Selected Health Conditions and Likelihood of Improvement with Treatment (2020) / Chapter Skim
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5 Musculoskeletal Disorders
5 Musculoskeletal Disorders
Pages 233-290
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, and other arthropathies -- as suggestions for conditions that the committee might wish to explore. Based on the committee's clinical expertise and knowledge of the medical and research literature on musculoskeletal disorders, the committee agreed that disorders of the back and OA were two of the most disabling musculoskeletal conditions; within the category of "other arthropathies," the committee agreed that inflammatory arthropathies in particular ranked among the most disabling conditions that might improve with treatment.
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Chronic pain and a loss of function are the primary mechanisms through which musculoskeletal disorders lead to disability and work loss. The National Health Interview Survey (NHIS)
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Most musculoskeletal conditions are initially diagnosed and treated in primary care, where family medicine and general internal medicine are the specialties providing most primary care for adults. Additionally, physical medicine and rehabilition physicians also diagnose and treat musculoskeletal disorders.
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Rehabilitation care may be provided in offices, in the hospital following surgery, in rehabilitation centers, or in skilled nursing facilities. Research on Musculoskeletal Disorders Considering the population prevalence and public health burden of musculoskeletal conditions, research on these conditions is funded at a lower rate than for other chronic conditions.
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Treatments for Pain in Musculoskeletal Disorders Musculoskeletal disorders are the most common causes of chronic pain, and pain accounts for much of the burden of musculoskeletal conditions. According to 2016 NHIS data, the estimated prevalence of chronic pain -- defined as pain on most days in the prior 6 months -- among U.S.
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. In 2013 back pain was the most common reason for health care visits among musculoskeletal disorders, with more than 57 million physician office visits.
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Other factors associated with worse functional outcomes in chronic low back pain include co-existing medical and psychiatric conditions and other chronic pain conditions. In addition, the overuse of biomedical approaches to treat chronic low back pain (e.g., opioids and spine surgery)
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. Professional Accepted Diagnostic Criteria Chronic low back pain is defined by its location (i.e., between the lower rib margin and the gluteal folds)
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. Treatments for Chronic Low Back Pain Numerous treatments have demonstrated effectiveness for improving function in chronic low back pain.
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In general, the approaches seem to have similar efficacy, and no one approach is effective for the majority of patients. A comprehensive Agency for Healthcare Research and Quality comparative effectiveness review of pharmacologic and non-invasive nonpharmacologic treatments for low back pain found moderate-strength evidence that exercise therapies improve pain and function in patients with chronic low back pain (Chou et al., 2016)
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. In general, medications are less beneficial for function than for pain in chronic low back pain, with most of their benefits demonstrated only in the short term.
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Laminectomy (for symptomatic spinal Second-line adjunctive treatment option stenosis) Spinal fusion (for non-radicular low Role uncertain back pain with degenerative disc findings)
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The primary symptom of OA is joint pain that worsens during activity and improves with rest. The main feature of OA is the articular cartilage degeneration in response to stress, injury, mechanical overload, and increasing age (Frontera et al., 2019)
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OA typically leads to progressive damage to articular cartilage, which in turn leads to joint pain and impaired joint function. Over time the joint may lose its normal shape.
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• Blood tests may be performed to rule out other causes for symptoms. • Joint fluid samples might be taken to look for other causes of joint pain, such as infection or gout.
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Although there are numerous treatments available, progressive knee OA may result in reduced mobility and resulting systemic complications of immobility and deconditioning. Initial treatments that might provide relief from pain include acetaminophen as a first-line therapy, followed by oral and topical NSAIDs.
