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Am Fam Physician. 2021;104(2):232

In chronic musculoskeletal pain, what nonpharmacologic and noninvasive treatments are effective?

Regular exercise is recommended for patients with chronic musculoskeletal pain. Because no specific type of exercise is superior, patients should be encouraged to engage in the type of low-impact exercise they prefer. This includes yoga for patients with chronic low back pain, lumbar radiculopathy, knee osteoarthritis, or fibromyalgia. Cognitive behavior therapy and mindfulness-based stress reduction can help patients with chronic low back pain or fibromyalgia. Physicians should consider spinal manipulation for patients with chronic low back pain or neck pain and acupuncture for patients with chronic low back pain, neck pain, or fibromyalgia. Massage or myofascial release for low back pain, neck pain, hip and knee osteoarthritis, and fibromyalgia may be helpful. Multi- or interdisciplinary rehabilitation may be an option for patients with chronic low back pain or fibromyalgia who do not respond to initial therapies or have a significant psychological component.

What diagnostic tools are appropriate for patients with NAFLD?

Routine screening for nonalcoholic fatty liver disease (NAFLD) is not recommended, even for high-risk adults. For patients with suspected NAFLD, ultrasonography is the imaging test of choice. Noninvasive tools such as decision aids (NAFLD Fibrosis score or Fibrosis-4 Score) or liver stiffness measurements using vibration-controlled elastography or magnetic resonance elastography are clinically useful for identifying patients with NAFLD who have a higher likelihood of developing fibrosis or cirrhosis. A liver biopsy should be offered to patients at increased risk of nonalcoholic steatohepatitis or advanced fibrosis based on noninvasive testing or to determine other possible causes of chronic liver disease.

How should patients presenting with suspected peripheral neuropathy be evaluated?

The initial evaluation of suspected peripheral neuropathy includes a complete blood count, comprehensive metabolic profile, fasting blood glucose, thyroid-stimulating hormone and vitamin B12 levels, and serum protein electrophoresis with immunofixation. Referral for electrodiagnostic studies is indicated if symptoms are worrisome (e.g., acute onset, asymmetrical, predominant motor or autonomic symptoms, rapidly progressive course) or if the initial workup is normal and symptoms persist.

Is administering beta blockers beneficial in the setting of acute MI?

A Cochrane review evaluated the effect of beta blockers initiated within 48 hours to up to 21 days post myocardial infarction (MI). Compared with placebo, beta-blocker use in patients with acute MI reduces short-term (less than three months) risk of MI (number needed to treat [NNT] = 196; 95% CI, 143 to 333) and long-term (more than six months) risk of cardiovascular mortality (NNT = 83; 95% CI, 48 to 500) and all-cause mortality (NNT = 91; 95% CI, 48 to 1,000). There are no significant harms.

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How should patients presenting with chest pain be managed in the outpatient setting?

Twelve-lead electrocardiography should be performed on all patients in whom cardiac ischemia is suspected. The presence of ST segment changes, new-onset left bundle branch block, presence of Q waves, and new T-wave inversion increases the likelihood of acute coronary syndrome and acute myocardial infarction, warranting prompt referral to the emergency department. Patients with a low to intermediate probability of coronary artery disease not requiring acute transfer should be evaluated for coronary artery disease with exercise stress testing, coronary computed tomography angiography, or cardiac magnetic resonance imaging.

How can adverse oral reactions to commonly prescribed medications be managed?

Before starting antiresorptive therapy patients should be counseled on the importance of good oral hygiene, routine dental visits, and tobacco cessation. The incidence of medication-induced gingival enlargement can be minimized by limiting intraoral plaque. If oral hyperpigmentation occurs from medication, discontinue the offending drug, and offer surgical laser therapy if resolution is not complete.

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