Musculoskeletal Conditions Part II
What are the recommendations for calcium and vitamin D?
USPTF 2018: Not for prevention Yes for treatment Keifer and Chong: for all pts with low BMD or fragility fx: Ca citrate or carbonate 1000-1200 mg total intake daily • Vit D: replete to >20ng/mL: 1000IU daily IOM 2011: • All adults 19-50: 1000mg/d ;men to 70 • Women >50 and men >70: 1200mg/d • Vit D: Adults 19-70: 600 IU/d, >70: 800 IU/d
What are the USPSTF recommendations for osteoporosis screening for post menopausal women?
Use screening tool before DEXA: PST, ORAI, SCORE, FRAX, OSIRI
What are the contraindications of estrogen? (5)
Vaginal bleeding Breast cancer Liver disease Thrombophlebitis Endometrial ca
What is are the two diagnostic tools for fibromyalgia?
Widespread Pain Index (WPI) Sum of severity score (SSS)
What are the score for patients who are diagnosed with fibromyalgia?
Widespread Pain Index (WPI) ≥ 7 AND Symptom Severity Score (SSS) ≥ 5 OR WPI 4-6 and SSS ≥ 9
What is Denosumab (Prolia) and how does it work?
mAB inhibits RANK ligand, reduces bone resorption
What is PTH and what does it do?
parathyroid hormone or parathomone - role is to regulate blood level of calcium - acts on bone, kidneys, directly on GI Anabolic agents that stimulate bone formation and increase bone remodeling rates
Which of the following individuals is most likely to be at higher risk for osteoporosis?
• A 70 yo AA woman who walks daily for exercise • A 42 yo obese woman from Cuba who has been taking prednisone 10mg daily for the past 12 years to control her asthma • A 55 yo Caucasian woman who is an aerobics instructor • A 45 yo Asian woman who has been on high dose steroids for 1 week
What are primary causes of osteoporosis? (4)
• Aging • Estrogen deficiency • Rate of bone resorption > bone formation • Most pronounced 5-10 years post menopause
What is pathophysiology of osteoporosis?
• Bone remodeling: • PTH -->osteoblasts --> secrete RANK --> osteoclasts --> break down bone --> Ca and phos release • Osteoblasts lay down osteoid, deposit Ca and phos, build bone Normal: resorption=formation Osteoporosis: resorption>formation Consequence of estrogen deficiency
Which labs should be ordered in patients with osteoporosis?
• CBC • Ca • Phos • Cr • LFTs • 25 OH-Vit D • PTH • TSH • Spot urine CrCl
What are the side effects of bisphosphonates? How do PPIs affect this medication?
• Can cause esophagitis, esophageal ulceration, may increase risk of esophageal cancer. (In oral form) • Avoid with ASA, NSAIDs: increases GI side effects • PPI : may increase release of drug from delayed-released form • Decreased absorption with food • Osteonecrosis of jaw: Dental eval before prescribing. • Rare (1 in 1700-1 in 263,000 in OP) • High dose in IV chemotherapy: risk 0.8%-12% • ADA: risk increases if treated > 4yrs • May cause severe musculoskeletal pain days to years after starting Rx
What are the USPSTF recommendations for screening tests in patients with osteoporosis?
• Central DEXA measurement of hip and lumbar spine • Defines osteoporosis •Treatment threshold to prevent osteoporotic fractures • Peripheral DEXA • Quantitative ultrasound
What are contraindications of bisphosphonates? (6)
• D/O of esophageal motility • GI bleeding • Hypocalcemia • Untreated Vit D deficiency • Renal disease (CrCl <35 ml/min) • Barrett esophagus
How do you interpreting DEXA Bone Scan Results: T-Scores and Z-Scores?
