Musculoskeletal Disorders PDF

Osteoarthritis Typically attacks 2 types of joints ○ Weight-bearing ○ Repetitive motions Characterized by the progressive loss of articular cartilage and remodeling of the underlying bone Most common form of arthritis ○ RA is an autoimmune disease versus oste...

Osteoarthritis Typically attacks 2 types of joints ○ Weight-bearing ○ Repetitive motions Characterized by the progressive loss of articular cartilage and remodeling of the underlying bone Most common form of arthritis ○ RA is an autoimmune disease versus osteoarthritis RA: will have chronic inflammation in joints ○ Osteoarthritis is common to see in elderly patients ○ Other types of arthritis: RA Gout: the cause is b/c of elevation of uric acid Psoriatic arthritis: Inflammatory conditon of the skin; autoimmune disease as well Juvenile arthritis: 3-6 y/o joint pain symptoms begin; joint swelling and pain Chronic uveitis is a common sign to have if patient has arthritis ○ Posterior synechia, cataracts, glaucoma secondary to synechia Leading cause of joint replacement surgery Disability: diminished quality of life among older individuals ○ Cannot perform normal activities and they cannot walk long distances; Onset before the 5th decade is unusual ○ Can see in obese patients because of the mechanical stress ○ Osteopenia: decreased mass of muscle* (mild decreased bone density without it being considered a disease) w/o being osteoporosis 45 years May be asymptomatic ○ Cervical spine can induce pain in the neck and head, with radiation down the arm weakness, or paresthesia ○ Occurring from compression of cervical nerves from osteophytie formation ○ Analogous process can occur in the lower thoracic and lumbosacral spine ○ ○ Inflammation presents in advanced stages but osteoarthritis is not inflammatory Diagnosis: history & physical exam Laboratory tests: CMP, CBC, Hepatic panel ○ Serologic test: Rheumatoid factor (RA will have a + rheumatoid factor) Antinuclear antibodies (+ in inflammatory conditions like rheumatoid arthritis or advanced stages) Elevated in lupus also, not elevated in osteoarthritis Protein C reactive Elevated in AI disease, normally not osteoarthritis HLA-B27 Elevated = ankylosing spondylitis, they have low back pain and are young patients  Radiographic imaging ○ Typically show osteophytes (reduction in joint space) ○ Joint space narrowing ○ Sclerosis of subchondral bone ○ Cysts ○ Joint deformity ○ Radionuclide scans & MRI are not routinely needed Treatment for osteoarthritis ○ Non-pharmacologic Weight reduction Physical and OT Orthotics and splints ○ Pharmacologic Glucosamine and chondritin sulfate Analgesics Acetaminophen helps with pain but not inflammation Anti-inflammatory NSAIDs (Naproxen - 1 g q 8 hrs, Ibuprofen- 200 to 800 mg q 6 or 8 hrs) ○ Issue: have to pass through the stomach and can give ulcers or can cause hepatotoxicity Secondary effects of corticosteroids (decrease bone density) ○ Surgery Arthroscopy Replacement Osteoporosis: decreased bone density ↑ reabsorption of bone or ↓ synthesis of bone due to physical inactivity ○ Decreases more if the patient is sedentary In the initial stage: won’t have ? Clinical features: ↓ bone mass = fractures are at risk when it’s fragile ○ Vitamin D and calcium is given to avoid the late-stage  Risk of osteoporosis ○ Aging ○ Race Caucasian and Asian women Common in women because estrogen decrease in menopause* But all races may develop the disease ○ Low body weight ( < 127 pounds) Decrease estrogen in perimenopause and menopause women ○ Small bone structure Lifestyle factors ○ Increased risk Physical inactivity Caffeine Excessive alcohol use Smoking Dietary calcium and vitamin D deficiency ○ Family hx of bone disease Non-pharmacologic treatment ○ Modifaction of general lifestyle factors Such as increasing weight-bearing When they exercise, they must have weights (not heavy but they have to increase muscle mass b/c it is important to maintain the density of the bone) Push-ups and squats are recommended Muscle-strengthening exercise Which epidemiologic studies have linked to lower fracture rates Optimum calcium and vitamin D intake Treatment ○ Bisphosphonates - first line of therapy For up to 5 years orally or 3 years IV Alendronate (Fosamax) #1 Risedronate (Actonel) Raloxifence (Evista) is a SERM (Selective Estrogen Receptor Modulators) Indicated for the tx and prevention of osteoporosis in postmenopausal women Rx to women > 50 y/o or postmenopausal women Commonly used by rheumatologists Fibromyalgia Chronic disorder occurs predominately in females (ratio is 10 : 1) ○ Syndrome that is dx after ruling out everything out, they come out negative for everything ○ Difficult to dx and they suffer from muscle pain Characteristics: ○ Pain amplification (exagerrated) You could touch them so lightly and they will say it hurts bad ○ Psychological distress** Usually secondary to anxiety and depression ○ Numerous somatic complaints ○ Fibromyalgia overlaps with other unexplained Illnesses as Chronic fatigue syndrome Central Sensitivity Syndromes (Currently Proposed Members) ○ Fibromyalgia (overlaps strongly with chronic fatigue syndrome) ○ Irritable bowel syndrome (includes