Osteoarthritis (OA): Causes and Risk Factors

Osteoarthritis (OA)

• A slowly progressive, localized, noninflammatory disorder affecting synovial joints, particularly weight-bearing ones
• Women are more likely to be affected
• Hand and knee OA are especially common after menopause
• Most adults start experiencing its effects around age 40
• Over 50% of individuals over 65 show X-ray evidence of OA in at least one joint

OA Risk Factors

• Increasing age is a primary risk factor
• Decreased estrogen levels at menopause elevates risk
• Obesity contributes to the development of OA
• ACL injury can predispose to OA
• Frequent kneeling and stooping increase the risk
• Regular moderate exercise helps reduce risk

Etiology and Pathophysiology

• Destruction of articular cartilage leads to narrowed joint spaces
• Cartilage loses elasticity and becomes softer
• Affected cartilage is less able to withstand wear from heavy use
• Articular surfaces become cracked and worn over time
• Spurs or osteophytes form on the bone
• Inflammation and thickening of the joint capsule and synovium cause early-stage pain and stiffness
• Central cartilage becomes thinner while edges thicken
• Osteophytes form, resulting in uneven weight distribution
• Bones rubbing together increase pain in later stages

Manifestations of OA: Joints

• Joint pain is the primary symptom, ranging from mild discomfort to significant disability
• Pain intensifies with joint use
• Early stages: rest can relieve pain
• Later stages: pain persists even at rest, causing trouble sleeping
• Pain may worsen with lower barometric pressure, such as during fall and spring season changes or before precipitation
• Pain contributes to disability and loss of function
• Pain may be referred to the groin, buttock, or outside of the thigh or knee
• Sitting down and getting up from a chair becomes difficult after periods of rest or being in the same position
• Early morning stiffness usually resolves within 30 minutes
• Overactivity can lead to mild joint effusion and temporary increases in stiffness
• Crepitation, a grating sensation, may be experienced
• OA typically affects joints asymmetrically

Joints Most Affected by OA

• Hips
• Knees
• Metatarsophalangeal (MTP) joints
• Cervical vertebrae
• Lumbar vertebrae
• Distal interphalangeal (DIP) joints
• Proximal interphalangeal (PIP) joints
• Metacarpophalangeal (MCP) joints

Other Manifestations

• Specific to the joint involved
• Heberden's nodes appear on DIP joints
• Bouchard's nodes appear on PIP joints
• Bouchard's and Heberden's nodes may appear red, swollen, and tender
• Varus deformity (bowlegged) affects the medial knee
• Valgus deformity (knock-kneed) affects the lateral knee
• One leg may become shorter than the other, affecting the hip
• Fatigue, fever, and organ involvement are not present

Osteoarthritis: Diagnostic Studies

• X-rays are used for confirmation and staging
• Bone scans, CT scans, and MRIs can show early bone changes but are costly and less frequently used
• There are no specific lab tests or biomarkers; rheumatoid factor is negative
• Synovial fluid analysis may be performed

Osteoarthritis: Treatment Goals

• There is no cure; care focuses on managing pain and inflammation
• Care focuses on preventing disability
• Care focuses on maintaining and improving joint function
• Nondrug interventions are the primary basis of OA management
• Drug therapy supplements nondrug treatments

Rest and Joint Protection

• Balance rest and activity
• Rest during acute inflammation
  • Functional positioning with splints or braces
  • Prevent stiffness by limiting immobility to less than one week
• Modify activities to reduce joint stress
• Avoid prolonged standing, kneeling, or squatting
• Use a cane, walker, or crutches as needed

Heat and Cold Applications

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

Nutritional Therapy and Exercise

• Weight reduction is critical for overweight individuals
• Dietary changes should be made as needed
• Recommended exercises include
  • Aerobic exercise
  • Range of motion exercises
  • Muscle strengthening
  • Water therapy

Health Promotion

• Health promotion includes
  • Altering modifiable risk factors
  • Avoiding cigarette smoking
  • Practicing good posture and body mechanics
  • Seeking help with tasks that may be injurious to joints
  • Warming up to prevent injury before exercise
  • Altering home/work environment by eliminating falling hazards like rugs, and improving safety with railings and night lights
  • Avoiding forceful repetitive motions
  • Seeking prompt treatment of traumatic injuries
  • Wearing well-fitting support shoes

Rheumatoid Arthritis (RA)

• RA is a chronic, systemic autoimmune disease
• RA is characterized by inflammation of connective tissue in diarthrodial (synovial) joints
• RA is marked by periods of remission and exacerbation
• RA can have extraarticular manifestations
• RA is a disabling form of arthritis leading to loss of independence and self-care
• All ethnic groups are affected
• Incidence increases with age, peaking between ages 30 and 50
• Women are three times more likely to be affected than men

