How to manage a patient with multiple chronic conditions and acute exacerbation of bilateral knee pain and new shoulder pain after physical therapy?

Management of Acute-on-Chronic Bilateral Knee and Shoulder Pain in a Multimorbid Rehabilitation Patient

For this patient with acute exacerbation of bilateral knee pain (7/10) following physical therapy, continue the current Journavx (JAK inhibitor) and scheduled acetaminophen 650 mg every 6 hours (not PRN), add topical NSAIDs to both knees, apply ice after therapy sessions, and temporarily reduce PT intensity while maintaining participation—escalation to tramadol or short-acting opioids should be reserved only if these measures fail after 48-72 hours given her multiple comorbidities including CHF, CKD-3, and anticoagulation. 1, 2, 3

Immediate Pain Management Strategy

Optimize Current Non-Opioid Regimen First

• Schedule acetaminophen at 650 mg every 6 hours around-the-clock rather than PRN dosing, as this provides more consistent analgesia and is the first-line oral analgesic for knee OA with a favorable safety profile (maximum 3,000-4,000 mg/day). 1, 2, 3

• Add topical NSAIDs to both knees as a strongly recommended intervention, particularly appropriate for this patient ≥75 years old with multiple comorbidities (CHF, CKD-3) where systemic NSAID exposure should be minimized. 1, 2, 3

• Continue Journavx (filgotinib) 50 mg BID as prescribed through the scheduled end date, as this JAK inhibitor has anti-inflammatory properties that may benefit OA symptoms. 1

• Apply ice to both knees immediately after PT sessions to reduce post-exercise inflammation and pain. 1, 2

Physical Therapy Modification

• Notify PT to temporarily reduce exercise intensity while maintaining participation, as exercise remains the cornerstone of OA management but must be titrated to symptom severity and irritability. 1, 2

• PT should focus on pain-free range of motion and isometric exercises until acute exacerbation resolves, then gradually progress load as tolerated. 1

• Continue supervised PT as it provides better outcomes than unsupervised exercise for knee OA. 1, 2

Escalation Pathway if Initial Measures Fail (48-72 Hours)

Second-Line Options (Choose Based on Risk Profile)

Given this patient's contraindications (CHF, CKD-3, anticoagulation with apixaban, age), oral NSAIDs are relatively contraindicated. 1, 3

• Tramadol 25-50 mg every 6 hours PRN is conditionally recommended as a second-line option when acetaminophen and topical NSAIDs are insufficient, but monitor closely for:

  • Serotonin syndrome risk (concurrent Lexapro/escitalopram) 1, 3
  • Seizure threshold lowering (concurrent divalproex for epilepsy) 1
  • Sedation and fall risk (already has gait instability) 1

• Intra-articular corticosteroid injections are strongly recommended for acute pain flares in knee OA, with benefits lasting up to 3 months—consider bilateral knee injections if pain remains 7/10 after 48-72 hours of optimized non-opioid therapy. 1, 2, 3

Third-Line: Short-Acting Opioids (Last Resort Only)

• Small amounts of short-acting opioid analgesics (e.g., oxycodone 2.5-5 mg every 6 hours PRN) are strongly recommended only for patients who have failed both non-pharmacologic and pharmacologic modalities and are unwilling or unable to undergo surgery. 1

• This patient meets criteria for opioid consideration given failure of conservative measures, but extreme caution is warranted due to:

  • Chronic diastolic CHF (respiratory depression risk) 1
  • Anxiety disorder on alprazolam (benzodiazepine-opioid interaction) 1
  • Fall risk with gait instability 1
  • Age-related pharmacokinetic changes 1

• If opioids are prescribed, dispense only 3-5 days of supply with explicit agreement on number of pills, frequency, and expected duration. 1

Shoulder Pain Management

Musculoskeletal Strain Post-PT

• Apply ice, gentle passive range of motion, and proper positioning for what appears to be exercise-induced musculoskeletal strain. 4

• Same analgesic regimen (scheduled acetaminophen, topical NSAIDs if accessible shoulder areas) applies to shoulder pain. 1, 4

• PT should assess shoulder mechanics and modify exercises causing pain—avoid overhead activities temporarily. 4

• Monitor for red flags: radicular symptoms, significant swelling, decreased range of motion, or night pain that would warrant imaging or specialist referral. 4

Critical Comorbidity Considerations

Medication Interactions and Contraindications

• Oral NSAIDs should NOT be used in this patient with CKD stage 3 (GFR 36), as they are contraindicated in CKD stage IV-V and should be used with extreme caution in stage III. 1

• If oral NSAID were considered (which it should not be), COX-2 selective inhibitors are contraindicated in patients with CHF due to fluid retention and cardiovascular risk. 1

• Apixaban anticoagulation increases bleeding risk with any NSAID use, further supporting topical-only approach. 1

Nutritional and Metabolic Optimization

• Continue Pro-Stat 30 mL daily and encourage high-protein intake as hypoalbuminemia (3.0) and protein-calorie malnutrition impair tissue healing and muscle function, potentially exacerbating pain and weakness. 1

• Continue magnesium chloride replacement (Mg 1.6) as hypomagnesemia can contribute to muscle pain and weakness. 1

• Address anemia (Hgb 9.5) as it may contribute to exercise intolerance and perceived pain severity during PT. 1

Multidisciplinary Coordination

Patient-Centered Approach

• Elicit patient preferences regarding pain management goals, functional priorities, and treatment burden tolerance—this patient expressed clear desire for pain relief ("Just make this knee pain go away") but also demonstrated irritability during assessment. 1

• Address anxiety and mood as the patient's irritability may reflect inadequate coping with pain exacerbation—consider increasing Lexapro dose or more frequent PRN alprazolam if anxiety is contributing to pain perception. 1

• Set realistic expectations that complete pain elimination may not be achievable, but functional improvement and pain reduction to tolerable levels (≤4/10) is a reasonable goal. 1

Communication with Rehabilitation Team

• Daily communication between physician, PT/OT, and nursing is essential to monitor pain levels, functional tolerance, and medication effectiveness. 1

• Adjust therapy schedule if pain is consistently worse after morning sessions—consider splitting sessions or scheduling after analgesic peak effect. 1

Common Pitfalls to Avoid

• Do not continue PT at current intensity if pain remains 7/10—this risks further tissue irritation and patient disengagement from therapy. 1

• Do not use PRN acetaminophen alone—scheduled dosing provides superior analgesia for chronic pain with acute exacerbation. 1, 3

• Do not prescribe oral NSAIDs in this patient with CKD-3, CHF, and anticoagulation—the risks far outweigh benefits. 1

• Do not jump to opioids without optimizing non-opioid multimodal analgesia first, given this patient's multiple risk factors for adverse effects. 1

• Do not ignore the psychosocial component—irritability, anxiety, and poor appetite may all amplify pain perception and require concurrent management. 1

Monitoring Plan

• Assess pain levels every shift using numeric rating scale and document functional impact (transfers, ADLs, PT participation). 1

• Reassess pain management plan in 48-72 hours—if pain remains >5/10 despite optimized non-opioid therapy, proceed to intra-articular injections or cautious tramadol trial. 1, 2

• Monitor for medication adverse effects: sedation, confusion, falls, constipation (if opioids initiated), bleeding (with anticoagulation), fluid retention (if any NSAID exposure). 1

• Weekly CMP monitoring already in place to track renal function and electrolytes—ensure no nephrotoxic medications are added. 1