Joint pain: A family Medicine Approach Eric Wooltorton MD Staff Physician TOH Civic Campus September 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 FIFE – the core of the Pt centred approach Pain: OPQRST Feelings Ideas (and fears) Function Expectations Onset Precipitate/Relief Quality Radiation Severty Timing

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: 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? 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 Inflammatory arthritis 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

Case 2: What else would you like to know about his pain? Why is family history important to ask? What physical examination would you do? What is Shober’s manoeuvre? Why would you check his eyes? What is your differential diagnosis for his back pain? Is there a role for diagnostic imaging at this point? Any other suggestions? 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 spine P175 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: 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? 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: 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. 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/LBPSUMM ARYnov24.pdf?_20150224221844