Transcript Joint Pain - Civic Unit - E. Wooltorton, February 2015

JOINT PAIN: A
FAMILY
MEDICINE
APPROACH
Eric Wooltorton MD Staff Physician TOH Civic Campus
September 2015
Objectives today: Diagnosis
List the most frequent causes (acute and chronic) of
monoarthritis and polyarthritis.
 2) Distinguish between osteoarthritis (OA), rheumatoid
arthritis (RA), septic arthritis and gout from the physical
exam.
 3) List causes of low back pain
 4) Identify risk factors and red flags from history and
physical exam for LBP
 5) List indications for diagnostic imaging for LBP
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Objectives today: Management
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Discuss the management of degenerative
arthritis.
 7) List the various indications, contraindications and
side effects of medication used to treat arthritis.
Acknowledgements
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Dr Gary Viner for use of his many of his slides
uOttawa Medical students, clerkship program, and
Department of Family Medicine for use of the
“Problem Assisted Learning” cases
Figures from many references listed at end of this
presentation
What does the CFPC (99 priority
topics) specify?
99 Priority topics continued…
Family Medicine approach: Illness
& Illness experience
FIFE – the core of the Pt centred
approach
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Feelings
Ideas (and fears)
Function
Expectations
Pain: OPQRST
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Onset
Precipitate/Relief
Quality
Radiation
Severty
Timing
Theme: The “Family Medicine Approach”
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How does being a Family Physician potentially help when
approaching a patient with ... Joint pain?
Relationship, trust – understand coping style/ illness behaviours
 Awareness of “whole person”, illness experience (Pt and
family), functional impact incl financial, drug plan?
 Family: context/impact on function, collateral history, family
history
 Following patients over time: progression
 Awareness of co-morbidities, medications
 Care for pt with pretense of looking after other problems; time
to approach Dx over weeks
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Joint pain presents an inpact on
function: ADLS, IADLS
ADL: grooming, toileting, bathing, dressing,
transferring, continence, and eating
 IADL: telephone use, shopping, transportation,
budget management, adhering to medication
regimens, cooking, housekeeping, and laundry
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Approach to arthritis
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DDx: ***Think about this – it focusses your
history, exam and testing
*****consider serious Dx (red flags) and most
common/likely
Red Flags:
Hx:
PE:
Investigations:
Initial characterization of arthritis
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Duration: acute (hrs to days) vs chronic (wks or longer)
# joints (Mono, oligo (2-4); polyarticular (>=5)
Symmetric or asymmetric, additive or migratory
Accurate delineation of involved joints
Inflammatory or non inflammatory
Constitutional sxs
Extra articular disease
Comorbid conditions
P 33 Lange Current Diagnosis and Treatment: Rheumatology, 2nd Ed. Ed Imboden et al.
Initial characterization of arthritis
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Duration:
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acute (hrs to days) eg gout or septic
vs chronic (wks or longer) egRA vs spondyloarthropathies
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Eg OA, IBD, psoriatic, torn meniscus, chondromalacia patellae, osteonecrosis,
celiac, hep C, hemochromatosis
# joints:
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Mono –bacterial incl gonococcal, crystals, trauma
oligo (2-4); Gonorr. , septic arthr, viral, bact endocarditis, reactive
arthritis, Rheumatic fever (eg poststrep), spondyloarthropathy
(reactive, ankylosing spondylitis, psoriatic, IBD, gout, pseudogout, )
polyarticular (>=5) –viral eg fifths, SLE, RA, paraneoplastic, sarcoid,
secondary syphilis, vasculitis
P 33 Lange Current Diagnosis and Treatment: Rheumatology, 2nd Ed. Ed Imboden et al.
Initial characterizations of arthritis
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Symmetric or asymmetric (asym – reactive arthritis)
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additive or migratory
Accurate delineation of involved joints
 Eg OA DIP, PIP, 1st MCP
 RA PIPs, MCPs, MCPs. & wrists
Inflamm. vs non inflamm.
 Psoriatic, RA, Septic, crystal vs OA
Constitutional sxs
 eg fever
Extra articular disease
 Eg IBD, psoriatic arthritis, gastroenteritis (reactive arthritis),urethritis, conjunctivitis
(along with reactive arthritis)
Comorbid conditions
http://www.rad.washington.edu/academic
Approach to arthritis
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Red Flags: temperature, previous history of cancer,
trauma and infection signs.
Hx: trauma, swelling, morning stiffness, sexually
transmitted diseases, osteoporosis, recent surgery,
infiltration, stability of the joints
PE: general appearance; obesity; presence or
absence of heat, redness, swelling and pain;
amplitude of movements, test for ligaments, test for
meniscus and test to determine the presence of
effusion in the joints; approach to patient with low
back pain
Approach to arthritis
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DDX: ligament or meniscus problems, osteoarthritis
vs. rheumatoid arthritis, monoarthritis vs.
polyarthritis, gout, multiple myeloma, metastasis,
scoliosis, ankylosing spondylitis.
