VOL: 97, ISSUE: 32, PAGE NO: 34
Sarah Ryan, PhD, RGN, is consultant nurse in rheumatology, Haywood Hospital, North Staffordshire Hospital NHS Trust, Stoke-on-Trent
Osteoarthritis used to be described as a wear-and-tear condition, but today it is more commonly referred to as joint failure. It is not simply an inevitable consequence of ageing but the reaction of a joint, or joints, to an insult or injury.
The condition is classified as primary where there is no apparent cause and secondary where metabolic, anatomical, traumatic or inflammatory factors may be involved (Box 1).
Radiological evidence shows that 80% of the population over the age of 75 has osteoarthritis (Cooper, 1994), with peak age of onset being 50-60.
It is difficult to provide a strict classification for the condition since there is poor correlation between radiographic, pathological and clinical manifestations. As a result, it is viewed as a heterogenous disease process rather than a disease entity (Cushnaghan and McDowell, 1999).
Its exact aetiology and pathogenesis is unknown but osteoarthritis may be related to genetic factors, trauma or previous joint disease. Obesity, occupation and previous injury often determine which joints are affected and the severity of the disease.
Common sites include the knees, hips, distal interphalangeal joints, thumb base joints of the hands and facet joints of the spine. With the exception of hip joints, the condition is more prevalent in women than men (Cushnaghan and McDowell, 1999).
Osteoarthritis causes destruction of the hyaline cartilage of the bone. The growth of fibrocartilage and bone at the base margins produces overgrowths of bone - termed osteophytes - which are visible on X-rays.
Other radiological changes include loss of joint space, bony cysts and sclerosis in the subchondral bone. These alterations to the bone may cause only minor inconvenience for some patients, while others will experience chronic pain and disability (Arthur, 1998).
The clinical manifestations and the main aims of treating osteoarthritis are outlined in Boxes 2 and 3.
Coping with pain
Pain can only be defined in terms of human consciousness and, as with all sensory experience, there is no way of being certain that any two people’s perceptions of pain are the same. It is a unique, subjective and unverifiable personal experience. But pain is also a major contributor to the morbidity, disability and socio-economic cost of musculoskeletal disorders.
Pain management requires the nurse to carry out an individual assessment (Box 4). There is no blueprint for managing chronic pain and the nurse will need to negotiate a programme with the patient that matches their physical, psychological and social needs. Regular evaluation of the programme is necessary to make adjustments and to prevent the patient feeling demotivated and helpless, since improvements in symptoms will only happen over a period of time.
An osteoarthritis management programme should cover areas such as exercise and analgesia, as well as weight management. Intra-articular injections of corticosteroid can be used in some instances, if there is evidence of inflammation.
Patients who are experiencing pain due to osteoarthritis often decrease their activity levels in an attempt to protect their body from further pain. This has the reverse effect, as periods of inactivity increase joint pain and stiffness, and also cause muscle weakness and wasting.
The patient often feels trapped in a pain cycle. They are reluctant to exercise because they feel it may exacerbate the pain, but the inactivity itself will increase the pain.
Patients need to be reassured that the pain they experience when they exercise will not exacerbate their condition. The pain is a natural reaction to muscles and joints that have become stiff owing to inactivity and it will reduce once the body grows accustomed to regular exercise.
It is often at this stage that the patient requires intervention from a physiotherapist for support and guidance regarding an exercise programme and to motivate them to carry on exercising in the long term.
Any exercise programme needs to be introduced gradually and become part of a patient’s daily routine. Swimming can be a useful starting point, as the buoyancy of the water supports the joints, making movement easier.
Exercise also needs to be fun if the patient is to continue doing it. At the Staffordshire Rheumatology Centre, a support group uses the hydrotherapy pool one evening a week. Patients with osteoarthritis and other forms of arthritis not only continue their exercises on a regular basis, but also meet people socially. Pain can isolate people and exercising in a group can help to build up social contacts.
Patients often find it difficult to change well-established behaviour patterns. Fatigue is often a feature associated with pain that will affect a patient’s mood.
Planning daily tasks so that periods of activity are alternated with periods of rest will not only help to minimise pain and fatigue, but will also improve the patient’s coping abilities.
It is impossible for any patient to change all their habits in one go, so it is worth getting the patient to focus on goal-setting, with the aim of altering one activity at a time. For example, instead of mowing the lawn in one attempt, do it in two sessions.
Once the benefits of changes in one activity are felt, it is easier to extend pacing and task simplification to others.
Combating inactivity stiffness
This can be eased by frequent alteration of position and engaging in gentle stretching exercises that put the body through the full range of movements.
If a patient with osteoarthritis is being nursed in a general medical or surgical ward, it is important to encourage or help them change position regularly and engage as many parts of the body as possible in gentle movement.
Patients who are overweight will have more pain in weight-bearing joints, especially the knees and lower back. It is important to keep them as mobile as possible to help with weight reduction.
The patient’s footwear should also be assessed: using soft insoles and wearing trainers will reduce the stress on knee joints. Patients may also require advice from a dietitian. Evidence of joint destruction will require a surgical review.
Patients with osteoarthritis are often best managed on simple analgesics: for example, paracetamol is an effective though undervalued agent (Cohen, 1994).
In patients aged over 65, the risk of side-effects often outweigh the potential therapeutic effects of non-steroidal anti-inflammatory drugs, although their use may be considered if the condition initiates a flare up of inflammatory symptoms. Here, their use would be suitable in the short term only in order to avoid the possibility of gastric and renal complications.
A three-year randomised controlled trial of 1,500mg daily glucosamine sulphate in knee osteoarthritis showed a moderate (20-25%) but significant and persistent reduction in pain and instability (Reginster et al, 2001).
Group management programmes
Patients often benefit from group programmes where they can develop coping skills in a supportive environment and learn from other patients who also have the condition.
Mullen et al (1987) reviewed the data from 15 studies on the effects of patient education. They found that education programmes resulted in patients experiencing less pain, depression and disability.
Lorig et al (1987) also found that such programmes enabled participants to develop coping skills and encouraged self-management of their condition.
Patients with osteoarthritis will be nursed in a variety of settings. The nurse involved in the patient’s care will require both knowledge and understanding of the management of the condition to provide care that is evidence-based and therapeutically effective.
- Further information can be found on the Arthritis Research Campaign website: www.arc.org.uk/common/research_f.htm