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Topics to review:
•Bony and articular pain •Soft tissue pain •Systemic rheumatic disease
The first question that you always need to ask yourself is:
Does this patient have a localized problem, or a systemic disorder (that perhaps presents with a focal symptom).
The next question that you always need to ask is:
• Where is the pain? “Point to it”. • How and when did it begin?
– Define time course (acuity of problem)
Bony and articular pain • Define the anatomy of the problem… – What is the SPECIFIC structure causing the pain?? • Define the pathology responsible for the symptoms… – – – – Mechanical pain Inflammatory pain Neuropathic pain Traumatic injury .
pain on movement Tendons…pain with passive stretch/resistance Soft tissues…pain with pressure/touch Radicular pain…distribution. pain quality .Defining the anatomy (And you thought you wouldn’t need to remember anatomy) • • • • • Bone…usually associated with wt bearing Articular…swelling.
not always accompanied by significant trauma . Can resemble inflammatory pain.Defining the pathology (the history is often the key) • Mechanical…pain with use. stiffness. relief with rest • Inflammatory…rest pain. …abrupt onset. throbbing • Neuropathic…burning pain in a distribution of nerve root. frequently positional • Malignancy-associated…actually not all that common. • Don’t forget fractures.
She notes pain in the distal IP joints and at the base of both thumbs. .Case 1. 63 yo female presents with a 2 year history of progressive hand pain. She has particular problems with her hobby of gardening. Pain is much more bothersome at the end of the day.
What is the most likely diagnosis? Are there additional diagnostic tests that are needed to confirm the diagnosis? .
Does the film tell you something that you didn’t already know? .
What is the best initial treatment for this patient? .
What is the best initial treatment for this patient? Think about this before leaping to the “obvious answer” .
– Finger and wrist splints – Topical capsaicin – Assistive devices • All the above available through Occupational Therapy . • Before reaching for the always-popular NSAID. think about possible local. nonpharmacologic treatment.Always ask yourself if you are dealing with a localized problem or a systemic problem with local manifestations.
Now what??? .OK….the nonpharmacologic approach didn’t work.
Treatment of mechanical pain • The key is analgesia more than suppressing inflammation. – So what about those COX-2 inhibitors? . try low dose first. – Acetaminophen used in full analgesic doses (1gm 4x day) can be as effective as NSAIDs in many patients – Some patients do respond better to NSAIDs.
COX-2 inhibitors vs nonselective NSAIDs • NOT more effective • Similar frequency of dyspepsia • Lower frequency of significant GI bleed – Frequency is pretty low in pts who are not “at risk” – Significant GI bleeding not usually preceded by GI sx – Low dose ASA may negate this benefit • Higher frequency of cardiac thrombotic events as compared to nonselective NSAID • $$$$ * see supplementary info at end for additional info re: COX-2 safety & alternative therapies for OA .
Arrives in office unable to bear weight on left side. PE shows minimal swelling above the ankle and medial tenderness 1 cm above the ankle . 63 yo female in generally good health except for some COPD experiences the sudden onset of severe pain in her left ankle as she is descending the stairs of her house.Case 2.
Is this a localized or systemic process? .
Define the anatomy • What are maneuvers that will help you define the anatomy?? .
Define the pathology • Based on the history. what is the most likely cause of her pain? .
What additional data do you need?
Radiographs of the left ankle and distal tibia are normal
Sudden onset of pain on weight bearing is a fracture until proven otherwise.
• Stress fractures frequently not apparent on initial plain films • Treatment can include immobilization and f/u film (if in the foot) • MRI is nearly 100% sensitive
– If sx are in hip, you must rule out stress fx, because these need to be stabilized.
but FREQUENTLY associated with osteoporosis. . • The management of osteoporosis depends on early recognition and intervention.Stress fractures • Not always.
BUT it is much harder (or impossible) to restore bone after the development of severe osteoporosis. • Use FRAX to determine fracture risk .Osteoporosis • Prevention should begin BEFORE menopause – Adequate calcium & vitamin D intake • Consider screening soon after the onset of menopause – There are a number of effective strategies that prevent bone loss.
FRAX – WHO fracture risk assessment tool www.ac.uk/FRAX/ .shef.
