Hello and welcome. We are going to talk about another topic in our musculoskeletal system, which is arthritis and connective tissue diseases chapter. Specifically, lupus and fibromyalgia will be the topics we are talking about.
Now, when we think about the musculoskeletal system itself, we always think about bones and muscles, but there is another part of that system that can become very diseased, and those are all the things that... hold the muscles and the the bones together as a matter of fact if we didn't have those then you know we actually wouldn't be able to move and have the ability that we have now so unfortunately that can come attack under attack by the body itself lupus affects a lot of different people and you know we may have patients coming in and they're having surgery they're having this but oh they have a history of lupus too And so this really needs to be taken in consideration. As we can see, it affects many different ethnicities.
Women specifically are affected by it and women of childbearing years. Now this can be concerning, especially if they are trying to do some family planning. These medications can be very toxic to fetal development or even affect fertility.
And it really does affect so many different systems. Our connective tissue isn't just about bones and muscles. It is about everything else, connecting our organs together and connecting our blood vessels together. So really, it can be a widespread disease. Why it happens?
It can be a bit of a challenge. Many different factors may be contributing to it. So genetic, hormone, infection, you know, Epstein-Barr actually has been implicated in a lot of other diseases too.
environmental exposure to chemicals or toxins or stress and and really a lot of times medications can cause a change and it isn't seen for quite a while too so unfortunately a lot of research and it is different for each person too as to why it may happen so when this process begins and the body starts attacking itself what it does it to develop specific antibodies that attack the nucleus of the cells of these connective tissues, also known as anti-nuclear antibodies, ANA, and they go and they actually destroy them. Now these complexes then deposit in the capillary membranes, but very specifically we think about musculoskeletal bones and joints, but actually kidney, heart, skin, brain, joints, all sorts of connective tissue located all over the body. and typically activated by B cells and T cells.
These B cells and T cells are kind of acting different. They're doing things that they shouldn't be. They're targeting our own tissue itself. So as we can see, lupus does affect so many different organs in the body.
But the ones that concern us also, besides the musculoskeletal ones and the organs, it can actually cause cardiomyopathy. It can cause... endocarditis or pericarditis.
It can cause Raynaud's phenomenon where the blood vessels just clamp down and then the tissue becomes necrotic because it doesn't have blood flow. It can cause a lot of respiratory problems too and then it can also cause hematological problems, anemias and leukopenia because it starts attacking those cells too and then even the platelets too can drop quite a bit. So like I said, a lot of different things are affected, we really want to pay attention, especially in this class, to the things that can really cause severe instability to our patient. Lupus can be highly recognized by some of the skin lesions that it has.
Like I said, it does attack the connective tissue. We got a ton of it in our skin. The vascular lesions may appear. For systemic lupus, a lot of times the butterfly rash will appear on the face itself.
but there is a skin specific form of it called discoid lupus which causes these ring-shaped shaped lesions but they they do get really scaly you can have some oral ulcers also and because of it does attack the skin and the hair then hair loss can also occur More classic and outward signs of lupus are the bone and joint changes that actually occur. You know multiple joint pain but it happens on both sides of the body. If it's osteoarthritis oftentimes it only happens on one side and oftentimes it gets much much worse with repetitive use.
For lupus typically it may be more bilaterally. It affects the body systemically. a lot of swelling and stiffness of course and it can cause the same type of deformity swan neck ulnar deviation the subluxations and hyperlaxity these remind you a lot of rheumatoid arthritis too don't they well they should these are all the symptoms of rheumatoid arthritis too but rheumatoid arthritis it does have and attack other organ systems too lupus is a lot more diverse And there's certain cell structures that it attacks that are different than the rheumatoid arthritis itself. But yeah, very similar in many ways when we look at those outward signs.
Now let's focus on some of the organs that may cause us great concern. Of course, lung disease, pleurisy, tachypnea, cough, maybe some impaired gas exchange, but dysrhythmias too. causing fibrosis of the SA and AV nodes. And we know that that can cause heart blocks, first degree block, third degree block. So this can be very concerning to our patients, even leading to needing a pacemaker.
Other symptoms of cardiac disease, pericarditis, myocarditis, where the muscle itself is inflamed, and endocarditis. And those are the valvular disorders that we talked about. Now, Also, the hematological system with some of the changes in our blood cells and even coagulations, they have a hypercoagulability, so they're at risk for stroke and heart attack because of this.
Now, a very common complication of lupus is renal failure, lupus nephritis or lupus nephropathy, so disease and breakdown of the kidneys themselves. 40% end up actually needing some sort of kidney supplementation. Several years after their diagnosis, it just continues to progress and progress and progress.
And it is due to glomerulonephritis, so it actually attacks the glomerulus itself, causing scarring. And so this will lead to end-stage renal disease needing dialysis. And now we can try and slow the process by giving them corticosteroids and immune suppressive medications. Now here's just a little hint when it comes to pharmacology. Typically, medications that end in a mab or a mib, that means that they are some sort of immune system modulating drug.
