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PBL > Unit 5: osteoarthiritis > Flashcards

Unit 5: osteoarthiritis Flashcards

1
Q

What is the difference between primary and secondary arthritis?

A

Primary OA has no known cause
Secondary OA is caused by another disease, illness or injury.

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2
Q

What are the risk factors for osteoarthiritis?

A

Gender - more common in females
Age - more common once aged over 40yrs
Obesity - particularly in the knee
Genetic
Previous joint injury
Joint abnormality
Occupation

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3
Q

How does occupation link to the risk of developing Osteo. arthritis?

A

Typing/finger dexterity - more common in hands
Kneeling (gardener) - knee arthiritis
Walking and weight bearing (construction worker)- hip arthritis

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4
Q

What histological changes occurs in a joint suffering from OA?

A

Duplication of the tide mark
Fibrillation in the cartilage surface layer
Loss of distinction between different layers in the cartilage.
Chondrocyte hypertrophy
Chondrocyte clustering
Vascular invasion of subchondral bone.

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5
Q

What are the key identifiable features of hip OA on an x-ray?

A

Obliteration of the superior joint space
Flattening of the femoral head
Subarticular sclerosis
Osteophytes
Subchondral bone cysts

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6
Q

What is the mechanism of action of paracetamol?

A

Crosses the blood brain barrier, inhibits Cox-3,
No peripheral action, only works in the CNS.
Decreases the production of prostaglandins, so less stimulation of nociception neurones and less stimulation of the hypothalamus.
This decreases fever and pain

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7
Q

What are the side effects of paracetamol?

A

Allergic reaction
Blood disorders - thrombocytopenia and leukopenia
Liver and kidney damage - most common in overdose
These are mainly only a problem with prolonged use or if using too high a dose.

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8
Q

What is the mechanism of action of naproxen?

A

Is a nonselective NSAID
Inhibits mainly cox1 (some action on cox2), this prevents the conversion of arachidonic acid to prostanoids. Leading to decreased:
- prostaglandins (particularly PGD2 and PGE2) - so less pain and inflammation

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9
Q

What are the side effects of naproxen?

A

Decreased production of PGE2/1 = less protection of the gastric mucosa, can lead to ulcers and stomach bleeding
Decreased PGE2 = disregulated proliferation, angiogenesis and metastasis
Decreases platelet aggregation increasing risk of bleeding/hemorrhage
Reduces renal blood flow - may cause high blood pressure by activating RAAS.
Note: as a selective NSAID has less adverse cardiovascular effects than non-selective NSAIDs that also inhibit cox-2.

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10
Q

What is the mechanism of action of omeprazole?

A

Proton Pump inhibitor
Oral route
Attracted to the acidic environment around parietal cells.
Sulfoxide to sulfenic acid
Forms a sulfide bond with cystene amino acid in the proton pump in the apical membrane of the parietal cell
Conformational change inhibits the proton pump, less H+ secretion increase gastric acid pH so less damaging

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11
Q

What are the side effects of omeprazole?

A

Mask symptoms of gastric cancer
Reduce immune deficiency of gastric acid.
Constipation/diahorrea
Nausea

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12
Q

What is the mechanism of action of aspirin?

A

Is a non-selective NSAID, that inhibits the conversion of arachidonic acid into prostaglandins by inhibiting cox-1 and cox-2 in the periphery.

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13
Q

What are the side effects of aspirin?

A

Increased risk of hemorrhage
Stomach pain or cramping.
Allergic reaction
Water retention

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14
Q

How are glucosamine and chondroitin used in over-the-counter medication in OA?
Are they effective?

A

Not NICE recommended
Taken as a joint supplement
Chondroitin - component of ECM, inhibits nitrogen oxide synthesis, inhibits Cox-2
Glucosamine - precursor for glucosaminoglycans in ECM, reduce NFKb and interferone gamma

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15
Q

How is rosehip extract used in over the counter medication in OA?
Are they effective?

A

Not FDA approved
Contains polyphenols - increase endorphin production and act as an anti-toxin
Contains large amounts of vitamin C - anti-toxin
Inhibits NF B signalling and decreases levels of CRP.

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16
Q

How is curcumin used in over the counter medication in OA?
Are they effective?

A

inhibits Cox-2, inhibits NF-b singnalling, reduces inflammatory mediators.

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17
Q

What over the counter medication is typically used in OA management?

