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PassPMR - 06 Rheumatology > 5- Osteoporosis > Flashcards

5- Osteoporosis Flashcards

1
Q

List 3 Types of bone cell and their function 🔑🔑 MOCK

A
  1. Osteoblasts: Bone forming cells → Produce an organic matrix and form mature lamellar bone
  2. Osteocytes: Osteoblasts incorporated in new bone matrix
  3. Osteoclasts: Bone resorption cells

Cuccurollo 4th Edition Chapter 12 Osteoporosis pg898

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2
Q

Q1: Define osteoporosis 🔑🔑 Leak 21

Q2: T-score? Z-score? 🔑🔑

Q3: When you would not use T-score for diagnosis of Osteoporosis?🔑🔑 MOCK

A

OSTEOPOROSIS

Bone mineral density of 2.5 standard deviation below healthy 30-year-old of the of same sex.

T-SCORE

T-score is a comparison of a person’s bone density with that of a healthy 30-year-old of the same sex.

  • Predictor of the fracture risk
  • Normal: 1 SD below or 1+ SD above young adult mean (YAM)
  • Osteopenia: 1 to 2.5 SD below YAM (T-score is between −1 and −2.5, including −2.5)
  • Osteoporosis: 2.5 SD or below YAM (T-score is < -2.5)

Z-score

Z-score represents the number of Standard Deviations (SD) the patient’s bone density is in relation to adults of the same age, gender, and ethnicity.

  • Indicates whether or not the BMD is appropriate for age
  • Predictive of an underlying secondary cause other than age or menopause.

NOT TO USE T-SCORE

  1. Premenapausal Women
  2. Men under 50yo
  3. Children

Rheumatology Secrets - Chapter 52 Metabolic Bone Disease

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3
Q

What are the Causes of Osteoporosis?🔑🔑 Leak 21
List 4 Modifiable & 4 Non-Modifiable factors for osteoporosis? 🔑

A

HEREDITARY, CONGENITAL

  1. Osteogenesis imperfecta
  2. Myotonia congenita

ACQUIRED

Generalized

  1. Age
    1. Idiopathic (midddle age or premenopausal women)
    2. Postmenopausal
    3. Age-related
  2. Metabolic:
    1. Malnutrition, vitamin deficiency (C or D), calcium deficiency, alcohol abuse
    2. Malabsorption syndromes
    3. Nephropathies
    4. Drug use: glucocorticoids, excess thyroid hormone replacement
  3. Malignancy (multiple myeloma, disseminated carcinoma)
  4. Lifestyle
    1. Sedentary lifestyle, immobility
    2. Smoking

Localized → Degeneration or mechanical unloading

  1. Inflammatory arthritis
  2. Fractures and immobilization in cast
  3. Muscular paralysis
  4. Limb dystrophies

Braddom 6th Edition Chapter 34 Osteoporosis pg691 Box 34.1

Cuccurollo 4th Edition Chapter 12 Osteoporosis pg898

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4
Q

List 4 Medications associated with osteoporosis

A
  1. Corticosteroids
  2. Excess thyrosine
  3. Anticonvulsants
  4. Lithium
  5. Loop diuretics
  6. Heparin

Cuccurollo 4th Edition Chapter 12 Osteoporosis pg900

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5
Q

What is Female Athlete Triad Syndrome? Treatment? 🔑🔑 MOCK

A

Triad of

  1. Eating disorder (Anorexia & Reduced Energy Availability)
  2. Menstrual disorders (Amenorrhea)
  3. Low BMD (Premature osteoporosis)

Treatment

  • Calcium and vitamin D supplementation
  • Improving caloric intake
  • Decreasing energy expenditure
  • Limiting aerobic exercise.

