This course is intended to provide the information necessary for a nurse to be able to provide adequate nursing care for a patient with osteoarthritis including understanding the disease, assessing the patient and helping the patient obtain optimal control over their disease.
After completing this educational activity, the participant will be able to meet the following objectives:
Osteoarthritis (OA) is the most common cause of disability in the older population. It is also known as degenerative arthritis or degenerative joint disease. Arthritis affects up to 54 million people and costs more than $140 billion annually in the United States. As the population ages, the burden of OA will increase.2 Managing arthritis improves mobility, decreases falls, decreases death rates and improves quality of life.
Osteoarthritis is defined as a joint disease with deterioration of the joint and abnormal bone formation. OA is present when the endings of the bones - called cartilage, which normally cushion the bones - no longer do their jobs. The ends of the bones rub together, and the cartilage wears away.
Two common types of arthritis are osteoarthritis and rheumatoid arthritis. Osteoarthritis is the more common type of arthritis in the individual over the age of 50. Rheumatoid arthritis - a chronic destructive, sometimes deforming disease - attacks the collagen in the body, especially in the joints. Rheumatoid arthritis is associated with widespread symptoms such as fatigue, fever, poor appetite, neuropathy, splenomegaly and adenopathy. Other diseases that affect the joints include gout, lupus, scleroderma and fibromyalgia.
Immobility, a major complication of arthritis, leads to less activity which is associated with many complications including worsening of joint stiffness, increased blood pressure, increased blood glucose and weight gain. Immobility leads to decreased physical activity - resulting in deconditioning. As deconditioning sets in, weakness and functional decline follow. This cascade that arthritis is associated with leads to a decrease in quality of life. Lack of physical activity is detrimental to the body and increases the risk of many fatal diseases such as diabetes, high cholesterol, hypertension and heart disease.
Mr. Farmer is a 62-year-old white male with a report of significant hand pain. He describes the pain as most severe in both thumbs but also in the distal joints of digits two through five of both hands. He has been having an increasingly difficult time using his screwdriver to fix things around the house, playing tennis and golf, and griping his utensils to eat.
Physical exam shows that there is enlargement of the distal interphalangeal joints (Heberden’s nodes) and the carpometacarpal (CMC) joints of both hands.
An x-ray demonstrates there is arthritis at the CMC joints of both hands and the distal interphalangeal joints of all fingers as evidence by cyst formation, sclerosis, and joint space narrowing.
The most common joint of the hand affected by OA is the distal interphalangeal joint and the second most commonly affected joint is the CMC. The proximal interphalangeal joint and the metacarpophalangeal joint are more commonly affected by rheumatoid arthritis.
The goal for the patient will be to reduce pain and help restore function. Treatment options for this patient include the use of finger or wrist splints, heat treatment, topical medications, occupational therapy to provide exercises, pain medication, steroid injections or surgery (joint fusion or joint reconstruction).
A gap in knowledge exists in the prevention and management of osteoarthritis. A recent symposium made up of 40 health care leaders identified multiple problems with the way OA is managed.
This symposium looked at the top barriers to and strategies for improving early assessment and treatment of OA. It specifically discussed the nurse’s role in reducing the disability caused by OA. Some of the barriers identified included items at the organizational level such as lack of provider time, lack of patient educational material, no reimbursement for an OA chronic disease model, and lack of financing for nursing intervention and nurse-managed care.
The symposium recognized three factors that were directly related to nursing knowledge deficit: lack of knowledge among nurse faculty and clinicians about OA best practices, lack of knowledge on how to promote disease self-management, and lack of knowledge about evidence-based practice in general.
Based on this knowledge deficit, the symposium made multiple recommendations to improve OA care. Many of these strategies revolved around improving nursing knowledge and the ability to disseminate this knowledge.