• DEXA scores are reported as "T-scores" and "Z-scores." • The T-score is a comparison of a person's bone density with that of a healthy 30- year-old of the same sex. • The Z-score is a comparison of a person's bone density with that of an average person of the same age and sex. • Lower scores (more negative) mean lower bone density: • A T-score of -2.5 or lower qualifies as osteoporosis. • A T-score of -1.0 to -2.5 signifies osteopenia • Multiplying the T-score by 10% gives a rough estimate of how much bone density has been lost. • Z-scores are not used to formally diagnose osteoporosis. Low Z-scores can sometimes be a clue to look for a cause of osteoporosis
A 66yo females DEXA reveals early-onset osteoporosis. The NP recommends all of the following except:
• Daily calcium and Vit D supplement • Decrease physical activity • Minimize alcohol intake • Begin smoking cessation program,
What is the epidemiology of fibromyalgia?
• Females:Males 8:1 • Common co-morbidity of rheumatic dz (RA, SLE) • Onset 40-50 years • Rarely after 55 • Affects 55 mil Americans • 2% of all Primary care visits • 10% of internal medicine referrals • 20% of all rheumatology referrals • Symptoms start gradually in adulthood, wax and wane in intensity • Rarely seen in children NO CURE
What should you ask when obtaining history in patients with osteoporosis? (10)
• Fractures , especially after 50 years old • Early menopause • RA, IBD, Diabetes, CHF, HIV • s/p gastric bypass • Hyperthyroidism • Alcohol use • Smoking • Nutrition: low Ca intake, anorexia • Exercise: weight bearing, sedentary • FHx: osteoporosis, cystic fibrosis, hemochromatosis
What is fibromyalgia? What is the cycle of symptoms?
• Generalized pain amplification • Widespread musculoskeletal pain • >3months, above and below the waist bilaterally • Fatigue • Non-restorative sleep • Headaches • GI complaints (IBS) • Anxiety • Depression Cycle: pain, muscle tension, daily stress, limited activity, fatigue, depression, muscle stiffness
What are secondary causes of osteoporosis? (9)
• Glucocorticoid Rx (most common 2nd cause) • Immunosuppressants: Biologics, DMARDs: autoimmune diseases: • AS, RA, IBD, COPD, amyloidosis, multiple myeloma • Anticonvulsants: seizure disorders • Heparin: CV disorder • Excessive thyroid hormone (thyrotoxicosis) • Leuprolide: prostate cancer, endometriosis • Chemo: cancer • Chronic disease • GI Disorders • Gastrectomy, IBD, chronic PPIs, celiac disease
What is a DEXA Scan? What population is is covered in? What are the most common exam sites? How often is it performed?
• Gold standard to dx osteoporosis (WHO) • Measures bone mineral density (BMD) • Covered by Medicare in women 65 or older • Non-invasive • Low radiation • Most common exam sites hip and lower spine • Performed Q1-2 years. • Paraplegia or glucocorticoid Rx: Q6mos-1 yr
What were the findings from the National Osteoporosis Foundation Report Medicare Cost of OP Fracture (Milliman report)?
• Hip Fx: 90% hospitalization rate twice the annual rate for subsequent fx within 1 year twice the annual rate for pressure ulcers 30% die within 12 months require nursing home for custodial care Preventing 5-20% subsequent fx could save MC $272mil-1$.1 bil annually
What is osteoporosis? What are the primary and secondary causes?
• Low bone mineral density (BMD) • Structural deterioration of bone tissue • Increased risk of fractures • Primary cause decreased estrogen levels • Secondary causes are autoimmune diseases, chronic glucocorticoid therapy, lifestyle
What are the three types of treatments for osteoporosis?
• Medications: • Muscle relaxants for spasm • Nonsteroidal anti-inflammatories, COX2 inhibitors • Acetaminophen • Narcotics sparingly: risk of falls in addition to other s/e • Bisphosphonates and calcitonin help reduce bone pain • Non-pharmacological • Moist heat or ice • Cane or walker • PT • Weight bearing exercise • Surgical interventions • Kyphoplasty • Vertebroplasty
What are the SE of Albaloparatide (Tymlos)?
• Nausea, dizziness, headache and palpitations
What are the effects of glucocorticoid tx on bone? (7)
• Osteoblast death • Prolongs osteoclast life • Decreases level of estrogen and testosterone • Increases metabolism of Vit D • Decreases intestinal absorption of Ca • Leads to rapid bone loss in first 6 months of Rx • Increase RR of fx by 75% in 1st 3 mos
What is Albaloparatide (Tymlos) How long do you give this medication for?