Etiology and Pathophysiology

• It has an autoimmune etiology
  • Combination of genetics and environmental triggers lead to the development of RA
  • Antigen triggers formation of abnormal immunoglobulin G (IgG)
  • Autoantibodies develop against the abnormal IgG
    • This includes rheumatoid factor (RF)
  • RF combines with IgG to form immune complexes that deposit on synovial membranes or cartilage in joints
    • This leads to inflammation and cartilage damage

Manifestations

• The onset is typically subtle
• Fatigue, anorexia, weight loss, and generalized stiffness that becomes localized is seen with progression
• A history of a precipitating stressful event may be reported
  • Like infection, stress, exertion, childbirth, surgery, or emotional upset
• There is no direct correlation found in research

Manifestations: Joints

• Specific joint involvement
  • The symptoms occur symmetrically
  • Small joints of PIP, MCP, and MTP are often affected
  • Larger joints and cervical spine may be involved
• Joint stiffness after periods of inactivity
• Morning stiffness lasting 60 minutes to several hours or longer
• MCP and PIP joints typically swollen
• Fingers spindle shaped
• Joints are tender, painful, and warm to touch
• Pain increases with motion, and 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 are firm, nontender masses on bony areas
  • No treatment is needed, but they can break down and become pressure injuries
  • Can form in lungs, usually harmless
• Cataracts and vision loss
• Sjögren's syndrome causes dry, gritty eyes and photosensitivity due to tear duct damage
• Felty syndrome
  • Enlarged spleen and low WBCs result in increased risk of infection and lymphoma
• Flexion contractures affect self-care

Diagnostic Studies

• Joint involvement (0-5)
• Serology (0-3)
• Duration of synovitis (0-1)
• Accute phase reactants (0-1)

Stages of Rheumatoid Arthritis

• Stage I:
  • Synovitis, soft tissue swelling occur
  • Possible osteoporosis, no joint destruction
• Stage II:
  • Increased joint inflammation
  • Gradual destruction in joint cartilage
  • Narrowing joint space from loss of cartilage Stage III:
  • Formation of synovial pannus
  • Extensive cartilage loss, erosion at joint margins, possible deformity Stage IV:
  • Inflammatory process subsides
  • Loss of joint function
  • Formation of subcutaneous nodules
• Laboratory tests:
  • CBC
  • ESR: active inflammation (erythrocyte sedimentation rate)
  • CRP: active inflammation (C-reactive protein)
  • RF (positive in 80% of adults)
  • Anti-CCP: antibody specific to RA (anti-cyclic citrullinated peptide)
  • ANA: autoimmune reaction

Drug Therapy

• Aggressive early treatment improves prognosis
• Drugs are the cornerstone of treatment; irreversible changes can occur in the first year
• Disease-modifying antirheumatic drugs (DMARDs)
  • Slow disease progression and decreases risk of joint deformity and erosion
  • Drug is chosen based on disease activity, functional level, and lifestyle considerations
  • Methotrexate
    • This is considered early treatment and has lower toxicity
    • Watch for side effects such as bone marrow suppression and hepatotoxicity
    • Monitor CBC and CMP
    • Therapeutic effects in 4-6 weeks; may be given alone or with Biological Response Modifiers (BRMs)
    • Female patients must use contraception during and for 3 months after
  • Sulfasalazine
    • Drink fluids to prevent crystal formation
    • May turn urine or skin orange-yellow color
    • Wear sunscreen
  • Hydroxychloroquine (antimalarial drug)
    • Eye exam: baseline, then every 6-12 months
    • Report decreased hearing or tinnitus
  • It is called biologicals or immunotherapy
  • It slows progression of the disease.
    • Moderate-severe disease which 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 start of 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 increases risk of blood clots, heart attack, and stroke

Health Promotion & Treatments

• Prevention is not possible
• Early treatment helps prevent further joint damage
• Community education programs
  • Promotes symptom recognition 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
  • About 8 -10 hours 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
  • 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 include the following:
    • Improve flexibility, strength, and endurance
  • Need both recreational and therapeutic exercise
    • Avoid overly aggressive exercise
  • Gentle ROM exercises should be done daily to keep joints functional
  • Aquatic exercises in warm water
    • Limit to 1-2 reps during acute inflammation

Psychologic Support

• Patient challenges:
  • Has limited function and fatigue
  • Loss of self-esteem
  • Altered body image
  • Fear of disability or deformity
  • Patients can take unproven or even dangerous remedies
  • Recognize fears and concerns
  • Self-help groups can be helpful for some patients
  • Use strategies to decrease depression

