Osteoarthritis: Causes, Symptoms, and Risk Factors

Arthritis & Connective Tissue Diseases

Osteoarthritis (OA)

• A slowly progressive, localized, noninflammatory disorder affecting synovial joints, particularly weight-bearing ones.
• More prevalent in women.
• Hand and knee OA are especially common after menopause.
• Most adults begin experiencing its effects around age 40.
• Over 50% of individuals older than 65 show X-ray evidence of OA in at least one joint.

Risk Factors for Osteoarthritis

• Increasing age.
• Reduction in estrogen levels due to menopause
• Obesity.
• ACL (anterior cruciate ligament) injury.
• Frequent kneeling and stooping.
• Regular moderate exercise lowers risk.

Etiology and Pathophysiology of Osteoarthritis

• Destruction of articular cartilage leads to narrowing of the joint space.
• Cartilage becomes softer and less elastic over time.
• Cartilage loses its ability to withstand wear with heavy use.
• Articular surfaces develop cracks and wear down.
• Spurs or osteophytes form.
• Inflammation and thickening of the joint capsule and synovium result in early-stage pain and stiffness.
• Central cartilage becomes thinner while edges become thicker.
• Osteophytes form which can cause uneven weight distribution in the joint.
• Bones rubbing together in later stages leads to increasing pain.

Manifestations: Joints

• Joint pain is a primary symptom that can range from mild discomfort to significant disability.
• Pain typically worsens with joint use.
• Early stages of OA: rest relieves pain.
• Later stages of OA: pain may occur even at rest, causing trouble sleeping due to increased joint pain.
• Pain may intensify with lower barometric pressure during fall and spring season changes, and before precipitation.
• Pain contributes to disability and loss of function.
• Pain may be referred to areas like the groin, buttock, or outside of the thigh or knee.
• Sitting down and getting up from a chair can become difficult, especially after periods of rest or remaining in an unchanged position.
• Early morning stiffness usually resolves within 30 minutes.
• Overactivity can lead to mild joint effusion and temporary increase stiffness.
• Crepitation, a grating sensation within the joint.
• OA tends to affect joints asymmetrically.
• Hips and Knees are the joints most affected by OA.
• Metatarsophalangeal (MTP) joints are commonly affected.
• Cervical and lumbar vertebrae can be sites of OA.
• Distal (DIP) and Proximal (PIP) interphalangeal joints.
• Metacarpophalangeal (MCP) joints are also commonly affected.

Other Manifestations

• Specific to the joint involved.
• Heberden's nodes: hard or bony swellings that occur in the DIP joints.
• Bouchard's nodes: hard, bony outgrowths located at the PIP joints.
  • Can appear swollen, red, and tender.
• Varus deformity: bowlegged appearance with medial knee deviation.
• Valgus deformity: knock-kneed appearance, with lateral knee deviation.
• One leg may become shorter than the other due to hip involvement.
• Fatigue, fever, and organ involvement are typically not present in osteoarthritis.

Osteoarthritis Diagnostic Studies

• X-ray is used for confirmation and staging.
• Bone scans, CT scans, and MRIs can show early bone changes, but are costly so infrequently used.
• No specific lab tests or biomarkers but rheumatoid factor is typically negative.
• Synovial fluid analysis may be conducted.

Treatment Goals

• OA has no cure; care focuses on managing pain and inflammation.
• Focus on preventing disability and maintaining/improving joint function.
• Nondrug interventions are the basis for OA management.
• Drug therapy supplements non-drug treatment.

Rest and Joint Protection

• Balance rest and activity.
• Rest during acute inflammation.
• Use functional positioning with splints or braces.
• Avoid increased stiffness by limiting immobility to less than one week.
• Modify activities to reduce joint stress.
• Use assistive devices like canes, walkers, or crutches as needed.

