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Abstract
The purpose of this article was to provide a review for orthopaedic nurses and nurse practitioners who evaluate, manage, and care for patients with joint pain. Joint pain is a common complaint evaluated by primary care providers. The causation of joint pain is complicated to identify because of an extensive range of differential diagnosis. The history and physical examination are crucial components in evaluating and managing joint pain. The primary care provider uses clinical factors such as patient demographics, presence of inflammation, acute/chronic duration, extra-articular manifestations, pattern of joint involvement, and disease chronology. Many rheumatologic laboratory tests are nonspecific, but aspiration of the joint with synovial fluid analysis may provide diagnostic clues, especially to differentiate infection versus inflammation. Primary care providers utilize both pharmacologic and nonpharmacologic regimens to manage acute and chronic joint pain.
Pain is the most common and compelling reason for seeking medical care. Patients seek medical care for evaluation and symptom relief of pain because it interferes with activities of daily living, causes emotional distress, and results in lack of confidence in one's health. Joint pain is a common complaint presented to family physicians and results in 315 million office visits yearly for musculoskeletal complaints (Palmer & Toombs, 2004). The prevalence of arthritis/chronic joint symptoms in 2001 was 33% or 69 million people; this was further broken down into three categories: 10.6% (22.4 million) had physician-diagnosed arthritis only, 10.0% (20.9 million) had chronic joint symptoms only, and 12.4% (26.6 million) had both (Centers for Disease Control and Prevention, 2002). Prevalence increased with age, and women had a higher prevalence than men (Centers for Disease Control and Prevention, 2002). Musculoskeletal pain is responsible for 5.5 hr/week of lost productive time among the U.S. workforce (Stewart, Ricci, Chee, Morganstein, & Lipton, 2003).
The large prevalence, impact upon a patient's activities of daily living, and impact upon people's ability to work make joint pain a growing concern. The primary care provider will be required to provide immediate and ongoing care for these complaints. The challenge for primary care providers will be the ability to differentiate between acute and chronic joint pain because the treatments, complications, and prognosis are diverse. Treatment plans will consist of both nonpharmacologic and pharmacologic regimens.
Definitions
Joint pain is defined as discomfort or tenderness in one or more joints (Uphold & Graham, 2003). Acute joint pain is any joint pain that is expected to resolve within 6-8 weeks; chronic joint pain persists beyond this window (Palmer & Toombs, 2004). Goals for treatment of joint pain, whether acute or chronic, include reducing pain, reducing inflammation, facilitating healing, preserving function, and reversing or slowing the disease process (Palmer & Toombs, 2004). Acute joint pain is typically due to infection or trauma, but a flare of a chronic condition or initial symptomatology of an undiagnosed chronic condition should also be considered in the differential diagnosis. Acute joint pain frequently becomes chronic joint pain.
Case Study
A 65-year-old man who was 72 inches in height and weighed 260 lb presented to the clinic with complaint of right-knee pain. The patient reported that pain had begun years ago and had gradually gotten worse. He rated the pain a 6 on a scale of 10: 0 being no pain and 10 being the worst he had ever had. He reported morning stiffness that got better as he moved around, but if he walked or stood for long periods, he noticed swelling of the right knee. He had played football in high school and college and reported multiple injuries to the right knee with two arthroscopies for partial menisectomies. He had tried ice and elevating the knee with little relief. He denied fever, weight loss, night sweats, or lethargy. No history of diabetes, thyroid problems, heart disease, bleeding problems, or inflammatory bowel disease was reported. The patient reported that the knee pain was affecting his golf game, which was what he enjoyed doing at the time of reporting. The patient was not taking any medications and had no allergies.
On examination, the patient ambulated with an antalgic gait. No obvious deformity of right knee was noted. No heat, erythema, or edema was noted. No pain with palpation was observed. Crepitus was noted. No laxity was noted with anterior/posterior drawer or Lachman's test. No atrophy of quadriceps muscle was noted. Full range of motion (ROM) with minimal pain was observed. Pain increased with weight bearing.
The patient was told to reduce weight-bearing activities. He was encouraged to begin weight loss program and exercise program, using swimming or stationary bicycle. The patient was to try two tablets of acetaminophen 500 mg every 6 hr, without exceeding 12 tablets in 24 hr. He might also thinly apply the capsaicin 0.025% cream to the affected joint four times daily and should wash hands after applying it. He was offered script for physical therapy but refused. He was encouraged to apply heating pad to the knee and elevate it above the heart while at rest. A two-view weight-bearing x-ray of the right knee was obtained and the patient was asked to return to the clinic in 1 week.
