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to dietary
medication.
Osteocytes
- mature bone cells
- main type of cell in bone
- dont divide
d) Osteoclasts
- multinuclear giant cells
- w/ tartrate-resitant acid phospatase (active in
bone resorption)
- located in endosteum
- resorption -> release enzymes & acids that
digesy bone
OSTEOPOROSIS
- age-related dec. in bone mass
- L2-L4 density level 2.5 standard deviations below
peak bone mass of 25 yr old individual measured
by DXA
- quantitative defect in bone (bone mineralization
normal)
- literally porous bone
* approx 30% of women > 50 -> osteoporotic
- women asymptomatic early course
*silent disease -> may not
osteoporosis until fracture occurs
realize
patient
physical
activity,
b) Modifiable
i. Poor Nutrition Recommended Ca intakes
1200-1300 mg/day, 14-70 y/o
ii. Thin Patients
relative risk of fracture
- obesity appears to protect the skeleton
from fractures
b) Osteoblasts
- have abundant amounts of alkaline phosphate
which precipitates calcium salts
- produce matrix
- surround themselves w/ matrix -> osteocytes
c)
factors,
have
using
DEXA
for precise
Treatment/Management
Goals:
- prevent development of osteoporosis
- prevent further bone loss
- dec. risk of osteoporotic fracture
Prophylaxis for at risk patients
- Diet w/ adequate Ca (low intake more degradation of
bones)
- Weight bearing exercise program
- Estrogen therapy evaluation for menopause
ARTHRITIS
- encompasses > 100 diseases that involve
synovial joints & periarticular structures
- patient usually presents w/ joint pain, limitation
of motion/stiffness, instability and deformity
- involves breakdown of cartilage (protects joint,
allows smooth movement & acts as a joint shock
absorber)
=> bones rub together causing pain,
swelling, inflammation, stiffness
- 4 Major Basic Groups: non-inflammatory,
inflammatory, infectious, hemorrhagic)
General treatment:
- Physical activities
- Ca supplements
- estrogen-progesterone therapy
- IM calcitonin (expensive)
- Vit. D 200 IU (1-50y/o), 400 IU (50-70y/o), 600 IU
(71y/0 >)
- Ca intake
1-10 y/o -> 800 mg/day
11-24 -> 1200 mg/day
Adults -> 1000 mg/day
Postmenopausal no estrogen => 1500 mg/day
- Ca source
OSTEOARTHRITIS
- most common NON-INFLAMMATORY arthritis
- leading cause of disability in developing world
- 11M Filipinos suffer
- 50% of 65 y/o patients & above have symptoms
of OA
Vitamin D
- adequate Vit. C & D intake to maintain bone
density and strength
- Vit d. deficiency common in Phil.
- helps in absorption of Ca from intestines, also in
kidneys to help resorb calcium
- sources -> sunlight, milk, cheese, cereal, fish
common
factors
jogging,
tennis,
aerobics,
Etiology
- wear & tear arthritis, progressive
- articular cartilage that covers ends of bones in joints
gradually tears away => joint motion is painful
- not an age related degenerative condition -> posttraumatic osteoarthritis
among elederly:
ligamentous laxity
failure of periarticular surfaces
dec. matrix prodn by chondrocytes
dec. responsivesness of chondrocytes to growth
Risk factors
- Female (>65y/o)
- Obese -> heavy joint load
- athletes -> w/ heavy physical activities
- history of joint trauma or fracture
- dec. proprioception
- patients w/ muscle weakness
- inactivity
- genetic predisposition
Types:
a) Primary OA secondary to natural wear & tear of joint
- mostly related to aging (water content inc,
protein dec. in cartilage) -> eventually cartilage
flake forming crevasses
- advanced cases -> total loss of cartilage cushion
w/c causes friction bet. bones
- deterioration of bearing surfaces
Osteochondral junction breakdown
Cartilage disintegration
Subchondral microfractures
- osteophyte devt (inflammation of cartilage
stimulate new bone outgrowth to form around
joints
- Subchondral cyst (arise sec. to microfracture &
may contain amorphous gelatinous matl)
- joint space narrowing secondary to degenerative
meniscus
Clinical Manifestations
- early morning stiffness
- joint swelling -> monoarticular & weight bearing
joints
Treatment
a) Supportive Measures
- recommend rest or change in activities to avoid
provoking OA
- avoid high impact activities (aerobics, running,
jumping etc.)
- encourage low-impact exercises (stretching,
walking, swimming, cycling)
- weight loss program recommended
- isometric exercises -> strengthen muscles
around joints
- NSAIDs -> reduce pain, inflammation
- glucosamine supplements (1500mg/day) ->
natural component of cartilage
- Visco-supplementation
-> gel injection, hyaluronic acid
-> lubrication to joint & smoothens joint
-> 6-18 mos
- Surgery
-> arthroscopic debt
-> total joint arthroplasty
GOUTY ARTHRITIS
- 2nd most common among Filipinos
- INFLAMMATORY type
- deposition of urate crystals in joint triggers
inflammatory rxns causing joint pains
- assoc w/ Hyperuricemia
=> abnormal high serum level uric acid
(6mg/dL/
360umol/L
for
women),
(6.8mg/dL/ 400umol/L for men)
Etiology:
- inc. urate prodn due to diet, accelerated
endogenous purine prodn, excessive degradation
of ATP]
-dec. uric acid excretion
=> 98% w/ hyperuricemia & gout have
defect in renal handling of uric acid
=> gouty individuals excrete 40% less uric
acid compared to normal
CM
- Monoarticular arthritis
=> benachmark feature
=> podagra pain in big toe
=> attack peaks 24-72hrs w/ in 7-10 days
- tophi => crystal salt deposits on soft tissue, for
chronic gout
- Nephrolithiasis => precedes
=> occurs in 50% of patients w/ elevated
serum uric acid levels
Diagnosis
RHEUMATOID ARTHRITIS
- most common INFLAMMATORY arthritis
- 1% of world pop.
