OA, a debilitating disease afflicting the joints, is the most prevalent form of arthritis in the U.S.¹ It is estimated to affect up to 40 million Americans.² According to the National Institutes of Health (NIH), 35 million people, which is 13% of the U.S. population, are 65 and older. More than half of them have radiological evidence of osteoarthritis in at least one joint. By 2030, an estimated 20% of Americans, about 70 million people, will be over the age of 65 and will be at increased risk for OA.³

The probability is great that you and many of your patients will develop OA, the major cause of activity limitation and disability in older people. OA occurs more frequently in males before 45 years of age and in females after age 55. Although rare before age 40, almost all people, including nurses, will have either radiologic or clinical evidence of OA by the age of 75.¹ This disease is not simply a result of aging, but of biomechanical changes and stresses affecting articular cartilage. And this is a disease where nurses can make a difference for themselves as well as their patients. What are you doing now to avoid the debilitating effects of OA?

Mrs. Dumont, a 48-year-old factory worker, visited her primary care provider with complaints of debilitating hip pain. Clinical examination found flexion contraction of the hips, limited motion in her lower extremities, significant pain on weight bearing and motion, and moderate obesity. X-rays revealed severe, bilateral hip OA. She was referred to an orthopedic surgeon who recommended bilateral total hip replacement and prescribed piroxicam (Feldene) to control the pain for the interim period before surgery. However, Mrs. Dumont did not fill the prescription because of concerns about adverse effects as well as the cost for the prescription. Conversely, she could not afford to take time off from work for surgery and recovery afterwards. Without pain medicine or treatment, the pain and OA continued until she was so debilitated that she could no longer work. At this critical point in her life, Mrs. Dumont decided to empower herself with knowledge that would allow her to develop an overall plan to manage her OA disease. She began participating in a weight-loss program, taking yoga classes, performing strength-training exercises, taking nutritional supplements, and using acetaminophen for pain. Although her OA management plan did not cure her disease, it enabled her to avoid surgery and return to work. She had independently initiated a program that is not often provided for patients with OA. Nurses have an opportunity to promote such programs for patients with OA by educating them about the therapies that are now available for managing the disease.

Managing the cycle of disease

Disease management is an approach to patient care that coordinates resources across the entire health care delivery system and throughout the cycle of a disease.⁴ This may be one of the best alternatives for reducing the long-term health care costs of chronic disease, while providing quality care. Nurses are an integral part of the development and implementation of a successful disease management plan for the patient with OA.

The first step in disease management of OA is to definitively diagnose the condition on the basis of clinical history, course, physical examination, radiologic changes, and laboratory results. The primary clinical sign is pain. Other clinical findings vary depending on the joints afflicted, and may include crepitus on active joint motion, morning stiffness, swelling, and joint enlargement. X-rays can document the presence and severity of disease, but little correlation is noted between radiologic and clinical findings with respect to the patient’s pain level.

No single laboratory test can confirm a diagnosis of OA: Patients with OA typically have normal test results, including complete blood count (CBC), erythrocyte sedimentation rate, rheumatoid factor (RF), and serum chemistries. The RF is negative in patients with OA, but positive for those with rheumatoid arthritis (RA). These two diseases are distinct clinical entities, and OA is not a precursor for RA. Clinicians can examine synovial fluid for characteristics of OA; the fluid may be clear, viscous, and/or have polymorphonuclear leukocytes greater than 2,000/cc.⁵

OA can be idiopathic, appearing in the foot, great toe, hand, hip, knee, cervical or lumbar spine, and/or other single joints. It can also be secondary to a past traumatic injury, developing years after injury to or near a joint. Repeated minor injuries to a joint or a single injury that changes the joint structure may serve as a precursor to development of OA. Repetitive activities stressing a joint can be squatting, kneeling, and/or heavy lifting. Mr. Galiano, a 55-year-old former professional football player, presented to his physician with complaints of knee pain. Still very active, he sought treatment for his OA pain primarily so that he could continue his active lifestyle. Mr. Galiano had been working through his pain during a low-impact exercise program, which facilitates distribution of the synovial fluid in his joint. Years of football and related injuries had resulted in OA that has affected him, but to a lesser extent than those who become inactive as a result of OA pain. Arthritis is the leading cause of disability in the U.S. By 2030, it is predicted that 25 million Americans with OA will be forced to limit their daily activities.⁶ Arthritis costs the U.S. economy more than $86.2 billion a year in lost productivity and direct medical costs.⁷

OA can also be a congenital or developmental disease, such as congenital subluxation/dislocation of the hip or acetabular dysplasia; calcium deposition disease; and/or other bone or joint disorders and diseases, such as avascular necrosis, Paget’s disease, and rheumatoid, gouty, or septic arthritis.²

The next step in a disease management program is to identify the available pharmacologic and nonpharmacologic therapies. Surgical procedures, including total joint replacements, are reserved for the most severe and debilitating disease after these remedies have failed.

