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PHYSICIAN ASSISTANT PROTOCOLS
It is the intent of this document to authorize the Physician Assistant at the Synovation Medical Group to
implement the Standardized Procedures, including all the policies and protocols under which they are to be
implemented, are defined in this document and will be referred to generally as the “Standardized
Procedures.” It is not the intent to have the Physician Assistant independently diagnosing, treating or
managing all the patient conditions she might encounter, but rather to utilize her assessment and health care
management skills in conjunction with the Standardized Procedures and the collegial Physician-Physician
Assistant relationship, to meet the health care needs of the patient.
1. The protocols should recognize that the Physician Assistant is acting only on behalf of and as an
agent for the supervising physician.
2. Although drugs listed in the formulary may be issued by the P.A. in accordance with the protocols,
all drug orders for Schedule II through V controlled substances must be issued with advance
approval by the supervising physician for the particular patient. This advance approval must be
noted in the chart, and the chart must note that the supervising physician has reviewed and dated the
chart within seven days thereafter.
3. The protocols must state that the electronic record shall contain written confirmation that the
supervising physician has reviewed and dated the chart entry within seven days, wherever a drug
order for Schedule II through V controlled substances has been issued.
4. These protocols apply to initial drug orders, refills, and dosage changes.
5. Each time a P.A. cares for a patient, and enters her name in the patient’s electronic record, the P.A.
must also enter the name of her supervising physician who is responsible for the patient’s care.
6. A supervising physician must be available in person or by electronic communication at all times
when the P.A. is caring for patients.
7. A supervising physician may only delegate to the P.A. those tasks and procedures consistent with
the supervising physician’s specialty and with his usual and customary practice.
8. Until assured of competency, the supervising physician must observe or review the P.A.’s
performance of all tasks and procedures delegated to the P.A.
9. The protocols must contain written procedures for the transportation and immediate care of patients
in need of emergency care beyond the P.A.’s scope of practice for any times when the supervising
physician is not in the office.
10. If a patient requires emergency care the P.A. should seek help from the medical staff on site, and
simultaneously call 911 to have the patient transferred to the nearest hospital or to the hospital
indicated of the Delegation of Services Agreement.
Protocols regarding procedures must state the information to be given to the patient, the nature of the
consent to be obtained from the patient, the preparation and technique of the procedure, and the follow-up
care that must be given to the patient. These protocols must be developed by the supervising physician,
adopted from or referenced to texts or other recognized sources, and signed and dated by the supervising
physician and P.A.
Development Revision and Review
The Standardized Procedures have been developed collaboratively by the Physician Assistant and
Physician. Review, and if necessary, revision, of the Procedures will be done annually every summer.
The completion of this task is ultimately the responsibility of the Physician Assistant and the Physician.
Approval and Agreement
Signature on the statement Approval and Agreement implies the following: approval of all the policies
and protocols in this document, the intent to abide by the Standardized Procedures, and willingness to
maintain a collegial and collaborative relationship with all parties. Physician Assistant and Physicians
who join the staff midyear or who cover the practice must also signify approval of the Standardized
Procedures. It is the task of office manager to see that written agreement by all the above parties is
obtained.
Setting
The Physician Assistant will perform these Procedures as the Pasadena Rehabilitation Institute. They may
also be performed by telephone or in other settings as part of the Physician Assistant practice in the Pain
Management Rehabilitation.
Record of Authorized Physician Assistant
The Physician Assistant must maintain a written record of all services provided.
Education and Training
The Physician Assistant must have the following:
• Certification by the State of California, Board of Physician Assistant as a Physician Assistant.
• Successful completion of a certified Physician Assistant Program.
• NCCPA certification.
Evaluation of Clinical Care
Evaluation of the Physician Assistant will be provided in the following ways:
Initial Evaluation
• For the first two weeks, all charts written by the Physician Assistant will be reviewed by the
Physician and cosigned.
• For the following three months, ten randomly selected charts written by the Physician Assistant
will be reviewed and cosigned by the Physician.
• Informal evaluation during consultations.
Introduction to the Standardized Procedures
The purpose of the Standardized Procedures is to define the scope of practice of Physician Assistants at the
Pasadena Rehabilitation Institute, in order to meet the legal requirements for the provision of health care by
Physician Assists. They are established to assist all health care providers with an understanding of the role
and Scope of practice of the Physician Assistant and to provide a safeguard so that the providers and
patients alike may be assured of the best health care possible.
These Standardized Procedures are based on the guidelines established by the Board of Physician
Assistants. Guidelines (see Appendix).
In order to provide the highest standard of care, these Standardized Procedures incorporate the following
qualities:
~ADAPTABILITY, in order to allow for the unique management needs of each individual patient,
~FLEXIBILITY, to accommodate the rapidly changing and complex nature of health care field and
acknowledge that medicine is not an exact science,
~PRACTICALITY, in order to be useful in a setting that must incorporate a variety of educational
backgrounds and personal management styles, and
~SPECIFICITY, to address the intent of the Standardized Procedure Guidelines which are meant to
protect the health care consumer.
The Standardized Procedures consists of the following:
General Policies: Gives authorization to the Physician Assistant, and defines the general conditions, for
implementation of the standardized procedures in this document.