Heat and Cold Application

• Heat helps reduce pain and stiffness.
  • Limit heat application to no more than 20 minutes at a time.
• Ice is typically used for inflammation or swelling. -Apply ice for 10-15 minutes at a time. -Use frozen vegetables, cold packs, or covered ice bags.
• Other methods include: hot packs, whirlpool baths, ultrasound, and paraffin wax baths

Nutritional Therapy and Exercise

• Weight reduction is critical for overweight individuals with OA.
• Dietary changes may be needed.
• Beneficial forms of exercise: Aerobic, Range of motion, Muscle strengthening, Water therapy.

Complementary and Alternative Therapies

• Acupuncture.
• Massage.
• Tai Chi.
• Nutritional supplements.
• Glucosamine and chondroitin are generally not recommended.

Interprofessional Care: Drug Therapy

• Medication is prescribed based on the severity of the patient's symptoms.
• For mild to moderate joint pain: -Acetaminophen. -Topical agents like capsaicin cream. -OTC creams containing camphor, eucalyptus oil, and menthol (BenGay, ArthriCare). -Topical salicylates (Aspercreme).

Moderate to Severe Joint Pain

• NSAIDs: start at a low dose and increase as needed. -Ibuprofen at 200 mg up to 4 times per day. -Misoprostol to reduce GI side effects. -Arthrotec: a combination of misoprostol and diclofenac. -Diclofenac gel: Avoid both oral and topical NSAIDs simultaneously. -COX-2 inhibitor such as celecoxib (Celebrex).
• Response to and cost of NSAIDs varies among individuals.
• Intraarticular corticosteroid injections if 4 or more injections without relief indicate a need for additional intervention.

Interprofessional Care: Surgical Therapy

• Arthroscopic surgery may be an option. -For patients with loss of function, unmanaged pain, and decreased independence. -Common for patients with knee OA. -May not provide additional benefit over physical therapy (PT) and medical treatment.
• Hip and knee replacement.

Health Promotion

• Alter modifiable risk factors.
• Avoid smoking cigarettes.
• Maintain good posture and body mechanics.
• Warm-up to prevent injury before exercise.
• Avoid forceful repetitive motions.
• Seek help with tasks that may be injurious to joints.
• Make home/work modifications, such as: eliminating scatter rugs and using railings and night lights.
• Prompt treatment of traumatic joint injuries.
• Wear well-fitting support shoes.

Rheumatoid Arthritis (RA)

• Chronic, systemic autoimmune disease characterized by inflammation of connective tissue in diarthrodial (synovial) joints.
• Periods of remission and exacerbation.
• Extraarticular manifestations.
• Disabling form of arthritis causing loss of independence and self-care.
• Mobility aids or joint reconstruction may be needed if treatment is inadequate.
• Affects all ethnic groups.
• Incidence increases with age, peaking between ages 30 and 50.
• 3 times as many women as men.

Etiology and Pathophysiology

• Autoimmune etiology, with a combination of genetics and environmental triggers.
• Antigen triggers formation of abnormal immunoglobulin G (IgG).
• Autoantibodies develop against the abnormal IgG. -Rheumatoid factor (RF) combines with IgG to form immune complexes that deposit on synovial membranes or cartilage in joints, leading to inflammation and cartilage damage.

Manifestations

• Onset typically subtle.
• Fatigue, anorexia, weight loss, generalized stiffness that becomes localized stiffness with progression.
• May report a history of a precipitating stressful event.
• Infection, stress, exertion, childbirth, surgery, or emotional upset.
• No direct correlation found in research.

Manifestations: Joints

• Symptoms occur symmetrically.
• Specific joint involvement includes pain, stiffness, limited motion, and signs of inflammation.
• Often affects small joints such as PIP, MCP, and MTP.
• Larger joints and the cervical spine may also be involved.
• Joint stiffness occurs after periods of inactivity.
• Morning stiffness lasts 60 minutes to several hours or longer.
• MCP and PIP joints typically swollen.
• Fingers take on a spindle shape.
• Joints become tender, painful, and warm to the touch.
• Pain increases with motion, and its intensity varies.
• Carpal Tunnel Syndrome symptoms.
• Subluxation: muscle atrophy and tendon destruction.
• Walking disability.
• Deformities in the hands: Ulnar drift, Swan neck, and Boutonnière's deformity.

