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Arthritis--rheumatoid and osteo: ONF-07-13-I.

About Arthritis

Affecting one percent of the total population, arthritis is one of the oldest and most common disease processes found in peoples throughout the world. Arthritis, referring to the inflammation of a joint, affects all ages, usually lasts a long time and for many, may never go away. In fact, arthritis, and the rheumatic diseases in general, constitute the major causes of chronic disability in the United States. There are more than 100 different types of arthritic conditions, depending upon their cause, but the two main types are rheumatoid arthritis and osteoarthritis.

Rheumatoid Arthritis

Classified as a collagen disease and considered an autoimmune disorder, the exact cause of rheumatoid arthritis (RA) is unknown. The presentation of a relevant antigen to an immunogenetically susceptible host is believed to trigger RA, but more is known about immunogenetic susceptibility than about causative agents. RA may be due to infection, or possibly a genetic disorder with an inherited predisposition to the disease. It is known that physical and emotional stress can lead to the onset of acute attacks.

In RA, the body produces abnormal antibodies against its own cells and tissues. Abnormal IgG antibodies are produced within synovial joints. Acting as antigens, they react with IgG and IgM antibodies. The specific IgM antibody created is known as the rheumatoid factor (RF). Immune complexes are formed within the joint, causing inflammation, swelling and increased synovial fluid. As this chronic, systemic condition progresses, surrounding cartilage, tendons and ligaments become involved. Thickening of synovial tissue eventually leads to calcification of the joint, joint pain, limited mobility and deformity. In a substantial percentage of persons with RA, the disease progresses to invasion of bone and cartilage. If not successfully treated, this progressive joint destruction results in loss of function, disability and increased mortality. The time from onset of symptoms to joint destruction is sometimes measured in months rather than years, but for 75 percent of persons with RA, the onset is gradual. Unfortunately, the time from disease onset to diagnosis and initiation of effective therapy is often prolonged, allowing development of irreversible joint destruction.

In a very high percentage of cases, the joints of the hand and wrist are affected initially. RA is usually bilateral, symmetric and poly articular. As the disease progresses, shoulder, elbow, hip, knee, ankle and cervical spine joints become affected. Other areas of the body where connective tissue is present may also be involved such as the lungs, heart, blood vessels and pleura. Early symptoms include malaise, fever, weight loss and morning stiffness of the joints. One or more joints may become swollen, painful and inflamed. Typically, there are increasingly severe and frequent attacks with subsequent joint damage and deformity. Deviation of the fingers to the ulner side and swan neck or boutonnier deformities of the fingers usually indicate RA.

Joint pathology in RA progresses through four stages. First, there is proliferative inflammation of the synovium with increased exudate, which eventually leads to thickening of the synovium. Secondly, there is formation of a layer of granulation tissue (pannus) which erodes and destroys the cartilage, and eventually spreads to contiguous areas causing destruction of the bone capsule and parts of the muscles that control the joint. The third stage is fibrous ankylosis resulting from the invasion of the pannus by tough fibrous tissue, and finally there is bony ankylosis as the fibrous tissue becomes calcified.

There is also atrophy of muscles, bones and skin adjacent to the affected joint, causing people with RA to appear under-nourished and chronically ill.

Persons with RA feel sick during flares or exacerbations of the disease. They experience decreased appetite, lose weight, run a low-grade fever, and have little energy. Many become anemic due to the effect of the disease on blood-form organs. Erythrocyte sedimentation rate is elevated and white blood cells may be slightly elevated. One-fifth of people with RA develop subcutaneous rheumatoid nodules along the pressure points of the extensor surface of the ulna. Dry eyes and a dry mouth are common, resulting from inflammation of tear glands and salivary glands (sicca syndrome). Although rare, vasculitis affecting the skin, nerves and other organs or Independent Study continued on page 14 tissues can occur. For most people, the problems caused by RA occur mainly in the joints.

