OSTEOARTHRITIS

DEFINITION OF OSTEOARTHRITIS

• Osteoarthritis (also known as OA) is a common joint disease that most often affects middle-age to elderly people. Osteoarthritis is a disease of the entire joint, involving the cartilage, joint lining, ligaments, and bone.
• It is caused by wearing out of joints characterized by breakdown of the cartilage (the tissue that cushions the ends of the bones between joints), bony changes of the joints, deterioration of tendons and ligaments, and various degrees of inflammation of the joint lining (called the synovium).

ETIOLOGY OF OSTEOARTHRITIS

• Causes of Primary Osteoarthritis:
  • Idiopathic- cause unknown
  • Ageing factor- the cartilage destruction occurs between ages 20-30 but the symptoms are experienced after age 50
  • Gender- Below Age 50 the incidence of OA is higher in men than women and after age 50 the incidence of OA is more in women than men
• Causes of Secondary Osteoarthritis:
  • Trauma: Fracture & Dislocation may lead to avascular necrosis or uneven stress on cartilage causing joint Inflammation
  • Mechanical: Repetitive Physical Stress like Sports activities can cause cartilage deterioration
  • Inflammatory: Release of enzymes in response to local inflammation can affect cartilage Integrity
  • Physical: Damage to the supporting structures causes joint Instability placing uneven stress on articular cartilage
  • Neurologic: Neurologic Disorders like pain, loss of Reflexes due to Diabetic Neuropathy cause abnormal movements that contribute to cartilage deterioration
  • Skeletal Deformities: Congenital or acquired conditions such as Legg-calve-perthes disease, hip dislocation contribute to cartilage deterioration
  • Hematologic: Chronic hemarthrosis like in hemophilia can contribute to cartilage deterioration
  • Drug Induced: Drugs like Indomethacin, colchicine & corticosteroids can stimulate collagen digesting enzyme in the joint synovium leading to joint Inflammation.

PATHOPHYSIOLOGY OF OSTEOARTHRITIS

Any of the pre-disposing etiological factors can lead to cartilage damage

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triggers a metabolic response at the level of the chondrocytes

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Change in the normal, smooth, white translucent articular cartilage into dull, yellow & granular cartilage

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This affected cartilage gradually becomes softer

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Decreased Elasticity & ability to resist wear with heavy use or strain to the joints

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Further destruction causes failure of the body’s attempt to repair the cartilage

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fissuring & erosion of the articular surface

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As the cartilage becomes thinner, the bony growth (Osteophytes) occur that increase the joint margins causing incongruity of the joint surface

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Development of uneven distribution of stress across the joint surface contributes

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 reduction of motion & Joint pain.

CLINICAL MANIFESTATION OF OSTEOARTHRITIS

• Joint Manifestations:
  • Joint Pain worsening with repeated use
  • Referred pain to groin, buttocks, medial side of thigh & knee
  • Reduced activity due to pain
  • Loss of function or disability
  • Difficulty sitting down & Raising up
  • Joint Stiffness
  • Mild joint Effusion during over activity of joints
  • Crepitation (grating sensation due to loose particles of cartilage in joint cavity)
  • Deformity or instability of the affected joints
  • Heberden’s Nodes: Red, swollen & tender nodes occurs in the Distal Interphalangeal joints due to osteophyte formation & loss of Joint Space
  • Bouchard’s Nodes: Red, swollen & tender nodes in the Proximal Interphalangeal Joint
  • Joint Disfigurement (Bow legged Appearance)
  • Altered gait
  • Leg looks shorter in the affected side than the other leg due to loss of Joint Space
• Systemic Manifestations: 
  • Fever
  • Fatigue
  • weakness
  • Generalized Body ache

DIAGNOSTIC STUDIES OF OSTEOARTHRITIS

• History & Physical Examination: 
  • History to identify the primary or secondary cause of Osteoarthritis
  • Physical Examination reveals Joint Pain, Stiffness, Reduced Motion & Deformity.
• Imaging Studies: 
  • X-rays of the Joint to Identify the progression of Joint damage
  • CT Scan & MRI to detect the Joint Changes like fissuring & Erosion.
• Laboratory Studies: 
  • Routine Complete Blood Count to identify Infection
  • Renal Function tests like urea, creatinine & Electrolytes to evaluate renal Function
  • Liver Function Studies like Bilirubin, SGOT, SGPT, GGTP, ALP, ALT, AST, LDH to monitor the Liver function.
• Arthrocentesis with Synovial Fluid Analysis
  • Protein is Increased
  • Glucose is decreased in the synovial fluid

