Prevention of fracture in patient with osteoporosis, especially elderly, is really important. The bone is fragile and easily broken. Fracture in elderly may increase the morbidity and mortality. As an example, it is common in elderly with osteoporosis to get hip or femur fracture after having a trivial injury like tripping over a bump on the floor. This type of fracture need longer time to heal. Previously, patient was immobilized on bed for a long time until the fracture united. During those time it was quiet common that those patients pass away due to complication of immobilization especially pneumonia. Recently, with advance development in the management of fracture, including surgery, the risk of complication from immobilization have been minimized as surgery allows the patient to mobilize early, however, for elderly with multiple morbidities, which is very common, the surgery is often delayed as patient is not fit for surgery. Therefore, the patient still susceptible to complication of immobilization.
Some tools can help patient to reduce risk of fall and trivial injury that can lead to fracture
1.Canes and walkers
These provide them more stability during walking.
2.Seat lift
These help to minimize the stress on the back bones
3.Hip protector
Hip fracture is common in osteoporosis. This hip protector has been shown to reduce the incidence of hip fracture in osteoporotic patient.
4.Reaching aids and stepstool with handrail
Among the movement that is not safe for osteoporotic patient is reaching up for things in a high shelf. This can cause imbalance and fall. Reaching aids and stepstool should be used to do this activity.
5.Shower organizer
Put stuffs in the shower organizer that can easily reached by patient. This avoid frequent bending which put stress on the spine.
6.Toilet with riser for the seat and a frame with arm rests
This helps patient to get up easily from the toilet with minimal stress over the back bones
7.Rubber tub mat in the tub
This can reduce the risk of fall due to slippery tub.
8.Rubber floor mat in bathroom
This can reduced risk of fall in the bathroom due to slippery floor.
Rheumatoid arthritis is a chronic inflammatory disease of the joints. It typically affects multiple of small joints such as fingers, wrists, toes and ankles, usually in symmetrical manners ,bilaterally. It is also classified under autoimmune disease as the inflammation occur is caused by the autoimmune process, in which there is presence of autoantibodies that attack normal cells and tissues in the body, in this disease it mainly attack the joint tissues. Women seems to be affected more than men.
Immune system in our body is a system that function to protect our body from foreign invaders that may impose harm on the body. This system consists of specialized organs, such as thymus bone marrow, spleen, that produce/store specialized cells including B cells,T cells, APCs, monocytes, plasma cells, etc. These cells work by identifying foreign invaders, initiating a complex cascade, causing inflammation and produce antibodies to attack and destroy the foreign invaders.
However, in rheumatoid arthritis and other autoimmune diseases, the specialized cells fail to differentiate between the normal tissues and the invaders, they even recognized the normal tissues as the invaders, therefore causing inflammation and produce antibodies to attack them endlessly. The antibodies that attack normal tissues are called 'autoantibodies', which is specifically known as rheumatoid factors in case of rheumatoid arthritis. In rheumatoid arthritis, this process mainly occurs in the joints. It may occurs in other sites, such as heart, kidney , bone marrow, or skin.
The cause is unclear, however, genetic has been suggested to have association with rheumatoid arthritis.
Inflammation in the joints lead to pain, swelling, stiffness and redness. If this condition left untreated, it may progressively lead to damage of the joints causing permanent deformity and loss of function.
There are combination of criteria used by doctors to diagnosed rheumatoid arthritis. These includes:
1)Presence of multiple joints inflammation, symmetrical bilaterally, involving the small joints of hands and feet, persist for at least 6 weeks. 2)Subcutaneous nodules, typically over the elbows/fingers. 3)X-ray changes of the joints - periarticular erosions.
Various stages of the disease, from early stage(left picture) to late stage(right picture)
Subcutaneous nodule over the elbow
X-ray changes in rheumatoid arthritis
Detection of rheumatoid factors alone in the absence of above criteria is not sufficient to make the diagnosis. Actually, the main value of rheumatoid factor test is to determine the severity of the disease. Detection of rheumatoid factor in a persistently high concentration indicate the disease is severe. Not all patients with rheumatoid arthritis have rheumatoid factor. There are some patients whose their rheumatoid factor test are negative, this condition is called seronegative rheumatoid arthritis.
NSAIDs helps especially in the early stage, when pain and stiffnes is the most highlighted issue for the patient at that moment. If NSAIDs is not adequate to control the pain ,corticosteroid usually is very useful as it greatly reduce the inflammation. The most important drugs in the management of rheumatoid arthritis is DMARDs such as methotrexate, as it delays the progression of the disease, however, it can not reverse what has been destroyed. Therefore, the earlier the treatment start, the more benefits patients can get.