.Case 3. His back pain dates back nearly 10 yrs but the pain has recently escalated. Worse with activity and at the end of the day. 68 yo farmer presents with 4 mo of progressively worsening back pain. No night pain and pain is relieved by rest. Pain is now compromising his ADLs.
Normal neurologic exam.Physical exam shows limited and painful lumbar flexion and twisting. .
Is this a localized or systemic process? What is the likely anatomic source of the pain? What is the likely pathologic cause of the pain? .
What tests are reasonable at this point? .
high WBC/CRP – Evolving neurologic symptoms • These patients require detailed imaging (MRI) even if plain films are normal .Diagnostic testing in low back pain. • Plain films are probably warranted • Beware of patients with “red flags” – Night pain – Rest pain – Escalating. severe pain – Fever.
Low back pain with an identifiable anatomic cause of pain • What are the treatment options for this patient…list 2 or 3? .
• What about opiates? • What about surgery? . – Many pts like this one derive some (or a lot) of benefit from an exercise program. Risk is zero. • Pharmacologic treatment should focus on analgesia.Low back pain with an identifiable anatomic cause of pain • Remember non-pharmacologic approaches.
Exam shows mild varus in the knees. and bony prominence of the medial compartment. a small cool effusion on the right. Now he has pain in the knees at the end of the day and after walking more than ¼ mi. .Case 3 (cont) He returns to see you 6 mo later and reports that his back pain is “manageable”.
Is this a localized or systemic problem? What is the anatomy of the problem? What is the pathologic process? Are there any diagnostic tests you should perform? .
When should you order radiographs in patients with osteoarthritis? • Is the diagnosis in question? • Do you suspect another problem? • Is the patient at a point where surgery could be considered? .
• Analgesics/NSAIDs as in back pain • Weight loss • ? Intraarticular glucocorticoid injection • What would make you refer the patient to an orthopaedic surgeon for TKR? .Management of OA of the knee • Quadricep strengthening exercises can be of some help (certainly are risk-free).
Management of OA of the knee • The indications for joint replacement surgery are: – Uncontrolled pain – Unacceptable loss of function .
The pain is most bothersome in the morning. 32 yo male presents with a 5 yr history of low back pain. . Generally the pain improves with activity and as the day progresses.Case 4. and he notes up to 2 hrs of AM stiffness.
. When he bends to touch his toes his fingers are 30 cm above the floor.Physical exam shows some flattening in the lower spine.
Is this a localized or systemic problem? What is the anatomic structure involved? What is the pathology responsible for the symptoms? What tests would be appropriate? .
CBC normal except platelets 488k. .2 mg/L. chemistry normal. CRP 6.
MRI scan showing marrow edema and inflammation in a patient with AS and a normal plain film .
Treatment options?? .
Response of 2 A. patients to treatment with either infliximab (b) or etanercept(d).S. .
pain frequently decreases .Advanced ankylosing spondylitis…once fusion has occurred.
Elbow hurts all the time and kept her up last night.Case 5 34 yo healthy female presents with 3d history of a painful swollen elbow. . Symptoms began 2 days after she landed hard on her elbow while playing with her son.
Is this a localized or systemic problem? What can you do to define the anatomy responsible for this problem? What is the pathologic cause of the patient’s symptoms? .
.Don’t be fooled into ascribing a problem to a bone or joint when the cause is really in the overlying tissue. but flexion stretches the bursa and is painful. The diagnosis here is olecranon bursitis. The key element of the physical exam is that the elbow can be extended without pain.
What diagnostic tests are appropriate? .
Aspiration of the olecranon bursa yielded 10 cc of slightly cloudy fluid Gram stain negative Now what??? .
• 90+% Staph aureus • Treat with antibiotics pending culture if WBC count is high • May require 3+ weeks of treatment • Do NOT succumb to the temptation to I &D! – Patient will likely be left with a fistula. • Infection is common (Gm stain sensitivity may be only 50%).Olecranon bursitis • Common in primary care • Does not “spread” to the elbow joint without penetration. .
index. but for the past 6 weeks she has regularly been awakened by burning pain in her thumb. A 42 yo secretary consults you because of 3 months of worsening hand pain.Case 6. The pain occasionally bothers her at work while typing. She tells you that she has to shake her hands and the pain disappears in 2-3 minutes. and long fingers. . Exam is totally normal.
