Phantom Limb Pain
September 2015Contributed by Robert I. Kawasaki, MD
Board Certified, Physical Medicine and Rehabilitation
Managing Member, Colorado Pain and Rehabilitation
Phantom limb pain (PLP) is a fascinating problem where patients with amputations experience severe pain in the limb that no longer exists. Patients describe their pain with neuropathic qualities “tingling, sharp, shooting, or electrical” and nociceptive qualities “cramping, squeezing, and dull”. The pain can involve the entire limb, or be localized to one region of the missing limb.
Between 2006-2012 the workers’ compensation system in Colorado averaged 106 amputations annually. The most common work-related amputations involved full or partial loss of fingers. Less commonly, amputations involved an arm, leg, foot, toe, nose or ear.
Among patients with amputations, 60%-80% patients experience PLP within the first week after amputation, lasting typically around six months. Some studies have reported prevalence of PLP and development of chronic pain after amputation as high as 85%.
Higher degrees of trauma, severity and duration of pain in the extremity prior to and after amputation has been correlated to increased severity and chronicity of PLP. A musculoskeletal, neurological and vascular examination for PLP includes gait assessment, range of motion, residual limb length and circumference, skin integrity, sensory and motor function. Differential diagnoses for post amputation pain includes infection, skin breakdown, heterotopic ossifications, fractures, myofascial pain, DVT, stroke, radiculopathy, Complex Regional Pain Syndrome (CRPS), neuromas and other peripheral nerve entrapments.
Treatment includes proper stump care, early application of prosthesis and physical therapy. Modalities include massage, TENS units, range of motion, acupuncture, edema control and desensitization techniques.
Non-opioid pharmacological treatment of PLP include medications commonly used for neuropathic pain and conditions such as CRPS:
- Tricyclic antidepressants: amitriptyline and nortriptyline
- Anticonvulsants: carbamazepine, gabapentin and Lyrica
- Other antidepressants: Cymbalta
- Topical anesthetics: lidocaine and various compound creams
- Postoperative intravenous (IV) calcitonin
- IV ketamine and dextromethorphan (require specialized monitoring)
Opioid medications can be effective in reducing PLP. Pain psychological and addiction risk screening should be utilized. Monitoring is required, including urine toxicology and frequent PDMP review. For acute pain, short-acting opioids may be appropriate in tapering doses. For PLP patients with chronic pain, conversion to long-acting opioids should be considered. Department of Regulatory Agency Policy for Prescribing and Dispensing Opioids and Division of Workers’ Compensation Medical Treatment Guidelines for Chronic Pain should be followed.
Interventional pain procedures may include:
- Local steroid injections
- Dorsal root ganglion blocks
- Selective nerve blocks
- Spinal cord stimulators
- Intrathecal pumps
Surgical indications are rare:
- Resection of symptomatic neuromas
- Stump revision for cases of obvious anatomic pathology
Emotional distress after amputation can be significant, with high risk of adjustment disorder, posttraumatic stress disorder and chronic pain syndrome. A full pain assessment with risk screening should be included per pain management guidelines. A comprehensive psychological assessment, including cognitive, emotional, interpersonal and vocational status, should be performed. Early emotional support, psychological evaluation and cognitive behavioral intervention are highly recommended.
PLP is an unfortunate, common problem for post amputation patients. Treatment options are similar to neuropathic pain, CRPS, and chronic pain guidelines.
Presurgical Psychological Evaluations Explained
September 2015Contributed by Daniel Bruns, PsyD
At first glance, the idea of a presurgical psychological evaluation seems counter-intuitive. How could a psychological evaluation possibly predict the outcome of an orthopedic surgery? Surprisingly, though, research has shown that psychological evaluations are reliable predictors of the outcome of numerous types of surgery.1,2 How can this be?
