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Etiology and Risk Factors

1. Define Osteoarthritis and outline the aetiology and risk factors for Osteoarthritis (out of 4 marks).

 Osteoarthritis is defined as the degeneration of joint cartilage and the underlying bone within a joint as well as bony overgrowth (Van Delft et al., 2019).  The risk of developing osteoarthritis is increased with age. The common risk factors of the   osteoarthritis are family history of Osteoarthritis, obesity, muscle weakness, age, previous joint injury which resulted in clinical manifestation of Osteoarthritis.  The women are more likely to be at high risk of developing osteoarthritis compared to men (Driban et al., 2020). The primary osteoarthritis is usually diagnosed in absence of pre disposing trauma while secondary osteoarthritis developed due to pre-existing joint abnormality. Manlapaz et al. (2019), reported that possible cause of the osteoarthritis is Scoliosis, Postsurgical, Hemochromatosis, Wilson disease, Hemophilia.

2. Describe the theories from the literature about the pathophysiology of Osteoarthritis (out of 5 marks).

 Osteoarthritis often involves  damages of cartilage as well as remodelling of bone in the articular cartilages. The inflammatory   cells in the surrounding tissues are also responsible for remodelling of the bone.  In the earliest level, OA are developed in   the articular cartilage which develop surface irregularity and focal erosions (Driban et al., 2020).   The erosion eventually extended down to the bone followed by more of joint surface.  The aging eventually changes the imbalance between catabolic and anabolic activity of the joint and overweight increases the stress on the joints (He et al.,2020). Similarly, the muscle weakness additional contributing factor behind Osteoarthritis.   On the microscopic level, after immediate damage of cartilage injury, the collagen matrix also damages to   initiate forming clusters of chondrocytes. Phenotypic changes are ossified and form osteophytes (Alekseeva, Taskina & Kashevarova, 2019).   Higher damages in chondrocytes often undergoes apoptosis followed by subchondral bone thickening.   O'Neill, McCabe and McBeth(2018),  reported that chondrocytes secrete tissue inhibitors that attempts to increase the production of proteoglycans  which further enhance degradative process.   In the end stage of Osteoarthritis, in calcium phosphate and calcium pyrophosphate crystal often initiate synovial inflammation. Hence, the patients often   exhibit clinical manifestation.

3. Relate Qu 1 and Qu 2 to the case study of Eva provided (out of 2 marks).  

 The case scenario suggested that Osteoarthritis of a 71-year-old woman who    presented with the clinical manifestation of Osteoarthritis.   Eva is presented with all of the risk factors that resulted in development of osteoarthritis. While   family history of Osteoarthritis is considered as the major risk factor of the clinical presentation, Eva has family history of osteoarthritis. On the other hand, she is overweight of 75kg which might be the risk factor as it may increase stress on the joint and result in joint deformity. The post-surgery is one of the risk factors because Appendicectomy at the age of 25 years (Van Delft et al., 2019).    The alcohol increases the risk of OA because Alcohol’s inflammatory effects often aggravate both degenerative joint in osteoarthritis.  Hence, since she   drink for 1-2 standard drinks 2 times per  week. Hence, she developed Osteoarthritis due to risk factors that resulted in deformities in hands, knees and hips and spine.

Pathophysiology

4. Describe the typical clinical manifestations (signs and symptoms) of Osteoarthritis (out of 3 marks).

 The clinical manifestations of the osteoarthritis or presentation and progression are often varied person to person. The triad of the symptoms are hallmark of OA such as joint pain, locomotor restriction and pain and stiffness (Nagy et al., 2020). The patients are often presented with balance issues as well as muscle weakness. On the other hand, Baloun  et al. (2020), reported that pain is another typical clinical manifestation because of OA because  pain  often developed due to   inflammation  and joint deformities which often restrict  activities of daily living (Van Delft et al., 2019).  Hence, activities of daily living are also clinical manifestation of OA. On the other hand, the patient   may experience joint deformities, instabilities and bony swelling (Van Delft et al., 2019).  OA also affects distal interphalangeal joints and proximal joints which also represented the joint deformities and pain.

5. Outline the clinical assessment and diagnosis of a patient presenting with Osteoarthritis - Include patient history, physical examination and any diagnostic processes/ screening tools used (out of 3 marks).

