Connective tissue

assessment

An evaluation technique for technology that requires analyzing benefits and risks, understanding the trade-offs, and then determining the best action to take in order to ensure that the desired positive outcomes outweigh the negative consequences. Techniques used to analyze accomplishments against specific goals and criteria. Examples of assessments include tests, surveys, observations, and self-assessment.

Musculoskeletal - NSAIDS

NSAIDs block the production of certain body chemicals that cause inflammation (Prostaglandins). NSAIDs are good at treating pain caused by slow tissue damage, such as arthritis pain. uAspirin (available as a single ingredient known by various brand names such as Bayer or St. Joseph or combined with other ingredients known by brand names such as Anacin, Ascriptin, Bufferin, or Excedrin). uIbuprofen (known by brand names such as Motrin and Advil). uNaproxen sodium (known by the brand name Aleve).

DRUG THERAPY for osteoarthritis

Oral NSAIDs are recommended for hand, knee, and hip OA especially in the presence of appreciable inflammation.1 When taken only as needed, these drugs provide more analgesia than anti-inflammatory effects. Lower (OTC) doses of ibuprofen (< 1200 mg/day) are usually not enough to provide good anti-inflammatory activity. There is not enough data to recommend one NSAID over another; when one NSAID does not appear to work, consideration for the use of a different NSAID should be made when inflammation is noted.

PQRST

provocative/palliative - what factors precipitated the discomfort quality - ask the pt to describe the pain/discomfort and its characteristics region/radiation - where is the pain, does it radiate? Is there pain anywhere else? severity - ask the pt to rate their pain/discomfort on a pain scale timing - how long has the pt had the pain? Does anything make it worse or better?

bone

strustructure/support, protect, stores Calcium, movement, creating of blood

cartilege

u: Chondrocytes, fibrous connective tissue,

osteporosis -diagnostics

uA simple test that measures bone mineral density—sometimes called BMD. BMD —the amount of bone in a given area—is measured at different parts of the body. Often the measurements are at the spine and the hip, the femoral neck, at the top of the thighbone (femur). Dual energy X-ray absorptiometry (referred to as DXA or DEXA and pronounced "dex-uh") is the best current test to measure BMD.

labs for RA

uAbnormal blood tests commonly seen in RA include: •Anemia (a low red blood cell count) •Rheumatoid factor (an antibody, or blood protein, found in about 80% of patients with RA in time, but in as few as 30% at the start of arthritis) •Antibodies to cyclic citrullinated peptides (pieces of proteins), or anti-CCP for short (found in 60 - 70% of patients with RA) •Elevated erythrocyte sedimentation rate (a blood test that, in most patients with RA, confirms the amount of inflammation in the joints)

patho - scleroderma

uAlthough the underlying cause is unknown, promising research is shedding light on the relationship between the immune system and scleroderma

Assessment - reason for visit

uAre you experiencing any current musculoskeletal symptoms such as muscle weakness, pain, swelling, redness, warmth, or stiffness? PAIN ASSESSMENT USING PQRST

Osteoarthritis

uArthritis is a serious health crisis. CDC estimates that 1 in 4 (or 54.4 million) US adults have some form of arthritis, a figure that is projected to reach 78 million by the year 2040. While there are estimated to be more than 100 types of arthritis, osteoarthritis (OA) is the most common form of arthritis, affecting 32.5 million US adults. The high prevalence of arthritis manifests in enormous societal and personal costs.

x-ray

uArthrography is an x-ray procedure in which a radiopaque dye is injected into a joint space to outline the structures, such as ligaments inside the joint. Arthrography can be used to view torn ligaments and fragmented cartilage in the joint. However, magnetic resonance imaging (MRI) is now generally used in preference to arthrography.

Assessment for RA

uAssess data relating to pain, joint swelling, tenderness, joint deformities and limitation of movement, fatigue, decreased ability to do ADL's.

osteoarthritis - joint replacment - assessment

uAssessment: uVitals uLOC ui/o uNeurovascular function uUrinary function, bowel elimination uWound uPain/comfort uPreventing immobility complications uAssess circulation and senation

osteoarthritis - drug therapy

uBased on either inconsistent data or lack of scientific evidence, No recommendations are available for the use of herbal supplements (e.g., glucosamine, chondroitin, turmeric, ginger, copper, omega-3) for the treatment or prevention of OA. uOther intraarticular therapies are more controversial in the OA literature, with some disagreement among guidelines. In general, the evidence for intraarticular hyaluronic acid is mixed, and their use is not widely supported by guidelines, although they may be useful for selected patients. Similarly, the evidence base for intraarticular platelet-rich plasma or mesenchymal stem cells is still evolving, and until more robust efficacy, safety, and optimal dosing data are available, these treatments are not generally recommended.

Osteoarthritis

uBecause there is neither a cure nor effective disease-modifying drug therapies for osteoarthritis (OA), management of symptoms (e.g. pain, tenderness and swelling) is essential for those patients who are living with the disease.

Medications for musculoskeletal disorders

uBiologics and biosimilars (bDMARDs) uThese newer medications are also a type of disease modifying drug, and they also work to control the immune system. However unlike other disease modifying drugs, biologics and biosimilars target specific cells and proteins that are causing the inflammation and tissue damage, rather than suppressing your entire immune system. uBiologics (or biologicals) have been created from a biological source (e.g. human cells). They're usually made of proteins that occur naturally in our bodies. Examples of biologics include Humira (adalimumab) and Enbrel (etanercept). uThe patents on many biologics have expired, so other companies can make a similar, slightly cheaper version - which has led to the appearance of biosimilars. They're very similar to biologics, but not the same as the original medication. uBiologics and biosimilars aren't prescribed to everyone due to the high costs associated with developing them. They also may not be the best choice in terms of side effects and the availability of other effective medications.

side effects of NSAIDS

uThe most frequently reported side effects of NSAIDs are gastrointestinal symptoms, such as: uGas. uFeeling bloated. uHeartburn. uStomach pain. uNausea. uVomiting. uDiarrhea and/or constipation. uThese gastrointestinal symptoms can generally be prevented by taking the drug with food, milk or antacids

osteoporosis

uBisphosphonates. The US Food and Drug Administration has approved certain drugs called bisphosphonates to prevent and treat osteoporosis. This class of drugs (often called "anti-resorptive" drugs) helps slow bone loss, and studies show they can decrease the risk of fractures. The Table shows the drug names and dosing (how often you receive the drug) of bisphosphonates approved in the US for management of osteoporosis

medications for musuloskeletal disorders

uBone reabsorption inhibitors/Antiresorptives such as Fosamax (alendronate) and Actonel (risedronate), are the most commonly prescribed medication for treating osteoporosis. They include the group of medications called bisphosphonates. uAnabolic medicines such as Forteo (teriparatide), are used to treat people with severe osteoporosis. uHormone replacement therapy (HRT) may be an option for some women around the time of menopause. It's a synthetic version of the hormones oestrogen and progesterone. uEstrogen plays an important role in maintaining bone strength, however during menopause, estrogen levels drop significantly and women experience a period of rapid bone loss. HRT is most commonly prescribed as a combination of estrogen and progestogen, however some women may take estrogen on its own. uHowever HRT is associated with some health risks and is only considered for osteoporosis treatment when all other drug options have been ruled out. Supplements- calcium and vitamin D are important for bone health.

medications for musculoskeletal disorders

uBones are living tissue and are constantly growing, rebuilding, replacing and repairing. When you're young, you build more bone than you lose to create a strong skeleton. As people get older, they begin to lose more bone than they rebuild. uIf this effects overall bone density and strength, bones can break more easily. This is osteoporosis. u uOsteoporosis Dx: factors such as your age, general health, and fracture risk for medication determination. uOsteoporosis/BONE RESORPTION INHIBITORS medicines work by: uslowing down bone loss and slow the progression of osteoporosis - antiresorptives uincreasing the amount of bone that's made - anabolic medicines.

