic evaluation—electromyography and nerve conduction studies—has been an integral part of PM&R since the 1950s. Other standard physiatric treatments include cortisone injections of trigger points, joints, bursae and tendon sheaths, instruction in tailored individual exercise programs and functional assessments. Physiatrists routinely assist injured workers and their employers to facilitate successful return-to-work strategies. PM&R doctors also are experts in the prescription of orthotics, prosthetics, assistive devices, wheelchairs and other DME.

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