We generally think about surgery as an objective solution to an objective medical problem. For example, an objective problem might be that a patient is suffering from a herniated lumbar disc, and the goal of surgery is to fuse two vertebrae together to alleviate this problem. In most cases, though, the ultimate goal of surgery goes well beyond the objective goal of achieving a successful fusion. The most common goals of surgery are helping the patient to return to work, to reduce opioid use and hopefully to be satisfied with medical care. Of these three goals, the first two are behaviors and the third one is an attitude. When it comes to predicting changes in attitudes and behaviors, it makes sense that psychological tests would be stronger predictors than MRIs or CT scans. Consistent with this, in the case of spinal pain, psychological tests have been shown to be more predictive of surgical outcome than MRIs.3,4 Beyond that, a thorough review of the evidence determined that psychological tests are the scientific equal of medical tests.3
A recent study of lumbar fusion surgery found that even though surgery was objectively successful 84% of the time, following the surgery 49% of the patients had worse pain, 44% were dissatisfied with their outcome and 38% were totally disabled at follow-up.5 Similarly, another study found that opioid pain medication use actually increased following lumbar fusion surgery.6 This illustrates an important point: It is possible for an orthopedic surgery to simultaneously be an objective success and a behavioral failure. To prevent this possibility, it is helpful to evaluate nonmedical risk factors prior to surgery.
Psychological, social and behavioral variables are known to affect the outcome of surgery and other medical treatments,7 and they do so in various ways:
- Depression increases the risk of nonadherence with physical therapy8 and of not taking medications as prescribed,9 and in general contributes to a poor medical treatment outcome.8
- Depression prior to surgery has been shown to predict dissatisfaction with the outcome of the surgery.10
- Emotional stress affects both the inflammatory response and the immune system, and this can negatively impact surgical outcome.11
- Deep sleep is needed to trigger the release of human growth hormone,12 which the body requires for wound healing.13 Emotional stress can thus interfere with recovery from surgery by reducing deep sleep, and this also increases the risk of chronic pain.14
- Job dissatisfaction is a significant predictor of failure to return to work.2,15
The Chronic Pain Treatment Guidelines published by the Colorado Division of Workers’ Compensation make recommendations about how and when to conduct presurgical psychological evaluations. These guidelines require or strongly recommend psychological evaluations for patients suffering from chronic pain or delayed recovery, and for patients prior to lumbar fusion, artificial disc surgery, spinal cord stimulation, discography, facet rhizotomy, IDET, some shoulder surgeries, and back surgery if Waddell signs are > 2.16
Under the guidelines, when performing a presurgical psychological evaluation, the first task of a psychologist is to look for what are called “primary risk factors.”16 Primary risk factors are psychosocial risk factors that are so severe that the presence of just one could preclude the patient from benefiting from the proposed surgery. Examples of primary risk factors would include suicidal impulses, daily use of methamphetamines or paranoid psychosis associated with mania. Patients exhibiting primary risk factors are generally thought to be too psychologically unstable to benefit from elective surgeries or to comply with treatment generally. Even though primary risk factors are extreme, one recent national study found that of patients in rehabilitation for pain or injury, over 10% exhibited one or more primary risk factor.7
Consider a case of a patient who suffers from both back pain and suicidality. Of the two, the suicidality is the more serious condition, as it is potentially fatal, whereas back pain is not. Because of that, treatment of the suicidality should take priority over the treatment of the back pain. Overall, when primary psychological risk factors are present, the patient is so psychologically unstable that there is a high risk that a surgery would have a poor outcome. It should be pointed out here that some surgeries are performed because of a medical emergency, such as a lumbar surgery for cauda equina syndrome to prevent paraplegia. In cases where there is a high level of medical necessity, the surgery is performed, and any associated psychosocial risk factors are managed perioperatively.
Under the guidelines, a presurgical psychological evaluation should also assess “secondary risk factors.”16 If primary risk factors could be thought of as “red flags,” secondary risk factors could be thought of as “yellow flags.” Secondary risk factors are moderate but significant psychosocial risk factors for surgical outcome. Examples of secondary risk factors would include moderate depression, moderate anxiety, job dissatisfaction, long-term use of prescribed opioids and excessive disability. Virtually all patients with a disabling injury will have one or more secondary risk factors. Unlike primary risk factors, where the presence of one severe risk factor may exclude the patient from being considered as a surgical candidate, in the case of secondary risk factors, it is the overall number of risk factors present that is assessed. When patients are exhibiting an elevated number of secondary risk factors,7 alternative, more conservative treatments should be considered. The presence of primary and secondary risk factors have been found to be associated with a poor outcome from medical treatment generally.