functional dyspepsia) ○ Temporomandibular disorders ○ Myofascial pain syndrome, regional soft tissue pain syndrome ○ Periodic limb movements in sleep ○ Female urethral syndrome, interstitial cystitis (painful bladder) ○ Post-traumatic stress syndrome ○ Depression ○ Migraines ○ Postural Tachycardia Faces of fibromyalgia: chronic, fatigue looks, inadequate and poor-quality sleep, impaired concentration, HA and poorly localized chest or abdominal pain w/o positive physical findings Clinical presentation ○ Widespread pain ○ Allodynia (unpleasant sensation on gentle touch) ○ Fatigue (may be the dominating symptom) ○ Subjective weakness ○ Insomnia ○ Depression ○ Anxiety Diagnosis: lab tests are normal (CBC, creatinine kinase, TSH, ESR, ANA, Pressure algometry = dolorimetry -> 4 tender points is highly suggestive) Principles of treatment ○ (1) Validation of distress ○ (2) diagnostic and therapeutic conservatism ○ (3) individualized combination of pharmacologic and nonpharmacologic measures  ○ (4) care rather than cure ○ Glucocorticoids do not help with pain so they need something stronger NSAIDs do not work at all ○ Anti-seizure drugs: Gabapentin (Neurontin) Pregabalin (Lyrica) ○ Antidepressants: Tricyclic antidepressants (Flexeril (Cyclobenzaprine)) SNRIs (Cymbalta) SSRIs (Prozac, Paxil) Ankylosing Spondylitis One of the spondyloarthropathies Young male adults* will have elevated HLA B27 90% of cases has the HLA B27 marker 3 times more common in males Clinical presentation ○ Inflammatory back pain and stiffness ○ Young adult ○ 20% present with peripheral joint involvement ○ >50% have spine and other joints affected at some stage Usually complains of lower back pain and will eventually become stiff and will not be able to bend Stiffness is because they fuse together and there is no space in b/w ○ Ocular manifestations ○ Iritis (uveitis) occurs in 25% to 30% ○ Unilateral non-granulomatous uveitis ○ AC cells and Flare + Ciliary injection Flare: proteins in the aqueous humor WBCs due to inflammation presenting in aq. humor ○ Severe unilateral throbbing pain (usually) ○ Associated with lacrimation  ○ Photophobia ○ Blurring of vision ○ Could have recurrent episodes of uveitis ○ Presents unilateral at first but can become bilateral w/ time ○ ○ WBCs attached to the endothelium (keratic precipitates) Complications ○ More severe = change in aortic valve Posterior synechias can give raise in the IOP Posterior subcapsular cataract is common to present in these patients Diagnosis ○ History: Inflammatory back pain  morning/nighttime pain Morning stiffness lasting > 30 min Worse w/ rest Improve w/ activity ○ Demographics: M>F Age of onset ~20-30 (but may present later in disease) ○ Labs: HLAB27*, CRP, ESR, Lumbar x-ray, MRI ○ ASAS Criteria Age 3 months of back pain + sacroilitis (spine and hip) + 1 inflammatory feature OR HLAB27 + 2 inflammatory features Inflammatory features like back pain, heel enthesitis, uveitis, psoriasis ○ Clinical history of back pain, eye manifestations ○ Physical examination ○ Radiologic findings ○ Sacroiliitis (Sacro-iliac joint inflammation) ○ Bamboo spine Pharmocologic treatment ○ NSAIDS: Ibuprofen, Indomethacin, Naproxen ○ Chemotherapeutic drugs: Methotrexate ○ Immunomodulator drugs: TNF inhibitors: Etanercept Infliximab Non-pharmacologic ○ Physical therapy Uveitis treatment ○ Topical Corticosteroids Prednisolone 1% q 4 hr, 6hr, 8 hr Cycloplegics Gout Inflammatory arthritis, also known as crystal-induced arthropathy Very painful Caused by hyperuricemia ○ Sodium urate crystals ○ Excess of uric acid after breakdown of purines ○ Buildup in joints Incidence 2%  Male predominance Etiology: ○ Elevation of the serum uric acid concentration occurs by Mechanisms: ○ Uric acid under-excretion by the kidney 85%-90% ○ Genetic defects causing overproduction of uric acid 5% Clinical presentation ○ Acute May affect any joint in the body (usually involves the metatarsophalangeal joint of the great toe) Has an abrupt onset in the early morning hours Erythema, warmth, and acute pain occur over the joint and the extensor tendons and surrounding tissue Without treatment, attack may last from 5 to 7 days, and resolve with scaling of the superficial dermis over the involved joint Acute podagra Laboratory findings of acute attack: Leukocytosis with (↑ PMN’s) Elevated sedimentation rate (ESR) Increased levels of acute-phase reactants ○ C-reactive protein Synovial fluid contains large numbers of PMN’s Serum uric acid may be normal and is of no value in the diagnosis of gout Radiographs are almost always normal ○ Chronic  Patients present with a chronic, sometimes deforming, arthritis affecting hands, wrists, feet, knees, and shoulders referred as Tophaceous Gout Chronic tophaceous gout Diagnosis Needle-shaped uric acid crystals in synovial, tenosynovial, or nodule fluid obtained by aspiration of the involved joints, tendons, or subcutaneous nodules Uric Acid serum elevated Treatment NSAIDs ○ Indomethacin 25, 50, 75, 100, 150 mg Corticosteroids ○ Prednisolone 1 mg/kg per day Colchicine Long-term management of gout is focused on lowering uric acid levels Agents used: ○ Allopurinol start 100 mg per day, can be increased weekly