Investigations: blood tests, uric acid, radiography,
knee aspiration
Separate into 4 groups
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Start with your case – as a group you will present
the answers to the others
Then move to the next case
Work together, move quickly through the cases
THINK LIKE A FAMILY PHYSICIAN!
 Use
the DDx to guide your Hx and PE
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organized, red flags first, then most likely to least don’t give a laundry list)
 FIFE, OPQRST
Case 1:
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4.
What else would you like to know about her pain?
What physical examination would you do?
What is your differential diagnosis for knee pain?
Is there a role for diagnostic imaging at this point?
Any other tests?
5. What would you recommend to manage her pain
Red Flags:
Hx:
PE:
DDx: incl meniscal tear, OA, less likely inflammatory, #
Investigations
2) Distinguish between how OA, RA, septic arthritis and
gout will present (Hx and PE)
Non-inflammatory arthritis
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Stiffness generally mild,
usually not a prominent
symptom
Pain tends to worsen with
activity, improve with rest
Usually N ESR and CRP
Inflammatory arthritis
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Stiffness worse in am or after
inactivity “gel phenomenon”
Pain tends to improve with
mild/mod activity
Warm large joints, erythema
WBC incr in synovial fluid
ESR, CRP incr
Case 2:
1. What else would you like to know about his pain? Why is
family history important to ask?
2. What physical examination would you do? What is
Shober’s manoeuvre? Why would you check his eyes?
3. What is your differential diagnosis for his back pain?
4. Is there a role for diagnostic imaging at this point? Any
other suggestions?
5. What would you recommend to manage his pain?
Red Flags:
Hx:
PE:
DDx:
Investigations
3) Causes of
Acute LBP
3) Causes of acute LBP cont
Alberta “LBP” guidelines
Acute LBP Red flags
Ankylosing spondylitis
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Prototype of spondyloarthropathies
 Reactive
arthritis, psoriatic arthritis, IBD
 Often includes enthesitis (insertion points of tendons, ligaments)
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Inflammatory back pain in young adults
Pos FHx
Radiographs: Sacroilitis
Anterior uveitis
Incr HLA-B27
Eventual fusion of L spine causes straightening of spine
P175 Gorman and Imboden, Current Diagnosis & Treatment: Rheumatology 2nd Ed.
4) LBP exam
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Non spine – abd exam.
Strength -legs
Reflexes –knees, ankles
Palpation spine, incl SI joints
Spine ROM
 Shober’s
Manoever for ankylosing spondylitis
5) Indication for LBP imaging
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Imaging not warranted for most pts w. acute LBP
W/o signs and sxs indicating a serious underlying
condition, imaging does not improve clinical outcomes in
these pts.
Even with a few weaker red flags, 4-6 wks Tx is
appropriate before consideration of imaging studies.
If serious condition suspected, MRI is usually best
CT is an alternative if MRI is CI or unavailable.
likelihood of false-positive results increases with age
Radiography may be helpful to screen for serious
conditions, BUT low sensitivity and specificity.
Case 3:
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What else would you like to know about his pain?
What physical examination would you do?
What is your differential diagnosis for his foot pain?
Is there a role for diagnostic imaging at this point?
Other investigations?
5. What would you recommend to manage his pain?
Red Flags:
Hx:
PE:
DDx:
Investigations
Gout
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Triggers – thiazides, CRF, cancer
Inflammatory often mono-arthritis
“Bed sheet tenderness”
Often 1st MTP –distal cool joints
Tophi
Incr urate – eg purine rich diet (meat, seafood, EtOH)
Crystals on aspirate
Acute Txs incl NSAIDs, colchicine, prednisone
Purine lowering Tx eg allopurinol – in acute phase, adjust in renal
failure
Case 4:
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5.
What else would you like to know about her pain?
What physical examination would you do?
What is your differential diagnosis for her shoulder pain?
Is there a role for diagnostic imaging at this point? Other investigations?
What would you recommend to manage her pain?
Red Flags:
Hx:
PE:
DDx: incl bursitis, rotator cuff tear, #, mets, OA, referred (eg liver mets)
Investigations
6) Discuss the management of degenerative arthritis.
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Treatments:
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Non pharmacological:
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weight loss, exercise, aqua fit, diet, stop alcohol, physiotherapy, prosthesis,
glucosamine.
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Pharmacological:
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Tylenol, NSAIDs.
 Side effects and complications of the NSAID such as gastro, renal, cardiac,
HTN, allergy.
Orthopedic surgeon for arthroscopy and knee replacement.
For RA, early Dx and refer promptly to a rheumatologist.
 Discuss role of oral cortisone, and other disease modifying medications
(DMARD’s)
References
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Lange Current Diagnosis & Treatment: Rheumatology 2nd Ed.
[Editors John Imboden, David Hellman, John Stone] 2007,
McGraw Hill. Toronto, ON
Casazza BA. Diagnosis and Treatment of Acute Low Back Pain.
American Family Physician 2012; 85(4): 343-50
Top Doctors Alberta, Low Back Pain guidelines (2011)
Available:
http://www.topalbertadoctors.org/download/573/LBPSUMM
ARYnov24.pdf?_20150224221844