Degenerative Diseases of the MS System Arthritis (joint inflammation) is a common, often crippling condition.

Assessment findings include joint pain, swelling, tenderness, heat, and difficult movement. Arthritis affects people regardless of age, race, socioeconomic group, or sex (although some kinds of arthritis are more common in women) Joint diseases have occurred for millions of years. Evidence of osteoarthritis has been identified in skeletal remains of dinosaurs living 100 years ago and in the skeletons of prehistoric people and Egyptian mummies. The cause of arthritis is unknown and has no cure it is often possible, however, to prevent or correct its crippling effects. Medication may be used and surgical techniques can sometimes restore function and relieve pain. Physical therapy is valuable in relieving pain and preventing deformity. There are acute and chronic forms of arthritis. There are two basic arthritic pathologic processes: 1. Inflammation -exudative, proliferative, combination 2. Degenerative Changes INFECTIOUS Rheumatoid Arthritis is the most virulent form of arthritis, it is a chronic, systemic disease with inflammatory connective tissue changes. Most often, small, peripheral joints (fingers and wrist joints) Bilateral affectation Women are affected two or three times more often than are men. While it occurs at any age, it is most common in people between ages 20 and 40 Etiology is unknown. Some speculate that the disease is caused by: a. An undefined virus or some other microorganism (Mycoplasma)

b. Metabolic aberrations c. Immunologic mechanisms (B-lymphocytes) Pathology of RA. If, unarrested, pathologic joint changes in RA pass through four stages 1. 2. 3. 4. Synovitis Pannus formation Fibrous ankylosis Bony ankylosis

Assessment Findings Early in the disease each exacerbation tends to be more stubborn than the preceding one. Occasionally, permanent remission occurs, but this is not usual. RA is generally progressive and deformity-producing. Onset of Rheumatoid Arthritis: Usually insidious Associated with physical and/or emotional stress

Synovial Joints: (Mainly hands and feet) Warm, tender, red, painful Guarded movement Limited ROM Limited strength Stiffness and pain worst in the morning

X-ray may show: Feet: Stiff, painful Broadened forefoot Depressed metatarsal heads Cockup toe deformity Soft tissue swelling Osteoporosis Cartilage erosion Narrowed joint space Bony cysts

Eyes: (In advanced disease) Episcleritis Keratoconjunctivitis

Hands: Red palms Enlarged dorsal veins Ulnar drift Joint pain and stiffness Weak grip Inability to make tight fist

Severe Wrist subluxation Finger swan neck Finger Boutonniere Z-shaped thumb

Systemic Effects Slight fever Malaise, weakness Weight loss Numb, tingling hands and feet Enlarged lymph nodes Enlarged spleen Depression Anorexia Fatigue by early afternoon

Laboratory Findings Serum protein factors (rheumathoid factors) ESR C-reactive protein WBC (slight) Leukopenia Abnormal synovial fluids

Subcutaneous nodules characteristic lesions of RA Pain is variable in intensity and tends to be most persistent upon use of involved joints.

Stiffness is often the most constant problem. Osteoarthritis (Degenerative Joint Disease/ Hyperthropic Arthritis) A non-inflammatory degenerative disease Unilateral affectation Most common form of arthritis Unknown cause but is associated with congenital abnormalities, genetic predisposition, aging, trauma, and obesity Weight bearing joints are mostly affected (Hip, Knee, Cervical and Lumbosacral joints) More prevalent in men before age 45. After 55, it is more common in women. Primary OA unknown cause Secondary OA caused by other conditions Pathology of OA Cartilage matrix is worn away and the bones rub together, causing painful, swollen joints Cartilage erosion follows. A proliferative response at joint margins then produces outgrowths of cartilage and bone called osteophytes or spurs Characteristic hypertrophic spurs swellings called Heberdens nodes and Bouchards node in terminal interphalangeal finger joints. Unlike RA, OA is not a systematic disease OA is often a wear-and-tear process. Mostly overweight. Assessment Findings It often produces no symptoms and intervention is not required. Symptoms usually develop gradually and progress slowly. Aching pain is the common symptom of OA. Other assessment findings include limited motion or contractures, and muscle spasm. Unlike RA, the pain with OA is more pronounced after exercise.

