Arthritis

By: Charmaine Baniqued

Anatomy & Physiology

Synovial Joints Ball and Socket Condylar

DEFINITION
Arthritis is a form of joint disorder that involves inflammation of one or more joints. There are over 100 different forms of arthritis.

EPIDEMIOLOGY
Predominantly a disease of the elderly

more common in women than men

1 in 5 adults in the US

Incidence of Arthritis

50% of adults 65 years or older

By 2030, an estimated 67 M Americans will be diagnosed An

estimated 1 in every 250 children in the U.S

Incidence of Arthritis

Extrapolated 11M/86M

This is the case of a 40 year old client who had no significant medical history except for sore throat, fever and coma 10 years prior to admission. Apparently spinal fluid analysis and culture done then were nonremarkable and she was treated with a combination of antibiotics and steroids.

Although her overall status markedly improved, she complained of severe pain and swelling in the left knee prior to discharge. Arthrocentesis reportedly showed inflammation but no crystals nor infection.

Her knee pain was treated transiently with a course of oral prednisone. She subsequently developed pain in her shoulders, elbows, hips, and ankles as well.

COMPARISON OF THE TWO OF THE MOST COMMON TYPES OF ARTHRITIS

Rheumatoid Arthritis Definition Pathology Chronic, systemic inflammatory disorder Progressive process marked by exacerbations and remissions Inflammation of synovial membrane with cartilage damage and bone destruction Ligament, tendon, and joint capsule damage Small joints (proximal interphalengeal, metacarpophalengeal), wrists, knees Symmetric Osteoarthritis Degenerative joint disease or the cartilage degradation of joint Progressive process of central cartilage (spurs) destruction Peripheral bone growth in joint

Affected joints

Weight-bearing joints (hips, knees, ankles), spine, distal interphalengeal and proximal interphalengeal joints Assymetric

Clinical Manifestations

Body Size

Pain, swelling, tenderness, redness and warmth Nodules over extensor surfaces Anemia, fatigue, and muscle aches Morning joint stiffness Pain at rest, especially at night Elevated ESR, often (+) rheumatoid factor Swans neck appearance or boutonnire deformity Usually average to below average weight for size

Localized pain and stiffness, mild swelling possible Plain with activity, improves with rest Heberdens and Bouchards nodules

Possibly overweight 4th-5th decade of life

Age at Onset Young to middle age

Gender

3:1 female-to-male ratio

2:1 female-to-male ratio

Heredity Diagnostic Tests

X-ray Evidence

Familial tendency Rheumatoid factor (80% positive); x-rays; joint fluid analysis; antinuclear antibodies (25-30% positive) Erosions, osteoporosis

Genetic factors contribute X-rays, to rule out RF, synovial fluid analysis, ESR, MRI

Osteophytes, subchondral cysts

Back to the case>>>

Nine years prior to admission, because of continued joint pain, she was evaluated by a rheumatologist who noted synovitis in both knees, elevated sedimentation rate, negative rheumatoid factor and negative ANA, and diagnosed seronegative rheumatoid arthritis.

She was treated with azathioprine 100 mg, prednisone 10 mg qid and folic acid. Eight years PTA, azathioprine was discontinued for unclear reasons. She complained of bilateral hip pain and was found to have bilateral pathological fractures and ischemic necrosis for which she underwent bilateral hip arthroplasties with excellent resolution of her pain.

6 years PTA, methotrexate was began.

Because of persistent knee pain and degenerative joint disease, she underwent left total knee arthroplasty. However, her knee pain never improved after surgery, and the knee remained warm, swollen and tender.

 Understanding the case>>>

**underwent bilateral hip arthroplasties with excellent resolution of her pain

CAUSES
Proposed Mechanisms

SIGNS AND SYMPTOMS

 RA criteria: (if 4 or more out of the s/s are present for at least 6 weeks);

Continued

At the time of her presentation 4 years PTA, she denied ever having pain or swelling in the wrists, small joints of her hands or feet.
She complained of chronic bilateral shoulder and left knee pain and limited range of motion of all three joints.

She denied morning stiffness, subcutaneous nodules or sicca symptoms,

Explanation..

Remission of the disease or these really are not manifested by the client

Shows the progress of the disease in later stages

Remember! Rf factor negative!

