Musculoskeletal
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Osteoarthritis
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2
Osteoarthritis (OA)
• Slowly progressive noninflammatory
disorder of the diarthrodial joints
• 30 million Americans affected
• Numbers expected to increase as
population ages
• More common in women
• Especially hand OA and knee OA (after
menopause)
• Most men affected by 70 to 80 years, except for
traumatic arthritis
• Hip OA more common
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3
Etiology and Pathophysiology
• Gradual loss of articular cartilage
• Formation of osteophytes at joint margins
• Not normal part of aging process
• Cartilage destruction
•
•
•
•
Begins between ages 20 and 30
Most adults affected by age 40
Symptoms manifest after age 50 to 60
More than 50% over age 65 have x-ray evidence of
OA in at least 1 joint
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4
Pathologic Changes in OA
(Fig. 64-1)
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5
Manifestations: Joints
• Joint pain – (Pain with movement)
 Primary symptom ranging from mild discomfort to
significant disability
 Pain worsens with joint use
• Early stages: rest relieves pain
• Later stages: pain with rest and trouble
sleeping due to increased joint pain
 Pain may worsen with lower barometric pressure
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6
Manifestations: Joints
7
• Joint stiffness occurs after periods of rest or unchanged
position
• Early morning stiffness usually resolves within 30
minutes
• Distinguishes from rheumatoid arthritis
• Overactivity leads to mild joint effusion, temporarily
increasing stiffness
• Crepitation (grating sensation)
• OA affects joints asymmetrically
• Assess infection risk, thinning skin, and elevated BGL
for all patients on steroids
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Manifestations: Joints
8
• Joints most affected by OA
Hips
Knees
Metatarsophalangeal (MTP)
Cervical vertebrae
Lumbar vertebrae
Distal interphalangeal (DIP)
Proximal interphalangeal
(PIP)
• Metacarpophalangeal (MCP)
•
•
•
•
•
•
•
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Fig. 64-2
Manifestations: Deformity
• Specific to joint involved
• Heberden’s nodes: DIP (see slide 19)
• Bouchard’s nodes: PIP
• Appear red, swollen, and tender
• Varus deformity (bowlegged): medial knee
• Valgus deformity (knock-kneed): lateral knee
• One leg shorter than the other: hip
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9
Heberden’s nodes
(Fig. 64-1D)
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10
Interprofessional Care
Nutritional Therapy and Exercise
 If overweight, weight-reduction critical
 Dietary changes as needed
 Exercise
 Aerobic
 Range of motion
 Muscle strengthening
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11
Ambulatory Care
 Home and work environment modification
 Eliminate scatter rugs; use railings and night lights
 Wear well-fitting support shoes
 Assistive devices
• Canes, walkers, elevated toilet seats,
grab bars
• CANE – “COAL” Cane Opposite Effected Leg
• Always lead with effected leg and device
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12
Osteoporosis
 Weakening of the bones
 Hallmark sign is frequent fractures /
breaks
 Patients will gradually lose height
 Runs in families, assess genetic risk
 Bone scans and Dual-energy x-ray
absorptiometry (DXA) to assess
extent
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13
Rheumatoid Arthritis
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14
Rheumatoid Arthritis (RA)
• Chronic, systemic autoimmune disease;
inflammation of connective tissue in
diarthrodial (synovial) joints
• Periods of remission and exacerbation
• Extraarticular manifestations
• Disabling form of arthritis causing loss of independence
and self-care
• Mobility aids or joint reconstruction may be needed if
treatment inadequate
• Teach to use cold packs prior to exercise to
decrease pain
15
Rheumatoid Arthritis
Fig. 64-3
16
Manifestations: Joints
• Onset typically subtle
• Fatigue, anorexia, weight loss, generalized
stiffness that becomes localized stiffness
with progression
• May report history of precipitating stressful
event
• Infection, stress, exertion, childbirth, surgery,
emotional upset
• No direct correlation found in research
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17
Typical Deformities of
Rheumatoid Arthritis (Fig. 64-4)
18
Extraarticular Manifestations
19
• Sjögren’s syndrome
• Dry, gritty eyes and photosensitivity
