In an intriguing case study review, this author emphasizes the importance of assessing comorbid conditions when evaluating patients with painful conditions.

Patients often seek out healthcare providers when it comes to musculoskeletal pain. Unfortunately, diagnosing and treating this pain may be complicated by comorbid conditions. Accordingly, we need to examine our comprehensive approach to patients who have arthritis and associated comorbidities. We also need to understand the impact of chronic pain and illness, and the implications for patients and their families.

Patients with arthritis experience both acute and chronic pain. When patients have acute arthritic pain, one must identify the underlying cause, administer indicated analgesics and reduce patient fears that the prescribed medication(s) may exacerbate their pain.

Often, the pain becomes the disease irrespective of the diagnosis and practitioners find themselves dealing with a psychosocial dynamic that interferes with the patient’s level of function, his or her perspective on the pain as well as the patient’s activity and overall quality of life.

It is important to understand the distinction between a disease and an illness. The disease becomes only one of innumerable factors that affect the totality of a person’s quality of life. For instance, the same medical condition may be tolerable to one person and yet overwhelmingly intolerable to another.

Quality of life goals may prove to be the standard for measuring the performance of healthcare. Quality of life includes the functional capacity and independence of the affected person, and provides the means for evaluating achievement of the person’s goals. The characteristics of the disease, the individual’s age, his or her degree of disability and the extent of medical intervention required to maintain a reasonable quality of life all have implications for both the individual and the provider.

Case Study: A Complex Case Of Fibromyalgia
A 33-year-old patient previously entertained audiences of up to 300 people a night as a singer in a chic nightclub. Now she says a good day is being able is to prepare two meals of natural foods for herself. On a bad day, she notes her symptoms occur all at once and she ends up staying in bed all day. A case of flu “became chronic over three months.”

A variety of diagnoses led to multiple and unsuccessful treatments. When she was finally diagnosed with fibromyalgia, she was given orders to take multivitamins and rest. She expected that her recovery would take six months at the most. Her singing career came to a halt as she returned to her parents’ home for recuperation. Two and a half years later, she lives in the dark, avoiding sudden increases in light. She says even the light caused by opening the refrigerator door can set off a crushing headache with blurred vision and green zigzags in her visual field. Reading and watching television are out of the question for her.
She also experiences multiple symptoms with stomach and foot pain as well as the omnipresent fatigue. She admits to now being sort of “anti-drug and anti-doctor.” She has turned to friends and other sufferers of fibromyalgia for suggestions and answers. Natural foods, especially raw juices, seem to give her strength and relieve her stomach symptoms.

The patient’s social life is nonexistent. Visitors are welcome but prove to be tiring. With the best of intentions, many of them bring recommendations for specialists to try, medications to take or the general admonition to just get out and be with people. She has not driven in two years. She says, “I am almost convinced that this is a virus in my body and it is going to stay there no matter what.”

The aforementioned patient developed a major depression. Insurance barriers precluded her from obtaining proper help. When she presented to a rheumatology clinic for her pain, we initiated antidepressant medication as well as cognitive behavioral therapy. Two and a half yearsThe patient subsequently joined a fibromyalgia support group in the community that allowed her to realize she was not alone. Today, the patient is back to entertaining and looking forward to enjoying her life.

Key Points In Addressing Fibromyalgia
There are ongoing debates about whether fibromyalgia is just a clinical entity. Some believe fibromyalgia has become such a broad label that it can include any symptoms. Others believe that fibromyalgia is a distinct disorder with a pathophysiology that has not yet been completely defined. Components of therapy include patient education, analgesia, aerobic exercise, physical therapy, correction of sleep disturbance and treatment of associated disorders. While fibromyalgia is not a diagnosis of exclusion, fibromyalgia patients often have other coexisting disorders.

Cognitive behavioral therapy, a psychologically-based therapy, identifies maladaptive illness behaviors and teaches patients improved coping strategies and how to reduce their symptoms. Cognitive behavioral therapy has proven efficacy for a wide range of chronic conditions. Effective therapy is dependent on the skill set and specialty of the therapists and programs.