A significant gap exists among primary care providers between what is believed should be done and what is done. A recent analysis suggested that over 55 percent of general practitioners thought OA should be monitored but only 15.2 percent routinely monitored their patients and 45 percent did not monitor their patients at all.4
Another recent analysis showed that there is a significant gap between what practices nurses feel confident in, and what ideally should be performed according to the NICE OA guidelines.5 This analysis showed that properly educated nurses can lead OA clinics that significantly benefit patients with OA.
Multiple organizations have goals to reduce the burden and help in the management of OA. Selected organizations working to lessen the burden of OA include the Center for Disease Control (CDC)6, the Arthritis Foundation7, Healthy People 20202, and many state government organizations.
The goal of the CDC is to help people with arthritis live life to the fullest and help them pursue activities they value and enjoy with minimal pain.8
The main goals of the National Arthritis Action Plan: A Public Health Strategy9 are to:
Healthy People 2020 provides objectives for the nation to reach with the overall goal of improving the national state of arthritis. Goals of Healthy People 2020 include:
The national goals are set to improve the care of arthritis. The first step in reaching these goals is improving the knowledge of both health care provider and patient.
In addition to the programs on the national level, many State Health Departments are working to improve the care of arthritis through increasing public awareness of the disease and improving the care of arthritis.
OA is characterized by osteophyte formation, changes in the subchondral bone, cartilage damage, inflammation of the synovial tissue and tendon and muscle weakness. OA is not only a disorder of the articular cartilage but also of the subchondral bone. OA is characterized by subchondral bone sclerosis and damaged cartilage. Subchondral bone is hypomineralized secondary to abnormal bone remodeling. In addition, the subchondral bone may have microdamage, bone cysts and bone marrow edema-like lesions.10
Multiple factors contribute to OA.11 Age is an important risk factor for the disease with older individuals being at greater risk than younger people. Females have a higher incidence of OA than males. Obesity is a strong risk factor due to the excess stress that extra body weight puts on the weight-bearing joints. Repetitive stresses, such stresses put on the joints by runners or assembly line workers, increase the risk of arthritis. Weak muscles in the legs also contribute to OA. Trauma plays a significant role in the development of OA – as those with a history of trauma near a joint or a broken bone near a joint are at increased risk for OA. While no specific genetic marker is known in OA there is a strong family connection. Defective cartilage or poorly structured joints commonly run in families and can increase the risk of osteoarthritis.
The hallmark symptom of OA is pain. Typical OA pain is worse with movements and improves with rest. Pain at night is common, especially as the disease progresses, and is usually worse after a more active day. OA commonly affects the weight-bearing joints, such as knees and hips, but other joints commonly affected include the fingers (DIP and CMC) and neck. Stiffness after prolonged rest is common with this disease. For example, getting out of bed in the morning or getting up after watching a movie often elicits pain and stiffness.
Physical exam reveals certain characteristics that are typical of OA. Moving the joint results in a crackling/crunching noise, that sounds like the cereal Rice Krispies and is known as crepitus. Arthritic joints are sometimes not able to move through a full range of motion. For example, a person with knee OA may not be able to straighten the leg fully.
Misalignment of the joints may be present and accompanied by enlargement of the bones surrounding the joint. Effusion may be noted, but rarely is there erythema over the affected joint.
The diagnosis of OA is typically made with a history and physical exam. If in doubt an X-ray is ordered. Diagnosis is specific to the joint affected.12
Laboratory tests alone do not diagnose OA but assist in the diagnosis and help rule out any other disease processes. If there is fluid in the joint, it may be removed. This procedure can help relieve some of the pressure associated with the excess fluid. The fluid is typically examined under a microscope to help rule out any other diseases that mimic arthritis such as gout.
Mr. X is a 66-year-old carpet installer who has been retired for 10 years. He has been experiencing progressive pain in both of his knees, but the right knee is more bothersome than the left. Over the last two months, the pain has been less responsive to over the counter pain medications. He complains of his knees being stiff for approximately 30 minutes when waking in the morning and for about five minutes after getting up from a seated position during the day. Walking more than 30 minutes is difficult due to pain. Pain is increased with squatting, kneeling and going down stairs. He claims more severe symptoms on cold or very humid days. He decides to make a visit to his nurse practitioner.