• Felty syndrome
• Enlarged spleen and low WBCs result in increased
risk of infection and lymphoma
• Flexion contractures
• Decreased self-care
• Depression
• Pain and disability
• Increased C-reactive protein levels
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Drug Therapy: DMARDs
20
• Methotrexate
• Early treatment
• Lower toxicity
• Side effects (rare): bone marrow
suppression and hepatotoxicity
• Need to monitor CBC and blood chemistry
• Therapeutic effects in 4 to 6 weeks; may be
given alone or with biologic response
modifiers
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Drug Therapy: DMARDs
• Sulfasalazine (Azulfidine) and
hydroxychloroquine (Plaquenil)
• Used for mild to moderate disease
• Drink fluids
• Wear sunscreen
• Eye exam: baseline, then every 6
to 12 months
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21
Other Drug Therapy
• Corticosteroid therapy
• Intraarticular injections
• Low-dose oral for limited time
• Complications: osteoporosis and avascular
necrosis
• NSAIDs and salicylates
• Treat pain and inflammation
• May take 2 to 3 weeks for full effectiveness
• Celecoxib (Celebrex): COX-2 inhibitor
• Non-aspirin NSAIDs increase risk of blood
clots, heart attack, and stroke
Naproxen = NSAID – Nephrotoxic and GI Irritation
22
Ambulatory Care
Rest
• Alternate rest periods with activity
• Helps relieve pain and fatigue
• Amount of rest varies
• Avoid total bed rest
• 8 to 10 hours of sleep plus daytime rest
• Modify activities to avoid overexertion
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23
Ambulatory Care: Cold and Heat
Therapy and Exercise
• Relieve pain, stiffness, and muscle spasm
• Cold
• Especially beneficial during periods of disease
activity
• Application should not exceed 10 to 15 minutes at
one time
• Bags of frozen vegetables, ice
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24
Ambulatory Care: Cold and Heat
Therapy and Exercise
25
• Moist heat
• Relieve chronic stiffness
• Should not exceed 20 minutes at a time
• Heating pads, moist hot packs, paraffin baths,
warm baths, or showers
• Do not use with topical heat-producing
cream
• Be alert for burn potential
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Ambulatory Care: Cold and Heat
Therapy and Exercise
• Gentle ROM exercises done daily to keep joints
functional
• Aquatic exercises in warm water beneficial
• Limit to one or two repetitions during acute
inflammation
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26
Ambulatory Care: Cold and Heat
Therapy and Exercise
• Gentle ROM exercises done daily to keep joints
functional
• Aquatic exercises in warm water beneficial
• Limit to one or two repetitions during acute
inflammation
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27
Gout
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28
Gout
• Incidence in United States
greater than 8 million
• Men three times more
than women
• Develops in men age 30 to
50
• Women rarely have gout
before menopause
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29
Gout: Etiology and
Pathophysiology
• Uric acid is the end product of purine
metabolism; excreted by kidneys
• Gout occurs if kidneys can’t excrete enough or if
too much is being made
• Primary hyperuricemia: genetic
• Secondary hyperuricemia: increased
production, decreased excretion, or drugs
that inhibit uric acid excretion; organ
transplant recipients getting
immunosuppressants also at risk
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30
Gout: Etiology and
Pathophysiology (2 of 2)
• Caused by interaction of factors
• Metabolic syndrome
• Increased intake of high purine foods
• Prolonged fasting
• Excessive alcohol
• Two processes must occur
• Crystallization
• Inflammation
• Phagocytosis causes increased inflammation
and tissue damage
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31
Clinical Manifestations
• One or more joints (usually less than 4)
• Most common is the great toe (podagral)
• Other: wrists, knees, ankles, midfoot, olecranon
bursae
• Dusky or cyanotic
• Very tender
• Triggers: trauma, surgery, alcohol, or
systemic infection
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32
Tophi of Chronic Gout
(Fig. 64-6)
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33
Diagnostic Studies
• Serum uric acid higher
than 6 mg/dL
• 24-hour urine for uric
acid
• Synovial fluid
aspiration
• Clinical symptoms
• X-ray of affected joint
34
Interprofessional and Nursing
Management
• Drug therapy
• Prevention
• Allopurinol (Zyloprim or Aloprim) or
febuxostat (Uloric)