And they will have the side effects and problems you have with those type of medications altering the immune system. Now we have a lot of connective tissue in our brain and nervous system too. And so these patients can have vocal changes caused by like microcirculation problems and clots, a lot of headaches especially during flares, or they can have a diffuse neuropsychiatric SLE or lupus itself where everything is very inflamed. They get a lot of behavioral changes and maybe even seizures because of it. I mentioned hematologically where they can have changes, anemia, leukopenia, and thrombocytopenia, plus that hypercoagulability too.
So hydroxychloroquine may reduce that and that is used as actually a very mild immunosuppressive type agent. And so with lupus it can be effective. The other thing is infection because of the attack on this hematological system. The white blood cells don't function very well, so they may not be able to fight off infection very well.
Pneumonia can be very common. Vaccines are safe, but we have to be careful if they are taking corticosteroids. And live viruses are different than the attenuated ones, and those have to be clarified with a provider if they have to have a live vaccine. All right, so how do we know a patient has lupus?
Well, we discussed a lot of the signs and symptoms and clues that we may see that they may have it, but then the type of tests we're going to do, we're going to do a lot of blood tests. One specifically is the ANA, like I mentioned, the anti-nuclear antibody. 97% of patients have this particular antibody present. It's an abnormal one. There are other tests too, anti-DNA, anti-Smith bodies, anti-phospholipid antibodies.
So they're looking for these abnormal white blood cells that are circulating. And then just monitoring ESR and CRP, the erythrocyte sedimentation rate and the C-reactive protein. Those just tell us that the body has inflammation. It does not tell us what's causing it.
This doesn't diagnose it, but it does help with monitoring the disease to see if they're going into a flare or an exacerbation of it. So we're looking at interprofessional care for these clients. You know, we treat them with a lot of medications, but yet these medications have some really profound side effects. So we really have to balance treatment with side effects to try and make sure that we're not causing more damage. But really, you know, survival depending on the severity of the disease.
There are many patients I'd have in who would have lupus for many, many years. It really just kind of stayed low-lying, but it was always there, and they were always able to manage it, not having these exacerbations. Other patients will struggle with it, and they have flare after flare after flare, and within a very short time, they may have several organs that are actually affected by it. So really, let's diagnose it early, right? Can we try and give that immunosuppressant to...
to prevent the the disease and the destruction of the organs itself and then really recognizing when the organs start failing if they start going into renal failure if they start having cardiac dysrhythmias or syncope or weakness or shortness of breath what do we need to do to get that under control very quickly so that it doesn't cause them to become very unstable some of the medications we're going to be using NSAIDs are very effective especially with the musculoskeletal symptoms that have but make sure we're watching the GI effect of it. The antimalarial medications like hydroxychloroquine are very effective like I said it's a very mild immunosuppression but it doesn't cause immunosuppression so that it actually changes their white blood cell counts. But this can cause cause eye problems so we have to make sure that we're doing frequent eye checks because of the retinopathy that can occur with high doses.
Critical steroids, lowest dose, shortest amount of time, tapering them off, trying not to keep them on them constantly. Other medications, immunosuppressive medications, to try and reduce the end organ damage are given like those immune modulating medications. Other anticoagulants to reduce blood clots and then topical modulators too to try and treat some of the skin symptoms.
All right so when we start our nursing process our our ab pi we want to look and see and really assess the patient to see what symptoms they have if they're having a flare out of the disease itself or are they able to to manage it and keep it really just under the radar so they're able to carry out their ADLs. Have they had any unusual fevers or joint inflammation or pain? Have they had any weight changes or changes in their I's and O's, especially looking for those renal symptoms?
And then checking their urine for protein. Protein should never be leaked into the kidneys, right? Looking at their creatinine clearance and their GFR to make sure that all of those things are within normal range.
And then if they are on any anticoagulants, coagulant are they having any signs of bruising or bleeding too and then do those neuro those vision checks especially with the medications that they may be on they may be having headaches are they having any seizures or personality changes especially depression or brain fog or anything unusual like that would need to be discovered so our clinical problems are to try and manage the musculoskeletal symptoms that they have so they can actually function better. They may be interfering with their role, with work, with family, but then they also have the impaired tissue integrity too. So our goal is to make them comfortable, but also trying to avoid things, pacing themselves, avoiding those things that make it worse, and try and have an optimal level of functioning as much as possible. But it is very unpredictable. and for the patient and for the family members too.
So there's a lot of family support that needs to be done, and there are organizations out there that can actually help to support them during these times too. Typically, lupus has a good prognosis for most people. Occasionally, like I said, there is some severe disease and they start going into multiple organ function. We really want to make sure that their perfusion, their heart, their lungs, their kidneys, their brain, clotting factors are all within normal level, trying to prevent the long-term tissue damage that can actually occur.