The patient is 5’9” and 225 pounds with a body mass index of 33.2. He was noted to walk with a slightly antalgic gait. The clinical exam shows boney enlargement and tenderness of both knees and he cannot extend his right knee beyond 120 degrees but can fully extend the left knee. There is a slight genu varum of both knees suggesting that the medial compartments of the knees are involved. Crepitus is noted in both knees and tenderness in noted over the joint line in the knee. An x-ray shows joint space narrowing and medial osteophytes.
The nurse practitioner recommends weight loss, prescribes meloxicam and refers the patient to an orthopedic surgeon who recommended a total right knee replacement. Mr. X. only gets moderate relief with the meloxicam, but he does not want to proceed with the total knee replacement, so he asks what other options are available. The orthopedic surgeon discusses other treatment options including lifestyle changes (exercise and weight loss), joint injections (corticosteroids and Intra-articular hyaluronic acid), medications and alternative treatments.
Treatment of osteoarthritis focuses on pain control and maintaining function. Soon there may be treatments available to reverse or even cure the disease process, but at present, symptom control is the only option. Treatment focuses on medications and non-medication means to control the pain and minimize disability.
Non-pharmacological treatment is first line management as it bypasses the negative effects drugs have on the body. Non-drug treatments include exercise, nutrition, physical and occupational therapy, heat and cold treatments, ultrasound, weight loss, magnets and patient education.
Weight loss can significantly reduce the pain and disability from OA by reducing the load that excess weight puts on the joints. Weight loss is accomplished through a combination of diet and exercise. Physical therapists or exercise specialists teach how to exercise safely, while a dietitian aids with dietary interventions for weight loss.
Exercise can help OA in a variety of ways. Exercise decreases pain and improves functioning. It improves the strength of the muscles around the arthritic joint, which reduces strain on the joint resulting in pain control and improvement in function. Exercise can also aid in weight loss, a key element of reducing symptoms of OA.
Exercise needs to be tailored for those suffering from OA. Exercise that does not overly tax the arthritic joints is recommended. Exercises that limits strain placed on the joints commonly affected by OA include water exercise, such a water aerobics; bicycling, especially recumbent biking; and elliptical exercise equipment, which can be found at many gyms. Exercises that strain the joints such as running and high impact aerobics are not recommended as they can damage the joints and cause more pain.
Recent research suggested that there is no difference between land-based exercise and water-based exercise for the treatment of knee osteoarthritis.13
Different types of exercises are important in the treatment of OA. Aerobic exercise - such as biking, swimming, walking and water aerobics - is important not only for the treatment of OA but also for general health. Flexibility training or stretching exercises reduce stiffness and helps improve function. Strength training keeps the muscles strong to support the joints.
Diet and exercise are beneficial in OA. In a recent study over 18 months, there was a reduction in knee compressive forces in those who dieted and lost weight. Those who participated in both diet and exercise together (when compared to those who just dieted or just exercised) had less pain and better function.14
Good nutrition is valuable in OA. Weight loss is a critical aspect in the prevention and treatment of osteoarthritis. While there is much media buzz about certain types of food being beneficial in OA, little research backs this up. It is generally recommended to eat a diet low in saturated fats and high in fruits and vegetables. Omega-3 fatty acids, which are found in fish such as mackerel, herring, salmon and rainbow trout, are theorized to be helpful in OA.15 One meta-analysis showed that fish oil in 3 of 4 clinical trials had positive effects on at least one clinical marker of OA.16 In addition, there is likely some benefit of the Mediterranean diet on individuals with OA.17 A recent analysis does not recommend the use of vitamin A, C, E, ginger, turmeric or omega-3 fatty acids in the management of OA. More research is needed to define the role of supplements in the management of OA.18 Another meta-analysis showed that some supplement showed benefit in the short-term, (including, passion fruit peel extract, curcumin, L-carnitine, undenatured type II collagen, methylsulfonylmethane, glucosamine and chondroitin), but not as much benefit was noted in the long term.19
Physical and occupational therapists can be extremely important in the treatment of OA. They can assist in strengthening the muscles, improving flexibility and providing non-drug means of pain control such as ultrasound or heat/cold treatments. OA is a profound contributor to disability and improving the home environment promotes function and safety. Occupational therapists provide home assessments. Home assessments can help maximize the safety of the home while implemented interventions to make the home safer. Bars in the bathroom, next to the toilet and in the shower or bathtub, are examples of home interventions carried out by occupational therapists.
