Arthritis care rounds

There is never a universal formula for arthritis care. The priority of the three core goals of pain relief, function maintenance, and complication prevention must be dynamically adjusted according to the patient's type, inflammation activity, and even daily habits. If you copy the guideline items, it is easy to get into trouble.

Let’s take Aunt Zhang, a 58-year-old woman from bed 3, who had an acute attack of rheumatoid arthritis. When she was admitted to the hospital, her C-reactive protein soared to 42 mg/L. The back of her hands was so swollen that she gasped in pain when she touched the quilt. When she was working as a nurse in the community, she was asked to do 20 minutes of finger flexion and extension exercises every day according to the general rehabilitation requirements, which almost made her cry. In fact, there are differences in the academic circles here. One group advocates early intervention in passive activities during the active period to avoid stiffness in the later stages of joint adhesion. The other group believes that when inflammatory indicators remain high, any additional stimulation will aggravate synovial damage and prolong the course of the disease. The plan we decided for her this time was middle-of-the-road: in the first three days, we prioritized inflammation control + pain relief, and only gently massaged her distal knuckles. After the C-reactive protein test yesterday dropped to 18 mg/L, and she said it didn’t hurt even if she didn’t touch it, we started to add passive flexion and extension within 10 minutes. Today during the ward round, she tried to clench her fists, but she still couldn’t hold them tightly, and her eyes were bright.

Turning to Uncle Li from bed 7, he is 67 years old and has knee osteoarthritis for 12 years. This time he knocked out his knee while climbing a flight of stairs. He suffered an acute synovitis attack and swollen like a small rubber ball. He was carried here by his son. He has an old concept: if a joint hurts, you have to take care of it, and if you can move, don't move. After lying at home for half a month, this time he came to evaluate the quadriceps muscle strength, which was only level 3, and the muscles were all soft. Think about it, degenerative osteoarthritis is a vicious cycle of cartilage wear + insufficient muscle support. The more you lie down, the weaker the muscles become, the greater the pressure on the joints, and the more severe the pain. Isn’t this stuck in an endless cycle? His situation is completely opposite to that of Aunt Zhang. As long as the inflammation indicators are stable, you have to force yourself to move. Even if you are sitting and doing straight leg raises, you can practice 3 groups of 10 times a day. Otherwise, when the synovitis disappears, you will not be able to lift your legs, and you will suffer even more when you practice again. Last year, I met an old man who was in almost the same situation as him. He was unwilling to move. He eventually developed venous thrombosis in his lower limbs and pressure ulcers in his sacrococcyx, which was more dangerous than arthritis itself.

Let me just mention a misunderstanding that many people have encountered: many family members and even novice nurses think that arthritis requires keeping warm. No matter what the situation is, you should wrap yourself up tightly, or even apply a hot water bottle if it hurts. It really depends on the situation. Last month, I admitted a young man with an acute attack of gout. His big toe hurt so much that he couldn't sleep. His mother wrapped him in two layers of thick socks and applied a hot water bottle. When he came in, his whole foot was swollen like a bun, and his uric acid level soared to more than 700 μmol/L. During an acute attack of gout, uric acid crystals stimulate the synovium to produce inflammation. Hot compresses will only dilate blood vessels, aggravate edema and leakage, and make the pain worse. At this time, local cold compresses are needed instead, and high-purine diets must be strictly avoided. This is exactly the opposite of the care requirements for rheumatoid arthritis. Failure to understand the type of care and care without understanding is simply a disservice.

There is also a lot of debate on the Internet about whether to take glucosamine or not. In fact, there is no unified clinical conclusion. I have seen patients in their 40s with mild cartilage wear and tear. After taking it for three months, they said that the pain of going up and down stairs was relieved. I have also seen a 70-year-old woman with almost no cartilage, but taking it for half a year has no effect at all. We now generally recommend that patients under 60 years old and with wear and tear of no more than 30% try it. If they don’t use it for 3 months, stop it. There is no need to force it and spend money in vain.

Oh, by the way, don’t just focus on joints and indicators. Many arthritis patients have emotional problems that are more torturous than pain. When Aunt Zhang was first admitted to the hospital, she cried every day, saying that she would be disabled in the future and could not even wear clothes. We asked an old rheumatoid patient who had been in the same ward for half a month and was already able to comb her hair to talk to her twice. Now she is learning to do finger exercises every day. Her mentality is much better, her cooperation is high, and her recovery is faster than we expected. In fact, many guides do not mention this in much space, but it is really important in practice. If the patient is willing to cooperate, it will be more effective than any rehabilitation plan.

To put it bluntly, what I talked about during today’s ward rounds is all the experience gained from going through countless pitfalls over the years. Guidelines are dead, but people are living. No care plan is as practical as the patient himself who feels comfortable and can slowly return to normal life. After a while, the care adjustment plan for these two patients was clearly explained to the nurse in charge. In the evening, I came over to see Aunt Zhang's finger mobility. Uncle Li practiced straight leg raise for the first time today, so he had to be warned not to strain it if he practiced too much.