The course of the disease is always variable and difficult to predict at its onset. However, a positive serum RA factor and bone erosive changes on x-ray imply a poor prognosis. Generally, onethird will have some functional limitation and one-third will become severely handicapped. Even though chronic RA is a very disabling and debilitating disease and needs constant care, the majority of those with RA do not become severely handicapped. About one in ten people with RA will have a single episode of disease activity and a spontaneous long-lasting remission.

Rheumatoid arthritis is perceived to occur more frequently in women, although it affects men and women equally, because three times as many women as men develop symptoms severe enough to require medical attention. RA can occur at any age, but usually strikes between ages 20 and 40. For women it is often diagnosed in later childbearing years. Hormones appear to play a role as women on oral contraceptives are less likely to develop RA. The prevalence of RA in adults under 35 years is less than 0.3 percent and exceeds 10 percent in those over 65 years. The disease is infrequent in young adult males.

A fundamental understanding of the pathophysiology of RA and identification of critical initiating or perpetuating mechanisms of the disease remain elusive. Current research is aimed at understanding the genetic and environmental factors that influence the development of RA. It is thought that perhaps RA does not have a single cause.

Osteoarthritis

Osteoarthritis (sometimes call degenerative joint disease, arthrosis, osteoarthrosis or hypertrophic arthritis) is one of the oldest and most common diseases of man. The onset of ostearthritis (OA) begins in middle age and by age 70, most people have some degeneration. Up to age 45, it is more common in men. Beyond 45, the disease is more common in women. Sixteen million people in the United States have OA and the number will only grow as the population ages and life expectancy increases.

Inflammation separates RA from the more common osteoarthritis. OA is a "wear and tear" disease characterized by the slow and steady progressive destructive changes of the joint. It is a nonsystemic, noninflammatory disorder causing bones and joints to degenerate. OA begins with disintegration of the cartilage that covers the ends of the bones. As the cartilage wears away, the roughened surface of the bone is exposed, and pain and stiffness result. In severe cases, the center of the bone wears away and a bony ridge is left around the edges. This ridge may restrict movement of the joint.

The breakdown of joint tissue caused by OA occurs in phases. In phase one, the smooth cartilage surface softens and becomes pitted and frayed. When this happens, the cartilage loses its elasticity and is more easily damaged by excess used or by injury. Over time, large sections of cartilage may wear away completely (phase two), causing the bones to rub together. In phase three, the joint may lose its normal shape. The bone ends thicken and form bony growth, or spurs, where the ligaments and capsule attach tot he bone. In phase four, fluid-filled cysts may form in the bone near the joint. Bits of bone or cartilage may float loosely in the joint space. The result is pain when the joint is moved.

The etiology of OA is unknown, but several predisposing or risk factors have been identified: heredity, obesity, injury and repeated overuse of certain joints. Heredity plays a part through slight congenital joint defects (bow legs or dislocated hip), laxity (double-jointedness), or a defect on one of the genes responsible for collagen, a major protein component of cartilage. These hereditary factors lead to a more rapid deterioration. Obesity is the greatest risk factor for developing knee OA, and a significant injury or overuse of hip or knee increases the risk.

Although OA can affect any joint, weight bearing joints of the lower extremities, the hands and cervical and lumbar vertebrae are most frequently affected. It also affects the joint at the base of the great toe which can be aggravated by wearing tight shoes or high heals. OA rarely affects wrist, elbows, shoulders, ankles or jaw except as a result of injury. Symptoms include early morning stiffness, pain after exercise, joint enlargement and characteristic hypertrophic spurs (Heberden's nodes) in the distal terminal interphalangeal finger joints. Bouchard's nodes, cartilaginous and body enlargements, may appear in the second joint of the fingers. Both types of nodes may make the finger joints painful, but usually do not interfere with hand function.

