Chapter 90: Osteoarthritis

Patient Care Process for the Management of Osteoarthritis

Collect

• Patient characteristics (e.g., age, weight, height, race, sex, pregnant)

• Patient history (past medical, family, social, and alcohol use)

• Symptom information: type and location of pain; duration; effect of motion and rest; range of motion and limitations on activities; instability

• Current and past medications, including nonprescription agents and dietary supplements, and medications' relief of symptoms

• Objective data (see Box 90-1)

  • Physical examination; appearance of joints

  • Radiologic evaluation—changes in joints; subchondral bone sclerosis; effusions (see Box 90-3)

  • Body mass index (presence of overweight or obesity)

  • Presence of renal or hepatic disease

Assess

• Distribution and severity of joint involvement

• Impact of symptoms on patients' daily activities, interference with occupational functioning, health-related quality of life

• Effects of pre-existing renal or hepatic disease on choice of medication selection and dose

Plan^*

• Patient education about disease, prognosis, treatment options, application and use of topical products

• Nonpharmacologic therapy (see Table 90-1)—weight loss (if overweight or obese), exercise, surgery (for severe pain or functional disability)

• Drug therapy regimen including specific analgesics, dose, route, frequency, and duration; specify the continuation and discontinuation of existing therapies (see Figures 90-4 and 90-5 and Tables 90-2 and 90-3)

• Monitoring parameters including efficacy (e.g., symptom relief), safety (medication-specific adverse effects) (see Table 90-3)

• Self-monitoring of symptoms, exercise, and weight—where and how to record results

• Referrals to other providers when appropriate (e.g., physician, orthopedic surgeon, physical therapist)

• Consider joint replacement if patient has severe pain or significant functional impairment, or drug therapy is ineffective or poorly tolerated.

Implement^*

• Provide patient education regarding all elements of treatment plan

• Use motivational interviewing and coaching strategies to maximize adherence. This is particularly important for nonpharmacologic interventions.

• Schedule follow-up monthly until symptoms controlled to assess efficacy of drug therapy regimen and assess adherence to nonpharmacologic interventions.

Follow-up: Monitor and Evaluate

• Assess symptom relief, effectiveness of weight loss and exercise programs

• Presence of adverse effects (see Table 90-3), including cardiovascular and renal effects of NSAIDs, hepatic effects of acetaminophen and glycemic effects of intraarticular corticosteroids.

• Closely monitor proper use of opioids in all patients, including dependence, addiction, tolerance, hyperalgesia, and diversion (see text).

• Patient adherence to treatment plan using multiple sources of information

KEY CONCEPTS

• Millions of Americans have osteoarthritis (OA). OA prevalence increases with age and number of other chronic conditions, with women more commonly affected than men.

• Contributors to OA are systemic (age, genetics, hormonal status, obesity, occupational, or recreational activity) and/or local (injury, overloading of joints, muscle weakness, or joint deformity).

• OA is primarily a disease of cartilage that reflects a failure of the chondrocyte to maintain proper balance between cartilage formation and ...