April- Pharmacology

[Kyle Feldman]

You are currently working with a 78 year old male in physical therapy for low back pain and bilateral leg pain secondary to lumbar spinal stenosis. He presents to the clinic for his 6th session and he reports that for the past 2 days he has had more severe calf cramping and pain down into the feet. He denies any falls, significant changes in activity, traveling, or changes to his medical status (surgeries, etc). Upon further questioning he does report his PCP changed in cholesterol medication last week.

Use the attached article to learn more about hyperlipidemia and statin use/side effects.

What clinical tests would you perform in the examination to determine what could be driving this patients symptoms?

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[zcanova]

I would first re-evaluate this individual’s neuro screen looking for any significant changes in myotomal strength, sensation, and reflexes of the lower quarter. Significant changes in any of these areas may correlate with a progression of the patient’s stenosis. I would also assess the patients gait pattern looking for any abnormalities. I would also want to see if his symptoms are recreated with lumbar ROM and/or PPIVM/PAIVM testing. If I can recreate his symptoms by narrowing the neural foramina bilaterally then it drives my diagnoses towards stenosis with claudication. The article also discusses the idea that muscle loss may occur in areas that are not being exercised and may be beneficial to assess some of the major muscle groups of the upper extremity for strength deficits.

I would also want to differentiate neurogenic versus vascular claudication. This may be assessed with a treadmill walk test. A treadmill walk test may be more beneficial as I can utilize the incline and have the patient assume a more flexed position as this should not provoke symptoms if it is neurogenic claudication. The patient would be asked to perform either of these tests until onset of symptoms. After symptom onset I would be assessing distal pulses, sensory changes, reflex changes, and relieving factors. For neurogenic claudication I would expect a normal pulse, dermatomal pattern of sensory loss, diminished reflex testing, and pain only relieved with sitting. For vascular claudication I would expect an absent/diminished pulse, variable/non-dermatomal sensory changes, normal reflex testing, and pain relieved with cessation of activity.

Other tests that could be utilized would be functional tests such as the 5 timed sit to stand, 6 minute walk test, or any other functional strength/endurance testing. I would be considerate of the positions the patient would have to be in for these tests as extension biased positions may provoke stenotic pathologies. I could also assess the variables discussed above for the treadmill test with these tests as well to differentiate between neurogenic and vascular origin.

[Kyle Feldman]

Great!

Based on the pharmacology, would you have asked about meds, would you have known the side effects of statins?

[Farisshd]

In addition to the testing and assessment mentioned by Zack above, discussion of other medications and specific foods that may increase risk for statin related myopathy or cell damage. Inquiring into whether the patient has been using antifungals, fibrates, calcium channel blockers, or if they are aware that grapefruit juice can increase risk of statin toxicity. Patients should also be encouraged to be adequately hydrated at all times, especially before, during, and after exercise sessions.

Being aware that statin use can increase risk of exercise related muscle injury is key in determining need for adjustment to exercise plan, and potentially referral back to the physician to determine if adjustments to dosage or dose frequency (though studies may not support dose dependency), or a change in choice of statin used, is indicated. The patient may require reduced intensity, load, or exercise time to prevent worsening tissue damage. If eccentric exercise has been the focus, other approaches may need to be considered.

Monitoring the patient for multi segmental strength decreases in targeted and non targeted exercises would be helpful to determine if referral is indicated due to potential for higher risk situations. Also, new onset weakness or fatigue with ADLs and things like stair climbing in healthy individuals would be a flag for serious side effects of statins. Id DOMS seems to be lasting too long, or non targeted muscles are sore, this would be another red flag.

[Kyle Feldman]

Very true and great points.

For him, it was a huge increase in pain and reduction in function.
Barely any desire to get out of a chair when walking in the neighborhood used to happen every day.
His wife was very concerned about this immediate change in status

Additional questions:

Where would you refer this patient and how would you communicate to the referring provider?
What is your method for reviewing relevant medications during evaluation and treatments?

[Author]

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