Muscle Strengthening Experience Presented by Jaishri Ramesh, MD. Medical Director Board Certified Internal Medicine Alliance Occupational Medicine 315 S. Abbott Ave. Milpitas, CA. 95035 2737 Walsh Ave. Santa Clara. CA. 95051 1901 Monterey Rd. Ste. 10 San Jose, CA. 95112 Copyright 2016 Alliance Occupational Medicine

What Is Muscle Strengthening? Muscle Strengthening is a controlled exercise program, using a computerized work simulator, used to treat “acute” pain injury conditions A work simulator is used to provide a more focused, progressive & safe exercise routine that cannot be duplicated by regular physical therapy modalities Acute pain injuries are injuries that have not yet fully healed but are progressing / for most injuries the “acute” phase of an injury lasts about 30 – 120 days Muscle strengthening is best used after the inflammatory cycle (15 – 45 days) has run its course but during the scar tissue formation healing stage so that the underlying muscles & tissues can be reactivated to their prior strength & endurance levels Muscle strengthening is injury & body part specific Muscle strengthening works by increasing the bulk and work force tolerance of our muscles & tissues / it is oftentimes referred to as “PT on steroids” and should be used only after 6-12 sessions of regular PT have already been tried Copyright 2016 Alliance Occupational Medicine

Copyright 2016 Alliance Occupational Medicine Case # 1 Mr. RF is a 54 yr. old male Presented with pain and tenderness over left elbow; had good ROM; but grossly reduced grip & lateral forearm extensor muscle bundle strength tolerances / Dx: Lateral Epicondylitis / DOI: 1/29/16 Job - county worker; his job required the lifting of up to 80# (tools & tree trunks of awkward size & shapes) / off work Sent to PT; ROM improvements noted; but patient reluctant to test left elbow & return to full duty due to fear of re-injury from heavy work demands. Referred to MSP due to persistent weakness in left elbow and job requirement of rigorous gripping & lifting; started MSP on 4/5/16 (67 days from DOI) Patient made steady progress through first 4 sessions; during the 5th session his strength motions reactivated (doubling his strength tolerances) & he regained confidence he could do his full duty job Patient was given a full duty return to work trial – successfully performing job at present Copyright 2016 Alliance Occupational Medicine

Copyright 2016 Alliance Occupational Medicine Case # 2 Mr. HK is a 33 yr. old male Presented with pain & tenderness in left elbow; “clicking” with pronation / supination; had good ROM; had persistent bilaterally weakness in forearms & elbows; Dx: Elbow Sprain & Tendinitis (Wrist / Hand / Forearm) / DOI: 01/08/16 Job - semiconductor worker; job required repetitive gripping, handling & grasping; working full duty but pain & motion were poorly integrated; worried he could not stay at work Sent to 12 sessions PT; helped ROM but his pain-motion integration remained unaffected Recommended MSP for strengthening to arms & to improve pain-motion normalization; started MSP on 4/12/16 (95 days from DOI) During first 4 sessions strength was labile & patient had difficulty progressing; during the 5th session the patient’s pain-motion renormalized; his strength increased 232% over his baseline levels; also felt he could better self manage his pain reactions and believed he could now stay at work even with some pain Given a full duty return to work trial – successfully performing at present Copyright 2016 Alliance Occupational Medicine

Copyright 2016 Alliance Occupational Medicine Case # 3 Ms. ST is a 64 yr. old female Presented with pain over left shoulder & mild clicking; had diminished ROM abduction, flexion & internal rotation; tenderness over bicipital groove & supraspinatus; reduced strength in shoulder / Dx: Left Shoulder Sprain / Strain / DOI: 12/4/15 Job - manufacturing & laser-micromaching technician; job required overhead work for long periods; working modified duty / off work Sent to 6 sessions PT; 6 sessions Acupuncture; had cortisone injection with temporary relief; she remained concerned she couldn’t do regular job Recommended MSP for strengthening shoulder; started 3/18/16 (104 days since DOI); initially had very low mobilization levels but steadily progressed; in her final sessions strength tolerances increased 201% but still had frequent compensatory pain and muscle guarding reactions but was willing to confront these behaviors Patient was willing to try a full duty return to work trial before considering a second set of MSP sessions – patient was able to successfully perform full duty & remains at work Copyright 2016 Alliance Occupational Medicine

Copyright 2016 Alliance Occupational Medicine Case # 4 Mr. RM is a 25 yr. old male Presented with low level objective findings and exaggerated pain complaints; had diffuse tenderness over splenius, cervicis, upper trapezius & para-thoracic muscled; neck & upper back ROM was limited with stiffness / Dx: Cervical & Thoracic Sprain / Strain / DOI: 1/28/16 Job – production associate / auto manufacturing; job required repetitive lifting to 40# / working 10-12 hour shifts / 6-7 days per week / off work Sent to 6 sessions PT; 6 sessions Chiropractics; 4 sessions Acupuncture; had cervical trigger point injection; given anti-inflammatory & muscle relaxant medications / all without relief Recommended MSP for strengthening; started 3/25/16 (57 days since DOI); had very poor participation levels; poor medication compliance; work dissatisfaction markers noted; high pain levels (8/10); subjective complains disproportionate to objective findings; disbelief in rehab as able to help him; pain behaviors and/or motivation issues suspected Patient MSP stopped after 2 sessions of poor participation / due to high pain complaints sent for MRI to r/o Cervical Radiculopathy / MRI results were negative / referred for WCE to identify work tolerances & to objective sort out delayed recovery barriers / work restoration was authorized but WCE was denied / awaiting appeal decision from insurance carrier as no baseline exists for work restoration Copyright 2016 Alliance Occupational Medicine

Questions? Thank You Jaishri Ramesh M.D. Phone: (408) 228-8400 jramesh@allianceoccmed.com Alliance Occupational Medicine 2737 Walsh Ave. Santa Clara, CA. 95051 315 S. Abbott Ave. Milpitas, CA. 95035 1901 Monterey Rd. Ste 10 San Jose, CA. 95112 Copyright 2016 Alliance Occupational Medicine