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Musculoskeletal

 

Diagnosis and management of polymyalgia rheumatica

16 Dec 2016Paid-up subscribers

Polymyalgia rheumatica (PMR) is a common inflammatory condition of unknown aetiology. There is no specific diagnostic test for PMR but the usual pattern is a commensurate rise in CRP and ESR. A small proportion of PMR patients will have normal inflammatory markers. At diagnosis and each follow-up visit it is imperative to consider the potential for associated giant cell arteritis (GCA). If there is any suspicion of GCA, urgent discussion with the rheumatologist should take place that day.

Improving joint pain and function in osteoarthritis

16 Dec 2016Paid-up subscribers

Osteoarthritis has become a major chronic pain condition. It affects more than 10% of adults and accounts for almost 10% of health service resources. The impact of osteoarthritis is amplified by underuse of effective muscle strengthening exercises and a focus on often less effective and poorly tolerated analgesic therapies. Muscle strengthening and aerobic exercise have been shown to improve joint pain and function. Weight loss not only improves joint pain and function but has a myriad of other health benefits.

Evaluating the patient with low back pain

22 Dec 2015Paid-up subscribers

In the UK, low back pain is the most common cause of disability in young adults and every year 6-9% of adults consult their GP about back pain. A thorough history and examination is required to exclude an alternative diagnosis, such as pain arising from the hip or trochanteric bursa and to categorise patients as having: serious spinal pathology, nerve root/radicular pain or non-specific back pain.

Diagnosis and management of osteoporosis

22 Dec 2015

Osteoporosis is a common condition characterised by low bone mineral density and an increased risk of fragility fractures. It affects up to 30% of women and 12% of men at some point in their lives. The diagnosis of osteoporosis can be confirmed by DEXA but this should only be performed in patients who have an increased risk of fracture on the basis of clinical risk factors. DEXA should be considered if the 10-year risk of major osteoporotic fracture is > 10%.

 

Patients with gout can be cured in primary care

15 Dec 2014Paid-up subscribers

Gout is associated with comorbidities such as nephrolithiasis, chronic renal impairment, metabolic syndrome, depression and heart disease. It is also associated with increased mortality. Untreated gout can result in disabling irreversible peripheral joint damage and chronic usage-related pain. However, gout is curable.  [With external links to the evidence base]

Early treatment of psoriatic arthritis improves prognosis

15 Dec 2014Paid-up subscribers

Psoriatic arthritis (PsA) is a chronic, autoimmune disease affecting up to 1% of the adult population and up to 40% of those with psoriasis. Around 20% of patients develop PsA before psoriasis, often many years before skin or nail changes. Aggressive treatment of early stage progressive PsA can substantially improve the long-term prognosis.


Optimising the management of congenital talipes

23 Oct 2013Paid-up subscribers

Congenital talipes equinovarus (CTEV) is a condition of the lower limb in which there is fixed structural cavus, forefoot adductus, hindfoot varus and ankle equinus. It is important to differentiate CTEV from a non-structural or positional talipes which is fully correctable. This positional variant occurs about five times as commonly as CTEV. The latter condition does not require casting or surgical treatment. The majority of CTEV cases are picked up at the early baby check or on prenatal ultrasound, and referred to the paediatric orthopaedic service. However, some cases are mistaken early on as the positional variant, and may therefore present to the GP e.g. at the six week check. Urgent referral is warranted as the Ponseti treatment should be started  early. [With external links to the evidence base]

Assessing fracture risk in patients with osteoporosis

23 Oct 2013Paid-up subscribers

In the past the management of osteoporosis centred on the use of diagnostic thresholds based on bone mineral density (BMD) measured at the spine or hip by dual x-ray absorptiometry (DXA). More recently it has been found that the presence of several clinical risk factors is associated with a fracture risk greater than can be accounted for by BMD alone. Assessment of fracture risk therefore needs to take into account specific risk factors that contribute to fracture risk as well as BMD. [With external links to the evidence base]

Early diagnosis crucial in ankylosing spondylitis

16 Dec 2011Paid-up subscribers

Back pain is common with up to 9% of the population consulting their GP with this problem each year. As the vast majority of these patients have non-specific back pain, it is often difficult to identify those with inflammatory disease such as ankylosing spondylitis (AS). It is critical to make this distinction as AS, if untreated, may cause significant morbidity with a substantial socio-economic impact both on the individual and society. Early diagnosis is particularly important as newer therapies are able to contain this condition and even induce remission in some cases. AS affects about 0.2-0.5% of the population. It is at least twice as common in men than women and most often manifests in the third to fifth decades. It is estimated that up to 5% of patients with chronic lower back pain in primary care have inflammatory disease. Diagnosis is usually delayed at least partly through lack of awareness of this condition. [With external links to the evidence base]

Diagnosis and treatment of gout in primary care

16 Dec 2011Paid-up subscribers

The prevalence of gout increases with age and up to 7% of men aged over 65 and 3% of women aged over 85 have gout. The risk of gout increases significantly with increasing serum uric acid levels. However, hyperuricaemia is far more common than gout implying that additional risk factors play a role in the development of the disease. Alcohol consumption, especially beer and to a lesser extent spirits, increases the risk of both incident and prevalent gout. Purine-rich foods such as red meat and seafood increase the risk of incident gout significantly, while dairy products and increasing coffee, but not tea, intake were found to be protective. A number of medications are well known to be associated with increased risk of gout. It is well established that gout is frequently associated with the metabolic syndrome which is characterised by hyperuricaemia, hyperlipidaemia, hypertension, diabetes and insulin resistance, and obesity. In addition, dehydration, increasing creatinine levels, and undergoing surgery are known to precipitate gouty flares. [With external links to the evidence base]