• PTH-related peptide analog • Less bone resorption and bone formation than teriparatide, less risk of hypercalcemia • Bone density better than terparatide • Give for 18 months then switch to alendronate
What are the complications of osteoporosis? (7)
• Pain: 84% have acute pain with vertebral fx that can become chronic • Spinal changes • Muscle spasms • Reduced exercise tolerance • Reduced pulmonary reserve • Abdominal protuberance may lead to early satiety and weight loss • Distorted body image
What is a kyphosis a late sign of?
• RA • Osteopenia • Osteoporosis • OA
What were the Milliman report recommendations?
• Setting of national goals for primary and secondary prevention of osteoporosis and fractures; • Prioritizing reduction of racial disparities; • Sharing of evidence-based information about the treatment and prevention of fractures and prevention of falls • Integration of information about osteoporosis and fractures into fall prevention programs and vice versa • Medicare pays for high-quality bone density testing to identify those who are at risk of bone fracture (prevention) • only 9% of women who suffer a fracture are screened for osteoporosis within six months of a new fracture. • Medicare also pays for FDA-approved drug treatments for osteoporosis that can help reduce spine and hip fractures by up to 70% and cut subsequent fractures by about half. But about • 80% go untreated, even after a fracture • Changes to Medicare payments to incentivize widespread use of model secondary fracture prevention/care coordination
How should patients take bisphosphonates?
• Take with a full glass of water, before eating or drinking • Sit up for 30 mins after med • Can cause erosive esophagitis
What is the prevalence of CTS?
•2.7 million office visits annually •Occurs in 3.8% of the population •9.2% of women•6% of men
What are common findings in patients with fibromylagia? How are symptoms usually diagnosed?
•3 out of 4 patients have headache (migraines) •Do not improve until other symptoms of FM are addressed •Multiple symptoms lead one to think that the patient is exaggerating •Often symptoms are diagnosed as only anxiety or depression and FM is not recognized •Result is ineffective treatment and persistent symptoms, unnecessary workups •Most people with FM get improve over time and the need for medication will also decrease
What should you focus on in your PE for patient's with CTS?
•Abrasions or ecchymosis on the wrist and hands •Bony abnormalities •Joint swelling of the carpal or distal phalanx •Thenar atrophy •Pattern of symptoms •at least two areas: either the first, second or third fingers. •may also involve the fourth and fifth fingers •wrist pain and radiation of pain proximally to the wrist •should not involve the palm or dorsum of the hand
What are the risk factors of CTS? (10)
•Activities that require repetitive wrist/hand motion •Hypothyroidism •Pregnancy RA •Obesity •Colles' fracture •Acromegaly •Amyloidosis • Chronic polyarthritis •Corticosteroids and estrogen Rx
What other medications can be ordered for patients with fibromyalgia? (2nd line)
•Amitriptyline (TCA): •For sleep •Anticholinergic •Cyclobenzaprine (muscle relaxer) (flexeril) •Sleep •Muscle stiffness •Pregabalin •Neurotransmitter regulator•Non-opioid analgesic •Duloxetine •NSSRI •Depression •Chronic MS pain •Neuropathic pain •Milnacipran •SNRI •FMS •Gabapentin •Similar to pregabalin •Better insurance coverage
What is the first stage of CTS?
•Awaken from sleep with a feeling of a numb or swollen hand •No actual swelling visible. •May feel severe pain coming from their wrist emanating to their shoulder, with a tingling in their hand and fingers •Shaking or flicking of their hand will stop the pain •Hand may feel stiff in the morning.
What area of the body is most affected by CTS? What is it characterized by?
•Both hands affected 50% of the time •Characterized by numbness on thumb, index and middle finger, medial aspect of 4th finger (innervated by median nerve) •Hand grip weakness •Difficulty lifting objects due to numbness and weakness •Chronic: atrophy of thenar eminence (late sign)
What is the second stage of CTS?
