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Management of Osteoarthritis and Rheumatoid Arthritis

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Management of Osteoarthritis and Rheumatoid Arthritis CHAPTER 28 MANAGEMENT OF OSTEOARTHRITIS AND RHEUMATOID ARTHRITIS Maura Daly Iversen and Linda Steiner Introduction Risk factors for OA can be classified into two major cate- gories: intrinsic risk factors and extrinsic risk factors. Intrinsic The term arthritis comprises a complex of diseases that factors include knee alignment (a determinant of joint load), 1 affect more than 70 million people in the United States. muscle strength, obesity, ligament laxity, and propriocep- Arthritis can manifest in more than 100 forms. This chapter tion. Extrinsic factors include repetitive physical activity focuses on rheumatoid arthritis and osteoarthritis and pro- and injury.2 Osteoarthritis is commonly referred to as vides an analysis and discussion of the rehabilitation man- osteoarthrosis. Although OA used to be considered a degener- agement of these two conditions. ative joint disease, this designation is no longer appropriate. Scientists now recognize that OA is a slowly progressing, Osteoarthritis dynamic disease that involves biomechanical, environmental, genetic, and biochemical factors (e.g., cytokines).3 Epidemiology and Pathophysiology Osteoarthritis (OA) involves the entire joint but is primarily a Categories of Osteoarthritis disease of the cartilage (Figure 28-1). OA affects nearly 40 mil- lion people in the United States and is the second leading cause Primary osteoarthritis: Results in articular changes, although the of disability. The exact pathogenesis is unknown. The most etiological basis for the disease is unknown commonly affected and symptomatic joints are the apophyseal Secondary osteoarthritis: Caused by underlying factors that joints of the spine, the distal and proximal interphalangeal accelerate age-related degeneration of cartilage joints, the carpometacarpal joints, the first metatarsophalan- These factors include inflammatory arthritis (e.g., rheumatoid arthritis or spondyloarthritis), hypermobility syndromes, metabolic geal joint, and the knee, hip, and patellofemoral joints.2 The diseases (e.g., diabetes), and congenital and acquired joint clinical features of OA are presented in Table 28-1. surface incongruities that accelerate damage to the cartilage, as well as trauma or sports-related injuries Joints Commonly Affected by Osteoarthritis Spinal apophyseal joints Our understanding of OA has increased considerably Proximal interphalangeal (PIP) joints over the past 10 years, partly as a result of advances in car- Distal interphalangeal (DIP) joint tilage imaging techniques. Early OA is a focal disease that Carpometacarpal (CMC) joints presents as a distinct lesion of the cartilage.4,5 Patients with First metatarsophalangeal (MTP) joint early OA have joint stiffness and progressive cartilage Hip destruction with pain on loading of the affected joint. Over Knee time, OA involves the entire joint, including the subchon- Patellofemoral joints dral bone. Lesions progress with repeated biomechanical loading, synovial membrane inflammation, and release of 859 860 CHAPTER 28 Management of Osteoarthritis and Rheumatoid Arthritis Cartilage Figure 28-1 Degeneration particles Osteoarthritis of the knee. of cartilage Narrowed joint space Bone hypertrophy Reactive Bone spur new bone Loss of cartilage Normal knee Early stages of Late stages of osteoarthritis osteoarthritis Table 28-1 Pathology and Clinical Features of Rheumatoid Arthritis and Osteoarthritis Tissue Predominantly Disease Involved Clinical Features Radiographic Features Rheumatoid Synovium Symmetrical and bilateral joint involvement Periarticular swelling, joint effusion, arthritis (RA) (inflammation) Joint pain, swelling, stiffness, and contracture regional osteoporosis, subchondral Muscle weakness and fatigue osteolytic erosions, joint subluxation Acute: Red, hot, swollen, painful joints; boggy feel, fatigue, with or without fever; ligamentous laxity; morning stiffness up to a few hours Subacute: Effusion, reduced redness and pain Stable: Generally no effusion, minimal stiffness Osteoarthritis Cartilage Affects hips, knees, spine, ankles, distal Osteophytes at joint margins, joint space (OA) (degradation) interphalangeal (DIP) joints, proximal narrowing, subchondral sclerosis and interphalangeal (PIP) joints, and cysts metacarpophalangeal (MCP) joints Joint pain, malalignment Decreased proprioception Muscle weakness Early: Focal cartilaginous lesions End stage: Loss of cartilage, bone on bone Modified from Iversen MD, Liang MH, Bae SC: Exercise therapy in selected arthritides: rheumatoid arthritis, osteoarthritis, systemic lupus erythematosus, systemic sclerosis and polymyositis/dermatomyositis. In Frontera WR, Dawson DM, Slovik DM, editors: Exercise