Osteoarthritis is less debilitating than rheumatoid arthritis, but activity is a challenge to those with OA. Affected joints hurt most after overuse or after long periods of inactivity. If the muscles surrounding the joint are not moved, the joint becomes weaker. Too much exercising of the muscles, in an effort to strengthen the joint, and the joint pain increases. Compounding the problem is that for many, coordination and posture are not as good as they once were, making exercise even more difficult.

Since osteoarthritis and rheumatoid arthritis are both common, it is quite possible for a person to have both of these conditions. A comparison of OA and RA points out some of the differences.

* OA Usually begins after age 40

* RA Usually beings between ages 20 and 40

* OA Usually develops slowly, over many years

* RA Often develops suddenly, within weeks or months

* OA Often affects the joints on only one side of the body at first

* RA Usually affects the same joint on both sides of the body

* OA Usually does not cause redness, warmth or swelling of the joints

* RA Causes redness, warmth and swelling of the joints

* OA Affects only certain joints, rarely affects elbows or shoulders

* RA Affects many joints, including elbows and shoulders

* OA Does not cause a general feeling of malaise

* RA Often causes a general feeling of malaise and fatigue, as well as weight loss and fever

Diagnosis of Rheumatoid Arthritis

The diagnostic criteria for RA are constantly being re-evaluated. Not all who meet the American Rheumatism Association's criteria for definite RA actually prove to have the disease. As with any disease, it is important to begin with a good history and physical examination. Assessment findings and the results of laboratory tests are then compared to the Association's eleven criteria.

1. Morning stiffness

2. Pain on motion or tenderness in at least one joint

3. Soft tissue swelling in at least one joint

4. Swelling of at least one other joint within past three months

5. Symmetric joint swelling

6. Subcutaneous nodules

7. X-ray changes: decalcification adjacent to affected joint 8. Positive rheumatoid factor

9. Poor mucin precipitate from synovial fluid

10. Histologic changes in synovium

11. Histologic changes in nodules.

For a diagnosis of:

Classic RA 7 of the 11 criteria and numbers 1 through 5 must be continuously present for at least 6 weeks.

Definite RA 5 of the 11 criteria and numbers 1 through 5 must be continuously present for at least 6 weeks

Probably RA 3 of the 11 criteria and one of the numbers 1 through 5 must be present for at least 6 weeks.

For a diagnosis of possible RA, 2 of the following 6 criteria and joint symptoms must be present for at least 6 weeks:

1. Morning stiffness

2. Pain on motion or tenderness recurring or persisting for three weeks.

3. History or observation of joint swelling.

4. Subcutaneous nodules

5. Elevated sedimentation rate or C-reactive protein

6. Iritis

Unfortunately, there is no single blood test that can establish or exclude the diagnosis of rheumatoid arthritis. Rheumatoid factor (RF) appears in the serum and synovial fluid several months after the onset of RA and is present for up to years after therapy. This macroglobulin type antibody produced in the synovium appears in the presence of autoimmunity, chronic infections or connective tissue defects, and is not affected by analgesia or anti-inflammatory medications. RF, though not specific for rheumatoid arthritis, is very helpful in its diagnosis, as high titers correlated with severe disease as compared to titers with other diseases. However, a positive RF can occur in 5 percent of normal persons under the age of 60, and in 30 percent of normal persons over 80 years old. Diseases such as chronic active hepatitis, cirrhosis, subacute bacterial endocarditis, infectious mononucleosis, tuberculosis, leprosy, viral infections, diabetes mellitus and others also produce a positive RF. A percentage of people with rheumatoid arthritis have a negative rheumatoid factor. All of these possibilities underscore the importance of integrating laboratory test results into the overall assessment findings for each individual.

A few additional laboratory test may also be helpful, as anemia is not uncommon in RA, and an increased sedimentation rate is usually present.