Health Care Management Protocols: Delineates the functions requiring a standardized procedure and
using policies and protocols, defines the circumstances and requirements for their implementation by the
Physician Assistant.
PAIN MANAGEMENT / REHABILITATION
HEALTH CARE MANAGEMENT – PRIMARY CARE
Policy
Primary care conditions are common acute and chronic conditions such as back and neck pain,
radiculopathies, muscle pains, myofascial pain syndromes, fibromyalgia, acute and chronic sprain
strains. The Assistant is authorized to diagnose and manage primary care conditions under the
following protocols:
Protocols
1) A treatment plan is developed based on the resources listed in this document.
2) All other applicable Standardized Procedures in this document are followed during health care
management.
3) All General Policies regarding Review, Approval, Setting, Education, Evaluation, Patient Records,
supervision and Consultation in these Standardized Procedures are in force.
HEALTH CARE MANAGEMENT – SECONDARY CARE
Policy
Secondary care conditions may be unfamiliar, uncommon, unstable or complex. The Physician
Assistant is authorized to evaluate and treat secondary care conditions under the following protocols:
Protocols
1) A physician is communicated with regarding the evaluation, diagnosis and treatment plan.
2) Management of the patient is in conjunction with a physician as needed.
3) The physician is notified if his name is used on the referral to an outside physician or agency.
4) The consultation or referral is noted in the patient’s chart including name of Physician.
5) All other applicable Standardized Procedures in this document are followed during health care
management.
Evaluation, Patient Records, Supervision and Consultation in these Standardized Procedures are in force.
HEALTH CARE MANAGEMENT – TERTIARY CARE
Policy
Tertiary care conditions are acute life-threatening conditions such as, but not limited to cardiac and
respiratory arrest. The Physician Assistant is authorized to evaluate tertiary care conditions under the
following protocols:
Protocols
1) Initial evaluation and stabilization of the patient may be performed with concomitant
notification of and immediate management by a physician or by dialing 911.
2) Initial treatment may include all the modalities of ACLS.
3) The referral is noted in the patient’s chart including the name of the physician and emergency
care agency.
4) All other applicable Standardized Procedures in this document are followed during health care
management.
5) All General Policies regarding Review, Approval, Setting, Education, Evaluation, Patient
Records, Supervision and Consultation in these Standardized Procedures are in force.
PROCEDURES AND MINOR SURGERY
Policy
The Physician Assistant may perform the listed procedures under the following protocols:
1) Suture removal.
2) Trigger point injections.
3) Injection or aspiration of a joint or tendon.
Protocols
1) The Physician Assistant has been observed satisfactorily performing the procedures by the
physician.
2) The Physician Assistant is following medical technique for the procedures as described in the
Resources.
3) Appropriate patient consent is obtained before the procedure.
4) All other applicable Standardized Procedures in this document are followed during health care
management.
5) All General Policies regarding Review, Approval, Setting, Education, Evaluation, Patient
Records, Supervision and Consultation in these Standardized Procedures are in force.
ORDERING LAB WORK/DIAGNOSTIC STUDIES
Policy
The Physician Assistant is authorized to collect, order and interpret lab work and, diagnostic studies
under the following protocols:
Protocols
1) Lab work and diagnostic studies obtained, such as, but not limited to, hematology and chemistry
profiles, EKG, urinalysis, and radiology films must be appropriate to the Health Care
Management outlined in this document.
2) CT scans, MRI may be obtained and EMG and NCVs.
3) All other applicable Standardized Procedures in this document are followed during health care
management.
4) All General Policies regarding Review, Approval, Setting, Education, Evaluation, Patient
Records, Supervision and Consultation in these Standardized Procedures are in force.
ORDERING THERAPIES
Policy
The Physician Assistant is authorized to order therapies such as occupational, speech and physical
therapy, and psychological counseling, under the following protocols:
Protocols
1) Therapies are ordered as part of a treatment plan implemented for the Health Care Management
as outlined in this document.
2) All other applicable Standardized Procedures in this document are followed during health care
management.
3) All General Policies regarding Review, Approval, Setting, Education, Evaluation, Patient
Records, Supervision and Consultation in these Standardized Procedures are in force.
MEDICATION MANAGEMENT
Policy
The Physician Assistant may independently initiate the oral transmission of a valid prescription order
in the name of the physician under the following protocols:
Protocols
1) The drug or device is being ordered in accordance with the Standardized Procedures for Health
Care Management in this document.
2) The ordering of drugs or devices include the initiation, discontinuation and/or removal of
prescriptive medications and/or their over the counter equivalent.
3) The drug or device is appropriate to the condition being treated.
4) Medication history has been obtained:
a) other medications being taken.
b) medication allergies and adverse reactions.
c) prior medications used for concurrent conditions.
5) Plan for follow-up and refills is written in the patient’s chart.
6) All other applicable Standardized Procedures in this document are followed during health care
management.
7) All General Policies regarding Review, Approval, Setting, Education, Evaluation, Patient
Records, Supervision and Consultation in these, Standardized Procedures are in force.
