Class 4 (1/28/21)

Question 1

Osteoporosis

Answer 1

Characterized by low bone density leading to bone fragility and an increased susceptibility to fractures, especially of the hip and and spine osteoporosis develops due to an imbalance between bone formation & bone degeneration.

Question 2

Types of osteoporosis

Answer 2

1. Postmenopausal osteoporosis: specific to women.
2. Senile osteoporosis: occurs in both men and women because of reduced bone formation (aging).
3. Secondary osteoporosis: secondary to medication, particularly corticosteroids (prednisome/cortisol).

Question 3

Bone cells

Answer 3

Osteoblasts: build
Osteocytes: maintain
Osteoclasts: degrade

Question 4

Maintenance of bone mass

Answer 4

Bone production
Stress (activity)
Nutrition (Ca, Mg, Vit. D)
Hormones (estrogen, testosterone, HGH)

Bone loss
Inactivity
Inadequate nutrition
Hormones (decreased/low estrogen and testosterone)

Question 5

Risk factors of osteoporosis

Answer 5

1. Gender: osteoporosis is more common in women than men.
2. Age
3. Race
4. In women: estrogen deficiency as a result of premature menopause (onset before age 45)
5. In men: low testosterone levels
6. Family history
7. Alcohol
8. Nutrition: low Ca intake, Vit. D deficiency
9. Cigarette smoking
10. Low body weight
11. Current low bone mass
12. Drugs: Glucocorticoids (cortisone/prednisone), Progestin (w/o estrogen), Anticonvulsants (phenytoin, Dilantin)

Question 6

Presentation of osteoporosis

Answer 6

A development of “fragility fracture” is regarded as the hallmark, e.g. hip fracture after falling from less than standing height or a vertebral fracture with activities of daily living.
Collapsed vertebrae may initially be seen as kyphosis (stooped posture = “Dowager’s hump”)

Question 7

Diagnosis of osteopororsis

Answer 7

Bone mass/mineral densitometry (BMD) = DEXA scan

• A fracture sustained after a fall from less than standing height or with minimal trauma should suggest the diagnosis.
• Radiographic evaluation: a compression fracture causes reduction in vertebral body weight.

Question 8

DEXA scan

Answer 8

Bone density scanning, also called dual-energy x-ray absorptiometry (DEXA) or bone densitometry, is an enhanced form of x-ray technology that is used to measure bone loss. DEXA is today’s established standard for measuring bone mineral density (BMD).

Question 9

Prevention

Answer 9

• The MOST critical time for formation of the calcium matrix ofbone which is specific for women is from about 2 years beforethe menses starts to about 5 years after, approximately age 9-16.
• Adequate calcium and vitamin D intake and regular weight-bearing exercise.

Vitamin D: Adequate intake, 600 IU/day; maximum safe upper level of intake, 4,000 IU/day.
Calcium: The amount you need depends on your age and sex. But, around 1000 mg.

Question 10

Initial BMD screening

Answer 10

BMD screening in postmenopausal women is widely recommended for those 65 and older
BMD screening in men: age 70 and over

Question 11

Non-Dairy Sources of Calcium

Answer 11

Dark green leafy vegetables
Sea vegetables (seaweed)
Seafood
Seeds

Question 12

Medication for osteoporosis

Answer 12

• Bisphosphonates (=Bisphosphonates slow down the osteoclasts, increase bone density).
• (Alendronate = Fosamax. Problem of Fosamax? Difficulty swallowing (dysphagia)).
• Calcitonin (it is a natural hormone made by the thyroid gland and controls the activity of the osteoclasts. It increases bone density).
• Hormone Replacement Therapy (HRT) that has estrogen in women.
• Testosterone Replacement Therapy in men.
• Testosterone Replacement Therapy: osteoporosis in men can be the result of a medical condition called hypogonadism (meaning low levels of the male hormone testosterone with associated symptoms e.g. sexual dysfunction). Increasing androgen levels increases bone density

Question 13

Rheumatology

Answer 13

It focuses on the treatment of any painful disorder affecting the loco-motor system including joints, muscles, connective tissues, soft tissues around the joints and bones.

Question 14

Osteoarthritis (OA)

Answer 14

• It is also known as degenerative joint disease (DJD).
  OA is the most common pathology of the joints. OA involves mechanical abnormalities involving degradation of joints, including articular cartilage and the subchondral bone.
• Subchondral bone ( it is the layer of bone just below the cartilage in a joint).

Question 15

Risk factors of OA

Answer 15

• Age: the prevalence of OA increases with age.
• Trauma or cumulative mechanical stresses abnormal physical forces lead to altered joint function and damage.
• Obesity
• Muscle weakness

Question 16

Pathogenesis of Osteoporosis

Answer 16

• The primary event is deterioration of articular cartilage.
• The joint lining, or the synovium, becomes inflamed due to cartilage breakdown causing cytokines (inflammatory cascade proteins) and enzymes that damage cartilage further (synovitis).
• Wear of cartilage causes changes to underlying bones.
• As the articular cartilage wears away, there is increased stress on the articular surfaces of the bone.
• This creates inflammation at the joint and the additional stress can cause local bone remodeling leading to the formation of bone spurs or osteophytes.

Question 17

Presentation of Osteoarthritis

Answer 17

• OA commonly presents over age 40.
• Signs and symptoms localized to affected joints (not a systemic disease).
• Pain is often insidious and gradually progresses over years.
• Osteoarthritis most commonly occurs in the weight-bearing joints of the hips, knees and lower back.
• Joint soreness after periods of overuse or inactivity.
• Relieved with rest.
• Stiffness after periods of rest that goes away quickly with movement.
• Morning stiffness, which usually lasts no more than 30 minutes.
• Deterioration of coordination, posture and walking due to pain and stiffness of large joints such as knee.
• Loss of function.
• Limited ROM.

Question 18

Lab results

Answer 18

It is normal in OA, whereas it is abnormal in rheumatoid arthritis.

Question 19

X-ray in OA

Answer 19

Narrowing of joint space, osteophytes.

Question 20

Treatment plan of OA

Answer 20

1. Exercise
2. Weight control
3. Joint protection
4. Physical and occupational therapy

Question 21

Medications of OA

Answer 21

• Analgesics (NSAIDS)
• Injectable glucocorticoids (Cortisone)
• Glucosamine and Chondroitin Sulfate
• Topical Analgesics: Tiger Balm, etc.

Question 22

Analgesics

Answer 22

• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• NSAIDs reduce inflammation and swelling as well as aid in pain relief.
• Examples of NSAIDs include: ibuprofen, naproxen, COX-2 inhibitors.
• Older NSAIDs (for example, aspirin, ibuprofen, naproxen, etc.) all act by blocking the action of both the COX-1 and COX-2 enzymes.
• COX-2 inhibitors selectively block the COX-2 enzyme and therefore have a lower risk of causing ulcers of the stomach or intestine.
• > > COX-2 inhibitors (blocks the enzyme cyclooxygenase-2 (COX-2). This action impedes the production of the prostaglandins that cause the pain and swelling of arthritis inflammation. Celebrex (celecoxib) is the only COX-2 painkiller still on the market.

Question 23

Injectable glucocorticiods (cortisone)

Answer 23

For fast, targeted pain relief.

Question 24

Glucosamine and Chondroitin Sulfate

Answer 24

Glucosamine sulfate - it is thought to help with cartilage formation and repair.
Chondroitin sulfate - have an anti-inflammatory effect.

Question 25

Joint replacement surgery

Answer 25

Indications for joint replacement are severe, unremitting pain with loss of joint function in the presence of radiographic evidence of articular damage.