Trinity University of Asia

St. Lukes College of Nursing

E. Rodriguez Sr. Avenue, Cathedral Heights, Quezon City, Philippines

Osteoarthritis

A case report Submitted by: Lady Karen V. Mangahas TUA-SLCN

Definition
Osteoarthritis (OA) also known as degenerative arthritis or degenerative joint disease, is a group of mechanical abnormalities involving degradation of joints, including articular cartilage and subchondral bone. A variety of causes hereditary, developmental, metabolic, and mechanical may initiate processes leading to loss of cartilage. When bone surfaces become less well protected by cartilage, bone may be exposed and damaged.

Signs and Symptoms

The main symptom is pain, causing loss of ability and often stiffness. "Pain" is generally described as a sharp ache, or a burning sensation in the associate muscles and tendons. OA can cause a crackling noise (called "crepitus") when the affected joint is moved or touched, and patients may experience muscle spasm and contractions in the tendons. Occasionally, the joints may also be filled with fluid. Humid and cold weather increases the pain in many patients. OA commonly affects the hands, feet, spine, and the large weight bearing joints, such as the hips and knees, although in theory, any joint in the body can be affected. As OA progresses, the affected joints appear larger, are stiff and painful, and usually feel better with gentle use but worse with excessive or prolonged use, thus distinguishing it from rheumatoid arthritis. In smaller joints, such as at the fingers, hard bony enlargements, called Heberden's nodes (on the distal interphalangeal joints) and/or Bouchard's nodes (on the proximal interphalangeal joints), may form, and though they are not necessarily painful, they do limit the movement of the fingers significantly. OA at the toes leads to the formation of bunions, rendering them red or swollen. Some people notice these physical changes before they experience any pain. OA is the most common cause of joint effusion, sometimes called water on the knee in lay terms, an accumulation of excess fluid in or around the knee joint.

Pathophysiology
The main cause of Osteoarthritis is an imbalance in the natural breakdown and repair process that occurs with cartilage. In Osteoarthritis, damaged cartilage cannot repair itself in the normal way. It occurs when the cartilage that covers and cushions the ends of bones in your joints deteriorates over time. Cartilage is composed of water, collagen, and specific proteins.

In healthy cartilage, there is a continual process of natural breaking down and repair of the cartilage in joints. This process becomes disrupted in Osteoarthritis, leading to cartilage deterioration and an abnormal repair response. The reason this normal repair process is disrupted is not known but it is likely caused by several factors.

With aging, the water content of the cartilage increases, and the protein makeup of cartilage breaks down. If the cartilage wears down completely, the result will be bone to bone contact. Repetitive use of worn joints over the years can irritate the cartilage, causing joint pain and inflammation of surrounding tissues. As pieces of cartilage break off, the bones thicken and broaden, causing inflammation. This inflammation may stimulate new bone outgrowths called spurs (also called osteophytes) to form around the joints. As the bones thicken and broaden, joints become stiff, painful, and may be difficult to move. Fluid may also build up in your joints.

Diagnostic Exam and Laboratory

X-rays will show typical changes of the adjacent bone called osteosclerosis. There often are osteophytes visible and possibly bone cysts in the bone adjacent to the joint. Blood tests can be done to rule out other causes such as gout, where the uric acid level would be high, or rheumatoid arthritis, where the sedimentation rate and the rheumatoid factor would be high.

All these tests tend to be normal with osteoarthritis. However, with osteoarthritis of the finger joints there is a characteristic distribution of degenerative changes on X-rays. The hand/finger joints have three levels that can get affected. The first level are the MCP joints (=metacarpophalangeal) between the hand and the fingers (commonly called the "knuckles"). The next row of joints are called the PIP joints (=proximal interphalangeal) and the last row at the end of the fingers are called DIP joints(=distal interphalangeal). Typically with osteoarthritis degenerative changes are confined to DIP joints and PIP joints, but not the MCP joints. This distribution pattern will tell the physician along with the characteristic X-ray changes mentioned above that this person suffers from osteoarthritis. A new method of detecting OA early is done by a modified form of magnetic resonance imaging to determine the concentration of a polymer known as glycosaminogycan (GAG) that holds lots of water and gives cartilage its tough, elastic properties. GAG also is a recognized biomarker for both osteoarthritis and degenerative disc disease a common cause of back pain. According to Jerschow, a low concentration of GAG is known to correlate with the onset of osteoarthritis and other cartilage disorders.

