the role of physiatry in occupational medicine january 31, 2013 james petros, m.d., q.m.e....
TRANSCRIPT
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The Role of Physiatry in Occupational Medicine
January 31, 2013
James Petros, M.D., Q.M.E.Board-Certified, Physiatry
Board-Certified, Pain Medicine
Board-Certified, Internal Medicine
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A little bit about Dr. Petros…
Curriculum Vitae
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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
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Nonsurgical
Address muscles, nerves, bones, joints, tendons, ligaments
Functional restoration
“Quality of life”
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“Over 95% of occupational injuries never require surgery”
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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
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Physiatry: The “Broad” Specialty
Pain management MusculoskeletalElectrodiagnosisSpinal cord injuryTraumatic brain injuryAmputation, Orthotics, ProstheticsGeneral rehabSports Industrial
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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
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Other Important factors…
CompassionAdvocacyRapportI love what I do
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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
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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
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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
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Showcase
Epidural Steroid Injections (ESIs) Facet Joint Procedures EMG/NCS
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Medical Criteria for ESIs
1) Persistent radiculopathy
2) Inflammation related to:Spinal disc herniation (“discogenic pain”)Degenerative disc diseaseSpinal stenosis
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What is Radiculopathy?
Spinal condition Compressed nerve root Pain, numbness, tingling, or weakness
along the course of the nerve
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Risk Factors for Radiculopathy?
Excessive or repetitive load on the spine Aging Obesity Smoking Family history
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Causes of Radiculopathy? Disk herniation Inflammation from trauma or degeneration Bone spur (osteophytes) Tumor Infection Scoliosis Diabetes
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Goals Following ESIs
Reduce pain/tingling/numbness/weakness Restore range of motion Facilitate progress in more active
treatment programs Avoid surgery
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“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].
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Transforaminal Epidural Injection
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Showcase
Epidural Steroid Injections (ESIs) Facet Joint Procedures EMG/NCS
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Facet Joint Anatomy
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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
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Facet Procedures
DiagnosticMedial branch blocks
Therapeutic Intra-articular steroid injectionRadiofrequency Ablation (Rhizotomy)
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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]”
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Intra-Articular Facet Injection
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Radiofrequency Ablation (Rhizotomy)
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Showcase
Epidural Steroid Injections (ESIs) Facet Joint Procedures EMG/NCS
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Electrodiagnosis
Electromyography (EMG)
Nerve conduction studies (NCS)
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Originated in 19th century
More consistently used over last 30-40 years
Extension of physical exam
Evaluate integrity of peripheral nervous system
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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
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Utility of EMG/NCS
Establish correct diagnosis Screen for other conditions Determine acuity vs. chronicity Localize lesion Determine treatment Prognosticate
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When to Consider EMG/NCS?
Pain Numbness Tingling Weakness Atrophy Fatigue
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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
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Test Segments
NCS
Latency Amplitude Conduction velocity Signal quality
EMG (needle)
Spontaneous electrical activity
Insertional activity Waveform shape Recruitment patterns
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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
• • •
• • •
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Case Study
44 y.o. male Generally healthy Limousine driver MVA on the job Vehicle totaled
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Immediate SymptomsDazed and confused (no LOC)HeadachesNeck StiffnessGeneralized soreness
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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
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Next Day Neck pain (main complaint)HeadachesMid back painLow back painRight knee pain
Patient referred to AOM
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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
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AOM Care (Day #3)
PlanPhysical therapyHEPNSAIDs, muscle relaxersRTC 2 weeks
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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
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AOM Care (Day #17)
PlanAdd VicodinStart chiropracticNo drivingRTC 2-3 weeks
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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
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AOM Care (Day #32)
PlanContinue medicationsHold therapyRefer for C-spine MRIRefer to Physiatry
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Multilevel Disk Herniations
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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
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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
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Dr. Petros Care (Day #53)
EMG/NCS Right C6-C7 radiculopathyNo other neuropathy
Refer for trial of C6-C7 ESI
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Dr. Petros Care
CESI authorizedPerformed on Day #70
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Dr. Petros Care (Day #84)
Right arm symptoms completely gone Neck pain still present Neurologic exam normalized ROM improved but still restricted
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Dr. Petros Care (Day #84)
PlanTrigger point injectionsRepeat PTHEPMeds as neededFull duty trialRTC 1-2 weeks
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Dr. Petros Care (Day #90)
Unwavering right neck painDown into top of shoulder blade
Intermittent headaches Exam unchanged
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What a pain in the neck!
What else is going on?Cervical facet syndrome?
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Dr. Petros Care (Day #90)
Request authorization for diagnostic right C4-C5 medial branch blocks
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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
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Dr. Petros Care (Day #105)
Request authorization for rhizotomy (RFA)
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Dr. Petros Care
Rhizotomy performed on Day #120Successful procedurePatient asymptomatic
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Permanent & Stationary (Day #134)
MMI (back to pre-injury status) No impairment Full duty No need for future medical
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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
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THANK YOU!
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… Questions?