Prevention of recurrent gout. Available by subscription: www.uptodate.com, Bassett R. (2010, May). UpToDate Online. UpToDate Online. Therefore, if an acute attack occurs they should continue their prophylactic medication and consult their care provider as soon as possible to treat the acute attack. Type and period of rest varies according to type and severity of injury. Available by subscription: www.uptodate.com, Venables PJW, Maini RN. Analgesic or antipyretics for pain and fever: Consider starting empiric antibiotics in consultation with physician; delay in treatment may result in joint destruction and/or sepsis. 0000008780 00000 n A cerebrovascular accident (CVA), an ischemic stroke or “brain attack,” is a sudden loss of brain function resulting from a disruption of the blood supply to a part of the Myofascial pain Efficacy of previous treatments Associated symptoms (for example, fever, chills, trauma, repetitive activity) Assess and monitor pain or discomfort using a pain intensity instrument such as the Wong-Baker Faces Pain Scale, the Numeric Rating Scale, or the Comfort Scale. RheumInfo. Gainsville, FL: Barmarrae Books Inc.; 2003. (2010, September). Myofascial pain is the most common type of acute and chronic neck pain. UpToDate Online. Chapter 120. Available by subscription: http://www.accessmedicine.com/content.aspx?aID=6391944. Toward Optimized Practice. 7e. (2010, September). Implementation of the Ottawa ankle rules. Knee examination. 29-39. This provides information about muscles and bony structures allowing functional movement.Footnote 3 Abnormalities result from neurological or mechanical disruption. Provide information about causes of low back pain, its good prognosis, the minimal information diagnostic tests usually provide, activity and work suggestions, and when to return to the clinic (if a red flag indicator occurs). Bickley, LS. It is frequently accompanied by sensory and motor disturbances such as hyperesthesia, paresthesia, hypalgesia, and a decrease in muscle strength. Management of rotator cuff tears. Complex regional pain syndrome 3rd ed. In: Gray J, editor. Anti-inflammatory analgesics to reduce pain and swelling for 5-7 days: Consult a physician when the above measures do not work for pain control and/or when there is rest pain and/or night pain. Available by subscription: http://www.accessmedicine.com/content.aspx?aID=6002779, Hatch RL, Clugston JR, Taffe J. In: Tintinalli JE, Stapczynski JS, Cline DM, et al. For previously diagnosed rheumatoid arthritis patients, refer if not controlled on their current regimen. Muscle-strengthening exercises should be started when range of motion is regained. If pain, swelling and/or muscle spasm prevents a full examination of the knee, treat the patient for their symptoms, and then have them return once the symptoms improve for a more thorough assessmentFootnote 46. Available by subscription: http://www.accessmedicine.com/content.aspx?aID=2897738, Kalunian KC. Chapter 20. RheumInfo. (2010, September). 0000010459 00000 n Influence of multiple factors on the articular cartilage of movable joints. For detailed information on the clinical presentation, assessment and management, see the chapter, "Musculoskeletal System" in the Pediatric Clinical Practice Guidelines. Symmetry of structure and function (for example, shoulders at the same level), Note alignment, size (muscle bulk, bone enlargement) and contour of the joint (for example, valgus: deviation or outward angulation of the distal segment of a bone or joint (a > < shape of the two legs is observed); or a varus: deviation or inward angulation of the distal segment of a bone or joint (a < > shape of the two legs is observed). Examine the patient while rising from a chair, manipulating a small object, rising from supine, and while using mobility aids. UpToDate Online. It is often very swollen. Then check for symmetry of pulses especially if it’s weak or thready. Consult a physician when the above measures do not work for pain control and/or when there is pain at rest and/or night pain. This is particularly important if a lot of force was involved (for example, motor vehicle collision) or a proximal third clavicle fracture is suspected. UpToDate Online. Harrison's principles of internal medicine. Available by subscription: www.uptodate.com, Koehler SM. See the teaching program for the Ottawa Ankle Rules. A poster is also available. University of Iowa family practice handbook. Examination of the elbow. 