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

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” Specialty

Pain 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 radiculopathy

2) 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 Segments

NCS

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?