Since returning to Southern California in 2015, I’ve continued to practice outpatient neuromuscular and musculoskeletal medicine, complex pain disorders, inpatient acute as well as subacute rehabilitation for the full spectrum of patients admitted to these environments, both in team coverage as well as liaison consultation settings.
In the past year, more attention has been devoted to the evolving subacute rehab population, or “Active” rehab protocols outside the conventional inpatient acute rehab unit. The trend is increasing for patients that do not meet the 3 hours / day minimum therapy requirements for inpatient acute rehab, or those with uncertain discharge plans, driving the challenge to find methods that will still accomplish functional recovery with a varied team of therapists, and typically more medically challenging patients. In managed care triage, unless young spinal cord or brain injured patients are involved, ongoing cost control efforts and longer average lengths of stay the subacute patients require, are motivating some of this shift.
In the outpatient setting, along with the expected complex pain and neuromuscular patients, spine injuries, preoperative and postoperative joint and spine surgery patients, the trend towards evidence based methods, outcome statistics, and newer technologies, in hand with the socially charged chronic opiates directives, newer ways to recover function without dependence producing medications, refinement of ultrasound guided injections of nonsteroid medications, prolotherapy, advances in physical therapy protocols, and strides in stem cell technologies, all of this changing the landscape for the chronic pain and chronically disabled patients, pushing us to forge protocols without steroids and opiates, without dependence producing medication whenever possible. And, of course, along with the valuable electrodiagnostic studies regularly used, imaging studies are advancing rapidly, all of this pushing the frontiers for the specialty at a rate never encountered before.
Most recent prior position: 2000-2011:
Kaiser Permanente South Sacramento: Staff Physician, Department of Physical Medicine. Duties entailed the full spectrum of physical medicine and rehabilitation services, including post-acute and aftercare of spinal cord injuries, stroke, brain injury, musculoskeletalpain, sports, and soft tissue injuries, chronic pain, electrodiagnosis, and inpatient consultations, (mostly since the trauma center opened.)
The majority of the practice is complex pain management, from clarification of the diagnosis (inaccurate in up to 40% of the referrals), to generation and execution of the careplan, be it further diagnosis or serial trials of rigorous conservative options, to procedural referrals or the surgeon’s opinion.. Postoperative pain care and long term pain options are routine. Addiction and medication dependence are routine issues along with outpatient detox or treatment.
Various team integration, from neurosurgery and other multispecialty trauma related surgeons, to the various members of the restorative therapy teams, including behavioral management, psychiatry, and the full complement of PT / OT/ speech, sometimes acupuncture, and other “Alternative” practitioners, were coordinated and consulted with regularly, when needed.
PREVIOUS POSITION: 1996-2000:
Private practice within the Greater Honolulu area with an island-statewide regional referral pattern. Emphasis is on the interdisciplinary care of complex neuromuscular and musculoskeletal patients, with a representative cross-section of complex pain, industrial injuries, peripheral and central nervous system trauma, arthropathic, motor vehicle injuries, electrodiagnosis, and chronic pain / joint disease.
Teaching responsibilities are active and current as an Assistant Clinical Professor with the Univ. of California Davis, previously with University of Hawaii, John A. Burns School of Medicine, basic clinical rotations in neuromuscular and musculoskeletal science sections, with elective exposure at the 4th year level.
Semester level courses were offered at the Academy for Lifelong Learning at the University of Hawaii in alternative approaches to pain management, and at area Allied
Sciences colleges for physical therapy assistant science, as well as community based free lectures on a twice monthly basis on a variety of common physical medicine topics.
Proportionally, an emphasis on the provision of forensic services, including special medicolegal evaluations, Independent Medical Evaluations and Electrodiagnostic Studies, and Lifecare Planning Summaries, has occupied approximately 20% of the practice hours.
The evolution of the current practice has allowed inclusion of alternative and progressive methods of non-drug, non-procedural (Complimentary) approaches alongside more conventional pharmacological, surgical, and injection techniques, in providing a balanced and diverse array of services and products for each group of patients. The unique exposure of a Waikiki based practice to international tourist as well as local patient populations has fostered an East-West meld of eclectic approaches.
Prior outpatient populations included a representative mix of the full scope of physical medicine and rehabilitation services, including post-acute traumatic brain injury, spinal cord injury, physical medicine, neuromuscular disorders, electrodiagnosis, spasticity procedures, complex pain disorders, amputee care, urodynamics, and chemical dependence; serving adult and pediatric populations. Interdisciplinary coordination of anesthesiological and surgical care, including spinal implantation (Stimulators and pumps) for pain and spasticity, has continued.