in rehabilitation medicine, Champaign, IL, 1999, Human Kinetics. cytokines; this stimulates the production of matrix metallo- The radiographic features of OA are graded according to proteinases, which cause cartilage degradation and loss. specific criteria. The Kellgren scale is commonly used for Eventually the joint surface is destroyed. The classic appear- this purpose (Table 28-2). On radiographs, secondary OA ance of primary OA on radiographs is localized disease with may appear as diffuse or localized disease, depending on evidence of unequal joint space narrowing, eburnation (a the etiology (e.g., rheumatoid arthritis [RA], diabetes, or hard, white appearance) of the subchondral bone, osteo- trauma). Secondary contractures occur around the involved phytes, and subchondral cysts (Figure 28-2). These find- joint and contiguous joints. These contractures alter joint ings increase in frequency after age 50. Only 40% of alignment and can increase the biomechanical forces on patients with severe radiographic features present with the joint, accelerating cartilage loss and increasing energy pain.6,7 requirements for activities. Management of Osteoarthritis and Rheumatoid Arthritis CHAPTER 28 861 Cystlike Loss of radiolucent articular cartilage lesions with joint space narrowing Sclerotic Osteophyte subchondral formation at bone joint margins A Figure 28-2 A, Radiographic hallmarks of osteoarthritis (Kellgren scale). B, Radiograph showing the main radiological signs of osteoarthritis. (A redrawn from McKinnis LN: Fundamentals of orthopaedic radiology, p 63, Philadelphia, 2005, FA Davis; B from Harris ED, Budd RC, Firestein GS et al: Kelley’s textbook of rheumatology, ed 7, p 1514, Philadelphia, 2005, WB Saunders.) Signs, Symptoms, and Impairments Classic Radiographic Appearance of Primary Osteoarthritis Joint Pain, Stiffness, Restricted Motion, and Alterations in Alignment Unequal joint space narrowing Osteoarthritis causes pain, aching, or stiffness and eventually Eburnation (hard, white appearance) of subchondral bone altered joint alignment. Cartilage does not have nerve end- Osteophyte formation ings; therefore the pain of OA may be caused by stretching Subchondral cysts of the joint capsule as a result of inflammation, the release of inflammatory cytokines in the synovial fluid, muscle spasms, and pressure on the subchondral bone.8 Patients fre- quently report that the pain increases with activity and is Table 28-2 relieved by rest. Some patients have nighttime pain and report Kellgren-Lawrence Classification of Radiological Joint stiffness on waking. The stiffness often resolves in less than an Changes in Osteoarthritis hour and may be present after rest or with prolonged sitting. Classification Description Limitations in joint range of motion (ROM) are the result of osteophyte formation, soft tissue and tendon con- Grade 0 No features tractures surrounding a joint, periarticular muscle spasm, Grade 1 Doubtful: Minute osteophyte, doubtful destruction of joint cartilage, persistent faulty posture, or significance muscular imbalance. Although a flexed position minimizes Grade 2 Minimal: Definite osteophyte, unimpaired intra-articular pressure and reduces pain, it leads to flexion joint space contracture. Crepitus may be felt when the joint is passively Grade 3 Moderate: Moderate diminution of joint moved through the ROM; this results when irregular space Grade 4 Severe: Greatly impaired joint space with opposing cartilage surfaces rub together. Localized joint sclerosis of subchondral bone swelling is evident in patients with erosive OA and presents as warmth and soft tissue swelling.9 From Kellgren JH, Lawrence JS: Radiological assessment of osteo- With hip OA, pain may be present in the hip, groin, ante- arthrosis, Ann Rheum Dis 16:494-501, 1957. rior thigh, knee, or buttocks. ROM often is restricted, 862 CHAPTER 28 Management of Osteoarthritis and Rheumatoid Arthritis particularly internal rotation, and may be accompanied by presence of varus or valgus is associated with a threefold to crepitus. Patients may experience difficulties with mobility fourfold increase in the odds of OA progression in the and personal hygiene, as well as increased energy expenditure medial compartment of the knee.2 Malalignment and with activities. Loss of hip range adversely affects the spine abnormal tracking of the patella may produce retropatellar and other joints, including the knee and ankle. Preventive pain and chondromalacia patellae. Retropatellar pain often stretching is important and should be initiated early and is experienced when the individual walks upstairs or on often. Functionally based exercises, such as repetitive sit to inclines or sits for prolonged periods. Knee pain can lead stand, help maintain strength in hip and knee extensors. For to disuse atrophy and deconditioning.2,10
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