The patient was followed up 1 week after initial visit with report of minimal relief. X-ray films showed moderate amount of joint space narrowing of right knee. It was explained to the patient that we could try other pain medications, therapies with physical therapy, or a knee injection of hylan GF 20 (Synvisc), which is a replacement of the joint lubrication fluid and required an injection each week for a total of 3 weeks. The patient opted to try hylan GF 20. On follow-up, 5 weeks after initial hylan GF 20 injection, the patient reported total relief from pain symptoms.
Differential Diagnosis and History
A thorough history and physical examination are essential in determining the diagnosis of joint pain, because of the extensiveness of the differential diagnosis. Factors that may assist in the narrowing of the diagnosis are patient demographics, presence of inflammation, acute/chronic, extra-articular manifestations, pattern of joint involvement, and disease course. A complete review of systems is often needed to determine other organ involvement. Ominous signs found during the history that indicate an immediate workup include nocturnal pain/unremitting pain, systemic symptoms (i.e., fever, chills, weight loss), and significant disability/change in abilities (Palmer & Toombs, 2004).
There are key questions that assist in determining whether the joint pain is acute or chronic. Questions that the primary care provider should pose include how many joints are affected, whether or not there was any trauma, whether there was any inability to bear weight, where the pain was exactly located, and whether there were any other symptoms, that is, erythema, redness, or warmth, or if the patient exerts high physical demand on the joint.
History questions that will determine the potential of chronicity are family history of rheumatoid arthritis, osteoarthritis, and gout. Onset and progression of the joint pain may point to autoimmune disease processes. Queries about weight loss, unexplained fevers, chills, night sweats, unrelenting/nocturnal pain, or increased disability may eliminate or include systemic differentials.
Physical Examination
As usual, the important aspects of physical examination include inspection, palpation, ROM, and special tests, such as the anterior drawer test. Conduct the anterior drawer test by having the knee flexed to 80[degrees] and then verifying hamstring relaxation by palpation. The examiner will then place the foot in a neutral position that is stabilized. A gentle grip is applied to the proximal tibia, and then anterior force is applied in a quick motion to assess for increased translation as compared with the other knee. The physical examination should establish whether the joint pain is truly articular versus periarticular, as in bursitis or tendonitis. Physical findings that may help differentiate the diagnosis are as follows: ecchymosis and edema, which would indicate fracture or tendon tears, and crepitus, which can indicate derangement of bone, cartilage, or menisci. Sensory changes are indicative of neurological or vascular involvement. An increased joint volume must be evaluated to determine whether it is due to hypertrophy or joint effusion. ROM should be assessed as well. Increased ROM may indicate an unstable joint and decreased ROM may indicate effusion, adhesive capsulitis, or bony abnormality (Palmer & Toombs, 2004). It must be stressed to examine the whole patient, not just the affected joint. Extra-articular symptoms may provide additional indications toward differential diagnosis. Rashes may be indicative of systematic lupus erythematous, tophi of gout, and conjunctivitis of Reiter's syndrome, and mouth ulcers are indicative of Behcet's syndrome, Reiter's syndrome, and systematic lupus erythematous (Uphold & Graham, 2003). Certain joints are affected by differing disease processes as well. Rheumatic arthritis usually affects metacarpophalangeal and wrists, whereas distal involvement of interphalangeal joints suggests osteoarthritis rheumatic arthritis (Uphold & Graham, 2003).
Certain findings on physical examination that would indicate an urgent workup include rapid onset of pain, joint warmth, erythema, and swelling, which could indicate septic arthritis, osteomyelitis, rheumatic process, and crystal-induced arthropathy. All of these disease processes can lead to rapid joint destruction and sepsis. Additional findings that may indicate inflammation or infection are joint swelling, fatigue, weight loss, or fever.
Diagnostics
Laboratory studies are useful only if the provider already has a suspicion of a specific diagnosis. Rheumatoid factor may be helpful in diagnosis of rheumatic arthritis but is negative in approximately 30% of cases (Palmer & Toombs, 2004) and is often positive when the patient may have other conditions (Uphold & Graham, 2003). Selection of laboratory studies should be based on history and physical examination. Joint aspiration and fluid count may be done to distinguish between inflammatory diseases, noninflammatory disease, or if a joint is infected when signs of inflammation are present. Uric acid levels are often elevated in gout, and complete blood cell count and erythrocyte sedimentation rate are useful to determine inflammatory processes.
