Download Thinking, knowing and feeling with the hands

Start simple with thoughts of good intention. Sometimes even a
thoughtful and caring touch can be more healing than you might imagine.
Thinking, knowing and
feeling with the hands
By Constance Young,
Freelance Medical Writer
A
OA Health Watch
interviewed physiatrist
Rebecca Fishman, DO,
about the osteopathic physiatrist’s
role in helping patients with diabetes
who have neuromusculoskeletal
complications. In this article, Dr Fishman
expounds on the tools osteopathic physiatrists
use in diagnosis and treatment.
18 AOA Health Watch
DOs Against DIABETES January 2009
Dr Fishman is program director
of the Osteopathic Physical Medicine
and Rehabilitation Residency Program
at Long Beach Medical Center, Long
Beach, NY. Launched three years ago,
the curriculum includes osteopathic
manipulative treatment where OMT
is incorporated into the treatment of
both inpatient and outpatient physiatry
services. Dr Fishman also has a private
practice in Lawrence, NY, on Long Island.
occupational, physical and speech
therapists, psychologists, orthotists, social
workers, nurses, vocational counselors
and other valuable healthcare providers.
Physiatrists are trained to evaluate
and manage diabetic complications,
including neuropathy, adhesive
capsulitis, Dupuytren’s contractures,
carpal tunnel syndrome, trigger fingers,
Charcot’s joints, peripheral vascular
disease, chronic regional pain syndrome,
calcific tendonitis, neurogenic bladder,
pressure ulcers, amputations, sexual
dysfunction and many other possible
diabetic complications.
What is the greatest obstacle to
successful diabetes management?
Dr Fishman: Misinformation and a
lack of patient education. Many patients
accept popular myths, as do some
referring physicians. Some diabetics,
like some patients in the general
population and some MDs, do not fully
understand the role of a DO, let alone a
DO who is trained in physiatry. I find that
patients often get their information by
talking to friends or visiting the Internet,
which can be either quite informative or
provide inaccurate information.
What is the role of the physiatrist in
managing diabetes mellitus patients?
Dr Fishman: Physiatrists are trained
to rehabilitate the effects of all
disease processes that compromise
an individual’s function. Our goal is to
increase the patient’s physical potential
and therefore quality of life. Because
diabetes can affect nearly every organ
system, patients would benefit from
having a “team” of physicians and
healthcare providers evaluate and
routinely treat diabetes patients.
While physiatrists in particular,
are trained to evaluate and treat
neuromusculoskeletal dysfunctions,
we coordinate and prescribe the
most appropriate therapies with other
“team members.” This might include
January 2009 DOs Against DIABETES
Are people with diabetes susceptible to
more musculoskeletal complaints than
people without diabetes as they age?
Dr Fishman: Yes, absolutely. But
not all diabetes patients progress to
having an associated musculoskeletal
dysfunction. However, to avoid such
dysfunctions, patients with diabetes
need tight glucose control. Even with
tight control, some patients still progress
to develop complications, and many
of these are neuromusculoskeletal.
Are there any musculoskeletal
complications that set off alarm bells
for you? Things that patients themselves
might not realize how important they
are to diagnose and treat?
Dr Fishman: All the musculoskeletal
conditions I mentioned can be
detrimental to a patient’s quality of life.
A physiatrist’s role is to maximize a
patient’s functional potential. We look at
everything, but in diabetes particularly
focus on conditions that we can prevent.
Obviously, peripheral neuropathy is a
common complication of diabetes that
causes numbness or other paresthesias
which can be annoying to the patient
and also result in injuries. Because of
the lack of sensation often associated
with complicated diabetes, physicians
should be aware of “silent cardiac
ischemia” and obtain cardiac clearance
prior to starting exercise programs
in individuals at risk. Additionally,
precautions regarding thermal
modalities should be clearly written
on physical and occupational
therapy prescriptions.
Although diabetes may be
controlled with appropriate intervention,
there are many people who will
develop complications. Therefore, it
is recommended that patients have a
baseline analysis of their musculoskeletal
system in consultation with a physiatrist,
even when not symptomatic.
Are the musculoskeletal complaints
generally due directly to the diabetes
or due to the obesity that is common
in type 2 diabetes?