Can you EXCLUDE certain anatomic causes…sometimes this is your best approach. What is the likely pathologic process causing the pain? .
Diagnostic tests? Treatment? (is this a localized or systemic problem?) .
. • BUT…you can delay the NCVs pending the response to splints. If you plan to send the patient to a surgeon. • NCVs (almost never need EMGs) can confirm the diagnosis. then NCVs are necessary to confirm the diagnosis. • Patients like this one may respond to night splints.Carpal tunnel syndrome • Characteristic clinical presentation.
The hand pain is centered in the MCP and PIP joints. She also notes the recent onset of severe afternoon fatigue. .Case 7 A 33 yo female presents with a 6 week history of pain and stiffness in the hands. Pain and stiffness is much worse in AM. 2 wks ago she began to have pain in the MTPs of her feet.
Is this a localized or a systemic problem? What anatomic structures are involved? What is the pathologic process? Additional testing? Most likely diagnosis? .
The pathology of RA (a disease of synovium) .
In RA the cartilage and bone are SECONDARILY involved .
Under treated RA almost always results in deformities .
patients with early RA were managed primarily with NSAIDs. • “Disease modifying agents” were added after the disease showed evidence of progression (bony erosions).Treatment of RA • Until relatively recently. • Current practice includes the early introduction of DMARDS to suppress the synovial inflammation (and prevent erosions) .
• Treatment options include – – – – – – Methotrexate Hydroxychloroquine Sulfasalazine TNF-alpha antagonists Anti B cell agents + Low dose prednisone • Many rheumatologists have stopped using regularly administered NSAIDs because of side effects in favor of more aggressive DMARD treatment .Treatment of RA • Get some help early in the disease.
His history includes both heavy alcohol use and IV drug abuse 2-3 times a week. The pain awakened him from sleep and is now so severe that he cannot bear to have sheets touching the ankle.Case 8 44 yo construction worker presents in the ER with a 6 hr history of severe pain in the right ankle. . and exquisite tenderness in the region of the ankle. mild erythema/ swelling. Exam shows warmth.
What is the pathologic process? What diagnostic tests are warranted? .Is this a local or systemic problem? What can you do to better define the anatomy in this case?…this time it’s really important to do this.
Acute monoarthritis • First of all…be sure that symptoms come from a joint rather than overlying soft tissue or tendons • With respect to the “ankle” you need to be precise…Is it the true ankle or is it in the subtalar joint or midfoot? • If you plan to aspirate you need to go into the right spot. .
• Evaluation of joint fluid – Culture (routine) – Cell count/diff (if enough) – Crystal exam .Acute monoarthritis • Almost always requires aspiration. • The main DDX is infection vs crystalline-induced arthritis.
Cephalosporin to cover Gm negative organisms (GC) .Treatment of monoarthritis • Assess probability of hematogenous spread of infection. • Cover Staph aureus and add 3rd gen. you should assume that the patient has an infected joint. • Admit and treat with IV antibiotics. • If the crystal exam is negative. or the risk of infection is high.
Evaluation of monoarthritis
• Most common cause of infectious arthritis in young sexually active adults is GC. Remember that the all sexually active individuals can be infected with GC. • Female:male about 3:1…usually coincides with menses. • Tenosynovitis and skin lesions are common in GC. • Staph aureus is responsible for majority of non - GC joint infections - usually large joints.
Clinical characteristics of gonococcal and nongonococcal arthritis Gonococcal Characteristics Patient profile Sexually active young adults, mainly women Migratory polyarthritis dermatitis, tenosynovitis Polyarticular ∼50% Newborns or adults with chronic disease (diabetes, RA, OA) Single joint involvement Nongonococcal
Pattern of joint involvement
Oligoarticular ∼90% Nearly 90% Usually bad prognosis, requiring joint drainage in most cases
Culture positivity Less than 50% Prognosis Good with adequate antibiotic therapy
Abbreviations: OA, osteoarthritis; RA, rheumatoid arthritis. Data from Goldberg DL. Septic arthritis. Lancet 1998;351:197–202.
arthritis of PIPs and moderately elevated BP (165/98) . and skin rash. fatigue. Physical exam shows a facial rash. She also notes intermittent chest pain.Case 9 A 26 yo female presents with a 2 month history of joint pain.