NSAIDS second generation

uCELEBREX can cause an increased risk of bleeding, ulcers, and tears (perforation) of the esophagus, stomach, and intestines, at any time during treatment, which can occur without warning and may cause death. uAll prescription NSAIDs, including CELEBREX, ibuprofen, naproxen, and meloxicam, have the same cardiovascular warning. They all increase the chance of a heart attack or stroke that can lead to death. uAs with all prescription NSAIDs (nonsteroidal anti-inflammatory drugs), CELEBREX can lead to the onset or worsening of high blood pressure.

2nd generation NSAIDS for musculosketal

uCELEBREX can cause serious side effects, including: unew or worse high blood pressure uheart failure uliver problems including liver failure ukidney problems including kidney failure ulow red blood cells (anemia) ulife-threatening allergic reactions ulife-threatening skin reactions uOther side effects of NSAIDs, including CELEBREX, are stomach pain, constipation, diarrhea, gas, heartburn, nausea, vomiting, and dizziness.

osteoporosis

uCalcitonin (Calcimar, Miacalcin). This medication, a hormone made from the thyroid gland, is given most often as a nasal spray or as an injection (shot) under the skin. It is FDA- approved for the management of postmenopausal osteoporosis and helps prevent vertebral (spine) fractures. It also is helpful in controlling pain after an osteoporotic vertebral fracture.

medical treatment for osteoporosis

uCalcium: Enough calcium in the diet or supplements. The National Osteoporosis Foundation recommends 1,000mg per day for most adults and 1,200 mg per day for women over age 50 or men over age 70. uVitamin D. Adequate amounts of vitamin D to absorb calcium. The recommended daily dose is 400-800 International Units/IU for adults younger than age 50, and 800-1,000 IU for those age 50 and older. (These are the current guidelines from the National Osteoporosis Foundation.) Doses may be as high as 50,000 units a week for 12 weeks. Physical activity. especially weight-bearing exercise, such as walking.

carpel tunnel syndrome

uCarpal tunnel syndrome is possibly the most common nerve disorder experienced today. The carpal tunnel is located at the wrist on the palm side of the hand just beneath the skin surface (palmar surface). Eight small wrist bones form three sides of the tunnel, giving rise to the name carpal tunnel. The remaining side of the tunnel, the palmar surface, is composed of soft tissues, consisting mainly of a ligament called the transverse carpal ligament. This ligament stretches over the top of the tunnel. uUsually carpal tunnel syndrome affects only one hand, but can affect both at the same time, causing symptoms in the thumb and the index, middle and ring fingers. In addition to numbness, patients with carpal tunnel syndrome may experience tingling, a pins and needle sensation or burning of the hand occasionally extending up to the forearm.

risk factors for osteporisis - medications

uCertain medications, including the following: uglucocorticoid medications (also called corticosteroids), such as prednisone (brand names: Deltasone, Orasone, etc.) or prednisolone (Prelone); see fact sheet on glucocorticoid-induced osteoporosis uexcess thyroid hormone replacement in those taking medications for low thyroid or hypothyroidism uheparin, a commonly-used blood thinner usome treatments that deplete sex hormones, such as anastrozole (Arimidex) and letrozole (Femara) to treat breast cancer or leuprorelin (Lupron) to treat prostate cancer and other health problems uDiseases that can affect bones uendocrine (hormone) diseases (hyperthyroidism, hyperparathyroidism, Cushing's disease, etc.) uinflammatory arthritis (rheumatoid arthritis, ankylosing spondylitis, etc.)

Osteoarthritis - drug therapy

uChecklist for Recommending Oral NSAIDs for OA u uNon-pharmacologic therapies (e.g., weight loss, exercise, and education) have been implemented, but pain persists uConsideration has been given to APAP/tylenol uAllergies have been reviewed and verified uPatient has been assessed for their risk of GI, renal, CV and other side effects (as indicated) uPotential drug interactions have been evaluated uPatient has been counseled on proper NSAID use including dosing and interactions uGastrointestinal prophylaxis has been considered and implemented where indicated

DMARDS for RA

uCommon DMARDs include methotrexate (Rheumatrex, Trexall, Otrexup, Rasuvo), leflunomide (Arava), hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine). uGold is an older DMARD that is often given as an injection into a muscle (such as Myochrysine), but can also be given as a pill — auranofin (Ridaura). The antibiotic minocycline (Minocin) also is a DMARD, as well as azathioprine (Imuran) and cyclosporine (Neoral, Sandimmune, Gengraf). These three drugs and gold are rarely prescribed for RA these days, because other drugs work better or have fewer side effects.

CT and MRI

uComputed tomography (CT) and magnetic resonance imaging (MRI) give much more detail than conventional x-rays and may be done to determine the extent and exact location of damage. These tests can also be used to detect fractures that are not visible on x-rays. MRI is especially valuable for imaging muscles, ligaments, and tendons. MRI can be used if the cause of pain is thought to be a severe soft-tissue problem (for example, rupture of a major ligament or tendon or damage to important structures inside the knee joint) uCT is useful if MRI is not recommended or unavailable. CT exposes people to ionizing radiation CT best images bone. uHowever, MRI is better than CT for imaging some bone abnormalities, such as small fractures of the hip and pelvis. The amount of time a person spends undergoing CT is much less than for MRI. uMRI is more expensive than CT and, with the exception of when the open-sided units are used, many people feel claustrophobic inside the MRI unit.

Assessment

uCurrent and past medications (for what has or has not worked). uAre you currently taking any medications, herbs, or supplements for your muscles, bones, or the health of your musculoskeletal system? uAll medications should be listed. uFamily hx uFunctional assessment: exercise, rest, sleep, diet.

Medical treatment of RA

uCurrent treatments give most patients good or excellent relief of symptoms and let them keep functioning at, or near, normal levels. With the right medications, many patients can have no signs of active disease. When the symptoms are completely controlled, the disease is in "remission".

