Osteopenia is decreased bone density. Osteoporosis is decreased bone density at a level that can
The risk factors for osteoporosis are:
Musculoskeletal Disorders
Case Study 32
eoporosis
Difficulty: Beginning
Setting: Outpatient clinic
Index Words: osteoporosis, risk factors, treatment, medications
M.S., a 72-year-old white woman, comes to your clinic for a complete physical examination. She has not been to a provider for 11 years because “I don’t like doctors.” Her only complaint today is “pain in my upper back.” She describes the pain as sharp and knifelike. The pain began approximately 3 weeks ago when she was getting out of bed in the morning and hasn’t changed at all. M.S. rates her pain as 6 on a 0- to 10-point pain scale and says the pain decreases to 3 or 4 after taking “a couple of ibuprofen.” She denies recent falls or trauma.
M.S. admits she needs to quit smoking and start exercising but states, “I don’t have the energy to exercise, and besides, I’ve always been thin.” She has smoked one to two packs of cigarettes per day since she was 17 years old. Her last blood work was 11 years ago, and she can’t remember the results. She went through menopause at the age of 47 and has never taken hormone replacement therapy. The physical exam was unremarkable other than moderate tenderness to deep palpation over the spinous process at T7. No masses or tenderness to the tissue surrounded the tender spot. No visible masses, skin changes, or
erythema were noted. Her neurologic exam is intact, and no muscle wasting is noted.
An x-ray examination of the thoracic spine reveals osteopenic changes at T7. What does this
be diagnosed by conventional x-rays. Bone loss is not detected by conventional x-rays until bone loss is in the 25% to 45% range. In this case, the patient reports pain in the area at the bottom of her
shoulder blades; however, lower back pain is also a frequent early symptom of osteoporosis.
The physician suspects osteoporosis. List seven risk factors associated with osteoporosis.
Female gender
White or Asian race
Lack of adequate exercise
Lifelong insufficient calcium and vitamin D intake
Low body weight (less than 128 pounds)
Postmenopausal status (estrogen deficiency)
oholism
History of fractures in a first-degree relative
Advanced age (65 years and older in women; over age 75 in men)
Long term of specific medications that can lead to loss of bone density, such as glucocorticoids and certain antiepileptic drugs
. What nonpharmacologic interventions will you teach M.S. to prevent further bone loss?
. “Take the medication with 8 ounces of water immediately upon arising.”
. . . Place a star or asterisk next to those risk factors specific to M.S.
Smoking cessation
b.
M.S. receives a prescription for alendronate (Fosamax) 70
M.S.’s diagnostic test revealed a bone density T-score of –2.7. How will this be interpreted?
What diagnostic test is most commonly used to diagnose osteoporosis?
“You can take this medication with your morning coffee or orange juice.”
c. “You can eat your breakfast along with this medication.”
“You need to sit or stand upright for at least 30 minutes after taking the medication.”
d.
e.
CASES
Cigarette smoking, female gender, low body weight, white or Asian race, lack of adequate exercise, postmenopausal status, advanced age
M.S. has never had an osteoporosis screening. She confides that her mother and grandmother were diagnosed with osteoporosis when they were in their early 50s.
The dual-energy x-ray absorptiometry (DEXA) scan. The DEXA scan is a precise test that emits less radiation than even a chest x-ray and is considered the best tool currently available for the diagnosis of osteoporosis. Other tests include the quantitative computed tomography, which is much more expensive than the DEXA, and quantitative ultrasound of the heel.
The T-score is a calculated result of the DEXA scan that assesses the patient’s bone mineral density –1). Osteopenia is 1 to 2.5 standard deviations below normal, or –1 to –2.5. Osteoporosis is greater than 2.5 standard deviations below normal. M.S.’s T-score of –2.7 standard deviations below normal is defined as osteoporosis and associated with an increased risk of skeletal fracture. For a T-score below –1.5,
in a patient with risk factors or a history of previous fractures, drug therapy for osteoporosis is recommended.
mg/week. Which instructions are appropriate as you provide patient teaching to M.S. about this drug?
(Select all that apply.)
“If you experience any severe abdominal pain, vomiting, or jaw pain, notify your doctor i m m e d i a t e l y . ”
Answers: A, D, E
Take the medication exactly as prescribed: Take the medication first thing in the morning; take it with at least 8 ounces of plain water. Mineral water, orange juice, caffeine, and other liquids decrease
absorption of the medication. Allow at least 30 minutes before eating or drinking anything else to
improve absorption of the medication. She needs to remain upright (sit or stand) for at least 30 minutes after taking the medication. Bending or reclining increases the risk of esophageal reflux of the medication, causing irritation. Abdominal pain, nausea, vomiting, and jaw pain are symptoms of possible severe side effects and should be reported immediately.
