NUR 7070 Module 4 Management Plan: Knee Osteoarthritis in a School Bus Driver Example

Ten Percent Lighter and Twice a Week in the Pool: An Evidence-Based Plan for Knee Osteoarthritis in a 61-Year-Old School Bus Driver

Student Name

M.S. in Nursing, Family Nurse Practitioner, Thomas Edison State University

NUR-7070: Primary Care Diagnosis, Management and Health Promotion

Mentor Name

Month Day, Year

Ten Percent Lighter and Twice a Week in the Pool: An Evidence-Based Plan for Knee Osteoarthritis in a 61-Year-Old School Bus Driver

Introduction

Ms. K. is an invented patient, a 61-year-old who has driven a school bus in Bergen County for 22 years. For two years her right knee has ached on the inner side, worse at the end of her route and after climbing the bus steps, which she does about forty times a day. Morning stiffness lasts ten minutes. The knee does not lock or give way. She takes ibuprofen most evenings and worries about her stomach, since she has had heartburn for years. A coworker received a gel injection and told her it worked. She carries a BMI of 33, her pressure reads 132/80, and her creatinine and eGFR are within range. Examination shows bony enlargement and crepitus at the medial knee, a small effusion and no warmth or redness. An x-ray shows medial joint space narrowing with osteophytes.

Confirming the Diagnosis

No scan is required to name knee osteoarthritis: in someone past 45 whose knee hurts with use and stiffens for under half an hour in the morning, the history and examination are enough. Imaging is not needed to make the diagnosis, though her x-ray, taken earlier for a fall, is consistent. The differential includes a degenerative meniscal tear, which causes mechanical symptoms such as locking, inflammatory arthritis, which brings longer morning stiffness, warmth and often other joints, and gout or pseudogout, which cause sudden hot swelling. None fits her history or examination.

Her risk factors are typical of the disease. Age, female sex, obesity and decades of repetitive loading on the knee all raise risk, and the medial compartment carries most of the body's weight during walking, which explains why her pain sits on the inner side. Naming these factors matters for the plan, because the one she can change most, her weight, is also the one with the strongest evidence behind it.

Ranking Treatments by Evidence

The 2019 American College of Rheumatology and Arthritis Foundation guideline (Kolasinski et al., 2020) ranks treatments by the strength of the recommendation. For the knee it strongly recommends exercise, weight loss for people who are overweight, self-management programs, tai chi, oral nonsteroidal anti-inflammatory drugs, topical nonsteroidal anti-inflammatory drugs and intra-articular corticosteroid injections. It strongly recommends against several commonly requested treatments, including glucosamine, chondroitin, bisphosphonates and hydroxychloroquine, and it conditionally recommends against hyaluronic acid injections in the knee. The OARSI guideline (Bannuru et al., 2019) places topical nonsteroidal drugs among the first-line choices for knee osteoarthritis because they act locally with little systemic exposure.

The plan for Ms. K. starts with the strongest recommendations and fits them to her job, her stomach and her request.

Weight Loss

Every kilogram of body weight adds several kilograms of load across the knee with each step, so modest weight loss reduces joint stress substantially. Messier et al. (2013), in the IDEA trial, randomized older adults with knee osteoarthritis and obesity to intensive diet alone, exercise alone or both. After 18 months, the diet and exercise group lost about 11 percent of body weight, had less pain and better function than the exercise-only group and showed lower knee compressive forces. A goal of 10 percent, about 9 kilograms for Ms. K., is therefore realistic and meaningful. She is referred to a dietitian, and a structured program is discussed.

Exercise

Exercise is recommended regardless of weight and should include strengthening of the quadriceps and hip muscles and low-impact aerobic activity. Ms. K. dislikes gyms but enjoyed swimming when younger. A physical therapy referral for six to eight sessions sets up a home strengthening program, and a pool exercise class at her local YMCA twice a week offers aerobic activity with little joint load. She is told that some soreness after exercise is expected and is not a sign of damage.

A simple rule helps her judge the right amount: pain that settles within two hours of exercise is acceptable, while pain that lasts into the next day means the session was too hard and should be scaled back rather than stopped.

Medication

Her nightly ibuprofen and history of heartburn are a concern, since oral nonsteroidal drugs raise the risk of gastrointestinal bleeding, kidney injury and high blood pressure, especially with long-term use. Topical diclofenac offers similar pain relief at the knee with far lower blood levels. She is prescribed 1 percent diclofenac gel: 4 grams, measured on the card that comes with the tube, rubbed into the right knee four times a day, and never more than 32 grams in a day if other joints are treated as well. She stops the evening ibuprofen. Acetaminophen may be used for breakthrough pain, though its benefit in osteoarthritis is small. A corticosteroid injection is offered for flares that limit her work, with the understanding that relief usually lasts weeks rather than months.

Answering Her Request

Ms. K. asked for a gel injection. The answer is explained with respect for her coworker's experience. Trials of hyaluronic acid show small effects that are hard to separate from placebo, and the ACR guideline recommends against routine use. Her money and time are better spent on the treatments with stronger evidence. If she remains limited despite them, referral to orthopedics to discuss other options remains open.

Follow-Up and Work

She returns in eight weeks to review pain, function, weight and her exercise routine. A validated knee score gives a measure to track. Because her job requires climbing the bus steps many times a day, she is shown a technique of leading with the stronger leg going up and the weaker going down, and a note is offered if her employer can provide a handrail on the steps.

Conclusion

Ms. K.'s knee osteoarthritis is managed with the treatments that have the strongest evidence: weight loss to a 10 percent goal supported by the IDEA trial, supervised and pool exercise, and topical diclofenac in place of oral ibuprofen given her reflux. Treatments that the guideline does not support are explained rather than simply refused, and follow-up focuses on her function at work.

References

Bannuru, R. R., Osani, M. C., Vaysbrot, E. E., Arden, N. K., Bennell, K., Bierma-Zeinstra, S. M. A., Kraus, V. B., Lohmander, L. S., Abbott, J. H., Bhandari, M., Blanco, F. J., Espinosa, R., Haugen, I. K., Lin, J., Mandl, L. A., Moilanen, E., Nakamura, N., Snyder-Mackler, L., Trojian, T., ... McAlindon, T. E. (2019). OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis and Cartilage, 27(11), 1578-1589. https://doi.org/10.1016/j.joca.2019.06.011

Kolasinski, S. L., Neogi, T., Hochberg, M. C., Oatis, C., Guyatt, G., Block, J., Callahan, L., Copenhaver, C., Dodge, C., Felson, D., Gellar, K., Harvey, W. F., Hawker, G., Herzig, E., Kwoh, C. K., Nelson, A. E., Samuels, J., Scanzello, C., White, D., ... Reston, J. (2020). 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Care and Research, 72(2), 149-162. https://doi.org/10.1002/acr.24131

Messier, S. P., Mihalko, S. L., Legault, C., Miller, G. D., Nicklas, B. J., DeVita, P., Beavers, D. P., Hunter, D. J., Lyles, M. F., Eckstein, F., Williamson, J. D., Carr, J. J., Guermazi, A., & Loeser, R. F. (2013). Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: The IDEA randomized clinical trial. JAMA, 310(12), 1263-1273. https://doi.org/10.1001/jama.2013.277669