Treatment of Pain requires more than just a pain medication prescription.
For most people, the solution for pain should not be to just take a pain medication. There’s a deeper and more thoughtful approach figuring out what’s wrong, and devising a plan to help improve the situation.
I saw an interesting patient recently that connects key musculoskeletal wellness issues. My patient is a 32-year-old woman, new patient to me, she has various aches and pains mainly in her shoulders and left wrist. So there are few things in her history that require some additional discussion.
The first is, it turns out she’s been using a medication called Arcoxia. I’ve never even heard of this medication so I had to google this, and it turns out it’s another name for the medication Vioxx. Vioxx has not been sold in the United States for a number of years. In large part because of significant rates of higher risks of heart disease. In addition this class of medication also has potential kidney and liver toxicity side effects as well.
Vioxx has been pulled from the United States market several years ago, but my patient received this medication through her parents who live in Israel. When you look up Vioxx, you realize that this medication while no longer sold in the United States is sold throughout the rest of the world. That’s really interesting that a medication that is thought to be unsafe for Americans is okay to be sold in other parts of the world. Is that appropriate? As a physician I have deep misgivings about this practice in a larger context.
Secondly, for this individual, because she’s seeing me, because she is requiring pain medication, that automatically triggers in my mind that we need to be thinking what are the next three to four steps to make her better. How do we treat this on a deeper level so that we can prevent this from getting worse, so that we can actually treat the cause of her pain, not just hand her a pain prescription.
It’s not good enough to have a one-step process in terms of treating her pain with medications only, we need to dig deeper, and go the three to four extra levels to really determine what’s going on, treat the source, and try to make this better long term. This requires a thoughtful diagnostic process and creation of a unique individual plan for her particular condition. The end result should be that she does not require daily pain medication usage long term.
Fortunately for this individual, we talked about the risks of taking this kind of medication long term, started the diagnostic process to accurately identify the cause of her pain, and will set her down a better path to improve her quality of life and reduce the use of pain medications long term.
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Art and Science of Inflammatory Arthritis Diagnosis
When it comes to making a diagnosis of inflammatory arthritis, how do we get there?
When you really look up what are the diagnostic criteria for inflammatory arthritis conditions, including rheumatoid arthritis, it can seem really complicated and convoluted, and not always very straightforward. The reality is that if you can simplify your thinking in a deep and meaningful way, you can take something that seems very complex and make it more straightforward, understandable, and meaningful. And in that way as a professional, as a physician, you can really make your understanding profound enough where your decision making can become more efficient and straightforward as well.
So in this patient’s case today, she wanted to know, how do you come to a diagnosis of inflammatory arthritis?
In her case, there were a few things that were really key. Number one, she had a story that was on point, namely multiple joints were involved, symptoms that were better with activity and worse first thing in the morning and with rest. Number two, her examination had some subtle findings that were consistent with an inflammatory arthritis diagnosis as well, although not really too overwhelming. But more than anything else, in the end, that combination of story, along with diagnostic musculoskeletal ultrasound, really helped to make her diagnosis.
Musculoskeletal ultrasound, if you are a physician that sees patients that have joint and tendon issues, this is your stethoscope. This is how you really can help confirm your diagnosis, how you can help make your diagnosis. In this patient’s case, she had some subtle effusions in a few joints, and she had one particular tendon in her left wrist that showed some very classic inflammatory findings. That combination, history, some subtle exam findings, and ultrasound, really sealed her diagnosis. So she asked about, is there some value in checking labs, any additional imaging? And there can be in some cases.
And in her case, we’ll check some additional labs, because it helps to not only confirm diagnosis, but it also gives us some sense of prognostic value as well. But really, her diagnosis, and thus, decision making in terms of what needs to be done in her case, are made based on a couple of very straightforward focused questions, some examination findings to help rule out other things and also rule in a diagnosis. And lastly, and possibly most profoundly, is really the ultrasound findings.
That combination can help simplify a diagnosis, help simplify in terms of what needs to be done, and put this patient on the right track to getting the right treatment, to getting better faster, sooner, and longer-term as well.
It’s interesting how you can take something that is relatively common and really go into depth and nuance about it. For example, knee arthritis is incredibly common. Many patients have knee arthritis. But you can take something that’s really, really routine and take it to a personalized care to a level that you can really, really get into some very interesting details.
I had a patient recently with a moderate level of osteoarthritis in her knee. She’s roughly 60 years old, and we were talking about possibly using platelet-rich plasma for her knee. And so, there are multiple levels to make this more personalized and appropriate for her. In her case, we talked about using platelet-rich plasma to help improve some of the instability that she has in her knee. The idea being that can you treat the ligaments, create a little bit more tightness to the ligaments so that they have more stability, which long term, will help with her pain and function as well. Number two, understanding that given her age, using a higher dose of platelet-rich plasma would make sense rather than a moderate dose of platelet-rich plasma from an arthritis standpoint.
In addition, she actually has a chronic effusion in the knee, and using something like Alpha 2 Macroglobulin, which has an anti-inflammatory component to it, to actually treat some of that chronic inflammation, as well. And lastly, she also has some mild neuropathic symptoms, as well, and so actually getting evaluated for her lower back, as well. Multiple layers of subtlety to this as opposed to just saying let’s inject your knee with platelet-rich plasma. I think that based on an appropriate scientific background, an appropriate understanding of the clinical pathology, and clinical medicine and tailoring it to her actual condition. Thank you for your time. Live well.