งานนำเสนอกำลังจะดาวน์โหลด โปรดรอ

งานนำเสนอกำลังจะดาวน์โหลด โปรดรอ

Osteoarthritis and exercise Sirintorn Chansirikarnjana MD.Msc.(Geriatric Med) Chief, Division of Geriatric Medicine Department of Medicine Ramathibodi.

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งานนำเสนอเรื่อง: "Osteoarthritis and exercise Sirintorn Chansirikarnjana MD.Msc.(Geriatric Med) Chief, Division of Geriatric Medicine Department of Medicine Ramathibodi."— ใบสำเนางานนำเสนอ:

1 Osteoarthritis and exercise Sirintorn Chansirikarnjana MD.Msc.(Geriatric Med) Chief, Division of Geriatric Medicine Department of Medicine Ramathibodi Hospital Sucheera1

2 2

3 Osteoarthritis  Age > 50 years  Hereditary for hand osteoarthritis  Insidious onset of joint pain, progress slowly over months to years  Mono/oligo arthralgia (knee, hip) > polyarthalgia (fingers)  No or only mild inflammation  Develops symptom when standing or prolong using  Improves with rest, may have gelling phenomenon  Can be associated with crystal-induce synovitis Sucheera3

4 Symptoms and signs  Joint involvement : common - DIP, PIP, first CMC, hip, knee, lumbar and cervical spine rare - MCP, MTP, wrist, elbow  Systemic symptom : rare  Localized symptoms : tenderness, crepitus and cracking  Sign : mild joint enlargement with firm consistency  Joint effusion : little or none Sucheera4

5 JOINT LOCATION Weight-bearing joints femoral head and knee joints decreased progressively with age, but not in the talus knee joint chondrocytes exhibit more interleukin (IL)- 1 receptors than ankle joint chondrocytes knee chondrocytes express mRNA for matrix metalloproteinase (MMP)-8 Sucheera5

6 Laboratory  ESR: usually normal  CBC : normal  RF, ANA : negative  Synovial fluid analysis : good viscosity with normal mucin clot; modest increase in leukocyte number, presence of fibrils an debris(wear particles) Sucheera R/o septic joint or crystal 6

7 Radiographic findings  Narrowing of joint space  Subchondral bony sclerosis(eburnation)  Marginal osteophyte formation  Bone cysts and bony collapse  Gross deformity with subluxation and loose bodies  Articular cartilage ulceration  New bone formation  Proliferation of cartilage and bone  Subchondral microfractures  Ligamentous laxity as a result of mechanical forces Sucheera7

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9 Knee Osteoarthritis Non uniform loss of joint space No erosion No demineralization Subchondral sclerosis Osteophyte formation 9

10 Heberden’s node Bouchard’s node Hand Osteoarthritis Sucheera10

11 Erosive osteoarthritis Hereditary, postmenopausal woman Clinical resemble RA PIP, DIP, CMC jt. Painful inflammatory episode Joint deformity, ankylosis Film: joint space narrowing, spur formation, subchondral bone sclerosis, prominent bony erosion Lab: RF, ANA - neg Sucheera11

12 Current Treatment of Osteoarthritis  Non-Pharmacologic Therapy Patient education Programmed exercises Weight loss Joint protection Thermal modalities  Surgical Approaches Arthroscopic debridement Osteotomy Total joint arthroplasty  Pharmacologic Therapy Nonopioid analgesics (e.g., acetaminophen) Topical analgesics (e.g., capsaicin) Nonsteroidal anti- inflammatory drugs Intra-articular steroid Intra-articular hyaluronate Opioid analgesics Sucheera12

13 NSAID gastropathy NSAID-related GI toxicity is most common serious drug-induced toxicity 1 Dyspepsia occurs in about 15% of patients 2 Prevalence of upper GI ulcers is 15–31 1 Higher risk of developing gastric than duodenal ulcers 3,4 Risk of complications increases 4-fold 4 Relative risk of bleeding Relative risk of perforation Relative risk of death Sucheera 1. Sung et al., J Gastroenterol Hepatol 2000; 15: G58– Larkai et al., J Clin Gastroenterol 1989; 11: 158– Graham et al., Ann Intern Med 1993; 119: 257– Hawkey, Gastroenterol 2000; 119: 521–35. 13

14 Risk Factors for Ulcer Complications  Definite Advanced age (substantial risk after age 65) Advanced age (substantial risk after age 65) Prior ulcer disease or ulcer complications High-dose, multiple NSAIDs (including low-dose aspirin) Concomitant use of anticoagulants Concomitant use of corticosteroid therapy Serious systemic disorder  Possible Cigarette smoking Alcohol consumption Infection with Helicobacter pylori Sucheera Singh et al., J Rheumatol 1999; 26(Suppl 56): Larkai et al., J Clin Gastroenterol 1989; 11: 158–62. Graham et al., Ann Intern Med 1993; 119: 257–62. Hawkey, Gastroenterol 2000; 119: 521–35. 14