Is this a local or systemic problem? What tests are warranted now? .
” .Evaluation of possible SLE • Ask the “lupus questions” • Don’t reach for the ANA right away! • Check the lupus criteria that don’t appear in the history or exam. – CBC/diff – UA with micro (on a fresh specimen) – BUN/creatinine • The ANA is very sensitive but has poor specificity… use it to confirm a diagnosis you suspect. DO NOT USE THE ANA AS A TEST TO “SCREEN FOR LUPUS.
• Not all patients have organ threatening disease. brain. kidneys.Evaluation of possible SLE • Major organ involvement may justify steroids: marrow. • Hydroxychloroquine may be enough for serositis. • Treatment needs to be individualized… there is no handy algorithm. . skin. • Patients respond to steroids. heart. but steroids have predictable toxicity.
PE reveals multiple tender points in nonarticular sites.Case 10 A 39 yo female presents with a 6-9 mo hx of fatigue. She has gained 20 # in the last 6 mo. . severe myalgias and arthralgias. She is missing work 1-2 times/wk. The remainder of the exam is normal. She hurts all the time and is having trouble with ADLs. She describes very poor sleep and feels tired in the AM.
mood. and physical inactivity? .Is this an inflammatory process? Are the symptoms a manifestation of an underlying disease? What about sleep.
Round up the usual suspects • • • • • • • • TSH CBC/diff Renal function/electrolytes Hb Alc Calcium. Magnesium CRP/ESR 25-OH Vitamin D Testosterone in males .
• ANA (remember this is NOT a screening test). . she has no arthritis. • Lyme serology…does not meet clinical criteria.Don’t order lab tests that will confuse the situation. • RF…so what if it is positive.
OK…all the tests come back negative. What is the likely diagnosis??? .
Avoid opiates. benzodiazepines). • NSAIDS minimal help. • Remove offending agents (caffeine. • Tricyclic at bedtime for deep sleep. • Enlist physical therapist as coach and gentle stretching and daily progressive low impact aerobic exercise program. self-management. Need to continue for months. . • Treat underlying depression.Management of fibromyalgia • Education. Let them adjust dose.
low grade fever.Case 11 A 70 yo male presents with a 10 week history of severe proximal myalgias. He notes severe AM stiffness that lasts > 3hr. additionally he had begun to notice R side headaches of increasing intensity. In the last week he noted the onset of painful swelling in several MCPs. There is mild synovitis in several MCPs . Physical exam shows normal strength and no tender points. 15# weight loss.
Is this a local or systemic problem? Possible diagnoses? Additional questions? Additional tests? .
PMR may be accompanied by GCA ( about 30%) Lab features – High ESR/CRP – Anemia • NEED TO RULE OUT: infections (esp.granulomatous). SPEP • Temporal artery biopsy if there are cranial/temporal symptoms . neoplasms (esp. Get CXR.PMR and Temporal Arteritis • • • • • Patients almost always over 65 (F:M =3:2) Severe prox. May have synovitis and significant wt loss. myeloma). myalgias and stiffness (not weakness).
– Arterioles and post cap.Vasculitis • May involve only skin and be self limited. • Can be manifestation of drug allergy. venules .
• Can be manifestation of drug allergy. • Is the vasculitis targeting medium or large vessels? .Vasculitis • May involve only skin and be self limited.
• Is the vasculitis targeting medium or large vessels? • Does vasculitis also involve visceral structures?? Recent onset of unexplained dysfunction in two or more organs. . • Can be manifestation of drug allergy.Vasculitis • May involve only skin and be self limited.
• Identify most likely pathologic process. . – Know in advance what your response will be to the potential outcome of tests. • Remember to consider non-pharmacologic approaches when appropriate. • Order tests that will MEANINGFULLY contribute to establishing the diagnosis or facilitate treatment.Take-home Messages • Is the problem: – Localized – Systemic – Localized manifestation of systemic disease • Define the anatomy as precisely as you can.
