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Osteoarthritis

Rheumatology

QuestionAnswer
OA prevalence: 60-90% of >65; 1 in 5 adults; knee OA most common cause LT disability in US
OA pathophys progressive loss of articular cartilage with assoc remodeling of subchondral bone
Generalized OA = 3 or more joint groups
Joints most affected by OA C-spine, L-spine, fingers, CMC, hips, knees, 1st MTPs
OA: xray findings loss of joint space; subchondral sclerosis; osteophytes; subchondral cysts
OA: early chondral erosions not visible on xray, but on arthroscopy
OA: dx criteria:knee Knee pain and x-ray osteophytes; and (one): age >50 yo; a.m. stiffness (<30 min); or crepitus with motion
OA: other dx Mechanical pain (deep, slow onset, local); Gel; joint-line tenderness, bony enlargemt +/- effusion; crepitus; Dec ROM; Mx atrophy (may precede sx); mild inflame; ESR <20 (M), <40 (F); non-inflam syn fluid (WBC 200-2000, <25% PMN)
Cartilage is nourished and maintained by: hydrostatic transfer of joint fluid (no vascular network); need ROM with joint loading
OA: Genl nonpharm tx Wt loss; pt education; joint protection; patellar taping, ergonomics, thermo, exercise
OA: wt loss min 5% if BMI >25; OR for OA = 1.4 per 10 lb increased wt; 5 kg loss = 50% dec risk in 10 yrs
OA sx improvement w/education 15 to 30%
Goals of OA tx Decrease pain; protect jts from further injury; preserve fn
OA tx that are not effective wedged insole (esp not for severe); unloader brace; some thermal (diathermy, infrared)
OA tx: patellar taping for P-F compartment, for medial pull of patella only; combo w/VMO exercise
Useful thermal tx OA US (only modality to increase hip temp); microwave (deeper)
Exercise that can worsen OA high impact, repetitive, high loading, collision sport
Exercise: hips & knees bike for hips, elliptical for knees
Mx decrease w/age strength dec 15% / decade (50-70 yo); mass dec 40% by 80 yo
OA: if Tylenol inadequate but GI risk high: NSAID & PPI; or COX-2; or Tramadol; or ST opioids, neuroleptic, or prednisone
OA: if effusion, consider: aspiration and (steroid) injection
OA alt tx: glucosamine / chondroitin (safe, won’t slow progression); doxycycline, vit C,D; acupuncture?
Tx: fish oil evidence for RA (not OA)
OA: surg tx wedge osteotomy okay; Arthro debridement no (except for torn meniscus); microfx (not LT cure); Carticel; OATS; joint replacement
Nodal OA distal & proximal IP joints; F > M; female first-degree relatives
OA comorbid disorders hemochromatosis & ochronosis; mutations in type II, IX, & X collagen genes
Most common cause of secondary OA is a severe joint injury
Common synovial crystals in OA calcium pyrophosphate dihydrate and apatite
Fibromyalgia defn chronic pain syn of unk origin; not inflame or autoimmune; does not r/o other dz (& vice versa)
Fibromyalgia: genetics pt w/ first-degree relative w/dz has 8x risk
Fibromyalgia: PE no joint swelling or inflammation; dx by press 18 tender points (press until thumb nail blanches)
Fibromyalgia tender points: back of head; chest (upper & lower); upper back (medial & lateral); low back; buttocks; gr trochanter ; medial knee; lateral epicondyles
Fibromyalgia: Labs within normal limits
Fibromyalgia: Tx multifaceted; Self-care/ pt ed (exercise, yoga, support grp); CBT; Sleep improvement
Fibromyalgia: Tx: antidepressants TCA; SSRIs (fluoxetine, paroxetine); SNRIs (duloxetine / milnacipran)
Fibromyalgia: Tx: analgesics: tramadol, gabapentin, pregabalin
Fibromyalgia: Tx: muscle relaxers: cyclobenzaprine
Fibromyalgia: Tx (genl) NSAIDS, prednisone not helpful; combination therapy best
OA pathophys progressive loss of articular cartilage with assoc remodeling of subchondral bone
Joints most affected by OA C-spine, L-spine, fingers, CMC, hips, knees, 1st MTPs
OA: dx criteria: knee Knee pain and x-ray osteophytes; and (one): age >50 yo; a.m. stiffness (<30 min); or crepitus with motion
OA: if effusion, consider: aspiration and (steroid) injection
Most common cause of secondary OA is a severe joint injury
Fibromyalgia defn chronic pain syn of unk origin; not inflame or autoimmune; does not r/o other dz (& vice versa)
Fibromyalgia: genetics pt w/ first-degree relative w/dz has 8x risk
Fibromyalgia: PE no joint swelling or inflammation; dx by press 18 tender points (press until thumb nail blanches)
Fibromyalgia tender points: back of head; chest (upper & lower); upper back (medial & lateral); low back; buttocks; gr trochanter ; medial knee; lateral epicondyles
Fibromyalgia & SLE 50% of patients with lupus have fibromyalgia
Female, fatigue, general aching, pain at neck, upper shoulders, sleeping problems, tender points Fibromyalgia (exercise program good management)
Heberden nodes OA at DIP
Bouchard nodules OA at PIP
OA usually spares joints at: MCP (except thumb), wrist, hip, knee, spine
OA s/s >50 yo; AM stiffness <30 min; crepitus; Bony tenderness & enlargement’ No palpable warmth
OA vs RA OA: worse w/motion (PM stiffness), better w/rest; hands DIP Heberdens; thumb CMC. RA: hand MCP/PIP; warm tender joint swelling; AM stiffness
OA tx short acting NSAID (motrin/naproxen) x2-4 wks; inc dose prn; COX-2 in some pts; Csteroid injxn
Osteoporosis RF *Advanced age; *Previous fx; Also LT glucocorticoid tx; Low body wt (< 58 kg [127 lb]); FH hip fx; smoking; Excess alcohol intake
Osteoporosis epi F>M (4:1); 1.7M fx in US; 6M hip fx world; W&Asian > Hisp > AA; 4 in 10 WF will fx
DEXA values T score: BMD > -1SD below YN = nml; severe osteo = BMD <-2.5
best predictor of fx risk bone density (75-85% of variance in bone strength)
DEXA used for: PA spine, lateral spine, hip, forearm, total body
T-score: osteopenia -1 to -2.5 SD below YN
Dz examples of bone loss Osteoporosis, FAS (amenorrhea, anorexia, osteoporosis)
Fibromyalgia DDx RA, SLE, hypothyroid, polymyositis (weakness, not pain), polymyalgia rheum, low PO4
Fibromyalgia F>M 20-50 yo; neg inflam sxs/labs; fatigue, HA, numbness; TCAs, Flexeril, SNRI
Osteoporosis = Reduction in bone mass (Low peak mass; inc bone loss; hyperparathyroid, chronic steroids)
Osteoporosis: DEXA Scan: T score of < -2.5
Osteoporosis: Clinical Features: vertebral compression fracture
Osteoporosis: Rx: Oral Ca & Vit D; exercise, SMK cessation; Estrogen in postmen reduces bone reabsorption; Bisphosphonates augment bone density; Raloxifene inc bone density & dec total & LDL-C
Examples of bone loss Osteoporosis, FAS (amenorrhea, anorexia, osteoporosis)
Dietary requirement of Ca: 1000-1500 mg/day
Created by: Abarnard