Back Pain
Joint Maneuvers
OA
Gout & Pseudogout
Clinical
100
Money spent on diagnosing, treating, and lost productivity in the U.S. per year:
-$10-20B
-$20-30B
-$30-40B
->40B
What is $100-200B? This includes lost productivity of over 100 million days. Second only to heart and vascular disease. On par with cancer. 5% of the chronic back pain patients account for 75% of the cost.
100
Demonstrate the Drop Arm test and what a positive test indicates.
Pt's arm abducted to 90 degrees then released
positive: immediate drop of the arm with pain
Positive test: Supraspinatus cuff tear/injury
Sensitivity: 10–73
Specificity: 77–98
https://www.youtube.com/watch?v=JXgRBeqToik
(0:40-1:10)
100
Patients with primary OA typically develop symptoms in this decade.
What are the 50s?
100
Rhomboidal shaped crystals that are positively birefringent
What is pseudogout?
100
Diagnosis of a hot, swollen, tender knee joint with joint aspirate revealing WBC of 80,000
What is septic arthritis?
200
Percentage of back pain patients that will recover (full functionality) in less than 3 months
<25%
25-45%
45-65%
65-85%
>85%
What is 90%?
200
Demonstrate the FABER test and what a positive test indicates, and state what FABER stands for.
Double points for the original name of the test.
FABER Test stands for Flexion, Abduction and External Rotation. It assesses the sacroiliac joint or hip joint being the source of the patient's pain.
Original Name: Patrick's test
Sens (88%) of pts w/hip pathology
https://www.youtube.com/watch?v=zfWKcTixM6E
(2:06-2:39)
200
Prominent osteophytes at the DIP joints
What are Heberden's Nodes?
200
Three classes of drugs for the treatment of acute gout
What are NSAIDs, Colchicine, corticosteroids?
200
Condition that includes the following symptoms:
Temporary morning stiffness.
Swelling in both first carpometacarpal joints, and some DIPJs.
Nodes found in both DIPs and PIPs
What is OA?
300
Your patient, 48 year old male, has seen you twice in the last month for back pain. He reports that he cannot seem to urinate despite straining for 36 hours. He has also leaked stool into his clothes and didn't even feel it. In this case, what are your concerns/presumptive diagnosis and what evaluation will you undertake with the what level of acuity?
Concerned for Cauda Equine syndrome.
Admission or transfer to facility with spine surgery capabilities.
Needs emergent MRI scan and surgical care.
300
Demonstrate a proper straight leg raise test and what constitutes positive or negative findings.
Double the points if can state what nerve root levels are indicated by a positive test and what motor deficit may be adversely affected by a patient with a positive test.
While patient supine, flex hip with knee extended and record the angle of induction of radiculopathy and the distribution.
Negative: Pain does not radiate below the knee when hip flexed to limit of hamstrings tension, between 30-60 degrees.
Positive: pain exacerbated by dorsiflexion of the ankle and would be relieved by knee flexion.
L5-S1 spinal roots are culprits in a positive test.
Motor deficit: L4 - Knee extension. L5 - Ankle dorsiflflexion, great toe extension, S1 - Plantar flexion.
Sens (92%), spec (28%) per cochrane systematic review in mostly surgical patients in 2010
https://www.youtube.com/watch?v=zfWKcTixM6E (0:29-2:35)
300
Two pharmacological classes of drugs for the treatment of OA
What are NSAIDs and Glucocorticoids?
300
A deposit of uric acid crystals surrounded by inflammatory mediators that can be found in cartilage, ligaments and tendons, usually in the olecranon and patellar bursae, Achilles tendons and earlobes
What is a tophus?
300
Diagnosis if pitting and onycholysis of fingernails present with grossly swollen fingers
What is psoriatic arthritis?
400
The commonly accepted indications for an MRI scan
What are...
Presence of red flags.
6 to 8 weeks or progressive or persistent radiculopathy with muscles weakness or parasthesias.
MRI's rarely discover unsuspected etiologies of back pain, they usually confirm clinical suspicions and affirm the pathology for surgical treatment.
400
Demonstrate the Lachman test and what a positive test indicates.
L hand on femur grasped above the knee, R hand on tibia; pull sharply toward abdomen with R hand while stabilizing with L hand.
Positive indicates ACL injury if tibia feels unrestrained during pull.
Sens (87%), spec (93%)
https://www.youtube.com/watch?v=c3643PM0a2o
(2:30-3:40)
400
Duration of pain relief with intraarticular injections.
What are...
1-2 months using glucocorticoids
~4months using hyaluronans
400
Characteristic synovial joint color, viscosity, and white blood cell count in gout and pseudogout
What are Yellow, Low, and 2000-40000 x10^9/mm^3?
400
First line treatment for the condition that presents with these s/sx:
Symmetrical, red and hot joints
Yellow joint aspiration with 5000 x10^9 WBC/mm3
Positive CCP
What is methotrexate for treatment of RA
500
Regarding epidural injections:
Indications to recommend a trial of injection and effectiveness of epidurals in the relief of back pain.
Indication: chronic (>12wks) radiculopathy from disk herniation unrelieved with conservative therapy with MRI findings of impingement consistent with the patients symptoms.
2009 Cochrane review found "insufficient evidence to support use in subacute or chronic low back pain...it cannot be ruled out that specific subgroups of patient may respond". They are about 50% effective.
500
Demonstrate the McMurray test (lateral and medial) and what a positive test indicates.
Lateral: place L hand on medial joint line w/knee fully flexed w/R hand evert foot, apply valgus stress. Gently flex and extend knee; positive w/clicking aroudn medial joint line; indicates meniscal injury
Medial: place L hand on medial joint line w/knee fully flexed w/R hand invert foot, apply varus stress. Gently flex and extend knee; positive w/clicking aroudn medial joint line; indicates meniscal injury
Spec (53-97%)
https://www.youtube.com/watch?v=c3643PM0a2o
(0:20-1:40)
500
Medication that may be synergistic with APAP and can be used cautiously in acute flares of pain.
What is Tramadol? (upto 200mg per day)
Cochrane systematic review 2006
http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD005522.pub2/abstract
500
3 indications to start prophylactic medications for gout and the goal serum uric acid level.
Indications to start prevention meds (allopurinol, fuboxostat etc):
>=2 attacks/year, erosive disease on radiograph, nephrolithiasis, CKD>=stage 2, tophi, or urinary uric acid >1.1 g/day
Goal serum UA level <6
500
Next step in management of patient with bilateral aching pain and stiffness of proximal muscles in the morning improved with movement in >50yo, elevated ESR, and blurred vision.
What is prednisone 15mg/day with anticipated improvement in 24-48 hours (GCA in PMR)?
