*With the exception of programs from the ACCEL series, each of which qualifies for up to 4 Category 1 CME credits.
Volume 36, Issue 16
August 21, 2013
Joint Pain Peng Thim Fan, MD
Low Back Pain Dr. Fan
From Meeting The Challenge Of Primary Care, Presented By The David Geffen School Of Medicine At The University Of California, Los Angeles
The following is an abstracted summary, not a verbatim transcript, of the lectures/discussions on this audio program.
Orthopaedics Program Info Accreditation InfoCultural & Linguistic Competency Resources
Pain Management: Techniques for Improving Care
From Meeting the Challenge of Primary Care, presented by the David Geffen School of Medicine at the University of California, Los Angeles
Peng Thim Fan, MD, Clinical Professor of Medicine, David Geffen School of Medicine at the University of California, Los Angeles
The goal of this program is to improve management of common musculoskeletal problems and low back pain (LBP). After hearing and assimilating this program, the clinician will be better able to:
1. Identify tissues targeted by osteoarthritis (OA), rheumatoid arthritis (RA), and seronegative spondyloarthropathy.
2. Describe patterns of joint involvement of OA, RA, and seronegative spondyloarthropathy.
3. Recognize fibromyalgia based on patient history and clinical findings.
4. Determine causes of LBP.
5. Discuss the role of conservative treatment and surgery in patients with LBP.
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Fan is on the Speakers’ Bureaus for Abbott Laboratories, Amgen, Bristol-Myers Squibb, Genentech, and Pfizer. The planning committee reported nothing to disclose.
Musculoskeletal problems: degenerative — osteoarthritis (OA); inflammatory — rheumatoid arthritis (RA); seronegative spondyloarthropathy (eg, ankylosing spondylitis, psoriatic arthritis, Reiter syndrome, reactive arthritis, arthritis of inflammatory bowel disease); nonarticular — fibromyalgia
Target tissues: OA — articular cartilage (hyaline cartilage that lines joint); RA — synovium (thin lining of joint capsule); seronegative spondyloarthropathy — enthesis (where ligament attaches to bone)
Osteoarthritis: clinical OA — incidence of activity-limiting joint problem due to OA 25 to 26 million; radiographic OA — incidence 44 million; increases with age; Dutch study found nearly all patients ≥75 yr of age had OA either in finger joint (most common; eg, distal interphalangeal [DIP] joint), knees, or hips; asymptomatic patients should not be diagnosed with or treated for OA; pathophysiology — hyaline cartilage worn down, fibrillated, and lost; underlying bone becomes thicker (thought to accelerate OA); bone spurs form; loss of cartilage leads to joint swelling, cysts, capsule thickening, and joint instability; in time, deep fissures develop in cartilage, and cartilage eventually lost
Pattern of joint involvement of OA: driven by mechanical degradation of hyaline cartilage; frequently used joints and joints that transmit weight affected first; primary OA pattern — lower cervical vertebra (C4 through C6); lower thoracic and lumbar vertebra (eg, L3); hips; knees; big toe; base of thumb; tips of fingers; can be symmetric or asymmetric, but typically more involvement on dominant side; patients with history of paralysis or hemiplegia have relative protection on paralyzed side; knuckles, metacarpophalangeal (MCP) joints, wrists, ankles, shoulders, and elbows relatively not involved in OA (involvement warrants further workup); mechanical problems (eg, ski injury with old ankle injury) most common reason for OA in unusual joint (obtain trauma history; consider other conditions, eg, metabolic bone disease [eg, hemochromatosis] or hyperparathyroidism with pseudogout); typical OA — space narrowing in lower cervical spine; protrusion of osteophytes in neural foramina; facet joint arthritis; patients complain about creakiness and pain in back of neck and scapula, numbness and tingling in fingers, and neck stiffness; myelopathy rare; cervical spinal stenosis can occur, but less common; radiculopathy and local pain (in, eg, tips of fingers, Heberden nodes, Bouchard nodes) common; MCP joints not involved; thumbs typically rotated inward due to squaring; lumbar spine — low back pain; disc space narrowing; subchondral sclerosis; spondylolisthesis; facet joint arthritis; spinal stenosis; hip — groin pain and pain in front of thigh and knee; no hip pain; hip pain often presents as knee pain; knee — patellofemoral pain; creakiness and crepitus; difficulty getting up from low seat; difficulty walking down stairs, compared to walking up stairs; whole joint not involved uniformly (usually only one compartment involved; hallmark of OA); usually asymmetric; malalignment of knee primary cause of progression of OA; big toe — shifts sideways; bunions; toes crowded together and pop up