Anatomy and age

uDecreased bone mass and density uDecreased strength uDecrease cartilage uDecreased muscle mass uFrom about age 30, the density of bones begins to diminish in men and women. This loss of bone density accelerates in women after menopause. As a result, bones become more fragile and are more likely to break

osteporosis - medications

uDenosumab (Prolia). This new class of "antiresorptive" drug is a fully human monoclonal antibody, a type of immune therapy. It works against a protein that interferes with the survival of bone-resorbing cells. This treatment is approved for use in postmenopausal women who have osteoporosis and are at high risk of fracture. Another approved use is for women and men at high risk of bone loss and fractures from hormone-depleting medications used to treat breast and prostate cancer. Patients receive this medicine as an injection under the skin every six months

Assessment - follow up questions using PQRST

uDescribe your concern today.How is it affecting your ability to complete daily activities? uP: Does anything bring on the symptom such as activity, weight-bearing, or rest? If activity brings on the symptom, how much activity is required to bring on the symptom(s)? Does it occur at a certain time of day? Is there anything that makes it better or go away? uQ: Describe the characteristics of the pain (aching, throbbing, sharp, dull). uR: Is the pain localized or does it radiate to another part or area of the body? uS: How severe is the pain on a scale of 0-10? uT: When did the pain first start? Is it constant or does it come and go? Have you taken anything to relieve the pain?

gout

uDiagnosis of gout can be made in several ways. Gout is often diagnosed upon the finding of uric acid based crystals. The physician may use a needle to extract fluid from an affected joint and will study that fluid under a microscope to find whether urate crystals are present. Crystals also can be found in deposits (called tophi) that can appear under the skin. These tophi occur in advanced gout. uGout can also be diagnosed based on the pattern of joint involvement, characteristic symptoms, time course, blood tests for uric acid, and advanced imaging tests.

medications for musculoskeletal disorders

uDisease modifying anti-rheumatic drugs (DMARDs) uWith some musculoskeletal conditions, the immune system mistakenly attacks healthy tissue - in and around the joints - causing ongoing inflammation and pain. uDMARDs work by controlling the overactive immune system. They help relieve pain and inflammation, and can also reduce or prevent joint damage. They're a long-term treatment for many types of musculoskeletal conditions. uAs their name suggests, they work on modifying the disease process, not just managing symptoms. It can take several weeks to months to notice any effect, so the patient may also need to take other medications to help control pain and inflammation until then. uThere are a number of different DMARDs on the market including Methoblastin (methotrexate), Plaquenil (hydroxychloroquine) and Salazopyrin (sulfasalazine). uDMARDs require regular blood tests to monitor the effects of the medication on the condition, and to watch for possible side effects before they have the potential to become serious.

Bone densitometry DXA

uDual-energy x-ray absorptiometry (DXA) uThe most accurate way to evaluate bone density, which is necessary when screening for or diagnosing osteopenia or osteoporosis, is with dual-energy x-ray absorptiometry (DXA). DXA is also used to predict a person's risk of fracture and can be useful for monitoring the response to treatment as well. This test is quick and painless and involves very little radiation. uIn this test, x-rays are used to examine bone density at the lower spine, hip, wrist, or entire body. Measurements of bone density are very accurate at these sites. When screening people for osteoporosis, doctors prefer taking measurements of the lower spine and hip. To help differentiate osteoporosis (the most common cause of an abnormal DXA scan result) from other bone disorders, doctors may need to consider the person's symptoms, medical conditions, drug use, and certain blood or urine test results as well as the DXA results.

Osteoporosis- medications: Hormone replacement therapy HRT

uEstrogen or hormone replacement therapy. Estrogen treatment alone or combined with another hormone, progestin, has been shown to decrease the risk of osteoporosis and osteoporotic fractures in women. However, combination estrogen and progestin can increase the risk of breast cancer, strokes, heart attacks and blood clots. Estrogens alone may raise the risk of strokes.

risk factors for osteoarthritis

uEthnicity uOlder African-American, Native American, and non-white Hispanic women are more likely to develop OA than white women. uAfrican-Americans are more likely to develop symptomatic knee and hip OA compared to other race/ethnic groups. uHip OA is 33% more prevalent in older African-American men than white men uGenetics uOA, like many common chronic conditions, is likely influenced by many genetic loci, each with only a small effect. uTwin studies have shown the heritability of hip OA to be approximately 60%, knee OA greater than 40%, hand OA 65%, and spine OA 70%. uMultiple gene interactions within collagen, cartilage, and bone may contribute to the development of OA.

Potentially modificable risk factors for osteoarthritis

uExcess Weight uMen and women who are obese have a 2.8-fold and 4.4-fold increase in developing knee OA, respectively. uTen pounds of additional weight increases the force exerted on the knee by up to 60 pounds with each step. There are likely metabolic (not just mechanical) factors at play, given that excess body weight has been associated with higher risk of hand OA, and not all people who are obese develop OA. uIn the IDEA trial (Intensive Diet and Exercise for Arthritis), subjects with knee OA who were overweight and who achieved a modest weight loss (10% of body weight) through diet and exercise, achieved a 50% reduction in pain scores. uOccupation and Sports uCertain occupations (e.g., construction, healthcare, farming, law enforcement, first responders, military) involving prolonged standing, squatting, lifting, kneeling, and repetitive motion with resultant excessive mechanical stress on a joint, raises the risk of OA and can worsen symptoms. uOsteoarthritis and back pain are the most common diagnoses related to disability-caused separation from the military, both during periods of peacetime and war

possible side effects of NSAIDS

uFluid retention (recognized by swelling of the mouth, face, lips or tongue, around the ankles, feet, lower legs, hands and possibly around the eyes). uSevere rash or hives or red, peeling skin. uItching. uUnexplained bruising and bleeding. uWheezing, trouble breathing or unusual cough. uChest pain, rapid heartbeat, palpitations. uAcute fatigue, flu-like symptoms. uVery bad back pain. uFeeling very tired and weak.

joint aspiration

uFor example, a sample of fluid may contain bacteria, which confirm a diagnosis of infection. Or, it may contain certain crystals. For example, finding uric acid crystals confirms a diagnosis of gout, and calcium pyrophosphate dihydrate crystals confirm a diagnosis of calcium pyrophosphate arthritis (pseudogout). Usually done in the doctor's office or an emergency department, this procedure is typically quick, easy, and relatively painless. The risk of joint infection is minimal.

risk factors for osteoarthritis

uFor most patients, OA is linked to multiple risk factors that can be grouped into modifiable and non-modifiable. Non-modifiable risk factors for OA include age, sex, ethnicity, genetics, previous history of injury or joint trauma. Potentially modifiable risk factors for OA include excess weight, certain occupations and sports, joint injury (injury prevention), joint malalignment and quadriceps weakness. uNON-MODIFIABLE RISK FACTORS uAge uAge is by far the most well-known risk factor for OA; however OA is not a normal part of aging. uOA is occurring in younger adults at increasing rates. uIn 2018, among US adults with self-reported OA, 57% were younger than 65.9 Over half of people with OA who were limited in their daily activities were under age 65. uSex uOA is twice as common in women as men. uKnee and hand OA are more common in women. Hip OA has similar rates in men and women.

medications for musculoskeletal disorders

uGlucocorticoids: CORTEF contain hydrocortisone which is a glucocorticoid. Glucocorticoids are adrenocortical steroids, both naturally occurring and synthetic. uRheumatic Disorders uAs adjunctive therapy for short-term administration (to tide the patient over an acute episode or exacerbation) in: uPsoriatic arthritis uRheumatoid arthritis, including juvenile rheumatoid arthritis (selected cases may require low-dose maintenance therapy) uAnkylosing spondylitis uAcute and subacute bursitis, Acute nonspecific tenosynovitis, Acute gouty arthritis, Post-traumatic osteoarthritis, Synovitis of osteoarthritis, Epicondylitis uCollagen Diseases uDuring an exacerbation or as maintenance therapy in selected cases of: uSystemic lupus erythematosus uSystemic dermatomyositis (polymyositis) uAcute rheumatic carditis

gout - patho

uGout occurs when excess uric acid (a normal waste product) collects in the body, and needle‐like urate crystals deposit in the joints. uThis may happen because either uric acid production increases or, more often, the kidneys cannot remove uric acid from the body well enough. uCertain foods and drugs may raise uric acid levels and lead to gout attacks.