15 Age and history of ulcer are strong predictors of ulcer complications Risk of hospitalisation or death 1 : 3/1000 patient-years for patients under 63 years 19/1000 patient-years for patients aged 63–75 years 42/1000 patient-years for patients over 75 years Relative risk of ulcer complications 1 : 2.9 for a history of dyspepsia 6.1 for a history of uncomplicated ulcers 13.5 for a history of bleeding ulcers Men have a 2-fold higher risk of developing complications than women 2 1. Sung et al., J Gastroenterol Hepatol 2000; 15: G58– Hernández-Díaz & García Rodríguez, Arch Intern Med 2000; 160: 2093–99. Risk factors for serious GI complications Sucheera15

16 The risk of ulcer complications increases with NSAID daily dose 1 : Low dose: relative risk 3.0 (95% CI, 2.6–3.4) Medium dose: relative risk 4.1 (95% CI, 3.6–4.5) High dose: relative risk 6.9 (95% CI, 5.8–8.1) NSAIDs increase the risk of ulcer complications in new and long- term users alike: 1–30 days’ NSAIDs: relative risk 5.7 (95% CI, 4.9–6.6) 181–365 days’ NSAIDs: relative risk 5.1 (95% CI, 3.9–6.5) Relative risk drops when NSAIDs are stopped and returns to baseline within about 2 months Hernández-Díaz & García Rodríguez, Arch Intern Med 2000; 160: 2093–99. Complications associated with NSAID dose and duration Sucheera16

17 Discontinue use of NSAIDs or substitute with less toxic agents Low-toxicity NSAIDs or COX-2 inhibitors Suppress acid secretion Normal-dose PPI therapy High-dose H 2 RA therapy Use mucosal protectants Misoprostol (side-effects can be problematic) Sucheera Seager & Hawkey, BMJ 2001; 323: 1236–9. Silverstein et al., Ann Intern Med 1995; 123: 241–9. Graham et al., Ann Intern Med 1993; 119: 257–62. Yeomans et al., N Engl J Med 1998; 338: 719–26. Rx of NSAID-induced PU disease 17

18 Antacids Limited efficacy, especially in preventing gastric ulcer H 2 RAs Effective in preventing gastric ulcer; some drug interactions, well tolerated PPIs More effective than H 2 RAs for healing NSAID- induced ulcers, well tolerated Sucheera Seager & Hawkey, BMJ 2001; 323: 1236–9. Goldstein et al., Gut 1999; 25(Suppl V): A101. Yeomans et al., N Engl J Med 1998; 338: 719–26. Acid suppression in NSAID-induced PU 18

19 NSAIDs and Cardiovascular  All NSAIDs : Salt and water retention Increase BP May cause CHF in patient with cardiac problem  Interfere with antihypertensive drugs ACEI Beta blocker Calcium antagonist Sucheera19

20 Effects and CV Risk PGI 2 TxA 2 Thrombotic Risk Low-Dose ASA Conventional NSAIDs Prob Naproxen (high-dose) Prob COX-2 Inhibitors +ASA ?? COX-2 COX-1 Sucheera20

21 COX-2 selective inhibitors VS NSAID: balancing GI and CV risk R A Moore, et.al : BMC Musculoskeletal Disorders 2007, 8:73 Conclusion: Calculating annualized event rates for GI and CV harm shows that while complicated GI events occur more frequently with NSAIDs than coxibs, serious CV events occur at approximately equal rates. For each coxib, the reduction in complicated upper GI events was numerically greater than any increase in APTC events. Event rate difference (coxib-NSAID) per 1000 per year Sucheera21

22 Shared Toxicities of NSAIDs Renal Sodium retention Sodium retention Weight gain and edema Weight gain and edema Hypertension Hypertension Type IV renal tubular acidosis and hyperkalemia Acute renal failure Papillary necrosis Acute interstitial nephritis Accelerated chronic renal failure Sucheera22

23 Indication for COX-2 Inhibitors  Age > 70 yr. with no cardiovascular, renal or hepatic diseases  History of aspirin induced asthma  History of major peptic ulcer complication (bleeding, obstruction, perforation)  Continue GI complication even after adding gastroprotective agents to conventional NSAIDs  Pre and post operative pain (short course) Sucheera23

24 Exercise Prescription for Special Populations Advanced age  Resistance training is recommended by most health promotion organizations for its effects on maintenance of strength, muscle mass, bone mineral density, functional capacity, and prevention and/or rehabilitation of musculoskeletal problems (eg,low back pain) Emedicine.medscape Jun 24, 2009 Amer Suleman, MD; Kyle D Heffner, MS, CPFT, CCT 24Sucheera

25 Exercise Prescription for Special Populations Advanced age  In elderly individuals, resistance training is both safe and beneficial in improving flexibility and quality of life Emedicine.medscape Jun 24, 2009 Amer Suleman, MD; Kyle D Heffner, MS, CPFT, CCT 25Sucheera

