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STUDY GUIDE MSK OA and RA What are the signs and symptoms of Osteoarthritis?  Destruction of cartilage and narrowing of the joint space  Most common in females after 55  Fingers, knees, hips and spine most commonly affected joints (most common fingers)  Usually asymmetrical joint pain that develops slowly and accompanies or follows physical activity  Morning stiffness that lasts 1 hour, resumes at end of the day or after activity  Joints are cool with possible crepitus  Osteophytes, or bony enlargements, form in the joints  treat conservatively with exercise, heat etc. followed by acetaminophen and NSAIDS, followed by steroid injections.  If pain is still present refer to rheumatologist What are Heberden’s and Bouchard’s nodes? Where are they located?  Heberden’s: Bony bumps on the finger joint closest to the fingernail  Burchard’s: Bony bumps on the middle joint of the finger What are the treatments for Rheumatoid and Osteoarthritis?  RA o Non-pharm  Exercise program  Splinting  Orthotics to prevent deformities  Functional insoles  Cold therapy for analgesic, anti-inflammatory effect  Heat therapy for relaxation and circulatory stimulation  Consider Mediterranean diet  Maintain or achieve healthy BMI  Avoidance of allergens  Surgery: arthroscopy with synovectomy, arthroplasty o Pharm  Disease-modifying antirheumatic drugs (DMARDs) (Enbrel, Methotrexate)  Anti-TNF Agents (initiate after trial of 2 DMARDs)  NSAIDS, COX-2 Inhibitors  OA o Non-pharm  USE FIRST  Weight loss  Education on therapy and muscle strengthening  Supervised exercise  Rest  Knee or elbow brace  Orthotic shoes, cane  Heat/cold to affected joints  Surgery (osteotomy, arthroplasty)  Acupuncture  Local creams o Pharm  Acetaminophen (1st line)  Add NSAID (see risks associated with long term NSAID use)  Short-acting NSAID has fewer side effects  Consider another med for GI protection  Topical NSAID great alternative for elderly  Narcotics indicated briefly for severe exacerbation  Steroid injections 4x/year for large joints How do you differentiate RA and OA?  RA: autoimmune, symmetrical joint pain, warm joints, symptoms wax and wane, can have systemic symptoms (malaise, wt. loss, low grade temp), small joints affected before large joints, lab tests to diagnose  OA: ‘wear and tear,’ asymmetrical joint pain, cool joints, crepitus, affects large joints (knees, back) before small, x-ray to diagnose, osteophytes, Heberden and Burchard nodes found When do you refer?  RA: always refer to rheumatologist  OA: refer if pain continues to be present after non-pharm and pharm tx **Know that a patient taking NSAIDS needs to have CBC, BUN/Cr and Liver functions monitored. If you do a stool for occult blood, they need to be off NSAIDS 2-3 days. What is Rheumatoid Arthritis?  an autoimmune disease and leads to joint deformity and destruction  Do initial lab work (because it may take several weeks to get into rheumatologist) and refer patient ASAP What diagnostic tests are done?  OA: No diagnostic laboratory tests o Diagnosed based on hx, physical and x-ray findings o X-rays: osteophytes, joint space narrowing  RA: 5 of the 7 must be present and the first 4 must be present for at least 6 weeks o Morning stiffness 1 hr o Soft tissue swelling of 3 or more joints (wrist, elbow, knee, ankle, hands, feet) o Swelling of at least 1 joint in hand or wrist o Symmetrical joint swelling o Rheumatoid nodules