However, systemically she felt well and attributed her sense of well being to the institution of methotrexate in 6 years PTA.
She had been on steroids since diagnosis of her disease and admitted to regulating the dose herself for several years, taking as much as 90 mg per day when she feels poorly, sometimes staying at this high dose for several months.

She denied Raynauds phenomenon, history of pleurisy or pericarditis, psoriasis, back pain, uveitis or conjunctivitis, dysentery.

Responded well to methotrexate and steroids as treatment for RA

90mg per day is way too high from the recommended low dose steroids of 7.5 mg per day and for quicker improvement: 25mg is instituted especially at the morning. Long term use of steroids may lead to osteoporosis aside from the bone loss as the direct result of the disease

These disease entities were assessed for other autoimmune system disease involvement

Past Medical Unremarkable History

The patient is a housewife. She is married with a nineyear-old child. She reported smoking two packs of cigarettes per day for many years, and having two alcoholic drinks each day.

Social History

Family History:

Negative for rheumatoid arthritis, lupus or other connective tissue disease

Past Medical Unremarkable History

May had been predisposed the client in the development of RA and osteoporosis
This is established for noting any autoimmune disease that runs in the family heredity

Social History

Family History:

 BP 102/64; pulse 92 regular, wt.: 136 lbs, afebrile. General PE was Physical entirely unremarkable. Examination Her skin examination was also normal no SQ nodules. Client was thin.

Noting for nonspecific symptoms brought about by inflammatory process Physical Assessed also for Examination appropriate weight because obesity is a predisposing factor for degenerative arthritis.

Joint examination

Right shoulder limited abduction and external rotation with pain in all planes of motion Elbows, wrists and small joints of the hands entirely normal. Hips status post total joint replacements, with good range of motion bilaterally. Left knee was warm, swollen and tender to palpation. Marked varus deformity of the left knee Right knee was without swelling or warmth

Joint examination

Exacerbation of RA pain Possibly because of poor bone quality, there is an increase periprosthetic problems TKA failure Marked varus deformity after TKA indicates instability.

L A B V A L U E S

Ref. 150,000450,000 per ul

Ref. 38-44% Ref. 50-70 %

Ref. 430010,800 cmm

Pathophysiology

Medical Management
NSAIDS
DMARDS/ BRM

Intermittent steroids

1. Reduced pain and inflammation

introduced within 2 yrs. post dx

Pain during activity, STOP

2. Joint protection and work simplification

Aim good body positioning

Strengthening

Therapeutic exercise

ROM

3. Maintain function

Do NOT exercise if flare-up exists

Severely inflamed joints: splint Heat and cold therapy

Pharmacologic

DMARDs

Immunosuppressants TNFalpha inhibitors

Steroids

NSAIDs

Meds

Other drugs

Alternative Medicines

Nursing Management
Goal: Promote a healthy, positive life course adaptation

Comfort

Self care
DOMAINS

Control

and Coping

Surgical Management

GOALS
Relieve pain Improve function Correct deformities

DNA CHIP TO PREDICT COURSE OF RA IN INDIVIDUALS

A new DNA microarray chip a technique that can be used to screen thousands of genes in a single test

Can help doctors predict whether a patient with RA is more likely to experience severe disability or remission The chip called the ARTchip

"Prognostic markers, identified through microarray chip, can be used to predict disease outcomes in RA patients which may help healthcare professionals to choose the best treatment for each patient depending on their level of disease activity-Alejandro Balsa, MD

JOINT REPLACEMENT (ARTHROPLASTY)

Total Knee Arthroplasty

Once the definitive components have been selected, they are cemented into place with polymethyl methacrylate cement.
If an uncemented system is being used, press-fit and bony ingrowth provides the short-term and long-term fixation of the component.

