Transcript The Role of Physiatry in Occupational Medicine

The Role of Physiatry in
Occupational Medicine
January 31, 2013
James Petros, M.D., Q.M.E.
Board-Certified, Physiatry
Board-Certified, Pain Medicine
Board-Certified, Internal Medicine
A little bit about Dr. Petros…

Curriculum Vitae
What is a Physiatrist?

Specialist in physical medicine and
rehabilitation (PM&R)

physikos – “physical”
iatreia – “art of healing”

Integrates functional medicine, orthopedics,
neuroscience, pain management, therapeutic
rehabilitation

Nonsurgical

Address muscles, nerves, bones, joints,
tendons, ligaments

Functional restoration

“Quality of life”
“Over 95% of occupational
injuries never require surgery”
Origins of Physiatry

Formed in the 1930s to address neuro-musculoskeletal problems

Grew drastically during WWII

Approved as a specialty of medicine in 1947
Physiatry: The “Broad” Specialty
 Pain management
 Musculoskeletal
 Electrodiagnosis
 Spinal cord injury
 Traumatic brain injury
 Amputation, Orthotics,
 General rehab
 Sports
 Industrial
Prosthetics
What Sets Dr. Petros Apart in Work
Comp?



Triple-board certification
Diverse skill set
Refined knowledge and
experience
 UR work
 AME/QMEs
 Case load






Attention to detail
RTW approach
“Make each visit count”
“A-Z” mindset
Manage and salvage
most complicated claims
Resources at Alliance
Other Important factors…




Compassion
Advocacy
Rapport
I love what I do
Conditions Treated









Low back pain
Mid back pain
Neck pain
Herniated disc
Spinal stenosis
Lumbar radiculopathy
(sciatica)
Facet syndrome
Sacroiliac dysfunction
Whiplash syndrome










Repetitive stress injuries
Shoulder/elbow/hand problems
Hip/knee/foot problems
Myofascial/muscle pain
Carpal tunnel syndrome
Cubital tunnel syndrome
Neuropathic (nerve) pain
Arthritis
Post-surgical pain
Headaches
My Specialized Skills







Diagnosis
Medication optimization
Therapy
Interpretation of X-rays & MRIs
Peripheral joint, muscle, bursa, tunnel, and
nerve injections
Spinal procedures under fluoroscopy
Electrodiagnosis
Spinal Procedures




Epidural Steroid
Injections (ESIs)
Facet Medial Branch
Blocks
Facet Intra-articular
Injections
Facet Radiofrequency
Rhizotomy





Sacroiliac Joint
Injections
Sympathetic Ganglion
Blocks
Piriformis Muscle
Injections
Discograms
Trigger point
injections
Showcase
Epidural Steroid Injections (ESIs)
 Facet Joint Procedures
 EMG/NCS

Medical Criteria for ESIs
1)
2)
Persistent radiculopathy
Inflammation related to:
 Spinal
disc herniation (“discogenic pain”)
 Degenerative disc disease
 Spinal stenosis
What is Radiculopathy?
Spinal condition
 Compressed nerve root
 Pain, numbness, tingling, or weakness
along the course of the nerve

Risk Factors for Radiculopathy?
Excessive or repetitive load on the spine
 Aging
 Obesity
 Smoking
 Family history

Causes of Radiculopathy?
Disk herniation
 Inflammation from trauma or degeneration
 Bone spur (osteophytes)
 Tumor
 Infection
 Scoliosis
 Diabetes

Goals Following ESIs
Reduce pain/tingling/numbness/weakness
 Restore range of motion
 Facilitate progress in more active
treatment programs
 Avoid surgery

“Based on the evaluation of multiple
randomized and non-randomized trials,
transforaminal epidural injections provide
strong evidence for short-term and longterm relief.”
Manchikanti L, et al. Evidence-based practice guidelines for interventional techniques
in the management of chronic spinal pain. Pain Phys 2003;6:3-81. [1175 references].
Transforaminal Epidural Injection
Showcase
Epidural Steroid Injections (ESIs)
 Facet Joint Procedures
 EMG/NCS

Facet Joint Anatomy
Facet Mediated Pain








“Facet syndrome”
30-50% of cases we see
Causes: abnormal spinal loading, trauma, inflammation,
degeneration, fracture
Diagnosis requires clinical suspicion
Focal tenderness over joint
Pain exacerbated by extension of spine (closing of facet
joints)
MRI may be normal
Treatment mainstays: education, medications, therapy
Facet Procedures

