Transcript PPS - Alliance Occupational Medicine

Pain Management Methodology
in Occupational Medicine
James Petros MD
Physical Medicine & Rehabilitation
Internal Medicine
Qualified Medical Evaluator
General Goals
• Alleviate pain
• Increase function
• Return to work
• Fully duty
• Stay at work
Guiding Principles
• Investigate exhaustively
• Diagnose clearly
• Treat systematically
Begin the Investigation
• History
• Physical
• Assess urgency of pain
• Differential diagnoses
Workup
• Labs
• X-rays
• CT scans
• MRIs
• EMG/NCS
• Diagnostic blocks
Pain Management Tools
• Education
• Medications
• Supplies
• Therapy
• Procedures
• Surgery
Education
• Etiology
• Prognosis
• Set realistic expectations
• Answer questions
• Teach coping strategies
• Review home exercise program
• Reassurance?
Medications
• NSAIDs
• Tylenol
• Muscle relaxers
• Opiates
• Adjuvants
• Antidepressant (e.g. amitriptyline)
• Anticonvulsants (e.g. neurontin)
• Alpha-2-adrenergic agonists (e.g. zanaflex)
• Steroids
Supplies
• Extremity splints
• Cervical orthotics
• Lumbar orthotics
• Ambulatory devices
• TENS units
Therapy
• Physical
• Occupational
• Chiropractic
• Acupuncture
• HEP (home exercise program)
Procedures
• Trigger point injections
• Peripheral joint cortisone injections
• Spine intervention under fluoroscopy
Surgery
• Refer immediately for urgent cases
• Consider referral if no progress with conservative care
• Last resort
Case Study #1
• 38 y.o. Female
• Receptionist/secretary at Company ABC
• 2-month history of intermittent right wrist, forearm, and
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elbow aching
Patient consults with own PCP
Diagnosed with “tendonitis”
Advised about possibility of work-related injury
Injury reported to employer
Patient referred to AOM
AOM Evaluation Begins
• Right-hand dominant
• Symptoms began gradually
• Symptoms are worsening
• Increased pain with typing, lifting, pinching/grasping
• Decreased pain with rest
• 5 out of 10 pain intensity at end of work day
• Occasional tingling/numbness at right hand
• Starting to drop objects with right hand
More History
• Past Medical History
• Hypothyroidism
• Occupational History
• No previous work comp claims
• Working full-time performing secretarial duties
• No work restrictions
• Ergonomics evaluation several months ago
• Previous Injuries
• Right wrist fracture from skiing accident 5 years ago
• Past Surgical History
• “Right wrist operation” 5 years ago (no residual
symptoms)
• Allergies
• “Ibuprofen upsets my stomach”
• Medications
• Thyroid supplements
• Not using pain meds (“I don’t really like to take pain
meds”)
• Social History
• Recently divorced
• 2 year old daughter at home
• No tobacco abuse
• No illicit drug use
• “Drink a couple of glasses of red wine each night to help
ease my mind and help me sleep”
• Review of systems
• Poor sleep
• Daily fatigue
• Low energy
• Stressed
• “Feeling down”
Initial Physical Examination
• No atrophy at upper extremities
• Slight tenderness over right wrist
• Moderate tenderness to palpation over right forearm
extensors and lateral compartment of right elbow
• Full range at all RUE joints
• Neurologic exam negative
• Tinel’s and Phalen’s negative at right wrist
Working Diagnoses
• Right wrist tendonitis due to occupational overuse
• Right forearm strain due to occupational overuse
• Right elbow tendonitis due to occupational overuse
Conservative Management Begins
• Referred to physical therapy x 6 sessions
• Provided with Biofreeze
• Patient declines naproxen (NSAID)
• Accepts soft wrist splint
• Kept on full duty
• Asked to sign release of non-industrial medical records
• Asked to follow-up in 2 weeks
Non-Industrial Medical Record
• 2004 skiing accident caused fracture of distal radius
• Successful ORIF performed
• Hypothyroidism x10 years
• Treated with levoxyl
• No mental health notes
Case Age: Day #14
• Completed 6 session of PT
• No noticeable improvement
• Tingling and numbness becoming more prominent at right
thumb and index finger
• Aching at wrist, forearm, and elbow taking longer to
dissipate with rest
• Symptoms starting to awaken patient from sleep
Treatment Plan
• PTP once again proposes NSAIDs
• Patient refuses
• More Biofreeze provided
• Rigid wrist splint provided for night use