Physiotherapy helps to keep the joints move, which is very important, as unmove joints may lead to contracture deformity. Occupational therapy and mechanical aids help patient especially those with permanent deformity (late stage) to overcome the effects of disability by improving their ability to perform basic tasks in their daily living. Surgery might be indicated for those with deformity if much function is desired.
Physiotherapy
Mechanical aids help with activities daily living
Reconstruction surgery to restore anatomy and function might be indicated
in permanent deformity if much function is desired
Although there is no cure for rheumatoid arthritis, but, early detection and early proper treatment is important, for example early usage of DMARDs is more beneficial as the progression of the disease can be delayed from the beginning. Other than that, self-management strategies is very helpful. Patients who learns the techniques and skills to manage their arthritis on day to day basis, including pain management, activities limitation, etc, are more confident and happy in their lives.
Low back pain is very common. It is often multifactorial, making diagnosis difficult. Commonly it is caused by mechanical spinal disorders, which usually not serious, plus other factors such as fatigue, obesity or lack of exercise. Serious spinal or extraspinal disorder are unusual causes. Warning signs often indicate a serious disorder and need for further investigations.
This is the most common cause of back pain. Mechanical back pain means that the pain is caused by placing repetitive and/or abnormal stress and strain on the structure of spine. Nonspecific mechanical spinal disorders are includes muscle strains and ligament sprains. Compare to nonspecific mechanical spinal disorders, in specific structural lesions, we are able to see the specific findings through imaging such as disc bulging/degenerate, osteophytes growth, spondylolisthesis, etc. These disorders includes disc herniation, compression fracture, osteoarthritis, spondylolisthesis, spinal stenosis, which are further discussed below.There is no specific treatment for nonspecific mechanical spinal disorders. General measures are usually adequate to relieve the symptoms and the symptoms usually are self-limiting.
Our intervertebral disc, which located between 2 vertebrae, is a structure that consist of 2 components, a tough covering of the outer layer (annulus fibrosus), and a soft, jelly-like interior (nucleus pulposus). If a disc is suddenly squeezed by the vertebrae above and below it, for example when lifting a heavy object, the outer covering may tear/rupture, causing pain. The interior of the disc can squeeze through the tear in the covering, so that part of the interior bulges out (herniates). This bulge can compress, irritate, and even damage the spinal root next to it, causing more pain. Sometimes the soft, jelly-like material of the interior part of the disc may prolapse out from the covering through the tear, causing disc prolapse, lead to more irritation/ damage to the spinal roots, and causing more pain. Diagnosis is confirm by MRI or CT myelography. Treatment is usually conservative with analgesics, activity modification, and exercise. Surgery is indicated in some cases includes patients with progressive or severe neurological deficits includes numbness/weakness of one/both legs, intractable pain, or signs of spinal cord compression such as loss of bowel/bladder control.
It is common in elderly due to osteoporosis. It is usually predisposed by trivial injury. Patients usually did not seek treatment initially because of the mild pain. However, later it may cause chronic back pain and disability. Diagnosis is by x-ray. Treatment is usually conservative unless there is spinal instability or spinal cord compression in which surgery is indicated
Lumbar spinal stenosis is narrowing of the lumbar spinal canal. It is commonly due to degenerative disc disease. With normal ageing the disc gradually dries out and becomes flatten. This lead to collapse of disc space, which is the space between the vertebrae. This puts pressure on the facet joints of adjascent vertebrae lead to osteoarthritis. If this is severe, osteophytes growth may narrow the spinal canal and the intervertebral foramina, and as damage to the facet joint becomes more severe the vertebra may slip causing spondylolisthesis, which worsen the spinal stenosis. Encroachment on the spinal canal is called spinal stenosis. Spinal stenosis may cause spinal root or spinal cord compression. Other causes of spinal stenosis besides degenerative disc disease are includes congenital vertebral dysplasia, Paget's disease and trauma. X-rays may show narrowed disc space, .spondylolisthesis and osteoarthritis. Measurement of the spinal canal can be carried out by x-rays but more reliable information is obtained from CT and MRI. Treatment is usually conservative unless surgery is indicated such as severe pain or disability, spinal cord compression or spinal instability.