Diagnostic
 Medial

branch blocks
Therapeutic
 Intra-articular
steroid injection
 Radiofrequency Ablation (Rhizotomy)
Lumbar Medial Branch Block
“Combined evidence of the medial branch
blocks from one randomized trial,
complimented with two non-randomized trials
(one prospective and one retrospective
evaluation) provided strong evidence of shortterm relief.”: Manchikanti L, et al. Evidencebased practice guidelines for interventional
techniques in the management of chronic
spinal pain. Pain Phys 2003;6:3-81. [1175
references]”
Intra-Articular Facet Injection
Radiofrequency Ablation (Rhizotomy)
Showcase
Epidural Steroid Injections (ESIs)
 Facet Joint Procedures
 EMG/NCS

Electrodiagnosis

Electromyography (EMG)

Nerve conduction studies (NCS)
Originated in 19th century
More consistently used over last 3040 years
Extension of physical exam
Evaluate integrity of peripheral
nervous system
EMG/NCS – FREQUENTLY ASKED QUESTIONS
What does the EMG/NCS test?
The EMG/NCS study examines the integrity of the peripheral nerves and muscles of
the body. The study does NOT examine the brain or spinal cord. It is important to
realize that you can have a nerve or muscle problem, even though you may not “think”
you have any nerve or muscle problems. This test does NOT measure pain. You may
have a normal EMG-NCS study, even though you have severe pain.
What are the different parts of the study?
The study is usually done in two parts: (1) NCS, and (2) EMG (i.e. “needle” exam).
How long is the study?
Each EMG/NCS study varies from patient to patient, depending on what results are
obtained. As such, the study may take as little as 20 minutes, or as much as 2 hours.
What is the Nerve Conduction Study or NCS?
The NCS involves examining the nerves in your arms or legs. This consists of
attaching wires to the surface of your skin, and administering a small “shock” to see
how well the nerves react and function. These results are monitored on a computer.
What is the Electromyography or EMG?
The EMG examines the muscle activity in your body. This study consists of inserting a
sterile, individually wrapped, needle into your various muscles and monitoring their
activity. These results are monitored on a computer. You will probably be stuck 5-7
times per arm or leg. There is NO shocking during the EMG.
Is the EMG or NCS painful?
The “shocks” during the NCS are not painful, although they may produce a tingling
sensation. The needle “sticks” during the EMG feels like a small ant bite, and can
sometimes be uncomfortable, but not painful.
Utility of EMG/NCS






Establish correct diagnosis
Screen for other conditions
Determine acuity vs. chronicity
Localize lesion
Determine treatment
Prognosticate
When to Consider EMG/NCS?
Pain
 Numbness
 Tingling
 Weakness
 Atrophy
 Fatigue

Electrodiagnostic Protocol


NCS
 Upper: median, ulnar, radial
 Lower: tibial, peroneal, sural, superficial peroneal
EMG
 Upper: cervical paraspinals, deltoids, biceps, triceps,
pronator teres, 1st dorsal interosseous, abductor
pollicis brevis
 Lower: lumbar paraspinals, gluteus medius, biceps
femoris, vastus medialis, tibialis anterior,
gastrocnemius
Test Segments
NCS




Latency
Amplitude
Conduction velocity
Signal quality
EMG (needle)




Spontaneous electrical
activity
Insertional activity
Waveform shape
Recruitment patterns
•
•
•
Examples of Electrodiagnoses


















Alcoholic neuropathy
Amyotrophic lateral sclerosis
Axillary nerve dysfunction
Becker's muscular dystrophy
Brachial plexopathy
Carpal tunnel syndrome
Centronuclear myopathy
Cervical spondylosis
Charcot-Marie-Tooth disease
Chronic Immune Demyelinating
Poly[radiculo]neuropathy (CIDP)
Dermatomyositis
Duchenne muscular dystrophy
Facioscapulohumeral muscular dystrophy
Familial periodic paralysis
Femoral nerve dysfunction
Friedreich's ataxia
Guillain-Barre
Lambert-Eaton

















