Clinical Case of Skeletal Disease

Musculoskeletal or skeletal system consists of bones, cartilages, ligaments and joints that accounts approximately 20% of our body mass. Bones made up our body shape, support and protect our organs and systems. There are 206 bones in an adult human body which contain the bones of skull, spines, ribs, arms and legs. Bones compound most of the skeleton in the body. In order to support the mass of our body, bones work together with muscles to manage body position and create controlled, precise movements. Without the skeleton to pull against, contracting muscle fibres could not make us sit, stand, walk or run. This report will discuss about Gillian who presents to GP with chronic bilateral knee pain and lumbar spine which have a major impact on her ability to move around. Besides these two main problems, she has noticed that she gains about 10kg in the past six months which it affects her pain. Furthermore, she also diagnoses with osteoporosis and osteoarthritis. There are many treatment options that available for her. As a nurse, firstly, they should manage the pain by nonmedical interventions, psychological support, and medication. Secondly, they would rather to control her blood glucose level since she suffers from type 2 diabetes and obesity because these factors are contributed to osteoarthritis. Thirdly, physical activities would be one of best option to improve her weight since her BMI is 30.5 which shows that she is overweight. Lastly, if there are no significant physically changes on Gillian, the nurse and doctor must prescribe her some medications.

Patient Outline

In the case study, Gillian presented to GP with chronic bilateral knee pain and lumbar spine pain which decreases her mobility significantly. She is known to have gained a significant amount of 10kg within the last six months which she stated to deteriorate her pain. She has a history of left knee injury, fracture right hip due to recent fall, high blood pressure and high cholesterol, type 2 diabetes and chronic joint pain. Furthermore, Gillian is menopausal since the age of 49. Regarding her family history, her mother and grand-mother had osteoporosis, one sister is diagnosed with osteoarthritis leading on to knee replacement and one is currently receiving the treatment for osteosarcoma. On physical examination, she demonstrated decreased spine flexion and extension, left hip discomfort when flexion and rotation and bilateral knee crepitus as well as enlargement/fluid in the left knee.

Diagnosis

Gillian has been complaint of chronic knee pain and lumbar spine pain, she stated that she desired to have a little bit of movement since she acknowledged how important movement is to aid reducing the pain. However, she found it difficult getting over initial pain. Arthritis refers to inflammation of a joint. There is a wide variety of arthritis diseases including osteoarthritis, rheumatoid arthritis or ankylosing spondylitis when the individual displayed stiffness and fusion of their spine. Consumers with arthritis often presented with restricted motion, articular pain or stiffness, swelling of limbs.

Osteoporosis is common in people aged 65 and above. Signs and symptoms of osteomalacia also include pain when more weight is put on the affected bone due to low intake of calcium or vitamin D leading to softer bone. Meanwhile, osteoporosis is more likely to be a silent disease and people are not aware of the disease until they experienced fall causing fracture.

From the scenario’s information, based on her signs and symptoms as well as background and current medical condition, one conclusion can be drawn that Gillian is experiencing both osteoarthritis and osteoporosis. The diagnosis of osteoporosis is based on family history, clinical assessment and clinical tests. As stated in Gillian’s case, both mother and grandmother had osteoporosis which indicates family history of osteoporosis. Clinical tests of osteoporosis include medical imaging methods and the preferred procedure is dual energy X-Ray absorptiometry (DEXA) which measures bone mass density (BMD), also known as T-score. The diagnosis of osteoporosis is evident by T-score lower or equal to 2.5. Additionally, CT scans, MRI or ultrasound can be adopted to investigate osteoporosis. For diagnostic studies of osteoarthritis, X-Ray, MRI or bone scan are useful for conforming osteoarthritis. X-Ray is used commonly since it displays narrowing of joint space or bony sclerosis (stiffening of bone). Synovial fluid analysis can be applied to differentiate between osteoarthritis and other inflammatory arthritis as fluid in OA appears yellow and slightly or not inflammatory .

Detailed Underlying Pathophysiology

Osteoporosis are 8 times more common in women than men due to hormonal changes in the body, women tend to consume lower calcium than men throughout their lives, women have less bone mass because of their smaller frames and bone resorption begins at an early age and after menopause, more common in people aged 65 and above, poor diet (decreased calcium, vitamin D), family history of osteoporosis.

Estrogen helps to keep the normal density of the skeleton by controlling osteoclast and promoting deposit of new bone. But after menopause the oestrogen level decreases in production and women experienced a greater rate of bone loss.

About 70% of maximum bone tissue is control by heredity. The bone loss from midlife and onwards are inevitable and the rate of loss varies. Heredity not only influences the bone mineral density but also impacts the bone size. Osteoblasts continuously deposit bone and are resorbed by osteoclasts. For the bone to remain at constant both bone resorption and deposition should be equal.

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Parizad (et al. 2019) showed the relationship between diabetes mellitus and osteoporosis in postmenopausal women. Postmenopausal women diagnosed with type 2 diabetes are more vulnerable to bone fractures. Diminished renal function and obesity experienced within patients with osteoporosis are contributed to osteoporosis. Anti-diabetic drugs exert negative impacts on bone and cause bone fractures. High levels of glucose in diabetes develops the generation of AGE crosslinks in bone which induces bone fragility. AGEs – advanced glycation end products are formed when inside body when proteins or lipids (fat) are exposed to glycation (sugar). AGE crosslinks are stated to alter mechanical properties of proteins such as collagen leading to stiffer tissues and decreased viscoelasticity. It is known to increase fracture risks in people diagnosed with DM.