Medications - gout

uGout occurs when uric acid, a normal waste product, builds up in the bloodstream and forms urate crystals in a joint. It can happen if the body makes too much uric acid, or the kidneys can't clear enough of it out, and it builds up in the blood. This is called hyperuricaemia. uThe first step in treatment is getting the pain and inflammation under control. This may involve anti-inflammatories and/or analgesics), cold packs on the swollen joint, and rest. uOnce the painful attack is under control, depending on the underlying cause of the hyperuricaemia, the doctor may prescribe medications that: uANTIGOUT: reduce the amount of uric acid the body produces - e.g. Progout (allopurinol), or uURICOLYTIC: increase the amount of uric acid you pass through your urine - e.g. Pro-Cid (probenecid) and kystexxa (IV medication).

Assessment - past medical history

uHave you ever been diagnosed with a chronic musculoskeletal disease such as osteoporosis, osteoarthritis, or rheumatoid arthritis? uHave you ever been diagnosed with a neurological condition that affected the use of your muscles? uHave you had any previous surgeries on your bones or muscles, such as fracture repair or knee or hip surgery? uIf so: Please describe the conditions and treatments.

osteoarthritis - occupation and sports

uHigh impact professional sports (e.g., hockey, soccer, and football), where there is not only repetitive loading with excessive force, but also increased joint trauma puts players at risk of OA.28 uIn addition to elite-level athletes (soccer, long-distance running, weight lifting and wrestling), non-elite soccer athletes are also at risk of developing OA.29 uProper precautions such as stretching and strengthening exercises, appropriate footwear and other devices, along with supportive workplace or athletic team policies, can help reduce onset and progression of OA in occupational and sports settings.

osteoarthritis - joint replacement

uHip precautions: Education to patients HIP PRECAUTIONS - ANTERIOR & POSTERIOR uAvoid these activities for 4-6 weeks. u• Do not drive until it is approved u• Do not lift any heavy objects. u• Do not do any activity which requires sudden starts, stops, or turns, such as tennis, jogging, skiing, u• Do not submerge your incision until authorized. This includes tub baths, hot tubs, uswimming pools u• Ask for assistance use a reacher uExercise regularly. • Schedule rest periods between activities; increase your activities as you get stronger every day

labs - creatine kinase

uThe level of creatine kinase (a normal muscle enzyme that leaks out and is released into the bloodstream when muscle is damaged) may also be tested. Levels of creatine kinase are increased when there is widespread ongoing destruction of muscle. u uIn rheumatoid arthritis, a blood test to identify rheumatoid factor or anti-cyclic citrullinated peptide (anti-CCP) antibody is helpful in making the diagnosis.

osteoarthritis - joint replacement

uHip precautions: Education to patients HIP PRECAUTIONS - ANTERIOR & POSTERIOR u• Do not bend/reach to pick up items that are lower than your knees, or on the floor. u• Do not reach to put on your shoes or socks. uDo not reach to pull up the covers from the bottom of the bed. u• Do not sit up straight in a chair or sit in a low, soft sofa or chair or recliner. u• Do not lift your knees higher than hip level. u• Do not put your feet on a stool while sitting. u• Do not bend sideways. u• Do not let your operated leg cross the midline. Do not cross your legs at the knee or ankle.

osteoarthritis - joint replacement

uHip precautions: Education to patients HIP PRECAUTIONS - ANTERIOR & POSTERIOR u• Do not twist to reach across to the opposite leg. u• Do not pull your leg up to put on your shoes and socks. • Do not stand, sit or lie down with your toes pointed toward each other (pigeon-toed). Keep your toes and knees pointed straight ahead u• Get in and out of the car carefully: - make sure to recline and push your car seat back to avoid bending hips past 90 degrees. u• Use the abduction pillow between your legs: - while you are in bed, - in the car, or - when sitting and resting. You may lie on your side with a pillow between your knees

Scleroderma- systemic- diffuse cutaneous

uIn Diffuse cutaneous systemic scleroderma, skin thickening and tightness usually also extends from the hands to above the wrists. This form of scleroderma more frequently involves internal organs, such as lungs, kidneys, or the gastrointestinal tract. A number of newer antibodies are being discovered to classify this form of scleroderma, but the most common antibody is Scl-70.

labs - SLA or lupus

uIn systemic lupus erythematosus (SLE or lupus), blood tests to identify autoimmune antibodies (autoantibodies), such as antinuclear antibodies and antibodies to double-stranded deoxyribonucleic acid (DNA), help in making the diagnosis. u uA blood test can be done to identify people who have a certain gene (HLA-B27). People who have this gene are at increased risk of developing spondyloarthritis, a group of disorders that can cause inflammation of the back and other joints as well as other symptoms, such as eye pain and redness and rashes.

Scleroderma - nursing interventions

uInadequate tissue integrity- it's important to keep the whole body warm, especially fingers and toes. It's also important to protect fingertips and other skin areas from injury, which can happen even during normal daily activities. uImpaired adl's uPain uInadequate nutrition- if patient has esophageal involvement. uPotential for fluid and electrolyte imbalance with renal crisis.

Gout

uIntensely painful, swelling joints (most often in the big toe or other part of the foot) and/or bouts of arthritis that come and go may indicate gout. uFinding the characteristic crystals in the fluid of joints allows to correctly diagnose gout. uGout treatments exist, but therapy should be tailored for each person. Treatment choices depend on kidney function, other health problems, personal preferences and other factors.

RA - DMARDS

uJanus kinase (JAK) inhibitors are another type of DMARD. People who cannot be treated with methotrexate alone may be prescribed a JAK inhibitor such as tofacitinib (Xeljanz) or baracitinib (Olumiant).

osteoarthritis - cse study

uJohn and his wife come in for a primary care visit following his hospital discharge. John is a 70-year-old man who is slightly overweight and has dyslipidemia, hypertension, and knee OA. He recently suffered a right cerebral vascular accident (CVA) due to atrial fibrillation that resulted in mild left hemiparesis. Prior to his stroke, he was prescribed a statin, ACE-inhibitor, diuretic, and calcium channel blocker. uIn addition, John has new prescriptions for novel oral anticoagulant (NOAC) for secondary stroke prevention and an NSAID for knee pain, which was exacerbated during his post-CVA physical therapy sessions in the hospital. John has been mostly sedentary since he retired 5 years ago. In fact, other than physical rehabilitation in the hospital, he has not been physically active in years. He will begin outpatient physical therapy tomorrow for post-CVA rehabilitation.

joint aspiration

uJoint aspiration is used to diagnose certain joint problems. For example, it is the most direct and accurate way to determine whether joint pain and swelling is caused by an infection or crystal-related arthritis (such as gout). uFor this procedure, a doctor first injects an anesthetic to numb the area. Then the doctor inserts a larger needle into the joint space (sometimes guided by ultrasonography), draws out (aspirates) joint fluid (synovial fluid), and examines the fluid under a microscope. A doctor removes as much fluid as possible and notes its color and clarity. Other tests, such as white blood cell count and culture, are done on the fluid. The doctor can often make a diagnosis after analyzing the fluid.

osteoarthritis - joint position and strength

uKnees that are not mechanically aligned properly- resulting in either varus (bowlegged) or valgus (knock-kneed) alignments- can result in increased risk of knee OA. The worse the malalignment, the greater decline in physical function likely to be experienced by patients. uKnee braces or shoe inserts may help with pain and stiffness when these conditions exist. Weaker quadriceps strength can result in increased functional disability and pain in people with knee OA. Muscle-strengthening exercises, whether with a physical therapist or through a community-based intervention program, can help reduce pain and functional limitations

diagnostic labs - assessment

uLaboratory tests are often helpful in making the diagnosis of a musculoskeletal disorder. For example, the erythrocyte sedimentation rate (ESR) is a test that measures the rate at which red blood cells settle to the bottom of a test tube containing blood. The ESR is usually increased when inflammation is present. However, because inflammation occurs in so many conditions, the ESR alone does not establish a diagnosis. uthe ESR can be particularly useful in helping to monitor the progress of treatment in rheumatoid arthritis or polymyalgia rheumatica. A decrease in the ESR suggests that treatment is working to reduce inflammation.