FURNISHING MEDICATIONS
Policy
The Physician Assistant may write a transmittal order for drugs or devices pursuant to Section 3502.1
of the Physician Assistant Regulation, and under the following protocols:
Protocols
1) The Physician Assistant has a current furnishing number.
2) The drugs and devices are incidental to the provision of:
a) Pain management services.
b) Rehabilitation services.
3) Patient education is given regarding the drug or device.
4) The name and furnishing number of the Physician Assistant is written on the transmittal order along
with that of the supervising physician.
5) No single physician will supervise more than 4 Physician Assistants at any one time.
6) Ability to furnish will be a part of the Physician Assistants annual evaluation.
7) All other applicable Standardized Procedures in this document are followed during health care
management.
8) All General Policies regarding Review, Approval, Setting, Education, Evaluation, Patient Records,
Supervision and Consultation in these Standardized Procedures are in force.
Continuing Evaluations

Continual evaluation by the supervisory physician occurs on an ongoing basis with the continual
review of charts, authorization request forms and verbal discussion of patient during daily care.
Patient Records
The Physician Assistant will be held responsible for the preparation of a complete medical record for
each patient contact per existing policies.
Supervision
The Physician Assistant is authorized to implement the Standardized Procedures in this document
without the direct or immediate observation, supervision or approval of the physician, except as may be
specified on individual Health Care Management Protocols. Physician consultation is available at all
times, either on site or by telephone.
Consultation
The Physician Assistant will be managing primary, secondary and tertiary care conditions as outlined
in this document. In general, however, communication with a Physician will be sought for all the
following situations and any others deemed appropriate. Whenever a Physician is consulted, a notation to
that effect, including the physician’s name, must be made in the chart.

Whenever situations arise which go beyond the intent of the Standardized Procedures or the
competence, scope of practice, or experience of the Physician Assistant.

Whenever patient conditions fail to respond to the management plan in appropriate times.

Any uncommon or unstable patient conditions.

Any unexplained physical examination or historical findings.

All emergency situations after initial stabilizing care has been started.

At the patient’s, the Physician’s Assistant, or Physician’s request.

Whenever administering, providing or issuing a drug order for scheduled II through V controlled
substances.
APPENDICES
RESOURCES
PHARMACEUTICALS
1)
Barnhart Pub., Physician’s Desk Reference,
2)
Goodman and Gittman, The Pharmacologic Basis for Therapeutics
PAIN MANAGEMENT
3)
Bonica; The Management of Pain Volume I and II,
4)
Stein; Opioids in Pain Control
5)
Waldman; Interventional Pain Management
6)
Travell and Simons; Myofascial Pain Dysfunction
The Trigger Point Manual
Publisher: Williams and Wilkins
REGIONAL ANESTHESIA
7)
Neural Blockade in Clinical Anesthesia and Management of Pain
Cousins and Bridenbaugh
Publisher: Lippincott
8)
Regional Block
Daniel Moore
Publisher: Charles C. Thomas
9)
Atlas of Regional Anesthesia
Jordan Katz
Publisher: Appleton Century Crofts
FORMULARY
The following is a list of medications which may be utilized in the treatment plan implemented for Health
Care Management:
All drug orders issued by the P.A. should be issued only for a reasonable quantity, in accordance with your
customary medical practice.
Written prescriptions for drugs should contain the standard information, including the printed name,
address and phone number of the supervising physician, as well as the printed or stamped name and license
number of the P.A., and the signature of the P.A. The federal controlled substances registration number of
the P.A. must be included for the issuance of any controlled substance.
Allergic Disorders
Diphenhydramine (Benadryl) 25-50 mg p.o. q 6° prn
Hydroxyzine (Vistaril) 50 mg p.o. or IM q 4° prn
Analgesics/Anti-Inflammatories/Arthritis Agents
Acetaminophen 1-2 p.o. q 4° prn not to exceed 4 grm per day
Butalbital Preps (Esgic, Fiorinal)
Imitrex 1 q d prn
Bextra 10-20 mg po q d
Aspirin 325 mg p.o. q d
Trilisate 800 mg b.i.d. to t.i.d.
Vioxx 25 MG p.o. q d
Ibuprofen (Motrin) 400-800 mg p.o.
Ketorolac (Toradol) 15-30 mg IM q 6° prn
Diclofenac (Voltaren) 25-75 mg b.i.d.
Indomethacin (Indocin) 75 mg b.i.d.
Nabumetone (Relafen) 500-750 MG q d to b.i.d.
Naproxen (Naprosyn) 500 mg b.i.d.
Piroxicam (Feldene) 20 mg p.o. q d
Celebrex 100-200 mg b.i.d.
Ultram/Ultracet 1-2 p.o. q 6° prn
Anesthetics
Lidoderm Patch 1 to skin q day
Lidocaine w/wo Epinephrine 1cc per trigger point
Viscous Lidocaine 2 ml swish and swallow
Bupivacaine 1cc per trigger point
T #3 – Schedule II-V
T #4 – Schedule II-V
Hydrocodone
Morphine
Demerol
Dilaudid
Oxycodone
Propoxyphene
Stadol
Fentanyl
Methadone
*See attached guidelines for prescription of opiates:
a. Pain Management Reference Card and
b. Physician Assistant’s Dosing Guidelines
c. Medical Board of California Prescribing Guidelines
Anti-Anxiety/Sedatives
Hydroxyzine (Atarax, Vistaril) 50 mg q 4° prn
Buspirone (BuSpar) 15 mg b.i.d.