Diagnosis of Osteoarthritis

The diagnosis of osteoarthritis is made from the symptoms presented and examination of the joints that are enlarged and tender. As there is a loss of joint cartilage and bone hypertrophy in OA, x-ray shows a narrowing of joint spaces and gross irregularities of joint structure. Pain is the chief symptom of OA. The characteristic pain of OA is the mechanical type, increasing with movement and weight-bearing and decreasing or ceasing at rest. The pain is worst when starting movement after rest; however, it then eases, but later increases after extended periods of movement. Heberden's nodes, nodular protrusions found on the dorsolateral aspect of the base of the distal phalanx are a sigh of OA. Laboratory findings do not play a very important role in the diagnosis, as persons with OA usually have a normal sedimentation rate and a negative rheumatoid factor. A careful history of the onset and course of the problem, along with a thorough examination of the joints are the basic tools for diagnosis.

Nursing management of Arthritis

Nursing management of arthritis revolves around assisting those affected with two main issues: pain control and promotion of functional independence. It is almost impossible to separate these issues as one constantly impacts the other. It is difficult to be functional when you are in pain, but lack of movement can actually increase pain. Then again, too much stress on joints can lead to increased symptoms. The key is finding the delicate balance between activity, rest, medications, assistive devices, self-esteem, abilities and limitations. Some people adapt quickly, making the necessary adjustments in their lives to accommodate the changes in their body's musculoskeletal system. Others find the changes frustrating, threatening to their independence and depressing when viewed in terms of lost abilities. Considering the chronicity of the disease, encouraging self care with the nurse as a resource, is a wise use of the health professional, and allows those with arthritis to maintain a sense of dignity and control. The nurse must act as nurse, teacher, sounding board, referral center, cheerleader, and even inventor to meet the challenges of arthritis.

The following are examples of the nursing diagnoses that may be applicable to either form of arthritis, potential goals and possible nursing interventions. It is important to remember that each person is unique and that the course of these disease will differ from individual to individual.

A nursing diagnosis for pain of RA may be: Pain, chronic, related to swollen, inflamed joints. For OA: pain, chronic, related to joint tenderness and edema. In both cases, the goal would be to decrease pain and minimize edema. An equally important goal may be the appropriate use of medications, as following the prescribed medication regime in RA can help keep pain to a minimum. In OA, analgesics will probably be taken for a long time, perhaps many years, and the avoidance of narcotics and implementation of alternative methods of pain control may be desirable. Nursing interventions may include teaching about the prescribed medication regime, including the drugs, their dosages, their actions, possible side effects and appropriate usage. Alternative pain control methods such as relaxation techniques, the proper use of heat and cold, and proper body alignment may decrease the need for analgesics.

A warm morning shower may be the only thing needed to relieve the stiffness and pain that interfere with dressing and grooming. For others, a consult with their physician about using a TENS unit to control pain may be necessary. With the chronicity of the disease, it is important to assess the effectiveness of any pain relief modality, and to strive for the lowest level of intervention that provides the greatest comfort.

Challenges to mobility may be expressed by a diagnosis of: impaired physical mobility related to pain, edema or joint deterioration. The goal would be to increase or maintain mobility. Nursing interventions include teaching or assisting with range of motion exercises. Collaboration with OT and PT may result in a planned exercise program that, when alternated with rest periods, can increase or maintain joint mobility. Appropriate and safe use of adaptive devices such as an overhead trapeze, handrests, canes, walkers, tub, shower and toilet handrails, or raised toilet set can greatly improve functional independence and quality of life. Recommending shoes and clothing that are easy to use, perhaps with velcro closures, promotes self-care. Some specialized stores or catalogues carry household items that have been adapted for those with limited mobility or decreased strength. If a particular assistive devise is not available, inventing adaptations or reorganizing the environment may call upon the innovation and creativity of the nurse. Through careful planning of the activities, people with arthritis can participate in the world around them.

Body image disturbance related to joint deformity and decreased muscle tone may be a nursing diagnosis. Acceptance of one's appearance as disease related changes occur is very difficult for some people. The nurse may use therapeutic communication to help the arthritic person express their feelings, identify copying skills and explore ways to enhance body image. For example, many women with RA of the fingers want to hide their hands. Perhaps a manicure and some attractive rings may help deflect negative self-perceptions of arthritic hands. The Arthritis Foundation, with its activities and support groups, can be an excellent referral.