So close monitoring of these patients is very important. The specialist that actually takes care of these type of patients is called a rheumatologist. They specialize in autoimmune diseases.
So all of your autoimmune diseases will see a rheumatologist. But really trying to get the disease under control, reducing the amount of flares that are going on because this is what will cause the end organ damage is when they go into these flares. So assessing their functioning in their ADLs, monitoring their weight, their I's and O's, but then also supporting them in their role. This is a chronic disease that can become quite acute.
How can we prevent it from being acute so that they are able to manage it on a day-to-day basis because it can really cause some devastating changes in their life and lifestyle. So considering the patient population, you know, women of childbearing years, high rate of them getting lupus at this particular time, you know, if they're family planning, this can be very challenging for them. So they really need to consult with a GYN, an OB specialist also, maybe even a fertility specialist, especially if they're already on medications and have been on them for quite a while.
Plus, if they do become pregnant, how are they supposed to manage this while they're carrying the child and not have the toxic effects of it. So hopefully with a lot of education and support, we can have these patients live out and have families and work and maintain a lot of the normalcy that they would have. We are going to move on to fibromyalgia.
So basically muscle pain, with fibrosis. This is an unusual disease. It's very subtle.
We may see patients coming in because of other things, but yet they have fibromyalgia. We need to try and manage this while we're managing their other conditions. Fibromyalgia is in a family of diseases called SEID, systemic exertional.
intolerance diseases and so there's several of them that fall into this category we're going to focus on fibromyalgia now this has widespread non-articular muscle pain so the muscles themselves hurt not the joints themselves they tend to have these tender points along these muscle lines and at neuromuscular junctions they're not sleeping well stiffness irritable bowel, lots of unusual things going on, but no specific cause. Women suffer from it more than men do, and typically more middle age than the younger or older population. Now, the theory with fibromyalgia is these patients have some sort of abnormal processing of pain receptors in the central nervous system.
They've kind of got... widespread neuro inflammation but there's no focal point or singular cause of it. Spinal fluid can have a little bit extra protein in it which can cause inflammation also. People typically at risk would have genetic problems or predispositions for it or if they have other autoimmune diseases or if they've had any type of infection or trauma. These patients will have widespread burning.
fluctuate throughout the day but like I said they can't really differentiate if it's muscles or the joints or soft tissues they're just kind of uncomfortable all over and then they can also have a lot of the spinal cord and those type of joints are also affected the patients will have these tender points they're very specific areas on the body 11 out of 18 of them have to be positive and it's typically symmetrical also. And so, like I said, sometimes all of them are, some of them are very, very sensitive if they're triggered, but a lot of times they'll use this along with a lot of the subjective reports of what's going on to identify if this patient has fibromyalgia. Other symptoms include neurocognitive changes, brain fog, unable to handle stress. Besides the headaches itself, some behavior changes like depression or anxiety. They don't sleep very well either.
The fatigue, of course, is overwhelming. And even when they do try and exercise and do things, they get very fatigued from that too. You can even get some neurological changes like paresthesias, restless leg syndrome, IBS.
And so really, you know, looking at these patients and trying to understand what's going on with them because The patients may not have consistent symptoms across the line. Some may suffer from bladder problems, but where others will not. Like was mentioned, typically with fibromyalgia, they have to put a bunch of diagnostic criteria together.
It is a syndrome, so it doesn't have a specific cause as of yet. So they'll have the tender points, they'll have long lasting pain that doesn't go away. It can be very widespread above and below the body and symmetrically on each side too. Now to take care of these clients, interprofessional and nursing care focuses on symptomatic treatment, right?
What are their symptoms? And really trying to restore that balance between the nervous system and the musculoskeletal system. So really a support for them and active participation in their treatment plan as to what is working and what may not be working. Certain medications to help regulate the nervous system, like the pregabalin or Cympalta or Savella, these things, these are neurotransmitter modulators and SSNRIs, SRIs.
And so all these things help restore sleep, but they also help regulate the neurotransmitters to stop sending those pain signals abnormally. Sometimes you can do some tricyclic antidepressants. or some benzos.
Muscle relaxants are helpful also with a lot of spasms and things, but really non-opiate things, things that aren't as addictive would be better choices. And then of course, trying to help them get some balanced sleep because with sleep, our nervous system and all those neurotransmitters can try and regulate a little bit better. Barber myalgia is oftentimes treated with our CAM, so gentle exercising and stretching, not overdoing it, nice and gentle yoga, tai chi, low impact exercising too, some massage, application of hot and cold for the muscles, but then also limiting those things that can actually irritate the muscles, irritate the neurotransmitters like sugar, caffeine, and alcohol, taking supplementations, vitamin and mineral supplementations.
But then also, you know, healthy diet and weight loss can also help. But biofeedback, imagery, meditation, and support also, all of these things combined together can really improve the quality of life of somebody who's suffering from fibromyalgia. Well, I hope this helps. Thank you so much.