The goal of a presurgical psychological evaluation is to identify primary and secondary risk factors, and based on that and other findings, recommend the best care plan for a patient. Surgical patients with a high level of psychosocial risk are much more likely to be dissatisfied with their care.7 For these patients, conservative care is often a better alternative to elective surgical procedures. Interestingly, studies have found that a psychological pain management treatment called cognitive behavioral therapy (CBT), which is sometimes combined with physical therapy, can produce outcomes equal to surgery.17,18,19 Even though surgery and CBT are equally effective for back pain, surgery can cost up to 168 times more than CBT and is associated with both adverse outcomes and risk of death. If the presurgical psychological evaluation suggests that the patient is at high risk for being unhappy with the surgical outcome, there is little reason to expose that patient to the risk of surgery. It is important to remember, though, that the presence of a high level of psychosocial risk factors does not mean that the patient will never be a candidate for surgery, as in many cases these risk factors can be addressed through appropriate treatment.
Overall, while studies have shown that patients with a high level of psychosocial risk are unlikely to benefit from surgery alone,1,2,7 these patients can often benefit when an interdisciplinary approach to care is used that integrates psychological and medical interventions.18,19 By helping to identify the best treatment plan for a patient, presurgical psychological evaluations play an important role in the treatment of injured workers.
Cumulative Trauma Job Site Evals vs. Ergonomic Evals
September 2015Contributed by Julie Miller, PT, MS, ATC
Clinic Director with Physiotherapy Associates
What’s the difference? Due to the complexity of assessment required to aid in the identification of occupational risk factors associated with cumulative trauma disorder, a thorough job site evaluation involving aspects of an ergo evaluation and additional job demands analysis are required. What this article will provide is a clear understanding of the additional components involved in a Cumulative Trauma Job Site Evaluation when establishing medical causality per the guidelines and requirements of Rule 17 of the Colorado DOWC.
Ergonomic Evaluation is a survey in which the employee is observed within the workstation to ensure that the physical aspects of their workspace, like chairs and keyboard, are in a position to provide minimum physical stress to the employee. In addition, the employee is advised on proper posture and body mechanics to perform work tasks safely.
Job Site Evaluation (as defined within Rule 17) is a comprehensive analysis of the physical, mental and sensory components of a specific job. These components may include, but are not limited to: (a) postural tolerance; (b) aerobic requirements; (c) range of motion; (d) torque/force; (e) lifting/carrying; (f) cognitive demands; (g) social interactions; (h) visual perceptual; (i) environmental requirements of the job; (j) repetitiveness; and (k) essential functions of the job.
Cumulative Trauma Disorder (CTD) is a group of diagnoses related to the upper extremity that include disorders of muscles, tendons and tendon sheaths; nerve entrapment syndromes; joint disorders; and neurovascular disorders. An example would be medial/lateral epicondylitis. Risk factors for the development of CTDs have been identified as posture, repetition, force, vibration, cold exposure and combinations thereof.
The key differentiation between an Ergonomic Evaluation and a Cumulative Trauma Job Site Evaluation is the requirement to identify risk factors that have been associated with CTDs and then determine if it is medically probable (greater than 50% likely) that the injury or condition is due to a work-related exposure or injury.
The job duties that can pose hazards or risk factors for CTD (and that require observation and evaluation) include pinching an unsupported object weighing 2 lbs more than 3 hours/day; gripping an unsupported object weighing 10 lbs more than 3 hours/day; repetitive motion (involving high, forceful exertion with the hands) more than 2 hours/day; intensive keying and/or mouse use more than 4 hours/day; repeated impact using the hand as a hammer more than 2 hours/day; and vibration (looking at both the frequency and the acceleration of the tool) more than 30 minutes at a time.
A typical Ergonomic Evaluation can be performed in 1 hour. A complete Job Site Evaluation will take a minimum of 2 hours of observation and assessment with the employee in order to assess all risk factor involved and to determine if those risk factors are present in sufficient degree and duration to cause the Cumulative Trauma Disorder.
