What to expect on your appointment

Your care in our office will be comprehensive, and based on the entirety of the training and experience of Dr. Schulman.

Your initial visit: a comprehensive consultation and exam

The initial appointment for all patients is a one-hour consultation and exam conducted personally by Dr. Schulman.

The visit begins with an interview covering the following topics:

• comprehensive personal health history
• discussion of current health issues
• discussion of past medical and surgical problems
• review of prior diagnostic tests
• “review of systems” (questions regarding the health of the entire body)
• discussion of psychosocial issues
• family health history
• obtaining of names and phone numbers of prior and current doctors
• review of current and recent medications and supplements with attention to possible interactions
• diet, including intake of caffeine, alcohol, refined carbohydrates

Following the interview, a physical examination is conducted.

At the end of the initial visit, Dr. Schulman makes recommendations for further diagnostic testing, treatment, and referral to appropriate providers.

In most cases, treatment is not provided during the initial visit. If you would like to have a treatment immediately following the initial visit, please let us know so that we can block out a larger period of time in the schedule.

What we look for

Many of our patients present with acute and chronic pain problems. In distinction from more procedure-based, interventional pain management practices, we take a holistic view of pain issues and consider multiple possibilities. We routinely assess for the following:

• Clues in the patient’s health history
• Patterns of pain in daily activities
• Motor patterns and posture
• Review of prior diagnostic studies for adequacy
• Laboratory tests that investigate the possibility of metabolic, infections or inflammatory processes that might be the source of the pain
• Laboratory tests for Lyme disease, vitamin/mineral deficiencies, and digestive dysfunction

Pain:

Pain can be caused by a variety of conditions. These conditions may be structural (intervertebral disc herniation), infections (Lyme disease), metabolic (diabetic neuropathy) or emotional (the affective component of pain). A patient’s history begins to reveal where to look. For example, a person with low back pain that radiates down both legs, is worse with walking and better with rest, is quite likely the result of lumbar spinal stenosis, (narrowing of the central vertrebral canal). On the other hand, low back pain that is better with walking, radiates down one leg, and causes numbness in the foot is more likely the result of a disc herniation. Low back pain that radiates into the groin, and is worse after prolonged sitting, may be the result of arthritis in the hip.

In some instances, the pain may occur at a site distant to the actually injury. For example, carpal tunnel syndrome (a pinched nerve in the wrist) may cause pain in the shoulder and arm. Hip arthritis commonly causes pain in the knee and there may be little to no pain in the hip itself.

Even when there is a structural component causing the pain, such as a disc herniation, the emotional environment of the patient plays a tremendous role in the coping and perception of the pain. This is known as the affective component. A patient may have a disc herniation, but also terrible trouble with his or her spouse. The solution in this case may be a divorce, not surgery!

A review of prior diagnostic studies and treatments is crucial toward understanding a given patient’s problem. In one instance, a patient came to Dr. Schulman with hip pain. Upon examination, the passive range of motion in her hip was clearly and markedly abnormal. She had had an MRI of the pelvis, ordered by her Internist, which was read as a normal hip. However, her Internist was unaware that an MRI of the pelvis is not the same study as an MRI of the hip. An MRI of the hip was performed, and revealed a large tear in the soft tissue (labrum) surrounding the socket (acetabulum). In another example, a patient had hip pain for almost one year. An MRI had revealed bursitis, however the pain was not responsive to treatment after many months. A second MRI of the hip was performed at a facility with more experience in musculoskeletal imaging. This scan revealed a benign bone tumor.  The tumor was treated quite easily, and the pain resolved in a matter of days.

Many times over the past ten years Dr. Schulman has seen patients with chronic problems who had been treated for Lyme disease. However, often the length of antibiotic treatment for the Lyme disease was insufficient. Blood tests in these cases often reveal signs of chronic infection, and a few months of oral antibiotics may be all that is needed to alleviate the symptoms. In one case, Dr. Schulman treated a patient who had been bed ridden on disability for the greater part of a year. Her Lyme disease was in fact still active (although she had been told that it was not). After two months of antibiotics, she was able to return to work, and stop all of the medication she had been on.

Sometimes the source of pain may be metabolic or nutritional. Vitamin D and vitamin B12 deficiency are often involved in painful conditions. Digestive disorders such as Celiac, Crohn’s and Ulcerative Colitis may also be responsible for musculoskeletal pain.

Medical treatment is a team effort. Physiatrists are particularly aware of this, as it is an integral part of our training. Coordination of care between the various treating physicians, therapists, family members, and even pharmacists is often necessary to create the best outcomes and alleviation of a patients symptoms and suffering.