0000001647 00000 n See RheumInfo's " The Shoulder Examination.". Available by subscription: www.accessmedicine.com, Schur PH, Maini RN, Moreland LW. 0000004816 00000 n Author L W Andrews. (2010, September). Treatment of acute gout. Arrange for physiotherapy (if readily available). (2010, September). Refer to a physician if symptoms persist after 4 weeks, or sooner if symptoms are worsening despite conservative treatment, Arrange referral to a physiotherapist (if readily available) after 3 weeks of pain, Arrange a medevac, after speaking to a physician, if any of the, Sensory and motor deficits; for example, weakness, gait disturbance (cervical spondylotic myelopathy), Loss of bowel or bladder function, sexual dysfunction (cervical spondylotic myelopathy), Headache, shoulder or hip pain, and/or visual changes in an older adult (rheumatologic diseases), Constitutional symptoms such as fever, chills, and/or unexplained weight loss along with immunosuppression, cancer, or intravenous drug use (tumour, infection), Injury to cervical paraspinal muscles and ligaments, May be related to posture and sleeping habits, Caused by flexion-extension injury (for example, whiplash) or due to an occupation where neck extension is required repeatedly, Common causes: rear-impact motor vehicle crashes, falls, diving accidents, other sports injuries, May involve damage to soft tissues, ligaments, nerves, intervertebral disks, and/or bony structures, Some patients remain symptomatic for years, Due to degenerative changes (most common), cervical foramenal stenosis, cervical herniated disk, herpes zoster, Lyme radiculopathy, diabetic radiculopathy, Rear end collision with patient in a stationary vehicle, Mechanism of injury or events occurring just prior to pain, if known, Radiation of pain (shoulders, chest, arm, scapula, occiput, face), Neuropathic signs (for example, paresthesia, numbness, weakness), Palpate paraspinal and upper trapezius muscles bilaterally for tenderness and spasm, Observe patient moving and resting the head and neck (including posture), Inspect cervical range of motion (forward flexion, lateral flexion, rotation, extension) and shoulder range of motion, Bilateral reflexes (brachioradialis, biceps, triceps), Motor and sensory testing (muscle strength and tone of shoulder and arm joints against resistance, gait, sensation of arms, hands, shoulders, and neck), Test for upper motor neuron signs (that is, spasticity, weakness, hyperactive reflexes, Babinski reflex, pronator drift), Whiplash-Associated Disorders Class I: pain, stiffness or tenderness without any physical changes or restrictions, Whiplash-Associated Disorders Class II: pain and tenderness with decreased range of motion, Whiplash-Associated Disorders Class III: pain and neurological signs (sensory, motor, or reflex changes) with no fracture or cervical instability, Whiplash-Associated Disorders Class IV: fracture or dislocation, Neurologic changes (reflexes, motor and/or sensory), Permanent nerve damage with compression of nerve root, Was a dangerous mechanism of injury (for example, fall from 3 feet or more/5 stairs, direct force to head, bicycle accident, vehicle rollover or ejection, motorized recreational vehicle accident) OR, Pain on palpation of the midline cervical spine OR, Simple rear-end motor vehicle accident OR, Any one of the above low-risk factors AND not able to actively rotate neck 45 degrees to the left and the right, Clients without systemic disorders should be treated with non-operative therapy for 3-6 weeks, Ice for a maximum of 15 minutes qid provides additional analgesia in some cases, Heat may decrease muscle tightness and improve range of motion, Posture modification (for example, sitting straight with shoulders back, driving with shoulders slightly shrugged, not carrying over-the-shoulder bags, limiting time sitting in one position), including while sleeping (should have head and neck aligned with body -- for example, sleep on back with pillows under thighs), Soft cervical collars (to support, but not extend neck) should not be used for long periods of time as they may delay improvement; wear for a maximum of 3 hours at a time, and for a maximum of 2 weeks; they may be most useful at night when there may be increased pain (to help the patient sleep); avoid immobilization if possible, Educate clients about the good prognosis