COLLABORATIVE MANAGEMENT

• Rest & Joint Protection: 
  • The affected joint must be rested during acute Inflammation and maintained in a functional position with splints & Braces
  • Immobility & rest should not be continued more than a week to prevent Joint Stiffness
  • Modify the usual activities to the affected Joint like avoid Prolonged periods of standing, kneeling or Squatting when the Knee is affected
  • Use Assistive Devices like walkers, Canes or crutches to decrease stress on Arthritic Joints
• Hot & Cold Applications: 
  • Heat therapy like hot packs, whirlpool baths, ultrasound, paraffin wax bath are helpful to reduce Joint Stiffness
  • Cold Applications like Ice packs can be used to treat Joint Pain
• Exercise: 
  • Weight loss and exercise are useful in Osteoarthritis. Excess weight puts stress to knee joints, hips and low back.
  • For every pound of weight reduced the chance of developing knee osteoarthritis is reduced up to 50 percent.
  • Exercise can improve muscle strength, decrease joint pain and stiffness, and lower the chance of disability due to Osteoarthritis
• Complementary & Alternate Therapies: 
  • Acupuncture is found to be a safe & Effective method for Arthritis Pain Management
  • Yoga, Massage, Guided Imagery & Therapeutic Touch can provide support to the client
  • Oral Nutritional Supplements like Glucosamine & Chondroitin Sulfate is found to relieve Joint pain & improves Joint Mobility
  • Splints are prescribed to rest & Stabilize the painful Joints

PHARMACOLOGICAL THERAPY IN OSTEOARTHRITIS

• Anti-pyretics & Analgesics: 
  • Acetaminophen should not exceed 4gm/day-To treat mild to moderate Joint Pain
  • Topical Agent Capsaicin (Zostrix) cream- Blocks pain locally by inhibiting the transmission of pain Impulses
• NSAIDs: 
  • Ibuprofen, Misoprostol (Cytotec) & Arthrotec (Combination of Misoprostol & Diclofenac)
  • To reduce Joint pain, Inflammation & Stiffness
• Antibiotics: 
  • Doxycycline (Vibriamycin) to treat Infection and to reduce the loss of cartilage
• Intra-Articular Injections: 
  • Intra-articular corticosteroid Injection is administered for elderly patients to treat local Joint Inflammation & effusion
  • Intra-articular viscous supplementation of Hyaluronic acid (Orthovisc, Synvisc,, Supartz, Nuflexxa & Hyalagan) are administered in 3 weekly Injections directly into the knee Joint to contribute to the viscosity & Elasticity of Synovial Fluid.

NUTRITIONAL THERAPY IN OSTEOARTHRITIS

FOODS TO EAT:

• Eat High Fiber Diet: 
  • Starchy foods, such as sweet potatoes, potatoes, beans, lentils, and whole-grain bread
  • Plenty of Fruits & Vegetables
• Non-vegetarian Diet: 
  • Include Fish in Diet
  • Eat less meat
• Choosing Oils: 
  • choosing products made from vegetable and plant oils, such as olive oil
• Flours: 
  • select whole meal options over those containing refined flour

FOODS TO AVOID

• Sugars: 
  • Processed sugars can prompt the release of cytokines, which act as inflammatory messengers in the body.
  • The sugars that manufacturers add to sweetened beverages, including soda, sweet tea, flavored coffees, and some juice drinks, are the most likely to worsen inflammatory conditions
• Saturated Fats: 
  • Foods high in saturated fat, such as pizza and red meat, can cause inflammation in the fat tissue.
  • As well as contributing to the risk of developing obesity, heart disease, and other conditions, this can make arthritis inflammation worse.
• Refined Carbohydrates: 
  • Refined carbohydrates, such as white bread, white rice, and potato chips, fuel the production of advanced glycation end (AGE) oxidants. These can stimulate inflammation in the body.

PATIENT & FAMILY EDUCATION

• Loose or maintain an ideal Body weight
• Use Assistive devices like walkers, canes & crutches if Indicated
• Avoid Forceful Repetitive Movements
• Avoid Trauma to the Joints
• Avoid positions of Joint deviation & Stress
• Avoid Cigarette Smoking
• Use good Posture & Proper Body Mechanics
• Exercise Regularly. Include endurance & weight Bearing Exercises
• Seek Assistance with necessary tasks that may cause pain
• Organize & pace activities for routine tasks
• Modify & Home environment to reduce stress while performing tasks
• Use correct Assistive devices like Splints & Braces while doing activity