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
