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

From the Guidelines

The patient's request for oxycodone for severe left knee pain should be declined in favor of conservative management, including a knee brace, x-ray of the left knee, and physical therapy, as the first line of treatment, based on the EULAR recommendations for the management of knee osteoarthritis 1. The patient's cervical spine issues, characterized by reversal of upper cervical lordosis with diffuse facet osteoarthropathy and multilevel degenerative disc disease, should continue to be managed with physical therapy for cervicalgia.

• The addition of lidocaine 4% patches, applied daily for 12 hours on and 12 hours off for two weeks, is a reasonable approach to help manage his neck pain.
• The patient should also continue using Icy Hot cream as previously prescribed. For his severe left knee pain, the following steps are recommended:
• A knee brace to provide support and stability
• An x-ray of the left knee to further evaluate the condition
• Physical therapy specifically for the knee to improve function and reduce pain The EULAR recommendations suggest that paracetamol should be considered as the first-line treatment for knee osteoarthritis, with NSAIDs (oral or topical) considered in patients unresponsive to paracetamol 1.
• Intra-articular injection of long-acting steroid is indicated for acute exacerbation of knee pain, especially if accompanied by effusion, but its benefit may be relatively short-lived 1.
• Symptomatic slow-acting drugs for OA (SYSADOA), such as glucosamine sulphate and chondroitin sulphate, may possess structure modification properties, but more studies are required to confirm their efficacy 1. The multimodal approach of combining physical therapy, topical analgesics, and supportive devices is a reasonable first-line treatment for the patient's knee pain, with opioid medications like oxycodone considered only if conservative measures fail, due to their potential for addiction and side effects 1.

From the Research

Patient Treatment Plan

The patient's treatment plan includes:

• A knee brace for severe left knee pain
• An x-ray of the left knee to determine the cause of the pain
• Physical therapy (PT) for left knee pain
• A lidocaine 4% patch for cervicalgia, to be used daily for 12 hours on and 12 hours off for two weeks
• Continued use of Icy Hot cream for cervicalgia

Evidence for Treatment Plan

The use of physical therapy for cervicalgia is supported by several studies, including 2 and 3, which found that active exercise, dry needling, and laser therapy are effective in treating cervicalgia. Additionally, 4 recommends the use of exercise therapy and mobilization/manipulation in combination with advice and simple exercises for patients with nonspecific neck pain.

Topical Pain Relief Options

The use of topical analgesics, such as lidocaine, is supported by 5, which found that topical lidocaine is effective in treating postherpetic neuralgia and may be suitable for other types of pain. The study also recommends considering patient preferences, comorbidities, and cost when choosing a topical agent.

Physical Therapy for Cervicalgia

3 found that an individualized physical therapy intervention based on a clinical decision-making algorithm was effective in improving impairment, physical performance, and disability in patients with neck pain. 6 also found that a specialized manual physical therapy program was effective in improving voice and reducing pain in patients with muscle tension dysphonia and cervicalgia.

Use of Knee Brace and X-ray

There is no direct evidence provided to support the use of a knee brace and x-ray for the patient's left knee pain. However, these interventions are commonly used in clinical practice to diagnose and treat knee pain.