For those with rheumatoid arthritis or osteoarthritis there may be knowledge deficits related to the disease process, factors that contribute to symptoms, measures to control symptoms, prevention of complications, treatment options, or home care management. Any one of these areas can present an opportunity for teaching by the nurse. So many misconceptions exist about arthritis and clients are so eager for relief that they often become easy prey for those offering bogus cures. Teaching the individual and the family can reduce their vulnerability, promote informed intelligent decisions and foster a sense of control Involving the family in stress management may also be beneficial, as the arthritis of one member impacts the functioning of the entire family.

Drug management of Rheumatoid Arthritis

Traditionally, drug management of RA is based upon a treatment pyramid. The base of the pyramid consists of education. Rest, exercise, counseling and salicylats or other nonsteroidal anti-inflammatory drugs (NSAIDS). Level two is antimalarials and gold therapy, and the third level penicillamine, methotrexate and sufasalazine. The tip of the pyramid represents experimental drugs and procedures. Throughout the pyramid, orthopedic treatments and corticosteroids are used as needed for flares or exacerbations.

Salicylates, such as aspirin, inhibit prostaglandin synthesis resulting in decreased pain. They also have the added benefit of being anti-inflammatory and antipyretic. Salicylate side effects include gastrointestinal upset, tinnitus, easy bruising, nausea and prolonged bleeding time. However, many people tolerate aspirin well, particularly when it is enteric-coated. Nursing interventions include instructions about taking aspirin with food and assessing the individual for bleeding and bruising. Reporting the experience of tinnitus is important, as it can be an indication of approaching therapeutic levels. Aspirin is contraindicated with oral anticoagulants.

NSAIDS such as ibuprofen, naproxen and phenylbutazone inhibit prostaglandin synthesis and reduce joint swelling and stiffness. Selection of a particular NSAID, other than aspirin, is based on dosage schedules and specific side effects of individual drugs. In general, NSAIDS can cause gastrointestinal irritation, nausea, vomiting, heartburn, gastrointestinal bleeding and ulceration, dizziness, headache, and liver toxicity. Nursing interventions again center upon proper administration with food and assessment for bleeding problems.

If, after a month of therapy with NSAIDS, the symptoms persist, a second-line drug may be added. An antimalarial (hydroxychloroquine sulfate) may bring about remission. Side effects include visual disturbances, nightmares, skin lesions, nausea, diarrhea and low blood count.

Nursing interventions involve monitoring the individual's response to the drug and monitoring CBC and liver function tests.

Gold salts is an effective anti-inflammatory agent, but potentially more toxic than many other drugs. Side effects include diarrhea, nausea, vomiting and jaundice. Weekly or biweekly monitoring of blood counts to prevent goldinduced thrombocytopenia, neutropenia or proteinuria is necessary. Orally administered gold (auranofin) is less toxic than the injectable forms, but is not as effective. The beneficial effects of gold salts may take three to four months to appear, and the nurse should stress the importance of keeping all appointments with the physician.

Low-dose methotrexate (5 to 15 mg once weekly) is now being used more often, before therapy with gold salts or penicillamine, with improvement in symptoms, although the mechanism of action is debatable. The potentially serious side effects of methotrexate include hepatic and pulmonary fibrosis among others. NSAIDS, salicylats and sulfonamides increase methotrexate toxicity and should not be used together. Nursing interventions may include performing a baseline pulmonary function test, watching for increases in SGOT, SGPT, and alkaline phosphatase, and encouraging increased fluid intake.

Penicillamine, a chelating agent, is used in severe cases when other medications have failed. Its action is palliative. Side effects are severe: bone marrow depression, fever, rashes, blood dyscrasias and liver toxicity. Epinephrine 1:1000 should be handy when this drug is administered because of the possibility of anaphylaxis. Forcing fluids, up to 3000 ml per day is necessary to prevent renal failure.