Valium 5-10 mg p.o. q 8°
Xanax 0.5-1.0 m p.o. q 8° prn
Klonopin 0.5-1.0 mg q 8-12°
Lorazepam 1 mg q d
Anti-Nausea
Prochlorperazine (Compazine) 10 mg IM or p.o.
Hydroxyzine (Vistaril) 50 mg IM or p.o.
Reglan 10 mg p.o.
Antibiotics/Anti-Infectives
Cephalosporins
Cephalexin (Keflex) 500 mg t.i.d.
Macrolides
Azithromycin (Zithromax, Z-Pack) 1 pack
Sulfonamides
Bactrim 1 p.o. b.i.d. x 5 days
Tetracyclines
Tetracycline 500 mg p.o. t.i.d.
Penicillins Broad-Based
Amoxicillin 500 mg qid x 5-10 day
Ampicillin 500 mg qid x 5-10 day
Augmentin 875 mg b.i.d. x 5-10 day
Quinolones
Ciprofloxacin (Cipro) 500 mg p.o. b.i.d. x 5-10 day
Anti-Convulsants (for pain management)
Carbamazepine (Tegretol) 100 mg tid – Check LFTs after 30 days
Phenytoin (Dilantin) 300 mg q HS
Neurontin 300 –1600 mg tid
Lamictal 500 mg b.i.d.
Trileptal 150-800 mg b.i.d.
Anti-Depressants
Amitriptyline (Elavil) 10-50 mg q HS
Desipramine (Norpramin) 25-25 mg q HS
Doxepin (Sinequan) 10-50 mg q HS
Imipramine (Tofranil) 25 mg q HS
Nortriptyline (Pamelor) 25-50 mg q HS
Trazodone (Desyrel) 50-100 mg q HS
Venlafaxine (Effexor) 75 mg b.i.d. to tid
Paroxetine (Paxil) 10-40 mg q prn
Fluoxetine (Prozac) 20-60 mg q AM
Sertraline (Zoloft) 50 mg p.o. q AM
(Wellbutrin) 75-150 mg b.i.d.
(Remeron) 15-30 q HS
Anti-Viral
Acyclovir (Zovirax) 800 mg qid x 5 days – must begin within 72 hrs. of acute onset
Famciclovir (Famvir) 500 mg q 8° x 7 days
Diuretics
Furosemide (Lasix) 20-80 mg p.o. q AM
Hydrochlorothiazide 25 mg p.o. q AM
Spironolactone (Aldactone) 50 mg p.o. q AM
Topical Steroids
Desoximetasone (Topicort) To skin of affected area b.i.d.
Triamcinolone (Kenalog) To skin of affected area b.i.d.
Gastrointestinal
Antacids
Amphojel 1 p.o. q prn
Maalox 1 Tsp. prn
Mylanta 1 Tsp. prn
Magaldrate (Riopan) 1 po q 12 hrs. prn
Anti-Ulcer/GERD
Cimetidine (Tagamet) 800 mg HS x4 wks and refer to internist if symptoms persist.
Famotidine (Pepcid) 10 mg p.o. q 12° prn and refer to internist if symptoms persist.
Ranitidine (Zantac) 150 mg b.i.d. and refer to internist if symptoms persist.
Omeprazole (Prilosec) 40 mg p.o. qd x 4-8 wks. If symptoms have not resolved after
4-8 wks refer to internist.
Sucralfate (Carafate) 1 gram b.i.d. and refer to internist if symptoms persist.
Anti-Diarrhea
Bismuth preps (Pepto-Bismol) 1 Tsp.
Loperamide (Imodium) 2 p.o. q 4° prn
Laxatives
Bulk:
Enema:
Softeners:
Stimulants:
Psyllium preps (Fiberall, Metamucil, and Citrucel) 1 Tsp prn
Fleets prn
Docusate, mineral oil 1 Tsp b.i.d.
Senna concentrate (Senokot), Dulcolax 1 p.o. b.i.d.
MUSCLE RELAXANTS
Carisoprodol (Soma) 350 mg p.o. q 8° prn
Chlorzoxazone (Parafon Forte) 500 mg p.o. t.i.d.
Cyclobenzaprine (Flexeril) 1 mg p.o. q 8° prn
Methocarbamol (Robaxin) 500-750 mg p.o. t.i.d.
Baclofen 10-20 mg p.o. t.i.d. to q.i.d.
Skelaxin 800 mg t.i.d.
Zanaflex 2-4 mg p.o. q 4° prn
Valium 5-10 mg po q 8° prn
SMOKING CESSATION AIDS
Nicotine Gum 1 prn. Taper over 4 wks.
Nicotine Patches 1 patch per week to start at highest dose and decrease by one step
each wk.
STEROIDS
Methylprednisolone (Medrol Dosepak) #1 Ed.D.