M.S. is also instructed to take a calcium plus vitamin D supplement. She asks, “If I am taking the osteoporosis pill, won’t that be enough?” How do you answer her?
Explain to her that a calcium supplement, such as calcium citrate or calcium carbonate, along with the vitamin D, are essential in order to provide the “materials” needed for the alendronate to build bone and promote bone healing.
: Smoking is known to accelerate bone loss and increase the metabolism of medications. Smoking cessation methods include gum, patches, hypnosis, and support groups.
Some patients fail many times before becoming successful at stopping smoking. She should not give up. 150
: Regular weight-bearing exercise decreases calcium loss from bones (swimming does not
qualify). Exercise for 30 minutes at least three times a week. Start slowly and increase gradually.
Walking is excellent. It is important to get enough weight-bearing exercise (at least 30 minutes on most days). If your feet touch the ground during exercise, it is considered weight-bearing.
Running and walking are weight-bearing; swimming and biking are not. Low-impact aerobic
movement or dancing is also effective. It is important for the exercise to be enjoyable to increase the likelihood of long-term compliance because the benefit of exercise is quickly lost once the individual stops exercising.
: Adequate protein, calcium, and vitamin D are essential to bone health. Dietary sources of calcium include milk, cottage cheese, yogurt, hard cheeses, and dark green vegetables such as broccoli or spinach. If taking supplemental calcium, the patient should take it with meals to ensure optimal absorption. M.S. should be referred to a registered dietitian for dietary analysis and recommendations for a nutritional plan that emphasizes vegetables, fruits, and low-fat dairy and protein sources. In addition, she needs to reduce her intake of caffeine.
ASE Y PROGRESS
M.S. seems overwhelmed and says, “I cannot possibly stop smoking and lose weight and exercise all at the same time.”
You encourage M.S. to start working on one problem at a time. Which problem should M.S. attempt first?
Let her choose the problem. She is more likely to be successful if she works on the problem that she feels most capable of resolving.
CHAPTER 3 MUSCULOSKELETAL DISORDERS CASE STUDY . mg tid 3 days only, and celecoxib (Celebrex) 100 . . . Scenario
mg/day for 3 months. He receives the × J.C. used to take piroxicam (Feldene) 20
Low Back Pain
Difficulty: Beginning
Setting: Hospital emergency department, home
Index Words: low back strain, rehabilitation, medications, risk factors
J.C. is a 41-year-old man who comes to the emergency department with complaints of acute low back pain. He states that he did some heavy lifting yesterday, went to bed with a mild backache, and awoke this morning with terrible back pain, which he rates as a “10” on a 1 to 10 scale. He admits to having had a similar episode of back pain years ago “after I lifted something heavy at
work.” J.C. has a past medical history of peptic ulcer disease (PUD) related to nonsteroidal antiinflammatory drug (NSAID) use. He is 6 feet tall, weighs 265 pounds, and has a prominent “potbelly.”
What questions would be appropriate to ask J.C. in evaluating the extent of his back pain and injury?
Obtain a clear chronologic narrative of problem onset, setting, manifestation, and past medical treatment. Principal symptoms should be described. Use the COLDERRA mnemonic to guide questions.
(COLDERRA: C haracteristics, O nset, L ocation, D uration, E xacerbation, R adiation, R elief, A ssociated S/S)
What observable characteristic does J.C. have that makes him highly susceptible to low back injury?
His potbelly puts undue strain on the lumbar joints, muscles, and tendons in his low back.
mg until he developed his duodenal ulcer. What is the relationship between the two? What signs and symptoms would you expect if an ulcer developed?
Piroxicam, like other NSAIDs, can precipitate peptic ulceration and GI bleeding, especially if taken on an empty stomach. S/S of GI bleeding would include abdominal pain or other GI discomfort, tarry, maroon-colored, or bloody stools.
PROGRESS
All serious medical conditions are ruled out, and J.C. is diagnosed with lumbar strain. The nurse practitioner (NP) orders a physical therapy consult to develop a home stretching and back-strengthening exercise pro-
gram and a dietary consult for weight reduction. J.C. is given prescriptions for cyclobenzaprine (Flexeril) following instructions: heat applications to the lower back for 20 to 30 minutes four times a day (using moist heat from heat packs or hot towels), no twisting or unnecessary bending, and no lifting more than 10 pounds.