Originally developed for RA, sufasalazine, an antibiotic, was granted FDA approval as a treatment for ulcerative colitis. Although commonly used, this drug has not been approved by the FDA for the treatment of RA, and the mechanism of action is still unknown. It is thought to have both anti-inflammatory effects and immunosuppressive effects. Gastrointestinal toxicity is the most common side effect and the incidence appears to be higher when first initiating therapy. Nursing interventions center on preventing GI toxicity, avoiding sunlight and watching for signs of superinfection.

Corticosteroids used to control RA flares act to decrease the inflammation, decrease pain, and increase mobility, but cause adverse reactions that are usually dose- or duration-dependent. Side effects include insomnia, fluid retention, gastrointestinal irritation, muscle wasting, impaired wound healing, and moon face. Abrupt withdrawal of corticosteroids can be fatal. Nursing interventions include teaching about dosage, proper administration with food, and monitoring weight, sleep patterns and serum potassium.

The current armamentarium for RA treatment has a disappointing record in terms of preventing the joint destruction of RA. Those drugs originally believed to be "disease-modifying" have shown little impact. At best, they reduce the destructive component of the disease modestly and inconsistently. A potential approach to treating RA is to neutralize the cytokines that are suspected of producing the damage. Anticytokine therapies are currently being tested with encouraging clinical results. There is, however, concern about toxicities arising from the longterm neutralization of cytokines. Investigations are also under way to attempt to induce tolerance to supposed arthritogenic antigens by monoclonal antibodies, other biologic agents, and vaccination or oral administration of antigen. Given the many pathways that seem to be involved in the pathogenesis of rheumatoid arthritis, a combination of two or more approaches may be necessary to suppress joint destruction.

Drug management of Osteoarthritis

Compared to rheumatoid arthritis, drug management of osteoarthritis appears straight forward. The approach is mainly symptomatic; relieve pain and control inflammation if present. Acetaminophen is an often overlooked, but effective, pain reliever for OA. A danger with acetaminophen is self-dosing and the possibility of severe liver damage, especially when alcohol ingestion potentiates the hepatotoxicity of this drug even at therapeutic levels. Acetaminophen does not reduce swelling or inflammation, but over-the-counter or prescription NSAIDS can reduce joint pain, stiffness and swelling. Medication teaching is always warranted with OTC drugs. Tramadol is a non-narcotic analgesic currently under investigation, which may help older people with OA who do not respond to acetaminophen or NSAIDS for pain control. Narcotic analgesics should only be used on a shortterm basis in acute pain.

Corticosteroids may be injected directly into the affected joint following joint aspiration, to relieve the pain and swelling of OA if inflammation is present. This procedure must be limited to three or four times a year, as repeated injections in weightbearing joints can result in cartilage damage.

Pain relief may also be obtained by the use of pain-relieving creams, rubs or sprays applied to the skin. Some topical analgesics may contain combinations of salicylates, skin irritants and local anesthetics. Methylsalicylate acts by decreasing the ability of the nerve endings in the skin to sense pain. Irritants stimulate the nerve endings of the skin to cause a feeling of cold or warmth which interferes with the sensation of pain. Topical capsaicin reduces the amount of substance

P which sends pain signals to the brain. Skin irritations, and tolerance to the action of these topicals may result from overuse.

The latest treatment for OA involves injecting affected knee joints with sodium hyaluronate, to relieve pain for those who do not get adequate relief from analgesics, exercise and physical therapy. Hyaluronate, a natural chemical normally found in high amounts in joint tissues and synovial fluid, acts as a lubricant and shock absorber. In OA, there may not be sufficient amounts of hyaluronate, and there may be a change in the quality of the hyaluronate that is present. Injectable sodium hyaluronate is manufactured from rooster combs, and persons with allergies to feathers, eggs or poultry may not be candidates for this treatment. After a series of three to five injections, pain relief can last for up to six months or longer. Some physical activities must be avoided for 48 hours following each injection. Possible side effects include pain, swelling, heat and/or redness of the knee joint. These reactions are generally mild and do not last long. The safety and effectiveness of repeated treatment cycles with sodium hyaluronate has not bee established. Nursing interventions could center on education about the treatment and its possible side effects.