Sleep studies are also helpful in identifying poor sleep patterns and enable the practitioner to encourage proper sleep hygiene, sleep agents and appropriate coping mechanisms for stress and anxiety.

In this case, a comprehensive multidisciplinary approach is needed. This is true in many cases when patients suffer from fibromyalgia and other pain syndromes.

A thorough individual evaluation is a prerequisite to providing effective treatment via pharmacologic and/or non-pharmacologic interventions. Accordingly, in order to achieve clinically significant improvement with these patients, clinicians should consider the following points.

• Pay attention to the totality of the patient.
• Identify life stressors that may be contributing to the patient’s pain.
• Provide resources (such as exercise programs or support groups) to help the patient cope.
• Recognize that high stress equals poor sleep.
• Assess the patient for multiple, diffuse tender points.
• Help the patient identify support systems that are available to him or her.
• Utilize antidepressants and analgesics as appropriate interventions.

Case Study: When There Is A Recurrence Of Gout
Gout affects approximately 2.1 million Americans. The condition is characterized by increased blood levels of uric acid, which cause recurrent bouts of acute “gouty” arthritis. Most patients with gout also need to understand how comorbid factors such as obesity, high cholesterol, elevated blood pressure, alcohol intake and diabetes can contribute to the frequency and intensity of their flares.

A 37-year-old Latino male maintenance supervisor presents for evaluation of gout. He first experienced symptoms in 1993 and was diagnosed and treated in 1996. Unfortunately, in June 2004, the patient again started having intermittent and frequent gouty attacks. In addition to a current prescription of colchicine 0.6 mg bid, the patient was given a combination of prednisone of 30 mg, allopurinol 300 mg qd and Indomethacin 70 mg bid.

He subsequently presented to our office in October 2004 complaining of fever, chills and bilateral hand swelling. He wanted to determine if his symptoms were caused by gout.

A Primer On Bone Mineral Density Parameters

- According to the World Health Organization Study Group (WHO), the following definitions are based upon bone mineral density (BMD) measurements at any skeletal site in Caucasian women. • Normal: A T-score higher than -1. This indicates BMD within one standard deviation (SD) of a “young normal” adult. • Osteopenia (low bone mass): A T-score between -1 and -2.5. This indicates BMD between 1 and 2.5 SD below that of a “young, normal” adult. • Osteoporosis: A T-score at or below -2.5. This condition is deemed severe if the low T-score is accompanied by a fracture history.

The patient’s medical history was significant for hypertension, hyperlipidemia, gout, diabetes, obesity, sleep apnea, poor kidney function, peripheral neuropathy and GERD. He had not had surgery in the past. He was taking a variety of medications including: Accupril 40 mg bid, Cardizem 240 mg bid, Glucovance 5/500 mg two in the morning, one in the evening and one qhs, hydrochlorothiazide 25 mg daily, Lantus insulin 35 units qhs, metoprolol 100 mg bid, Neurontin 2400 mg daily, OxyContin 20 mg in the morning and 40 mg in the evening, and Protonix 40 mg daily. The patient has no known drug allergies.

In terms of his family history, the patient’s father passed away at 60 due to colon cancer and gout. His mother is alive and well at 62. The patient’s sister is 31 and has diabetes. As for the patient’s social history, he is married with one daughter, who was recently diagnosed with lupus. He does not engage in tobacco, alcohol or drug use and has not had exposure to harmful agents and/or activity. He has a good family support system. The patient has had recent challenges with going to work secondary to pain and inability to function and perform activities of daily living (ADLs).

When a former nightclub singer was finally diagnosed with fibromyalgia, she was given orders to take multivitamins and rest. Two and a half years later, she was living in the dark, avoiding sudden increases in light. Her social life was nonexistent.

