School Of Public Health

Arthritis falls within the rheumatic diseases, which are exemplified by different illnesses requiring varying treatments based on the person and the prognosis. The similarity between all forms of arthritis is they affect tendons, cartilage, joints, ligaments, and muscles. There are studies that indicate some internal areas of the body are affected by arthritis.

Arthritis Treatment Varies Based on Forms of the Disease

Because the forms of the disease are different, arthritis treatment can vary too. More than 100 known types of arthritis are currently on the books and that is increasing. Osteoarthritis is attributable to the wear on cartilage. Rheumatoid arthritis comes from the overactive immune system, which causes inflammation. It is no wonder by the types and arthritis treatments that the disease is the most common illness of a chronic type in the U.S.

Worldwide, over 350 million people have arthritis. Contrary to what some people believe, arthritis does not only affect older people, because more than 50% of sufferers are under the age of 65. Women do make up a higher percentage rate at 60%.

Contributing Factors to Arthritis Treatment

There are many contributing factors to arthritis treatment. Not only does the type of arthritis play a hand in treatment, but the location, persistence, severity, and medical history of the sufferer also have a role. Arthritis treatment is customized by the doctor for each patient.

There are many forms of arthritis treatment that have been handed down for generations that still supply relief. These home remedies are often combined with nonprescription medications to decrease the cost of treatments, but some cases warrant very strong prescription drugs, surgical operations, and joint injections.

Obese or overweight people with arthritis may be asked to lose weight to reduce the stress on their joints. Treatments serve two general purposes. They should relief the pain and inflammation and they should contribute to joint health, both improving and protecting joint function.

One of the first actions prescribed by doctors is rest and carefully using the affected areas. Heat and cold compresses have some comforting effect and creams for pain do provide incremental pain relief. Extended use of joint supplements may provide some relief from osteoarthritis, especially those with chondroitin and glucosamine additives.

Many arthritis treatments are a matter or trial and error to see what works best. Supplements are controversial because of lack of clinical support, and most doctors suggest their use only if there is obvious improvement when they are taken. If there is no improvement within two months, a supplement is probably not going to help the situation.

Exercise can help strengthen up muscles around arthritic joints, taking pressure off those painful areas. This may include physical therapy, going to a fitness center, and/or a home program. Along with that, steroid injections into the problematic area may give substantial relief for months. This may allow people to dramatically improve their activity and avoid surgery, or at a minimum delay it.

Bracing may also help arthritic joints, such as a knee offloading brace or a back brace in a time of a pain flare up. A TENS Unit may also help decrease pain as well.

If a patient has mild to moderate pain, an over the counter medication such as Tylenol or nonsteroidal anti-inflammatories may make life much more tolerable. In those instances where pain is substantial, a short term course of narcotics can help a patient get through the rough patch.

You can get paid for unlisted procedures, but the road is not always easy, mor eso in pain management and anesthesia practice. However, there are ways you can boost your chances of reimbursement.

You should make an effort to obtain pre-authorization from the payer in a letter. If you have clinical trials that have been conducted by recognized bodies of physicians, see to it that you include that information in your pre-authorization letter requesting approval for a pain management procedure for which you’ll be using an unlisted code.

The letter should also include any current CPT codes that are similar in work and risk.

Study payer’s policies for tips. Most medical policies that payers publish on their websites include disclaimers that every benefit plan defines what services are covered and what services are excluded. One of the things you want to keep up with are those policies payers publish on their websites. It may so happen that sometimes those policies can very much work to your advantage.

Keep a watch on employer plans. Payers often handle medical plans for employers. It is essential to check the patient’s benefit plan for payment information even if the payer website says that the procedure isn’t covered. Be prepared for a bit of a surprise as well because sometimes a specific plan may cover the procedure.

But in the end you should stick to the AMA official coding guidelines unless your contract with a payer stipulates otherwise. If you have any difficulty with a payer processing any unlisted procedure code, then you may take in hand the issue with the payer rep who may direct your provider that it’s all right to report a CPT code breaking away from the AMA CPT guidelines.

To get free CPT code information, there are various one-stop websites that offer free trials. Once you’re sure the website meets your purpose, you can get yourself registered there.

What are occipital nerve blocks?

An occipital block is an outpatient injection performed on either side of the head around the areas of the occipital nerves for pain relief. These are peripheral nerves supplying sensation to the base of the head moving up to the top of the head bilaterally.

What do they work well for?