•Daytime symptoms •Occur with repeated hand or wrist movements •When maintaining the same position for a prolonged time. •Clumsiness when using their hands to grip objects, resulting in the objects falling.
What is the effect of exercise in patients with fibromyalgia?
•Exercise at moderate-to-high intensity results in better improvements in functional capacity •The effects of aerobic, progressive-resistance stretching and flexibility exercises on FMS patients have been analyzed by several studies. •Some of these studies demonstrated that AE has positive effects on sleep, quality of life, self-esteem, depression, pain. •Growth hormone levels significantly increased after intervention
What are the differential diagnoses for patient's with suspected CTS?
•Fracture •Dislocation •Crystal deposition disease •Vascular abnormalities •Nerve entrapment: 90% of all entrapment neuropathies is CTS •Tendon disorder •Overuse of muscle •Non-specific pain syndromes
What is the third stage of CTS?
•Hypotrophy or atrophy of the thenar eminence. •Sensory symptoms may no longer be felt at all.
What questions do you ask regarding the history of a patient with CTS?
•In addition to the assessing for risk factors •Timing of symptoms: •night or during the day •certain positions or repeated movements provoke their symptoms •use of vibratory instruments for work, whether their symptoms are •felt in the hand, wrist or shoulder •what patients may do to alleviate symptoms (shaking, flicking, etc.)
What is the treatment for stage 1 CTS?
•NSAIDs •Splint •Rest joint •PT •Heat/Ice
What are the diagnostic tests for CTS?
•No labs unless you suspect another inflammatory disease •Xray if you suspect fracture •Hand fx requires immediate ortho referral •Nerve conduction studies by ortho or neurology
What is the treatment for stage 2 CTS?
•Ortho referral •Cortisone injection •EMG (gold standard for diagnosis• Surgical repair
What is carpal tunnel syndrome? What population is most commonly involvement?
•The American Academy of Orthopedic Surgeons (AAOS) defines CTS as "a symptomatic compression neuropathy of the median nerve at the level of the wrist" •Women: men. 3:1
How do you diagnoses CTS?
•Tinel's sign: (sensitivity = 57%-91%; specificity = 33%-86%) •Tap anterior wrist briskly --> pins and needles of medial nerve •Phalen's sign: (sensitivity = 23%-60%; specificity = 64%-87%) •Forearms vertical •Full flexion of wrist for 60 seconds •Positive --> tingling sensation of the MN by passive flexion •Katz Hand Diagram •where they are experiencing symptoms •classify the symptoms as numbness, pain, tingling or hypoesthesia.
What are the USPSTF recommendations for medications in patients with osteoporosis?
Bisphosphonates, PTH, raloxifene, estrogen. Based on clinical situation and individual risk and benefit Fall prevention Calcium Vit D supplementation (?)
What is the pathophysiology of fibromyalgia?
CNS dysfunction, not muscular or autoimmune, or viral disease • Peripheral pain processed in spinal cord brain • Studies have shown that the pain becomes louder in the brain • "Central Sensitization": Pain is recognized at a lower threshold Hypersensitivity fro pain • Hypothalamus or pituitary decreases levels of growth hormone (GH) and insulin-like growth factor (IGF) disturbing sleep • Hypopituitary axis releases decreased cortisol FMS may be due to disturbances in autonomic and endocrine stress response systems Primary cause of central dysregulation is unknown Often follows physical or mental trauma, viral illness, and stress
What are the screening tools for osteoporosis? (2)
FRAX- fracture risk assessment tool • BMD (femoral neck) + clinical risk factors • Criteria can vary by country • Does not have high sensitivity in women <65 • Predicts fracture risk, not osteoporosis • SCORE (calculator app) (Simple Calculated Osteoporotic Risk Estimate) • More sensitive in predicting osteoporosis in women 50-64
What are the effects of estrogen on bone turnover?
Inhibits bone remodeling, likely via the osteocyte • Inhibits bone resorption by direct effects on osteoclasts • -Inhibits osteoblast apoptosis • increase osteoblast lifespan • increasing the functional capacity of each osteoblast.
What is the relation of osteoblasts and osteoclasts in patients with osteoporosis?
