The Role of Physiatry in Occupational Medicine January 31, 2013
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Transcript of The Role of Physiatry in Occupational Medicine January 31, 2013
The Role of Physiatry in Occupational Medicine
January 31, 2013
James Petros, M.D., Q.M.E.Board-Certified, PhysiatryBoard-Certified, Pain MedicineBoard-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-musculo-skeletal problems
Grew drastically during WWII
Approved as a specialty of medicine in 1947
Physiatry: The “Broad” SpecialtyPain management MusculoskeletalElectrodiagnosisSpinal cord injuryTraumatic brain injuryAmputation, Orthotics, ProstheticsGeneral rehabSports Industrial
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…
CompassionAdvocacyRapportI 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) Persistent radiculopathy2) Inflammation related to:
Spinal disc herniation (“discogenic pain”)Degenerative disc diseaseSpinal 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 long-term 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
DiagnosticMedial branch blocks
Therapeutic Intra-articular steroid injectionRadiofrequency 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 short-term 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]”
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 30-40 years
Extension of physical exam
Evaluate integrity of peripheral nervous system
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.
EMG/NCS – FREQUENTLY ASKED QUESTIONS
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 SegmentsNCS 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 SymptomsDazed and confused (no LOC)HeadachesNeck StiffnessGeneralized soreness
EMS activated on the scene ER
Non-focal neuro examC-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)HeadachesMid back painLow back painRight knee pain
Patient referred to AOM
AOM Care (Day #3)
Additional x-raysThoracic spine: NegativeLumbar spine: NegativeRight knee: Negative
Diagnoses:C/T/L strains due to whiplashRight knee sprain from impact with dashboard
AOM Care (Day #3)
PlanPhysical therapyHEPNSAIDs, muscle relaxersRTC 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)
PlanAdd VicodinStart chiropracticNo drivingRTC 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)
PlanContinue medicationsHold therapyRefer for C-spine MRIRefer 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 radiculopathySuperimposed cervical strainCannot exclude cervical facet syndrome
Dr. Petros Care (Day #42)
PlanRefer 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 radiculopathyNo other neuropathy
Refer for trial of C6-C7 ESI
Dr. Petros Care
CESI authorizedPerformed 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)
PlanTrigger point injectionsRepeat PTHEPMeds as neededFull duty trialRTC 1-2 weeks
Dr. Petros Care (Day #90)
Unwavering right neck painDown 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 #100100% relief of symptoms for 3 full daysPatient 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 #120Successful procedurePatient 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?