• 6 more sessions of PT prescribed
• Work restrictions started
• Minimal grasp/pinch with right upper extremity
• No lifting over 15 lbs with right upper extremity
• Limit typing to 4 hrs/day
• RTC in 2 weeks
Case Age: Day #28
• No changes in clinical condition
• Aching, tingling, numbness, and hand weakness persist
• Feeling more “depressed”
• No interest in oral medication
• Working light duty
• Continuing to use splints and Biofreeze
Treatment Plan
• Request authorization for transfer of care to Physiatric
Specialist
Case Age: Day # 40
• Comprehensive Physiatric Consultation
• All records reviewed
• Outside records
• AOM provider notes
• PT notes
• Medication logs
• History
• Physical
• Treatment plan
• History
• Details of cumulative injury confirmed
• New info: “Dad passed away 6 months ago”
• Physical exam
• Pain with palpation of right lateral epicondyle
• Positive right Cozan’s test
• Pain with palpation of right dorsal forearm musculature
• Full ROM at wrist and elbow
• Positive Phalen’s on right
• Negative Tinel’s on right
• Positive carpal compression test on right at 10 seconds
Case Highlights
• Mechanism of injury is related to “overuse” from
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occupational tasks
Patient has hypothyroidism
Patient has history of right wrist fracture s/p surgery
Patient has “depressed” mood in context of family death
Last ergo evaluation was “several months ago”
Patient is opposed to oral pain relievers
Patient is not improving with conservative care
Presentation is concerning for right lateral epicondylitis
and possible peripheral nerve entrapment
My Initial Approach
• Discuss patient’s resistance to pain medications
• Side effects?
• Fear of addiction?
• Philosophical?
• Aversion to pills by mouth?
• Review home exercise program
• Frequency
• Duration
• Specific exercises performed
• Demonstration
• Educate
• Differential diagnoses
• Need for future tests
• Need for procedures
• Prognosis
• Answer questions
Questions I Would Ask Myself
• Are working diagnoses still legit?
• Can I find a medication that would be acceptable by
patient?
• Is further therapy needed? What kind?
• Are other supplies needed?
• Is further diagnostic testing necessary?
• Are injections needed?
• Is this potentially a surgical case?
• Is another ergo evaluation needed?
• Should work restriction be adjusted?
• Has patient sought out support for mal-adjustment to
father’s passing?
Back to Case…
• Patient states that she is afraid of becoming dependent
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on oral pain meds and concerned about GI upset
Agrees to try topical Voltaren Gel
Admits to slacking on home exercises but agrees to
perform more routinely
Referred for wrist X-ray
Referred for EMG/NCS
New ergo evaluation is requested
Counterforce tennis elbow brace is provided
No changes in work restrictions
Asked to see own PCP for mental health referral
Right Wrist X-ray
• Well-healed callus at distal radius
• No acute pathology
EMG/NCS
• Electrodiagnostic evidence of sensorimotor median
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mononeuropathy at right wrist, consistent with mildmoderate carpal tunnel syndrome at right wrist
No electrodiagnostic evidence of ulnar mononeurpathy
No electrodiagnostic evidence of radial mononeuropathy
No electrodiagnostic evidence of brachial plexopathy
No electrodiagnostic evidence of polyneuropathy
No electrodiagnostic evidence of myopathy
No electrodiagnostic evidence of cervical radiculopathy
Case Age: Day #52
• Patient returns for scheduled follow-up
• “Mild” improvement
• New ergonomic set-up at work
• Receiving psychological counseling thru Kaiser
• Voltaren gel helping to “take edge” off symptoms
• Using soft/rigid wrist splints and elbow brace
• HEP has become routine daily activity
• Exam is unchanged
• Informed about X-ray results
• Informed EMG/NCS results
Next Treatment Steps
• Recommend cortisone injection to right elbow
• Patient acquiesces
• Consent obtained
• 10 mg of Kenalog injected to right lateral epicondyle
• Refer to acupuncture x 6 sessions
• Start to loosen work restrictions
• RTC 10 to 14 days
Case Age: Day #62
• Patient returns ecstatic about dramatic resolution of