Pharmacologic therapies

Pharmacologic therapies include nonnarcotic analgesics, topical analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs) and COX-2 inhibitors, narcotic analgesics, and intra-articular injections.

Nonnarcotic analgesics, such as acetaminophen or aspirin, are relatively inexpensive, over-the-counter (OTC) medications that can provide sufficient pain relief. However, because patients do not require a prescription or visit to a health care provider to obtain these analgesics, they may be less likely to have routine encounters with health care personnel and be left with the difficulties of managing their disease on their own.

Acetaminophen (325 mg tablets, one to two every four to six hours, not to exceed 4,000 mg per day) is an appropriate first-line agent for the treatment of OA. Hepatotoxicity and severe hepatic failure have occurred in chronic alcoholics following therapeutic doses. A safe dose for a chronic alcohol abuser has not been determined. Patients who are chronic alcoholics should be cautioned to limit acetaminophen intake to less than 2,000 mg per day.⁸

Aspirin is also an effective drug for the use of pain from OA. Aspirin is the most commonly used drug worldwide. Although considered safe, incorrect use can lead to serious effects, such as the bleeding associated with high doses. The use of aspirin during pregnancy may produce adverse effects in the mother, such as anemia, antepartum or postpartum hemorrhage, prolonged gestation, and prolonged labor. Salicylates are possible teratogens and pregnant women should avoid them, especially during the third trimester of pregnancy.⁸

NSAIDs, such as ibuprofen (Advil, Motrin, Nuprin), ketoprofen (Orudis), and naproxen (Aleve), are available OTC. Other NSAIDs and COX-2 inhibitors, listed in the sidebar, require a prescription.⁸

Improvement of OA is demonstrated by a reduction in tenderness with pressure, pain in motion and at rest, night pain, stiffness and swelling, and overall disease activity, along with better range of motion.⁸ Although NSAIDs can do all that, they are more expensive than other nonnarcotic and topical analgesics. They are also associated with more gastrointestinal, central nervous, renal side effects, hypersensitivity, and renal and hepatic function impairment. Finally, warnings for the elderly, pregnant or lactating women, and children temper the use of NSAIDs.⁸

NSAIDs target the enzyme cyclooxygenase, which is responsible for much of the inflammation resulting in patients’ pain. Celecoxib (Celebrex) and rofecoxib (Vioxx) were the first of the new class of COX-2 inhibitors that were approved by the Food and Drug Administration for OA in 1998 and 1999, respectively. COX-2 inhibitors potentially had fewer “stomach-plaguing adverse effects” than NSAIDs.⁹ In one study where celecoxib was used for six months in doses two to four times the maximum therapeutic dosage, a lower incidence of combined upper GI events than in a comparative NSAID group with ibuprofen and diclofenac at standard therapeutic dosages was observed.¹⁰ A more recently approved (2001) COX-2 inhibitor is valdecoxib (Bextra).

In 2004, Merck, the manufacturer of rofecoxib, voluntarily pulled this drug from the market worldwide when data from a clinical trial found increased risk of heart attack and stroke. Likewise, Pfizer found an increased risk of heart attacks and strokes for patients taking high dosages of its drug, celecoxib, although no plans were announced for its withdrawal. Increased heart problems have also been associated with Pfizer’s valdecoxib. Such incidents are drawing the attention of the FDA, which has advised physicians to consider prescribing alternate drugs.

Narcotic analgesics, such as propoxyphene, codeine, and oxycodone hydrochloride, are effective in the short-term for the treatment of OA pain. However, due to the inherent problems with controlled substances, such as tolerance, dependence, and addiction, narcotic analgesics are not recommended for long-term use. Safety for use during pregnancy has not been established for these narcotics.

Topical analgesics, such as capsaicin (Dolorac, Zostrix) and methyl salicylate creams, appear to be valuable adjuvants to current arthritis treatment to enhance pain control. For example, one study of 70 patients with OA of the knee found that topical capsaicin cream significantly reduced pain over a placebo without the risk of the systemic side effects or adverse drug interactions associated with systemic therapies.¹¹ Patients can purchase methyl salicylate creams, such as Ben-Gay, Exocaine, and Icy Hot, OTC. Other topicals suggested to reduce associated pain include products ranging from those with menthol creams to Epsom Salt gel.

