AFP Journal Review December 1, 2007 Issue

1. AFP Journal Review December 1, 2007 Issue T. Lianne Beck, MD Assistant Professor Emory Family Medicine

2. Articles • Diagnosis and Treatment of Otitis Media • The Physical Therapy Prescription • Evaluation of Back Pain in Children and Adolescents • Chronic Pancreatitis

6. Type B Type C

10. Diagnosis and Treatment of Otitis Media

11. The Physical Therapy Prescription • Supervised Therapeutic Exercise • More beneficial than home-based exercise in patients with low back injury, osteoarthritis of the knee, or intermittent claudication • Home-based exercise is as beneficial as supervised physical therapy for postoperative recovery after anterior cruciate ligament reconstruction.

14. Components of a Physical Therapy Prescription • Diagnosis - proper coding should be used to allow for accurate insurance billing and reimbursement • Frequency and duration of therapy (e.g., daily for five days, three times per week for four weeks) depending on the condition being treated • Specific protocols or treatments that the physician wants the therapist to use • Safety precautions (e.g., joint range-of-motion limitations, weight-bearing limitations, illnesses that impact therapy decisions) • Physician signature and date are required for a therapist to perform the requested services

16. The Physical Therapy Prescription

17. Evaluation of Back Pain in Children and Adolescents • Red Flags (Require urgent imaging) • Abnormal Exam Findings • Trauma • Nighttime pain • Systemic Symptoms • Neurologic Symptoms • Activity Limitations • Pain lasting > 1 month

18. Neurologic Signs/Symptoms • Radicular pain • Positive straight leg raising test result • Paraesthesias • Muscle Weakness • Loss of bladder/bowel continence • Decreased Reflexes

20. Nighttime Pain and Systemic Symptoms • Usually associated with tumors or infections • Osteomyelitis • Diskitis • Osteoid osteoma • Osteoblastoma • Eosinophilic granuloma • Aneurysmal bone cyst • Leukemia • Ewing's sarcoma • Spinal cord tumors (neurofibroma, astrocytoma)

21. Pain Worsens with Spinal Movement • Pain with forward flexion • Strain on the anterior elements of the spine (vertebral bodies, disk spaces) • Herniated disk, slipped apophysis, vertebral lesions (diskitis, osteomyelitis, vertebral body tumor) • Pain with extension • Strain on the posterior elements of the spine (facet joints, pars interarticularis, pedicles) • Spondylolysis (fracture of the pars interarticularis) • Lesions (osteoblastoma)

22. Spondylolysis Spondylolisthesis

23. Pain Associated with Recent-Onset Scoliosis • Association between pain and idiopathic scoliosis in children and adolescents is controversial. • One study reported 32 % of patients with presumed idiopathic scoliosis had pain; 9 % of these patients were found to have an underlying pathology. • Most commonly found: Spondylolysis, spondylolisthesis, Scheuermann's kyphosis, slipped vertebral apophysis, herniated disk, hydromyelia, tethered spinal cord, and intraspinal tumor

24. Physical Exam • Inspection • Midline defects, abnormal markings, asymmetry or accentuated alignment, leg length discrepancy, muscle atrophy • Palpation • Areas of tenderness • Range of Motion • Flexion, extension and whether pain is worsened by either • Neuro Exam • Motor (Gait, Toe walk, heel walk) • Sensory • Reflexes • Special Tests • Straight Leg Raise – Sciatica • FABER test – SI joints

25. Neurological Features Associated with Lumbosacral Radiculopathy. Nerve Muscle Reflex Sensory root weakness changes changes

26. FABER Test Flexion Abduction External Rotation Assess sacroiliac joint problems Juvenile ankylosing spondylitis

27. Radiographic and Laboratory Studies • Plain Xray - AP, Lateral • Oblique views if spondylolysis suspected • MRI – Tumors, infections, and disk herniations, but may require sedation • Bones Scan – reasonable alternative in younger children, with 91% specificity • CT scan – if spondylolysis is suspected and negative xray, can be performed quickly • CBC, ESR, CRP, Blood cultures – tumors, infections • ANA, RF, HLA-B27 - autoimmune

29. Evaluation of Back Pain in Children and Adolescents

30. Chronic Pancreatitis • Progressive and irreversible destruction of the pancreas characterized by permanent loss of endocrine and exocrine function. • Commonly accompanied by chronic disabling pain. • Chronic alcohol use accounts for 70 percent of the cases of chronic pancreatitis in adults. • Genetic diseases and anatomic defects predominate in children. • Disease characteristics include inflammation, glandular atrophy, ductal changes, and fibrosis.