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right elbow pain
No further forearm pain
Self-discontinued acupuncture
Paresthesias at right hand now rare
Exam has normalized
Next Treatment Steps
• Cortisone injection offered for right carpal tunnel, but
patient declines
• Continue HEP, wrist splints, Voltaren gel prn
• Full duty trial
• RTC 1-2 weeks
Case Age: Day #70
• Tolerating full duty
• Generally asymptomatic
• Maximally medically improved
• Permanent and Stationary
Worker’s Compensation Issues
• Causation
• Lateral epicondylitis
• Overuse
• Carpal tunnel syndrome
• Overuse
• Hypothyroidism
• History of wrist fracture
• Apportionment
• Apportion to causation (not required in this case)
• Impairment
• 0% WPI
• Future medical
Case Study #2
• 50 y.o. Male
• Works in ‘Shipping & Receiving’ at Company XYZ
• Gradual-onset of escalating LBP during heavy repetitive
lifting of boxes at warehouse
• Patient completes shift
• Goes home and starts taking Motrin
• Next morning:
• Unable to get out of bed
• Back pain is severe
• Right leg and foot have tingling/numbness
• Right leg feels heavy
• Worker’s Comp Claim opened
• Referred to AOM
AOM Evaluation Begins
• Symptoms are constant
• 50% at mid/right low back
• 50% at posterior thigh, calf, lateral foot
• Pain intensity: 7 out of 10
• No bowel/bladder problems
• Pain increased with lifting and bending forward
• Pain decreased with rest and Motrin
• Past Medical History
• Hypertension
• GERD
**No history of low back pain
• Occupational History
• No previous work comp claims
• Has worked full-time at Company XYZ for 15 yrs.
• Previous Injuries
• None reported
• Past Surgical History
• None
• Allergies
• None
• Medications
• Mortin 400 mg BID
• Norvasc 5 mg daily
• Social History
• No tobacco/alcohol/illicit drug abuse
• Married with kids
• Rare exercise
• Review of Systems
• Poor sleep; otherwise unremarkable
Initial Physical Examination
• Mild distress
• BP 125/80
• Antalgic gait
• Increased pain with forward flexion
• Decreased sensation at right foot
• Decreased ability to push-off with right foot
• Hypoactive right ankle jerk
• Positive right straight leg raise
Working Diagnosis
• Disk protrusion with impingement of nerve root(s)
(Right-sided lumbar radiculopathy)
Conservative Management Begins
• Order lumbar x-rays (AP & lateral)
• Referred to physical therapy x 6 sessions
• Ibuprofen 800 mg TID
• Limit push/pull/lifting to 5 lbs.
• Minimal stooping/bending/crouching
• Follow-up in 1-2 week
Case Age: Day #12
• Routine follow-up
• No improvement
• No new tingling/numbness/weakness
• Not working (due to lack of accommodations)
• Taking ibuprofen TID (“if I remember”)
• Exam unchanged
• BP 135/90
• Lumbar x-ray: Degenerative disk changes
Treatment Plan
• Referred to six more sessions of PT
• Switched from ibuprofen to Mobic 15 mg daily
• Added flexeril 10 mg qhs
• No change in work restrictions
• Asked to follow-up in 2 weeks
Case Age: Day #26
• Routine follow-up
• No significant improvement
• Complains of “heartburn”
• Still not working (restricted duties)
• Endorsing increased anxiety
• Exam unchanged
• BP 145/90
Treatment Plan
• Request authorization for transfer of care to Physiatry
Case Age: Day # 40
• Comprehensive Physiatric Consultation
• All records reviewed
• AOM provider notes
• PT notes
• Medication logs
• History
• Physical
• Treatment plan
• History
• Details of acute injury confirmed
• Lack of pre-existing injury confirmed
• Physical
• No apparent distress, BP 150/95
• Normal gait
• Abnormalities:
• Flexion 75°/90° (with pain)
• Decreased sensation to pin-prick at right S1 dermatome
• Right S1 myotome 4+/5
• Right ankle jerk is less brisk than contralateral side
• Right SLR with Lasague’s sign is positive
Case Highlights
• Right S1 radiculopathy
• Persistent at 6 weeks
• No progressive response to 12 sessions of PT, NSAIDs,
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muscles relaxers, and relative rest
Multiple work restrictions in place
Increasing blood pressure
Worsening GERD
Increasing anxiety
Educate Patient
• Diagnosis
• Need for future tests
• Need for procedures
• Prognosis
• Answer questions
• Set expectations
Questions I would ponder…
• Medications
• Should NSAIDs be discontinued given increasing BP?
