Musculoskeletal / Orthopedics

Proactive intervention for osteoarthritis

Osteoarthritis

Osteoarthritis (OA) affects 27 million Americans and is one the most common causes of disability. It negatively affects the quality of life for many, but often patients don’t discuss symptoms with their healthcare providers until it has progressed to severe pain or disability.

Clinicians may have limited time to address OA in its early stages. In addition, research has found that healthcare providers consistently fail to recommend effective nonsurgical first-line therapies, such as weight loss plans and exercise. They often opt for early referral for surgical interventions after treating with nonsteroidal anti-inflammatory drugs (NSAIDs) and pain medications alone.

Nurses can play an important role in identifying those at risk for OA and facilitating early intervention and treatment. This includes assessing the risk for OA or progression of disease, and providing education about interventions.

Getting started: OA basics

To intervene effectively in OA, nurses need to know and recognize the risk factors:

  • aging
  • family history of OA
  • history of previous trauma or injury to a joint, including sports associated injuries
  • obesity
  • repetitive overuse of a joint.

OA can also develop in the absence of these risks due to wear and tear on joints from everyday use.

The following facts can help differentiate OA from other joint abnormalities:


  • OA is most common in the knees, hips, and hands.
  • It does not usually affect joints symmetrically.
  • Rest usually relieves the pain and symptoms.
  • Early morning stiffness usually last for less than 30 minutes.

Assessment should include the nature of joint related symptoms, including pain and functional limitations. Remember to ask patients how their symptoms affect work, family life, and lifestyle.

Get to know the guidelines

Nurses should be familiar with evidence-based guidelines for the management of OA. (See Clinical guidelines for nonsurgical management of osteoarthritis.) There is currently no cure for OA, but early intervention can slow disease progression. Goals include decreasing pain while increasing activity and overall wellness.

Working in collaboration with the provider, nurses can help patients achieve better outcomes by giving them the tools needed for self-care. This includes providing information about nonpharmacologic management such as exercise, weight control, and self-management.

Exercise and physical therapy

Exercise can be a valuable aid in relieving a patient’s pain and reducing the impact of progressive OA. Common exercise therapies include:

  • low-impact aerobics
  • aquatic exercise
  • strength training
  • neuromuscular education (balance training, proprioception, and core strengthening).

Water aerobics can decrease the pain of weight bearing while increasing muscle strength and fitness. Strengthening core muscles in the abdomen, back and pelvis improves posture and assists in stability. This conditioning can reduce progression of OA and assist in rehabilitation after surgery, if needed.

Many patients are reluctant to participate in exercise due to pain. For those with minimal joint pain and dysfunction, many fitness centers have qualified trainers who can design programs to limit joint irritation and improve general fitness. For more advanced OA, a physical therapist or physiatrist may need to develop a medically supervised therapy plan. An occupational therapist can address functional impairment, which can improve skills needed for activities of daily living.

Physical therapy clinics are often associated with local fitness facilities. When clients are ready, they can transfer to a fitness facility to continue their plan, maintaining continuity of care. This is a win-win situation if surgical intervention is needed in the future. Patients are already comfortable with the facility and are usually in better physical condition for surgery.

It is essential to create a handy referral list of community-based resources for exercise therapies. Start with a list of online and national resources and add local contact information.

Weight control

Obesity is a common condition that significantly affects people with OA. Wear and tear of an affected joint is made worse when body mass index (BMI) rises over 25. When combined with exercise, dietary modification can benefit the patient with OA significantly. Studies have shown that even a moderate weight loss of 5% can reduce pain and physical disability.

Nurses should explore different weight loss options with patients. Some patients will have comorbid conditions, such as diabetes or hypertension. These conditions warrant specific diet modifications. It’s important to be aware of the DASH diet (http://dashdiet.org/) and American Diabetic Association dietary recommendations (http://www.diabetes.org/food-and-fitness/food/what-can-i-eat/) to educate patients.

Reviewing dietary ideas, setting goals, and giving written instructions will help patients who are struggling with their weight. If clinic resources aren’t sufficient, seek out resources in the community. Compile a contact list of local dieticians available for outpatient consultation.