New Senior Medical Director, Care Integration
September 2015Pinnacol is pleased to announce that Dr. Rick May has been selected for the new position of senior medical director, care integration. He will provide strategic guidance and clinical and care management leadership in support of network providers and population health, safety, wellness and return-to-work programs. He will also represent Pinnacol on the Governor’s Consortium for Prescription Drug Abuse Prevention.
Dr. May brings a wealth of experience as both a practicing physician and a healthcare leader. In addition to serving as an orthopedic surgeon in Denver for 12 years, he founded and led several companies driving innovations and improvements in care, as well as improving clinical quality and outcomes across hospitals and clinical settings. Dr. May served as vice president of clinical consulting for HealthGrades and as president of chairman of the Colorado Medical Society.
Before joining Pinnacol, Dr. May served as CEO of Ascent Clinical Quality Improvement, working with hospitals, nurses, and doctors to improve clinical care for patients. He earned his medical degree at University of Colorado Health Sciences Center.
New Partnership with Health Links
Workers' Comp Coordination
September 2015As part of our ongoing commitment to helping our policyholders keep their employees healthy, Pinnacol Assurance has entered into a partnership with Health Links. A nonprofit initiative of the Colorado School of Public Health, Health Links helps small businesses implement worksite wellness programs.
Through this partnership, Health Links will provide onsite support and resources to help policyholders reach wellness and safety benchmarks and to earn Healthy Business Certification. The voluntary certification provides a visible way for companies to demonstrate their commitment to health and safety and is another way for Pinnacol to engage policyholders in wellness.
If you have any questions about the Health Links program, please contact:
Worksite Wellness Director
Health and Wellness Promotion Specialist
2014 Annual Report
September 2015Pinnacol Assurance’s 2014 Annual Report is now available online. This year’s report highlights 100 years of workers’ compensation in Colorado, and details how Pinnacol is evolving to meet our customers’ changing needs.
Current Pharmacy Initiatives
From Pinnacol's Medical Director
Current Pharmacy Initiatives and Resources for Physicians
Pharmacy utilization continues to be a major contributor to medical spend for the healthcare industry and workers’ compensation. The most recent data from the 2014 IMS Institute for Healthcare Informatics report documents that the healthcare industry experienced pharmaceutical expenditure of $373.9 billion in 2014.
Pinnacol Assurance is currently working with Helios – our pharmacy benefits management company – to identify opportunities to help physicians and injured workers with prescription medications. There are two initiatives at present, Clinical Escalation Alert (CEA) and Targeted Intervention Letter (TIL).
Helios will send a CEA to the assigned claims representative (CR) and/or medical case manager (MCM) when one or more of the following occurs: prescriptions for new claims include long-acting opioids, long-acting Tramadol, and/or Fentanyl Citrate; opioid use is in effect for more than 90 days; daily opioid use is greater than 120 morphine equivalents; or daily Acetaminophen doses exceed 4,000 mg. The CR and/or MCM then plan what additional action will be taken (e.g., sending a letter to the prescribing physician or initiating a physician advisor peer review). If you, as a treating physician, receive a CEA letter, please respond as quickly as possible.
The second initiative is the use of a Targeted Intervention Letter. This initiative addresses situations that could involve generic versus brand-name medications, multiple opioid usage, and/or multiple providers prescribing opioid medications. Helios provides Pinnacol claims and MCM specialists a monthly report that identifies injured workers who potentially may be in need of an intervention. The claims and MCM specialists share this information with the assigned CR and MCM and request that they consider sending a TIL to the injured worker’s medical providers. Some of you may already have received a TIL. Attached to the letter is a form for the medical providers to complete and return to Pinnacol. The claims and MCM specialists are compiling responses from medical providers and the results. We would appreciate your assistance with this initiative. If you receive a TIL from Pinnacol, please complete the form and fax it to the number indicated on the form as quickly as possible.
If you identify situations of inappropriate use of prescription medications in your practice through the Colorado Prescription Drug Monitoring Program, please be aware that you have Pinnacol and Helios resources to assist you in medication management for your patients. Pinnacol has physician advisors whose practices specialize in treating patients with complex medication utilization. Please contact the nurse assigned to the injured worker claim if you would like to have a physician advisor review and provide recommendations or if you would like a peer-to-peer discussion.