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. As noted in Frontera TABLE 5-4 Stepped Care Approach for the Treatment of Osteoarthritis Severe Moderate Mild Encourage regular exercise Encourage weight loss if necessary Consider physical therapy Patient education concerning activity modification, muscle strengthening, and maintaining joint range of motion Begin with acetaminophen Start NSAID therapy, beginning with ibuprofen or naproxen Switch to different NSAID if initial choice is not effective Combination glucosamine and chondroitin for knee OA Discontinue glucosamine and chondroitin if no change after 3 months Consider corticosteroid injection for knee OA Consider hyaluronic acid injection for knee OA Total joint replacement for OA of the hip, knee, or shoulder Joint arthroplasty for first carpal metacarpal joint OA Joint fusion or arthroplasty for wrist OA Joint fusion for finger joint OA NOTE: NSAID = non-steroidal anti-inflammatory drug; OA = osteoporosis.
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OA affects all structures within and around a joint. OA is characterized by a progressive loss or erosion of articular cartilage, subchondral bone sclerosis, and the formation of osteophytes, leading to joint pain and impaired joint function and, in some instances, joint deformity and contracture (AAOS, 2017)
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. The decision concerning the type of treatment should be individualized and based TABLE 5-5 Clinical Diagnostic Criteria for Osteroarthritis of the Hip, Knee, Hand, and Wrist Hip Pain on range of motion Pain in groin, buttock Limitation of range of motion, especially internal rotation Knee Pain on range of motion Joint contractures Joint effusion Crepitus on range of motion Presence of popliteal cyst Lateral instability Valgus or varus deformity Shortening of the limb Hand Pain in range of motion Hypertrophic changes at distal and proximal interphalangeal joints Tenderness over carpometacarpal joint of thumb Wrist Pain in range of motion Joint stiffness Tenderness and swelling SOURCE: Adapted from Sinusas, 2012.
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Although there are numerous treatments available, progressive knee OA may result in reduced mobility and the resulting systemic complications of immobility and deconditioning. The risk of falls will likely be increased with decreased mobility of the knee.
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. Professionally Accepted Diagnostic Criteria OA of the hand most commonly develops in the first carpal metacarpal joint (the base of the thumb joint)
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. Joint arthroplasty can decrease pain for patients with severe first carpal metacarpal joint OA,3 and joint fusions can decrease pain and improve function for patients with severe wrist and finger joint OA.
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. During disease flares, inflammation results in a short-term worsening of joint pain and swelling; in patients with longstanding and severe disease, persistent inflammation will over time result in the erosion of cartilage and bone, leading to joint destruction and deformities that in turn cause chronic pain and functional limitations (Sokka and Pincus, 2001)
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/European League Against Rheumatism (EULAR) classification criteria for RA form the generally accepted diagnostic criteria for the condition, although, notably, these criteria were developed for research studies to allow for the identification of individuals with earlier-stage RA and were not primarily intended for clinical practice.
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. We review the major measures used to assess treatment response below, noting that while these measures are widely used in research and clinical trials, their application in routine clinical practice by U.S.
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. It is not recommended for monitoring treatment response in clinical practice -- other disease activity scales, described below, are considered more feasible to implement in clinical settings (Greenberg et al., 2009)
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DMARDs include methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine; biologic DMARDs include anti-tumor necrosis factor (TNF) agents (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab)
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For patients who do not improve sufficiently with traditional DMARD monotherapy (i.e., RA disease activity remains moderate to high) , the recommended approach is either a combination of traditional DMARDs, a biologic DMARD (with or without methotrexate)
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Short-term, low-dose glucocorticoid treatment may be added for patients on traditional or biologic DMARDs whose disease activity remains moderate or high, or for RA flares. Once low disease activity is achieved on a specific DMARD regimen, it is recommended that the regimen be continued, given that clinical experience suggests a high risk of relapse and the need for resuming therapy in the absence of DMARD treatment.
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. Baricitinib is a JAK-inhibitor7 that was approved for the treatment of RA in 2018 and is therefore not discussed in the 2015 ACR guidelines; the 2016 EULAR guidelines note that there is some evidence for its superior efficacy relative to adalimumab,8 but because long-term safety data are limited, as with tofacitinib, it is recommended that biologic DMARDs be tried first (FDA, 2018; Taylor et al., 2017)
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HAQ scores are predictive of work disability, and the HAQ is commonly used as a secondary outcome measure in clinical trials testing RA therapies. Among pharmacologic agents, a range of medications including traditional DMARDs (e.g., methotrexate, leflunomide)
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. Accordingly, many clinical trials of RA therapeutics now assess treatment response at both 3 and 6 months, and the EULAR treatment guidelines for RA recommend changing therapy if no improvement is seen after 3–6 months (Ramiro et al., 2014)
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. Professionally Accepted Diagnostic Criteria for Psoriatic Arthritis The diagnosis of PsA is based on the clinical history, a physical examination, laboratory findings, and radiography.