• Probenecid—uricosuric: increase urinary
excretion of uric acid; must avoid
aspirin
• Lesinurad (Zurampic): uricosuric (new)
• Duzallo—combination lesinurad and
allopurinol
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35
Interprofessional and Nursing
Management: Gout
• Monitor serum uric acid regularly
• Dietary restrictions
• Limit alcohol and food high in
purine
• Adequate urine volume
• Weight reduction
• Nursing interventions
• Supportive care of inflamed joint
• Assess motion limitations and pain
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36
Lyme Disease
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37
Lyme Disease
• Borrelia burgdorferi infection transmitted by
deer tick bite
• Most common vector-borne disease in United
States; 7.9 cases per 100,000 people
• No person-person transmission
• Summer is time of peak transmission
• Three areas in United States
• Northeast: Maryland to Massachusetts
• Midwest: Wisconsin and Minnesota
• Northwest coast: California and Oregon
• Reinfection common
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38
Manifestations
• Characteristic: erythema migrans (EM)
• Bull’s eye rash (see slide 136)—occurs in 80%
• Appears within 1 month of exposure
• May occur elsewhere on body with disease
progression
• Central red macule or papule expanding to
outer red ring up to 12 in
• Warm to touch; not itchy or painful
• Occurs with acute flu-like symptoms:
• Low-grade fever, headache, neck stiffness,
fatigue, loss of appetite, migratory joint,
and muscle pain
• Resolve over weeks to months, even without
treatment
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39
Erythema Migrans (EM)
(Fig. 64-7)
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40
Manifestations
• Without treatment can spread to heart,
joints, and CNS
• Arthritis: second most common symptom
• 60% get chronic arthritic pain; knee
• Cardiac: heart block and pericarditis
• Neurologic: Bell’s palsy
• Other: short-term memory loss, cognitive
impairment, shooting pains, numbness, and
tingling in feet
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41
Septic Arthritis
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42
Septic Arthritis
• Infectious or bacterial arthritis
• Microorganism invades joint cavity
• Hematogenous spread, trauma or surgical
incision
• Most common: Staphylococcus aureus
• Risk factors:
• Diseases with decreased host resistance
• Corticosteroid or immunosuppressant
therapy
• Debilitating chronic illness
• Gonorrhea is a common cause, assess
sexual risk factors and causes
43
Septic Arthritis
• Most affected joints: knee and hip
• Symptoms: severe pain, redness, and
swelling; fever, shaking chills
• Hip: avascular necrosis
• Diagnosis:
•
•
•
•
Arthrocentesis (joint aspiration)
Synovial fluid culture
WBC count
Blood cultures
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44
Spondyloarthropathie
s
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45
Spondyloarthropathies
• Group of multisystem inflammatory disorders
affecting the spine, peripheral joints and
periarticular structures.
• Includes: ankylosing spondylitis, psoriatic
arthritis, and reactive arthritis
• Seronegative arthroplasties are RF negative
• Genetic and environmental factors
• HLA-B27 associated with these diseases
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46
Ankylosing Spondylitis
• Chronic inflammatory disease that
primarily affects axial skeleton
• Sacroiliac joints, intervertebral disc spaces, and
costovertebral articulations
• Onset: 30’s or adolescence
• Men three times greater than women
• Women have milder course; undetected
• Straight leg Raising test – Raise the pts leg to
60 degrees from the side of the bed to assess
spinal herniation
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47
Clinical Manifestations
48
• Inflammatory spine pain is first sign
• Low back pain, stiffness, and limitation of
motion that is worse in morning and night;
improves with mild activity
• Uveitis may present before arthritic symptoms
• Chest pain and sternal/costal tenderness
• Postural abnormalities and deformities (see slide 151)
Advanced ankylosing spondylitis
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Fig. 64-8
49
Systemic Lupus
Erythematosus (SLE)
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50
Systemic Lupus Erythematosus
• Multisystem inflammatory autoimmune
disease
• Complex multifactorial disorder
•
•
•
•
Genetic
Hormonal
Environmental
Immunologic
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51