Along with the current available treatments for both forms of arthritis, antidepressants and/ or sleep medications may be helpful at times. Research into future treatments for OA includes delivering therapeutic reagents to joints in the form of genes, and autologous chondrocyte implantation for repairing cartilage defects.

Non-Drug management of RA and OA

In general, the non-drug management of both the rheumatoid and osteo forms of arthritis are similar. Most have already been mentioned under nursing management: counseling and/or support groups for depression and coping, stress management, relaxation techniques, massages and TENS units. At the other end of the spectrum, joint repair or joint replacement surgery may be necessary. There are disease management interventions, however, that those with arthritis can implement on a daily basis which may assist in delaying or avoiding surgical intervention.

A well-balanced diet is important for two reasons. First, is the issue of weight control to reduce the strain on joints. Some arthritis sufferers see an improvement in symptoms by weight loss alone. Secondly, poorly nourished individuals are prone to infections and infection results in exacerbation of RA symptoms. There is some evidence that fatty acids, derived from fish or plants, when substituted for the arachidonic acid found in animal fats can effect clinical improvement in RA. Both those with RA and OA should have an adequate intake of protein and calcium.

Following an activity and exercise program is important to keep joints flexible, muscles strong, and heart and lungs fit. Range of motion exercises and isometric exercises should be performed even during flare-ups of RA. With OA, exercise can improve functional capacity without exacerbating symptoms. Days of exercise should alternate with days of rest and stretching exercises. The Arthritis Foundation certified aquatics program is an excellent resource. Aquatic exercises can be done comfortably even when inflammation is present. Learning how to properly use heat or cold to prepare for exercise, and for short-term relief from pain and stiffness, reduces dependence upon chemical pain relief. Soaking in a warm bath or using microwaveable heat packs relaxes aching muscles. Pain persisting two hours after exercise should prompt a decrease in exercise intensity or duration. Repetitive motion exercises and occupations should be avoided.

Joint protection is paramount and nonpharmacologic modalities cannot be overstated. A simple elastic bandage improves knee proprioception, which would improve gait. Walking aids or assistive devices can improve joint position, avoid excess joint stress, and decrease pain. Consistent, proper use of these devices can prevent unwanted additional harm to joints and muscles.

Nursing should be instrumental in teaching people how to integrate self-care techniques into their lives, empower them to take control of their arthritis and cheer them on over the long course of the disease.
Differential Diagnosis

Aspect        Rheumatoid          Osteoarthritis
              Arthritis

Age           Adults under 40     Middle age
Etiology      Nonspecific or      Metabolic
              infectious          disturbance or
                                  repeated use/
                                  trauma
Mode of       Usually             Insidious
onset         insidious;
              Occasionally
              acute.
Involvement   Periarticular and   Spurring and
              synovial, no        lipping of
              effusion            bones at joints
Joints        Many, large         Weight-bearing
Affected      and small           and distal
                                  phalangeal
                                  joints of
                                  figures.
Results       General             General health
              debility; joint     good; no
              ankylosis and       ankylosis;
              deformity           mainly
                                  pain
Diagnostic    Increased sed       Absence of
aids          rate of RBCs        evidence of
              Presence of RF      infection
X-ray         Rarefaction of      Spurring and
findings      ends of bones;      lipping of
              thinning of joint   bones
              space
Course        Chronic with        Chronic
              acute
              exacerbations
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Title Annotation:Independent Study
Publication:ISNA Bulletin
Date:Nov 1, 2008
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