Occipital nerve blocks have been studied in many research studies, and actually need a lot more research in some conditions to establish efficacy or not. One reason is a lot of these studies did not utilize a control, but just did a bunch and looked back at the results retrospectively.

It has been shown to work well for cluster headaches, cervicogenic headaches, and occipital neuralgia. Additionally, it has shown good results for patients who overuse narcotic medication and have headaches and possibly those in the withdrawal phases to make the headache pain less.

There are also multiple studies that have looked at it for migraines with encouraging results. These studies overall showed approximately a 50% good to excellent result from ONB’s for anywhere from 1 to 6 months.

How are they performed?

The physician sterilizes the injection site and injects in and around the area of greatest tenderness to palpation. Typically the injection contains both numbing medicine along with a steroid, such as Kenalog or Depo-Medrol.

What is injected?

Most physicians who perform occipital nerve blocks will inject a steroid medication along with a numbing medication. The studies performed have not delineated whether or not the addition of the steroid is absolutely necessary to make the results last longer. It has been postulated that simply the numbing medicine can break the “cycle of pain” in multiple forms of headaches. Since the answer is unclear and the risk of adding the steroid is low, it is typically included.

Should multiple occipital nerve blocks be performed?

As with most pain management injections, occipital nerve blocks typically do not produce effective results forever. Therefore, they will most likely need repeating once they wear off.

An additional consideration is that if the initial nerve block works slightly, it may be repeated sooner rather than later (2 week point versus 3 months or so) to potentiate the results and give more effective pain relief.

Do patients need to have tenderness around the region of the occipital nerves to obtain relief from these nerve blocks?

Occipital neuralgia by definition involves tenderness around the occipital nerves. Cluster, tension, and migraine headaches may not have tenderness in these areas. One study showed that almost half of patients with migraines did in fact have tenderness in the area of the nerves.

The answer to that question is it is unclear if tenderness needs to be present for the injection to work. However, multiple research studies have in fact shown that in patients with tenderness around the occipital nerves that an occipital block has a higher chance of success than otherwise.

This is not to say that if tenderness does not exist around the occipital nerve that the injection would be unsuccessful.

Spinal Degenerative Spondylolisthesis is an extremely common condition that results from spinal arthritis. One vertebra slips on another, and it becomes a mechanical problem that cannot be “fixed”. It may be painless and seen as an incidental finding on x-rays. Or symptoms may include back pain along with buttock, hip, and/or leg pain.

Once diagnosed with degenerative spondylolisthesis, what are treatment options? Here are 7 nonoperative pain management treatment options:

1. Ignore it
2. Physical Therapy
3. Chiropractor Treatment
4. Spinal Decompression
5. Pain Medication
6. Interventional Pain Treatments
7. Bracing and TENS Unit

Ignoring the symptoms of degenerative spondylolisthesis is a treatment known as benign neglect. It’s not a fatal condition and will not paralyze anyone, so if they symptoms are tolerable it is OK to simply deal with it until it rises to the level of concern. If you are wondering whether or not there is something you can do to prevent the condition from worsening, the answer is – not really.

There is some thought that nutraceutical substances like glucosamine and chondroitin sulfate may hold off the arthritis that may result in the spondylolisthesis, but this is not a definite.

Physical therapy and chiropractor treatment have been shown to very effective for back pain conditions, especially when they come on acutely (less than one month duration). It may be that your symptoms are an acute exacerbation and if treated with these options, may lessen back to a tolerable baseline.

Spinal decompression therapy is a revolutionary treatment option involving intermittent traction. It is very safe, FDA cleared, relatively painless, and extremely effective. Patients with degenerative spondylolisthesis are OK for the machine unless they have severe osteoporosis or post surgery with hardware.

Pain medications include NSAIDS, Tylenol, neuropathic medications, or narcotics. Over the counter medications according to the manufacturer’s dosage specifications may control the pain very well such Aleve or ibuprofen. Neuropathic medications may include Neurontin or Lyrica. Narcotics should be provided under the guidance of a physician and should only be obtained by one doctor.

Interventional pain treatments include facet injections (facet blocks), epidural injections, or radio frequency ablation. For spinal arthritis or pinched nerves, spinal steroid injections have been shown to be extremely helpful. They are very low risk and may have very high benefit.

Spinal bracing may be very helpful in instances of back pain due to instability with one segment shifting on the segment below. A TENS Unit may keep symptoms at bay when utilized in moderation. It should be used according to your doctor’s recommendations typically no more than an hour at a time with an hour off.