Arthrocentesis may be urgently indicated in the presence of inflammatory signs in the joint, for example, warm joint and erythema with effusion. Only 2-3 ml of aspirated synovial fluid is needed and should be sent for analysis, which should include cell count, culture, and crystals. A synovial fluid white blood cell count of up to 2,000 per mm3 suggests a normal synovial fluid, whereas a count from 2,000 to 50,000 per mm3 usually indicates inflammation, and a count greater than 50,000 per mm3 indicates infection (Baer, Patel, & McCormack, 2006). Removing fluid from the joint may provide symptomatic relief from pain as well. Disclosure is important to the patient as arthrocentesis is invasive and carries a risk of infection with it.
Indications for obtaining radiographs are discerned during the history and physical examination. Key indicators include trauma, focal bone pain, inability to bear weight, gross deformity, and skeletal immaturity. Plain radiographs are the screening modality for joint deformities. Weight-bearing films are indicated for knees and hips to determine joint narrowing. If soft-tissue pathogenesis is in question, magnetic resonance imaging provides unparalleled visualization of soft-tissue abnormalities.
Pharmacologic Management
A major factor in managing acute joint pain is being aggressive about pain management. Medication can be tapered as improvement occurs. Severe pain may require opioids; moderate-to-severe pain may be managed with nonsteroidal anti-inflammatory drugs (NSAIDs) or cyclo-oxygenase-2 (COX-2) specific inhibitors. It should be noted that COX-2 inhibitors and NSAIDs have shown an increased risk of acute myocardial infarction and thromboembolic events (Gislason et al., 2006). The risk of serious cardiovascular events has been found to be equal between NSAIDS and COX-2s (Moore, Derry, & McQuay, 2007). The prescribing provider would have to evaluate the risks and benefits for each patient. Milder pain may be controlled with acetaminophen. Adverse effects are unlikely with short-term use of these drugs, but specific contraindications include anyone with peptic ulcer disease, gastrointestinal (GI) bleeds, occult blood in stool, or sensitivity to aspirins or NSAIDs.
Pain control again is key in management of chronic joint pain. The provider may have to increase, change, and adjust medications frequently to provide adequate pain relief. Dosing of medications for pain management must be calibrated to the severity of the joint pain. Explain to the patient that pain management may require a trial-and-error approach.
Acetaminophen
Acetaminophen is the initial choice for reducing pain with minimal risks in the treatment of joint pain. Maximum dosage is 4 g/day with 4- to 6-hr dosing (Buttaro, Trybulski, Bailey, & Sandberg-Cook, 2003). At higher dosages, there is concern for nephropathy and increased risk of GI bleeding. This drug is contraindicated in patients with liver disease or alcohol use.
Nonsteroidal anti-inflammatory drugs and COX-2 inhibitors are effective in reducing inflammation and pain. They are excellent choices for mild-to-moderate pain control and minimizing disease progression among patients with joint pain. COX-2 inhibitors are proposed to be gentler on the GI tract than traditional NSAIDs. COX-2 inhibitors bypass the COX-1 prostaglandins that protect the stomach and act directly on the COX-2 prostaglandins, which are the source of the inflammation (Geier, Keeperman, Sproul, Roth, & Reynolds, 2002). Contraindications for NSAIDs include history of peptic ulcer disease, GI bleed, renal disease, liver disease, and sensitivity to aspirin and NSAIDs.
Opioids are useful when pain is unresponsive to acetaminophen or NSAIDs. There is no ceiling on pure opioids, but there is a defined ceiling on products combined with acetaminophen or NSAIDs based on the dose of nonopioid medication. Side effects of opioids are mainly GI and sedation. Constipation is the main GI side effect. It is recommended that a stimulant laxative be suggested when prescribing opioids. Caution should be taken when prescribing opioids to the elderly, because of the high incidence of sedation. Patient education should include avoiding driving, operating machinery, or activities that require alertness when taking opioids.
