Osteoarthritis (OA)

Arthritis & Connective Tissue Diseases

Osteoarthritis (OA)

• Slowly progressive, localized, noninflammatory disorder of synovial joints, particularly weight-bearing ones.
• More common in women, specifically hand and knee OA occur after menopause.
• Most adults begin experiencing effects by age 40.
• X-ray evidence of OA is present in over 50% of adults aged 65+.
• Risk factors include increased age, decreased estrogen at menopause, obesity, ACL injury, and frequent kneeling/stooping.
• Regular moderate exercise can decrease the risk of Osteoarthritis.

Etiology and Pathophysiology

• Destruction of articular cartilage narrows joint space.
• Cartilage becomes softer, less elastic and less able to resist wear with heavy use.
• Articular surfaces become cracked and worn.
• Spurs or osteophytes may form.
• Inflammation and thickening of the joint capsule and synovium causes pain and stiffness in early stages.
• Central cartilage thins, while edges thicken.
• Osteophytes form, leading to uneven weight distribution.
• Bones rub together in later stages, which increases pain.

Manifestations: Joints

• Joint pain, the primary symptom, ranges from mild discomfort to significant disability.
• Pain worsens with joint use; rest relieves pain in early stages, but later pain occurs even at rest, which causes trouble sleeping due to increased joint pain.
• Pain may worsen with lower barometric pressure, such as during fall and spring season changes 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 unchanged position.
• Early morning stiffness usually resolves within 30 minutes.
• Overactivity can lead to mild joint effusion and temporary increases in stiffness.
• Crepitation, or a grating sensation, may occur.
• OA often affects joints asymmetrically.
• Joints most affected by OA include hips, knees, metatarsophalangeal (MTP) joints, cervical vertebrae, lumbar vertebrae, distal interphalangeal (DIP) joints, proximal interphalangeal (PIP) joints, and metacarpophalangeal (MCP) joints.
• Heberden's nodes will occur within the DIP joint.
• Bouchard's nodes will occur within the PIP joint.
• There may be red, swollen, and tender areas.
• Possible varus deformity (bowlegged) will affect the medial knee.
• Possible valgus deformity (knock-kneed) will affect the lateral knee
• One leg may appear shorter than the other due to the hip.
• Fatigue, fever, and organ involvement are not present.

Osteoarthritis: Diagnostic Studies & Treatment

• X-rays confirm and stage the disease.
• Bone scans, CT scans, and MRIs can show early bone changes but are costly.
• No specific lab tests or biomarkers exist; rheumatoid factor is negative.
• Synovial fluid analysis can be conducted.
• There is no cure for OA; treatment goals focus on managing pain and inflammation, preventing disability and maintaining/improving joint function.
• Nondrug interventions are the foundation for OA management.
• Drug therapy supplements nondrug treatment.
• Balance rest and activity.
• Rest is important during acute inflammation.
• Functional positioning with splints or braces can be helpful.
• Limit immobility to less than 1 week to avoid increased stiffness.
• Modify activities to decrease joint stress.
• Avoid prolonged standing, kneeling, or squatting.
• Use a cane, walker, or crutches as needed.
• Heat helps reduce pain and stiffness
  • Should not be used for more than 20 minutes at a time.
• Ice is typically used for inflammation or swelling. -Should be used for 10-15 minutes at a time.
  • Can be applied using frozen vegetables, cold packs, and covered ice bags.
• Hot packs, whirlpool baths, ultrasound, and paraffin wax baths can be used.
• If overweight, weight-reduction is critical.
• Dietary changes may be needed.
• Exercise is important; including aerobic, range of motion, muscle strengthening, and water therapy exercises.
• Complementary and alternative therapies may be used.
  • Examples include acupuncture, massage, Tai Chi, and nutritional supplements. -Glucosamine and chondroitin is not recommended.