A

Rosehip extract
Curcumin
Glucosamine and chondroitin
NSAIDs such as aspirin

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18
Q

What is the prevelance of osteoarthiritis?

A

almost 1/3 of Uk population have a muscular skeletal disorder
10% of adults over 45yrs have OA
33% of UK population over 45yrs have sought treatment for OA, 60% of which are female and 40% of which are male.

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19
Q

How can we prevent OA occurrence or progression?

A

Recomends exercise and stretching
Healthy BMI

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20
Q

What are the consrvative treatment for OA?

A

Physiotherapy - stretching and aerobic exercise
Healthy BMI (weight loss is obese)
Education advice and access to information

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21
Q

What are the different surgical treatments for OA?

A

Joint injection - pain relief
Joint replacement
MSC transplant - taken from bone marrow, transplanted into joint space to encourage regneration of cartilage
Cartilage transplant - taken from another artciular surface, cultured in blood, chondrospheres implanted in a mosaic pattern, form loose adhesion within 10 minutes, 6 weeks to heal.

22
Q

How do you take a drug history?

A
  • does the patient have any concerns or questions about their medication
    For each medication collect
  • what it is they take?
    -How much of it they take ? dose wise
  • how frequently they take it?
  • when did you begin taking it?
  • how do you take it?
  • what is it for?
23
Q

What is part of a hip examination?

A

Visual examination, patient often in shorts to expose lower limb
Observe from all four angles, look for muscle wasting, hypertrophy, injuries, scars, fasiculations etc.
Feel the joints for heat, perform tests such as patella tap to identify inflammation.
Passive movement of joints
Active movement of joints
Observe gait, look for any walking aids
Check the patient for pain at any point in the exam.
Compare both sides of the body
If patient has previously had a joint replacement the range of motion should be limited to avoid dislocation.

24
Q

What is a visual analogue scale?

A

A picture chart to rank pain.
10 cm in length with ten intervals from 0 to 10
Each interval is one cm in length.
Each ranking has a smily face image to help depict the degree of pain at each interval from no pain to worst possible pain.

25
Q

How is the demand for hip replacement changing?

A

Increasing hip replacement demand - linked with ageing population.
Becoming more selective on who can qualify and increased weighting times for surgery

26
Q

What are the different types of hip replacement surgery wise?

A

Anterior -
Posterior -
Division made by where the cut is made in the joint in relation to the femoral head, this is mainly surgeon preference.

27
Q

What are the different types of hip replacement material wise?

A

Metallic
Ceramic
Polyethylene
Metal on metal is no longer recommended by the FDA
Complete ceramic or ceramic (head) on polyethene (socket)

28
Q

What are the general outcomes of hip replacement surgery?

A

Risk of DVT (50% without precaution),
surgical infection (2% superficial)
Dislocation (4%)
85% of hip replacement are woking 20yrs after surgery
1 in 10 have pain after surgery that can not be fixed

29
Q

How long does it take to recover from hip replacement surgery?

A

Hospital for 3-5 days
drive - 6 weeks with doctors approval
Return to office based work - 6 weeks
Crutches for 4-6 weeks
Normality - within 3 months
Recommend - avoiding past 90 degrees, swiveling activity, low lying seats (including toilets)

30
Q

How do you qualify for hip replacement surgery?

A

When other pharmacological and non-pharmacological treatments have failed
OA is having a severe impact on the patientes quality of life.

31
Q

What are the NICE guidelines for the treatment of OA?

A

1 st tear - education, exercise, stretching and healthy BMI
2nd tear - escaltor of pain medication, paracetamol when needed, topical NSAIDS 9 knee), oral NSAIDs (with PPI), joint injection, opiods
3rd tear - surgical intervention
Splints and braces are not routinely offered

32
Q

What is meant by ageing as a social construct?

A

Age groups are expected to act, think and behave in a certain way.
Due to societal stereotypes and normality.
Affects others opinion on the elderly and the elderlys opinion on themselves.

33
Q

What physiological models link to behavioural changes in people diagnosed with muscoloskeletal conditions?

A

Model 1: acceptance, coping, self management, integration and adjustment
Model 2: denial, false normality, true normality, disruption

34
Q

What internal factors can influence pain perception and coping?

A

coping stratery - differences in behaviour, emotion and cognitive pattern
Personality - anxious v confident
Self image/identity - how important not being ill is

35
Q

What external factors can influence pain perception and coping?