Helios has clinical pharmacists with considerable experience in workers’ compensation and pain management. This clinical pharmacist team is knowledgeable in guidelines for workers’ compensation, including the Colorado Division of Workers’ Compensation Medical Treatment Guidelines and the American College of Occupational and Environmental Medicine Guidelines. This pharmacist team is a resource to assist with appropriate use of pharmaceutical therapy and treatment guidelines by offering actionable recommendations. You can request a medication review by contacting the Pinnacol nurse assigned to the injured worker claim so that she/he can forward your request to Helios. Please inform the Pinnacol MCM if you want a discussion with a Helios Pharm.D. in addition to a written report.
Case Law Review
A Former IME (But Not DIME) Physician May Become The ATP
Contributed by Harvey Flewelling, Pinnacol Assurance Appeals Counsel
The recent case of Lopez v. Scott Contractors involved a worker who injured both of his legs, including a fractured left tibia, while trying to extricate one of his employer’s trucks from snow on December 6, 2011. He underwent two surgeries, including the insertion of two metal plates through the use of six screws placed into the tibia. The authorized treating physician (ATP) providing primary care for the injury subsequently recommended conservative therapy, but the worker continued to complain of pain in his left leg. In 2013, two surgeons recommended that the surgical hardware be removed from the worker’s left leg. The ATP recommended against the procedure, and the employer declined to authorize the surgery.
The employer appealed the ALJ’s decision. The employer did not dispute that the injured worker made a “proper showing” to secure permission to have a change of physician, but argued that once the ALJ determined a change of physician was required, he was obligated to either direct the former ATP to make a referral to a new doctor or allow the employer to designate a substitute physician. The employer also contended that the ALJ erred in authorizing the new ATP because the injured worker had previously used that physician to provide an independent medical examination (IME) opinion pertinent to the hardware removal surgery.
The Industrial Claim Appeals Office (ICAO) affirmed the ALJ’s decision. ICAO rejected the employer’s first argument, noting that the statute allows the ALJ to authorize only a change to “a physician of the employee’s selection,” and thus under such circumstance neither the former ATP nor the employer has the right to designate a new ATP. ICAO also held that while a treating physician would not qualify as an “independent” examiner, a former IME physician is not precluded from undertaking direct care of the injured worker. ICAO noted that a former Division of Workers’ Compensation IME (DIME) physician may not become a treating physician, but a DIME was not involved here. ICAO concluded that the employer failed to show that the ALJ abused his discretion in ordering the change of physician.
Nineteen PCPs Receive Summit Elite Designations
June 2015This spring, Pinnacol Assurance awarded our Clinic Performance Initiative (CPI) Summit Elite designation to 19 SelectNet primary care clinics for their superior performance, as demonstrated by their maintenance of a five-star rating for two or more consecutive metric periods.
“Achieving Summit Elite status within the Pinnacol Assurance CPI program was truly a team effort,” Balak added. “St. Mary’s Occupational Medicine uses an education component and a follow up a process wherein we cross-checked one another to ensure we were sharing the information in a complete and timely fashion. Ultimately, our goal was to ensure injured workers received quality care and understood they are part of the treatment team along with their doctor, their insurance carrier and their employer.”
Linda Torres of Premier Occupational Medicine, which also received the designation, said, “We are proud to be a Summit Elite provider ― combining the very best in medical care with strong communication to patients, our partner companies and Pinnacol Assurance.”
Congratulations to the current Summit Elite designees:
Aviation & Occupational Medicine
Colorado Mountain Medical – Eagle
Colorado Mountain Medical – Edwards
Colorado Mountain Medical – Vail
Colorado Occupational Medicine Physicians
EmergiCare Medical Clinic – Bijou
HealthONE Occupational Medicine & Rehabilitation - Aurora
High Country Occupational and Travel Medicine, LLC
Longmont Clinic – Primary Care
Occupational Health Services – Boulder
Premier Occupational Medicine
SCL Physicians – Broomfield
SCL Physicians – Green Mountain
SCL Physicians – Larkridge
SCL Physicians – Southwest
St. Mary’s Occupational Medicine
Steamboat Medical Group
If you have any questions about Summit Elite designation or Pinnacol’s CPI program, please contact Ken Crane, SelectNet network operations lead, at 303.361.4950.