Post op
Emphasis on knee exercise Goal of rehabilitation: To obtain maximal ROM with good muscle control

Can be accomplished by: consistent physical therapy or continuous passive motion (CPM) machine. The machine moves the knee slowly through its arc of motion settings determined by physician

Machine is placed in slightly abducted position on the bed

Initiated at 0 degrees of extension and 10-40 degrees of flexion Should be gradually and regularly increased to achieve the goal of 90 degrees of flexion in acute care setting Depends on the surgeon: CPM can begin immediately after surgery or delay until the evening or morning post-op

The CPM machine should be used a minimum of 6-8 h per day Client in supine during the use of the CPM machine with HOB elevated at no more than 15 degrees Should be removed from the machine for meals

When client no longer using the CPM machine, knee immobilizer is ordered to promote knee extension No pillows under the clients knee promotes flexion contracture For functional recovery: ROM and strengthening exercises are important

Ankle pumps decrease the risk for blood clots in the lower extremities Physical therapist lead the client to active ROM and gentle stretching to increase knee flexion or extension
Isometric exercises to strengthen the qudriceps, hamstrings and gluteal muscles Straight-leg raises

Home exercise program: ROM exercises plus isometrics with weekly increases in resistance as tolerated without joint irritation Client is usually allowed to transfer from bed to chair within 24 hours When client has regained sufficient strength to move operated leg without assistance, crutch walking can begin until quadriceps function is sufficient to be able to ambulate independently

If TKA has failed:

Signs and Symptoms

Causes of Implant Failure

Surgical Options

TOTAL KNEE REVISION

Rotating Hinge Knee

Utilized for the treatment of global instability or severe bone loss around the knee Intended to more closely replicate normal knee motion

Rotating knee replacements will have less stresses on the implant

less stress on the implant, the plastic part of the knee replacement may last longer

Clinical Indications
Significant bone loss

Connective tissue disorders

Gross ligamentous deficiencies

Trauma

Salvage knee arthroplasty

VARUS-VALGUS Ligament reconstruction IMPLANTS alone cannot provide enough stability for the treatment of CONSTRAINTS
chronic lateral instability May provide short to intermediate stability of the knee
Should the reconstruction fail, a salvage procedure with rotating-hinge knee devices is still available.

NURSING
CARE

PLANS

Nursing Priorities 1. Alleviate pain. 2. Prevent complications. 3. Promote optimal mobility. 4. Provide information about diagnosis, prognosis, and treatment needs.

Discharge Goals 1. Mobility increased. 2. Complications prevented or minimized. 3. Pain relieved or controlled. 4. Diagnosis, prognosis, and therapeutic regimen understood. 5. Plan in place to meet needs after discharge.

NURSING DIAGNOSIS: Acute Pain r/t surgical procedure secondary to preexisting chronic joint disease

NURSING DIAGNOSIS: Risk for infection related to inadequate primary defensesbroken skin; invasive procedures; surgical manipulation; implantation of foreign body and immunosuppressionlong-term corticosteroid use

NURSING DIAGNOSIS: Impaired physical mobility related to pain and discomfort in surgical site; restrictive therapies

END

JoUrNaL
Long term alcohol intake and risk of rheumatoid arthritis in women: a population based cohort study
(Published 10 July 2012)

TiTle

Objective

To analyze the association between alcohol intake and incidence of rheumatoid arthritis in women

Prospective Design cohort study

 34 141 women born between 1914 and 1948, followed up from Participants 1 January 2003 to 31 December 2009 Age: 54-89y/o

Main outcome measures

Newly diagnosed cases of rheumatoid arthritis identified Data on alcohol consumption were collected in 1987 and 1997

Methods

1 standard glass=15 g ROH 500ml beer 150ml wine 50ml liquor

Methods

Categories Never Former Occasional (<2 ROH drink/wk) Regular (>2 ROH drink/wk.)

Results

During the follow-up period 197 incident cases of rheumatoid arthritis were identified.

Results

Statistically significant 37% decrease in risk of rheumatoid arthritis among women who are regular drinkers

Results

Among the women who developed RA, 105 (53%) were occasional drinkers (2 drinks a week), while 65 (33%) were regular drinkers (>2 drinks a week).

Results

the risk of RA was 9% larger for never drinkers and 19% smaller for regular drinkers compared with occasional drinkers

Moderate consumption of Conclusion alcohol is associated with reduced risk of rheumatoid arthritis.

Biologic Mechanism

Alcohol has been shown to down regulate immune response and to decrease the production of selected proinflammatory cytokines

 Ethanol, delays the onset and stops the Biologic progression of RA by Mechanism interacting with innate immune responsiveness

END