Patient Management Strategies in Arthritis

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Patient Management Strategies in Arthritis

• Anna Mae Smith, MPAS, PA-C
• Lock Haven University of PA
• Physician Assistant Program

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DJD/Osteoarthritis

• Obesity
• increase in body mass
• altered biodynamics of gait
• genetic predisposition (genetically obese mice
  are susceptible to osteoarthritis)
• altered metabolism (e.g., estrogens)

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Risk Factors

• Occupational

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Treatment

• Physical measures may be subdivided into..
• Exercise
• Supportive devices
• Alterations in activities of daily living
• Thermal modalities

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Exercise

• Associated with reduced pain improved function.
• Passive range of motion
• Rest periods
• Active range of motion, isometric, isotonic,
  isokinetic

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• Improved muscle tone reduces muscle spasm and
  prevents contractures. It is theorized that
  improved muscle support of the joint will retard
  the progression of osteoarthritis.

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Which Exercises

• Swimming
• Biking (Stationary)
• Walking

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Support Devices Orhotics

• Devices such as canes, forearm crutches,
  crutches, and walkers can improve balance and
  decrease pain.

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• The total length of a properly measured cane
  should be equal to the distance between the upper
  border of the greater trochanter of the femur and
  the bottom of the heel of the shoe. This should
  result in elbow flexion of about 20.

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• The cane should be held in the hand contralateral
  to and moved together with the affected limb. The
  healthier limb should precede the affected limb
  when climbing up stairs when climbing down
  stairs, the cane and the affected limb should be
  advanced first. The cane can unload the affected
  hip by 60.

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Modified activities of daily living

• Proper positioning and support when sitting,
  sleeping or driving a car
• Adjusting ways of performing such activities as
  getting dressed, etc.
• Adjusting furnishings around the house or at work
  (e.g., raising the level of a chair or toilet
  seat)

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Thermal modalities

• Superficial heat (e.g., hot packs, paraffin
  baths)
• Deep heat (e.g., ultrasound)
• Cold applications (e.g., cold packs, vapocoolant
  sprays)

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HEAT

• The therapeutic value of applying heat includes
  decreasing joint stiffness, alleviating pain,
  relieving muscle spasm, and preventing
  contractures.
• The use of heat is contraindicated over tissues
  with inadequate vascular supply, bleeding, or
  cancer. Heat should also be avoided in areas
  close to the testicles or near developing
  fetuses.

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Miscellaneous

• Pulsed electromagnetic fields
• TENS
• Acupuncture
• Chiropractic
• Spa, massage, and yoga therapy

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Short acting drugs

• Nonsteroidal anti-inflammatory agents
• Nonantiinflammatory analgesics (opioids,
  nonopioids)
• Antispasmodics

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Long Acting Agents

• Intra-articular depocorticosteroids
• Intra-articular hyaluronic acid
• S-adenosylmethionine (SAM)
• Oral chondroitin sulfate
• Glucosamine sulfate (Dona)
• Intra-articular orgotein
• Diacerhein
• Avocado/soy nonsaponifiables

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Capsaicin

• Capsaicin is derived mainly from capsicum, the
  common pepper plant
• Nonprescription drug and available in two
  strengths to be applied from two to four times
  per day
• Interferes with substance P-mediated pain
  transmission.

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Capsaicin

• Initially, its use is accompanied by a sensation
  of heat or burning in the area of the skin where
  applied. If not used continuously, the nerve
  endings will renew their sensitivity to substance
  P.

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Hyaluronic Acid Derivatives

• In general, they are reported to reduce pain for
  prolonged periods of time potentially to
  improve mobility

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Hyaluronic Acid Derivatives

• There is evidence for an anti-inflammatory effect
  
• A short-term lubricant effect
• An analgesic effect by direct buffering of
  synovial nerve endings
• A stimulatory effect on production of normal
  hyaluronic acid by synovial lining cells

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S-adenosylmethionine (SAM)

• A methyl group donor and oxygen radical
  scavenger, has been used by intravenous loading
  and oral maintenance

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Chondroitin Sulfate

• Those receiving chondroitin sulfate consumed
  fewer NSAIDs than the controls at both the
  completion of the treatment and the
  treatment-free phase.

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Glucosamine sulfate

• An intermediate in mucopolysaccharide synthesis,
  has been tried both orally and intramuscularly.
  Glucosamine sulfate (400 mg) administered
  intramuscularly twice weekly for 6 weeks, reduced
  the severity of disease
• 1500mg/day (500tid)

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Recombinant human superoxide dismutase (rH-SOD)

• Has been used in animal models
• It catalyzes peroxide formation from free
  radicals, therefore limiting free radical
  concentrations and ability to inflict damage in
  the joint.

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Intra-articular orgotein

• A metalloproteinase with superoxide dismutase
  activity is still under investigation

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avocado/soy nonsaponifiables

• Have been found to potentially modulate
  chondrocyte synthetic and repair activity
• An early report of decreased pain and stiffness
  as well as decreased analgesic use by
  osteoarthritis patients has appeared.

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DIET

• Avoid coffee, artificial additives, red meats
  processed foods
• Limit tomatoes,potatoes,eggplants, peppers,
  simple carbohydrates(white flour refined
  sugar).
• Fresh fruits veges, complex carbs, wheat
  germ oily fish

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DIET

• Vit. A 10,000iu/day
• Vit. C 2grams/day
• Vit. E 600iu/day
• Vit. B6 50 mg/day

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Rheumatoid Arthritis
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First-line therapy

• Anti-inflammatories
• Aspirin
• Nonsteroidal anti-inflammatory

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Second Line Therapies

• Antimalarials (chloroquine, hydroxychloroquine)
• Sulfasalazine
• Methotrexate
• Gold salts
• Auranofin
• Parenteral gold
• D-penicillamine

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Second Line Therapies cond

• Azathioprine
• Cyclosporin A
• Combination therapies
• Corticosteroids
• Systemic steroids
• Low-dose oral
• Parenteral pulse steroids
• Intra-articular

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Investigational

• EPA (eicosapentaenoic) - anti-inflammatory effect
  of fish oil fatty acid
• Plant seed oils particularly those extracted from
  evening primrose oil and borage seed oil that
  contain large amounts of gamma linolenic acid.

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Light Therapy

• Extracorporeal photochemotherapy and
  extracorporeal protein A immunoadsorption

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Vitamins

• Vit. C 2grams/day
• Vit. E 600iu/day
• B complex vitamin
• Calcium 1200-1500/day
• Selenium 100mg/day
• Zinc 30mg/day

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Hydrotherapy

• Cold compresses when acutely inflamed followed by
  alternating hot cold
• Massage - lavender, tiger balm chamomile oils

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Herbs

• Black cohosh
• Wild yam
• Willow bark
• Licorice