Gillian’s BMI is 30.5 which is within a range from overweight and obese. Roberts (2015) stated that overweight is one of modifiable risk factors of osteoarthritis because the more significant weight gained, the more pressure on weight-bearing joints including knee joints. Kane (n.d) provided that every pound of excess weight produces four pounds of extra pressure on the knees. However, it’s not just about the excessive stresses on joints but the fat itself is an active tissue that synthesises and releases chemicals that develops osteoarthritis. Fat tissue is stated to be the main source of pro-inflammatory factor – cytokines. Moreover, the development of pro-inflammatory factors causes nitric oxide (NO) production which induces the death of chondrocyte – cells in cartilage connective tissue, and, inhibits collagen synthesis. Consequently, cartilage degenerates and is inflamed leading to the breaking off in joint or ‘joint mice’. Roberts (2015) asserted that the common group diagnosed with arthritis aged over 75 is women.

Treatment Options

First and foremost, pain management is really important in this case. Since the patient has long history of chronic arthritis pain, available treatment options includes nonmedical interventions, psychological support, and medication. Chen & Michalsen (2017) show that complementary and integrative (CIM) medicine significantly reduce chronic pain. The common use of CIM modalities consist of traditional medicine (naturopathy, homeopathy, anthroposophical medicine), mind-body system (tai chi, yoga, qigong, relaxation, cognitive-behavioural therapy, meditation, biofeedback, music and art therapy, prayer, dance therapy), body-based methods (osteopathic manipulation, chiropractic manipulation, massage), and biological-based therapies (natural and herbal products, dietary supplements, nutritional intervention). Furthermore, Sydne et al (2017) explain that intra-articular platelet- rich plasma production, or the combination of glucosamine and chondroitin can release pain and support arthritis function. other pain killer options are paracetamol, ibuprofen, and chondroitin sulfate. These activities should be approved by a general practitioners before doing, and can be admin by a nurse, a therapist, and a pharmacist.

Secondly, overweight is also an issue in this case. Lifestyle change is a solution. Muscle-strengthening exercise and weight-bearing can improve strength, balance, posture, and ability of musculoskeletal system, reduce weight as well as fall and fracture risks. A therapist can assess fall risk factors and recommend solutions such as balance training exercises, home safety assessment. The patient should seek advises from a general practitioner in avoidance of focal sensory system depressant drugs, cautious observing of antihypertensive medicine, and visual amendment if required, and correction of vitamin D deficiency.

Thirdly, advising on calcium and vitamin D intake is necessary. A healthy balanced diet is significantly in need. A diet is considered healthy and balanced if it consists fruits, vegetables and rich in low-fat dairy in order to provide calcium as well as other nutrients. A recommended total calcium intake is 1200 mg/day for women age 51 or older. On the other hand, vitamin D is found most in vitamin-D fortified milk such as soy milk, fortified cereals and juices, liver, and salt water fish. NOF recommend a daily intake of 800 -1000 IU of vitamin D for individuals age 71 or above. If diet is insufficient or not enough, incorporating with supplement is required. Most calcium supplement contain vitamin D. However, patient can use independently cholecalciferol (vitamin D3) or ergocalciferol (vitamin D2 – based on plant sources – used for vegetarian diet). This can be advised by a nutritionist, a nurse or a health educator.

Last but not least, the therapy will not complete without medications. As pre-diagnosis with osteoporosis, the most common prescribed medications are bisphosphonates that include alendronate, risedronate, ibandronate, or zoledronic acid. Otherwise, hormone like medications such as raloxifene are accepted for osteoporosis prevention and treatment. Denosumab is recommend for people who cannot take bisphosphonate due to reduction of kidney function. While teriparatide and abaloparatide as recommend for people who had fractures since it rebuilds bone.

Likely Outcome

Osteoporosis is a chronic condition, which requires a long-term treatment. Therefore, there is an importance of understanding the relationship between drug-taking behaviour influences of individuals and health care expenditure, and individuals’ outcomes. According to Lidsay (2015), side effects including physical and psychological effects are biggest issues that against the efficacy of treatment. On the other hand, there is evidence showed that patients tend to not check their medicines stock regularly and only refill them when running out. Furthermore, late in seeking treatment is a phenomenon, which negatively affected the efficiency in osteoporosis therapy. The patient can avoid these conditions by frequently doing health-check, regularly looking for abdominal signs and symptoms, and seeking help if necessary. Using zoledronic acid in a single 5mg infusion, and bisphosphonates are believed to increase bone mineral density, and decrease risk of fracture. Barreto et al (2018) share that long-term exercise, especially multicomponent training, balance exercises and moderate intensity can reduce fractures, falls, and injurious fall in older population. The exercise performance should be assisted by a physiotherapist in order to secure safety and effective.

Conclusion

Gillian suffers from osteoporosis, osteoarthritis, obesity which affects her skeletal system. Within a nursing assessment, the nurse carefully creates an excellent nursing care plan for her including physically and chemically. Exercise performance, nonmedically treatment and medication treatment are available for Gillian. With this ongoing assessment, Gillian will get better if she listens carefully and follow the instruction that given by the nurse and the GP. She will be able to get back onto her exercise per normal, lose some weights as her wishes and it helps her to reduce the risk of osteoporosis, osteoarthritis, type 2 diabetes, hypertension and hypercholesterolaemia.