18529 appendix 4 msk course teaching materials osteoporosis and osteoarthritis
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7/29/2019 18529 Appendix 4 MSK Course Teaching Materials Osteoporosis and Osteoarthritis
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Osteoporosis
A systemic skeletal disease characterised by
low bone mass and microarchitectural
deterioration of bone tissue with subsequent
increased risk of fracture.World Health Organisation
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Epidemiology of Osteoporosis
20 000 fractures / year in UK
Cost to NHS over 940 million
Increased mortality and morbidity Early mortality with hip #
Late mortality with vertebral #
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Histology
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Radiographic Changes
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Fracture Sites
Wrist
risk >55y
Vertebral
risk>60y
Hip
risk>65-70
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Risk factors
Postmenopausal women
Corticosteroids
Other medical problems Inflammatory arthritis
Inflammatory bowel disease
Hyperthyroidism
Malignancy
Family history esp maternal hip #
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Risk factors
Lifestyle Factors
Smoking
Alcohol
Low Body Mass Index
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How to Measure Bone Density
DEXA scan gold standard
Compares patient value to mean expected
peak bone mass.
Population data from white Caucasian women
T score = number of standard deviations from
peak bone mass
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DEXA and Osteoporosis
T score between 0 and -1.0
NORMAL
T score between -1.0 and -2.5
OSTEOPENIA
Tscore less than -2.5 OSTEOPOROSIS
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Is a DEXA compulsory to diagnoseosteoporosis?
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Case History 1
A 55 year old woman.
Postmenopausal
Colles #
T score Hip -1.4
T score L spine -1.0
Otherwise well
Not on other treatment
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Case History 2
65 year old woman
Postmenopausal
Vertebral #
Rheumatoid arthritis
Prednisolone 10mg
T score Hip -3.0
T score L spine -3.0
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Case History 3
35 year old woman
Premenopausal
Family history
No #
T score Hip -1.5
T score L spine -2.0
Otherwise well
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Case History 4
35 year old woman
Hysterectomy and oophorectomy 10 y ago
On HRT only last 2 years
No #
T score hip -3.0
T score L spine -3.5
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Treatment
Aim to reduce fracture risk
Increasing BMD as measured by DEXA may notequate totally with this!
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Non-Pharmacological
Lifestyle alterations
Smoking
Alcohol
Diet
weight bearing exercise
Fall reduction
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Calcium/Vitamin D
Should be given to all if intake thought to be
low.
Poor use as a sole agent apart from frail
elderly.
? treating subclinical osteomalacia
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HRT
Most evidence from observational data
1 RCT showed effect on non-vertebral # risk
reduction.
Beneficial effect ceases on stopping Rx
Worries about breast cancer/CVS mortality
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Alendronate
Prevention and Rx/SIOP
10mg daily
Fracture Intervention Trial Increases in BMD
Reduction in vertebral #
Problems with GI side effects
New equivalent weekly preparation
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Risedronate
Prevention/Rx/SIOP
5mg OD
RR of new vert # 0.35 after 1y , 0.59 at 3y RR of non-vert # at 3 y 0.6
Significant increases in BMD
Placebo incidence of GI side effects
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Raloxifene
Prevention/Rx
BMD increases 2-3%
RR of vert # 0.7 No effect on hip# risk
? reduced risk of bresat cancer
Thromboembolism risk
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How to treat Case 1?
Lifestyle advice
Ca/Vit D
Raloxifene
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How to treat Case 2
Lifestyle
Ca/Vit D
Bisphosphonate Risedronate if fast risk reduction preferrred
prednisolone to lowest possible dose
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How to treat Case 3
Lifestyle
Ca/Vit D
NO BISPHOSPHONATES
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How to treat Case 4
Lifestyle
Ca/Vit D
Calcitriol? Continue HRT?
Bisphosphonate?
No uterus/ovaries Young
absolute # risk low
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Conclusion
Osteoporosis a major health problem
Ageing population
Better patient awareness Better treatments
Guidelines
www.rcplondon.ac.uk
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Tratment Options
Premenopausal
Lifestyle
ca/vit D
?bisphosphonates
Postmenopausal
?HRT for symptoms
SERM for 5-10 years then bisphosphonate
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Osteoarthritis
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Introduction
Chronic degenerative disorder
loss of articular cartilage
most prevalent disease in society In England and Wales, 1.3-1.75M people
affected
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Risk factors
Age
Trauma
Occupation esp kneeling, bending
gender
men>women under 50
women>men over 50
obesity
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Case 1
65 year old man
symptomatic knee OA
on aspirin
no response to paracetamol
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Management
Non-drug
exercise
weigt loss
mechanical aids
Drugs
simple analgesia
NSAIDs ? COX-2 drugs
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Management
Intra-articular steroids
Hyaluronic acid derivatives
Glucosamine sulphate
analgesic ?disease modifier
Surgery
arthrodesis
arthroplasty
washouts
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Case 1
25 year old legal secretary
1 year worsening pain both arms and pins and
needles in hands
difficult to work
anxious
Little to find on examination Neuro normal
Slight lateral epicondyle tenderness
Neck ok. trapezius tender
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The workplace and upper limb pain
Numbness/tingling in the hands very
common. Prevalence ~33%
Several causes
Cervical root entrapment
peripheral nerve entrapment
WORK!
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History
Symptoms
relation to work
relation to rest eg holidays
psychosocial issues
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Workplace ergonomics
Sensible advice, but little/no evidence!
Details:
apple.com/about/ergonomics/index.html
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Examination
Neck
Neurological examination
Tests for adverse neural tension
Carpal tunnel
risk if repeated finger/wrist movements
bending/straightening of elbow
carrying>5kg in one hand
Posture
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Solutions
Workplace ergonomics
Treat carpal tunnel
Posture advice
Physio for adverse neural tension
restrict time at desk
Exercise!
? C Spine X Ray to exclude pathology
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