 The clinical history of the patient must be considered   for assessing the patient and examination will be musculoskeletal exam.  The clinical diagnosis of this OA can be only confirmed if the patient represented with two to three criteria such as 1) worsening with activity as well as  better with rest 2) aged more than 45 years  3) limitation of the daily activities of living  4)  bony joint enlargement  (Sacitharan,2019).

The typical examination findings often include bony enlargement, effusions along with limited range of motions.    On the other hand, physical examination of tenderness can be done because represents the tenderness at the joint.  Other the physical examinations are also done for    confirming OA which represents posterolateral swellings in Heberden’s nodes and Bouchard’s nodes (Wang, Oo & Linklater, 2018).    The other test can be conducted to confirm OA such as blood tests, CBC test. ANA test can be conducted but usually ruled out due to normal data. On the other hand, when assessment of    synovial fluid is obtained, white blood cells count lower than 2000/microL must be considered for diagnosis as it is consistent with the diagnosis (Deveza & Loeser, 2018).  X can be also be conducted because X often shows   joint space narrowing, cysts while Ultrasound can be conducted because it can provide the idea of effusion, osteophytes and synovial inflammation.

Relationship to the Case Study

6. Relate Qu 4 and Qu 5 to the case study of Eva provided (out of 2 marks).

 In this current context, Eva also exhibited various clinical manifestations that can confirm diagnosis of OA because she frequently complains about swelling and stiffness and loss of flexibility in her right knees. She also exhibited limited daily activities as she suggested limitation in doing cleaning, gardening as well as household cooking (Deveza & Loeser, 2018). The pain and bone swelling reflected in the clinical examination as her hands and right knee suggested tender to touch, swollen and appear to be hot when they encounter the issues. On the other hand, as suggested above, pain is typical clinical manifestation which reflected in 5/ 10 score pain experienced by Eva.  She also finds it difficult to stand for long period (Khella et al., 2021). On inspection, Eva had some hand and finger deformities   along with reduced range of motion.  Even though her vitals are normal, physical examination confirm the presence of OA.

  While Eva gone through clinical assessment or physical examination which suggested that she had swelling and stiffness and loss of  flexibility  in her right knees, she can be  provided with   blood  tests, , CBC test and Ultrasound to gain idea of  presence of  effusion, osteophytes and synovial inflammation (Deveza & Loeser, 2018).  Her clinical diagnosis confirms OA because she already had worsening with activity as well as better with rest and she is 71 years and currently   have joint deformities. 

7. Outline recommended evidence based management strategies for treating Osteoarthritis – pharmacological and non-pharmacological (out of 4 marks).

  • Pharmacological:

 Pharmacotherapy of OA often involves the drugs that can be applied on intraarticular options and topical or oral consumption. Zeng et al. (2021), reported that patients with OA are often provided with Acetaminophen and oral NSAIDs as initial choice of pharmacological because it is a pain reliever that   reduce the production of prostaglandins that is responsible for inflammation as well as swelling. They are also administrated orally and topically but topical NSAIDs are often less efficacious that oral counterparts (Clarke, 2021).  On the other hand, when patients exhibit no response to Acetaminophen, they are often provided with Duloxetine as second-line agent for treatment (Pergolizzi et al., 2021).

  • Non-pharmacological:

Non pharmacological interventions of OA can be exercise and acupuncture. The exercise, especially aerobic exercises such as climbing up and down stairs, brisk  for 30 to 45 minutes improves circulation of the blood,  reduce stiffness and pain while strengthening muscles and improves flexibility (Khella et al., 2021).  Hence, it can be recommended to her to improve quality of life.  On the other hand, acupuncture can improve her complications because it can decrease inflammation and spread healing.

Clinical Manifestations

8. Discuss in brief ONE potential complication of Osteoarthritis that Eva may experience (out of 2 marks).

 The potential complication of OA  is  significant joint deformities followed by complete restriction of the movement (Van Delft et al., 2019). As the patient already exhibited deformities in hands, knees and hips and spine, it might be potential complication of  Eva.

