Pain Management Methodology in Occupational Medicine

James Petros MDPhysical Medicine & RehabilitationInternal MedicineQualified Medical Evaluator

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

• Investigate exhaustively• Diagnose clearly• Treat systematically

Guiding Principles

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

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

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 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

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

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

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, 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• 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

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

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)

• Investigate exhaustively• Diagnose clearly• Treat systematically within confines of MTUS

Conclusions

THANK YOU!

Questions?