Gout

uLifestyle changes such as controlling weight, limiting alcohol intake and limiting meals with meats and fish rich in purines also can help control gout.

Scleroderma - localized

uLocalized scleroderma usually affects only the skin, although it can spread to the muscles, joints and bones. It does not affect internal organs. Symptoms include discolored patches on the skin (a condition called morphea); or streaks or bands of thick, hard skin on the arms and legs (called linear scleroderma). When linear scleroderma occurs on the face and forehead, it is called en coup de sabre.

sarccopenia

uLoss of muscle (sarcopenia) is a process that starts around age 30 and progresses throughout life. In this process, the amount of muscle tissue and the number and size of muscle fibers gradually decrease. The result of sarcopenia is a gradual loss of muscle mass and muscle strength. This mild loss of muscle strength places increased stress on certain joints (such as the knees) and may predispose a person to arthritis or falling

risk factors for Osteoporisis

uMajor risk factors that you cannot change include: uAdvancing age, menopause uNon-Hispanic white or Asian ethnic background uSmall bone structure uParents you have broken their hips uPrior fracture due to a low-level injury, particularly after age 50 uRisk factors that you may be able to change include: uLow levels of sex hormone, mainly estrogen in women (e.g., menopause) uThe eating disorders anorexia nervosa and bulimia uCigarette smoking uAlcohol abuse uLow calcium and vitamin D, from low intake in diet starting during teens and 20's or inadequate absorption in the gut uSedentary (inactive) lifestyle or immobility

NSAIDS for osteoarthritis

uNSAIDs pose a risk of gastrointestinal (GI) (e.g., ulceration and bleeding), renal (e.g., acute renal failure), and cardiovascular (e.g., hypertension, heart failure, stroke, myocardial infarction) side effects, and caution should be used when recommending and dispensing these agents to patients. uThe FDA has issued a black box warning on all NSAIDs regarding their potential cardiovascular side effects. u Senior patients are most vulnerable to the adverse effects of NSAIDs; furthermore, seniors may also experience sedation, confusion, and/or falls when taking NSAIDs. NSAIDs should be used at the lowest effective dose for the shortest time possible in an effort to minimize these potentially serious side effects.

nerve and muscle tests

uNerve and muscle tests uNerve conduction studies help determine whether the nerves supplying the muscles are functioning normally. Electromyography, usually done at the same time as nerve conduction studies, is a test in which electrical impulses in the muscles are recorded to help determine how well the impulses from the nerves are reaching the connection between nerves and muscles (neuromuscular junction) and, from there, the muscles.

nerve and muscle tests

uNerve conduction studies, together with electromyography, help indicate whether there is a problem primarily in the uMuscles (such as myositis or muscular dystrophy) uNervous system (the brain, spinal cord, and nerves), which controls the muscles (such as a stroke, spinal cord problem, or polyneuropathy) uNeuromuscular junction (such as myasthenia gravis) uNerve conduction studies are particularly useful for the diagnosis of peripheral nerve disorders, such as carpal tunnel syndrome and ulnar nerve palsy.

Gout - NSAIDS

uNonsteroidal anti‐inflammatory drugs - commonly called NSAIDs - are aspirin‐like medications that can decrease inflammation and pain in joints and other tissues. NSAIDs, such as indomethacin (Indocin) and naproxen (Naprosyn), have become the treatment choice for most acute attacks of gout. uIn patients with chronic undertreated gout crystals can be found in uric acid deposits (called tophi) that can damage joints & can appear under the skin. Corticosteroids, such as prednisone, methylprednisolone, and triamcinolone, are useful options for patients who cannot take NSAIDs.

gout - colchicine

uOne treatment for active gout flares is colchicine. This medicine can be effective if given early in the attack. However, colchicine can cause nausea, vomiting, diarrhea and other side effects. Side effects may be less frequent with low doses. Patients with kidney or liver disease, or who take drugs that interact (interfere) with colchicine, must take lower doses or use other medicines. Colchicine also has an important role in preventing gout attacks

patho - osteoarthritis

uOsteoarthritis is not simply caused by "wear and tear" of the joint but is rather a complex disorder characterized by molecular, anatomic, and physiologic changes. As such a complex disease, there are a variety of risk factors—both modifiable and non-modifiable—that contribute to its onset and progression, some of which can be mediated with appropriate management strategies. uPathophysiology: a disorder involving movable joints characterized by cell stress and extracellular matrix degradation initiated by micro- and macro-injury that activates maladaptive repair responses including pro-inflammatory pathways of innate immunity. The disease manifests first as a molecular derangement (abnormal joint tissue metabolism) followed by anatomic, and/or physiologic derangements (characterized by cartilage degradation, bone remodeling, osteophyte formation, joint inflammation and loss of normal joint function), that can culminate in illness.

Osteoporosis

uOsteoporosis is a common condition. Bone is living tissue that is in a constant state of regeneration. The body removes old bone (called bone resorption) and replaces it with new bone (bone formation). By their mid-30s, most people begin to slowly lose more bone than can be replaced. As a result, bones become thinner and weaker in structure. This accelerates in women at the time of the menopause. In men bone lost usually becomes more of an issue around age 70.

s/s osteoporisis

uOsteoporosis is silent because there are no symptoms Sometimes a notice in height lost by noticing the clothes are not fitting right. Other times it may come to attention only after a break of a bone. uThe most common fractures occur at the spine, wrist and hip. Spine and hip fractures, in particular, may lead to chronic (long-term) pain and disability, and even death. uThe main goal of treating osteoporosis is to prevent such fractures in the first place.

osteoporosis

uOsteoporosis results from a loss of bone mass (measured as bone density) and from a change in bone structure. Many factors will raise the risk of developing osteoporosis and breaking a bone. uAge is not the only risk factor for osteoporosis. Lifestyle choices, certain diseases and even medications can lead to this condition. uA simple test known as a bone density scan, or DEXA(dxa), can give important information about bone health. uNewer medications can slow and even stop the progression of bones getting weaker, and can help decrease fracture risk.

other signs and symptoms of rheumatoid arthritis

uOther signs and symptoms that can occur in RA include: uLoss of energy uLow fevers uLoss of appetite uDry eyes and mouth from a related health problem, Sjogren's syndrome uFirm lumps, called rheumatoid nodules, which grow beneath the skin in places such as the elbow and hands

Osteoarthritis

uPREVALENCE BY AGE, GENDER, AND ETHNICITY uAge u43% of people with OA are 65 or older and 88% of people with OA are 45 or older. uAnnual incidence of knee OA is highest between 55 and 64 years old. uMore than half of individuals with symptomatic knee OA are younger than 65. uGender u62% of individuals with OA are women. uAmong people younger than 45, OA is more common among men; above age 45, OA is more common in women. uEthnicity u78% of individuals with OA are non-Hispanic whites. uHowever, within their own race/ethnic groups, non-Hispanic black and Hispanic populations have higher rates of OA than non-Hispanic whites.