Interprofessional Care & Health Promotion strategies

• Treat mild to moderate joint pain by using acetaminophen and topical agents like capsaicin cream, OTC creams (containing camphor, eucalyptus oil, and menthol), and topical salicylates.
• For moderate to severe joint pain NSAIDs may be started at a low dose and increased if needed.
• Ibuprofen 200 mg is effective up to 4 times per day.
• Misoprostol may be taken to decrease GI side effects.
• Arthrotec (combination of misoprostol and diclofenac) can be used.
• Diclofenac gel should avoid concurrent oral and topical NSAIDs.
• COX-2 inhibitors like celecoxib (Celebrex) can be used.
• Intraarticular corticosteroid injections can be given; more than 4 injections without relief suggests the need for additional intervention.
• Arthroscopic surgery may be required for patients with loss of function, unmanaged pain, and decreased independence, especially for knee OA and may provide not an additional benefit.
• Hip and knee replacements are the last resort.
• Modify risk factors
• Avoid cigarette smoking
• Practice good posture and body mechanics.
• Seek help with tasks that may be injurious to joints
• Warm-up to prevent injury before exercise
• Home/work modifications through eliminating scatter rugs; use railings, night lights.
• Wear well-fitting support shoes.

Rheumatoid Arthritis (RA)

• Chronic, systemic autoimmune disease characterized by inflammation of connective tissue in diarthrodial (synovial) joints.
• RA is marked by periods of remission and exacerbation.
• Extraarticular manifestations are possible.
• Disabling form of arthritis causing loss of independence and self-care; treatment can include mobility aids or joint reconstruction.
• Affects all ethnic groups.
• Incidence increases with age, peaking between ages 30 and 50.
• Occurs three times as often in women as in men.
• Etiology is autoimmune and involves a combination of genetics and environmental triggers.
• Antigen triggers formation of abnormal immunoglobulin G (IgG).
• Autoantibodies develop against the abnormal IgG.
• Rheumatoid factor combines with IgG to form immune complexes, which deposit on synovial membranes or cartilage in joints, leading to inflammation and cartilage damage.
• Onset is typically subtle.
• Can cause fatigue, anorexia, weight loss, and generalized stiffness which progresses to localized stiffness.
• Can follow a history of a precipitating stressful event, like infection, stress, exertion, childbirth, surgery, or emotional upset.
• No direct correlation has been found in research.
• Specific joint involvement manifests as localized pain, stiffness, limited motion, and inflammation; symptoms occur symmetrically and often affect small joints (PIP, MCP, and MTP).
• Larger joints and the cervical spine may be involved.
• Morning stiffness lasts 60 minutes to several hours or longer.
• MCP and PIP joints are typically swollen.
• Fingers may become spindle-shaped.
• Joints are tender, painful, and warm to the touch.
• Pain increases with motion, and intensity varies.
• Carpal Tunnel Syndrome symptoms can manifest.
• Subluxation, muscle atrophy, and tendon destruction can occur.
• Walking disability may occur.
• Deformities in the hands include ulnar drift, swan neck, and boutonnière's deformity.
• Extraarticular manifestations affect all body systems.
• Rheumatoid nodules include firm, nontender masses on bony areas.
• These nodules do not need treatment but can break down and become pressure injuries.
• Nodules may form in the lungs and are usually harmless.
• Cataracts and vision loss, as well as dry, gritty eyes and photosensitivity due to tear duct damage (Sjögren's syndrome) can result.
• Felty syndrome, which is when an enlarged spleen and low WBCs increases the risk of infection and lymphoma.
• Flexion contractures affects self-care. The joint involvement includes joint involvement, serology and acute phase reactants and duration of symptoms

Rheumatoid Arthritis: Stages & Diagnosis

• Stage I is synovitis and X-ray shows soft tissue swelling, possible osteoporosis, no joint destruction.
• Stage II is increased joint inflammation, gradual destruction in joint cartilage, and narrowing joint space from loss of cartilage.
• Stage III is formation of synovial pannus and extensive cartilage loss erosion at joint margins, possible deformity.
• Stage IV is when inflammatory process subsides, loss of joint function, and formation of subcutaneous nodules.
• Diagnostic lab tests for RA include:
  • CBC
  • ESR to determine active inflammation
  • CRP to confirm active inflammation
  • positive RF is found in 80% of adults
  • Anti-CCP as antibody specific to RA
  • ANA as autoimmune reaction
• Bone scans can expose early joint changes.
• X-rays can illustrate progression.
• Synovial fluid analysis reveals cloudy, straw-colored fluid with fibrin flecks and MMP-3.