- women 3X affected
- onset: 40-50
- GENETIC: 10% of RA patients have 1 st degree
relative affected
* chronic multisystem disease
=> eye problems
- affect eyes causes inflammation of episclera
Relief of pain
Reduction of inflammation
Articular surface protection
Maintenance of function
Control of systemic disease
CM
- persistent inflammatory synovitis
- hallmark: cartilage destruction & bone erosion
- promdome symptoms: fatigue, anorexia, body
malaise
*Medical Mngt:
NSAID
Glucocorticoids
DMARD methotrexate
=> blocks synthesis of folic acid -> inhibits
cellular replication (no DNA synthesis) in rapidly
proliferating cells (GI, bone marrow, stem cells)
=>indication carcinomas, psoriasis, RA
=> rapidly absorbed in GIT
Actively transported to cell membranes
Cross placenta, enters breast milk
Excreted unchanged
Dose: 7.5mg/wk
Max: 20mg/wk
*Surgery:
Synovectomy (drug therapy fails)
Soft-tissue realignments (not favored)
Reconstructive procedures (inc. risk of infection)
Other forms:
STRAIN
- caused by TWISTING or PULLING a muscle or
tendon that cause damage to muscle or attaching
tendons
- you can put undue pressure on muscles during
the course of normal daily activities (quick heavy
lifting, sports)
- Muscle damage: tearing (part or all) of muscle
fibers and tendons attached to muscle
*sudden acceleration while running cause rupture to calf
muscle or Achilles tendon
MYALGIA
- muscle pain
- symptom of many diseases and disorders
- not a disease entity but a symptom
* most common etio: OVERUSE & OVERSTRETCHING of
muscle groups
a)w/out traumatic history: viral infections (flu,
dengue, Lymes)
b) long term myalgias: indicative of
1. metabolic myopathy
2. nutritional deficiencies
3. Chronic fatigue syndrome
Types:
a) Acute strain caused by TRAUMA or injury (e.g. blow
to the body)
- caused by improperly lifting heavy objects or
overstressing muscles
b) Chronic Strain result of overuse prolonged repetitive
movement of muscle and tendons
*Common types:
a) back muscle strain
most common cause of back pain in
clinics
- common cause of patients pain w/
scoliosis
b) Hamstring strains
- involves muscles spanning two or more
joints are more prone to muscle strains
- usually seen in running and jumping
sports
c) Tendonitis
- tendinitis => inflammation to the
tendon often caused by trauma or tendon
overuse
- De Quervains tenosynovitis
d) Tennis Elbow (lateral epicondylitis)
e) Golfers Elbow (Medial Epicondylitis)
- both conditions are 2ndary to over
stretching or overuse of common extensor
tendon or common flexor tendon leading
to inflammation of its attachment at the
humeral epicondyle
CM:
SPRAIN
Sprain injury to LIGAMENT (involving stretching
or tearing of tissue)
- typically occur to people who fall and
land on outstretched arm, slide into base, land on
the side of their foot or twist a knee w/ foot
planted firmly on ground
* ankle: most commonly injured joint
- ankle sprains: foot abruptly inverted or everted;
one or more lateral ligaments are injured
CM:
Pain
Bruising
Loss of functional ability
Feel pop or tear when injury happens
Sprain Severity
Grade I Sprain (Mild)
- overstretching or slight tearing of ligaments w/
no joint instability
- minimal pain, swelling, little or no loss of
functional ability
Bruising (absent or slight)
- able to put weight on affected joint
Grade II Sprain (Moderate)
- partial tearing of ligament and is characterized
by bruising, moderate pain and swelling
- some difficulty putting weight on the
affected joint and some loss of function
- X-ray or MRI needed
Grade III Sprain (severe)
- complete tear or rupture of ligament
CM:
Diagnosis
- X-rays and MRIs not needed
- x-ray may ensure here is no other problem (like
fracture)
- in case of olecranon bursitis: X-ray can be used
- MRIs identify swelling and show bursitis
Treatment
Rest & protect Area
- keep pressure off affected area, limit
activity of joint
- elastic bandage or brace maybe used to
immobilize
- movement and pressure on inflamed
area can exacerbate symptoms
Apply Ice Pack
Control inflammation & decrease
swelling to easily return to usual state
and function
Medications
- NSAIDs (Ibuprofen, Motrin, naprosyn,
celebrex)
- cortisone injections (persistent cases and
injected directly to site of inflammation)