Systemic Lupus Erythematosus
• Affects
• Skin
• Joints
• Serous membranes
• Pleura
• Pericardium
• Renal system
• Hematologic system
• Neurologic system
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52
Butterfly Rash of SLE
(Fig. 64-10)
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53
Clinical Manifestations and
Complications
• Musculoskeletal problems
• Polyarthralgia with morning
stiffness
• Diffuse swelling
• Arthritis
• Swan neck deformity in
fingers
• Ulnar deviation
• Subluxation with
hyperlaxity of joints
• Increased risk of bone loss and
fracture
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54
Swan Neck Deformity
(Fig. 64-4D)
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55
Nursing Implementation
56
• Lupus and Pregnancy
• SLE common in women of childbearing age;
pregnancy/treatment during pregnancy must be
addressed
• Infertility may have occurred from renal
involvement, high-dose corticosteroids, and
immunosuppressive drugs
• Spontaneous abortion, stillbirth, and
intrauterine growth retardation are common
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Scleroderma
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57
Scleroderma (Systemic sclerosis)
• Connective tissue disorder
characterized by fibrotic,
degenerative, and sometimes,
inflammatory changes in the skin,
blood vessels, synovium, skeletal
muscle, and internal organs
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58
Scleroderma
• Types:
• Localized: more common, better
prognosis. Skin changes limited to
few places; does not involve trunk
or internal organs
• Systemic: rapidly progressive skin
and connective tissue changes
with internal organ involvement
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59
Scleroderma
Etiology and Pathophysiology
• Exact cause unknown; believed to develop due
to immunologic and vascular abnormalities
• Overproduction of collagen (see Fig. 64-11 in
the textbook) causes progressive tissue fibrosis
and blood vessel occlusion
• Disrupts function of lungs, kidneys, heart, and
GI tract
• Vascular problems involving the small arteries
and arterioles occur early
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60
Sclerodactyly in the Hand
(Fig. 64-12)
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61
Clinical Manifestations
• Internal organ involvement
• Sjögren’s syndrome: dry eyes and mouth; 20%
with systemic disease
• Dysphagia, gum disease and dental decay
• Esophageal fibrosis can cause gastric acid
reflux
• Hypomotility of esophagus and dysphagia
can lead to decreased food intake and
weight loss
• Constipation from colonic hypomotility
• Diarrhea due to bacterial overgrowth
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62
Polymyositis and
Dermatomyositis
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63
Polymyositis (PM) and
Dermatomyositis (DM)
• Polymyositis: diffuse, idiopathic,
inflammatory myopathy of striated
muscle
• Dermatomyositis: muscle changes of
polymyositis with skin changes
• Rare disorders
• Affect adults older than 20 years
• Women two times more than men
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64
PM and DM
• Clinical manifestations and complications
• Muscular
• Weight loss
• Fatigue
• Muscle weakness in the shoulders, legs,
arms, and pelvic girdle
• Difficulty performing routine activities and
repetitive movements
• Unable to move against resistance or gravity
• Dysphagia and dysphonia due to weak
pharyngeal muscles
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65
Mixed Connective Tissue Disease
• Combination of clinical features of
several rheumatic diseases
• SLE, scleroderma, and PM
• Affects women in 20s to 30s
• Overlap syndrome
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66
Sjögren’s Syndrome
• Common autoimmune disease that targets
moisture-producing exocrine gland
• Xerostomia and keratoconjunctivitis
sicca
• Other glands in stomach, pancreas, and
intestines
• Affects people over age 40
• Women 10 times more than men
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67
Sjögren’s Syndrome
68
• Primary Sjögren’s syndrome
• Lacrimal and salivary symptoms
• 20% to 40% also have lung, liver, kidneys, and skin
involvement
• Increased risk for non-Hodgkin’s lymphoma
• Etiology: genetic and environmental
• Genes: Whites; Japanese, Chinese, African
American
• Trigger: viral or bacterial infection; lymphocytes
attack lacrimal and salivary glands
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Sjögren’s Syndrome
• Manifestations