Other features of OA: no systemic symptoms; low morning stiffness; erythrocyte sedimentation rate (ESR) and C-reactive protein normal; uncommon in patients <40 yr of age, unless due to trauma or inheritance; knobby fingers common inheritance pattern
Rheumatoid arthritis: synovium transformed into proliferative tissue; severe inflammation with destruction of underlying cartilage and bone by invasion; joint swelling due to entrance of inflammatory cells, mediators, and cytokines; normal joint destroyed by inflamed synovium; confined to joint; spongy joint on clinical examination; if patient does not have synovitis, patient does not have RA
Pattern of involvement of RA: symmetric disease of small and large joints; all joints lined by synovium (eg, shoulders, elbows, wrist, MCP joints, proximal interphalangeal [PIP] joints, hips, knees, ankles, metatarsophalangeal [MTP] joints) can be affected; DIP joints and spine often not involved, except at C1 and C2; C1 and C2 — tiny synovial joints buffer C2 from C1; patients with severe RA have eroded odontoid process; can lead to atlanto-axial subluxation (excessive motion of C2 on C1; critical); obtain flexion view of neck in patients with RA undergoing surgery (if separation between C2 and C1 >3 mm, then spinal cord may be compromised and susceptible to damage if patient wrongly positioned under anesthesia); other joints — in patients who have difficulty walking, ataxic gait, and hyperreflexia in knee or ankle, consider myelopathy; finger deformities (eg, boutonniere or swan neck deformities); most patients can go into remission with very little progression; can lead to ulnar deviation, muscle wasting, collapse of thumb, and carpal tunnel syndrome; weak grip due to inability to extend wrist; fingers can spontaneously rupture; popliteal cysts where fluid dissects into calf; suprapatellar swelling; pain and spreading of toes; callouses on feet; consider RA in young woman with metatarsal pain
Seronegative spondyloarthropathy: inflammation of enthesis; characteristics — seronegative for rheumatoid factor; involvement of spine; sacroiliitis; arthropathy; usually asymmetric; development of “sausage” digits (swelling of entire finger or toe); ankylosing spondylitis — tends to be more symmetric; affects cervical, thoracic, and lumbar spine; sternoclavicular joints, manubrium, sacroiliac (SI) joints, and symphysis pubis can be affected; synovitis tends to occur in large joints (eg, shoulder); patients often have problems bending sideways or taking deep breaths; wasting of pectoral muscles
Inflammatory back pain: typical presentation — young man with morning stiffness and back pain that improves with movement; inability to sleep through night; alternating buttock pain; no true radicular symptoms; affects SI region; sacroiliitis — inflammation of SI joints (look irregular with sclerosis); leads to loss of joint due to fusion (results in symptom improvement); early detection by magnetic resonance imaging (MRI); squaring and fusion of spine can lead to “bamboo” spine (spine becomes one solid piece); leads to disability (with lack of chest expansion, no forward motion of spine, and hyperextension of neck) and abdominal protrusion; ankle swelling (not due to synovitis); RA vs psoriatic arthritis — symmetric synovitis in RA (psoriatic arthritis asymmetric); synovial inflammation in RA; sausage digits, nail pitting, and scalp psoriasis in psoriatic arthritis; nodules present in RA (no nodules in psoriatic arthritis)
