Physical Medicine and Litigation

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Physical Medicine and Litigation

• Eden Wheeler, M.D.
• Physical Medicine and Rehabilitation
• Rockhill Orthopaedics, P.C.

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Terminology of Function

• Impairment Any loss or abnormality of
  psychological, physiological or anatomical
  structure or function
• Disability Any restriction or lack of ability
  resulting from an impairment to perform an
  activity in the manner within the range
  considered normal for that human being
• Handicap Disadvantage for given individual
  resulting from an impairment or disability that
  limits or prevents the fulfillment of a role
  that is normal for that individual--depending on
  age, sex, social and cultural factors

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Symptom Magnification Examination

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  please e-mail SPA at gnorthcr_at_aol.com. Please
  provide name, e-mail address, title and company.

4
Pathological Examination

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  please e-mail SPA at gnorthcr_at_aol.com. Please
  provide name, e-mail address, title and company.

5

• Diagnostic tools
• Radiographs can demonstrate degenerative
  changes or acute fractures
• Bone scan useful only if looking for occult
  fracture
• MRI
• CT with or without myelogram Best for bony
  changes, spinal or foraminal stenosis
• EMG / NCV can demonstrate radiculopathy or
  peripheral nerve entrapment, but not positive in
  first 3-6 weeks

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• Treatment
• CONSERVATIVE
  INVASIVE
• Medications
  Injections
• -NSAIDS/ Epidural steroids
• -Muscle -Trigger point
• -Membrane stabilizers
  -Sacro-iliac joint
• Narcotics --Facet
  joint blocks
• Physical therapy
  Surgery -Modalities
  
  -Fusion
• -Exercise/strengthening
  -Laminectomy
• -Stretch/Body work
• -Work conditioning
• job site evaluation
• HEP vs. formal program

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• C. Sacroiliitis
• 1. History
• Trauma is very common
• Repetitive LS motion--lumbar rotation or axial
  loading
• No specific correlation with exacerbating
  activities
• Commonly have leg length discrepancy or condition
  contributing
• 2. Biomechanics
• Movement of the SIJ is involuntary, usually from
  muscle imbalances
• Can occur at multiple levels lower extremities,
  hip, LS spine
• Motion is complex and not single-axis based

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• 3. Differential Diagnosis
• Fracture
• Traumatic
• Insufficiency stress fracture
• -elderly patient with osteoporosis
• -no history of trauma
• Fatigue stress fractures
• -usually athletes/soldiers
• -caused by abnormal muscular stress on
  bone
• Infection
• Hematogenous spread
• Clinically with usually unilateral symptoms
• Predisposing history

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• Seronegative spondyloarthropathies
• Ankylosing spondylitis
• Psoriatic arthritis
• RA--usually not until late in course of disease
• Degenerative joint disease
• Reiters disease
• Metabolic disease
• CPPD
• Gout
• Ochronosis
• Acromegaly
• Primary SI tumor
• Rare and usually synovial villoadenomas

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• Iatrogenic instability
• Via pelvic tumor resection or bone graft site
• Osteitis condensans ilii
• Prevalence of 2.2
• Usually self-limiting and bilateral
• Primarily in multiparous women
• Increased bone density on inferior iliac side
• Referred pain
• Reactive disease as sequellae of PID

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• 4. Diagnostic Tools
• X-rays
• can see erosions, bridging, joint space
  narrowing, sclerosis
• up to 25 of asymptomatic adults over 50 years
  can have abnormalities
• MRI
• can diagnose early inflammatory changes or tumors
• CT
• Bone scan
• good for fractures but less favorable for
  inflammation
• can demonstrate bilateral disease with unilateral
  symptoms

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• 5. Treatment
• Medications NSAIDS
• Physical therapy
• modalities
• electrical stimulation/TENS
• sacral stabilization
• HEP/stretching
• Correct limb discrepancy
• Injection
• fluoroscopy-guided vs. local
• Surgical fusion
• few figures for efficacy

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Chronic Pain IssuesPain Reinforcing Factors

• To receive the complete Powerpoint presentation
  please e-mail SPA at gnorthcr_at_aol.com. Please
  provide name, e-mail address, title and company.

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Risk Factors for Delayed Recovery
To receive the complete Powerpoint presentation
please e-mail SPA at gnorthcr_at_aol.com. Please
provide name, e-mail address, title and
company.
15
Discouraging Chronic Pain

• To receive the complete Powerpoint presentation
  please e-mail SPA at gnorthcr_at_aol.com. Please
  provide name, e-mail address, title and company.

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Specific Disorders Low Back Pain

• Epidemiologist
• 60-90 lifetime incidence with 5 annual
  incidence
• 90 of cases of LBP resolve without treatment
  within 6-12 weeks
• 40-50 LBP cases resolve without treatment in 1
  week
• 75 of cases with nerve root involvement can
  resolve in 6 months
• LBP and lumbar surgery are
• 2nd and 3rd highest reasons for physician visits
• 5th leading cause for hospitalization
• 3rd leading cause for surgery

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• Disability
• Also leading cause of disability of adults lt 45
  years old and third cause in those gt 45 years
  old
• Prevalence rate of disability for LBP increased
  140 from 1970 to 1981 with only 125
  population growth---nearly 5 million persons in
  U.S. on disability for LBP
• Lifetime Return to Work
• Less than 50 if off work greater than 6 months
• 25 rate if off work greater than 1 year
• Nearly 0 if return to work has not occurred in
  2 years