Intraarticular injections, using steroids or hyaluronic acid (HA), can be of particular benefit for patients who cannot tolerate NSAIDs or other long-term use of analgesics. However, the benefit of intraarticular injections with corticosteroids is still debated in the medical community despite their use over the last 50 years.

In OA of the knee, when simple painkillers, exercise, and physical therapy are not enough, HA can make previously painful daily activities more comfortable to perform. HA is thought to have an effect that protects cartilage. Injections of HA are typically provided weekly for three to five weeks and relieve pain for six months or more. As with any injection, the patient may feel temporary, mild pain at the injection site. Adverse effects include swelling, heat and/or redness, rash, itching, or bruising around the joint. These reactions are generally mild and usually do not last long. Patients with infection or skin disease around the area to be injected should not receive intra-articular injections. The safety and efficacy of HA has not been established in pregnant women or women who are nursing.⁸

Nonpharmacologic therapy

Nonpharmacologic therapy includes patient education, dietary counseling, and physical and occupational therapy. The goals are to control symptoms, minimize disability, and equip patients and their families with an understanding of the disease, and its therapy. This therapy for treating OA uses a multidisciplinary team approach. However, due to the managed care environment and in the face of limited and, in some cases, no health insurance, the nurse of the 2000s may need to be the patient educator or even the provider of these nonpharmacologic therapies.

Patient education, particularly about dietary issues and physical and occupational therapies, is a fundamental aspect of the disease management plan. Nurses can teach patients informally by providing them with OA information, for example, about diet, nutrition, and exercise, or more formally by suggesting patient participation in self-help courses offered by the Arthritis Foundation or the Arthritis Society.

One study reported that health education in chronic arthritis may add significant and sustained benefits to conventional therapy, while reducing costs.¹² This study evaluated the effectiveness of an arthritis self-management program in two groups of 224 and 177 patients. Pain diminished by a mean of 20%, visits to physicians declined by 40%, and even physical disability decreased.

Results of the Arthritis Self-Help Course offered by the Arthritis Foundation have been favorable. Attendees have reported less pain, decreased frequency of physician visits, and overall improvement in quality of life. In addition, the Arthritis Society offers self-help books that can help people with arthritis change their activities and abilities, reduce their pain, and most important, develop more confidence in themselves as caretakers of their bodies.¹³ These books emphasize that —

• Each person is different, and therefore, no one treatment is right for everyone.
• People can do a number of things that may help to relieve pain, maintain or increase mobility, and prevent deformity, but they will not cure arthritis.
• With knowledge, each person is the best judge of which self-management techniques are best.

Both education and communication about the status of therapies are important to achieving the end goal of reducing patients’ pain and enhancing their functional outcomes. Nurses need to provide social support for patients via routine telephone contact. Patients should know that their nurses are in close contact with primary health care providers regarding the status of their OA.

Dietary counseling to develop a comprehensive weight management program and to assist patients with weight reduction as needed is a fundamental step in the management of OA. For example, obesity is a major risk factor for the development and progression of OA of the knee and is considered to be a major contributor to the anatomical damage in women.¹ Additional body weight may force changes to a patient’s walking gait as well as to posture and can alter the normal structure of a joint. Being overweight can further exacerbate osteoarthritis once the degenerative process has begun.

More than half of all U.S. adults are overweight or obese, with approximately 97 million Americans thus predisposed to OA. Being overweight, coupled with OA, can result in decreased physical activity, a vicious perpetuating cycle of pain and inactivity, and/or disability.

Nurses can calculate body mass index (BMI) to determine the patients who are overweight or obese. The BMI formula is as follows:

BMI calculators can also be used, such as the one found at this CDC website: www.cdc.gov/nccdphp/dnpa/bmi/adult_BMI/english_bmi_calculator/bmi_calculator.htm. A BMI of 25 to 29.9 is overweight and a BMI of 30 or above is obese. A male or female 5’8” and 137 lbs has a BMI of 20.8, a normal weight category finding (18.5-24.9 BMI). Add 30 lbs, and the patient is overweight with a BMI of 25.4. Add another 60 lbs (5’8”, 197 lbs), and the patient is obese with a BMI of 30. It should be noted that patients with increased musculature may have higher BMIs, a finding indicative of muscle mass weighing more than fat.

Waist circumference is another measure of obesity as it is associated with abdominal fat. A waist circumference of over 40 inches in men and over 35 inches in women may result in higher risk for diseases such as OA.

