Madam X was admitted to the ward for a bilateral knee replacement. She is 57 years old and is obese with difficulty in physical motion in addition to severe chronic pains at the joints and back. Her situation was best described as osteoarthritis. Osteoarthritis is a common type of arthritis with its main symptoms leading to the wearing of protective cartilage at the ends of the bones gradually. OA leads to massive deterioration especially in the quality of life leading to impairment in daily activities. It includes loss of the extracellular matrix or the cartilage surface. It develops due to functionally and structurally compromised AC known as the articular cartilage (Field 2016).
According to Lluch et al. (2014), the disorder majorly occurs in the joints of the spine, hands, hips, and knees. Maintaining a healthy lifestyle, and a reasonable weight often slows down the progression of the complication with a considerable improvement of the joints functionality (Glover et al. 2015). Its main symptoms and signs include tenderness in the joints, loss of body flexibility, bone spurs, stiffness majorly after an extended period of inactivity (Glover et al. 2015). The patient also does experience sharp pains at the joint after of during movements. According to Lluch et al. (2014), obesity is the leading cause of the condition. At the same time, Karlsson (2015), stated that among the population in older people, osteoarthritis is a widespread cause them in chronic pain.
During assisting Madam X to bed, she complained of severe pain and having difficulty during transfer to the bed. She was trying to step on the floor and slow motion while being moved to the bed. Madam X was experiencing chronic nociceptive pain that consists of four processes and this connected to lumbar spine nerve. Lumber spine nerve entails the lower back, the section that the spine bends (curves), inwards to the abdomen (Lluch et al. 2014). It begins slightly above the shoulder blades connecting to the thoracic spine extending towards the sacral spine (Hassan 2016). The lumbar spine is developed for both flexibility and power for the body (Rini et al. 2015). At the sacrum, the lumbosacral meets the lumbar spine where much rotation occurs allowing the pelvis to swing during running or walking (Wallace & Vaughan 2017). It could thus explain the difficulty Madam X experienced when she was being moved to the bed. Figure 1 below shows the lumbar spine and the nerve point a patient will experience most pain during or after movement.
Fig 1 (Vitiello et al. 2014)
In transduction stage, noxious stimuli occur to both knees joint cartilage which already damaged and worn (Glover et al. 2015). Interactions occurring between the connecting tissues and the leukocytes often and many a time cause inflammation of the RA (Lluch et al. 2014). Several pathological conditions induce the production of Th1 cytokines in addition to the macrophages leading to the creation of the inflammatory mediators that include nitric oxide, and chemokines (Wallace & Vaughan 2017). IL-18 starts the production and release of the T1 cytokines together with the macrophages. Interleukin-18 (IL-18) refers to the proinflammatory cytokine linked with several pathological situations that include rheumatoid arthritis (RA). IL-8 further acts on endothelial leading to the induction of cell adhesion and angiogenesis. Reduced adhesion and increased tension in the joints is the leading cause of pain (Rakel et al. 2015). Madam X osteoarthritis is nociceptive pain, a throbbing, sharp, and aching pain. In osteoarthritis, it is as a result of nerve damage, or too much pressure on the nerve endings (Paterson et al. 2016). Madam X felt the pain when she was attempting to move, due to the friction occurring among the femur bone and tibia bone under the knee cartilage. The affected sections often feel tender arising from the dull ache and burning sensation in the affected nerves (Rini et al. 2015).
Osteoarthritis pain transmission by C-fiber aims at conducting an electrical impulse to CNS which is related to damage and inflammation of Madam X joints (Glyn-Jones et al. 2015). Besides that, descending pain in modulation pathway also release substances such as norepinephrine and serotonin which have increases their availability to inhibit the noxious stimuli (Thakur, Dickenson & Baron 2014). At last perception stage, the critical part of the thalamus to somatosensory cortex conducted the pain signals to Madam X's brain of the pain location, and that is why she felt the pain from the knees (Besson et al., 1987).
Transmission of pain is characterized by the sensitivity that arises from the increased activity of the CNS neurons that come in the form of illness laced with inputs from reduced threshold mechanoreceptors. The obturatory nerve is responsible for the transmission of pain in the knee that innervates the hip joints (Hassan et al. 2016). At the same time, inflammatory cytokines and sensory innervations in the hyperplastic synovia are linked with pain transmission primarily in the transmission of pain in Osteoarthritis (Cherian et al. 2016). Although the dominance and distribution of the nerves involved remain unknown. Pain from the joint, primarily, the hip joint originates from the groin, after that followed at the knee, buttock, and the inner thigh (Hassan et al. 2016). It is after that developed at the lower back (Rini et al. 2015). Diagnosis and an interview with Madam X revealed that night pain, and rest pain remain prevalent and in most cases occurring with various patterns and varies from a dull ache, sharp, and stabbing pain. However, according to Rakel et al. (2015) studies have shown that several transmitting substances that lie between the OA at the hip and the ordinary hip offers a clear understanding of the pathogenesis of the pains encountered by patients of OA such as in Madam X condition. At the transmission stage, the tips of the vertebrate collagen are examined by the application of the transmission electron microscopy that entails the sectioned tissues to gauge the level of transmission of the pain (Vitiello et al. 2014). The fabrics involve the excellent fibril tips (Rakel et al. 2015). By the application of quantitative dark field transmission scanning electron microscopy, the tips of the affected tissue are the paraboloidal shape (Wallace & Vaughan 2017). They are formed by cleavage that entails the C-proteinase (Perrot et al. 2015).