Cuccurollo 4th Edition Chapter 12 Osteoporosis pg900

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6
Q

List 4 Indications for BMD Measurement

A
  1. Women age 65 and older and men age 70 and older
  2. Adults who have a fracture after age 50
  3. Women with low body weight, or high-risk medication
  4. Estrogen-deficient women
  5. Immune mediate disease (i.e. RA) and with chronic use of corticosteroid
  6. Primary hyperparathyroidism
  7. Following response to treatment
  8. Testosterone-deficient men
  9. Research—epidemiologic studies, clinical therapy trials

Cuccurollo 4th Edition Chapter 12 Osteoporosis pg901-902

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7
Q

List 4 Ways to manage osteoporosis 🔑🔑 Leak 21 & OSCE Dr. Salem

A

💡 ER - POLICE - MIS

RISK FACTORS, PREVENTION & EDUCATION

  1. Proper nutrition: calcium and vitamin D
  2. Avoid smocking and alcohol.
  3. Avoid immobility and sedentary life
  4. Fall Prevention Program

PROTECTION & ORTHOSIS

  1. Weighted kypho-orthosis
  2. Flexion control orthosis for compression fracture

MODALITIES

  1. Heat and Cold modalities for pain

OPTIMAL LOADING

Physiotherapy

  1. Avoid spine flexion exercises in spinal osteoporosis
  2. Encourage high impact activities (Jogging or running, Weight training, Dancing)
  3. Strengthening: Back extension and isometric exercises to strengthen the lumbar region, abdomen, and upper and lower extremities
  4. Gait & Balance Exercises

Occupational Therapy

  1. Deep breathing exercises
  2. Posture correction: Avoid kyphotic posture → Pectoral stretching
  3. Balance and transfer training
  4. Proper lifting techniques and body mechanics

MEDICATIONS

  1. Vitamin D: 400 to 800 International Units (IU) → Increases Ca+ absorption in gut
  2. Calcium: 800-1200mg daily → Optimal bone health
  3. Calcitonin: 200 IU per day
  4. Bisphosphonates
    • Alendronate (Fosamax): Prevention 5 mg/day, treatment 10 mg/day
    • Ibandronate (Boniva): 3 mg IV every 3 months
    • Zoledronic acid (Aclasta): 5 mg IV yearly; to be infused in no less than 15 minutes
  5. Teriparatide (Forteo): Recombinant human PTH 20 mcg subcutaneous (SC) daily
  6. Denosumab injection (Prolia): Human monoclonal antibody given 60 mg sq twice yearly

Cuccurollo 4th Edition Chapter 12 Osteoporosis pg903-906

DeLisa 5th Edition Chapter 39 Osteoporosis pg997-998 Table 39.12 & 39.13

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8
Q

Write a bisphosphonate prescription for osteoporosis 🔑🔑

A
  1. Alendronate (FOSAMAX): Prevention—5 mg/day; treatment—10 mg daily
  2. Ibandronate (BONIVA): 3 mg IV every 3 months
  3. Zoledronic acid (ACLASTA): 5 mg IV yearly, infused in no less than 15 minutes

Cuccurollo 4th Edition Chapter 12 Osteoporosis pg903-906

DeLisa 5th Edition Chapter 39 Osteoporosis pg997-998 Table 39.12 & 39.13

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9
Q

What are the complications of bisphosphonates?🔑🔑

A

Cuccurollo 4th Edition Chapter 12 Osteoporosis pg904

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10
Q

List 4 Physical recommendations for patient with osteopenia. 🔑🔑 OSCE Dr. Salem

A
  1. Stretching Exercises
    • To improve postural alignment
    • Stretch pectoralis and shoulder for 5-10 up to 30-60 seconds two to three times
  2. ROM Exercises
    • To increase functional mobility
  3. Aerobic Exercises
    • To improve cardiovascular and respiratory conditioning and respiratory
    • How? Walk 20-40 mins daily, goal is 150 mins weekly
    • Include it in warmup and cool down
  4. Resistance Exercises
    • Abdomen and truck control exercises
    • Back strength exercises with extension focused program
    • Weight training three times a week
    • Large muscle groups, each group pick 2 exercises
    • Start with 1-2 lbs for 2 sets of 8-15 repetitions and rest 1-2 minutes
  5. Proprioception, Balance & Stability
    • Tai Chi
    • Gait training +/- aid
    • Balance exercises
    • Fall prevention program