Chronic joint pain management may benefit from the addition of glucosamine and chondroitin preparations, which have shown the benefit with glucosamine, but not chondroitin with neither having unfavorable side effect reviews. The patient should be advised that the supplements do not work immediately and do not work for everyone. Patients taking anticoagulants, aspirin, or naiads should exercise caution when taking chondroitin, because of an increased risk of bleeding (Roberts, 2003). Theoretically chondroitin has a risk for increased bleeding when taken in combination with anticoagulants, aspirin, or NSAIDS due to its structural similarity to Heparin, but there have been no reports of bleeding from chondroitin (Abrams, Lammon, & Pennington, 2006; Fiebach & Barker, 2007).
Capsaicin cream has shown evidence of effectiveness by blocking substance P, which is responsible for pain transmission, and prompts the release of pain blocking endorphins (Roberts, 2003). The side effects range from burning to erythema and the cream should not be applied to broken or irritated skin.
Muscle relaxants may be used in conjunction with NSAIDs; their primary adverse effect is sedation. Tricyclic antidepressants and antiepileptics are useful in modulating pain signals and managing chronic pain syndromes.
Intra-articular injection of corticosteroids with local anesthetic can be useful in suppression of inflammation and anesthetic relief from pain. Contradictions include septic arthritis, local cellulitis, bacteremia, acute fracture, joint prosthesis, Achilles tendon or patellar tendinopathy, and history of allergy to corticosteroids or local anesthetics. Potential adverse effects include tendon rupture, iatrogenic infection, postinjection steroid flare, and soft-tissue atrophy.
Aspiration of fluid from a joint may be considered for the relief from pain caused by swelling and diagnostic purposes. Relief from pain may be short-lived because of the reaccumulation of fluid. The provider must have a thorough knowledge of anatomy to identify the site for injection and/or aspiration of the joint. Joint injection can lead to increased revenue for the primary care provider who masters it, and the patient will appreciate you saving him or her a trip to the specialist. Medicare reimburses $50 for injection of a small joint and up to $67 for a large joint. It takes the provider 5 min or less to do and has a potential reimbursement per hour of $804 (Martz, 2003).
Nonpharmacologic Therapies
Treatment is gauged at reducing swelling and pain associated with acute joint pain, usually trauma or arthritis. A mnemonic commonly used for these treatment measures is PRICE: P, protection, for example, bracing or wrap; R, rest, for example, avoid activities that cause pain; I, icing, 15 min at a time several times a day; C, compression, elastic wrap compression; and E, elevation of the affected joint above the level of the heart.
Nonpharmacologic Therapies
There has been a correlation between obesity and chronic joint pain (Adamson, Ebrahim, Dieppe, & Hunt, 2006), which leads to a need to discuss weight loss with the patient. This is complicated because the patient needs to exercise to lose weight, but improper or excessive exercise can hasten joint damage. Low-impact exercise (walking, water aerobics, etc.) has shown an increase in functional improvement and decrease in pain (Palmer & Toombs, 2004). Application of heat has been found to be effective in relieving knee pain related to osteoarthritis and back pain (McCarberg & D'Arcy, 2007). Topical heat can be applied with various options such as heating pad or heat wraps.
Physical therapy and occupational therapy can offer exercises that reduce pain by optimizing strength, endurance, and neuromuscular control, while reducing instability and pain associated with disuse due to pain (Menefee & Monti, 2005). Cryotherapy and heat are also widely used nonpharmacologic therapies utilized by physical therapists and occupational therapists. Physical therapists have also used transcutaneous electrical nerve stimulation devices with good results in pain management of joint pain (Fitzgerald & Oatis, 2004).
Office Interventions
Intra-articular steroid injections can provide short-term pain relief that lasts several weeks (Lavelle, Lavelle, & Lavelle, 2007). Common practice is to limit injections to every 3-4 months because it is not clear whether or not frequent injections will cause articular cartilage damage.
Viscosupplementation with hyaluronan provides improved resting pain and with physical activity. Injections are completed in a series of 3-5 injections over a period of 12 weeks. Viscosupplementation is most effective in use with patients who suffer from mild to moderate osteoarthritis (Bellamy et al., 2006). The most common adverse effect is iatrogenic infection.
Summary
Joint pain is a common complaint that is frequently seen and addressed in the primary care provider's office. The primary care provider must be able to provide appropriate evaluation and should seek referral for urgent findings. The primary care provider, who makes an effort to become knowledgeable about the medications and procedures required to provide the care, can adequately provide the management of patients with joint pain. Joint pain is also one of the most common reasons for hospitalization that require orthopaedic nurses to remain current with the most recent evidence-based treatments to maintain the quality of care.
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