Gout

• Gout is an arthritis type
• Gout is characterized by hyperuricemia
  • Deposition of uric acid crystals in one or more joints
• Sodium urate crystals may be in articular, periarticular, and subcutaneous tissues
• Experiencing painful flares for days to weeks, then long asymptomatic periods
• Incidence:
  • in US >8 million
  • More common in Blacks > whites
  • More common in Men 3 times more than women
• Women rarely have gout before menopause
• Uric acid is the end-product of purine metabolism, excreted by kidneys
  • Gout occurs if kidneys can’t excrete enough or if too much is being made
• Caused by interaction of factors
  • Metabolic syndrome, increased intake of high purine foods, prolonged fasting, alcohol
• Two processes must occur for tophi to form
  • Crystallization that leads to Inflammation & tissue damage

Clinical Manifestations of Gout

• It is one or more joints (usually 4)
  • Most common is the great toe
  • Wrists, knees, ankles, midfoot, olecranon bursae
• Is dusky or cyanotic
• It can be very tender; Sensitive to light touch
• Triggers: trauma, surgery, alcohol, or systemic infection
• Symptom onset at night
  • Sudden swelling and severe pain
  • Low-grade fever
• Duration of 2 to 10 days with or without treatment

Chronic Gout Manifestations

• Clinical Manifestations
  • Multiple joint involvement
  • Tophi are visible deposits of crystals
    • Under the skin, synovial membranes, tendons, and soft tissues that occur years after onset
• Severity of gout is variable - It may involve infrequent, mild attacks or multiple severe episodes (up to 12 per year) with slow, progressive disability
  • High serum uric acid causes an increase in episodes and tophi
    • Chronic inflammation leads to joint deformity, cartilage destruction, & OA
      • Large crystal deposits may pierce skin, draining sinuses, and causing infection

Complications

• Excessive uric acid excretion leads to kidney or urinary tract stones
• Pyelonephritis contributes to kidney disease

Diagnostic Studies & Drug Therapy

• Diagnostic Studies
  • Serum uric acid exceeds 6 mg/dL
  • 24-hour urine for uric acid
  • Synovial fluid aspiration if needed
  • Clinical symptoms X-ray of affected joint
• Goals:
  • End acute attack
  • Control hyperuricemia and gout with patient education and adherence
• Drug therapy
  • Oral colchicine: anti-iflammatory
• Relieve pain in 12 hours when aiding in diagnosis - NSAIDs: analgesia - Corticosteroids: oral or intraarticular - ACTH
• More about drug therapy
  • Xanthine oxidase inhibitor: decreases uric acid
    • for example, allopurinol
  • Probenecid—uricosuric: increases urinary excretion of uric
    • avoid aspirin
  • Can cause renal impairment; take with food and
    • recommend 2 L/day

Alternate gout drugs

• Pegloticase (Krystexxa)
  • Metabolizes uric acid to harmless chemical
• Losartan (Cozaar): use in older adult who has gout and HTN

Treatments

• Monitor serum uric acid regularly
• Dietary restrictions
  • Limit alcohol and food high in purine
    • Like red meats
    • Organ meats
    • Shellfish
    • Fructose containing drinks
• Adequate urine volume
• Weight reduction
• Nursing interventions
• Provide 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 time of peak transmission
• Three areas in US
• Northern East Coast from Virginia to Maine
  • Midwest: Wisconsin and Minnesota
• Reinfection 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 body with disease progression
• Central red macule or papule expanding to outer red ring up to 12 in
• 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 may require hospitalization
  • Neurologic: Bell’s palsy
  • Other: brain and spinal cord inflammation, dizziness, SOB, numbness and tingling in feet

Diagnose Lyme Disease

• Based on manifestations and history of exposure
• Is recommended that you do a 2-step testing procedure
  • Enzyme immunoassay
  • (EIA)
  • Western blot test
    • Both positive confirms Lyme disease
• CNS symptoms: CSF examination
• May need to do a lumbar puncture to collect cerebral spinal fluid

Lyme Disease Treatment

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

Prevention

• The most important one is to reduce exposure to the bacteria that causes it.

Septic Arthritis

• Infectious or bacterial arthritis
• Microorganism invades joint cavity
  • Hematogenous spread, trauma
  • Most common: Staphylococcus aureus
• Risk factors:
  • Diseases that reduce host resistance
  • Corticosteroid or immunosuppressant therapy
  • Debilitating chronic illness
  • Joint trauma, including having an artificial joint
  • Skin conditions
  • IV drug use

Symptoms and Diagnosis of Septic Arthritis

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

Treat Septic Arthritis

• Treatment includes the following
• Aspiration or surgical
• drainage, very important to avoid irreversible joint damage
• Broad-spectrum antibiotics are needed here until culture identification IV transitioned to oral over a 2 to 6-week period Assess and monitor joint inflammation
• Manage the pain
• Use Gentle ROM
• Teach the patient the importance of treatment