For OA patients who are also overweight or obese, the nurse can suggest the following strategies for weight loss, per the guidelines released by the National Heart, Lung, and Blood Institute in June 1998: calorie reduction, increased physical activity, and behavior therapy designed to improve eating and physical activity habits. Additional recommendations include:

• Moderate physical activity, progressing to 30 minutes or more on most or preferably all days of the week.
• Reduce dietary fat, which can help reduce calories.
• Reduce body weight by approximately 10% from baseline within a six-month period, losing 1-2 lbs per week. Further weight loss would be patient specific to facilitate BMI of normal weight.

Some nutritional supplements, such as glucosamine, chondroitin sulfates, manganese, methylsulfonylmethane, vitamin C, and cod liver oil, have been touted as “wonder drugs” for OA. However, it is difficult to substantiate claims that nutritional supplements can stop or reverse OA disease by research that meets the same regulatory requirements for safety and efficacy as that of pharmaceutical products.

Physical therapy and regular physical activity have produced numerous well-documented benefits.¹⁴ Besides an improved overall sense of well-being, exercises focusing on range of motion, muscle strengthening, and endurance can reduce pain and maintain joint function. Isometric exercises for muscle strength can help stabilize joints and provide a more even distribution of weight to prevent further injury.¹⁵

A disease management plan should include exercise, whether it is yoga, aerobic conditioning, quadriceps strengthening exercises, or an organized exercise program in which good posture is stressed. The individual patient’s condition guides physical therapists to tailor a comprehensive exercise program that may include supervised physical therapy and unsupervised home exercise. Moist heat, massage, and prescribed exercises can relax muscles and reduce aching and stiffness.

Occupational therapy is important to patients with either moderate or severe debilitating disease. An occupational therapist determines the assistance patients’ need on a daily basis to perform activities of daily living as independently as possible. Patients can take advantage of numerous assistive devices, ranging from walking sticks, canes, and walkers to dressing sticks, wall bars, and raised toilet seats. Occupational therapists can also educate patients with OA about techniques for protecting their joints and energy conservation to prevent and/or minimize further disability.

Surgical procedures

Surgical procedures are typically performed on patients with severe cases of OA after the pharmacologic and nonpharmacologic therapies have failed. Surgical procedures include arthroscopic surgery, tidal knee irrigation, joint lavage, debridement, osteotomy, endoprosthesis, and total joint replacement of the hip or knee. Osteotomy provides pain relief and may prevent progression of disease in patients who are not yet considered to be candidates for total joint arthroplasty. Total joint arthroplasty provides pain relief and functional improvement in the majority of patients with knee OA.¹

Disease management program

A disease management program should include three elements: (1) the economic ramifications of a disease to create guidelines for what care should be provided, by whom, and in what setting; (2) a delivery system of health care professionals and organizations that can break down traditional boundaries between medical specialties and institutions to provide closely coordinated care throughout the course of a disease; and (3) a continuous improvement process that measures clinical behavior, refines treatment standards, and improves the quality of care provided.

Once a patient has been diagnosed with OA, three steps can help the nurse develop and implement a disease management program.

• Consider the severity of disease, number of afflicted joints, and coexisting conditions to identify the appropriate combination and timing of pharmacologic, nonpharmacologic, and/or surgical procedures. Ideally, nurses should be able to participate in the development and implementation of medical guidelines. For example, guidelines may specify to first start with a nonnarcotic analgesic and a comprehensive weight reduction program for a patient with mild symptoms of pain, stiffness, and impaired function. For the patient with severe knee pain that has not responded to pharmacologic and nonpharmacologic therapies, a surgical procedure, such as a total knee replacement, might be warranted.
• Determine the health care professionals who will administer the therapies. In some cases, it may be only the physician and the nurse, and in others, a larger multidisciplinary team comprising, in addition to the nurse, the primary care provider, rheumatologist, orthopedic surgeon, dietitian, physical and occupational therapists, and those who work in facilities for laboratory testing and x-rays.
• To ensure quality, develop a sound methodology for communicating the disease management program to the multidisciplinary team. The team needs to be aware of the patient’s progress and medical condition, as well as changes to the disease management program due to, for example, insurance coverage issues. Equally important is gaining patients’ support by keeping them educated about the pharmacologic, nonpharmacologic, and surgical therapies available to them. Effective disease management of OA begins with the implementation of a disease management program by the nurse and successfully continues with the coordination skills of the nurse and the multidisciplinary team. The final essential element is the participation of the patient.