Management of MSK Disease

Question 1

What are the benefits of education in the management of MSK disease and how is it done?

Answer 1

Proven to reduce pain/disability
Reduces healthcare costs of many MSK conditions
1-1 discussion/written literature/group classes

Question 2

What are the benefits of physiotherapy in the management of MSK disease and how is it done?

Answer 2

Aerobic training = reduces pain/disability, improve sleep, aids wt loss
Local strengthening exercises = reduces pain/disability

Question 3

What are the benefits of reducing adverse mechanical factors in the management of MSK disease and how is it done?

Answer 3

Pacing of activities related to functional ability
Shock-absorbing footwear to reduce impact loading
Contralateral walking sticks take wt off damaged joints

Question 4

What are the benefits of physical treatments in the management of MSK disease and how are they done?

Answer 4

Local heat/cold treatments provide temporary relief

Question 5

What are the benefits of coping strategies in the management of MSK disease and how are they done?

Answer 5

Relaxation techniques, distraction techniques improve pain

Question 6

What is the MoA of Corticosteroids?

Answer 6

Inhibit transcription of COX-2, cytokines, ILs

Increase annexin-1 production, anti-inflammatory effects

Question 7

What are the side effects of Corticosteroids?

Answer 7

Infection/poor wound healing
Peptic ulceration
Acute adrenal insufficiency upon withdrawal
Cushing's syndrome
Diabetes mellitus
Osteoporosis
Avascular necrosis
Psychological effects
Inter-scapular fat pad

Question 8

What is the preferred Corticosteroid for MSK disease?

Answer 8

IM methylprednisolone

-depot effect that self-tapers down

Question 9

What should patients on long-term Corticosteroids be co-prescribed?

Answer 9

Gastro protection (PPIs)
Vit D
Bisphosphonates

Question 10

What is the benefit of intra-articular injections?

Answer 10

Diagnostic & therapeutic effect

• preparation contains LA, if pain resolves w/i short period of time can be confident pain coming from structure
• do not repeat 3x in 6mo
• systemic absorption/side effects possible

Question 11

What are DMARDs?

Answer 11

Disease modifying anti-rheumatic drugs

• Methotrexate
• Sulfasalzine
• Hydroxychloroquine
• Penicillamine
• Gold compounds

Question 12

What are the benefits of DMARDs?

Answer 12

Reduces pain/disability score & RF level

Question 13

How are DMARDs initiated?

Answer 13

As soon as diagnosis of inflammatory arthritis reached
Clinical effect slow
-steroids used to cover induction phase
Combination therapy superior

Question 14

What is Methotrexate?

Answer 14

1st line DMARD

Folic acid antagonist

Question 15

What are the benefits of Methotrexate?

Answer 15

Quick onset of action
Once weekly dosing (oral/IM)
-take folic acid on any other day

Question 16

What are the signs of Methotrexate toxicity?

Answer 16

Bruising
Infection
SOB

Question 17

What are the common side effects of Methotrexate?

Answer 17

Nausea
Headaches
Tingling

Question 18

How should Methotrexate treatment be monitored?

Answer 18

Bloods every 10wks

• FBC
• LFTs
• U&Es

Question 19

In which pts is Methotrexate unsuitable?

Answer 19

Pregnancy

Males /Females attempting to conceive

Question 20

How long does Sulfasalazine take to produce a response?

Answer 20

8wks

Question 21

What are the common side effects of Sulfasalazine?

Answer 21

Nausea & dyspepsia
Rashes
Blood dyscrasias
Azoospermia
Yellow-orange discolouration of urine/contact lenses

Question 22

How should Sulfasalazine treatment be monitored?

Answer 22

3 monthly

• FBC
• LFTs
• U&Es

Question 23

How long does Hydroxychloroquine take to produce a response?

Answer 23

6 wks

-least effective, least toxic

Question 24

How should Hydroxychloroquine treatment be monitored?

Answer 24

Baseline visual acuity

Annual re-check

Question 25

What are the common side effects of Hydroxychloroquine?

Answer 25

Rash GI disturbances Peripheral neuropathy Retinal damage

Question 26

What are the most common biologics?

Answer 26

Anti TNF agents - Infliximab - Etanarcept

Question 27

What are the contraindications to the use of biologics?

Answer 27

``` Active infection Latent TB Malignancy Pulmonary fibrosis Severe heart failure ```

Question 28

What are the common adverse effects of biologics?

Answer 28

Opportunistic infections Non-melanoma skin cancers Injection site reactions

Question 29

How should the risk of infections be managed when treating patients with biologics?

Answer 29

Vaccinate patients each year CXR require to exclude TB prior to commencing treatment Present early if signs of potential infection

Question 30

What are the general contraindications to performing surgery in MSK disease?

Answer 30

Actively infected joint | Recurrently infected joint

Question 31

What are the general complications of orthopaedic surgery?

Answer 31

``` Wound infection DVT MI Local neurovascular injury Compartment syndrome Periprosthetic fracture Complex regional pain syndrome ```

Question 32

In which patients are nutripharmaceuticals & alternative medicines most useful?

Answer 32

Pts w/ complaints of chronic back pain/fibromyalgia w/ no demonstrable pathological cause

Question 33

What alternative techniques are available for the management of MSK disease?

Answer 33

``` Glucosamine for OA Chiropody & Osteopathy Relaxation techniques Acupuncture Massage ```