Supplementary Information •Recommendations for use of Cox-2 inhibitors •Alterative therapies for OA .
other trade name and generic products). • December 23. Naprosyn. naproxen (Aleve. 2004 . may be associated with an increased CV risk compared to placebo. Celebrex.FDA Public Health Advisory: Recommendations for use of Cox-2 Inhibitors • Why: Recently released data from controlled clinical trials showing that COX-2 selective agents (Vioxx. Why: preliminary results from a long-term clinical trial (up to three years) suggest that long-term use of a non-selective NSAID. and Bextra) may be associated with an increased risk of serious cardiovascular events (heart attack and stroke) especially when they are used for long periods of time or in very high risk settings (immediately after heart surgery).
– Consumers are advised that all over-the-counter (OTC) pain medications. – Individual patient risk for cardiovascular events and other risks commonly associated with NSAIDs should be taken into account for each prescribing situation. 2004 . or are not doing well on nonselective NSAIDs may be appropriate candidates for Cox-2 selective agents. including NSAIDs. – Patients who are at a high risk of gastrointestinal (GI) bleeding. have a history of intolerance to non-selective NSAIDs. December 23. should be used in strict accordance with the label directions. Consult a physician if use of an (OTC) NSAID is > 10 days. should consider this emerging information when weighing the benefits against risks for individual patients.FDA Public Health Advisory: Recommendations for use of Cox-2 Inhibitors • What: – Physicians prescribing Celebrex (celecoxib) or Bextra (valdecoxib).
(One 2001 study theorized that sulfate may be important in the effectiveness of glucosamine and nonsulfate preparations may not have any benefits. – A well-controlled 2001 study observed a beneficial trend after three months of treatment.) • Chondroitin Sulfate. – In four of the studies it was equal or superior to NSAIDs. – A major 2001 analysis of studies reported that glucosamine sulfate was safe and effective for osteoarthritis. – Studies in 2000 and 2001 reported that glucosamine sulfate slowed or even prevented progression of joint changes that cause osteoarthritis.Alternative treatments: OA • Glucosamine and chondroitin sulfate: – are natural substances found in and around cartilage. – A review of seven European trials involving chondroitin sulfate indicated that pain scores dropped by about 60% with chondroitin versus only about 20% from placebo. • Glucosamine Sulfate. – extracts from animal products have been used in Europe for more than a decade to reduce pain and improve mobility in patients with osteoarthritis. – both substances may possibly play a role in cartilage repair and maintenance. .
– A major US trial is under way to determine both risks and benefits. – No one should take either or both agents without seeking medical advice. suggests that major drugstore brands (CVS.Alternative treatments: OA • Side Effects.) . It should be noted that a preliminary study suggests that glucosamine reduces the metabolic action of insulin. however. – Although at this time few adverse side effects have been reported. (Note: Some supplement products for the joints that contain a blend of ingredients in addition to glucosamine and chondroitin sulfate are being reformulated to contain lower levels of manganese. which would be of great concern among diabetic and obese individuals. – An analysis of commonly available brands. Wal-Mart) of combination products are manufactured with appropriate ingredients. long-term effects are still unknown. Walgreens. – Potential users need to be aware that the FDA does not regulate glucosamine and chondroitin products. which should not exceed 11 mg a day because excessive amounts of the mineral can cause liver damage.
offered painrelieving benefits for arthritis of the knee. – Efficacy: • 2002 study: viscosupplementation. Synvisc) into the joint approved as medical device for the treatment for osteoarthritis. • Other studies reported: – between 39% and 56% of patients were at least nearly free of weightbearing pain 10 to 24 weeks after the final injection. usually given in situations not approved by FDA.Alternative treatments: OA • Viscosupplementation: (Synvisc. Hyalgan). and more work is needed. . alone or with an NSAID. pain at the injection site and knee pain and swelling. • Serious adverse reactions are rare • most common side effects. – Injection of hyaluronic acid (Hyalgan. • Injections are also expensive. are usually mild and temporary. – Response better or much better for 87% of knees after a second course. – Side Effects. which was administered about eight months later. • More research is needed to confirm their benefits and long-term risks: Case reports of pseudosepsis. • Nevertheless. a number of studies on viscosupplementation have shown little or no benefits. – Hyaluronic acid is a naturally occurring substance in joints that acts as a lubricant for slow movements and a shock absorber for fast motions. particularly during physical activity but also for pain at rest.
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