What is the best course of treatment for a 63-year-old male patient with knee pain and cervical spine issues, currently experiencing limited mobility due to pain, and presenting with a knot in the cervical spine?

From the Guidelines

The patient's treatment plan should prioritize non-pharmacological interventions, including physical therapy, an adjustable knee brace, and insoles, to address his knee pain and improve his overall quality of life. For the knee pain, I recommend physical therapy to improve strength and mobility, an adjustable knee brace for stability during activities, and insoles to improve biomechanics and reduce joint stress, as suggested by the EULAR recommendations for knee and hip osteoarthritis 1. The medication change from ibuprofen 200mg to naproxen 500mg twice daily is appropriate as naproxen may provide more sustained anti-inflammatory effects with less frequent dosing.

For the neck complaint, an ultrasound of the cervical spine is a reasonable first diagnostic step to evaluate the reported "knot," which could represent various conditions from muscle spasm to a lipoma or other mass, as it is a non-invasive imaging modality. This diagnostic approach is in line with the principles of minimizing harm and maximizing benefit, particularly in the absence of strong evidence guiding specific recommendations for medications in patients with neck pain or cervical spine conditions.

The patient should be advised that naproxen should be taken with food to minimize gastrointestinal side effects, and he should report any symptoms of gastrointestinal distress, as NSAIDs carry risks particularly in older adults, as highlighted in the discussion on the use and misuse of opioids in chronic pain 1. The comprehensive approach addressing both mechanical support and inflammation should help improve his knee function and potentially allow him to resume physical activity, which would benefit his overall health, considering the recommendations for the management of chronic pain conditions, including osteoarthritis and low back pain 1.

Key considerations in the management of this patient include:

• Monitoring for gastrointestinal side effects with NSAID use
• Regular review of the effectiveness of the current treatment plan
• Consideration of alternative therapies, such as exercise therapy, acupuncture, or cognitive-behavioral therapy, if the patient does not improve with the current plan, as suggested by the guidelines for the diagnosis and treatment of low back pain 1
• The potential benefits of physical activity in improving overall health and function, despite the limited evidence for its effectiveness in low back pain, as discussed in the context of chronic musculoskeletal pain disorders 1.

From the FDA Drug Label

Naproxen has been studied in patients with rheumatoid arthritis, osteoarthritis, juvenile arthritis, ankylosing spondylitis, tendonitis and bursitis, and acute gout. In patients with osteoarthritis, the therapeutic action of naproxen has been shown by a reduction in joint pain or tenderness, an increase in range of motion in knee joints, increased mobility as demonstrated by a reduction in walking time, and improvement in capacity to perform activities of daily living impaired by the disease The patient can expect pain relief from naproxen 500 mg BID for his knee pain, as it has been shown to reduce joint pain and improve mobility in patients with osteoarthritis 2.

• The onset of pain relief can begin within 1 hour
• The analgesic effect has been found to last for up to 12 hours However, the patient should be monitored for potential adverse events, particularly gastrointestinal events, as they are common in patients taking naproxen 2.

From the Research

Patient's Condition and Treatment Plan

• The patient is a 63-year-old male with knee pain, which is a common complaint in adults, accounting for approximately 5% of all primary care visits 3.
• The patient's knee pain may be related to osteoarthritis (OA), patellofemoral pain, or meniscal tears, which are among the most common causes of knee pain 3.
• The treatment plan includes physical therapy, an adjustable knee brace, and insoles, which is consistent with the recommended first-line management of OA, comprising exercise therapy, weight loss (if overweight), education, and self-management programs 3, 4.
• The use of an adjustable knee brace is supported by evidence, as it has been shown to be a significant and valuable intervention for patients with knee OA, improving their quality of life 4.

Medication and Additional Complaints

• The patient will stop taking ibuprofen 200 mg and start taking naproxen 500 mg BID, which is a common medication adjustment for managing knee pain.
• The patient is also complaining of neck pain and a knot in his cervical spine, for which an ultrasound (US) of the cervical spine has been ordered.
• There is no direct evidence in the provided studies to support the use of ultrasound for diagnosing or treating neck pain or cervical spine issues.

Physical Therapy and Exercise

• Physical therapy is a recommended treatment for knee pain, including OA, patellofemoral pain, and meniscal tears 3, 4, 5, 6.
• Exercise therapy is a key component of physical therapy for knee pain, aiming to improve strength, function, and reduce pain 3, 4, 5, 6.
• The patient's treatment plan includes physical therapy, which is consistent with the evidence-based recommendations for managing knee pain.