Prednisone – Up to 40 mg per day for a maximum of 10 days
Depo-Medrol – Up to 80 mg injection
Triamcinolone – Up to 40 mg injection
VITAMINS/MINERALS
Multivitamins
Vitamins A, D, B6, B12, C, E, in combination or singly
TREATMENT PROTOCOLS FOR CHRONIC PAIN PROBLEMS
The following protocols are designed to guide the Physician Assistant:
A.
LOW BACK PAIN
1. History and Physical Exam
- Develop a diagnosis
- metastatic disease to the spine
- diffuse degenerate disease of the spine
(rheumatologic disorders)
- facet or sacroiliac joint arthropathy
- myofascial pain syndrome
- herniated disc
- lumbar spinal stenosis
- scar tissue/arachnoiditis
- behavioral chronic pain syndrome
2. If no plain films, then order L/S spine series. If this is suggestive of malignant disease, then
an urgent oncology referral is the next step. If negative for malignant disease, then proceed with
the appropriate procedures based on diagnosis, as listed below.
- DJD Spine:
Epidural and facet joint blocks, if epidurals fail.
P.T. for lumbar stabilization exercises, stretching exercises and mobilization.
Consider low dose tricyclic antidepressant. If patient not improved, then
order MRI or CT as available. If surgical lesion is present, then refer for
orthopedic or neurosurgical consultation. If surgical intervention not
indicated, then reevaluate with the supervising physician for possible
functional restoration program referral or consideration for implant.
- Facet/S.I.:
Facet and S.I. Joint blocks.
P.T. for lumbar stabilization exercises, stretching exercises and mobilization.
Consider low dose tricyclic antidepressant. If patient not improved, then
order MRI or CT as available. If surgical lesion is present then, refer for
orthopedic or neurosurgical consultation. If surgical intervention not
indicated, then reevaluate with the supervising physician for possible
functional restoration program referral or consideration for implant.
- Myofascial:
- Disc:
P.T for stretching program, posture training, home exercise program.
Trigger point injections.
Consider acupuncture, biofeedback referral.
Low dose tricyclic antidepressant.
If patient not improved, then refer to functional restoration program.
Implants are not indicated.
Epidural blocks.
P.T. for lumbar stabilization exercises, stretching exercises and mobilization.
If patient not improved, then order MRI or CT as available.
If surgical lesion is present, then refer for orthopedic or neurosurgical
consultation.
If surgical intervention is not indicated, then reevaluate with the supervising
physician for possible functional restoration program referral or
consideration for implant.
- Stenosis:
Epidural blocks.
P.T. for lumbar stabilization exercises, stretching exercises and mobilization.
If patient not improved, then order MRI or CT as available.
If surgical lesion is present, then refer for orthopedic or neurosurgical
consultation.
If surgical intervention is not indicated, then reevaluate with the supervising
physician for possible functional restoration program referral or
consideration for implant.
- Scar tissue
Arachnoiditis:
- Behavioral:
Epidural blocks.
P.T. to treat secondary muscle problems.
Meds:
Tricyclic antidepressants
Anticonvulsants
Mexitil (Mexiletine)
MMPI, Behavioral Medicine Interview
If behaviorally and anatomically appropriate, do SCS or Pump implant.
If behaviorally inappropriate or if patient fails Pump or SCS, refer to
functional restoration program.
MMPI, Behavioral Medicine interview.
Refer to functional restoration program.
B.
HEADACHES
The vast majority of headaches (90%) are myofascial or muscle/stress type headaches (including
TMJ). About 6% are vascular in origin and the remainder are secondary to tumor, trauma, an expanding
vascular mass, infectious process or other major medical difficulty. Most patients with chronic H.A., who
will be referred to you, will already have undergone significant workup, although some may still need a
baseline MRI or CT. Nerve blocks, per se, do not usually play a big role in the management of this
problem. The suggested treatment paradigm is as follows:
1. Intake history and physical exam.
- Develop a diagnosis.
- Myofascial.
- Occipital Neuralgia.
- Vascular.
- Tumor, trauma, infection, etc.
2. If the origin of the pain is unclear and the patient has not had a baseline MRI or CT, then this
should be ordered. If the pain is secondary to tumor, trauma, infection or other major medical
problem, then the patient should be referred to a neurologist for further care.
3. If no major medical problems are identified then the recommended treatment paradigm by
diagnosis is as follows:
- Myofascial: P.T. for stretching program, posture training, home exercise program.
Trigger point injections.
Consider acupuncture, biofeedback referral.
Low dose tricyclic antidepressant.
Referral to TMJ dentist for splint, if TMJ is part of the problem.
If patient not improved, then reevaluate with the supervising physician for possible
functional restoration program referral or consideration for implant.
- Vascular:
Identify and treat myofascial triggers as above.
Drug therapy:
Ergotamine
Propranolol
CA Channel Blockers
Tricyclic antidepressants
Tegretol
Triptans
- Occipital neuralgia:
Occipital nerve block. If produces only short term relief then:
a. Try Meds:
- Tricyclic antidepressants
- Anticonvulsants
- Mexitil
And do behavioral medicine interview.
b. If occipital nerve block produces temporary relief, and
medications fail, and the behavioral interview does not produce
any contraindications, then refer patient for consideration of
radiofrequency neurolysis of the occipital nerve vs. C2.