In Madam X's pain and ailment, the straining pattern of the joints and fibrils produced tendons that had clear pointed ends referred to as the C-ends, containing collagen particles (molecules). The fragments comprise carboxyl at the tips laced with collagen containing amino termini at the far end. At the transmission, the tips of the fibrils are determined to investigate any further changes or damages to the joints (Thakur, Dickenson & Baron 2014). During transmission stage, physiological processes underlying spinal sensitivity becomes complex and numerous, leading to further amplification of signals from the neural within the CNS eliciting hypersensitivity pain around the affected joint (Rini et al. 2015). The pain also spreads to the neighboring regions characterized by numbness, sharp pain, and whiplash trauma (Da Costa et al. 2017). At any stage during treatment, therapy and drugs are aimed at inhibiting ascending transmission of vital information majorly from the spinal code to the primary pain control tissue/circuits that originate from the midbrain to the rostral ventromedial region (McDougall et al. 2017).
Madam X demonstrated hyperalgesia to a variation of experiments noxious stimuli. It entailed various examinations and clinical interventions that exposed her stimulus to a variety of tests (LopezOlivo et al. 2018). Multiple analyses show associations between clinical pains and laboratory measures, and it becomes unclear if and when individual variability especially in quantitative sensory testing commonly known as QST (McAlindon et al. 2014). Madam X responded with the baseline predicting to responsiveness to clinical pain especially to analgesic therapy. Her pains, especially at the knees, became highest at the baseline and sensory nerves that joined at her kneecaps.
According to Reed, Collaku, and Moreira, (2018) pain modulation and response to the treatment exposed multiple measures that involved pain symptomology that also included daily procedures, especially on her soft exposed painful joints (Reed, Collaku, & Moreira, 2018). Although Madam X demonstrated less pain at numerous joint places, she showed increased condition pain modulation especially in several anatomic regions of her bones. However, she experienced neuropathic pain signs in addition to activity related aching (McDougall et al. 2017). The neuropathic pains further led to temporal summation pain with the highest levels of degree of pain at the baseline of her back. Madam X exhibited endogenous pain, majorly associated with treatment-related modifications that reduced with higher treatment with diclofenac gel (Reed, Collaku, & Moreira, 2018).
The perception of the illness changed over time with the changes associated with the progression of the disease. According to McAlindon et al. (2014), the perception of the disease and pain is closely linked to the degree of awareness of the stage of the complication. However, pain perception grows from the response that arises from a complex of essential neurophysiological occurrences that involve transduction in stimuli, conduction of coded information and modulation of activities involved both at the central levels and peripheral points (Reed, Collaku, & Moreira, 2018). The relation that exists between the injured tissues and the occurring symptoms grows less defined and more vulnerable to extraneous stimulus majorly coming from within and exterior to the patient (McAlindon et al. 2014). Madam X progression of the disease increased with the symptoms associated with the disease chronicity, negativity, and the beliefs linked with immunity (Cherian et al. 2016). With other patients, decreased perception is related to the understanding of the progression of the complication. A higher level of symptoms related to OA showed a higher perception of the side effects of the consequences (Reed, Collaku, & Moreira, 2018). It thus means that illness perception changed over time and is closely linked to the outcome of the side effects of the disease (Wallace & Vaughan 2017). At the same time, according to the findings, illness perception is predictive of any resulting disability.
It may thus imply that any intervention with the aim of changing the disease may lead to a better outcome (Kuptniratsaikul et al. 2014). In the case of Madam X, a better perception of the resulting result over time will point to better intervention methods with positive predictions.
The above perception of the disease was measured within six years in 240 patients a study undertaken by Visser, Scharloo, and Kaptein among others. Participants were aged between 59 and 82 percent among women. They use the Illness Perception Questionnaire and the Health Assessment Questionnaire. All the mean changes were reported and the relationship defined by the highest quartile of score recorded. According to Reed, Collaku, and Moreira, (2018), by the use of the logistic progression, the predictive value was assessed with the highest quartile value of score determined. Perception of patients is thus pegged on numerous factors with the resulting outcome serving as a pointer to intervention methods applied (McDougall et al. 2017). For example, Madam X perception would play a significant role in determining the functional outco...
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