The patient has several comorbidities with the combination of hypercholesterolemia, hypertension, diabetes and obesity. We are faced with the challenge of having to break a gout flare. It is also important to keep in mind that traditional NSAID management could be problematic in the realm of poor kidney function, diabetes and hypertension.

Emphasizing Comprehensive Care
This patient reflects the cultural aspect of patient care and the importance of patient education. His diabetes, blood pressure and cholesterol were poorly managed. He lacked an overall understanding of how the chronicity of his disease would lead to further problems and compound a significant illness.

Who Should Be Tested For Bone Mineral Density?

- • All postmenopausal women who are younger than 65 and have one or more additional risk factors for osteoporotic fracture other than menopause • All women older than 65 • Postmenopausal women who present with fractures. In these cases, one can confirm the diagnosis and determine disease severity. • Women who have been on hormone replacement therapy for a prolonged of time

We proceed to emphasize extensive patient education and helped to coordinate care to manage the patient’s comorbidities. We ensured close monitoring of his prednisone therapy and facilitated nutritional counseling. This combination resolved the gout flare and ultimately put him on a better path to good health.

When treating patients with gout, clinicians should screen for potential risk factors and take the time to educate the patient. One should also consider potential comorbidities and determine the appropriate treatment goals. In this case, clinicians should:

• terminate the acute flare and protect against further flares;
• treat the hyperuricemia and prevent disease progression; and
• ensure proper coordination of care.

Case Study: When Osteoporosis Significantly Affects Activities Of Daily Living
A 72-year-old retired businesswoman and widow of six years was healthy except for a history of peptic ulcer and a cataract of the left eye. She stumbled and fell, sustaining a fracture of femur that was pinned without complication. She was transferred from the acute care facility to a convalescent hospital for continued physical therapy and recovery. During a transfer from her wheelchair to the toilet, she fell without sustaining injuries.

However, her self-confidence was shattered. Subsequently, two nursing assistants helped her with ambulating and transfers. Her daughter, who lived out of town, noted this increase in aid and advised her mother to stay at the hospital until she could take care of herself as before. A bladder infection caused problems with urinary incontinence. The patient began to exhibit confusion and made several attempts to get out of bed at night without the alerting the staff. After helping her from the floor twice, the staff applied restraints at night in order to prevent further falls.

A representative from a home healthcare agency attempted to arrange the patient’s discharge and visitation schedules. The patient expressed fear about being at home alone. Now her family and staff assume most of her daily living tasks and business transactions. They did consider alternate living situations for the patient. Her wish to return to her own home is very uncertain.

Understanding The Impact Of Osteoporosis And Key Diagnostic Considerations
Interventions on behalf of the chronically ill require responsible management by healthcare providers and responsible achievement by the involved individual. Proactive intervention can help facilitate preventive methods of self-care. Indeed, clinicians should strive to help patients decrease dependence and increase the opportunities for patients with arthritis and comorbid conditions to enjoy ADLs. Recommending available resources to these patients can help prevent poor outcomes.

Osteoporosis is a reflection of the disruption in bone remodeling that occurs as we age. Often coined the “silent disease,” osteoporosis is characterized by low bone density and a subsequent increased risk to fracture. Osteoporotic fractures generally involve the proximal femur, vertebral body and distal forearm. Such fractures are often the first sign of disease and demonstrate the need for osteoporosis treatment and prevention.

A Guide To Risk Factors For Osteoporosis

- • Increasing age • Caucasian or Asian ancestry • Thin body frame • Early menopause < 45 years old • Calcium/vitamin D-deficient diet • Sedentary lifestyle • Cigarette smoking • Heavy ethanol use • Family history of osteoporosis • Late menarche >16 years old • Amenorrhea or irregular menstrual periods • Immobilization

Patients with a history of osteoporotic fractures clearly demonstrate a decline in ADLs such as bending, lifting, reaching and walking. In addition, there is a fear that is associated with subsequent falls. This can lead to diminished activity and impairment in performing ADLs such as dressing, cooking, shopping and housework. Approximately 40 percent of hip fracture survivors were able to return to their prior level of performance for ADLs whereas only 25 percent returned to their prefracture level for instrumental activities of daily living (IADLs).