C.
NECK PAIN
An intake history and physical are done, a diagnosis reached and a treatment plan developed and
discussed with the referring physician. The treatment paradigm is as follows:
1.
History and physical exam.
- Diagnosis
- DJD
- Cervical disc disease
- Myofascial
- Facet Joint Arthropathy
- Cervical spinal stenosis
- Scar Tissue/arachnoiditis
- Behavioral
2.
If no C-spine films have been taken, then order a C-spine series at the time of the first
visit. If this should show any evidence of malignant disease, then the patient should be
urgently referred to an oncologist for further workup. You should continue to manage
the patient’s pain in conjunction with the oncologist.
3.
If the C-spine series is negative for evidence of malignant disease then proceed as per
diagnosis below.
- DJD:
Epidural and facet joint blocks, if epidurals fail. P.T. for posture training,
stretching exercises and mobilization.
Consider low dose tricyclic antidepressant.
If patient not improved, then order MRI or CT as available. If surgical lesion
is present, then refer for orthopedic or neurosurgical consultation.
If surgical intervention not indicated, then reevaluate with the supervising
physician for possible functional restoration program referral or
consideration for implant.
- Disc:
Epidural blocks.
P.T. for posture training, traction, stretching exercises and mobilization.
If patient not improved, then order MRI or CT as available. If surgical lesion
is present, then refer for orthopedic or neurosurgical consultation.
If surgical intervention not indicated, then reevaluate with the supervising
physician for possible functional restoration program referral or
consideration for implant.
- Myofascial: P.T. for stretching program, posture training, home exercise program.
Trigger point injections. Consider acupuncture, biofeedback referral. If
patient not improved, then refer to functional restoration program.
Implants are not indicated.
- Facet:
Facet Joint blocks.
P.T. for posture training, stretching exercises and mobilization.
Consider low dose tricyclic antidepressant.
If patient is not improved, then order MRI or CT as available. If surgical
lesion is present, then refer for orthopedic or neurosurgical consultation.
If surgical intervention not indicated, then reevaluate with the supervising
physician for possible functional restoration program referral or
consideration for implant.
- Stenosis:
Epidural blocks.
P.T. for posture training, stretching exercises and mobilization.
If patient not improved, then order MRI or CT as available. If surgical lesion
is present, then refer for orthopedic or neurosurgical consultation.
If surgical intervention not indicated, then reevaluate with the supervising
physician for possible functional restoration program referral or
consideration for implant.
- Scar tissue
arachnoiditis: Epidural blocks.
P.T. to treat secondary muscle problems.
Meds:
- Tricyclic antidepressants
- Anticonvulsants
- Mexitil
MMPI, Behavioral Medicine Interview.
If behaviorally and anatomically appropriate, do SCS or Pump implant. If
behaviorally inappropriate or if patients fails Pump or SCS, refer to
functional restoration program.
- Behavioral: MMPI, Behavioral Medicine interview.
Refer to Center for Rehabilitation and Pain Management.
D. CHRONIC ABDOMINAL PAIN
This section will cover pain secondary to benign pathology only. These patients will almost always
present after multiple comprehensive workups by internists, gastroenterologists and general surgeons.
They often will have had multiple surgeries. There is a high correlation with both drug use and with a
history of physical and/or sexual abuse. Should a patient present with chronic abdominal pain and no
previous medical workup, then the patient should be referred to a gastroenterologist or internist for W/U
and referred back, if appropriate. There are some specific instances where invasive procedures can be
useful. If the origin of the patients pain is unclear, then a diagnostic block done with local anesthetic can be
useful in establishing if the pain generator is utilizing a visceral pattern of innervation. The recommended
treatment paradigm is as follows:
1. History and physical exam.
- Establish a diagnosis.
- Chronic or Recurrent Pancreatitis
- Adhesions secondary to previous surgeries
- Irritable bowel syndrome
- Crohn’s Disease/Ulcerative Colitis
- Myofascial
- Behavioral
2. If no previous workup done, then refer to gastroenterologist or internist. It is important to
have a diagnosis and to assure no malignancy is present. Once diagnosis is reached, then
proceed as per diagnosis.
- Pancreatitis: Patient should be under simultaneous care by an
internist/gastroenterologist. Celiac plexus block with local anesthetic may be
appropriate in the treatment of an acute recurrence and as a diagnostic block
prior to ETOH ablation. ETOH ablation usually provides about six months
relief, however, can be repeated.
If pain is chronic non-remitting, then patient may be appropriate for a pump
trial.
Behavioral problems are often present and, if any doubt is raised as to their
role, then an MMPI and Behavioral medicine interview should be performed.
- Adhesions: Patient should be under simultaneous care by an internist/gastroenterologist.
Celiac plexus block with local anesthetic may be appropriate in the treatment
of an acute recurrence and as a diagnostic block prior to ETOH ablation.
ETOH ablation usually provides about six months relief, however, can be
repeated.