for recovery and lack of neurological deficits in most cases, Continue usual activities as soon as possible, Home exercises daily once symptoms are controlled (for example, cervical range of motion holding each end range for 5 seconds, stretching, shoulder rolls); 15 repetitions twice daily after applying moist heat to neck; continue exercises every other day after acute pain resolves, Arrange follow-up at 1-2 days, at 7 days and then every 2 weeks to assess response to treatment, Start range-of-motion exercises within pain-free range once symptoms are controlled, Advise client to begin stretching and strengthening program when full range of motion is regained, Pain (including aching or stiffness) affecting fingers (DIP and PIP joints), knee, hip, and/or spine most often, Stiffness in morning (lasting < 30 minutes) or after inactivity lasting < 30 minutes, Radiologic findings of osteophytes or joint space narrowing (especially for hip and knee); the findings may not correspond to clinical examination, Obesity (for knee and hand, possibly hip), Sports activities (for example, regular wrestling, boxing, cycling, cricket, soccer), Occupation (physical labourer -- type affects risk for specific kinds of osteoarthritis; for example, repetitive knee bending predisposes to knee osteoarthritis), Joint malalignment (for example, varus/valgus knees), Developmental joint abnormalities (for example, developmental dysplasia of the hip), Muscle weakness (quadriceps and knee osteoarthritis); increased hand strength and hand osteoarthritis, Proprioceptive deficits (for knee osteoarthritis), Crystalline deposit disease (for example, gout, pseudogout), Pain in one or more joints (joints most affected are DIP [distal interphalangeal], PIP [proximal interphalangeal], MCP [metacarpophalangeal], knees, hips, spine [C5, T8, L3 are most common]), Pain often increases with activity, is relieved by rest and may progress so it occurs at rest and at night, Pain may be referred (for example, to knee from hip), Localized joint stiffness may be present in the morning (< 30 minutes duration) or after periods of inactivity, Joint enlargement with limited range of motion may be present, Flare-ups of pain may occur after prolonged, unaccustomed use, Difficulty with mobility may be present if spine (cervical or lumbar), hips, feet, or knees are affected, Range of motion limited according to extent of joint involvement, Muscle strength and joint stability (ligament) may be affected, Osteophyte formation (bony enlargement on peripheral joint), DIP and PIP joints may have osteophyte formation (Heberden's and Bouchard's nodes), First carpometacarpal and metatarsophalangeal joints commonly affected, Tenderness may be present on joint palpation, Crepitations may be felt or heard with movement of joint, Trochanteric bursitis (in clients with hip problems), Ligamentous or meniscal problems, local bursitis, loose bodies (in clients with knee problems), Progressive joint destruction with increasing loss of function and pain, Weight-reduction strategies to reduce stress on joints if client is obese, Daily exercise program (walking is best, or swimming, bicycling) to maintain joint function and muscle strength, decrease arthritis pain and limit disability; the most benefit is gained early in the disease process, Range-of-motion exercises, flexibility, muscle-strengthening, and aerobic exercises to target muscle groups that are weak (to help decrease disability and pain), Application of moist heat and cold for 20 minutes at a time to reduce joint pain, Discourage bed rest or inactivity, as this will cause further loss of function and increase immobility, Rest the affected joint for short periods (maximum 24 hours) if pain develops after prolonged use, If knee osteoarthritis, patient can try soft, elastic heeled sports shoes, wedged shoe insoles, canes, walkers, and/or a sleeve elastic knee brace, Explain prognosis, process, physical limitations, therapeutic options and expected course of the disease, Educate about the importance of exercise to decrease pain and disability, Discuss coping mechanisms (for example, activity avoidance, denial) and potential for depression; encourage patient self-management, Counsel client about appropriate use of medications (dose, frequency, side effects) and nonpharmacologic interventions, acetaminophen (Tylenol), 325 mg, 1-2 tabs PO q4-6h prn (maximum 4 g/day [12 regular strength