Self-management

Studies have shown that persons with OA who are active in their own care reach goals and are able to sustain behavioral changes that improve quality of life. Both the American Academy of Orthopaedic Surgeons (AAOS) and the American College of Rheumatology (ACR) also recommend self-management

The American Arthritis Foundation has multiple self-management programs available for patients with OA. The self-management programs vary from 6-week courses to phone follow up and workshops through the Arthritis Foundation. (See Resources for osteoarthritis management.)

Resources for osteoarthritis management

EXERCISE
YMCA www.YMCA.net
sFitness Factor www.fitnessfactor.net
Core Fitness www.thecore247.com
Rehab at Work (PT) www.rehabatwork.com
Arthritis Foundation: Exercise Program, Walk with Ease Program, Aquatic Program www.arthritis.org
WEIGHT CONTROL
Weight Watchers www.weightwatchers.com
Nutrisystem www.nutrisystem.com
SELF-MANAGEMENT PROGRAMS
Arthritis Foundation www.arthritistoday.org
CDC Arthritis Programs www.cdc.gov.arthritis
TAI CHI
Arthritis Foundation www.arthritis.org
Tai Chi videos www.taichiforseniorsvideo.com

When more invasive treatment is needed

More invasive treatments are considered when conservative therapies don’t relieve symptoms of advanced OA. Treatments can include serial cortisone injections or viscous supplementation injections into the joint. If injections fail, surgery, such as total joint arthroplasty, may be needed.

Surgery can benefit many people with advanced OA. Risks include postoperative infection and complications from anesthesia. Among conditions that increase postoperative risks are anemia, dental conditions, and obstructive sleep apnea. Studies have shown that identifying and addressing these conditions before surgery can minimize complications.

Anemia

Anemia can complicate surgical blood loss. If the hematocrit and hemoglobin are low, then further evaluation is needed to determine if the patient has iron deficiency that can be treated with iron. If the hematocrit and hemoglobin are too low, then referral to a hematologist may be needed. If these evaluations aren’t done early, surgery may have to be postponed until the patient is healthy enough.

Dental care

Nurses should educate patients with OA on the need for regular dental care. After joint arthroplasty, even routine dental work can increase the risk of infection of the metal implant. Patients should have a dental evaluation and treatment of problems before surgery.

Obstructive sleep apnea

The risk of postoperative atelectasis is higher in persons with obstructive sleep apnea. Preoperative evaluation is indicated if the patient has symptoms such as obesity, snoring, excessive daytime sleepiness, morning headaches, or periods of breathing cessation.

Being proactive pays off

Whether patients with OA need surgery or can be treated with conservative methods, proactive nursing can make a big difference in their outcomes and quality of life.

Selected references

AAOS (2013). Treatment of osteoarthritis of the knee evidence-based: guideline 2nd edition. 2013. www.aaos.org/research/guidelines/TreatmentofOsteoarthritisofthekneeGuideline.pdf.

Dziedzic KS, Healey EL, Main CJ. Implementing the NICE osteoarthritis guidelines in primary care; Role for practice nurses. Musculoskeletal Care. 2013;11(1):1-2.

Hochberg MC, Altman RD, April KT, et al. American College of Rheumatology 2012 Recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res. 2012;64(4):465-474.

Lawrence RC, Felson DT, Helmick CG, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States: Part II. Arthritis Rheum. 2008;58(1) 26-35.

Porcheret M, Healey E, Dziedzic K, et al. Osteoarthritis: a modern approach to diagnosis and management. Reports on Rheumatic Diseases. 2011;6(10). http://www.arthritisresearchuk.org/health-professionals-and-students/reports/hands-on/hands-on-autumn-2011.aspx

Robbins L, Kulesa MG. The state of the science in the prevention and management of osteoarthritis. Orthop Nurs. 2012;31(2):74-81. 

Sally Pearson is an assistant professor in the BSN Program, Mississippi University for Women in Columbus, Mississippi.

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