Mononeuropathy
Motor neuron disease
Multiple system atrophy
Myasthenia gravis
Myopathy (muscle degeneration, which may
be caused by a number of disorders,
including muscular dystrophy)
Myotubular myopathy
Neuromyotonia
Peripheral neuropathy
Poliomyelitis
Polymyositis
Radial nerve dysfunction
Radiculopathy
Sciatic nerve dysfunction
Sleep bruxism
Spinal stenosis
Tibial nerve dysfunction
Ulnar nerve dysfunction
Case Study
44 y.o. male
 Generally healthy
 Limousine driver
 MVA on the job
 Vehicle totaled


Immediate Symptoms
 Dazed
and confused (no LOC)
 Headaches
 Neck Stiffness
 Generalized soreness
EMS activated on the scene
 ER

 Non-focal
neuro exam
 C-spine X-rays (negative)
 Head CT scan (negative)
 Discharge to home with neck brace, NSAIDs,
muscle relaxers, and Vicodin

Next Day
 Neck
pain (main complaint)
 Headaches
 Mid back pain
 Low back pain
 Right knee pain

Patient referred to AOM
AOM Care (Day #3)

Additional x-rays
 Thoracic
spine: Negative
 Lumbar spine: Negative
 Right knee: Negative

Diagnoses:
 C/T/L
strains due to whiplash
 Right knee sprain from impact with dashboard
AOM Care (Day #3)

Plan
 Physical
therapy
 HEP
 NSAIDs,
muscle relaxers
 RTC 2 weeks
AOM Care (Day #17)
Mid back pain resolved
 Low back pain resolved
 Right knee pain resolved
 Neck pain worse

 RUE
paresthesias
Neck ROM decreased
 Weak triceps
 Right Spurling’s positive

AOM Care (Day #17)

Plan
 Add
Vicodin
 Start chiropractic
 No driving
 RTC 2-3 weeks
AOM Care (Day #33)
Worsening neck pain and headaches
 Neck pain radiating stronger into RUE
 Neck ROM still limited
 Weak elbow extension
 Right hand dorsal numbness
 Spurling’s still positive

AOM Care (Day #32)

Plan
 Continue
medications
 Hold therapy
 Refer for C-spine MRI
 Refer to Physiatry
Multilevel Disk Herniations
Dr. Petros Care (Day #42)





Records reviewed
History confirmed
Exam findings validated
 Add: TTP over right facets
MRI reviewed
Diagnoses
 Right cervical radiculopathy
 Superimposed cervical strain
 Cannot exclude cervical facet syndrome
Dr. Petros Care (Day #42)

Plan
 Refer
for EMG/NCS
Confirm radiculopathy
 Determine location of active lesion
 Establish target(s) for intervention
 Rule out peripheral neuropathy

Dr. Petros Care (Day #53)

EMG/NCS
 Right
C6-C7 radiculopathy
 No other neuropathy

Refer for trial of C6-C7 ESI
Dr. Petros Care

CESI authorized
 Performed
on Day #70
Dr. Petros Care (Day #84)
Right arm symptoms completely gone
 Neck pain still present
 Neurologic exam normalized
 ROM improved but still restricted

Dr. Petros Care (Day #84)

Plan
 Trigger
point injections
 Repeat PT
 HEP
 Meds as needed
 Full duty trial
 RTC 1-2 weeks
Dr. Petros Care (Day #90)

Unwavering right neck pain
 Down
into top of shoulder blade
Intermittent headaches
 Exam unchanged

What a pain in the neck!

What else is going on?
 Cervical
facet syndrome?
Dr. Petros Care (Day #90)

Request authorization for diagnostic right
C4-C5 medial branch blocks
Dr. Petros Care

Cervical medial branch blocks performed
on Day #100
 100%
relief of symptoms for 3 full days
 Patient happiest he has been in a long time
Dr. Petros Care (Day #105)

Request authorization for rhizotomy (RFA)
Dr. Petros Care

Rhizotomy performed on Day #120
 Successful
procedure
 Patient asymptomatic
Permanent & Stationary
(Day #134)
MMI (back to pre-injury status)
 No impairment
 Full duty
 No need for future medical

Summary

Physiatry offers cost-effective and
knowledgeable orchestration of expert
diagnostics and treatment

Surgery is always considered a last resort

Able to get workers back on the job (and to full
duty) safely and quickly
THANK YOU!
… Questions?