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• Occupational Risk Factors
• Low job satisfaction
• Monotonous or repetitious work
• Educational level
• Adverse employer-employee relations
• Recent employment
• Frequent lifting
• especially exceeding 25 pounds
• utilization of poor body mechanics in technique

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• Differential Diagnosis
• Lumbar strain
• Disc bulge or herniation producing radiculopathy
• Degenerative disc disease
• Spinal stenosis
• Spondyloarthropathy
• Spondylosis
• Spondylolisthesis
• Sacro-iliac dysfunction
• Definitions
• Sprain traumatic overstretching or tearing of
  ligaments or tendons encompassing a joint
• Strain injury to muscle or ligamentous
  structures

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• Diagnostic tools
• Examination
• Radiographs
• Bone scan
• MRI
• CT with or without myelogram
• EMG/NCV Electromyography and Nerve conduction
  velocity testing

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Treatment

• CONSERVATIVE
• Medications
• NSAIDS
• Muscle relaxers
• Membrane stabilizers
• Narcotics
• Physical therapy
• Modalities
• Electrical
• Exercise/Strengthening
• Stretch/Body work
• Work conditioning

• INVASIVE
• Injections
• Epidural steroids
• Trigger points
• SI joint
• Facet blocks
• Surgery
• Discectomy
• Fusion
• Laminectomy

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Cervical Neck Pain

• Epidemiology
• Population over 45 years
• 50 complain of neck stiffness
• 25-40 complain of associated radiation to upper
  extremity
• Incidence in general population with or without
  arm pain 10 -20
• Incidence generally higher in women and 30-50
  year old adults
• Whiplash injuries are the most common cause of
  neck pain, with gt than 1 million cases in U.S.
  per year

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• 2. Cervical injury after MVA
• Mechanism primarily occurs via rear-end
  collisions acceleration of vehicle and delayed
  acceleration of trunk and shoulders with passive
  extension of head and neck followed by neck and
  head flexion
• MVA with whiplash injuries (Deans, et al
  Injury 1987)
• 62 of those evaluated in ED post-MVA with
  symptoms
• 33-66 develop symptoms within 24 hours
• 30-42 with continued intermittent pain at 1
  year
• 6 with continuous pain at 1 year
• MVA at 10 years (Gargan, et al JBJS 1990)
• 28 with chronic symptom

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• 3. Pain Generators
• Musculotendinous
• Anterior sternocleidomastoids/scalenes
• Paravertebrals
• Extrinsic shoulder muscles with cervical
  attachment
• trapezius, rhomboid, levator scapulae, latissimus
  dorsi
• Ligaments via stretch or tear injuries
• C1/C2 stability transverse, alar and
  atlantoaxial ligaments
• flexion/extension stability ALL, PLL
• flexion stability ligamentum flavum, supra and
  interspinous ligaments, ligamentum nuchae

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• Vertebral bodies with traumatic or
  osteoporotic fractures
• Zygopophyseal (Facet) joint
• may cause neck pain in up to 50-60
• may result in post-traumatic headaches in 33
• usually at C2-3 and C5-6 levels
• Intervertebral disc with/without herniation

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• 4. Barre-Lieou syndrome
• Felt due to injury to vertebral artery vs. CNS
  vs. sympathetic chain
• Clinical
• headaches
• cranial nerve dysfunction
• tinnitus/hearing changes
• dizziness/vertigo
• hoarseness/aphonia
• ocular pain/blurred vision
• upper extremity dysesthesias
• decreased concentration/memory

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• 5. Diagnostic
• Radiographs
• usually normal or loss of cervical lordosis can
  see pre-existing degenerative bony or disc
  changes
• Bone scan
• Elecrodiagnostics (EMG / NCV)
• CT with/without myelogram
• Best for bony changes, spinal or foraminal
  stenosis
• MRI
• Abnormal if disc herniation or acute ligamentous
  injury
• Cervical HNP seen in 10 of asymptomatic persons
  under 40 years and 5 of those over 40 years
  (Boden, et al JBJS 1990)
• degenerative disc changes present in 25 of
  asymptomatic adults under 40 years, 60 of
  those over 40 years and 70 over 70 years

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• 6. Treatment
• Medications
• NSAIDS
• Membrane stabilizers -TCA/Neurontin
• 
  - re-establish sleep patterns
• 
  -reduce radicular dysesthesias
• Muscle relaxers - re-establish sleep patterns
• - more
  useful in myofascial/muscular pain
• Narcotics rarely indicated
• Steroids more useful for radiculitis

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• Physical therapy
• modalities
• electrical stimulation/TENS
• postural education
• massage/mobilization/myofascial release
• traction
• Injections
• epidural/sub-occipital blocks
• facet
• trigger point

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• Considerations of PM R Treatment
• Physical therapy initially usually one of
  modalities with progression into more active
  exercise
• Pre-conditioning therapy more functional with
  transition into Work Conditioning (Work
  Hardening) program
• Always consider return to work, whether modified
  duty with restrictions or limiting hours worked
• If patients poorly tolerate standard therapy,
  consider pool therapy intervention which allows
  elimination of gravity effects
• Functional Capacity Evaluations utilized if
  patients are not progressing through therapy or
  if have reached a plateau and abilities as well
  as restrictions need to be assessed
• Job site evaluations appropriate if concerns re
  ergonomics