1. Pain Management Methodology in Occupational Medicine
James Petros MD
Physical Medicine & Rehabilitation
Internal Medicine
Qualified Medical Evaluator

2. General Goals Alleviate pain Increase function Return to work
Fully duty
Stay at work

3. Guiding Principles Investigate exhaustively Diagnose clearly
Treat systematically

4. Begin the Investigation
History
Physical
Assess urgency of pain
Differential diagnoses

5. Workup
Labs
X-rays
CT scans
MRIs
EMG/NCS
Diagnostic blocks

6. Pain Management Tools Education Medications Supplies Therapy
Procedures
Surgery

7. Education Etiology Prognosis Set realistic expectations
Answer questions
Teach coping strategies
Review home exercise program
Reassurance?

8. Medications NSAIDs Tylenol Muscle relaxers Opiates Adjuvants
Antidepressant (e.g. amitriptyline)
Anticonvulsants (e.g. neurontin)
Alpha-2-adrenergic agonists (e.g. zanaflex)
Steroids

9. Supplies Extremity splints Cervical orthotics Lumbar orthotics
Ambulatory devices
TENS units

10. Therapy Physical Occupational Chiropractic Acupuncture
HEP (home exercise program)

11. Procedures Trigger point injections
Peripheral joint cortisone injections
Spine intervention under fluoroscopy

12. Surgery Refer immediately for urgent cases
Consider referral if no progress with conservative care
Last resort

13. Case Study #1 38 y.o. Female Receptionist/secretary at Company ABC
2-month history of intermittent right wrist, forearm, and 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

14. 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

15. 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

16. 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”)

17. 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”

18. Review of systems
Poor sleep
Daily fatigue
Low energy
Stressed
“Feeling down”

19. 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

20. Working Diagnoses Right wrist tendonitis due to occupational overuse
Right forearm strain due to occupational overuse
Right elbow tendonitis due to occupational overuse

21. 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

22. 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

23. 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

24. Treatment Plan PTP once again proposes NSAIDs More Biofreeze provided
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

25. 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

26. Treatment Plan
Request authorization for transfer of care to Physiatric Specialist

27. Case Age: Day # 40 Comprehensive Physiatric Consultation
All records reviewed
Outside records
AOM provider notes
PT notes
Medication logs
History
Physical
Treatment plan

28. History Physical exam 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

29. Case Highlights
Mechanism of injury is related to “overuse” from 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

30. My Initial Approach Discuss patient’s resistance to pain medications
Side effects?
Fear of addiction?
Philosophical?
Aversion to pills by mouth?

31. Review home exercise program
Frequency
Duration
Specific exercises performed
Demonstration

32. Educate
Differential diagnoses
Need for future tests
Need for procedures
Prognosis
Answer questions

33. 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?

34. 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?

35. Back to Case…
Patient states that she is afraid of becoming dependent 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

36. Right Wrist X-ray Well-healed callus at distal radius
No acute pathology

37. EMG/NCS
Electrodiagnostic evidence of sensorimotor median mononeuropathy at right wrist, consistent with mild-moderate 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

38. 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

39. 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

40. Case Age: Day #62
Patient returns ecstatic about dramatic resolution of right elbow pain
No further forearm pain
Self-discontinued acupuncture
Paresthesias at right hand now rare
Exam has normalized

41. 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

42. Case Age: Day #70 Tolerating full duty Generally asymptomatic
Maximally medically improved
Permanent and Stationary

43. Worker’s Compensation Issues
Causation
Lateral epicondylitis
Overuse
Carpal tunnel syndrome
Hypothyroidism
History of wrist fracture
Apportionment
Apportion to causation (not required in this case)
Impairment
0% WPI
Future medical

44. 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

45. 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

46. 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

47. Past Medical History Occupational History Previous Injuries
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

48. Past Surgical History Allergies Medications None Mortin 400 mg BID
Norvasc 5 mg daily

49. Social History Review of Systems No tobacco/alcohol/illicit drug abuse
Married with kids
Rare exercise
Review of Systems
Poor sleep; otherwise unremarkable

50. 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

51. Working Diagnosis Disk protrusion with impingement of nerve root(s)
(Right-sided lumbar radiculopathy)

52. 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

53. 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

54. 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

55. 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

56. Treatment Plan
Request authorization for transfer of care to Physiatry

57. Case Age: Day # 40 Comprehensive Physiatric Consultation
All records reviewed
AOM provider notes
PT notes
Medication logs
History
Physical
Treatment plan

58. History Physical 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

59. Case Highlights Right S1 radiculopathy
Persistent at 6 weeks
No progressive response to 12 sessions of PT, NSAIDs, muscles relaxers, and relative rest
Multiple work restrictions in place
Increasing blood pressure
Worsening GERD
Increasing anxiety

60. Educate Patient Diagnosis Need for future tests Need for procedures
Prognosis
Answer questions
Set expectations

61. 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?

62. Therapy
Should therapy be continued?
What kind of therapy should I order?
Is HEP being followed?
Frequency
Duration
Specific exercises performed
Demonstration

63. Diagnostics
Are further tests required to clinch diagnosis?
Are further tests needed to guide treatment?
Which diagnostic study will be most helpful?

64. Procedures
Will the patient benefit from any spinal interventions?
Is patient a surgical candidate?

65. Work status
Can patient’s restrictions be updated?

66. Back to Case… Medications Therapy Diagnostics Procedures Work status
Discontinue Mobic
Start Arthrotec
Increase Norvasc
Start Neurontin
Start Vicodin prn
Take meds with food
Therapy
Continue HEP
Start chiropractic x 6 sessions
Diagnostics
Flexion/extension lumbar x-ray series
MRI lumbar spine
Procedures
Pending diagnostics
Work status
No change until further treatment is rendered and response gauged

67. Case Age: Day #50 Routine follow-up “Slightly” improved
No further “heart burn”
HEP ongoing
BP normalized (120/80)
Exam unchanged (continued neuro deficits)

68. 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

69. Treatment Plan
Request authorization for right S1 transforaminal epidural steroid injection
Continue medications
Continue HEP
No change in work restrictions

70. Case Age: Day #62
Right S1 transforaminal epidural steroid injection performed

71. 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

72. Treatment Plan Discontinue flexeril, neurontin, vicodin
Change arthrotec scheduling to “strategic” prn
Continue HEP (core strengthening)
Loosen work restrictions
Follow-up in 2 weeks

73. Case Age: Day #80 Routine follow-up Enduring pain relief
Tolerating loosened work restrictions
HEP ongoing
Arthrotec prn only
Exam generally unremarkable

74. Treatment Plan
Full duty trial
RTC 2-3 weeks for P&S evaluation

75. Case Age: Day #95
Soreness at low back by end of work day but tolerating full duty
Maximally medically improved
Permanent & Stationary

76. 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

77. Future Medical
Medical follow-up for flare-ups or improved pain 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

78. 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)

79. Conclusions Investigate exhaustively Diagnose clearly
Treat systematically within confines of MTUS

80. THANK YOU! Questions?