OA, RA, Gout

What is osteoarthritis?

Slow and progressive non-inflammatory disorder of diarthrodial joints - it is not a part of the normal aging process

What is the pathophysiology of OA?

Gradual loss of articular cartilage. The central cartilage becomes thinner, the edges become thicker, and osteophytes form, resulting in uneven weight distribution. In later stages, the bones rub together, leading to increasing pain.

What are the RF for OA?

• Age

• menopause

• obesity

• ACL injury

• frequent kneeling/stooping

What are the s/s of OA?

• Primary s/s ranges from mild discomfort to significant disability

• Joint and pain stiffness

• Sitting becomes difficult (and getting up from chair when hips are lower than knees)

• Intervertebral joints affected - local pain and stiffness

• Crepitation

• Affects joints asymmetrically

• Deformity
  

How does pain change in OA?

• Early stages - relieved with rest

• Later stages - occurs with rest

• may worsen with lower barometric pressure

• pain may be referred to groin/buttock/outside of thigh/knee

• main worsen with joint use

how does joint stiffness change in OA?

• occurs after periods of rest/unchanged position

• early morning stiffness usually resolved w/in 30mins

• overactivity may increase stiffness

What deformities may occur with OA?

• Heberden’s nodes - bony growths on DIP joints (closest to knuckle)

• Bouchard’s nodes - bony growths on PIP joints (closest to finger tip)

• Bowlegged (varus deformity)

• Knock-kneed (lateral knee)

• One leg shorter than the other

What is the tx for OA? Rest and joint protection

• Rest and joint protection

• Balance rest/activity

  • Rest during acute inflammation (limiting immobility to <1wk)

  • Modify activities to decrease joint stress

• Avoid prolonged standing/kneeling/squatting

• Assistive devices PRN

what is the tx for OA? Heat and cold

• Heat and cold

  • Ice for acute inflammation

  • heat therapy for stiffness

    • hot pacs, whirlpool baths, US, paraffin wax

What is the tx for OA? Nutrition/therapy/exercise

• Weight loss (only if overweight)

• Dietary changes

  • Supplements w/anti-inflammatory effects

    • Fish oil

    • Ginger

    • SAM-E

• Exercise

  • Aerobic

  • ROM

  • Muscle strengthening

What is the drug therapy for OA? mild-moderate joint pain

• For mild-moderate joint pain

  • Acetaminophen

  • Topical agents, OTC creams containing camphor, eucalyptus oil, menthol

  • Topical salicylates

  • Capsaicin creams

What is the drug therapy for moderate-sever joint pain in OA?

• Moderate-severe pain

  • NSAIDs (start low-dose, increase as needed)

  • Ibuprofen 200mg (up to 4x/day)

  • Misoprostol to decrease GI effects

  • Arthrotect (misoprostol + diclofenac)

    • Avoid topical + PO NSAIDs together

  • COX-2 inhibitors - Celebrex

What are the other drugs used for OA?

• Intra-articular corticosteroid injections

  • Not recommended anymore - has long term effects

• Hyaluronic acid injections - for knees

  • No longer recommended

• DMOADs

What is the surgical tx for OA?

• Arthroscopic surgery

  • For pts w/loss of function/unmanaged pain/decreased independence

• Hip and knee replacement

What other tx can be used for OA?

• Acupuncture

• Massage

• Tai-chi

What is the pt teaching for OA?

• Pain management (different meds for mild-moderate and moderate-severe)

• Body mechanics + correct use of assistive devices

  • Canes, walkers

  • Elevated toilet seats

  • Grab bars

• tx options

• If knee OA - avoid standing, kneeling, or squatting for long periods of time

• Environment modification

  • Eliminate scatter rugs

  • Use railings and night-lights

  • Wear well-fitted supporting shoes

what is rheumatoid arthritis?

Chronic, systemic autoimmune disease where inflammation of connective tissue in synovial joints occurs.

what is the pathophysiology of RA?