gout - nursing interventions

uPain uImpaired mobility uImpaired fluid balance uEducation for diet and need for increase in fluids.

osteoarthritis - joint replacement interventions

uPain- administer analgesics, nonpharmacological pain reducing methods- ice packs. uPotential for injury- using call light, proper alignment, particular precautions such as hip precautions (see blue box guidelines for nursing care pf specific joints pg 862) uImpaired mobility- using proper dme, repositioning, incentive spirometer uInadequate circulation: calf pumps, dvt prevention, assess of circulation, administer anticoagulant meds as prescribed uPotential for infection- monitor for temp, assess wound uAnxiety- education on what to expect next. uInadequate self care- education for self care.

interventions for RA

uPain- heat or cold therapy, medication education and signs and symptoms to report uImpaired mobility- rest periods, asking for assistance, PT/OT, uInadequate coping- TLC uDecreased socialization- Support and emphasize the importance of appropriate social activities. uInability to manage tx program

osteoarthritis nursing interventions

uPain: educate patient regarding pain medications, report ineffective therapy. uImpaired mobility: education on exercise (low impact- swimming/water aerobics), education on weight loss, bathroom bar grips, shower seat, reach stick uInadequate coping: active listening, help patient to prioritize activities uInability to manage treatment program Blue box p. 861

osteoarthritis - risk factors - joint injury (injury prevention)

uParticipating in short neuromuscular training exercise programs can reduce the risk for traumatic knee injury by up to 70%.30 See the OA Prevention module for more information. uPatients at risk of falling can build strength and improve balance to reduce their risk of fall-related joint injuries and should be counseled to engage in or increase their physical activity. The CDC's STEADI initiative (Stopping Elderly Accidents, Deaths, & Injuries) includes educational materials for providers and handouts for patients on preventing falls.

Gout

uPatients may need medications to lower their elevated blood uric acid levels that predispose to gout. uGout treatment aims for a uric acid level of 6 mg/ dL or lower to dissolve or prevent crystals. uThere are two types of medicine for gout. For control of acute attacks of joint pain, there are NSAIDs, colchicine and corticosteroids. After gout flares have resolved, there are medications that can lower the level of uric acid over time in order to prevent or lessen attacks.

Gout- medications: uric crystal removal

uPatients who have repeated gout flares, abnormally high levels of blood uric acid, or tophi or kidney stones should strongly consider medicines to lower blood uric acid levels. uThese medications do not help the painful flares of acute gout, so most patients should start taking them after acute attacks subside. uThe drug most often used to return blood levels of uric acid to normal is allopurinol (Lopurin, Zyloprim). It blocks production of uric acid. Febuxostat (Uloric), a newer drug, also blocks uric acid.

biologic DMARDS for RA

uPatients with more serious disease may need medications called biologic response modifiers or "biologic agents." They can block immune system chemical signals that lead to inflammation and joint/tissue damage. FDA-approved drugs of this type include abatacept (Orencia), adalimumab (Humira), anakinra (Kineret), certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi) infliximab (Remicade), rituximab (Rituxan, MabThera), sarilumab (Kevzara) and tocilizumab (Actemra). uMost often, patients take these drugs with non-bio DMARDS-Nmethotrexate, as the mix of medicines is more helpful.

Gout- medications- crystal removal

uPegloticase (Krystexxa) is given by injection and breaks down uric acid and gets secreted by kidneys. This drug is for patients who do not respond to other treatments or cannot tolerate them.

NSAIDS - side effects

uPossible side effects: uBlurred vision. uRinging in the ears. uPhotosensitivity (greater sensitivity to light). uVery bad headache. uChange in strength on one side is greater than the other, trouble speaking or thinking, change in balance. uPossible allergic reactions and other problems

possible side effects of NSAIDS

uPossible side effects: uGastrointestinal/urinary uBlack stools — bloody or black, tarry stools. uBloody or cloudy urine. uSevere stomach pain. uBlood or material that looks like coffee grounds in vomit (bleeding may occur without warning symptoms like pain). uInability to pass urine, or change in how much urine is passed. uUnusual weight gain. uJaundice. uHead (vision, hearing, etc.):

osteoporosis - nursing interventions

uPotential for injury uPain uInability to manage tx uEducation for prevention: exercise, smoking cessation, no excess etoh, decreasing fall risk

s/s rheumatoid arthritis

uRA is a chronic disease that causes joint pain, stiffness, swelling and decreased movement of the joints. Small joints in the hands and feet are most commonly affected. Sometimes RA can affect the organs, such as eyes, skin or lungs. uThe joint stiffness in active RA is often the worst in the morning. It may last one to two hours (or even the whole day). It generally improves with movement of the joints. Stiffness for a long time in the morning is a clue, as this is not common in other conditions. For instance, osteoarthritis most often does not cause prolonged morning stiffness.

patho - rheumatoid arthritis

uRA is an autoimmune disease. In an autoimmune disease, the immune system mistakenly sends inflammation to the healthy tissue. The immune system creates a lot of inflammation that is sent to the joints causing joint pain and swelling. If the inflammation remains present for a long period of time, it can cause damage to the joint. This damage typically cannot be reversed once it occurs. The cause of RA is not known. There is evidence that autoimmune conditions run in families.

medical diagnosis of RA

uRA is diagnosed by examining blood test results, examining the joints and organs, and reviewing x-ray or ultrasound images. There is no one test to diagnose RA. Blood tests are run to look for antibodies in the blood that can been seen in RA. Antibodies are small proteins in the bloodstream that help fight against foreign substances called antigens. Sometimes these antibodies are found in people without RA. This is called a false positive result. Blood tests are also run to look for high levels of inflammation. The symptoms of RA can be very mild making the diagnosis more difficult. Some viral infections can cause symptoms that can be mistaken for RA.

RA - DMARDS

uRA patients should begin their treatment with disease-modifying antirheumatic drugs — referred to as DMARDs. uThese drugs not only relieve symptoms but also slow progression of the joint damage. Often, doctors prescribe DMARDs along with nonsteroidal anti-inflammatory drugs or NSAIDs and/or low-dose corticosteroids, to lower swelling and pain. uDMARDs have greatly improved the pain, swelling, and quality of life for nearly all patients with RA.

Scleroderma - symptom treatment

uRaynaud's phenomenon can be treated with drugs such as calcium channel blockers or drugs called PDE-5 inhibitors ⎼ sildenafil (Viagra), tadalafil (Cialis). uHeartburn (acid reflux) can be treated with antacid drugs, especially proton-pump inhibitors (omeprazole and others). These medications ease gastro-esophageal reflux. uScleroderma kidney disease can be treated with blood pressure medications "angiotensin converting enzyme inhibitors" (ACE inhibitors). These can often effectively control kidney damage if started early and use of these drugs has been a major advance for treating scleroderma. uMuscle pain and weakness can be treated with anti-inflammatory drugs such as intravenous immunoglobin (IVIg) and/or immunosuppressive medications. Physical and occupational therapy may be useful to maintain joint and skin flexibility. Early referral to therapy should be considered to help prevent the loss of joint motion and function.

rheumatoid arthritis

uRheumatoid arthritis (RA) is the most common type of autoimmune arthritis. It is caused when the immune system (the body's defense system) is not working properly. RA causes pain and swelling in the wrist and small joints of the hand and feet. uTreatments for RA can stop joint pain and swelling. Treatment also prevents joint damage. Early treatment will give better long term results. uRegular low-impact exercises, such as walking, and exercises can increase muscle strength. This will improve your overall health and lower pressure on your joints. uStudies show that people who receive early treatment for RA feel better sooner and more often, and are more likely to lead an active life. They also are less likely to have the type of joint damage that leads to joint replacement. uIt is important to get the help of a rheumatologist.