Fibromyalgia: no specific target tissue; diagnosis based on history; widespread (ie, above and below waist on both sides of body) chronic pain and tenderness at specific body sites lasting >3 mo; passive range of motion normal; no mechanical disability; no atrophy or muscle weakness; tests (eg, ESR, x-rays, electromyography) normal; criteria — widespread pain and tenderness at ≥11 of 18 tender points; fatigue; morning stiffness; sleep disturbance; paresthesia; headache; anxiety; dysmenorrhea; dry eyes and mouth; depression; irritable bowel or bladder; Reynaud phenomenon; affective spectrum disorder; cognitive symptoms (recent memory); laboratory tests least important
Low Back Pain
Determining presence of systemic disease: perform more thorough investigation in older patients; consider cancer, compression fractures, spinal stenosis, and aortic aneurysms; bone pain due to metastasis of myeloma (most common at T4 through T7) tends to be continuous, progressive, and prominent with recumbence; lower back pain (LBP) that does not resolve with bed rest or worsens at night concerning; inflammatory back pain worse with recumbence and inactivity in men <40 yr of age; back pain due to infection not relieved by bed rest; if no relief after bed rest, perform further work-up; perform thorough evaluation in patients with fever, especially if on tumor necrosis factor inhibitors (suppress immune response; consider, eg, subacute bacterial endocarditis); bone destruction across disc space implies infection; if no significant findings, treat symptomatically
Cauda equina syndrome: surgical emergency; squeezed filament terminale must be decompressed; caused by tumor or massive midline disc herniation; causes severe acute pain and bowel or bladder dysfunction; saddle anesthesia; bilateral sciatica with leg weakness; poor rectal sphincter tone and no cremasteric reflexes
Anatomic causes of LBP: disc; facet joint slippage; spondylolysis can be from birth defect or stress fracture; spondylolisthesis can be degenerative or associated with spinal stenosis; nerve root compromise — most commonly L5, S1, and L4 nerves; L4 associated with pain and numbness in side of flank, front of thigh, and knee; L5 associated with pain in lower back and buttock area, down side of body to foot; S1 associated with gluteal pain down back, calf, and bottom of foot; 95% of disc herniations involve L5 and S1; weakness in forward hip flexion associated with L2 and L3 (backward hip flexion associated with L4 and L5); check great toe dorsiflexion (patients with motor L5 radiculopathy weaker with dorsiflexion); trouble with heel walking, L5, with toe walking, S1
Examination: insignificant findings — loss of lumbar lordosis; mild to moderate pelvic tilt; scoliosis, kyphosis; lordosis; soft tissue tenderness (consider fibromyalgia); leg-length discrepancy; important findings — vertebral tenderness (check for fibromyalgia); straight-leg raising “probably mystical” but <60° suggestive of concerning finding (can be negative in spinal stenosis); crossed straight-leg raising equally mystical; hyperflexion of knee in prone position may be important; MRI — not recommended; findings usually do not correlate with cause of LBP; increases likelihood of back surgery by 2.5 times
Spinal inflammation: ankylosing spondylitis — patient unable to touch toes due to inflammation in back; problems with lateral motion and turning; wasting; difficulty with deep breathing; morning stiffness lasts >30 min; LBP that improves with exercise but not rest suggests need for further workup; in patients who awaken during second half of night, consider infection, multiple myeloma, cancer, and ankylosing spondylitis; alternating buttock pain
Sacroiliitis: early MRI recommended (specify need for imaging of SI joints); sensitivity for early sacroiliitis nearly 100%; patients do not need HLA-B27 testing
Spinal stenosis: narrowing of canal; can be congenital; problems include ovoid rather than round trefoil; short pedicles; thickening of ligamentum flavum; protrusion of spinal discs; facet joint hypertrophy that may encroach on disc; common with advanced age; computed tomography superior to MRI; neurocompression causes symptoms; neurogenic claudication relieved by extension and increased by flexion; pain radiates beyond back to buttocks, thighs, and lower legs, and causes patient to stop walking; numbness or tingling in one or both legs; patients prefer to sit or stoop forward; pain relieved by leaning over table or resting with trunk prone over stairway; less pain with sitting or pushing grocery cart; symptoms may improve and evolve slowly; 15% improve over 4 yr; 70% remain stable; only 15% deteriorate