• Dry eyes: burning, blurred vision,
photosensitivity
• Dry mouth: buccal fissures, change in taste,
dysphagia, mouth infections, dental decay
• Other: dry skin, rashes, joint and muscle pain,
and thyroid problems (e.g., Grave’s disease and
Hashimoto’s thyroiditis)
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69
Myofascial Pain
Syndrome
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70
Myofascial Pain Syndrome
• Chronic muscle pain and tenderness
• Chest, neck, shoulders, hips, and lower back
• Referred pain to:
• Buttock, hand, and head
• Can cause temporomandibular joint (TMJ)
pain
• Occurs most with middle-aged adults and
women
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71
Myofascial Pain Syndrome (3 of
3)
• Treatment
• Physical therapy
• “Spray
and stretch” method—painful area is
iced or sprayed with a coolant and then
stretched
• Topical patches
• Trigger point injections
• Massage, acupuncture, biofeedback, ultrasound
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72
Fibromyalgia
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73
Fibromyalgia
• Chronic central pain syndrome
• Widespread, nonarticular musculoskeletal pain
and fatigue
• Multiple tender points
• Also have:
• Nonrestorative sleep
• Morning stiffness
• Irritable bowel syndrome
• Anxiety
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74
Fibromyalgia
• Common disorder
• Major cause of disability
• Affects 3.7 million in United States
• More common in women ages 40 to 75 years
• Many shared features with systemic exertion
intolerance disease (SEID)
• See Table 64-20 in the textbook
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75
Tender Points in Fibromyalgia
76
• Physical examination
• Point tenderness in 11 of
18 sites
• Pain throughout body
• Pain from unusual
stimulus (allodynia)
• Pain varies day to day
• Sometimes fewer than
11 sites
• Sometimes all sites
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Fig. 64-14
Fibromyalgia: Clinical
Manifestations and Complications
• Stiffness
• Nonrefreshing sleep
• Fatigue
• Paresthesia in hands and feet
• Restless legs syndrome – (Teach Regular Exercise)
77
Fibromyalgia
Interprofessional Care
• Drug therapy for chronic widespread pain
• Pregabalin (Lyrica)
• Duloxetine (Cymbalta)
• Milnacipin (Savella)
• Low-dose tricyclic antidepressants (TCAs),
SSRIs, or benzodiazepines
• Muscle relaxants
• OTC and nonopioid analgesics
• Zolpidem (Ambien)
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78
Fibromyalgia
Nursing Management
• Limit intake of sugar, caffeine, alcohol
• May be muscle irritants
• Vitamin and mineral supplements
• Avoid “miracle” diets and supplements
• Relaxation strategies
• Biofeedback, imagery, meditation, cognitive
behavioral therapy
• Psychologic counseling and support group
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79
Systemic Exertion
Intolerance Disease
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80
Systemic Exertion Intolerance
Disease (SEID)
• Formerly: chronic fatigue syndrome
• Complex, multisystem disease
• Physical, emotional, or cognitive exertion impaired
and accompanied by profound fatigue
• Affects at least 1 million people in United
States
• Many undiagnosed
• Women 3 to 4 times more than men
• Affects all ethnicities; more common in
minorities and socioeconomically
disadvantaged
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81
SEID Etiology and Pathophysiology
• Precise mechanisms remain unknown
• Many theories exist about cause
• Neuroendocrine abnormalities involving a
hypofunction of HPA axis and
hypothalamic-pituitary-gonadal (HPG)
axis
• Several microorganisms investigated
• Changes in CNS
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82
SEID: Interprofessional
Management
• Severe occupational and psychosocial loss; social
pressure and isolation
• Labeled lazy or crazy
• SEID does not appear to progress
• Most patients recover or gradually improve over time
• Some do not show significant improvement
• Recovery more common with sudden onset
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83
Musculo Wrap Up
84
• Joint Abnormalities
• Osteoarthritis – Non inflammatory, pain with movement
• Rheumatoid – Inflammatory, autoimmune, causes
discomfort and deformities such as Swan Neck
• Bursitis – Inflammation of fluid filled sac that cushions
the joint
• Osteoporosis – Softening of the bone with aging. Can
cause Pt to become shorter. Assess with DXA or bone scan
• Pain management
• Alternate rest with activity
• Use cold packs prior to exercise