Reference

Alekseeva, L. I., Taskina, E. A., & Kashevarova, N. G. (2019). Osteoarthritis: epidemiology, classification, risk factors, and progression, clinical presentation, diagnosis, and treatment. Modern Rheumatology Journal, 13(2), 9-21.

https://mrj.ima-press.net/mrj/article/view/905?locale=en_US


Baloun, J., Kropá?ková, T., Hulejová, H., Tom?ík, M., R?ži?ková, O., Šléglová, O., ... & Šenolt, L. (2020). Chemokine and cytokine profiles in patients with hand osteoarthritis. Biomolecules, 11(1), 4. https://www.mdpi.com/2218-273X/11/1/4


Clarke, J. (2021). Topical NSAIDs come out top for knee OA. Nature Reviews Rheumatology, 17(9), 508-508.

https://www.nature.com/articles/s41584-021-00676-1


Deveza, L. A., & Loeser, R. F. (2018). Is osteoarthritis one disease or a collection of many?. Rheumatology, 57(suppl_4), iv34-iv42. https://academic.oup.com/rheumatology/article/57/suppl_4/iv34/4753701?login=true


Driban, J. B., Harkey, M. S., Barbe, M. F., Ward, R. J., MacKay, J. W., Davis, J. E., ... & McAlindon, T. E. (2020). Risk factors and the natural history of accelerated knee osteoarthritis: a narrative review. BMC musculoskeletal disorders, 21(1), 1-11.

https://link.springer.com/article/10.1186/s12891-020-03367-2


He, Y., Li, Z., Alexander, P. G., Ocasio-Nieves, B. D., Yocum, L., Lin, H., & Tuan, R. S. (2020). Pathogenesis of osteoarthritis: risk factors, regulatory pathways in chondrocytes, and experimental models. Biology, 9(8), 194. https://www.mdpi.com/2079-7737/9/8/194


Khella, C. M., Asgarian, R., Horvath, J. M., Rolauffs, B., & Hart, M. L. (2021). An evidence-based systematic review of human knee post-traumatic osteoarthritis (PTOA): Timeline of clinical presentation and disease markers, comparison of knee joint PTOA models and early disease implications. International Journal of Molecular Sciences, 22(4), 1996. https://www.mdpi.com/1422-0067/22/4/1996


Manlapaz, D. G., Sole, G., Jayakaran, P., & Chapple, C. M. (2019). Risk factors for falls in adults with knee osteoarthritis: a systematic review. Pm&r, 11(7), 745-757. https://onlinelibrary.wiley.com/doi/abs/10.1002/pmrj.12066


Nagy, E. E., Nagy-Finna, C., Popoviciu, H., & Kovacs, B. (2020). Soluble biomarkers of osteoporosis and osteoarthritis, from pathway mapping to clinical trials: an update. Clinical Interventions in Aging, 15, 501.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7152733/


O'Neill, T. W., McCabe, P. S., & McBeth, J. (2018). Update on the epidemiology, risk factors and disease outcomes of osteoarthritis. Best practice & research Clinical rheumatology, 32(2), 312-326.

https://www.sciencedirect.com/science/article/abs/pii/S1521694218300706


Pergolizzi, J. V., Magnusson, P., LeQuang, J. A., Breve, F., Taylor, R., Wollmuth, C., & Varrassi, G. (2021). Can NSAIDs and Acetaminophen Effectively Replace Opioid Treatment Options for Acute Pain?. Expert Opinion on Pharmacotherapy, 22(9), 1119-1126. https://www.tandfonline.com/doi/abs/10.1080/14656566.2021.1901885


Sacitharan, P. K. (2019). Ageing and osteoarthritis. Biochemistry and cell biology of ageing: part II clinical science, 123-159. https://link.springer.com/chapter/10.1007/978-981-13-3681-2_6


Van Delft, M. A. M., van Beest, S., Kloppenburg, M., Trouw, L. A., & Ioan-Facsinay, A. (2019). Presence of autoantibodies in erosive hand osteoarthritis and association with clinical presentation. The Journal of rheumatology, 46(1), 101-105.

https://www.jrheum.org/content/46/1/101.abstract


Wang, X., Oo, W. M., & Linklater, J. M. (2018). What is the role of imaging in the clinical diagnosis of osteoarthritis and disease management?. Rheumatology, 57(suppl_4), iv51-iv60. https://doi.org/10.1093/rheumatology/kex501


Zeng, C., Doherty, M., Persson, M. S., Yang, Z., Sarmanova, A., Zhang, Y., ... & Zhang, W. (2021). Comparative efficacy and safety of acetaminophen, topical and oral non-steroidal anti-inflammatory drugs for knee osteoarthritis: evidence from a network meta-analysis of randomized controlled trials and real-world data. Osteoarthritis and Cartilage, 29(9), 1242-1251.

https://www.sciencedirect.com/science/article/abs/pii/S1063458421008104

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[Accessed 23 February 2024].

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