Medical Director, Spasticity Management and Motor Movement Disorders Clinic
Long Beach Memorial Medical Center, Long Beach California
Full clinical and dynamic electrodiagnostic assessments of all types of motor movement disorders, leading to interdisciplinary team conclusion of interventions, including Botulinum Neurotoxin, Neuroablative phenolizations, pharmacologic protocols, or combined interventional therapies, special equipment Rx, etc.
Private practice, San Pedro, California.
Initially medical director, then supervising attending on a 20-bed general rehab unit. All outpatient and inpatient activities were overseen.
Director of Rehabilitation Services
Long Beach, CA.
Pain Management Medical Center
Full range of outpatient and inpatient complex pain disorders management. Direction of the inter- disciplinary team, supervising biofeedback, structural and physical therapy, and psychologists; Procedures included facet and selective nerve root blocks, epidural and soft tissue injections, examinations under anesthesia, coordination of pump and stimulator teams.
Director of Rehabilitation
Post-acute Program Director
Director, Dysphagia and Nutrition Programs
Developed mixed subacute and skilled nursing level Rehabilitation programs. Training and coordination of in-house Fiberoptic Endoscopic Evaluation of Dysphagia program (FEED)
Director, Pharmacological Restraint Committee
Developed team-based agitation management strategy, monitored in-house use of all psychotropic drugs in geriatric patients.
Driftwood Healthcare Center Subacute Program Torrance, California
Teaching responsibilities to medical students through senior residents as Assistant Clinical Professor, University California at Irvine, Department of Physical Medicine and Rehabilitation, Long Beach Memorial Hospital, Long Beach, California.
Harbor – UCLA Medical Center, Guest Faculty, Department of Neurology (Neuro-urology lectures).
Associate Medical Director
Rehabilitation Institute of New Orleans (RINO) at F. EDWARD HEBERT HOSPITAL.
Gulf Coast Regional Spinal Cord Injury Program
Urodynamics Evaluation Laboratory
Developed CORF based Industrial Medicine Center for Work Recovery, (IMCWR)Medical Director, Pediatric Neurology Unit, ORTHOPEDIC HOSPITAL, Los Angeles, California
Mississippi Methodist Rehabilitation Hospital
Stroke Rehabilitation Unit
Spinal Cord Injury Unit
- Phenolizations (neuroablative)
Over 3000 done
- Botulinum Toxin Injections
- Dystonia, Torticollis, Motor
- Movement Disorders, Spasticity
- Intrathecal Baclofen Pumps
Physiatrist on Infusion Team Long Beach Memorial
- Coordinator of Interdisciplinary Care and Pharmacologic Trial Protocol- CVA, SCI, TBI, MS
- Fiberoptic Endoscopic Evaluation of Dysphagia (FEED)
- Videofluroscopic Correlation/Clinical Evals
- Pharmacologic Management of Subcortical Function
- Full Lower Motor Neuron Assessment
- Neuropathy, Myopathy
- Radiculopathy and Entrapments
- Current Perception Threshold (CPT) screens
- Specialized Myofascial Tissue Injury Assessment (Forensic), see citation above
- Detoxification in Complex Patients
- Agitation Management/Control
- Neurobehavioral Intervention in TBI/CVA
- Chemical Dependence/Alcoholism in Rehab Diagnoses
- Full 6 – Channel Study Capability
- Diagnostic/Therapeutic Pudendal Blocks
- Fluoroscopic (VCUG) Correlation
- Uro-neurologic Pharmacologic Evals
- Erectile Dysfunction/Treatment
- Central Pain
- Sympathetic Maintained Pain Syndromes (RSD)
- Myofascial/Fibromyalgia Pain
- Nerve Blocks/Myofascial Injections
- Manual Medicine (Manipulation) Techniques
- Work recovery protocols
- Drug detox and treatment
- Non-narcotic pain medication trials
- Cranial Electrotherapy (Microcurrent) Protocols (Fisher WallaceI and Alpha Stim)
(aka: Transcranial Microcurrent)
- HakoMed and Magnetic Coil trials
COMPLEX PAIN PROCEDURES:
- Selective Nerve Root Blocks
- Examinations under anesthesia
- Differential blocks, peripheral
- Injured worker evals
- Work recovery and jobsite analysis
- Lifecare plans
- Custom musculoskeletal Recovery Plans
- Implantable pump and Dorsal Column Stimulators
- DuPenn Catheter Protocol
SPINAL CORD INJURY:
- Ventilator Dependence/weaning
- Alternative Ventilation Methods
- Functional Neuromuscular Stimulation
- Orthotics/Hybrid Ambulation
- Sexuality/Fertility Issue
- Special Equipment Prescription
- Addiction in the Disabled Patient “Triple diagnosis disorders”