Transcript Document

The 1rst Kuwait-North American
Update in Internal Medicine Conference
8-9 February 2014
CLINICAL RHEUMATOLOGICAL
PEARLS FOR INTERNISTS
Henri A. Ménard, MD, FRCP (C)
Professor of Medicine
McGill University
McGill University Health Center
BASIC CLINICAL
RHEUMATOLOGY
THREE CONTRIBUTIONS
1. The Knee
2. The Spine
3. The Hindfoot
THE KNEE
Q. What is the normal temperature of the knee?
A. The normal knee is always colder than the rest of
the leg. (Ménard, Can. Med. Ass. J. 1974)
FEELING THE KNEE
Δ Temperature
+
+
Threshold
<2
> 65
AGE (years)
Dr H Ménard, McGill 2012
FEELING THE KNEE
+
+
NORMAL
+
+
KNEE PROBLEM
+
+ + +
VENOUS PROBLEM
+
ARTERIAL PROBLEM
+
HIP PROBLEM
(referred pain)
+
+
Dr H Ménard, McGill 2012
THE SPINE
Dr H Ménard, McGill 2012
PHYSICAL EXAMINATION OF JOINTS
Q. What do you do when you examine
joints?
A. You vary the intra-articular pressure.
Range Of Motion And IntraArticular Pressure
PAIN
PRESSURE (mmHg)
MAX
PAIN
0
Full
Flexion
Resting
Dr H Ménard, McGill 2012
Full
Extension
THE OSLERIAN APPROACH
Osler’s original clinical discoveries were
OBSERVATIONAL.
His major contribution was the emphasis on
INTERACTION WITH THE PATIENT.
Osler taught us that
THE PATIENT, NOT THE DISEASE, IS THE ENTITY
And that
WE ARE TREATING PATIENTS, NOT IMAGES, NOR TESTS!
THE PATIENT HAS ALL THE QUESTIONS
AND ALL THE ANSWERS.
The Clinical Diagnostic Approach
Consists In Answering Two Questions
1. Where is the lesion ?
2. What is the lesion ?
THE ANTERIOR SPINE
INNERVATION OF POSTERIOR SPINE
Vertebral Body
Medulla
Facet Joint
Nerve Root
Posterior Rami
Ganglion
Paravertebral Muscles
POSTERIOR
Lower
Intra-Articular
Pressure
POSTERIOR
Higher
Intra-Articular
Pressure
Flexion
Higher
Intra-Discal
Pressure
Extension
Lower
Intra-Discal
Pressure
Where is the lesion?
NEITHER
ANTERIOR
FLEXION
POSTERIOR
EXTENSION
What is the lesion?
R. Deyo, Ann Int Med 2002
Mechanical (97%)
All the rest (~1%)
Visceral (2%)
The best surprise is no surprise
RATIONALE
1. THE BASIC PRINCIPLE OF THE MSK EXAM IS FOR THE EXAMINER TO INCREASE
PRESSURE IN OR STRESS A MSK STRUCTURE BY PERFORMING PASSIVE OR
ACTIVE RANGE OF MOTION OR APPLYING EXTERNAL PRESSURE.
2. IF THE STRUCTURE IS ABNORMAL THE PATIENT WILL FEEL DISCOMFORT OR
PAIN AND THAT WILL PROVOKE A VARIABLE BUT OBSERVABLE ANTALGIC
GUARDING REACTION.
3. IN THE SPINE, EXTENSION AND LATERAL/POSTERIOR-LATERAL FLEXIONS
EXPLORE POSTERIOR STRUCTURES.
4. BECAUSE FACET JOINTS AND PARA-SPINAL MUSCLES SHARE THE SAME
INNERVATION, ROM SOLLICITING POSTERIOR STRUCTURES SHOULD CHANGE
THE SPINAL MUSCLE KINOPHYSIOLOGY.
HYPOTHESIS FOR THE
EARLY DIAGNOSIS OF AS
The earliest objective manifestation of
inflammation in mobile spondyles is a clinically
detectable antalgic contraction of the lumbar
para-vertebral muscles during early passive
lumbar extension reflecting an increased
intraarticular pressure in the inflammed joints.
THE MÉNARD & MORNEAU TEST
(The M&M TEST)
During a standardized passive extension of the L-spine,
the para-vertebral muscles are normally felt to relax.
The test is abnormal
if relaxation is not felt or if muscles contract.
That is interpreted as a posterior (facet joint) problem.
Palpation Of The Paravertebral Muscles
Starting
position
Extension
Bergeron S et al. 2009
Lumbar Paraspinal Muscles
EMG During Extension ( )
NORMAL
SPONDYLITIS
Paraspinal muscles EMG in A.S. Patient (µV vs time in s)
30
microvolts/sec
Electrical activity in µV
microvolts/sec
25
20
15
10
5
0
1
3
5
7
9 11 13 15 17 19 21 23 25 27 29 31 33
Time in s
seconds
seconds
Bergeron S et al. (Ménard HA)
CAN Annual 2009 Meeting, Vancouver
Quantitative M&M by Surface EMG
Microvolt/sec Change During Extension
B
B
n=10
- 18 ± 0.9
Normal
*
P< 0.002
C
- 15,9 ± 2.3
Inactive AS
A
Active AS
C
n=28
+ 7.5 ± 1.6
n=6
Mean ± sem
Student test
p = 0.6
A
A
C
p < 0.0000002
*
B
Bergeron S et al. 2009
A
ns
D (OA) – 18.2 ± 1.4
ROM For Posterior Problems:
Para-Vertebral Muscle Contraction
Improving
PRESSURE
Max
AS
Worsening
Grey Zone
OA
Min
Initial
Extension
Resting Posture
Full
Extension
EARLY DIAGNOSIS OF AS
In back pain with an inflammatory pattern, one
should expect
1. A relatively less painful antero-flexion
2. A contraction of the lumbar para-vertebral muscles
in early extension.
7/18/2015
HA Ménard
Take Home Message
A young person with LBP may or may
not have any of the current “early” AS
clinical features but if he refuses to
extend his lumbar spine because of
pain, he has a real posterior spine
problem. He should IMMEDIATELY be
given a trial of full dose of NSAIDs, sent
for HLA B27 and PA pelvis x-ray and, be
referred to a rheumatologist for further
evaluation and treatment.
FORGET THIS OSLER’S QUOTATION
"When a patient with arthritis comes through
the front door,
I want to leave by the back door".
Times are changing
HA MÉNARD, Jan 2013
THANK YOU FOR YOUR ATTENTION
QUESTIONS ?
COMMENTS ?
THE IDIOPATHIC HINDFOOT
Q. When was the last time you saw an idiopathic
degenerative hindfoot problem?
A. The last time you missed a case of
hemochromatosis with the so-called silent HFE
mutation.
– with a normal or abnormal biochemical phenotype
– With a major and/or minor HFE mutation (work in
progress on OA type 2)