Night pain and morning stiffness may also occur. Flexion contraction of the hip and loss of ability to extend the knee may be disabling. Pain at rest may be caused by muscle spasm. Symptom severity and the degree of degenerative joint changes are often not correlated. Therefore, a person with minor degenerative changes may be quite uncomfortable, while a person with advanced changes may have few or no symptoms. Crepitus are often detectable X-ray abnormalities are often apparent, but laboratory findings indicative of inflammation are absent Intervention The main goals are: Preventing joint deformity Preserving joint function Reducing inflammation and pain

Rest Physical and emotional rest are important. Complete bed rest is indicated for a limited time for its anti-inflammatory effect. Positioned to prevent deformities The patient should lie flat on the back with affected joints in position of extension up to 10 hours a day while on bed rest. A small pillow may be placed under the ankles to straighten the knees. Position arms with palms upward by placing small pillows under elbows or wrists to maintain extension. Use sandbags and trochanter rolls as necessary to maintain proper body alignment. Splints may be used to rest inflamed joints. Splints are removed periodically and the joints exercised to prevent fibrous ankylosis

Physical therapy To strengthen weakened muscles and improve function. Isometric exercises are important in maintaining muscle function even when splints are applied. Exercise must be done within the persons pain tolerance Never massage acutely inflamed joints, because it my aggregate the inflammation

Teaching proper posture Heat and cold application to relieve aches, swelling and stiffness. Serves as an anesthetic effect

Medication Aspirin Analgesic and anti-inflammatory Nursing considerations: 1. Take with food 2. Watch signs of bleeding Other NSAIDs Adrenocorticosteroids

Surgical treatment Tendon transfers A functioning tendon is shifted from its original attachment to a new one to restore the action that has been lost. Osteotomy Excising or cutting through bone Synovectomy Removal of synovial Arthodesis Surgical immobilization or fusion of joint Arthroplasty

Surgical formation or reformation of a joint with or without replacement of joint parts with prostheses Joint replacement Silicone implants are used to replace joints as small as those of fingers Total Hip Replacement Total Knee Replacement

Gouty Arthritis Is a familial disorder of purine metabolism resulting in abnormal amounts of urates in the body. Purines are products from the digestion of certain proteins. Inability to properly metabolize purines produces an excessive accumulation of uric acid in the blood plasma. As a result, urate crystals may be deposited throughout the body. These deposits initiate local irritation and an inflammatory response. Acute attacks of gouty arthritis may accompany other disorders (hematopoietic disorders such as polycythemia or leukemia). These attacks are called secondary gout Arthritis is the main clinical problem with gout. Early in the course of illness, a recurring, acute arthritis occurs that is usually monoarticular. Later a chronic, deforming arthritis develops. About 95% of people with gout are men over 30. If gout develops in women, it is usually after the menopause. Gout is characterized by acute periodic episodes of joint pain, swelling, and inflammation. Foot joints and knee are most often affected On histologic examination it is characterized by the formation of tophi in soft tissues or monosodium urate crystals in synovium or synovial fluids The attack is usually sudden, occurring at night. Crushing and often pulsating pain increases until there is no relief from any body position. It is most often involves the metatarsophalangeal joint of the great toe. The involved joint is usually intensely painful, swollen, and extremely tender Xray shows punched out areas in the bone

3 stages 1. Asymptomatic Hyperuricemia 2. Acute gouty arthritis 3. Tophaceous gout Intervention Colchicine To reduce frequency of acute attacks Probenecid Block the tubular reabsorption of filtered urate in the kidneys Allopurinol Inhibits uric acid formation Dietary management Surgical removal of large tophi

Osteoporosis Is a metabolic bone disorder in which bone mass is decreased. Bone become borous and brittle Bone resorption occurs faster than bone formation Most often affects women between ages 50 and 70 Osteoporosis may occur: Primary lost of estrogen Secondary Cushing Long term large doses of corticosteroids Prolonged immobilization Calcium deficiency

It can be detected by x-ray and nuclear medicine scans Symptoms begin with pain in weight bearing vertebrae. Bodys supporting structure is weak, therefore risk for spontaneous fractures Intervention Symptomatic Goals are to control pain and prevent fractures.

Gentle exercise is important. Estrogen may decrease bone resorption and Flouride may promote bone formation. Calcium and Vit. D may be taken either in the diet or as a supplement

Osteomalacia Is a disorder in which adult bone becomes spongy because of disturbed calcium and phosphate metabolism resulting from: Lack of dietary intake of vitamin D The bodys failure to absorb or use vitamin D Lack of exposure to ultraviolet rays Osteomalacia may be identified by reduced calcium and phosphorus levels, rachitic bone deformities, bone pain and tenderness, x-ray changes. Biopsy may help establish diagnosis. A smaller disorder occurs in children like rickets Intervention Vitamin D Adequate intakes of calcium Calcium salts and phosphate supplements may be prescribed