Scleroderma

uScleroderma differs from person to person but can be very serious. uThere are medications, as well as steps individuals can take, to ease the symptoms of Raynaud's phenomenon, skin problems and heartburn. uEffective treatments are available for those with severe disease, including acute kidney disease, pulmonary hypertension, lung inflammation and gastrointestinal problems. uIt is important to recognize and treat organ involvement early on to prevent irreversible damage.

Scleroderma - s/s

uScleroderma is a chronic disease that causes the skin to become thick and hard, a buildup of scar tissue, and damage to internal organs such as the heart and blood vessels, lungs, stomach and kidneys. The effects of scleroderma vary widely and range from minor to life-threatening, depending on how widespread the disease is and which parts of the body are affected.

scleroderma

uScleroderma is an autoimmune disease affecting the skin and other organs of the body, meaning that the body's immune system is causing inflammation and other abnormalities in these tissues. The main finding in scleroderma is thickening and tightening of the skin and inflammation and scarring of many body parts, leading to problems in the lungs, kidneys, heart, intestinal system and other areas. There is still no cure for scleroderma, but effective treatments for some forms of the disease are available

Osteoporosis- medications: Selective estrogen receptor modulators

uSelective estrogen receptor modulators. These medications, often referred to as SERMs, mimic estrogen's good effects on bones without some of the serious side effects such as breast cancer. However, there is still a risk of blood clots and stroke with use of SERMs. The SERM raloxifene (Evista) decreases the risk of spine fractures in women. It is approved for use only in postmenopausal women

causes of gout

uShellfish, gravies, red meat, soups and organ meats such as liver are high in purines uAlcohol in excess uSugary drinks and foods that are high in fructose uSome medications, such as: ulow-dose aspirin (but because it can help protect against heart attacks and strokes, we do not recommend that people with gout stop taking low-dose aspirin) ucertain diuretics such as hydrochlorothiazide (Esidrix, Hydro‐D) and Lasix uimmunosuppressants used in organ transplants such as cyclosporine (Neoral, Sandimmune) and tacrolimus (Prograf) uOver time, increased uric acid levels in the blood may lead to deposits of urate crystals in and around the joints. uThese crystals can attract white blood cells, leading to severe, painful gout attacks and chronic arthritis. Uric acid also can deposit in the urinary tract, causing kidney stones.

scleroderma - sytemic

uSystemic scleroderma is the most serious form of the disease, can affect the skin, muscles, joints, blood vessels, lungs, kidneys, heart and other organs. uThere are two major forms of systemic scleroderma: limited cutaneous systemic sclerosis (formerly called CREST syndrome) and diffuse cutaneous systemic scleroderma.

osteoporosis - medications

uTeriparatide (Forteo). Teriparatide is a form of parathyroid hormone that helps stimulate bone formation. It is approved for use in postmenopausal women and men at high risk of osteoporotic fracture. It also is approved for treatment of glucocorticoid-induced osteoporosis. It is given as a daily injection under the skin and can be used for up to two years. If a patient has ever had radiation treatment or the parathyroid hormone levels are already too high, the patient may not be able to take this drug.

s/s gout

uThe first symptoms usually are intense episodes of painful swelling in single joints, most often in the feet, especially the big toe. uThe swollen site may be red and warm. uFifty percent of first episodes occur in the big toe, but any joint can be involved.

DXA - osteoporisis

uThe test is quick and painless. It is similar to an X-ray, but uses much less radiation. Even so, pregnant women should not have this test, to avoid any risk of harming the fetus. DXA test results are scored compared with the BMD of young, healthy people. This results in a measure called a T-score. The scoring is as follows: u uDXA T-score Bone mineral density (BMD) uNot lower than -1.0 Normal uBetween -1.0 and -2.5 Osteopenia (mild BMD loss) u-2.5 or lower Osteoporosis uIf your t score is below 2.5 (Osteopoross) then you most likely need treatment. u uIf the t score is between -1.0 and -2.5 (Osteopenia) a FRAX score is determined to see if tx is needed.

muscle fibers

uThe types of muscle fibers are affected by aging as well. The numbers of muscle fibers that contract faster decrease much more than the numbers of muscle fibers that contract slower. Thus, muscles are not able to contract as quickly in old age.

RRA

uThere is no cure for RA. The goal of treatment is to improve the joint pain and swelling and to improve the ability to perform day-to-day activities. Starting medication as soon as possible helps prevent the joints from having lasting or possibly permanent damage. No single treatment works for all patients. Many people with RA must change their treatment at least once during their lifetime.

Ultrasonography

uUltrasonography is being used more and more frequently to identify inflammation in and around joints and tears or inflammation of tendons. uUltrasonography is also used as a guide when a needle needs to be put into a joint (for example, to inject drugs or to remove joint fluid). uAs an alternative to computed tomography (CT) and magnetic resonance imaging (MRI), ultrasonography is less expensive and, unlike CT, involves no exposure to radiation.

gout - medical diagnosis

uUric acid levels in the blood are important to measure but can sometimes be misleading, especially if measured at the time of an acute attack. Levels may be normal for a short time or even low during attacks. Even people who do not have gout can have increased uric acid levels. uX-rays may show joint damage in gout of long duration. Ultrasound and dual energy computed tomography (commonly called dual energy CT) can show early features of gouty joint involvement. These imaging techniques also can help suggest the diagnosis.

osteoarthritis - case study

uWhat drug therapy poses the least risk for Betty? uA. Topical capsaicin uB. Oral NSAID uC. Acetaminophen uD. Glucosamine with chondroitin Rationale (C): Given Betty's age as well as her history of hypertension and diabetes, an NSAID should be avoided as first-line therapy. Neither glucosamine nor chondroitin will treat her acute pain and the benefit of these agents in OA is unsubstantiated. Alternatively, APAP (< 3 grams per day) may be a safe and effective treatment option for Betty. While taking APAP, Betty should be counseled to avoid other APAP-containing products (e.g., cough and cold remedies or any product claiming to be "aspirin free").

osteoarthritis - case study

uWhat non-pharmacologic treatment modalities should you education the patient for? uA. Weight loss uB. Reduce periods of physical inactivity uC. Community-based physical activity programs uD. All of the above Rationale (D): It would be important to encourage John to lose even a minimal amount of weight through improved diet and increased physical activity. Reducing his periods of inactivity will also help with his knee OA pain, as sustained periods of rest can worsen OA symptoms; therefore, promoting simple activity (e.g., every 20-30 minutes) may reduce OA pain and stiffness. You can also encourage him to discuss specific exercises with his outpatient physical therapist that will target the OA in his knee; the PT can give him exercises to do on his own at home. There are also many community programs designed specifically for patients with OA that John could transition to when his PT sessions are complete.