If pain is chronic non-remitting, then patient may be appropriate for a pump
trial.
Behavioral problems are often present and, if any doubt is raised as to their
role, then an MMPI and
Behavioral medicine interview should be performed.
A trial of a tricyclic antidepressant may be warranted.
- Irritable bowel
Syndrome: Patient should be under care of G.I. or internist. This is not usually
amenable to invasives. There is a high incidence of behavioral problems.
Try low dose tricyclic antidepressant.
MMPI – behavioral medicine interview.
- Crohn’s/
U.C.:
Patient should be under the care of G.I. or internist.
Pain usually corresponds to pathology. As with all chronic disease problems,
behavioral issues may develop secondary to the illness. If these are felt to be
significant, order MMPI and a behavioral medicine interview.
If patients pain is almost continuous, then consider chronic opiate therapy.
If patient fails p.o. meds, then do pump trial.
- Myofascial: P.T. for stretching of involved muscles.
Trigger point injections.
Consider biofeedback/acupuncture.
Consider low dose tricyclic antidepressant.
- Behavioral: MMPI - Behavioral Medicine interview.
If appropriate refer for functional restoration program.
E. CHRONIC PELVIC PAIN
These patients should have undergone a standard gynecologic workup prior to being treated. If this has
not occurred, then referral to a gynecologist should be the first step. If the patient has failed standard Gyn
treatment (i.e., Indocin, hormonal suppression, laparoscopy with fulguration of any endometriotic foci),
then the patient will have as high as a 90% probability of having suffered physical and/or sexual abuse.
The primary treatment becomes a combination of psychotherapy, acupuncture and antidepressants.
Invasives play a role when combined with psychologic support. It is of course important to ensure
malignancy has been ruled out as a cause of the pain. This should be done by the Gynecologist. Nonmalignant causes are described below.
1. History and physical exam.
- Establish a diagnosis.
- Endometriosis
- Adhesions
- Behavioral
- Myofascial
2. Treat as per diagnosis.
- Endometriosis:
MMPI – Behavioral Medicine interview.
Psychotherapy/Acupuncture
Hypogastric plexus block.
- Adhesions:
MMPI – Behavioral Medicine interview.
Psychotherapy/Acupuncture
Hypogastric plexus block.
- Behavioral:
MMPI – Behavioral Medicine interview.
Referral to functional restoration program.
- Myofascial:
P.T. for stretching of involved muscles.
Trigger point injections.
Consider biofeedback/acupuncture.
Consider low dose tricyclic antidepressant.
F. REFLEX SYMPATHETIC DYSTROPHY
1. History and physical exam.
- Establish the diagnosis: Sympathetic blocks to the affected area until the problem
resolves, or further diminution in pain is not forthcoming from further blocks. P.T. to the
affected extremity, to regain range of motion.
TENS MEDS:
TCA/Propranolol/Ca Channel Blockers/
Phenoxybenzamine/Anticonvulsants
Pump vs SCS.
If patient fails above, then refer for intensive rehab program.
G. PERIPHERAL NEUROPATHIES
1. History and physical exam.
- Establish the diagnosis.
- Traumatic/Post Surgical
- Ischemic
- Diabetic
- Trigeminal Neuralgia
- Post Herpetic Neuralgia
- Phantom Limb Pain
2. Traumatic:
Meds:
- TCA
- Anticonvulsants
- Mexitil
Diagnostic sympathetic block. If significant relief of pain with block, then repeat until effect
plateaus or until pain is gone.
Consider neurolytic sympathetic block, if relief is reproducible on several occasions with
local anesthetic.
If in intercostal area, then consider cryoprobe to intercostal segments involved.
Pump vs SCS.
If behavioral issues appear to be involved, then do MMPI – Behavioral Medicine interview.
Ischemic:
If patient is not a viable candidate for revascularization, as determined by a vascular
surgeon, then do a diagnostic sympathetic block. If this produces good pain relief,
then repeat the block with neurolytic solution (10% phenol or 95% ETOH). This is
preferable to open sympathectomy.
Diabetic:
Meds:
- TCA
- Anticonvulsants
- Mexitil
Diagnostic sympathetic block. If significant relief of pain with block, then repeat until
effectplateaus or until pain is gone.
Consider neurolytic sympathetic block, if relief is reproducible on several occasions with
local anesthetic.
If in intercostal area, then consider cryoprobe to intercostal segments involved.
Pump vs SCS.
Trigeminal Neuralgia:
Meds:
- Neurontin up to 2400 mg tid
- Dilantin
300 mg q hs
- Tegretol
200 mg tid
- Klonopin 1 mg bid
- Elavil
25-75 mg q hs
- Baclofen 10 mg tid
Doses are suggestions only – you must titrate to effect.
If patient fails medical management, then proceed to trigeminal ablative procedure vs
Jannetta Procedure.
Post Herpetic Neuralgia:
Meds:
- TCA
- Anticonvulsants
- Mexitil
Epidural or sympathetic block. If significant relief of pain with block, then repeat until
effect plateaus or until pain is gone.
Consider neurolytic sympathetic block, if relief is reproducible on several occasions with
local anesthetic.
If in intercostal area, then consider cryoprobe to intercostal segments involved.