Braddom 6th Edition Chapter 34 Osteoporosis pg700 Box 34.5

Dr. Maitham Note

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11
Q

Management of Acute and Chronic Pain in Osteoporosis

A

💡 ER - POLICE - MIS

  1. EDUCATION & RISK FACTOR
    • Relaxation, support group and self management skills
    • Avoidance of exertional exercises that add compressive-vertical load on the spine
    • Proper body-mechanics during lifting
  2. PROTECTION & ORTHOSIS
    • Rest for 2 days in acute flare up
    • Back support for 7-10 days in acute flare up
    • Kypho-orthosis
    • Spinal bracing: CASH of rigid TLSO in case of cord compression
    • Gait Aid
  3. LOADING “Chronic”
    • Improve posture
    • Gait & Transfer training
  4. ICE & MODALITIES
    • Cold packs for acute flare ups
    • Massage, US, TENS
  5. MEDICATIONS
    • Analgesics, Lidocaine Patches
  6. SURGERY
    • Vertebroplasty

Braddom 6th Edition Chapter 34 Osteoporosis Box 34.2

DeLisa 5th Edition Chapter 39 Osteoporosis Table 39.14

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12
Q

List 6 Risk Factors for Falls in the Elderly 🔑🔑 Leak 21 & OSCE

A

INTRENSIC

  1. Age
  2. Vision impairment: glaucoma, cataracts, macular degeneration
  3. Psychological conditions: depression
  4. Fatigue & insomnia
  5. Neurologic symptoms and conditions
    1. Dizziness
    2. Cognitive impairment, dementia
    3. Parkinson disease, stroke
    4. Peripheral neuropathy
  6. Cardiovascular conditions:
    1. Arrythmias
    2. Postural hypotension
    3. Cardiovascular deconditioning
    4. Orthopnea
  7. Musculoskeletal conditions:
    1. Chronic pain, osteoarthritis (knee, hip, spinel),
    2. Decreased coordination (cerebellar degeneration)
    3. Balance disorder (vestibular dysequilibrium, peripheral neuropathy)
    4. Weakness (i.e., inability to rise from a chair without using one’s arms)
    5. Gait apraxia
    6. Sarcopenia
  8. Urologic conditions: incontinence, nocturia

EXTRENSIC

  1. Environmental: obstacles, slippery floors, uneven surfaces, poor lightning
  2. Improperly fitting shoes, slippers
  3. Medications: Sedative use & Polypharmacy
  4. Alcohol (>3 drinks/d)
  5. Previous falls

Braddom 6th Edition Chapter 30 Geriatrics pg598 Box 30.1

Braddom 6th Edition Chapter 34 Osteoporosis pg694 Box 34.1

DeLisa 5th Edition Chapter 39 Osteoporosis pg988 Table 39.7

Cuccurullo 4th Edition Chapter 10 Osteoporosis pg907

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13
Q

Fall Prevention Program 🔑🔑 Leak 21 & OSCE

A

💡 ER - POLICE - MIS

EDUCATION

  1. Environmental modification: Adequate lighting, removal of throw rugs, handrails for stairs, ramps

PROTECTION & ORTHOSIS

  1. Assistive devices: Canes, walkers, grab bars, tub benches
  2. Adequate shoe wear, avoid high heels

OPTIMAL LOADING

  1. General conditioning exercises
  2. Balance exercises

MEDICATIONS

  1. Modification of meds (Orthostatic hypotension and sedation)

Cuccurullo 4th Edition Chapter 10 Osteoporosis pg907

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14
Q

What factors contribute most to the risk of developing an osteoporotic fracture? 🔑🔑

A

RISK OF OSTEOPOROSIS

  1. Bone health: Current low BMD, Low body weight
  2. Demographic: Caucasian race, Advanced age, Female sex
  3. Lifestyle: Inadequate physical activity, Current smoker, Alcoholism
  4. Hormonal: Estrogen deficiency,Testosterone deficiency
  5. Nutrition: Vitamin D deficiency, Low lifetime calcium intake
  6. Medications: Corticosteroid use

RISK OF FRACTURE

  1. Cognition: Dementia
  2. Vision: Impaired eyesight despite correction
  3. Recurrent falls
  4. Personal history of low-impact fracture
  5. Hip fracture of either parent

