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

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Presentation on theme: "Pain Management Methodology in Occupational Medicine James Petros MD Physical Medicine & Rehabilitation Internal Medicine Qualified Medical Evaluator."— Presentation transcript:

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 Investigate exhaustively Diagnose clearly Treat systematically Guiding Principles

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 dont 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 Tinels and Phalens 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 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 Details of cumulative injury confirmed New info: Dad passed away 6 months ago Physical exam Pain with palpation of right lateral epicondyle Positive right Cozans test Pain with palpation of right dorsal forearm musculature Full ROM at wrist and elbow Positive Phalens on right Negative Tinels 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 patients 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 fathers 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 Workers 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

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 Workers 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 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 None Allergies None Medications Mortin 400 mg BID Norvasc 5 mg daily

49 Social History 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 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 Lasagues 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 patients restrictions be updated?

66 Back to Case… Medications 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 Workers 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 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 Investigate exhaustively Diagnose clearly Treat systematically within confines of MTUS Conclusions

80 THANK YOU! Questions?

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