Extraarticular Manifestations

• Affects all body systems.
• Rheumatoid nodules: Firm, nontender masses on bony areas. -No treatment needed, but can break down and become pressure injuries. -Can form in lungs; usually harmless. -Cataracts and vision loss possible.
• Sjögren's syndrome: Dry, gritty eyes and photosensitivity due to tear duct damage.
• Felty syndrome: Enlarged spleen and low WBCs, results in increased risk of infection and lymphoma.
• Flexion contractures results in decreased self-care.

Diagnostic Studies

• H&P (History and Physical).
• Criteria for diagnosis (69.6): Joint involvement, Serology, RF, Acute phase reactants, Duration of symptoms.

Stages of Rheumatoid Arthritis

Stage I

• Synovitis occurs with soft tissue swelling.
• Possible osteoporosis, but no joint destruction.

Stage II

• Increased joint inflammation.
• Gradual destruction in the joint cartilage.
• Narrowing of the joint space as cartilage is lost.

Stage III

• Formation of synovial pannus.
• Extensive cartilage loss with erosion at joint margins.
• Possible deformity.

Stage IV

• Inflammatory process subsides.
• Loss of joint function.
• Formation of subcutaneous nodules.

Diagnostic Studies: Lab tests

• CBC (Complete Blood Count).
• ESR (Erythrocyte Sedimentation Rate) for active inflammation.
• CRP (C-reactive protein) for active inflammation.
• RF (Rheumatoid Factor), positive in 80% of adults.
• Anti-CCP (Anti-cyclic citrullinated peptide) antibody specific to RA
• ANA (Antinuclear Antibody): indicates autoimmune reaction.

Other Diagnostic Studies:

• Bone scans detect early joint changes.
• X-rays show progression.
• Synovial fluid analysis shows cloudy, straw-colored fluid with fibrin flecks and MMP-3.

Drug Therapy

• Aggressive early treatment improves prognosis.
• Drugs are the cornerstone of treatment and irreversible changes can occur in the first year.
• Disease-modifying antirheumatic drugs (DMARDs). -Slow disease progression and reduces the risk of joint deformity/erosion. -Drug choice is based on disease activity, functional level, and lifestyle considerations.

Drug Therapy: DMARDS

Methotrexate

• Early treatment; Lower toxicity.
• Side effects are rare, but includes bone marrow suppression and hepatotoxicity.
• Monitor CBC and CMP.
• Therapeutic effects occur in 4-6 weeks; may be given alone or with BRMs.
• Female patients must use contraception during and for 3 months after.

Sulfasalazine

• Drink fluids to prevent crystals.
• May turn urine or skin orange-yellow color.
• Wear sunscreen.

Hydroxychloroquine

• Antimalarial drug.
• Eye exam done: baseline, then every 6-12 months.
• Report decreased hearing or tinnitus.

Drug Therapy: Biologic Response Modifiers (BRMs)

• Also called biologics or immunotherapy.
• Slows progression.
• Used for moderate to severe disease that is not responsive to DMARDs.
• Used alone or in combo with DMARDs.
• Tumor necrosis factor (TNF) inhibitors bind with TNF, inhibiting inflammation. -Etanercept (Enbrel): subcutaneous. -Infliximab (Remicade): IV infusion. -Adalimumab (Humira): subcutaneous.
• TB test and chest x-ray before starting therapy.
• Monitor for infection.
• Avoid live vaccinations.

Other Drug Therapy

• Corticosteroids. -Intraarticular injections. -Low-dose oral for limited time. -Complications: osteoporosis and avascular necrosis.
• NSAIDs and salicylates. -Treat pain and inflammation. -May take 2 -3 weeks for full effect. -Celecoxib: COX-2 inhibitor. -Non-aspirin NSAIDs increase risk of blood clots, heart attack, and stroke.

