JOINT PAIN: A FAMILY MEDICINE APPROACH

Eric Wooltorton MD Staff Physician TOH Civic CampusSeptember 2015

Objectives today: Diagnosis

1) 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

Objectives today: Management

6) Discuss the management of degenerative arthritis.

7) List the various indications, contraindications and side effects of medication used to treat arthritis.

Acknowledgements

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

Onset Precipitate/Relief Quality Radiation Severty Timing

FIFE – the core of the Pt centred approach

Pain: OPQRST

Feelings Ideas (and fears) Function Expectations

Theme: The “Family Medicine Approach”

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

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

Approach to arthritis

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 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 Duration:

acute (hrs to days) eg gout or septic vs chronic (wks or longer) egRA vs

spondyloarthropathies Eg OA, IBD, psoriatic, torn meniscus, chondromalacia

patellae, osteonecrosis, celiac, hep C, hemochromatosis

# joints: 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

Symmetric or asymmetric (asym – reactive arthritis) 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/academics/academic-sections/msk/teaching-materials/online-musculoskeletal-radiology-book/appendicular-arthritis

Approach to arthritis

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

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

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 (be organized, red flags first, then most likely to

least - don’t give a laundry list) FIFE, OPQRST

Case 1:

1. What else would you like to know about her pain?2. What physical examination would you do?3. What is your differential diagnosis for knee pain?4. 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)

Stiffness generally mild, usually not a prominent symptom

Pain tends to worsen with activity, improve with rest

Usually N ESR and CRP

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

Non-inflammatory arthritis

Inflammatory arthritis

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

Prototype of spondyloarthropathies Reactive arthritis, psoriatic arthritis, IBD Often includes enthesitis (insertion points of

tendons, ligaments) Inflammatory back pain in young adults Pos FHx Radiographs: Sacroilitis Anterior uveitis Incr HLA-B27 Eventual fusion of L spine causes straightening

of spineP175 Gorman and Imboden, Current Diagnosis & Treatment: Rheumatology 2nd Ed.

4) LBP exam

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

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:

1.  What else would you like to know about his pain?2. What physical examination would you do?3. What is your differential diagnosis for his foot pain?4. 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

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:

1. What else would you like to know about her pain?2. What physical examination would you do?3. What is your differential diagnosis for her shoulder pain?4. Is there a role for diagnostic imaging at this point? Other investigations?5. 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.

Treatments: Non pharmacological:

weight loss, exercise, aqua fit, diet, stop alcohol, physiotherapy, prosthesis, glucosamine.

  Pharmacological:

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

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/LBPSUMMARYnov24.pdf?_20150224221844