Osteoblasts are low (bone forming) Osteoclasts are high (bone resorption) Causes reduction in bone mass
What T score defines osteopenia? Osteoporosis?
Osteopenia: spine or hip BMD 1- 2.5 SD below the mean. • WHO definition: Bone mineral density 2.5 SD or less below young, normal mean (T-score ≤ -2.5) as measured by dual energy x-ray absorptiometry (DEXA) •
Fibromyalgia is a disorder of
The musculoskeletal system •The cardiovascular system •The central nervous system •The behavioral system
What labs should be taken in patients with suspected fibromyalgia to r/o other disease?
Not needed to confirm diagnosis but can R/O other disease •CBC •ESR •CRP •CMP • Thyroid function tests •25-OH Vit D•B12 •Iron studies If synovitis on exam :RF, ANA, CCP NO IMAGING
How should you educate patient's and family for osteoporosis? (6)
Nutrition • Psychosocial • Risk factor modification • Proper body mechanics • Safe home environment • Refer: National Osteoporosis Foundation • www.nog.org
What are bisphosphonates? How do they work? Name four bisphosphonates.
Synthetic analogues of pyrophosphate Reduce bone resorption and bone loss, deactivate osteoclasts Most common medications prescribed for osteoporosis treatment. • Alendronate (Fosamax): po daily or weekly • Risedronate (Actonel): po daily, weekly or monthly • Zoledronic acid (Reclast): IV yearly • Ibandronate (Boniva): IM, monthly, expensive
What are the effects of estrogen deficiency in bone? (5)
-Enhances endocortical resorption in cortical bone • Increases intracortical porosity • Leads to decreased bone mass • Disturbs bone architecture • Reduces bone strength
•Diagnostic criteria for FMS include
Tender points above and below the waist bilaterally Sudden onset of symptoms •Elevated C-RP •Focal neurological finding ie: numbness or weakness
What medications are PTH? How long do you take this medication?
Teriparatide (Forteo): sub q • Increases bone density at hip and spine 2% and 8% • Effective in men and women, and those on glucocorticoid Rx • Decreases vertebral fx by 65%, non-vertebral fx by 35% • More effective than alendronate for glucocorticoid induced osteoporosis • Approved for 2 yrs • Rapid decrease in bone density after cessation
What are unmodifiable risk factors for osteoporosis? (6)
1. Advanced age 2. Female 3. Caucasian or Asian race 4. Personal h/o f/x 5. FH of f/x (1st degree relative) 6. Dementia
What is Romosozumab (Evenity)?
Antibody against sclerostin, an inhibitor of bone formation
What is Dowager's hump?
Advanced osteoporosis of the spine, increased kyphosis, can develop vertebral fractures and spinal hump. Deterioration of vertebral support
What medication do you give patients after Teriparatide is completed?
Alendronate
What is the first-line treatment in patients with fibromyalgia?
Education :•Reassurance about benign nature of the syndrome •May wax and wane, become chronic •Currently there is no cure •Validate the pain •Treating comorbidities will improve symptoms •Physical activity: •Tai Chi •Massage •Yoga •Gentle exercise •Cognitive Behavioral Therapy •Support groups Aerobic exercises help with sleep
What is the gold standard for CTS diagnosis?
Electrodiagnostic tests •Quantify and stratify the severity of CTS •Nerve conduction studies •Future decision of treatment options •Sensitivity of 56% to 85% and a specificity of at least 94%
What are the risks of taking estrogen? (3)
Endometrial hyperplasia CAD Thrombosis
What is seen upon physical examination in patients with fibromyalgia?
Except for pain and fatigue, should be normal •Note diffuse tenderness especially in trigger points Not FMS: Synovitis Rash Focal neuro findings: numbness, weakness
What are the USPSTF recommendations for Vitamin D and calcium supplementation in patients with osteoporosis?
Found inadequate evidence that supplementation prevented fx • Current evidence is insufficient to assess risk and benefit for primary prevention of fractures • These recommendations do not apply to persons with a history of osteoporotic fractures, increased risk for falls, or a diagnosis of osteoporosis or vitamin D deficiency.