Degeneration of the disc lead to disc space collapse,
which, in turn puts pressure on the facet joints
Osteoarthritis lead to enlarged facet joint, plus
enlarged ligament, lead to stenosis and compression of the
spinal root/cord
As the facet joints become arthritic, the vertebrae
may slides forward causing spondylolisthesis, which
worsen the stenosis and compression of nerve structure
Degenerative spine disease - starts from degeneration of disc, lead to
arthritis of facet joint hence become hypertrophic/enlarge, which in turn
causing spondyolisthesis and narrowing of intervertebral foramina and
spinal canal (stenosis), then lead to compression of nerve root and spinal cord
It is degenerative disease of the joint and can occur in other joints as well such as knee, hip and others. The osteoarthritic changes that may occur in the affected joint includes. Diagnosis is by x-rays. Treatment is usually conservative unless complicated with spinal cord compression, severe pain or disability, or spinal instability, in which surgery may be indicated.
Spondylolisthesis is forward displacement of a vertebrae on other vertebrae below it. It can be due to degenerative changes or due to trauma. Spondylolisthesis can lead to spinal stenosis, spinal cord compression, or spinal instability. Diagnosis is by x-rays. Treatment is usually conservative unless surgery is indicated.
Infection involving the spine may cause back pain. These infections can be spine tuberculosis, osteomyelitis or discitis. Besides back pain, patients may also complain of associated symptoms such as fever, night sweat, loss of appetite. Raised in white cell count, ESR, or CRP, may further make the diagnosis of infection more likely. Further work up need to be done including x-rays and MRI to look for the lesions such as osteomyelitic changes or tuberculosis features. Sometimes, tissue biopsy /aspirate is taken for organism culture. Definitive treatment will be depend on the diagnosis and organisms.
Tumor involving the spine can be primary tumor or metastases, usually from prostate, breast or lungs. Patients usually complain of constitunal symptoms besides complaining of back pain. The constitunal symptoms include loss of appetite, loss of weight, intermittent fever. Further investigations such as x-rays, MRI, CT scan need to be done. MRI enable us to see the features of the lesions. CT scan usually done to look for primary source or other lesions in other part of the body and for staging of the disease. Diagnosis is confirmed by tissue biopsy. Definitive treatment will depend on the diagnosis.
Common mechanical spinal disorders usually is not serious and have no specific treatment. General measures such as pain killer, rest, exercise usually enough to relieve the symptoms. However, in some cases, back pain is caused by serious disease, in which patient need to seek medical attention to get proper treatment. Patients should consult a doctor if there is presence of any of these warning signs:
Because low back pain is often caused by several problems, diagnosing a single cause may not be possible. Doctor may only be able to tell that the cause is a mechanical and not serious. Therefore the doctor 's important aim is to identify any serious disorder.
1)The doctor usually would want to differentiate between mechanical and nonmechanical causes of the back pain. Non-mechanical causes usually more serious than mechanical one, such as infection and tumor, which need further investigations and proper treatment. Patient with mechanical disorders may have history of trauma that involving the back, or have history lifting heavy objects / doing heavy works. Non mechanical causes is suggested when patients also presented with symptoms such as fever, loss of weight, loss of appetite, besides back pain
2)The doctor would want to detect presence of spinal root/cord compression which may need urgent intervention. Spinal root/cord compression may cause patient to have numbness/weakness of one/both legs, difficulty in bowel/bladder control, or difficulty in emptying the bladder. The doctor may want to proceed with MRI to confirm the condition if those signs and symptoms present.
3)The doctor would want to rule out extraspinal causes that can be more serious compared to spinal causes.
Activity modification includes avoiding activities that cause stress on the spine such as lifting heavy objects, bending, and bad posture. Bed rest should no t be longer than 1/2 days as prologed bed rest may cause stiffness and worsen the back pain.
Pain killers and muscle relaxant might be needed initially to relieve the pain.
Application of cold and heat might be helpful as well. Cold is usually preferred to heat for the first few days of injury.
Massages, acupuncture maight be helpful for muscle spasm, strain or sprain.
After the pain subsided, light activities may help with healing and recovery. Specific exercises to strengthen the muscles of the back is encouraged to prevent chronic or recurring low back pain.
Discectomy or laminectomy might be necessary if there is severe pain / numbness / weakness / loss of bladder and bowel control, indicating presence of spinal root/cord compression. Discectomy is surgical removal of the disc while laminectomy is surgical removal of part of vertebrae.
Spinal fusion , in which few vertebra are fused together in a surgical procedure, is usually done for or to prevent spinal instability.