Rheumatoid Arthritis: Drug Therapies & Health Promotion

• Aggressive early treatment improves prognosis.
• Drugs are the cornerstone of treatment because irreversible changes can occur within the first year.
• Disease-modifying antirheumatic drugs (DMARDs) slow disease progression and reduce the risk of joint deformity and erosion.
• Drug chosen based on disease activity, functional level, and lifestyle considerations.
• Methotrexate is an early treatment, which has lower toxicity.
  • Side effects are bone marrow suppression and hepatotoxicity, but these are rare.
  • Monitor CBC and CMP.
  • Therapeutic effects in 4-6 weeks; may be given alone or with BRMs.
  • Female patients must use contraception.
• Sulfasalazine can be used; need to drink fluids to prevent crystals, may turn urine or skin orange-yellow color, and needs sunscreen.
• Hydroxychloroquine need eye exam: baseline, then q6-12 months and report decreased hearing or tinnitus.
• Also called biologics or immunotherapy, biologic response modifiers (BRMs) slow progression.
• Use with moderate-severe disease not responsive to DMARDs or used alone or in combo with DMARDs.
• Tumor necrosis factor (TNF) inhibitors bind to TNF, inhibiting inflammation. Examples of TNF inhibitors:
  • Etanercept (Enbrel): subcutaneous
  • Infliximab (Remicade): IV infusion
  • Adalimumab (Humira): subcutaneous
• All patients need a TB test and chest x-ray before starting therapy and need to monitor for infection.
• Avoid live vaccinations.
• Corticosteroids can be used as intraarticular injections or low-dose oral agents for limited time, but can cause osteoporosis and avascular necrosis.
• NSAIDs and salicylates are used to treat pain and inflammation but may take 2 to 3 weeks for full effect.
• Celecoxib is a COX-2 inhibitor.
• Non-aspirin NSAIDs increase the risk of blood clots, heart attack, and stroke.
• The goals and treatments are aimed for pain relief.
• Prevention is not possible.
• Can provide early treatment to prevent further joint damage.
• Community education programs and early symptom recognition can promote early diagnosis and treatment.
• Balance rest and activity; need hear and cold application, relaxation techniques and joint protection.
• Includes biofeedback, TENS and Hypnosis.
• Alternate rest periods with activity to relieve pain and fatigue.
• Need an amount of rest that vary.
• Avoid total bed rest.
• 8-10 hrs of sleep plud daytime rest and modify activities to avoid overexertion.
• Use firm mattress or bed board and encourage positions of extension, avoid flexion positions.
• Avoid pillows under knees and use a small, flat pillow under head and shoulders.
• Use energy conservation and work simplification techniques and pace and organizing.
• Use of carts, joint protective devices delegation.
• Need both recreational and therapeutic exercise by individualized exercise plan to improve flexibility, strength, and endurance.
• Avoid overly aggressive exercise and gentle ROM exercises done daily to keep joints functional and aquatic exercises in warm water
• Limit to 1-2 reps during acute inflammation.
• Patient challenges from Psychologic Support include limited function and fatigue, loss of self-esteem, altered body image and even unproven or dangerous remedies.

Gout

• Type of arthritis characterized by hyperuricemia and deposition of uric acid crystals in one or more joints.
• Painful flares for days to weeks, then long asymptomatic periods.
• Sodium urate crystals may be in articular, periarticular, and subcutaneous tissues.
• Incidence is US is greater than 8 million men.
• Blacks are more affected than whites.
• Affects Men 3 times more than women.
• Women rarely have gout before menopause.
• Uric acid is the end-product of purine metabolism and is excreted by kidneys; problems arise if the kidneys can't excrete enough or if too much is being made.
• Caused by the interaction of metabolic syndrome with high purine, Prolonged fasting, Alcohol
• Two processes must occur: crystallization and inflammation that lead to tissue damage.
• Most common is the great too especially if one or more of the joints (usually <4) is affected.
• Also effects Wrists, knees, ankles, midfoot, and olecranon bursae.
• Possible trigger include alcohol, or systemic infection.
• Also effects triggers such as trauma, surgery alcohol, or systemic infection.
• The joint will become Dusky or cyanotic
• Joints will be Very tender and sensitive to light touch,
• Will experience Symptom onset at night .
• Includes Sudden swelling and severe and can also come with Low-grade fever.
• Duration of these Symptoms will last. for 2 to 10 days with or without treatment.
• Tophi are visible deposits of crystals that appear in subcut tissues, synovial membranes, tendons, and soft tissues that occur years after onset.
• This may involve infrequent, mild attacks or multiple severe episodes (up to 12 per year) with slow, progressive disability.
• Chronic inflammation caused causes issues such as leading to joint deformity, cartilage destruction, & OA or Large crystal deposits piercing skin, draining sinuses and causing infection

