Back pain is the most common type of injury in workers’ compensation. General principles related to the effective management of this condition are applicable to most types of injuries. Below is a fictional case study designed to assess both your knowledge of back pain management and care coordination in general. Please read the vignette carefully in order to identify as many problematic aspects of the case as you can.
Injury and initial treatment
A 46-year-old female restaurant worker develops acute nonradicular back pain while she is lifting a box of cleaning supplies onto a high shelf. She is seen in urgent care, where the treating provider notes that she has a fifth-grade education, has been smoking 1.5 packs of cigarettes per day for 30 years, drinks a “moderate” amount of alcohol, and recently went through a divorce. She is referred to an occupational medicine physician for ongoing care. A week later, after determining the patient has no neurological red flags, the physician orders an MRI, which shows a “small” L5-S1 central disc protrusion. The physician also refers the patient for physical therapy and to a physiatrist for an epidural injection and refills her muscle relaxant and NSAID prescriptions.
Complications/ongoing treatment
A month later, when the patient fails to realize a benefit from these interventions, the physiatrist refers her to a pain medicine physician who prescribes Nucynta, an opioid analgesic. With neither improvement nor worsening of symptoms six weeks later, the physiatrist refers her to an orthopedic surgeon for an opinion. The orthopedic surgeon orders a second MRI, which is read in a different imaging center by a different radiologist, who comments on a “moderate” left central L5-S1 protrusion.
After comparing the two MRI dictations, the surgeon informs the patient that her disc problem has worsened and that, although discectomy is an option, surgery provides no guarantee of benefit and that she should discuss this option with her primary care provider. The patient sees her occupational medicine physician a week later and announces that she has decided to proceed with surgery. She then undergoes surgery, yet again she fails to realize any improvement.
Ultimately, after being off work for almost nine months since the date of her injury, she is declared at MMI and given an impairment rating. She disagrees with the rating and engages the services of an attorney.
Test yourself
This fictional but realistic vignette raises a host of issues. While physicians always need to independently exercise their best clinical judgment, the vignette helps to illustrate important principles related to the care of an injured worker with back pain. Many of these principles are delineated in the DOWC Medical Treatment Guidelines (MTGs) by means of evidence statements derived from the peer-reviewed literature, and others are based on well-established norms related to how physicians can best communicate and coordinate care.
Before reading further, how many distinct areas of concern can you identify in the clinical management of this patient? (Identifying one or two items means that there is significant room for improvement; three to four means that there is opportunity to enhance your knowledge; five to six is very good; and seven or more is superior.)
Ideally, the occupational medicine physician would have kept close tabs on the patient and asserted control at critical junctures. The occupational medicine provider should have stressed to the physiatrist that he or she (the occupational medicine physician) was the ATP, but the physiatrist should also have known this without being told. The physiatrist could have shared an opinion with the occupational medicine physician but should not have directly referred the patient to a surgeon. After – or ideally before – the surgery consult, the occupational medicine physician could have scheduled a long visit with the patient (which is reimbursed within Colorado’s workers’ compensation system) to carry out shared decision-making and perhaps get agreement about decreasing alcohol use and increasing exercise. This process might have revealed the patient’s fear of surgery. The patient might have been reticent to undergo surgery after learning its benefit is highly doubtful in the absence of neurological findings. Ultimately, she might have decided to pursue conservative treatment after receiving some additional guidance.
Summary
This vignette illustrates several ways in which the MTGs can help both physicians and patients make reasonable decisions while highlighting the importance of effective communication and coordination of care.
What did you think of this exercise? Would you like us to create more like it? I’d love to hear from you at tom.denberg@pinnacol.com.