Dr Fishman: Obesity is a common
finding in type 2 diabetes, which could
lead to issues such as osteoarthritis.
Patients with type 2 diabetes often have
an increased frequency and earlier onset
of severe osteoarthritis, which may not
be caused by diabetes directly, especially
in early stages, but is associated with
obesity.
Are there any other issues that are
more directly related to the diabetes?
Dr Fishman: Peripheral neuropathy
and Charcot’s joints, also known as
neuropathic joints, are joints—
particularly in the foot and ankle—
with severe degenerative destruction.
Neuropathic joints can hinder a person’s
ability to walk because there is a lack
of sensation and proprioception.
Such patients will not feel microtraumas
that cause small fractures. Because
they can’t feel the movement, ligaments
in the foot become lax and the bones
tend to degenerate. Patients can have
severe deformities without feeling them.
AOA Health Watch 19
When should a primary care
physician consider referring a patient
with diabetes to a physiatrist?
Dr Fishman: Because our training
addresses the evaluation and treatment
of all of the neuromusculoskeletal
complications associated with diabetes,
it is my opinion that all diabetes patients
should have a baseline evaluation.
Asymptomatic diabetes patients
should have annual follow ups and
timely referrals for all neuromusculoskeletal complaints. The
physiatrist can continue to treat a
patient with diabetes at every stage
throughout the disease process.
How do you arrive at your diagnosis?
Dr Fishman: We are not usually the
first provider to diagnose the patient,
since people with diabetes usually come
to us with complications of diabetes.
However, I do see some patients who
first present with complaints of
numbness, tingling and painful joints,
or any of the other diabetes-associated
complications.
Before I do an EMG on these
patients, because it can be a painful
test, I often start with physical therapy
and obtain necessary blood work.
If I suspect a patient has diabetes,
as a healthcare team member I would
send that patient either to a primary
care doctor, such as an internist, or
endocrinologist for the workup, while
I focus on the rehabilitative issues
for the diabetes complication.
Are there certain musculoskeletal
analgesics and muscle relaxants
that are better to use in patients
with diabetes than others?
20 AOA Health Watch
Dr Fishman: The medications
I prescribe are always based on
an individual’s needs or limitations.
For example, I would use pregabalin,
duloxetine hydrochloride and
gabapentin for neuropathic pain
and paresthesias. And, if treating
muscle spasms, I would use a less
sedative muscle relaxant like metaxalone
if balance and proprioception are
impaired. I would use corticosteroids
with caution as they can transiently
raise glucose levels. When deemed
necessary for joint pathology,
I always warn patients of this
possible complication which usually
lasts approximately 48 hours.
Those are the medications
I tend to use first.
If a primary care physician suspects
a diabetes patient has a neuropathy,
how would the care of a physiatrist
differ from that of a neurologist?
Dr Fishman: Physiatrists are
trained to evaluate and manage
diabetes complications, whether it
be neuropathy—which of course is
what a neurologist would address as
well—and all other non-neurological
complications such as those mentioned
earlier. It is important to remember
that not all neurological complications
of diabetes patients are due to
peripheral neuropathy.
Is it safe to say that most
osteopathic physiatrists use OMT
in patient management whether
or not patients have diabetes?
Dr Fishman: No, unfortunately they
do not all use it. I imagine today’s time
restraints and the possible lack of
OMT practice in many of the residency
programs would deter DOs from using
their special skills. I have found that
even two minutes of simple myofascial
techniques can make a difference for
a patient. No one should let their lack
of technical confidence get in their way.
Start simple with thoughts of good
intention. Sometimes even a thoughtful
and caring touch can be more healing
than you might imagine.
Not only is having the training to
perform OMT very beneficial in the
treatment of musculoskeletal complaints,
but so is our increased diagnostic ability.
Our exceptional training as DOs has
prepared us to utilize thinking, knowing
and feeling hands. It was a gift bestowed
upon me by my exceptional osteopathic
mentors, including Stanley Schiowitz,
DO; Dennis J. Dowling, DO; Claudia L.
McCarty, DO; Richard M. Bachrach, DO
and many other incredibly gifted teachers
and osteopathic physicians. It is the tool
that I use every day. They, in the true
sense of osteopathy, have taught me to
listen to my patients, not only with my
ears, but with my hands and my heart. HW
DOs Against DIABETES January 2009