Disease remission the goal of therapy in rheumatoid arthritis

20 Dec 2010Paid-up subscribers

Rheumatoid arthritis was Previously considered a severe systemic disease leading to inexorable decline. However, the outlook for patients has altered dramatically over the past few years with disease remission now the therapeutic goal. This is dependent on a number of critical interventions and the role of the GP is pivotal in the process. Without early recognition and rapid referral by the GP the ability to achieve the desired outcome of disease remission would be greatly hindered. A recent article in this journal highlighted the benefits of intensive therapy with tight control of disease. [With external links to the evidence base]

Optimising pain control in osteoarthritis

20 Dec 2010Paid-up subscribers

Many current treatments for OA are thought to target the synovium e.g. NSAIDs and this may be why they are effective. Changes in the subchondral bone are also common on MRI and are also associated with pain. At present most data assume that OA pain is nociceptive in origin and there is limited evidence for a neuropathic mechanism. All available treatments for OA are directed at symptom control as there are not yet any widely accepted drugs that can affect the structural progression of OA. Current guidelines recommend a combination of non-pharmacological and pharmacological management. Treatment needs to be adjusted according to individual symptoms, past medical history, comorbidities and lifestyle. NSAIDs, for example, may be inappropriate in a patient with renal impairment, gastrointestinal diseases or a history of ischaemic heart disease.The initial approach centres on self-help and patient-driven treatments and should be started in primary care. This includes: education, advice and access to information. Both verbal information and patient information leaflets should be offered; local strengthening exercises and aerobic fitness training; weight loss in patients who are overweight or obese. [With external links to the evidence base]

Improving recognition of psoriatic arthritis

17 Dec 2009Registered users

 Psoriatic arthritis (PsA) is a common form of inflammatory arthritis but is underdiagnosed. Psoriasis affects more than 1.5% of the UK population so a GP with an average list size is likely to care for around 40 patients with psoriasis. Around 15% of these patients will be diagnosed with PsA, but up to 40% of them may have evidence of arthritis if reviewed thoroughly. [With external links to the evidence base]

GPs have key role in shared care of patients with SLE

15 Dec 2009Registered users

Twenty to thirty years ago, the mortality rate for SLE was as high as 50% at five years. The current 20-year survival rate is 80%. GPs play a key role in early referral to specialist centres and subsequent shared care pathways for the management of these patients. [With external links to the evidence base]

Diagnosing shoulder pain

01 Jan 2009Paid-up subscribers

The prevalence of shoulder disorders has been reported to range from 7 to 36% of the population accounting for 1.2% of all GP consultations. Shoulder pain has been said to be the second most common musculoskeletal complaint presenting in primary care. On average GPs are consulted approximately seven times each week for a complaint relating to the neck or upper extremity; three of these consultations will be for new complaints or new episodes. [With external links to the evidence base]

Exercise vital in patients with osteoarthritis

17 Dec 2008Paid-up subscribers

Osteoarthritis (OA) is the most prevalent joint disease in the uk. it is a common cause of pain and disability and the main reason for hip and knee replacement. Three million GP consultations for OA took place in the UK in 2000, and with the ageing population this figure is set to increase.

Assessment of fracture risk key in osteoporosis

17 Dec 2008Paid-up subscribers

Osteoporotic fractures are a major health problem in older people, affecting one in two women and one in five men over 50. These fractures are associated with significant morbidity and increased mortality, and cost the health services an estimated £1.8 billion annually. Recently, it has been shown that prediction of fracture risk can be improved by the use of clinical risk factors independent of BMD. These risk factors, alone or in combination with BMD measurement, form the basis of the WHO-supported FRAX tool for predicting fracture risk. This is available free online at www.shef.ac.uk/frax and can be used to assess the 10-year probability of a patient developing a major osteoporotic fracture (wrist, spine, hip and humerus) or hip fracture.

Early diagnosis crucial in polyarthralgia

01 Dec 2007Paid-up subscribers

Polyarthralgia is a common presentation in primary care. While the true incidence is unknown, 35% of a large UK community cohort aged over 55 years reported pain in more than one joint. Polyarthralgia is more common in women and with increasing age. Patients often present a diagnostic and management challenge. However, early assessment and diagnosis is important, as there is increasing evidence of the benefit of early intervention in patients with inflammatory arthritis. A window of opportunity exists where the benefits of early treatment may be significant and long-lasting.

Gout is a risk factor for cardiovascular disease

01 Dec 2007Paid-up subscribers

Gout develops when monosodium urate crystals (MSU) precipitate in a joint, characteristically causing pain, swelling and erythema. The incidence of gout, in the UK, is 13 per 10,000 patient years. It increases with age to a maximal incidence in patients aged 65-84 years. Gout is approximately twice as common in men. Oestrogenic hormones are thought to have a mild uricosuric effect in premenopausal women. [With external links to the evidence base]

Managing wound problems fol­lowing joint replacement

01 Feb 2007Paid-up subscribers

Although total hip replacement (THR) and total knee replacement (TKR) are two of the most successful operations in the UK, a peri-prosthetic joint infection (PJI) is a potentially devastating complication associated with high levels of patient morbidity, substantial financial costs and frustration for clinicians. The use of prophylactic antibacterial agents, ultra-clean air and laminar flow systems has reduced the rates of PJI in THR and TKR from about 10 per cent when the operations were first introduced to 0.5-1 per cent for THR and 1-2 per cent for TKR. 'Ringfencing' of elective arthroplasty beds is also beneficial, but this protocol is not universally applied. However, as the UK's population is ageing the number of primary arthroplasty operations and revisions is rising, and the prevalence of PJI is expected to increase.