• Rheumatoid factor combines w/IgG to form immune complexes which deposit on synovial membranes or cartilage in joints, leading to activation of complement and inflammatory response

• Neutrophils become attracted to site of inflammation and release proteolytic enzymes that dmg cartilage and thicken synovial lining

• T-helper cells are activated, and they stimulate monocytes, macrophages, and synovial fibroblasts to secrete proinflammatory cytokines. (interleukin-1,6 and TNF)

What are the joint manifestations of RA?

• Localized stiffness with progression, limited motion

  • increases with inactivity

  • Morning stiffness last 60mins or hours

• Pain that may increase with motion

• Signs of inflammation

• s/s occur symmetrically

• Subluxation - muscle atrophy and tendon destruction

• Tenosynovitis affecting wrists may lead to CTS s/s

• Inflammation and fibrosis may cause deformity and disability

  • Issues with walking

  • Deformities of hands

What s/s of inflammation may be present in the joints w/RA?

• MCP and PIP joints swollen

• Spindle shaped fingers

• Joints tender, painful, and warm to touch

What are the extra-articular clinical manifestations in RA?

• Rheumatoid nodules

  • Firm and nontender masses found on bony areas exposed to pressure

• Cataracts, vision loss

• Atherosclerosis - risk of MI increases

• Nodular myositis

• Pleurisy, pleural effusion

• Pericarditis, pericardial effusion, cardiomyopathy

• Sjorgen’s syndrome, Felty Syndrome

• Flexion fractures and deformities - cause decrease grasp strength and affect ability to perform self care

• Depression

  • Due to pain and disability

  • May have increased CRP levels

What is Sjorgen’s syndrome?

Dry gritty eyes, photosensitivity

What is Felty syndrome?

• enlarged spleen and low wbc

  • increased risk for infection and lymphoma

What is the RA deformity ulnar drift?

Fingers of hand bend/shift towards pinky

What is swan neck in RA?

a deformity where the PIP joint is hyperextended and the DIP joint is flexed

What is boutonniere’s deformity?

deformity where the PIP joint is permanently bending downward while the DIP joint id hyperextended

What criteria must be met for diagnosis of RA?

• Joint involvement - at least 1 joint w/clinical synovitis

• Serology

• Acute phase reactants

• Duration of s/s

What labs are used to diagnose RA?

• CBC

• ESR, CRP - indicate activate inflammation

• RF (positive in 80% of people)

• Anti-CCP - antibody specific to RA

• ANA(antinuclear antibodies) - indicates autoimmune reaction

What scans/tests are used to diagnose RA?

• Bone scans - identify early joint changes

• X-ray to check for progression

• Synovial fluid analysis - cloudy, straw-colored fluid w/fibrin freckles and MMP-3

What are the main drug classes for treating RA?

• Disease-modifying anti-rheumatic drugs (DMARDs)

  • Slow progression and decrease risk of joint deformity and erosion

• Biologic response modifiers (BRMs/Biologics/Immunotherapy)

  • Slow progression

• Corticosteroid therapy (IAI or low-dose oral for limited time)

• NSAIDs and salicylates

• Celebrex (COX-2 inhibitor)

  • Other drugs: Immunosuppressants, pencillamine, gold preparations

What are the complications of RA?

• Ulnar drift, Swan neck, Boutonniere

• Hallux valgus

• Pericarditis

• Accelerated CAD risk

What is the patient teaching for RA? balancing rest and activity

• Alternate rest periods with activity (may help with pain and fatigue)

• Amount of rest varies

  • No total bed rest

  • 8-10hrs of sleep + daytime rest ideal

• Work simplification

• Pacing and organizing

• Use of carts

• Delegation of tasks

what is the pt teaching for RA regarding heat/cold application?