What happens to the bones in patients with estrogen deficiency?
Gap between bone resorption and bone formation, due to • Loss of the effects of estrogen on decreasing osteoblast apoptosis • Without estrogen, the lifespan of osteoblasts and their functional capacity is now shorter • Loss of the effects of estrogen on decreasing stress, osteoblastic NFκB activity, and perhaps osteoclasts
What are the contraindications of Teriparatide? (2)
Hypercalcemia Increased risk of osteosarcoma
What are modifiable risk factors for osteoporosis? (11)
Hypogonadism Current cigarette smoking Excessive alcohol or caffeine use Low Ca intake Low body weight (<58kg) Sedentary lifestyle Visual impairment Glucocorticoid or anticonvulsant use Thyrotoxicosis Recurrent falls Poor health, nutritional status, frailty
What history is important to ask about in patients with fibromyalgia?
Important to get an in-depth history to avoid unnecessary work ups• General health: fatigue, HA• Persistent pain: all characteristics •Neuropathy •Recent trauma (physical or emotional) •Medications •Nutrition •Exercise •Social history •Travel •Psych: anxiety, depression * note diffuse b/l migratory, worsening, tender, stiffness, hyperresponsivenss to light or noise
What do you look for upon physical examination in patients with osteoporosis?
Look for secondary causes of osteoporosis: • Band keratopathy: calcium salt deposit in eye, appears like opaque, white band across cornea. • Hyperparathyroidism • Excess Vit D intake • Paget's disease • Sarcoidosis • Exophthalmos, goiter, tremor, warm moist skin, weight loss: • Hyperthyroidism • Dorsal fat, supraclavicular fat, hypertension, central obesity, edema, proximal muscle weakness • Cushing syndrome • Height and weight, BMI • Decrease in height • Low BMI (<25) • Risk of Falls: Assess gait and balance • Skeletal: Kyphosis Focal back pain (compression fx) Frailty
What are the USPSTF recommendations for osteoporosis screening? Population/ Risk assessment?
Population: • Women 65 years • Postmenopausal women at risk <65 • Men: insufficient evidence Risk Assessment: • Parental h/o osteoporosis • Smoking • Excessive alcohol • Low body weight
Which patients should be referred for osteoporosis?
REFER premenopausal women and men <50 to endo
A 65 yo woman's bone density result shows severe demineralization of cortical bone. All of the following pharmacologic agents are useful in treating this condition except
Raloxifene (Evista) • Calcitonin (Miacalcin) • Medroxyprogesterone (Depo-Provera) • Calcium with Vit D
What is the American College of Physicians recommendation regarding the use of estrogen in patients with osteoporosis? How does it work?
Recommends against estrogen for osteoporosis prevention • Not approved by FDA for treatment of osteoporosis, only prevention • Inhibits bone resorption • Decreases bone remodeling • Increases absorption of calcium
What are the adverse effects of SERMs? (4)
Risk of venous thrombosis Fatal stroke Hot flashes Leg cramps
What is Raloxifene (Evista)?
SERM Receptor agonist on skeletal tissue, but antagonist on breast and uterine tissue ie will not increase risk of cancer 1.5% -3% increase in spine and femoral neck after 3 years 30% reduction in new vertebral fx
What are SERMs? What population are they for?
Selective estrogen receptor modulators For women only
How does Calcitonin work?
Slow bone loss and temporarily increase vertebral bone mass by decreasing osteoclastic activity
What SSS score? How is it calculated?
Sum of the severity score of 3 symptoms: fatigue, waking unrefreshed and cognitive symptoms (0-9) Number of the following symptoms over the past 6 months (0-3): • Headache • Pain in abdomen • Depression Final score 0-12
What is the treatment for stage 3 CTS?
Surgical repair •Tertiary care
How do you calculate the fibromyalgia severity (FS) scale?
WPI + SSS
What is the WPI? How is it scored?
WPI Score: number of areas patient had pain in last week. (0- 19) Includes all regions of the body (see p.970 Buttaro)
What are osteoblasts?
bone forming cells
What are osteoclasts responsible for?
bone resorption