Health Promotion and Treatments

• Prevention is not possible.
• Early treatment helps prevent further joint damage.
• Community education programs. -Recognize symptoms to promote early diagnosis and treatment.
• Nondrug therapy. -Balance of rest and activity. -Heat and cold application. -Relaxation techniques. -Joint protection. -Biofeedback. -TENS -Hypnosis.

Rest & Activity

• Alternate rest periods with activity. -Helps relieve pain and fatigue.
• Amount of rest varies. -Avoid total bed rest. -8 -10 hrs of sleep plus daytime rest.
• Modify activities to avoid overexertion.
• Use a firm mattress or bed board.
• Encourage positions of extension.
• Avoid flexion positions. -No pillows under knees.
• Small, flat pillow under head and shoulders.

Joint Protection

• Energy conservation.
• Work simplification techniques.
• Pacing and organizing.
• Use of carts.
• Joint protective devices.
• Delegation.
• Assistive devices.

Cold and Heat Therapy and Exercise

• Cold is especially beneficial during periods of disease activity and to decrease joint pain, especially before activities.
• Moist heat. -Heating pads, moist hot packs, paraffin baths, warm baths, or warm showers. -Be alert for burn potential.
• Individualized exercise plan to: -Improve flexibility, strength, and endurance.
• Need both recreational and therapeutic exercise. -Avoid overly aggressive exercise.
• Gentle ROM exercises done daily to keep joints functional.
• Aquatic exercises in warm water.
• Limit to 1-2 reps during acute inflammation.

Psychologic Support

Patient challenges:

• Limited function and fatigue.
• Loss of self-esteem.
• Altered body image.
• Fear of disability or deformity.
• Unproven or even dangerous remedies.
• Recognize fears and concerns.
• Self-help groups are helpful for some patients.
• Strategies to decrease depression.

Gout

• Type of arthritis characterized by hyperuricemia and the deposition of uric acid crystals in one or more joints.
• Sodium urate crystals may be in articular, periarticular, and subcutaneous tissues.
• Painful flares last for days to weeks, followed by long asymptomatic periods.

Incidence of Gout

• The incidence of gout in the US is >8 million.
• More common in Blacks than whites.
• 3 times more common in men than women.
• Women rarely have gout before menopause.
• Uric acid is the end-product of purine metabolism and is excreted by the kidneys. -Gout occurs if kidneys cannot excrete enough uric acid or if too much uric acid is being made.
• Caused by interaction of factors: Metabolic syndrome, increased intake of high purine foods, prolonged fasting, and alcohol.
• Two processes must occur (not everyone with high uric acid levels have gout): -Crystallization, Inflammation & tissue damage

Clinical Manifestations

• One or more joints involved (usually <4). -Most common is the great toe. -Wrists, knees, ankles, midfoot, olecranon bursae may be affected. -Dusky or cyanotic appearance. -Very tender; Sensitive to light touch.
• Triggers: trauma, surgery, alcohol, or systemic infection.
• Sudden onset of symptoms at night involves sudden swelling and severe pain and low-grade fever.
• Duration of 2 to 10 days with or without treatment.
• Tophi are visible deposits of crystals in subcut tissues, synovial membranes, tendons, and soft tissues and occur years after onset.
• Severity of gout is variable -May involve infrequent, mild attacks or multiple severe episodes (up to 12 per year) with slow, progressive disability. -High serum uric acid causes increased episodes and tophi. -Chronic inflammation leads to joint deformity, cartilage destruction, and OA. -Large crystal deposits may pierce the skin, draining sinuses and causing infection.
• Complications. -Excessive uric acid excretion leads to kidney or urinary tract stones. -Pyelonephritis contributes to kidney disease.

Gout: Diagnostic Studies

• Serum uric acid > 6 mg/dL.
• 24-hour urine for uric acid.
• Synovial fluid aspiration.
• Clinical symptoms.
• X-ray of the affected joint.

