Non-Autoimmune Musculoskeletal Conditions

Question 1

Potentially beneficial interventions in osteoarthritis

Answer 1

Non-pharmacological

• Weight loss
• Exercise
• Patient education
• CBT

Pharmacological

• NSAIDs
• Duloxetine - modest effect, often poorly tolerated
• NGF inhibitors e.g. tanezumab
  
  • Initial trials → effective analgesics but subsequently found to be A/W accelerated joint destruction and increased need for arthoplasty
• Intra-articular steroids → unlikely to get benefit beyond 2 months for knee joint infection. Regular injection → possible A/W accelerated joint destruction

Surgery

• Arthoplasty

Question 2

Interventions to avoid in osteoarthritis

Answer 2

• Fish oil, glucosamine, chondroitin
• Medications
  
  • Paracetamol (no evidence of benefit)
  • Opioids
  • Gabepentinoids
  • Glucocorticoids
  • Intraarticular therapies except for glucocorticoids
• Arthroscopy
• No evidence for magnets/acupuncture/shock wave therapy/cold therapy/kinesio taping etc.

Question 3

Diagnostic criteria for fibromyalgia

Answer 3

Question 4

Management of fibromyalgia

Answer 4

• Goal may be improve function rather than abolish pain
• Avoid excessive use of caffeinated stimulants in patients with symptoms of fibrofog
• Careful evaluation of new symptoms to exclude other medical conditions
• Small doses of exercise → avoid exercise to exhaustion, with gradual dose increases
• Avoid opiates
• Treat other sources of nociceptive pain (e.g. osteoarthritis)

Pharmacological

• TCAs
• Gabapentinoids
• SNRIs
• Tramadol
• Low dose naltrexone
• Propranolol

Always start low with slow up-titration of medications

Interventions to avoid

• Opioids, paracetamol, NSAIDs, glucocorticoids, benzodiazepines, sparse evidence for cannabinoids → not currently recommended

Question 5

Risk factors for osteoarthritis

Answer 5

• Family history and genetics - esp. hip and knee
• Developmental problems: hip dysplasia, slipped femoral epiphyses
• Repetitive loading: athletes, manual workers, squatting
• Biomechanical: Paget’s, ligament rupture, menisectomy
• Obesity
• Trauma
• Hormonal: aromatase inhibitors, oestrogen deficiency

Question 6

Pathophysiology of osteoarthritis

Answer 6

• IL-1B, TNF, and IL-6 → pro-inflammatory cytokines involved
• IL-1B and TNF → downregulate synthesis of major ECM components by inhibiting anabolic activities of chondrocytes
• IL-1B downregulated expression of aggrecan and Type II collagen → structural components of cartilage & stimulates release of proteolytic enzymes → metalloproteinases MMP1, 3 and 13 → key regulators of cartilage destruction

Question 7

Radiographic findings in osteoarthtis

Answer 7

• Osteophytes
• Subchondral sclerosis
• Subchondral cysts