Physician Approach to MSK Complains in Elderly. Dr Tjan Soon Yin, Consultant and Deputy Head, TTSH Rehab Medicine

Transcription

1 Physician Approach to MSK Complains in Elderly Dr Tjan Soon Yin, Consultant and Deputy Head, TTSH Rehab Medicine

2 Impact of MSK Conditions Neuro-musculoskeletal and cardiorespiratory systems determines human functional capacity Rapid decline in musculoskeletal system functions from age 45 Musculoskeletal diseases=number one cause of disability and decreased QOL (more than stroke, IHD,cancer, renal diseases) Many of our elderly today has suffered MSK strains during younger days and had relatively sedentary lifestyles when older

3 Arthritis is a leading cause of disability (USA) 1,2 ~39 million physician visits/y >500,000 hospitalizations/y Arthritis 17.5 Back or spine Heart trouble, hardening of the arteries Lung or respiratory Deafness or hearing Limb/extremity stiffness Mental or emotional Diabetes Blindness or vision Stroke Disabilities (%) References: 1. McNeil JM, Binette J. MMWR. 2001;50: CDC. National Arthritis Action Plan. A Public Health Strategy

4 Musculoskeletal conditions:* large impact on quality of life Urogenital conditions Hearing impairment Psychiatric disorders Dermatologic conditions Cardiovascular conditions Cancer Endocrinologic conditions Visual impairment Chronic respiratory diseases Gastrointestinal conditions Cerebrovascular/neurologic Renal disorders Musculoskeletal conditions Summed rank score of impact on QoL dimensions *Includes OA, RA, back impairments, and other joint complaints. Includes physical functioning, bodily pain, general health, vitality, social functioning, and mental health. Reference: Sprangers MAG et al. J Clin Epidemiol. 2000;53:

5 Functional threshold Insult Functional reserve Dysfunction

6 Identifying MSK Problems When elderly is getting out of the bed Watch how they stand up from chair Watch them doing turning Ask if they have UL pain when using walking aid Check with the nurse or care giver if they need help doing dressing and bathing

7 Common Presentations Pain, stiffness, instability leading to decreased functions or participation. High impact trauma/deformity (ortho), inflammation or systemic symptoms/signs(rai), complex intractable pain (pain management). Nociceptive, neuropathic, other types of pain (CRPS, central sensitization, fibromyalgia).

8 Common Diagnoses Shoulders--rotator cuff problems (internal rotation of shoulder, wearing bra) Wrists--ligaments strain(extension of wrist, pressing down on bed/chair) Hips--OA hips (Flexion and internal rotation of hip, anterior hip pain on getting up from chair) Knees--OA knees (flexion beyond 90 degrees, half squatting or pain climbing stairs) Ankle & Feet--various (Big toe pain, heel pain on walking)

9 Identifying Pain Generator Ask mechanism of pain onset/injury. Ask if there is pain referral from proximal structures. Exclude red flags. 1. Get patient to point to location of pain 2. Ask patient to perform action that reproduces pain 3. Perform pain provocation test(s) after explaining to patient 4. Perform same actions with provocation removed 5. Do diagnostic test (e.g. injection) or therapeutic trial to check if pain is removed

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11 Web Resources Google NIAMS or enter it via Medlineplus.gov Other resources include familydoctor.org or emedicine.com For videos on Youtube--check if author affiliation is present and authenticated e.g. shoulder and knee exam by Rheumboy, anatomy by Dr. Nabil Ebraheim

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14 Red Flags High velocity injury including fall Presence of constitutional symptoms like LOW, fever, signs of inflammation or new deformity Presence of symptoms that suggest non MSK system involvement History of cancer or immuno-compromise Presence of neurological deficit(s) together with MSK complain

15 When to Order X-ray More than often--x-rays are not needed. Order them only if they may change your management MRI may be needed when NL deficit present. Ultrasound more useful in soft tissue conditions When high velocity injury present Presence of deformity or abnormal increase in ROM New onset pain in axial spine associated with risk of osteoporosis When suspecting joint eroding inflammatory diseases

16 Functional Impact Ask patient for fear of falls Ask patient and care giver in their perception of self care proficiency Ask patient and care giver if elderly is mobile in community Ask patient if there is difficulty in using walking aid Ask types and how much pain killers patient is taking

17 Conclusion MSK conditions are common especially in the aging population and should be included as refresher in physician training A focus approach to diagnosing it requires identification of common diagnoses in our specific clinical settings, screening to rule out dangerous conditions and identify possible diagnoses, focus approach of examination to find pain generator(s) follow by rational order of investigation.