Musculoskeletal disorders (MSDs) is medical condition mostly caused by work related occupations and working environment, affecting patients’ muscles, joints, tendons, ligaments and nerves and developing over time. A community sample of 73 females and 32 males aged 85 and over underwent a standardised examination at home. Musculoskeletal pain was reported by 57% of those interviewed. A major restriction of joint movement range was frequent in the shoulder but uncommon in other joints. A shoulder disorder was found in 27% of subjects, rheumatoid arthritis in 1% and osteoarthritis (OA) of the hand, hip, and knee in five, seven, and 18% of subjects, respectively. Disability was frequent: a walking distance of < 500 m was found in 60% and ADL dependency in 40% of the group. Factors related to one or both of these disability measures included female gender, hip and knee OA, impaired vision, cognitive impairment and neurological disease(1).
III. Rheumatoid Arthritis
Rheumatoid Arthritis is defined a chronic disorder as a result of inflammation, affecting mostly the flexible (synovial) joints and tissues and organs in the body. The disease affects more women than in men and generally occurs after the ages of 40 and diminishes the quality of life of many elders.
E.1.In conventional medicine perspective
The aim of treatment is to stop the progression and relieve the symptoms of the diseases
1. Non Medication
a. Physical therapy
In the study to evaluate the efficacy of a 6 week home based physical therapy (PT) intervention for people with moderate to severe rheumatoid arthritis (RA), showed that participation in a short term home based PT intervention delivered by specially trained therapists reported improved outcomes following treatment, and these improvements were maintained at one year followup. Future studies need to explore the relative contributions of education, exercise, home based care, therapist training, and reinforcement strategies in improving long term outcomes in RA(50).
In the assess to investigate the therapeutic effects of hydrotherapy which combines elements of warm water immersion and exercise, Dr. Lineker SC, and the research team at the University Health Network, indicated that all patients improved physically and emotionally, as assessed by the Arthritis Impact Measurement Scales 2 questionnaire. Belief that pain was controlled by chance happenings decreased, signifying improvement. In addition, hydrotherapy patients showed significantly greater improvement in joint tenderness and in knee range of movement (women only). At followup, hydrotherapy patients maintained the improvement in emotional and psychological state.(51).
c. Relaxation therapy and biofeedback training
In the study of Rheumatoid arthritis: a study of relaxation and temperature biofeedback training as an adjunctive therapy, results of the first study revealed significant and positive changes following treatment that were primarily related to pain, tension, and sleep patterns for both groups, but no differential effects were noted between temperature elevation or reduction conditions. This was attributed to both groups having maintained temperature above baseline during biofeedback training. The results of the second study consistently favored the relaxation and biofeedback over the physiotherapy group on the physical/functional indices. The psychological measures tended to remain constant throughout both studies, leading to the conclusion that the effectiveness of treatment was specific to physical functioning rather than to a psychological enhancement of well-being(52).
d. Both heat and cold treatments
Some researchers suggested that suggest that cold and hot patterns in traditional Chinese medicine were related to different pathways, and the network analysis might be used for identifying the pattern classification in other diseases(53).
d. Low level laser therapy
Some research suggested that Low level laser therapy (LLLT) should be considered for short term relief of pain and morning stiffness in RA, particularly since it has few side effects. For OA, the results are conflicting in different studies and may depend on the method of application and other features of the LLLT. Clinicians and researchers should consistently report the characteristics of the LLLT device and the application techniques. New trials on LLLT should make use of standardized, validated outcomes. Despite some positive findings, this metaanalysis lacked data on how effectiveness of LLLT is affected by 4 factors: wavelength, treatment duration of LLLT, dosage, and site of application over nerves instead of joints. There is a need to investigate the effects of these factors on effectiveness of LLLT for RA and OA in randomized controlled clinical trials(54).
e. Occupational therapy
In the study of Thirty-eight out of 58 identified occupational therapy studies fulfilled all inclusion criteria. Six controlled studies had a high methodological quality. Given the methodological constraints of uncontrolled studies, nine of these studies were judged to be of sufficient methodological quality. The results of the best evidence synthesis shows that there is strong evidence for the efficacy of “instruction on joint protection” (an absolute benefit of 17.5 to 22.5, relative benefit of 100%) and that limited evidence exists for comprehensive occupational therapy in improving functional ability (an absolute benefit of 8.7, relative benefit of 20%). Indicative findings for evidence that “provision of splints” decreases pain are found (absolute benefit of 1.0, relative benefit of 19%)(55).
f. Prosorba column apheresis therapy (PCT)
Approval of Prosorba column apheresis therapy (PCT) for rheumatoid arthritis (RA) in 1999 to use only in some medical centers and generally is used only for very severe rheumatoid arthritis. some studies indicated that postmarketing study of PCT used commercially in 59 rheumatology practice settings supports the safety and efficacy of this treatment regime in selected patients with RA and compares favorably with the initial sham controlled clinical trial. PCT is a relatively underutilized choice for the management of active, aggressive RA(56).
2. Medication, surgery and others
Medication or combined medication is used to stop the progression and relieve the symptoms of the diseases
In the study of 2012 Brazilian Society of Rheumatology Consensus for the treatment of rheumatoid arthritis, Dr. da Mota LM, and scientists at the Universidade de Brasília suggested that (57)
1) The therapeutic decision should be shared with the patient;
2) Immediately after the diagnosis, a disease-modifying antirheumatic drug (DMARD) should be prescribed, and the treatment adjusted to achieve remission;
3) Treatment should be conducted by a rheumatologist;
4) The initial treatment includes synthetic DMARDs;
5) Methotrexate is the drug of choice;
6) Patients who fail to respond after two schedules of synthetic DMARDs should be assessed for the use of biologic DMARDs;
7) Exceptionally, biologic DMARDs can be considered earlier;
8) Anti-TNF agents are preferentially recommended as the initial biologic therapy; 9) after therapeutic failure of a first biologic DMARD, other biologics can be used;
10) Cyclophosphamide and azathioprine can be used in severe extra-articular manifestations;
11) Oral corticoid is recommended at low doses and for short periods of time;
12) Non-steroidal anti-inflammatory drugs should always be prescribed in association with a DMARD; 13) clinical assessments should be performed on a monthly basis at the beginning of treatment;
14) Physical therapy, rehabilitation, and occupational therapy are indicated;
15) Surgical treatment is recommended to correct sequelae;
16) Alternative therapy does not replace traditional therapy;
17) Family planning is recommended;
18) The active search and management of comorbidities are recommended;
19) The patient’s vaccination status should be recorded and updated;
20) Endemic-epidemic transmissible diseases should be investigated and treated.
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