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Overview of Interventional Procedures and Medical Cannabis

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Overview of Interventional Procedures and Medical Cannabis Overview of Interventional Procedures and Medical Cannabis Christina Gonzaga, DO Medical Director Park Nicollet Pain Management Clinic St. Louis Park, Minnesota April 27, 2018 Agenda About Me Disclosures Objectives Overview of Pain Tests Case 1 Intervention Case 2 Medical Cannabis References About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References About Me • Medical Director • Pain and PM&R • BA in history from Loyola University Chicago • DO from Western University of Health Sciences Pomona, CA • Residency: St. Vincent’s Manhattan, NS-LIJ • Fellowship: Anesthesia pain, Thomas Jefferson University, Philadelphia About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References I have nothing to disclose About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Learning objectives • The state of pain care today • Review of the pain history and physical examination • Brief review of interventional pain procedures • Review of medical cannabis: risks, benefits and the future About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Current State of Pain Care Rehab Services Surgical External Services pain clinics Addiction Primary Medicine Patients Care with Pain PMR Chiro Urgent Mental Care Health Emergency Center About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Why do we need to design a better way? • Increases in opioid related deaths • CDC guidelines “Unless the nation develops an increased tolerance to chronic pain, reduction in opioid leaves a vacuum that will be filled with other therapies.”12 About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Interdisciplinary Care Model Pain- boarded Physician MTM Nursing Care Coordination Pharmac y Patients with Pain Pain Rehab Psycholog Services y (OT/PT) About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Role of the Pain Physician • Team player • Work in collaboration with all members of the interdisciplinary team • Trouble shoot medical aspects of the patient • Medication management and interventional management • Goals: Keep in mind the CDC guidelines. Decrease to lowest effective dose, work with the individual needs of patients, work along side team to educate, guide, and help patients develop multiple tools to help them manage pain. About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Interventional Procedures: How do you choose? •Back to the basics: history and the physical •Do not treat the diagnostic exam, treat the person in front of you •Talk to and LISTEN to your patient About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References History Location Character Severity Timing Onset Duration Frequency Alleviating and aggravating factors Associated signs and symptoms About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Back Pain RED FLAGS Back pain in children Loss of anal sphincter tone Constant progressive pain or fecal incontinence, at night saddle anesthesia Widespread progressive History of cancer/Marked motor weakness or gait weight loss disturbance Use of systemic steroids Inflammatory disorders Intense pain with minimal (ankylosing spondylitis) motion/structural deformity Marked morning stiffness Peripheral joint Drug abuse or HIV infection involvement Systemic illness Persisting severe restriction Difficulty with urination of motion About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Physical Examination Active range of motion • Observation: Forward flexion (Discogenic?) • Skin, muscle mass, bony structures, Extension (Facet joints?) as well as observation of overall posture Side bending (Facet joints?) • Position of lumbar spine (Scoliosis) Rotation (Facet joints?) • Gait Tendinopathy? Tear? Neurologic Examination • Palpation: Manual muscle testing • Bones Pinprick and light touch sensation, • Facet joints Reflexes • Ligaments and intradiscal spaces Balance Muscles • Babinski About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Sensation and Sensory Examination Mechanical Nociceptors: • Pin Prick and pinch Heat Nociceptors: • Temperature greater than 45 degrees Celsius Polymodal Nociceptors: • Respond equally to mechanical, heat , and chemically noxious stimuli Fast Pain: • Transmitted by well-localized myelinated A-fibers and is characterized by sharp, shooting pain Slow Pain: • Transmitted by unmyelinated C fibers and is characterized as dull, poorly localized burning pain About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Motor Examination: Muscle Grading • 5 Normal=Complete range of motion against gravity with full resistance • 4 Good=Complete range of motion against gravity with some resistance • 3 Fair=Complete range of motion against gravity • 2 Poor=Complete range of motion with gravity eliminated • 1 Trace=Evidence of slight contractility; No joint motion • Zero=No evidence of contractility About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Muscle Stretch Reflexes/DTRs Grading 0 =No response 1+ = Reduced, less than expected 2+ = Normal 3+ =Greater than expected, moderately hyperactive 4+ =Hyperactive with clonus (upper motor neuron sign) About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Commonly Test Nerve Root Levels C5-C6 Biceps reflex C7-C8 Triceps reflex L3-L4 Patellar reflex S1-S2 Achilles reflex About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References What’s the root cause? Root Dermatome Muscle Weakness C4 Shoulder Levator Scapulae (Shoulder shrug) C5 Lateral arm Biceps C6 Lateral forearm, first and Extensor carpi radialis second finger (weakness in wrist extension) C7 Middle finger Triceps (weakness in elbow extension) C8 Fourth, fifth finger; medial FDP; Finger flexion of middle forearm finger T1 Medial arm Dorsal interossei; Difficulty in keeping fingers abducted against resistance About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Root Dermatome Muscle Weakness L1 Back, over the greater None trochanter and groin L2 Back, front of thigh to knee Psoas, hip abductors L3 Back, upper buttock, front Psoas, quadriceps of thigh and knee, medial lower leg L4 Inner buttock, outer thigh, Tibialis anterior, extensor inside of leg, dorsum of hallucis; quadriceps foot L5 Buttock, back and side of Extensor hallucis, thigh; lateral aspect of leg; peroneals, gluteus medius, dorsum of foot; inner half ankle dorsiflexors, of sole and first, second, hamstrings, calf wasting and third toes About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Physical Examination Root Dermatome Muscle Weakness S1 Buttock, back of Calf and hamstrings; thigh, and lower leg wasting of gluteus, plantar flexors S2 Buttock, back of Calf and hamstrings; thigh, and lower leg wasting of gluteus, plantar flexors S3 Groin , inner thigh None S4 Perineum, genitals, Bladder, rectum lower sacrum About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Dermatomes About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Upper Extremity Dermatomes About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Lower Extremity Dermatomes About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Physical Examination Abdominal muscle strength Pelvis stabilizer strength, i.e. gluteus medius, maximus Tightness or stiffness of hamstrings Tightness or stiffness or hip flexors Tightness or stiffness of hip rotators Other specialized musculoskeletal examinations About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Spurling’s Test: Cervical radiculopathy •Extension and sidebending impinges the neural foramen and causes shooting pain down that arm About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Drop Arm Test •May be sign of rotator cuff tear •Careful to differentiate possible weakness of deltoid (could be a root problem) About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References YergasonTest •Palpate the bicipital groove •Examiner provides resistance •Patient actively tries to pronate while examiner upinates/external rotates arm •Pain in groove may be sign of bicep tendinitis About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Patrick’s Test Illustrated •Stresses the hip and sacroiliac joints •Same side hip pain = degenerative disease of hip •Opposite side pain may be due to SI joint dysfunction •AKA: FABER About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Tinel’s sign for CTS •Test for carpal tunnel syndrome •Tap over carpal tunnel, testing median nerve •Pain shooting down first three digits is a positive test About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Phalen’s test for CTS •Hold for 1 minute •Tests the median nerve •Pain shoots down first three digits About Me Disclosures Objectives Overview Tests Case 1
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