osteoarthritis - case study

uWhat points of information should be shared with Betty? uA. Education about OA uB. Weight loss counseling uC. Sample hand exercises uD. Offer a referral to Occupational Therapy uE. All of the above Rationale (E): Providing Betty with education about OA and explaining that it does not "spread" is a good place to start. It is important, however, to identify Betty's risk factors and explain the importance of self-management strategies. While weight loss may not appear relevant to hand OA and could be daunting for a patient who is obese, education on the importance of weight loss, even a modest 5-10 pounds, can significantly improve mobility and function as well as reduce pain and may even help prevent OA in other joints such as her knees. You can encourage Betty to engage in healthy eating habits as well as hand exercises. One simple suggestion to increase mobility is that while Betty is watching TV, for example, she opens and closes her hands 5-10 times when a commercial is played. You can request to submit a referral to an occupational therapist who can evaluate her for splinting, suggest additional exercises for hands, and recommend joint protection strategies in addition to assistive devices. If you feel that Betty can handle additional information, consider giving her the Resources for People with Arthritis handout that includes community-based activity programs designed specifically for patients with arthritis.

osteoarthritis - case study

uWhat should be your primary concern? uA. Assessing whether John is able to take care of himself at homeB. Addressing a drug interactionC. Submitting a referral for occupational therapyD. Recommending community-based physical activity programs Rationale (B): Given the significance of the drug interaction between the NSAID and NOAC, this should be your primary concern. While an oral NSAID may provide pain relief for his knee OA, John's age, co-morbidities, and concomitant drug therapy makes an oral NSAID relatively contraindicated. You learn that a trial of acetaminophen at a dose of 3 grams per day was not helpful in relieving Johns' increased knee pain, so you could consider a topical NSAID. While these drugs carry the same black box warnings as oral NSAIDs, research has shown that the drug interactions with the NOAC, ACE-inhibitor, and diuretic are reduced; thereby, reducing the risk of bleeding and acute renal failure.

uPhysical exam: Older Adults

uWhen assessing older adults, it is important to assess their mobility and their ability to perform activities of daily living. •Do you use any assistive devices such as a brace, cane, walker, or wheelchair? •Have you fallen or had any near falls in the past few months? If so, was there any injury or did you seek medical care? •Describe your mobility as of today. Have you noticed any changes in your ability to complete your usual daily activities such as walking, going to the bathroom, bathing, doing laundry, or preparing meals? If so, do you have any assistance available?

Labs - ESR erythrocycte sedimentation rate

uWhy? uTo detect the presence of inflammation caused by one or more conditions such as infections, tumors or autoimmune diseases; to help diagnose and monitor specific conditions such as temporal arteritis, systemic vasculitis, polymyalgia rheumatica, or rheumatoid arthritis uWhen? uWhen you might have a condition causing inflammation; when you have signs and symptoms associated with temporal arteritis, systemic vasculitis, polymyalgia rheumatica, or rheumatoid arthritis such as headaches, neck or shoulder pain, pelvic pain, anemia, poor appetite, unexplained weight loss, and joint stiffness uSample Required? uA blood sample drawn from a vein in your arm uTest Preparation Needed? uNone

scleroderma - diagnosis

uX-rays and computerized tomography (CT) scans are used to look for abnormalities. Thermography can detect differences in skin temperature between the lesion and normal tissue. Ultrasound and magnetic resonance imaging (MRI) can aid soft tissue assessment. u uRaynaud's phenomenon: This term refers to color changes (blue, white and red) that occur in fingers (and sometimes toes, often after exposure to cold temperatures. It occurs when blood flow to the hands and fingers is temporarily reduced. uThis is one of the earliest signs of the disease; more than 90 percent of patients with scleroderma have Raynaud's. Skin thickening, swelling and tightening: This is the problem that leads to the name "scleroderma" ("Sclera" means hard and "derma" means skin). The skin may also become glossy or unusually dark or light in places. The disease can sometimes result in changes is personal appearance, especially in the face. When the skin becomes extremely tight, the function of the area affected can be reduced (for example, fingers).

x-rays

uX-rays are typically done first. They are most valuable for detecting abnormalities in bone and are taken to evaluate painful, deformed, or suspected abnormal areas of bone. uOften, x-rays can help to diagnose fractures, tumors, injuries, infections, and deformities (such as developmental dysplasia of the hip). uAlso, sometimes x-rays are helpful in showing changes that confirm a person has a certain kind of arthritis (for example, rheumatoid arthritis or osteoarthritis). uX-rays do not show soft tissues such as muscles, ligaments, tendons, or nerves. To help determine whether the joint has been damaged by injury, a doctor may use an ordinary (non-stress) x-ray or one taken with the joint under stress caused by certain positions (stress x-ray).

x-rays for RA

uX-rays can help in detecting RA, but may be normal in early arthritis. Even if normal, initial X-rays may be useful later to show if the disease is progressing. MRI and ultrasound scanning can be done to help confirm or judge the severity of RA. uRA is a chronic arthritis. Generally the symptoms will need to be present for more than three months to consider this diagnosis. However there are patients who are diagnosed sooner

osteoarthritis - case study

uYou are seeing Betty, a 65-year-old woman, for the first time. Her reason for scheduling this appointment was to ask for advice regarding ibuprofen or glucosamine with chondroitin to help with "arthritis pain" in both her hands. From looking at her chart, you see that she has a BMI of 31, has hypertension and type 2 diabetes mellitus, and is currently employed as a seamstress. u uQ1. What are Betty's risk factors for OA? uA. Gender uB. Age uC. Weight uD. Occupation uE. All of the above Rationale (E) Female sex is associated with an increased risk of OA, especially OA of the hand, foot, and knee. Advancing age is by far the most well-known risk factor for OA. Betty's weight is also a risk factor, even though her OA symptoms are currently only present in her hands; there is research showing that obesity can increase the risk of hand OA. Certain occupations that involve repetitive motion of a joint, like sewing, can worsen OA symptoms.

Tendons

uare similar to ligaments, except these tension-withstanding fibrous tissues attach muscle to bone. Tendons consist of densely packed collagen fibers.

muscles

ueither individually or in groups, are supported by fascia. Fascia is strong sheath-like connective tissue. The tendon that attaches muscle to bone is part of the fascia.

osteoarthritis - joint replacement - CPM

uhttps://www.youtube.com/watch?v=BG-VS6thrnw

ligments

ulinks bone to cartilage. Yellow and white ligaments. White support. Yellow stretch. The system of ligaments in the vertebral column, combined with the tendons and muscles, provides a natural brace to help protect the spine from injury. Ligaments aid in joint stability during rest and movement and help prevent injury from hyperextension and hyperflexion (excessive movements)

As people age

utheir joints are affected by changes in cartilage and in connective tissue. The cartilage inside a joint becomes thinner, and components of the cartilage (the proteoglycans—substances that help provide the cartilage's resilience) become altered, which may make the joint less resilient and more susceptible to damage. uThus, in some people, the surfaces of the joint do not slide as well over each other as they used to. This process may lead to osteoarthritis. Additionally, joints become stiffer because the connective tissue within ligaments and tendons becomes more rigid and brittle. This change also limits the range of motion of joints.

scleroderma - diagnosis s/s

•Enlarged red blood vessels on the hands, face and around nail beds (called "telangiectasias") •Calcium deposits in the skin or other areas •High blood pressure from kidney problems •Heartburn; this is an extremely common problem in scleroderma •Other problems of the digestive tract such as difficulty swallowing food, bloating and constipation, or problems absorbing food leading to weight loss •Shortness of breath •Joint pain