tablets/day]), ibuprofen (Advil, Motrin, generics), 200 mg, 1-2 tabs PO qid prn (maximum anti-inflammatory dose is 3.2 g/day), Combination analgesics (for example, acetaminophen with codeine [Tylenol #3]) may also be prescribed to select patients who have insufficient relief with NSAIDs, Intra-articular corticosteroid injections are sometimes used, Topical therapies include diclofenac topical solution (Pennsaid) or gel (Voltaren gel) and capsaicin (Zostrix, many generics) topical cream, Rheumatoid factor autoantibody (more likely to have extra-articular disease), Occupational exposure to dust and fibres (for example, silica, asbestos, wood and electrical workers), Recent systemic illness or trauma (usually for monoarthritis) may have occurred, Onset of symptoms generally insidious with many joints affected (polyarthritis); other onset patterns include intermittent joint involvement (palindromic), or one joint (usually a large one; monoarthritis), Hands, wrists, elbows, shoulders, ankles and feet are the joints most commonly affected; joints exhibit pain, swelling, stiffness, warmth, and/or redness, Pain and stiffness exacerbated by prolonged rest or strenuous activity, Joint stiffness (slowness or difficulty moving) for at least 30 minutes to 1 hour upon rising in morning, over a period of more than 6 weeks; improves after moving, Fatigue, general malaise, low grade fever, depression, and weight loss may be present during acute exacerbations, including onset, Adversely affects daily routine and quality of life (for example, activities of daily living, employment type and ability to complete tasks), Morning and resting stiffness lasts for longer periods (an indication of disease progression), Disease progresses to involve multiple other joints, including DIP, all arm joints, all foot joints (similar to hand damage), knee, hip, cervical spine, cricoarytenoid joint (hoarseness, inspiratory stridor), Affected joints swollen (bilateral symmetric joint involvement common and diagnostic, especially MCPs, MTPs, and PIPs); may feel "boggy"; may not be equal damage symmetrically, Affected joints are warm and tender to pressure or movement, Range of motion reduced (in particular, finger flexion, wrist and elbow extension, knee flexion), May be thickening of palmar flexor tendons, Joints become deformed: PIP joints take on fusiform shape (Boutonniere deformity); flexion contractures may occur (for example, swan neck deformity); ulnar deviation of MCP joints; deviation of wrists, Subcutaneous rheumatoid nodules that are not attached to bone or skin may be present (small seed to marble sized; most common over proximal ulna), Absence of an alternative diagnosis that better explains the synovitis, A total score = 6 from the 4 domains forming the classification criteria below, Inflammatory bowel disease (for example, Crohn's disease, ulcerative colitis), Acute viral polyarthritis (for example, due to rubella, parvovirus, hepatitis B virus), Progressive joint destruction or deformity, Loss of mobility (due to muscle weakness), Hematologic involvement (for example, anemia of chronic disease, neutropenia), Pulmonary involvement (for example, pleural effusion, interstitial fibrosis), Renal involvement (for example, glomerulonephritis, drug toxicity), Dermatitis (for example, subcutaneous rheumatoid nodules, skin ulcers), Coronary involvement (for example, pericarditis, coronary artery disease), Vascular involvement (for example, vasculitis, peripheral artery disease, stroke), Neurologic involvement (for example, neuropathy, carpal tunnel syndrome), Eye concerns (for example, episcleritis, scleritis, keratoconjunctivitis sicca, Sjogren's syndrome), Quickly achieve and maintain control of disease activity (for example, remission or lowest possible amount of disease activity), Previously undiagnosed clients (for example, those with early inflammatory arthritis suspected of having rheumatoid arthritis), Clients whose disease is not controlled by current therapy (including those with a flare of increased symptoms, physical and laboratory findings of inflammatory synovitis), Clients in whom a complication is developing, Rest for affected joints when they are inflamed and/or taking a nap when fatigued, Splint affected joint during acute phase to reduce pain prn, Ice packs to reduce pain and swelling of affected joints; moist heat applications to reduce pain, muscle spasms and stiffness (15 min QID prn), Adequate, balanced, nutritious diet, high in fish oil, Exercise program at least twice a week to maintain joint mobility (range of motion exercises) and muscle strength; should also include regular aerobic exercise (for example, walking, swimming, cycling), Maintenance of ideal body weight or loss of weight if obese, Joint protection (for example, pace self, good body mechanics, enlarged grips, orthotics), Bone protection if client is on corticosteroids, Heart protection (for example, smoking cessation, regular monitoring of blood pressure and lipids, regular exercise), Explain risk factors for, and the course and prognosis of the disease, Often improves during pregnancy, but drug use must be discussed with a physician prior to pregnancy, Counsel client about appropriate use of medications (dose, frequency, side effects, compliance) and nonpharmacologic therapies, Instruct client to take medications with meals to reduce gastrointestinal upset, Stress importance of daily exercise in maintaining function and mobility of joints, Pneumococcal and annual influenza vaccines are important due to immunocompromised state, Teach the client relaxation exercises that may work for them (for example, guided imagery), Assess family support systems and encourage family members to become active in client's treatment program, Advise client to return to clinic if acute episode occurs, ibuprofen (Advil, Motrin, generics), 200 mg, 2-3 tabs PO tid-qid, Follow up in 48-72 hours to assess response to therapy, Follow up regularly (frequency depends on stage of disease; for example, severely active disease every 2-3 weeks, well-controlled disease every 3-6 months), Evaluate C-reactive protein, erythrocyte sedimentation rate to monitor disease activity every 1-2 months (or as guided by a physician); creatinine (every 6 months); urinalysis (yearly); other laboratory evaluations may be necessary depending on the medication(s) the patient is on, Assess weight, appetite, energy level, sense of well-being, Joint evaluation (changes, new joints affected, swelling, tenderness, decreased motion, deformity); if hands are involved, examine wrists, elbows, shoulders, knees, MCP and PIP joints, Functional status can be assessed by the Stanford Health Assessment Questionnaire (HAQ), a self-report questionnaire available at, Monitor symptoms and physical changes for progression of disease (for example, complications), Encourage joint mobility through exercise program, Patients on hydroxychloroquine require annual optometric examination, Repetitive movements (in particular overhead movements), Manual labourer (for example, painter, mechanic), Pain in one shoulder predisposes one to problems in the other shoulder, The posterior shoulder muscles may be atrophied if impingement present for a long time, Decreased strength (compared to the opposite and uninjured shoulder) of the rotator cuff muscle(s) that is/are affected if impingement present for a long time, Active range of motion may be decreased due to pain, Shoulder pain (often localized to lateral deltoid) worse with overhead movement and often at night (for example, lying on the shoulder), Pain is increased with resisted abduction, external rotation, Pain present during activities of daily living, May be muscle atrophy over scapular fossa if tendinopathy present for a long time, Asymmetric movement of the affected scapula may be present, Pain with range of motion greater than 90 degrees abduction or on internal rotation, Decreased strength on internal and external rotation (with elbows at 90 degrees and next to thorax), Weakness and stiffness that impairs functional use of the affected shoulder, Some rotator cuff tears are not painful, particularly in older adults, Unable to smoothly control shoulder adduction (drop arm sign), Decreased strength on external rotation (with elbows at 90 degrees and next to thorax) and abduction, A full thickness tear can be accurately diagnosed in patients over age 60 with a painful arc, drop arm sign, and external rotation weakness, Secondary adhesive capsulitis (loss of mobility), Avoid aggravating positions and activities (for example, all overhead activities), Heat is contraindicated in acute soft tissue injury, Heat may be used for chronic pain or swelling, Start range-of-motion exercises within pain-free range within 2-3 days, if possible.
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