Treatment and Medical Management

The primary goal of treatment of OA is to control pain and to maintain the normal function of the joints to improve the quality of life of the patient. In addition, it is desirable to halt the progression of the disease. Based on recent safety and efficacy studies, acetaminophen is the preferred agent for OA as recommended by the American College of Rheumatology. Acetaminophen possesses analgesic and antipyretic activity similar to aspirin; however, acetaminophen has no peripheral anti-inflammatory activity or effects on platelet function. Acetaminophen inhibits the synthesis of prostaglandins in the central nervous system and peripherally blocks pain impulse generation; it produces antipyresis from inhibition of the hypothalamic heat-regulating center. Acetaminophen is effective for the relief of both acute and chronic pain. It is important to note that doses effective for acute pain relief (325 to 650 mg/day) may not be effective in chronic pain states such as OA, since they may require higher daily doses. Oral steroids are not recommended in the treatment of OA because of their modest benefit and high rate of adverse effects. Injection of glucocorticoids (such as hydrocortisone) leads to short term pain relief that may last between a few weeks and a few months. Topical capsaicin and joint injections of hyaluronic acid have not been found to lead to significant improvement. Tanezumab, a monoclonal antibody that binds and inhibits nerve growth factor, appears to relieve joint pain enough to improve function in people with osteoarthritis of

the knee, according to research published online Sept. 29 in the New England Journal of Medicine. The FDA is reviewing the safety of tanezumab that could still emerge as an effective treatment for the pain of osteoarthritis. While electrostimulation techniques (NEST) have been used for twenty years to treat osteoarthritis in the knee, a Cochrane Review of studies determined that there is no evidence to show that it reduces pain or disability If the above management is ineffective, joint replacement surgery or resurfacing may be required in advanced cases. Arthroscopic surgical intervention for osteoarthritis of the knee however has been found to be no better than placebo at relieving symptoms.

Nursing Management
One of the most common concerns of Osteoarthritis to nurses is pain management of the client. It is also important to facilitate non-pharmacological treatment of Osteoarthritis like ROM exercises, physical therapy, weight loss, occupational therapy, nutritional counseling, joint protection, and assistive devices. Heat therapy (warm bath, compresses, shower) is especially effective to relieve stiffness and may be used 2 to 3 times a day for a half hour each time. Using heat therapy before activities can increase endurance. Cold therapy (compresses, ice packs) is often effective to relieve swelling and discomfort when a joint is inflamed. You must balance rest and activity to prevent further injury. An acutely inflamed joint should rest until the inflammation subsides. Wearing a splint or brace that keeps the joint in functional position or using assistive devices (cane, walker) can relieve joint strain. Lack of mobility and sedentary lifestyle often lead to increased weight, putting strain on the already damaged joints. A nutritional assessment helps to develop a healthy weight-maintenance or health-reduction plan. Because osteoporosis is common with osteoarthritis, the diet should contain adequate vitamin D and calcium. Don t forget to promote social support for the client and help them cope with the disease.
References
1. 2. 3. 4. 5. 6. 7. 8. www.wikipedia.org www.osteoarthritisremedy.com www.nursingtimes.net www.pharmacytimes.com www.ihaveosteoarthritis.com www.orthosupersite.com www.nethealthbook.com Moreland LW. Intra-articular hyaluronan (hyaluronic acid) and hylans for the treatment of osteoarthritis: mechanisms of action.