Gout: Diagnosis and Treatment

• Diagnostic Studies include:
  • Serum uric acid > 6 mg/dL
  • 24-hour urine for uric acid
  • Synovial fluid aspiration
• Clinical symptoms; X-ray of affected joint Treatment Includes.
• Drug therapy is aimed for acute attacks.
• Also use Oral colchicine that acts as a anti-inflammatory.
• Pain relief will become apparent usually in 12 hours: which ids in diagnosis.
• Use NSAIDs as analgesia and Corticosteroids either oral or intraarticular also used is ACTH.
• Prevention for Drug therapy Includes
  • Xanthine oxidase inhibitor: decreases uric acid production; for example, allopurinol (Zyloprim or Aloprim).
  • Probenecid uricosuric: that promotes ↑ urinary excretion of uric acid while avoiding aspirin.
• Be careful about Renal Impairment patients need to be sure to take it with food and water and recommend 2 L/day with it;
• Also use Losartan (Cozaar) for older adult with gout and HTN, especially Alternates: Pegloticase (Krystexxa).
• Treatments include metabolizing uric acid to harmless chemical.
• Dietary restriction for these patient is important such as to Limit alcohol and food high in purine such as Red meat, organ meats, shellfish and fructose containing drinks.
• Patients also need adequate urine volume to flush out the uric acid and Weight Reduction plans for those patients.
• Provide routine nursing intervention that include Supportive care of inflamed joint and assess Motion limitations and pain.

Lyme Disease

• Borrelia burgdorferi infection transmitted by deer tick bite.
• It does not transmit from person to person.
• Summer is time of peak transmission.
• Areas in US such as Northeast specifically Virginia to northern Maine.
• Also occurs in the Midwest: Wisconsin and Minnesota
• Reinfection is common.

Lyme Disease: Manifestation & Diagnosis

• In eighty percent of case. will feature Bull's eye rash .
• The Rash. will appears within 1 month after being expose.
• May also occur elsewhere on body with disease and also features a Central red macule or papule expanding to outer red ring up to 12in.
• Will fee Warm to touch; or will be itchy and paintful.
• Occurs will Acute flu-like symptoms which leads to Low-grade fever, headache, neck stiffness, fatigue, loss of appetite, migratory joint, and muscle pain;
• These will Resolve over weeks to months, or without treatment.
• Without treatment can spread within weeks or months to heart, joints.
• It can also caused several thing such as a cause and include ;
• Arthritis
• Cardiac
• Neurologic.
• Other.
• Lyme Disease Diagnosis are Based on manifestations and history of exposure.
• CDC recommends 2 step testing. 1 - Enzyme immunoassay (EIA) 2- Western blot test
  • Both positive confirms Lyme disease -CNS symptoms: CSF examination
• Lyme Disease Treatments includes Oral antibiotics
• Use Doxycycline, cefuroxime, and amoxicillin; early treatment and prevention of progression .
• Preferred to use 10 to 14 days doxycycline.
• Risk of untreated Lyme is more weigh than long term antibiotic.
• Prevention is important so try to reduce exposure

Septic Arthritis

• Infectious or bacterial arthritis involving the invasiveness if microorganisms into joint cavity through trauma.
• Hematogenous spread from an Most common: Staphylococcus aureus .
• Risk factors includes
• Diseases with decreased host resistance
• Corticosteroid therapy .
• Debilitating chronic illness
• Joint trauma, artificial joint
• Skin Conditions
• Also found in
• IV drug use
• The Most affected joints: knee and hip
• Symptoms: severe pain, redness, and swelling Fever, shaking chills Hip: avascular necrosis
• Diagnosis is based on Arthrocentesis , Synovial fluid culture which is key.
• WBC count is also a factor .
• Also helpful is Blood cultures helps with Antibiotics choices
• Also help to ASPIRATE diagnosis
• Treat positive joints to take to OR, open joint, and place splint in its functions position to help with joints
• If positive (gram stain, cloudy synovial fluid or frank pus),take to OR, open joint, and place drain(can leave the knee open in some cases).
• Since shoulder and hip may be difficult to aspirate opening the joined is required
• Splint in position of function and then begin active ROM by day 10.
• Provide an early Aspiration of surgical drainage to prevent joint damage .
• Provide Broad-spectrum antibiotics until culture identification such as IV is transitioned to oral; and 2 to 6weeks