As OA progresses, mobility becomes increasingly impaired. Reliance on mobility aids – such as canes and walkers - becomes essential to ambulate. Physical therapists can help teach patients how to use canes, walkers and other mobility devises.
Heat and cold treatments are helpful for patients with OA. Cold treatment decreases inflammation and reduces pain. It is best to apply cold in a moldable form such as a bag of frozen peas for no more than twenty minutes at a time and watch for any complications associated with cold such as any red or white patches on the skin or if the area becomes completely numb.
Heat is another common modality in the treatment of OA. Heat will increase the blood flow to the area, aid in healing and relaxes muscles. It should be used no longer than 30 minutes per application and should not be applied directly to the skin. While neither heat nor cold will modify the course of the disease either is acceptable. Which every modality provides more comfort and pain relief should be used. Many patients find heat more soothing for their aching joints than cold. It is recommended that patients experiment to determine which intervention provides the greatest relief to their symptoms.20
Utilizing ultrasound has the potential to reduce pain in those with osteoarthritis. Research on ultrasound is mixed. Research has shown that long-duration, low intensity ultrasound improves the joint’s function and lessens pain in those with moderate to severe knee arthritis.21 Another study looked at the use of ultrasound five times a week for two weeks in addition to exercise training. The study concluded that therapeutic ultrasound offered no additional advantage in improving pain and function in addition to exercise training.22
Magnets are a popular therapy for OA because they can decrease pain. Scientific data to prove their effectiveness is lacking but magnets do not have significant side effects and are considered safe for use. Magnets are sold in a variety of places including pharmacies, grocery stores, online and on TV. Current research does not support the use of static magnets for pain relief. More research is needed before their use in OA is completely disregarded.
When non-drug methods do not provide adequate relief, medications are used to treat OA. Previous guidelines touted acetaminophen (Tylenol) as a first line agent, primarily due to its lack of negative side effects (when compared to non-steroidal anti-inflammatory medications), but more recent guidelines refute this recommendation.
Two extra strength acetaminophen tablets every eight hours is the maximum dose recommended. The maximum amount of acetaminophen is three grams a day. It can be taken on a routine basis or on an as needed basis. Prolonged use of acetaminophen in higher than recommended doses or when combined with alcohol or certain medicines such as statins (e.g., atorvastatin, simvastatin) can damage the liver.
Caution should be used in patients who take acetaminophen when they are on warfarin. The combination of acetaminophen and warfarin can increase the INR (but less than non-steroidal anti-inflammatory agents). Absolute contraindication to acetaminophen is liver failure while relative contraindications include chronic alcohol abuse or hepatic insufficiency.
The American Academy of Orthopaedic Surgeons23 does not recommend for or against the use of acetaminophen. Their position paper reports that acetaminophen has no benefit over placebo. Others recommend that acetaminophen is the least effective option when compared to NSAIDs or the combination of glucosamine and chondroitin.24 They do acknowledge that the side effect profile of acetaminophen is less toxic than non-steroidal anti-inflammatory agents (NSAIDs). NSAIDs are considered more effective than acetaminophen in providing relief from hip and knee pain in osteoarthritis.25 Like acetaminophen, they act synergistically with opioids.