DeLisa 5th Edition Chapter 39 Osteoporosis pg983 Table 39.4

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15
Q

Management of Vertebral Body Fracture 🔑

A

ER - POLICE - MIS

EDUCATION

  1. Relative rest
  2. Avoid constipation
  3. Avoid exacerbating activity, in particular flexion-based movements
  4. Avoid flexion-based activities → increase vertebral compression forces
  5. Behavioral modifications
  6. Body mechanics

PROTECTION & ORTHOSIS

  1. Soft corset (Abdominal corset) for comfort
  2. Rigid TLSO
    • CASH brace or Jewett brace
    • Avoided to prevent disuse atrophy and discomfort
    • Orthotics that cause excessive hyperextension forces on the spine may induce posterior element type pain or fractures in the osteoporotic patient.
  3. Weighted kypho orthosis
    • Postural training supports (2 lb) worn for 1 hour twice daily.

OPTIMAL LOADING

  1. Core muscle strengthening
  2. Postural exercises
  3. Balance exercises
  4. Flexibility

ICE & MODALITIES

  1. Superficial heat or cold
  2. Transcutaneous electrical nerve stimulation (TENS)

MEDICATIONS

  1. Analgesic use for comfort
  2. Nonsteroidal anti-inflammatory drugs (NSAIDs) use controversial—may delay fracture healing.

SURGERY

  1. Balloon Kyphoplasty
  2. Vertebroplasty

Cuccurollo 4th Edition Chapter 12 Osteoporosis pg907 & pg909

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16
Q

List 2 Risks of Prolonged Use of Orthosis 🔑🔑

A
  1. Weakening/atrophy of trunk muscles
  2. Increased fracture risk due to disuse osteoporosis
  3. Reduced spinal mobility

Cuccurollo 4th Edition Chapter 12 Osteoporosis pg909

17
Q

Indications & Contraindications for Spinal Bracing in case of Vertebral Body Fracture 🔑

A

INDICATIONS

  1. Pain relief: decreases paraspinal muscle spasm and overuse
  2. Decrease flexion
  3. Spinal stabilization
  4. Prevent further fracture
  5. Prevent soft-tissue shortening
  6. Compensate for weak erector spinal muscles

CONTRAINDICATION

  1. Hiatal hernia
  2. Inguinal hernia
  3. Orthopnea secondary to COPD
  4. Obesity
  5. Kyphoscoliosis

Cuccurollo 4th Edition Chapter 12 Osteoporosis pg908-909

18
Q

Why SCI patients are at risk of osteoporosis? How do you prevent it?🔑

A

RISK

Mechanical unloading lead to osteopenia and further osteoporosis.

NON-PHARMACOLOGICAL

  1. Lifestyle modifications (smoking cessation and caffeine intake)
  2. Physical Activity
  3. Weight-bearing activities (standing and walking)
  4. Reciprocal weight bearing
  5. Neuromuscular Electrical Stimulation (NMES)
  6. Functional electrical stimulation (FES)

PHARMACOLOGICAL

  1. Consider calcium and vitamin D supplementation
  2. Bisphosphonates is controversial.

https://community.scireproject.com/topic/osteoporosis/

19
Q

List 4 Preventive measures for Physical therapy for osteoporosis in SCI patient.

A
19
Q

List 4 Preventive measures for Physical therapy for osteoporosis in SCI patient.

A
20
Q

75 F presents with acute onset mid back pain. Known osteoporosis and on appropriate meds for this. No other medical history. Lives alone in apartment. Has difficulty transferring in your exam room due to pain. Point tenderness in the midline found at T12. X-rays confirm compression fracture at T12, ~30% loss of height. What are 5 specific recommendations for management of this patient?

A

EDUCATION

  1. Bed rest x 2 days.
  2. Training proper lifting, reducing back strain.

PROTECTION & ORTHOSIS

  1. Avoid constipation.
  2. Avoid exertional exercise.
  3. Back supports/bracing to decrease pain/improve ambulation.
  4. Gait aids (if needed).

LOADING

  1. Physiotherapy (ice pack then mild heat & stroking massage).

MEDICATIONS

  1. Analgesics (avoid constipating medications like narcotics).

Ref: Braddom 917.

PassPMR - 06 Rheumatology (5 decks)

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