A

Situational factors - who else is there
what else you are meant to be doing
reactions of others, e.g shouting/ calling 999

36
Q

Can osteoarthiritis be diagnosed without an x-ray?

A

Yes in above 45yrs with aches in joints in morning not lasting longer than 30 minutes, and activity related joint pain.

37
Q

What is trendelenburgs test?

A

Test of hip stability, indicates week hip abductors.
Examiner stands behind the patient, ask to raise one leg, if the hip falls on the raised side then the standing side has a weak gluteus medius muscle.

38
Q

What stretching and strengthening exercies are encouraged in OA management?

A

Exercises the strengthen the muscles around the affected joint
For hip - squats, heel rises
Aerobic - swimming, biking, walking and yoga

39
Q

What is a joint injection for pain relief in OA?

A

Intraarticular corticosteroid injections
Relieve inflammation from several weeks to months.
Swelling often increases immediately afterwards but soon resolves
Risks include a compromised immune system. There are risks of depression or underactive adrenal glands.
Is given by a specialist doctor, may be offered at the GP.

40
Q

How can occupational therapy help with OA?

A

Adjustment as home such as raised toilet seets or hand rails to help sitting/standing
Advice on how to pace exercise
May recommend splints or braces
Help the patient adapt to everyday tasks.

41
Q

What are the pros/cons of a hip replacement surgery?

A

Cons - risk of dislocation means range of movement is limited e.g no squatting
- risks of surgery and recovery time
- 1/10 patients have pain that will not go away after surgery
- one leg shorter than the other, solved by insoles

pros - relieves pain and increases mobility, lasts for 15 yrs.

42
Q

What are the different coping styles?

A

avoidant - mal adaptive, denial, no information and poor help seeking behaviour
Active - help seeking, education, acceptance,

43
Q

How do hip OA patients often present to their GP?

A

Aching and stifness in the groin, buttock or thigh.
Pain radiating from the hip down the leg when weight bearing
Discomfort and aching lasting less than 30 minutes in the morning
Pain increases with exercise and decreases with rest.
Progressive condition
Reduce mobility, struggle to stand up or sit down.

44
Q

How does obesity influence the risk of OA?

A

Increase the incidence and progression of OA.
Overweight x2 as likley to develop knee OA
Obese over x4 as likely to develop knee OA
Increased weight and pressure on the joint
Often decreased muscle mass so less stability in the joint
Adipocytes are associated with a higher risk of inflammation.

45
Q

What are the different beneficial effects of NSAIDs?

A

Analgesic - reduce pain
Anti-inflammatory
Antipyretic - reduce fever

46
Q

What are the different types of prostanoids and there effects?

A

Thromboxane - platelet aggregation
Prostaglandins - gastroprotection, inflammation, fever and pain
Prostacyclin - vasodilation, inhibits platelet aggregation

47
Q

What is the link between pain and depression?

A

Depression is four times more common among people in persistent pain compared to those without pain.

48
Q

Describe how we get referred pain.

A

Referred pain typically happens in areas supplies by the same spinal root.
The second order neurone becomes sensitised to pain, so is more likley to detect pain from secondary sources.
This pain is still modifed by descending inhibitory and exctatory controls.

49
Q

Give an overview of the pathogenesis of OA?

A

Chondrocytes become more active, secrete collagenases, MMPs and pro-inflammatory cytokines
Chondrocytes collect together in isogenous groups
Destruction of ECM and degradation of the cartilage.
Cleavage of aggregan from hyaluronic acid results in decreased water content so less able to withstand compression.
Cartilage thins and DAMPs trigger synovitis.
Chondrocytes eventually undergoe apoptosis
Homeostatis is disregulated, destroy faster than they are repaired.
Chronic damage with a slow progression

50
Q

What is the general procedure of a hip replacement?

A

General anesthetic
Incision - femoral head removed and shaft hollowed out.
Acetabulum may be reshaped by a hemispheric reamor
Acetabulum is resurfaced
New shaft is inserted into the hollowed femur
Often attached by ceramic bone glue.
Typically takes two hours.

51
Q

What are the different types of hip replacement based on the anatomical changes?

A

Full - femor and acetabulum
Partial - just femor
Resurfacing - bones remain are only grinded down and resurfaced

PBL (23 decks)

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