NSAIDs, such as ibuprofen (Motrin, Advil), naproxen sodium (Aleve, Naprosyn), choline and magnesium salicylates (Trilisate), diclofenac sodium (Voltaren, Voltaren XR), celecoxib (Celebrex), meloxicam (Mobic), and nabumetone (Relafen), are recommended over acetaminophen.26
These medications have more side effects than acetaminophen. Side effects common to NSAIDs include hypertension, edema, gastrointestinal bleeding, dyspepsia, headaches, constipation, mental status changes and renal insufficiency/kidney failure.
Absolute contraindications to NSAIDs include chronic kidney disease, an active peptic ulcer, and heart failure. Relative contraindications include a Helicobacter pylori infection, history peptic ulcer disease, hypertension, or concomitant use of selective serotonin receptor inhibitors or corticosteroids. Common interactions with NSAIDs include aspirin, warfarin, antihypertensive medications, selective serotonin reuptake inhibitors and corticosteroids.
Risk factors for gastric ulceration include older age, current use of corticosteroids, bleeding problems, or a history of gastric ulceration. These individuals should likely not use NSAIDs. The use of a proton pump inhibitor or misoprostol reduces the risk of gastric ulceration with the use of NSAIDs.
Another option for those with risk for gastric ulceration is the use of celecoxib. Celecoxib is the only available selective inhibitor of cyclooxygenase (COX) -2. COX-2 inhibitors are less likely to lead to gastric irritation. In those at very high risk for gastrointestinal bleeding a COX-2 agent along with a proton pump inhibitor can be used. Monitoring for and eradication of Helicobacter pylori reduces the risk of NSAID induced gastrointestinal injury.
NSAIDs have the potential to cause nephrotoxicity because they inhibit prostaglandin synthesis which is associated with vasoconstriction of the afferent arteriole in the kidney and may lead to renal impairment. When compared to traditional NSAIDS, celecoxib has a lower risk of GI bleeding.27
NSAIDs are associated with cardiovascular complications. They interfere with the cardio protective effect of aspirin28, elevate blood pressure and may precipitate or aggravate heart failure. NSAIDs also may amplify the risk of clotting and need to be used cautiously in those with a history of venous thrombosis. They should also be avoided in those with thrombocytopenia.
Generally, NSAIDs are equally effective29, but if one agent is ineffective another NSAID may be effective as there is individual variation in response to different NSAIDs. One study showed that diclofenac 150 mg/day was the most effective NSAID in managing pain and improving function.30
Topical NSAIDs may be used especially if the disease is localized to one area. Topical agents are associated with a significantly less adverse event profile than systemic agents. In the United States, diclofenac sodium topical gel and diclofenac sodium topical solution are available for the management of osteoarthritis.
Other topical agents can provide significant relief for patients with OA. Capsaicin (Zostrix) decreases the neurotransmitter called substance P, which is involved in the transmission of pain. Capsaicin is applied three to four times a day. It takes Capsaicin a few weeks before it provides significant pain relief. Hands should be washed after contact with the substance.
Another topical agent sometimes used for the treatment of localized pain is the lidocaine patch. This is not approved by the Food and Drug Administration for use in OA but is often used. It is a small patch applied to the skin around the painful joint wore for no more than 12 hours a day.
Other agents used in the treatment of osteoarthritis include duloxetine and hydroxychloroquine. These agents are not approved by the Food and Drug Administration for OA. Duloxetine is sometimes tried in those who do not respond to or have contraindications to NSAIDs. Research has shown that these agents result in some improvement in function and a reduction in pain, but associated with significant side effects including fatigue, dry mouth, constipation, reduced appetite and nausea. Duloxetine has only been studied in OA in the short term (up to 13 weeks).12
Hydroxychloroquine is theorized to reduce synovitis and possibly help patients with hand arthritis. While it may be helpful in some individuals, research does not show it significantly improves symptoms in hand arthritis.12
Tramadol (e.g., Ultram®, Ultram® ER) is dosed 50-100 mg every 4-6 hours for the immediate release form and 100 mg daily for the extended release form. For individuals suffering from chronic arthritic pain, the immediate release is initiated at 25 mg in the morning and increased by 25-50 mg per day every three days. The maximum dose for the immediate release form is 400 mg per day. The extended-release form is started at 100 mg once a day and increased by 100 mg every five days with a maximum dose of 300 mg per day. Side effects include constipation, dizziness, nausea, vomiting, euphoria, headache, itching, agitation, somnolence, hallucinations, and anxiety.
