What is the appropriate management for a 58-year-old male patient with cervicalgia due to reversal of upper cervical lordosis, diffuse facet osteoarthropathy, and degenerative disc disease, and severe left knee pain, currently receiving physical therapy (PT)?

From the Guidelines

I strongly recommend a comprehensive, non-pharmacological approach for this 58-year-old male with cervicalgia and left knee pain, prioritizing physical therapy, diagnostic evaluation, and targeted therapies over opioid medication. For his cervical issues, continue physical therapy and add lidocaine 4% patches applied for 12 hours daily (alternating 12 hours on, 12 hours off) for two weeks, along with continued use of Icy Hot cream, as suggested by the American College of Rheumatology 1. The lidocaine patches will provide localized pain relief without systemic side effects, complementing the physical therapy addressing his cervical lordosis reversal, facet osteoarthropathy, and degenerative disc disease.

For his left knee pain, I recommend a knee brace, obtaining an x-ray to assess for structural abnormalities, and initiating physical therapy specifically for the knee, as recommended by the EULAR task force for the management of knee osteoarthritis 1. This approach is further supported by the American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee, which conditionally recommend the use of oral and topical NSAIDs, tramadol, and intraarticular corticosteroid injections for the management of knee OA 1.

I would not prescribe oxycodone at this time, as it's preferable to first pursue these conservative measures, diagnostic evaluation, and targeted therapies before considering opioid medication, in line with the expert consensus recommendations for the diagnosis and treatment of chronic non-bacterial osteitis (CNO) in adults, which emphasize the importance of a step-wise approach to treatment, starting with non-pharmacological interventions and progressing to pharmacological treatments only when necessary 1. This approach addresses both pain complaints while minimizing opioid exposure and focusing on functional improvement through multiple modalities.

Key considerations in this approach include:

• The use of non-pharmacological modalities, such as physical therapy and education, to provide additional benefit over and above analgesic use 1
• The importance of diagnostic evaluation, including x-rays, to assess for structural abnormalities and guide treatment decisions 1
• The need to prioritize functional improvement and minimize opioid exposure, in line with the principles of evidence-based medicine and the recommendations of expert consensus guidelines 1

From the Research

Patient Treatment Plan

The patient is receiving physical therapy (PT) for his cervicalgia, and the plan is to continue with PT for his left knee pain.

• The patient will be prescribed a knee brace and an x-ray of the left knee.
• For his cervicalgia, the patient will be prescribed lidocaine 4% patch daily 12 hours on 12 hours off for two weeks, and should continue using Icy hot cream 2.
• The use of physical therapy in the treatment of cervical disk disease is supported by a study that suggests physical therapy should be implemented during the acute and chronic phase of cervical disk disease, with a focus on active modalities and gradual discontinuation of passive modalities as the patient is able to continue with an active program without unbearable pain 3.

Topical Analgesics for Pain Management

Topical analgesics are a non-opioid option for the treatment of chronic pain conditions, including neuropathic pain, musculoskeletal pain, and osteoarthritis.

• Studies have found topical NSAIDs to be useful in treating acute musculoskeletal pain syndromes and show some efficacy in treating hand and knee osteoarthritis 2, 4.
• Topical lidocaine has been widely studied and found to reduce pain in patients with postherpetic neuralgia 2.
• The evidence for other topical analgesics, such as capsaicin and salicylate rubefacients, is variable, with some studies showing limited efficacy 4.

Physical Therapy for Knee Osteoarthritis

Physical therapy, including Kinesio taping and conventional physical therapy, has been shown to be effective in the management of knee osteoarthritis.

• A randomized clinical trial found that Kinesio taping plus conventional physical therapy was more effective than conventional physical therapy alone in reducing pain and improving physical functioning in patients with knee osteoarthritis 5.
• The Royal Dutch Society for Physical Therapy recommends the use of physical therapy, including exercise therapy and mobilization, in the treatment of patients with nonspecific neck pain, including cervical radiculopathy 6.