J.C. is instructed to rest his back for 1 or 2 days, getting up only now and then to move around to relieve muscle spasms in his back and strengthen his back muscles. He is given a written excuse to stay off work for 5 days and, when he returns to work, specifying the limitation of lifting no more than 10 pounds for 3 months. He is instructed to contact his primary care provider if the pain gets worse.
J.C. looks at the prescription for cyclobenzaprine (Flexeril) and states, “I’m glad you didn’t give me that Valium. They gave me Valium last time and that stuff knocked me out.” How would you respond to J.C.?
The skeletal muscle relaxant, cyclobenzaprine, might also cause extreme drowsiness, as well as dizziness and blurred vision. He needs to change position slowly to avoid orthostatic hypotension.
J.C. states, “Well, I’m glad I’ll still be able to take my sleeping pill.” True or False? Explain.
Cyclobenzaprine is a centrally acting skeletal muscle relaxant. There is no evidence that muscle
It was prescribed to reduce the chronic inflammatory processes causing his back pain. Celecoxib
Although it is frequently used for chronic joint pain, acetaminophen is an analgesic and antipyretic
CASES
General instructions also include to avoid driving or using sharp objects until the response to the drug is known, but he is to stay off work for 5 days and in bed for the first 1 to 2 days.
Why do you think that cyclobenzaprine was prescribed instead of diazepam (Valium)?
relaxants help when used more than 1 week. Diazepam is a sedative hypnotic, anticonvulsant, and muscle relaxant. It is a schedule IV drug because of the risk for abuse.
False! You need to remind him that skeletal muscle relaxants, such as Flexeril, cannot be taken with other central nervous system (CNS) depressants such as sleeping pills (hypnotics), sedatives, or alcohol, because increased CNS depression and mental confusion might result.
C
ASE
Y PROGRESS
J.C. asks, “What is Celebrex? I hope it won’t do what that Feldene did to me years ago.”
Why do you think it was prescribed for J.C., considering his GI history?
(Celebrex) is a COX-2 inhibitor that selectively inhibits prostaglandins responsible for joint pain. It is a newer member of the NSAIDs and has fewer GI adverse effects in comparison with older NSAIDs because of its COX-2 selectivity. However, GI toxicity is still a possibility, and, especially with his history, he needs to be very careful to watch for GI bleeding.
. You know that it has been over 5 years since his last episode of GI bleeding. Are there any other conditions that you need to assess for before J.C. begins to take the celecoxib? Explain.
The FDA has issued a Black Box Warning for all NSAIDs. This warning includes information that patients with cardiovascular disease or risk factors for cardiovascular disease might be at greater
risk for serious cardiovascular events such as thrombotic events, MI, and stroke. J.C.’s cardiovascular status and risk factors need to be assessed closely.
Why would the NP prescribe an NSAID rather than acetaminophen for J.C.’s pain?
but lacks anti-inflammatory properties and does not stop the damage caused by chronic inflammatory processes.
A physical therapist teaches J.C. maintenance exercises he can do on his own to promote back health. Identify two common exercises that would be included. : Lie on the back with knees bent at 90-degree angle and feet flat on the floor. Clasp hands behind one knee at a time and gently pull toward chest; hold 5 to 10 seconds.
Alternate knees. Complete 6 to 10 repetitions at least twice a day. This can also be done from a seated position; as you lean forward, extend your arms and touch the floor.
: Lie on the back with knees flexed and feet flat on the floor, with arms extended beside knees. Inhale deeply. Tuck chin and exhale while slowly lifting shoulders from the floor. Hold position for 5 seconds, continuing to exhale and inhale while slowly returning to resting position.
: Lie on the back with knees flexed and feet flat on the floor. Inhale deeply. Exhale slowly as you tighten buttocks and abdomen, pressing back into floor and tilting your pelvis toward the ceiling. Hold for 5 to 10 seconds while exhaling, then relax. Complete 6 to 10 repetitions at least twice a day.
: Sit with one leg extended on the bed and the other leg off the side of the bed. Bend
forward, reaching the hands toward the foot of the extended leg, and hold 10 to 30 seconds, then relax. Turn around and repeat with the other leg outstretched. Repeat 6 to 10 times at least twice daily.