Goals:

• End acute attack.
• Control hyperuricemia and gout with patient education and adherence.

Drug therapy

• Oral colchicine: anti-inflammatory.
• Pain relief in 12 hours: aids in diagnosis.
• NSAIDs: analgesia.
• Corticosteroids: oral or intraarticular.
• ACTH.

Gout: Drug therapy

• Prevention -Xanthine oxidase inhibitor: decreases uric acid production; for example, allopurinol (Zyloprim or Aloprim) -Probenecid uricosuric: ↑ urinary excretion of uric acid; avoid aspirin -Can cause renal impairment; take with food and water; recommend 2 L/day
• Alternates: -Pegloticase (Krystexxa). -Metabolizes uric acid to harmless chemical. -Losartan (Cozaar): for older adults with gout and HTN.

Treatments: Gout

• Monitor serum uric acid regularly.
• Dietary restrictions. -Limit alcohol and food high in purine. -Red meats, Organ meats, Shellfish, Fructose containing drinks
• Adequate urine volume.
• Weight reduction.
• Nursing interventions. -Supportive care of inflamed joint. -Assess motion limitations and pain.

Lyme Disease

• Borrelia burgdorferi infection transmitted by deer tick bite.
• No person-person transmission.
• Summer is the time of peak transmission.
• Occurs in northeast (Virginia to northern Maine), midwest (Wisconsin and Minnesota) regions of the US.
• Reinfection is common.

Lyme Disease Manifestation

• Characteristic erythema migrans (EM). -Bull's eye rash occurs in 80%. Appears within 1 month of exposure. May occur elsewhere on the body with disease progression. Central red macule or papule expanding to outer red ring up to 12 inches. Warm to touch; not itchy or painful.
• Occurs with acute flu-like symptoms. -Low-grade fever, headache, neck stiffness, fatigue, loss of appetite, migratory joint, and muscle pain. -Resolve over weeks to months, even without treatment.
• Without treatment, can spread within weeks or months to heart, joints, and CNS. -Arthritis: second most common symptom -Cardiac: palpitations, irregular heart-beat (Lyme carditis) may require hospitalization -Neurologic: Bell's palsy -Other: brain and spinal cord inflammation, dizziness, SOB, numbness and tingling in feet.

Lyme Disease Diagnosis

• Based on manifestations and history of exposure.
• CDC recommends 2-step testing. -Enzyme immunoassay (EIA). -Western blot test. -Both positive confirms Lyme disease.
• CNS symptoms: CSF examination.

Lyme Disease Treatment

• Oral antibiotics. -Doxycycline, cefuroxime, and amoxicillin: early treatment and prevention of progression. Preferred: 10 to 14 days of doxycycline
• Some need extended antibiotic treatment. -Risks of untreated Lyme outweigh those of long-term antibiotic therapy.
• Prevention reduce exposure

Septic Arthritis

• Infectious or bacterial arthritis when microorganisms invade joint cavity. -Hematogenous spread, trauma or surgical incision. -Most common: Staphylococcus aureus.

Risk factors:

• Diseases with decreased host resistance.
• Corticosteroid or immunosuppressant therapy.
• Debilitating chronic illness.
• Joint trauma, artificial joint.
• Skin conditions.
• IV drug use.

Septic Arthritis Symptoms and Diagnosis

• Most affected joints: knee and hip. Symptoms: severe pain, redness, and swelling; fever, shaking chills. -Hip: avascular necrosis.
• Diagnosis by -Arthrocentesis (joint aspiration). -Synovial fluid culture. -WBC count. -Blood cultures.

Septic Arthritis Treatment

Treatment involves:

• Aspiration or surgical drainage-emergent to avoid irreversible joint damage.
• Broad-spectrum antibiotics until culture identification.
• IV transitioned to oral antibiotics; 2 to 6 weeks.
• Assess and monitor joint inflammation.
• Pain management.
• Gentle ROM.
• Patient education about treatment.