26 Contraindications Absolute contraindications to exercise include  Suspected acute coronary syndrome  3 rd -degree heart block  Uncontrolled hypertension  Acute heart failure  Uncontrolled diabetes mellitus Merch Manaul April 2009 by Brian D. Johnston; Paul L. Liebert, MD 26Sucheera

27 Contraindications Relative contraindications include  Cardiomyopathy  Valvular heart disease  Complex ventricular ectopy Merch Manaul April 2009 by Brian D. Johnston; Paul L. Liebert, MD 27Sucheera

28 Screening 1 Detecting cardiac disorders and Physical limitations to exercise For sedentary patients who plan to begin intense exercise, stress testing is indicated if they have any of the following: Merch Manaul April 2009 by Brian D. Johnston; Paul L. Liebert, MD 28Sucheera

29 Screening 2  Known coronary artery disease  Symptoms of coronary artery disease  > 2 cardiac risk factors (hypercholesterolemia, hypertension, obesity, sedentary lifestyle, smoking, family history of early coronary artery disease)  Suspected lung disease  Suspected diabetes Merch Manaul April 2009 by Brian D. Johnston; Paul L. Liebert, MD 29Sucheera

30 Exercise program Exercise should ideally include  Aerobic activity  Strength training  Flexibility and balance Merch Manaul April 2009 by Brian D. Johnston; Paul L. Liebert, MD 30Sucheera

31 Physical Activity and Public Health in Older Adults: Recommendation from the American College of Sports Medicine and the American Heart Association 31Sucheera

32  30 minutes a day of aerobic activity five days a week  Resistance training exercise to reduce stress on joints, bones and soft tissues;  Add flexibility and balance to the mix 32Sucheera

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34 Sucheera34

35 การบริหารกล้ามเนื้อคอ เอียงคอ ซ้าย - ขวา Sucheera35

36 การบริหารกล้ามเนื้อคอ หันหน้าไปไหล่ ซ้าย - ขวา Sucheera36

37 การบริหารกล้ามเนื้อคอ ใช้มือดันหน้าผาก-ก้มศีรษะไปด้านหน้า Sucheera37

38 การบริหารกล้ามเนื้อคอ ประสานมือหลังศีรษะ-ดันศีรษะไปด้านหลัง Sucheera38

39 การบริหารกล้ามเนื้อคอ ใช้มือดันศีรษะด้านข้าง-เอียงศีรษะไปด้านข้าง (ทำสลับ ซ้าย-ขวา) Sucheera39

40 Sucheera40

41 การบริหารกล้ามเนื้อข้อเข่า ห้อยเท้า ผูกน้ำหนักที่ข้อเท้า ½ - 1 กิโล ทั้ง 2 ข้าง (ทำวันละ 1-3 ครั้ง ครั้งละ 5-15 นาที) Sucheera41

42 การบริหารกล้ามเนื้อข้อเข่า วางเท้าบนเก้าอี้ พร้อมกดเข่าลงนาน 5-10 วินาที แล้วพัก 1 นาที (ทำวันละ 3 ครั้ง) Sucheera42

43 การบริหารกล้ามเนื้อข้อเข่า เกร็งกล้ามเนื้อต้นขา-กระดกข้อเท้ายกเท้าขึ้นค้างไว้ 5-10 วินาที (ทำวันละ 3 ครั้ง) Sucheera43

44 การบริหารกล้ามเนื้อข้อเข่า เกร็งกล้ามเนื้อต้นขา-กระดกข้อเท้ายกเท้าขึ้นสูงจากพื้น 1 ฟุต ค้างไว้ นับ 1-10 สลับกัน 2 ข้าง (ทำวันละ 3 ครั้ง) Sucheera44

45 Sucheera45

46 การบริหารกล้ามเนื้อข้อสะโพก เกร็งกล้ามเนื้อต้นขา-กระดกข้อเท้ายกเท้าขึ้น กางขาออกด้านข้างในท่าตะแคง สลับกัน 2 ข้าง (ทำวันละ 3 ครั้ง) Sucheera46

47 การบริหารกล้ามเนื้อข้อสะโพก เกร็งกล้ามเนื้อต้นขา-กระดกข้อเท้างอเข่าขึ้น สลับกัน 2 ข้าง (ทำวันละ 3 ครั้ง) Sucheera47

48 การบริหารกล้ามเนื้อข้อสะโพก เกร็งกล้ามเนื้อต้นขา-กระดกข้อเท้ากางขาออกด้านข้าง สลับกัน 2 ข้าง (ทำวันละ 3 ครั้ง) Sucheera48

49 การบริหารกล้ามเนื้อข้อสะโพก เกร็งกล้ามเนื้อต้นขา-กระดกข้อเท้ากางขาออกด้านหลัง สลับกัน 2 ข้าง (ทำวันละ 3 ครั้ง) Sucheera49

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ดาวน์โหลด ppt Osteoarthritis and exercise Sirintorn Chansirikarnjana MD.Msc.(Geriatric Med) Chief, Division of Geriatric Medicine Department of Medicine Ramathibodi.

งานนำเสนอที่คล้ายกัน


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