Treatment of acute episodes of LBP: only 10% of patients with herniated disc have pain at 6 wk sufficient for consideration of surgery; sequential MRI shows partial or complete resolution in two-thirds of patients after 6 mo; nonsteroidal anti-inflammatory drugs (NSAIDs) helpful; cyclooxygenase-2 inhibitors (eg, celecoxib [Celebrex]) helpful for older patients; cyclobenzaprine (Flexeril) reasonable first-line agent; 2.0 to 2.5g/day of acetaminophen (eg, Acephen, Panadol, Tylenol); bed rest only for 2 days; refer to physical therapy after 3 to 4 wk; return to regular occupation recommended; back exercises not helpful in acute phase; traction, facet joint injections, transcutaneous electrical nerve stimulation, corsets, and braces ineffective in controlled trials; manipulation as effective as other treatments, but limited for first 2 to 3 wk; acupuncture may be effective; trigger point injections controversial; narcotics — patients with herniated discs may need narcotics for pain (give on scheduled basis); no data available about long-term (>16 wk) use; most studies show no significant pain reduction, compared to placebo; 22% risk for dependence; epidural injections — may provide temporary relief; do not reduce rate of surgery; ineffective for axial disease; insufficient evidence for spinal stenosis or cervical radiculopathy; wait ≥1 mo before proceeding to surgery; if LBP severe, perform CT and MRI; 80% of patients with uncomplicated LBP improve with any mode of treatment; all modalities have same reported success rate; data suggest recurrence rate 22% to 36% in 1 to 3 yr
Advising patients: inform patients that most patients improve within 4 to 6 wk without treatment or with simple measures that can be done at home; studies show patients recover faster when they remain active; therapy, (eg, manipulation, yoga, or massage) not necessary in first 4 wk; advise patients not to exercise while still in pain; patients can start exercising when symptoms improve; walking, swimming, cycling, and low-impact exercises recommended; twisting, bending, and high-impact activities should be avoided; some exercises may help strengthen lower back muscles; patients with frequent episodes of LBP should continue exercises indefinitely due to risk for recurrence
Role for surgery: herniated disc — role for early discectomy; study of patients with severe sciatica for 6 to 12 wk found similar disability scores at 1 yr between patients who received early microdiscectomy and patients who received conservative treatment, but patients who had surgery had higher perceived recovery and relief of leg pain; degenerative spondylolisthesis with spinal stenosis — trial saw substantially greater improvement with surgery as early as 6 wk and persisting for 2 yr; modest improvement with nonsurgical treatment; surgery reasonable; spinal stenosis in absence of spondylolisthesis — intention-to-treat analysis found that at 2 yr, surgery improved pain but not physical function and disability; as-treated group did better in pain and physical improvement; cannot unreservedly recommend surgery in this setting unless patients younger with single-level stenosis without associated spondylolisthesis; if no slippage, then consider conservative treatment first; absolute need for surgery in cauda equine syndrome, neurologic deficit, or fracture; best cases for surgery include leg and back pain, poor response to conservative treatment, agreement between history, physical examination, and imaging studies, and patient well informed; techniques — pedicle screws can be used but not highly beneficial; fusion for disc disease not beneficial; artificial discs not superior to fusion; success rate of second surgery 23% (of third surgery 5%; of fourth and fifth surgeries 0%)
Dr. Fan was recorded in Wailea, Maui, Hawaii, at Meeting the Challenge of Primary Care, presented March 13-16, 2013, by the David Geffen School of Medicine at the University of California, Los Angeles. For course listings from this sponsor, visit www.cme.ucla.edu/courses/. The Audio-Digest Foundation thanks Dr. Fan and the David Geffen School of Medicine at the University of California, Los Angeles for their cooperation in the production of this program.
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