Pump vs SCS.
If behavioral issues appear to be involved, then do MMPI – Behavioral Medicine interview.
Phantom Limb Pain:
Meds:
- TCA
- Anticonvulsants
- Mexitil
Epidural or sympathetic block. If significant relief of pain with block, then repeat until
effect plateaus or until pain is gone.
Consider neurolytic sympathetic block, if relief is reproducible on several occasions with
local anesthetic.
If in intercostal area, then consider cryoprobe to intercostal segments involved.
Pump vs SCS.
If behavioral issues appear to be involved, then do MMPI – Behavioral Medicine interview.
CANCER PAIN
It is important to remember that not all pain in patients with malignant disease is secondary to the
malignancy. In adults with metastatic cancer, who also have pain, there is only a 66% probability that the
pain is secondary directly to tumor invasion. In children there is only a 33% probability that the pain is
directly related to tumor invasion. Therefore, it is important to assign a specific etiology to the pain.
1. History and physical exam.
- Establish the diagnosis.
- Tumor invasion
- Post surgical
- Chemotherapy related
- Radiation damage
- Deconditioning
- Depression
- Of benign origin
2. Suggested treatment paradigm:
- Tumor Invasion:
- Post Surgical:
Begin with Aspirin and NSAIDs.
Oral narcotics; utilizing the narcotic ladder. All meds should be given on a
time contingent basis.
TCA for sleep.
Low dose benzodiazepines for anxiety.
Amphetamine 5 mg at 8AM and noon for drowsiness.
This also potentiates pain relief.
If patient fails the above, then go to: S.Q. or I.V. M.S. infusion or trial or
epidural narcotics.
If the patient has good relief with a trial of epidural narcotic, then proceed
with device implantation.
If patient has localized pain in the thoracic area, then neurolytic intercostal
block is useful. If the patient has lower extremity pain, and has lost motor
function to bladder, bowel and the lower extremities, then a neurolytic spinal
done with 100% ETOH can be carried out with relatively little risk.
This is usually secondary to nerve trauma and should be treated as a
peripheral neuropathy.
Meds:
- TCA
- Anticonvulsants
- Mexitil
Diagnostic sympathetic block. If significant relief of pain with block, then
repeat until effect plateaus or until pain is gone.
Consider neurolytic sympathetic block, if relief is reproducible on several
occasions with local anesthetic.
If in intercostal area, then consider cryoprobe to intercostal segments
involved.
Pump vs SCS.
If behavioral issues appear to be involved, then consider behavioral medicine
interview.
- Chemotherapy
related:
This is a neuropathic or deafferentation pain syndrome secondary to
peripheral small fiber damage. It may disappear spontaneously over 6 months
to several years.
Meds:
- TCA
- Anticonvulsants
- Mexitil
Diagnostic sympathetic block. If significant relief of pain with block, then
repeat until effect plateaus or until pain is gone.
Consider neurolytic sympathetic block, if relief is reproducible on several
occasions with local anesthetic.
If in intercostal area, then consider cryoprobe to intercostal segments
involved.
Pump vs SCS.
If behavioral issues appear to be involved, then consider behavioral medicine
interview.
- Radiation:
This occurs secondary to direct nerve fiber death or to radiation fibrosis
encasing a nerve or nerve plexus.
Meds:
- TCA
- Anticonvulsants
- Mexitil
Diagnostic sympathetic block. If significant relief of pain with block, then
repeat until effect plateaus or until pain is gone. Consider neurolytic
sympathetic block, if relief is reproducible on several occasions with local
anesthetic.
If in intercostal area, then consider cryoprobe to intercostal segments
involved.
Pump vs SCS.
If behavioral issues appear to be involved consider behavioral medicine
interview.
Radiation especially in the head and neck area may produce fibrotic changes
which in turn produce a significant myofascial pain syndrome.
This should be treated as follows with the addition of narcotic analgesics as
needed.
P.T. for stretching of involved muscles.
Trigger point injections.
Consider biofeedback/acupuncture.
Consider low dose tricyclic antidepressant.
- Deconditioning:
This exacerbates other pain problems and is best dealt with via mild physical
therapy for activation as tolerated.
- Of benign origin:
To be treated as consistent with the diagnosis, as under chronic pain
protocols.
RECOMMENDED TEXTS
REGIONAL ANESTHESIA
1.
Neural Blockade in Clinical Anesthesia and Management of Pain
Cousins and Bridenbaugh
Publisher: Lippincott
2.
Regional Block
Daniel Moore
Publisher: Charles C. Thomas
3.
Atlas of Regional Anesthesia
Jordan Katz
Publisher: Appleton Century Crofts
COMPREHENSIVE PAIN MANAGEMENT
4.
The Management of Pain
John Bonica
Publisher: Lea and Febiger
5.
Textbook of Pain
Wall and Melzack
Publisher: Churchill Livingstone
OTHER
6.
Myofascial Pain and Dysfunction
The Trigger Point Manual
Travell and Simons
Publisher: Williams and Wilkins
7.
Workers’ Compensation and Personal Injury Patients
Mark Freifeld
MLF publications
1-310-474-6672