• Should opiates be started?
• Should adjuvants be instituted?
• Should anti-hypertensives be titrated?
• Therapy
• Should therapy be continued?
• What kind of therapy should I order?
• Is HEP being followed?
• Frequency
• Duration
• Specific exercises performed
• Demonstration
• Diagnostics
• Are further tests required to clinch diagnosis?
• Are further tests needed to guide treatment?
• Which diagnostic study will be most helpful?
• Procedures
• Will the patient benefit from any spinal interventions?
• Is patient a surgical candidate?
• Work status
• Can patient’s restrictions be updated?
Back to Case…
• Medications
• Diagnostics
• Discontinue Mobic
• Flexion/extension lumbar x-
• Start Arthrotec
ray series
• MRI lumbar spine
• Increase Norvasc
• Start Neurontin
• Start Vicodin prn
• Take meds with food
• Therapy
• Continue HEP
• Start chiropractic x 6 sessions
• Procedures
• Pending diagnostics
• Work status
• No change until further
treatment is rendered and
response gauged
Case Age: Day #50
• Routine follow-up
• “Slightly” improved
• No further “heart burn”
• HEP ongoing
• BP normalized (120/80)
• Exam unchanged (continued neuro deficits)
Diagnostic Results
• Flexion/Extension X-rays
• No dynamic instability
• MRI Lumbar Spine
• Multi-level DDD
• Multi-level facet arthropathy
• L5-S1 right-sided 7 mm disc protrusion impinging on
right S1 nerve root
Treatment Plan
• Request authorization for right S1 transforaminal epidural
steroid injection
• Continue medications
• Continue HEP
• No change in work restrictions
Case Age: Day #62
• Right S1 transforaminal epidural steroid injection
performed
Case Age: Day #76
• Routine follow-up
• Dramatic >90% relief of back and right leg symptoms
• Back to pre-injury functional level
• Able to walk pain-free
• Able to bend pain-free
• Patient extremely happy
• Still using most pain meds (arthrotec, flexeril, neurontin)
• No longer needing Vicodin
• Neurologic exam has normalized
Treatment Plan
• Discontinue flexeril, neurontin, vicodin
• Change arthrotec scheduling to “strategic” prn
• Continue HEP (core strengthening)
• Loosen work restrictions
• Follow-up in 2 weeks
Case Age: Day #80
• Routine follow-up
• Enduring pain relief
• Tolerating loosened work restrictions
• HEP ongoing
• Arthrotec prn only
• Exam generally unremarkable
Treatment Plan
• Full duty trial
• RTC 2-3 weeks for P&S evaluation
Case Age: Day #95
• Soreness at low back by end of work day but tolerating
full duty
• Maximally medically improved
• Permanent & Stationary
Worker’s Compensation Issues
• Causation
• Acute low back lifting injury
• Apportionment
• 50% employer
• 50 pre-existing degenerative disease
• Impairment
• Lumbar Spine DRE Category II
• 5 % Whole Body Impairment
• Future Medical
Future Medical
• Medical follow-up for flare-ups or improved pain
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management
Medication refills to optimize function and quality of life as
it relates to this injury
2-12 sessions of rehabilitation per flare-up including
physical therapy, acupuncture or chiropractic care (the
type being dependent on which is most likely to improve
function and/or improve capacity for self-care)
Epidural injections by specialist if needed
Diagnostics and interventional treatment to follow only if:
a) recommended by specialist, and b) directly related to
the original claim
Alternate Ending to Case #2
• After ESI(s), patient still symptomatic to the point where
he is unable to tolerate full duty
• Consider: Surgical consultation
• Consider: Work Capacity Evaluation (WCE)
Conclusions
• Investigate exhaustively
• Diagnose clearly
• Treat systematically within confines of MTUS
THANK YOU!
Questions?