Pain Management Methodology in Occupational Medicine

1. Pain Management Methodology in Occupational Medicine James Petros MD Physical Medicine & Rehabilitation Internal Medicine Qualified Medical Evaluator

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

3. Guiding Principles • Investigate exhaustively • Diagnose clearly • Treat systematically

4. Begin the Investigation • History • Physical • Assess urgency of pain • Differential diagnoses

5. Workup • Labs • X-rays • CT scans • MRIs • EMG/NCS • Diagnostic blocks

6. Pain Management Tools • Education • Medications • Supplies • Therapy • Procedures • Surgery

7. Education • Etiology • Prognosis • Set realistic expectations • Answer questions • Teach coping strategies • Review home exercise program • Reassurance?

8. Medications • NSAIDs • Tylenol • Muscle relaxers • Opiates • Adjuvants • Antidepressant (e.g. amitriptyline) • Anticonvulsants (e.g. neurontin) • Alpha-2-adrenergic agonists (e.g. zanaflex) • Steroids

9. Supplies • Extremity splints • Cervical orthotics • Lumbar orthotics • Ambulatory devices • TENS units

10. Therapy • Physical • Occupational • Chiropractic • Acupuncture • HEP (home exercise program)

11. Procedures • Trigger point injections • Peripheral joint cortisone injections • Spine intervention under fluoroscopy

12. Surgery • Refer immediately for urgent cases • Consider referral if no progress with conservative care • Last resort

13. 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

14. 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

15. 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

16. 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”)

17. 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”

18. Review of systems • Poor sleep • Daily fatigue • Low energy • Stressed • “Feeling down”

19. 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

20. Working Diagnoses • Right wrist tendonitis due to occupational overuse • Right forearm strain due to occupational overuse • Right elbow tendonitis due to occupational overuse

21. 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

22. 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

23. 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

24. 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

25. 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

26. Treatment Plan • Request authorization for transfer of care to Physiatric Specialist

27. Case Age: Day # 40 • Comprehensive Physiatric Consultation • All records reviewed • Outside records • AOM provider notes • PT notes • Medication logs • History • Physical • Treatment plan

28. 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

29. 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

30. My Initial Approach • Discuss patient’s resistance to pain medications • Side effects? • Fear of addiction? • Philosophical? • Aversion to pills by mouth?

31. Review home exercise program • Frequency • Duration • Specific exercises performed • Demonstration

32. Educate • Differential diagnoses • Need for future tests • Need for procedures • Prognosis • Answer questions

33. 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?

34. 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?

35. 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

36. Right Wrist X-ray • Well-healed callus at distal radius • No acute pathology

37. 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

38. 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

39. 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

40. 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

41. 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

42. Case Age: Day #70 • Tolerating full duty • Generally asymptomatic • Maximally medically improved • Permanent and Stationary

43. 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

44. 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

45. 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

46. 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

47. 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

48. Past Surgical History • None • Allergies • None • Medications • Mortin 400 mg BID • Norvasc 5 mg daily

49. Social History • No tobacco/alcohol/illicit drug abuse • Married with kids • Rare exercise • Review of Systems • Poor sleep; otherwise unremarkable

50. 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