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Other treatment response criteria developed specifically for PsA include the Psoriatic Arthritis Response Criteria (PsARC) and the Minimal Disease Activity (MDA)
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. As with RA, PsA disease activity scores correlate closely with the degree of functional impairment, and several of these scores are based in part on functional assessments.
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. Under all sets of guidelines, the goal of therapy is clinical remission or minimal to low disease activity (Gossec et al., 2016)
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. First, in the 2015 EULAR recommendations traditional DMARDs are preferred as a first-line therapy over biologic DMARDs.
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Tofacitinib Infections Reactivation of tuberculosis Reactivation of herpes zoster Cytopenias NOTE: DMARD = disease-modifying antirheumatic drug; IL = interleukin; NSAID = nonsteroidal anti-inflammatory drug; TNF = tumor necrosis factor. SOURCES: Gossec et al., 2016; Graham, 2006; Mease et al., 2017a,b,c; Singh et al.
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. Length of Time to Improvement for Psoriatic Arthritis As with RA, NSAIDs and low-dose glucocorticoids can provide symptom relief within days for PsA.
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. NEW AND DEVELOPING TREATMENTS FOR MUSCULOSKELETAL DISORDERS The use of biologics in orthopedics has become popular as an adjuvant in healing musculoskeletal injuries.
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These disorders may result in pain and loss of function and are among the most disabling and costly conditions in the United States. Chronic pain and loss of function are the primary mechanism through which musculoskeletal disorders lead to disability and work loss.
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Inflammatory arthropathies are conditions characterized by inflammation of the joints and often other tissues. These include RA, psoriatic arthritis, ankylosing spondylitis, juvenile idiopathic arthritis, and systemic lupus erythematosus, among others.
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2008. Reporting disease activity in clinical trials of patients with rheumatoid arthritis: EULAR/ACR collaborative recommendations.
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and Disease Activity Score with 28-Joint Counts (DAS28) , Simplified Disease Activity Index (SDAI)
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2019. Health effects of direct triaging to physiotherapists in primary care for patients with musculoskeletal disorders: A pragmatic randomized controlled trial.
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2019. Emerging treatment options for the treatment of moderate to severe plaque psoriasis and psoriatic arthritis: Evaluating bimekizumab and its therapeutic potential.
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2016. Apremilast, an oral phosphodiesterase 4 inhibitor, in patients with psoriatic arthritis and current skin involvement: A phase III, randomised, controlled trial (PALACE 3)
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, and Rheumatoid Arthritis Disease Activity Index (RADAI)
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2018. Modification of the Psoriatic Arthritis Disease Activity Score (PASDAS)
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2018. Residual symptoms and disease burden among patients with rheumatoid arthritis in remission or low disease activity: A systematic literature review.
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2005. Psoriatic arthritis assess ment tools in clinical trials.
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2017b. Efficacy and safety of abatacept, a T-cell modulator, in a randomised, double-blind, placebo-controlled, phase III study in psoriatic arthritis.
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, a rheumatoid arthritis index without formal joint counts for routine care: Proposed severity categories compared to disease activity score and clinical disease activity index categories. Journal of Rheumatology 35(11)
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2018. Early response to therapy predicts 6-month and 1-year disease activity outcomes in psoriatic arthritis patients.
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2011. Use of Clinical Disease Activity Index score for assessment of disease activity in rheumatoid arthritis patients: An Indian experience.
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2019. Assessing disease activity in psoriatic arthritis: A literature review.
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2012. Measuring disease activity in psoriatic arthritis.
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