Introduction to joint disease

Question 1

When does osteoporosis increase in prevalence?

Answer 1

as age increases - starts very early on in life, lots of intervention available

Question 2

What group of people does osteoporosis primarily affect?

Answer 2

Women after the menopause (decrease in oestrogen)

*can also affect men

Question 3

What fractures are most common in osteoporosis?

Answer 3

Hip, wrist and spine (hip fractures are main problem - high bed occupancy and mortality)

Question 4

What is the thick outer shell of bone called?

Answer 4

cortex

Question 5

What is the meshwork of bone inside cortex called?

Answer 5

trabecular bone

Question 6

What happens to the trabecular bone in osteoporosis?

Answer 6

Becomes more holey and weaker

Question 7

What builds new bone?

Answer 7

Osteoblasts

Question 8

What breaks down old bone? (resorption)

Answer 8

Osteoclasts

Question 9

What is Osteoporosis caused by?

Answer 9

Reduced osteoBLAST activity and increased osteoCLAST activity (bone is being broken down quicker than its being remodelled )

Question 10

What peak bone mass do patients with osteoporosis have?

Answer 10

low peak bone mass between 25 and 40 yrs and then 1% lost per year

Question 11

What is the WHO definition for osteoporosis?

Answer 11

osteoporosis is a generalized skeletal disorder of low bone mass (thinning of the bone) and deterioration in its architecture, causing susceptibility to fracture.

Question 12

How long does it take for bone to be remodelled?

Answer 12

100 days

Question 13

What is bone turnover influenced by?

Answer 13

Hormones (oestrogen/testosterone), cytokines and prostaglandins

Question 14

What are the phases in bone remodelling?

Answer 14

Resorption 
Reversal Phase 
Formation
Resting Phase 
Activation

Question 15

What are the signs and symptoms of osteoporosis?

Answer 15

• Fracture (usually first presentation)
• Reduced bone density on DXA scan
• Pain
• Reduced mobility
• Kyphosis - in vertebral fractures, curving of the spine
• Reduction in height

Question 16

What are the problems that come with vertebral fractures?

Answer 16

• can result in height reduction of 10-20cm
• often undiagnosed
• can cause problems with indigestion, neck weakness, back pain, loss of mobility

Question 17

How is Bone Mass Density determined?

Answer 17

by DEXA scan

Question 18

When do you have peak bone mass?

Answer 18

Between 25 and 40 yrs and then Post maturity bone loss of 0.5-1% / year

Question 19

What do women in menopause have regarding bone mass?

Answer 19

Accelerated bone loss around menopause due to loss of protective effect of oestrogens - important to have a diet rich in calcium and vitamin D

Question 20

When are DXA scans used?

Answer 20

Only for high risk patients / those with established OP

Question 21

What do DXA scans measure?

Answer 21

Usually measures bone density at hip/lower spine to get a “T score”

Question 22

What T score indicated Osteoporosis?

Answer 22

Less than or equal to -2.5

Question 23

What can portable DXA scanners scan?

Answer 23

ankle - not as reliable

Question 24

What are the risks factors for OP?

Answer 24

• History of fracture (and/or in 1st degree relative)
• Smoking
• Low body weight (bone density is reduced)
• Female
• Oestrogen deficiency
• Corticosteroid use (prednisolone ≥ 7.5mg daily for 3/12 or more)
• White race
• Increase age
• Low calcium intake
• Excess alcohol
• Lack of exercise
• Recurrent falls
• Dementia
• Impaired eyesight
• Poor health/fraility - especially RA, renal disease, liver disease, IBD

Question 25

What is included in the primary prevention of OP?

Answer 25

Lifestyle changes: - Adequate Ca and Vit D - Weight bearing exercise - Reduced alcohol intake - Stop smoking - Reduce risk of falls esp in elderly

Question 26

What is included in the secondary prevention of OP?

Answer 26

``` Pharmacological management: - Calcium - Vit D - Calcitriol - HRT - SERMS - Bisphosphonates - Calcitonin - Strontium - PTH - Denosumab In addition to lifestyle changes ```

Question 27

What is Osteoarthritis?

Answer 27

Disease of wear and tear - usually limited to one or two joints (differs from rheumatoid arthritis)

Question 28

What groups of people are affected by Osteoarthritis?

Answer 28

- Over 65s - Onset most common at 40-60 yrs - More common in women - Common in obesity

Question 29

What are the clinical features of OA?

Answer 29

- Joint pain, worsened on movement and at end of day - May be accompanied by swelling - Most common in knee, hands, lumbar & cervical spine - EMS (early morning stiffness) up to 30 mins

Question 30

What happens in OA (pathogenesis)?

Answer 30

- Cartilage gradually roughens and becomes thin - Thickening of underlying bone - Formation of osteophytes - Thickening & inflammation of synovium - Thickening and contraction of ligament Some joints repair themselves, others don’t

Question 31

What is the difference between a normal joint and a joint with mild OA?

Answer 31

- Normal: bone and cartilage protecting bone, meniscus is extra protection. Synovium is membrane - Mild OA: bone underneath becomes thicker and starts to wear away cartilage. Inflammation occurs

Question 32

What happens to a joint with severe OA?

Answer 32

Bone can touch opposing bone and is very painful, needs joint replacement

Question 33

What are the goals for management of OA?

Answer 33

- Reduce pain - Optimise mobility (encourage weight loss and exercise) - Minimise joint deformity - Patient education - Multidisciplinary approach

Question 34

What non-pharmacological management is there for OA?

Answer 34

- Weight reduction - Physiotherapy - Exercise plan - Heat or cold packs - Occupational therapy review - Psychological support - Surgery

Question 35

What is some pharmacological management for OA?

Answer 35

- Simple analgesics - NSAIDs – only if inflammation present - Corticosteroids – not oral, only injections - Chondroprotective agents

Question 36

What is Rheumatoid arthritis?

Answer 36

- Systemic condition that can affect many joints in many ages - Onset most common at 30-50 yrs - Reduced life expectancy - Female:Male = 3:1

Question 37

What are the clinical features of RA?

Answer 37

- Slow progressive symmetrical polyarthritis - Pain & stiffness in small joints of hands & feet - Involvement of wrists, shoulders, elbows, knees & ankles - Early morning stiffness (EMS) – can progress throughout the day - Pain tends to decrease as day progresses

Question 38

What are the Extra-articular symptoms of RA?

Answer 38

- Sjorgen’s syndrome – drying of secretions e.g. dry eyes/mouth - Vasculitis – inflammatory condition of blood vessels - Neuropathy - Subcutaneous nodules - Lymphadenopathy - Cardiovascular disease - Depression - Respiratory disease

Question 39

What is the pathogenesis of RA?

Answer 39

- Lymphocytes infiltrate synovial membrane, causing inflammation & thickening - Formation of pannus over cartilage causes erosion into bone - Eventual degeneration of cartilage & joint

Question 40

What are the goals of management for RA?

Answer 40

- Relief of pain & inflammation - Prevention of joint damage - Preservation/improvement of functional ability - Maintenance of lifestyle - Multidisciplinary approach

Question 41

What is the pharmacological management of RA?

Answer 41

- Analgesics - NSAIDs - Conventional DMARDs – methotrexate, sulfasalazine - Biological DMARDs – injection, much better at managing condition - Steroids