Tramadol interacts with narcotic medications and many antidepressants. For those with moderate to severe renal insufficiency or severe liver insufficiency, it should be used carefully. Tramadol lowers the seizure threshold and should, therefore, be used cautiously in those with a history of seizures. Caution must be used with tramadol as it has abuse potential.
Narcotic medicines are used when pain cannot be controlled by other means. When used they should only be used on a time-limited basis in those with disabling symptoms and/or severe pain that have not responded to other treatment modalities. Prior to starting opioid therapy, it is important to determine the effect the pain is having on the patient’s life, including functional ability and psychological impact. Narcotics are more powerful pain medications but have side effects. Narcotics have the potential side effects of sedation, respiratory depression, dizziness, falls, constipation, addiction and dependence. Narcotics medications include codeine, hydrocodone, hydromorphone, oxycodone, fentanyl, and morphine.
Intra-articular steroid injections can be used for painful joints. This involves placing a needle directly into the arthritic joint and injecting a steroid along with a numbing agent. Prior to administration of the medication, aspiration of synovial fluid may occur. These can be effective treatments, but their length of effect is variable from weeks to months. Reduction in pain may occur as soon as one week after the injection. Corticosteroid injections have the potential to damage cartilage and no more than three injections per year should be given.12
Intra-articular hyaluronic acid is sometimes used to mimic the joint lubricant, which is often reduced in those with OA, that naturally occurs in the knee. It is classified as a medical device and not a drug. Products include Hyalgan, Supartz, Orthovisc, and Euflexxa, and Synvisc. The use of hyaluronic acid is of uncertain benefit.27 In addition, cost can be prohibitive and side effects include pain and rarely joint infection.
Platelet-rich plasma (PRP) is a newer treatment option for the treatment of osteoarthritis. It involves intraarticular injections. An analysis of the randomized controlled trials on PRP31 concluded that it was a relatively safe procedure and likely provides some benefit up to 12 months. Those individuals with severe disease and younger age respond better to treatment. Many questions remain including how many injections it takes to be effective, the length of time between injections and the volume needed to be injected. Evidence regarding this treatment is limited and more research is needed before it is routinely used. In addition, insurance companies typically do not pay, and this tends to be an expensive treatment.
When medical treatment fails, surgery is the next option. Surgical options include arthroscopy, osteotomy, total joint arthroplasty, or joint fusion. In OA, arthroscopy can be used to remove meniscal tears and loose bodies. Success rates are variable after surgery. After arthroscopy, the patient often needs to be non-weight bearing for a while and may need to go through physical therapy.
Osteotomy, when the surgeon removes a wedge of bone, may be used to stave off joint replacement in younger patients to reduce pain. It can be used in those with a misaligned hip or knee in conditions such as genu varus or genu valgus.
Joint replacement surgery replaces the damaged joint with an artificial one (plastic or metal). Even under the best of circumstances, surgery cannot return the joint to its normal state (artificial joints do not have all the motion of a normal joint). However, an artificial joint will very likely diminish pain and improve function. Typically, the artificial joint is viable for at least 10-15 years. The two joints most commonly replaced are the hip joint and the knee joint. Complications after surgery include infection, thrombophlebitis and pulmonary embolism.
A joint fusion is the joining together of the bones on each side of the joint. The range of motion is significantly reduced, but pain is improved. Fusions are typically not a first-line procedure for knee or hip arthritis but are sometimes used when a joint arthroplasty fails.
Osteoarthritis is a common condition, particularly in the older population. It is characterized by pain and disability. Diagnosis is typically made based on signs and symptoms, but diagnostic testing may be done when the clinician is uncertain. Multiple treatment options are available ranging from lifestyle changes to surgery.