• May relieve pain, stiffness, and muscle spasm

• Cold is especially beneficial during periods of disease activity

  • Should not exceed 10-15mins at a time

• Moist heat relieves chronic stiffness

  • Should not exceed 20mins at a time

  • Use heating pads, moist hot packs, paraffin baths, warm baths, or showers

    • No topical heat producing cream

What is the pt teaching for RA regarding exercise?

• To improve flexibility, and strength

• Increase overall endurance

• Avoid overly aggressive exercise

  • Gentle ROM daily

  • Aquatic exercises in warm water beneficial

  • Limit to 1-2 reps during acute inflammation

what is the pt teaching for RA regarding joint protecting?

• Firm mattress/bed board

• Positions of extension when resting, avoid flexion positions

• No pillows under knees, but a small and flat pillow under head and shoulders

• Modify tasks for less stress on joints

• Joint protective devices

What other pt teaching for RA should someone get?

• home management

• s/s of infection

• use of relaxation techniques

• biofeedback and tens are effect non-drug therapy ideas

What is gout?

Type of arthritis characterized by hyperuricemia and deposition of uric acid crystals in one or more joints. It has remissions and exacurbations.

What is the patho of gout?

Kidneys cannot excrete enough uric acid or too much is being produced, leading to a build up of it. Two process must occur for gout to develop - crystallization and inflammation.

What are the diagnostic studies/labs + results for gout?

• Serum uric acid - >6

• 24-hr urine for uric acid

• Synovial fluid aspiration - the gold standard, shows needle shaped crystals

• Clinical symptoms

• X-ray of affected joints - tophi may appear as eroded areas in the bone

what are the causes of gout?

• Primary hyperuricemia is genetic

• Secondary hyperuricemia is due to increased production/decreased excretion/drugs that inhibit uric acid excretion

• Caused by interaction of factors: metabolic syndrome, increased intake of high purine foods, prolonged fasting, excessive alc

What are the s/s of Gout? joint manifestations

• Affects one or more joints (usually <4)

• Most commonly affected joint is great toe

• Skin becomes dusky or cyanotic

• The area becomes very tender

What are the s/s of gout at onset?

• Sudden swelling and severe pain

• Sensitive to light touch

• Low-grade fever

• Lasts 2-10 days w or w/o treatment

• Redness

What are the s/s of chronic gout?

• Multiple joint involvement

• Tophi develop (deposits of crystals in subq tissue, synovial membranes, tendons, and soft tissues)

• Typically develop years after onset

what are other s/s of gout?

• Severity of gout is variable

  • Can involve frequent, mild attacks or multiple severe attacks

  • Slow progressive disability

• High serum uric acid causes increase in episodes/tophi

• Chronic inflammation leads to deformity, cartilage destruction, secondary OA

• Large crystals may pierce skin, draining sinuses and causing infection

What is the drug therapy for acute gout attacks?

• PO colchicine for acute attacks

  • Anti-inflammatory

• NSAIDs - aspirin should be avoided as it can increase uric acid levels

  • Ibuprofen is better option

• Corticosteroids - PO or IA for prevention

• Adrenocorticotropic hormone - in pts where NSAIDs, colchicine, or steroids are problematic

What is the drug therapy for chronic gout?

• Xanthine oxidase inhibitors (Allopurinol, febuxostat)

  • Decreases uric acid production (Includes allopurinol, febuxostat)

• Uricosuric (Probenecid, Zurampic, Duzallo (combo of probenecid/zurampic)

  • Increase urinary excretion of uric acid

    • PT:

      • AVOID ASA, Take with food and water (2L/day)

How is gout managed outside of drugs?

• Monitor serum uric acid regularly

• Dietary restrictions

  • Limit alc and food high in purine

  • Limit Organ meats, sardines, aspirin

  • Increase fluid intake

  • DASH diet

• Weight reduction

• Teach about factors that may increase risk of acute attack

  • Fasting, drug use (diuretics), and major medical events