31. Clinical Presentation • Recurrent episodes of acute pancreatitis. • Commonly described as mid-epigastric post-prandial pain that radiates to the back. • Relieved by sitting upright or leaning forward. • In some patients there is a spontaneous remission of pain by organ failure (pancreatic burnout theory). • Steatorrhea, malabsorption, vitamin deficiency (A, D, E, K, B12), diabetes, or weight loss. • Approximately 10 to 20 percent of patients may have exocrine insufficiency without abdominal pain.

32. ACE-I, Statins, Didanosine (Videx), Azathioprine (Imuran), Steroids, Lamivudine (Epivir), HCTZ, Valproic acid (Depakene), OCPs, and Interferon

33. More Common Acute cholecystitis Acute pancreatitis Intestinal ischemia or infarction Obstruction of common bile duct Pancreatic tumors Peptic ulcer disease Renal insufficiency Less Common Acute appendicitis Acute salpingitis Crohn's disease Ectopic pregnancy Gastroparesis Intestinal obstruction Irritable bowel syndrome Malabsorption Ovarian cysts Papillary cystadenocarcinoma of ovary Thoracic radiculopathy Differential Diagnosis

39. Indications for Surgery • Biliary or pancreatic stricture • Intractable chronic abdominal pain • Duodenal stenosis • Pseudocysts • Fistulas (peritoneal or pleural effusion) • Suspected pancreatic neoplasm • Hemorrhage • Vascular complications

41. Chronic Pancreatitis

42. Quiz • In which one of the following groups is observation an option for the treatment of acute otitis media? A. Infants younger than six months with mild symptoms. B. Infants younger than six months with an uncertain diagnosis. C. Children six months to two years of age with an uncertain diagnosis. D. All children older than two years.

43. Quiz • Which one of the following drug regimens is the recommended first-line treatment in non-allergic children with acute otitis media? A. Amoxicillin, 20 to 40 mg per kg per day. B. Amoxicillin, 80 to 90 mg per kg per day. C. Amoxicillin/clavulanate (Augmentin), 90 mg per kg per day. D. Azithromycin (Zithromax), 20 mg per kg per day.

44. Quiz • Home-based exercise programs have been shown to be as effective as supervised physical therapy in which one of the following cases? A. Low back injury. B. Postoperative recovery after anterior cruciate ligament reconstruction. C. Osteoarthritis of the knee. D. Intermittent claudication.

45. Quiz • Which one of the following statements about ultrasound therapy for the treatment of musculoskeletal injury is correct? A. Well-designed studies have shown that it is beneficial. B. Allergic skin reaction is the most common adverse effect. C. It has been shown to promote healing of some acute bone fractures. D. It is indicated for long-term pain relief.

46. Quiz • A 12-year-old boy presents with back pain that has awakened him over the previous three weeks. Which one of the following causes is most commonly associated with the patient's presentation? A. Spinal infection or tumor. B. Inflammatory joint disorder. C. Psychological problem. D. Scheuermann's kyphosis.

47. Quiz • Groin pain during the Flexion, Abduction, and External Rotation (FABER) test suggests a problem with which one of the following? A. Hip. B. Spine. C. Knee. D. Muscles.

48. Quiz • Which one of the following is the best initial imaging study for patients with suspected chronic pancreatitis? A. Endoscopy retrograde cholangiopancreatography. B. Endoscopic ultrasonography. C. Magnetic resonance cholangiopancreatography. D. Contrast-enhanced computed tomography.

49. Quiz • Which one of the following statements about laboratory evaluation of patients with suspected chronic pancreatitis is correct? A. Serum amylase and lipase levels are usually elevated to at least three times the upper limit of normal. B. Pancreatic function tests are the most accurate tests available. C. Serum trypsinogen can be used to assess pancreatic exocrine function. D. The secretin stimulation test lacks sensitivity.

50. Quiz • Which of the following signs and symptoms is/are necessary to make a diagnosis of acute otitis media? A. Rapid onset of symptoms. B. Signs and symptoms of middle ear inflammation. C. Signs and symptoms of effusion. D. Fever (subjective or measured at more than 100°F [37.8°C]).