The ability to perform ADLs and IADLs is a crucial geriatric assessment tool in determining the level of independence these patients can assume. A large percentage of patients with hip fractures require institutionalization. For our elders, this results in physical and emotional loss, increased dependence, depression and an overall decreased quality of life.

In regard to the pathophysiology of osteoporosis, aging alters the bone remodeling cycle of reabsorption by osteoclasts and deposition by osteoblasts. As one reaches skeletal maturity and gradual bone loss begins, a variation exists between age-related bone loss and hormone-related bone loss. The increase in bone loss rate is highest during the third to sixth year after menopause and subsequently tapers to the slower, age-related bone loss. Estrogen deficiency accelerates the rate of bone loss. As the patient ages, changes in the peripheral skeleton increase and ultimately catch up to the axial degradation rate at approximately five years post-menopause. This is relevant to the timeframe of where and when bone density evaluation should occur. (See “Who Should Be Tested For Bone Mineral Density?” on page 31.)

Bone mineral density (BMD) is the most important predictor of future fracture risk. Assessing the BMD of the spine and hip has become the standard test for assessing osteoporosis risk. The lower the result, the higher the risk of fracture. The test is highly accurate and reproducible. The scan time is short (less than 5 minutes per site) and the radiation dose to which the patient is exposed is extremely low (1/20 the radiation of a chest radiograph).

BMD is estimated in gm/cm2 and then one compares this with data from two groups of normal individuals of the same gender and race. (See “A Primer On Bone Mineral Density Parameters” on page 32.) One group consists of individuals of the same age and the other group is of young adults. Comparison with the first group produces a Z-score, which is the number of standard deviations (SD) above or below the normal BMD for the same age. Comparison with the second group produces a T-score, which is the number of SD above or below the normal BMD of young adults. The T-score is the more important result because it demonstrates how much bone is left compared with the peak bone mass of a normal young adult. According to the World Health Organization, a BMD ranging from 1 to 2.5 SD below that of a normal young adult classifies the patient as osteopenic while a BMD below 2.5 SD is considered osteoporotic. Generally, a drop of 1 SD doubles the risk of fracture.

Osteoporosis is a vital component in the differential diagnosis of a patient who presents with height loss, fracture risk or a simple inquiry about his or her bone health. Osteoporosis is a diagnosis of exclusion. Secondary causes of low bone density include but are not limited to thyroid dysfunction, rheumatoid arthritis, eating disorders and hypogonadism among men. One should also ascertain if patient have had prolonged corticosteroid therapy.

Emphasizing Patient Understanding
As clinicians, we must ensure and emphasize the patient’s understanding of this condition. Clinicians must be able to explain bone density scan results to their patients. A study by Fitt suggested that the number of women receiving preventive therapy increases after diagnosis via densitometry. However, this study also found that patient compliance is greatly dependent on adequate communication of test results by clinicians.
It is important to empower our patients with accurate education and practical lifestyle modifiers in order to facilitate a team-oriented approach to patient care.

In terms of treatment, we must ensure an adequate intake of calcium and vitamin D, consisting of at least 1200 mg/day of calcium and 400-800 IU of vitamin D per day for individuals at risk. In addition, emphasizing fall prevention programs and offering safety tips for the home are key preventative measures.
Ensuring a prompt patient assessment and patient understanding of BMD testing will help facilitate compliance to the recommended treatment regimen and an overall better quality of life, particularly for our elders.

In Conclusion
Whether the patient is a grandfather with a history of rheumatoid arthritis who wants to be able to take his wife dancing again or younger patient who fears his or her arthritis is only a negative precursor to a more significant disease, we have to treat the patient as a whole in order to help achieve optimal outcomes for patients.