Huerta Exam 2 Study Materials on Rheumatic Diseases (Osteoarthritis and Rheumatoid Arthritis)

rheumatoid diseases are most commonly referred to as

arthritis

50 mins

arthritis

inflammation of a joint

arthritis is characterized by

- chronic pain

- progressive physical impairment

- affects joints, skin, muscles, ligaments, and/or tendons

arthritis is among the leading causes of

disability

rheumatic diseases

▪Osteoarthritis (OA)

▪Rheumatoid arthritis (RA)

▪Lupus

▪Ankylosing spondylitis

▪Scleroderma

▪Gout

▪Fibromyalgia

Common wear and tear joint disorder

osteoarthritis - OA

OA is most common in what gender

females

OA risk increases with

age

earlier onset

a) OA

b) RA

RA

develops suddenly or within weeks or months

a) OA

b) RA

RA

many joints affected, including wrists, elbows, and shoulders, mainly smaller joints on both sides of the body

a) OA

b) RA

RA

warmth, swelling, and joint redness are common

a) OA

b) RA

RA

morning stiffness lasts longer

a) OA

b) RA

RA

systemic symptoms present

a) OA

b) RA

RA

individual joints

a) OA

b) RA

OA

non-inflammatory

a) OA

b) RA

OA

body attacking its own structures

a) OA

b) RA

RA

most common

a) OA

b) RA

OA

incidence increases with age

a) OA

b) RA

OA

use heat to tx

a) OA

b) RA

OA - because there is no inflammation

inflammatory disease

a) OA

b) RA

RA

very common in 40-60 year old females

a) OA

b) RA

RA

ulnar deviation is most common in

a) OA

b) RA

RA

fusiform swelling of joints and heberden's nodes are most common in

a) OA

b) RA

OA

most common type of degenerative joint disease

a) OA

b) RA

OA

strongly correlated with age

a) OA

b) RA

OA

associated with heredity, obesity, anatomical joint abnormality, injury, overuse

a) OA

b) RA

OA

Before the age of 50, ... are more likely to have OA; past the age of 50, who predominates?

before 50: men

after 50: women predominate.

OA is classified as

primary or secondary

Primary OA: cause

has no known cause

may be localized (ie, involvement of one or two joints) or generalized (ie, diffuse involvement generally including three or more joints).

Secondary OA cause

can be related to an identifiable cause, such as trauma, anatomic abnormalities, infection, or aseptic necrosis.

hairdressers have a high risk of what disease?

OA - constant wear and tear of the hands and wrists

Cartilage wears down and interferes with joint movement

a) OA

b) RA

OA

bone erosion

a) OA

b) RA

RA

lines of the hands are normal and some swelling at the joints

a) OA

b) RA

OA

Boutonniere deformity

flexion of PIP joint and hyperextension of DIP joint

common in RA

Swank neck deformity

PIP hyperextension

DIP flexion

common in RA

DJD

degenerative joint disease

ambulating with poor posture for a long time can lead to

a) OA

b) RA

OA

common joints that OA affects

- hands (DIP, PIP, thumb CMC)

- feet (MTP)

- hips

- knees

- spine (cervical and lumbar)

*may arise on both sides of the body

morning stiffness in OA

common but of short duration

usually less than 20 minutes

short morning stiffness

a) OA

b) RA

OA

swelling in OA

warm, swelling and joint redness are usually MINIMAL or NOT PRESENT

clinical features of OA

- pain

- stiffness

- tenderness

- limited movement

- variable degrees of local inflammation

- crepitus

- may see reduced ROM --> with crepitus and hard end field

crepitus

an audible or palpable crunching or popping in the joint caused by the irregularity of opposing cartilage surfaces

Pain and stiffness typically occur with activity and are relieved by rest, but eventually they become present at rest and at night.

a) OA

b) RA

OA

OA is a two part process:

1) deterioration of articular cartilage

2) new bone formation

type of OA related to an indetifiable cause

secondary

- trauma

- repetitive motions

- anatomical abnormalities

- infections

- necrosis

type of OA with no known cause and may be localized or generalized

primary OA

*most common

The diagnosis of OA is initially made on the basis of the patient's

history and physical examination, with a lack of systemic symptoms ruling out inflammatory disorders such as RA.

- X-rays

- MRI

does OA have a cure?

no

OA Hand Deformities

Heberden's nodes (DIP)

Bouchard's nodes (PIP)

Thumb Capometacarpal

Goals in the treatment of OA are

relieve symptoms

improve function

limit disability

avoid drug toxicity

OA medications may target ... or .... . What types of meds?

system or local joints

- pain relievers

- anti-inflammatory

- non pharmacological agents

*know symptoms and side effects and how they affect occupations (nausea, flush, sleep)

OA surgical management

- Arthroscopic joint debridement (small camera, clean out area)

- grafting (take part of the body and substitute)

- fusion (no movement = no pain)

- joint replacement

Tx for OA

positioning --> splints (why? help area rest, provides function, facilitates pinch)

pain management (meds, stretching)

joint protection techniques

increased function

OA and pain management techniques

1) positioning

2) splinting

3) thermal modalities

4) rest

5) medication management

6) energy conservation

7) relaxation techniques

8) TENS (e-stim for pain)

9) joint protection (consider internal and external forces)

10) exercise

when considering joint protection, what are some examples of external forces placed on the joints?

- odd shaped objects

- slippery surfaces

- tight fit objects (lids, covers)

- small handle

- cold object

most joints become stressed in what position?

flexion

- grasping objects tightly

- poor placement of hand and joints

what position must we avoid if RA is present? what activities?

ulnar deviation!

Avoid/find different ways to:

- holding knives

- lifting plates

- opening jars

- turning doorknob

- pushing in a drawer

- wringing out cloth

Adaptations for RA and OA

-use tools with large/rounded handles (avoid tight grasp)

- used spike board to stabilize veggies when cutting them

- grasp objects between the palms of both hands instead of using handles

The purpose of joint protection is to

reduce internal and external joint stress, pain, and inflammation in the involved joints and preserve the integrity of joint structures during the performance of daily activities

joint protection principles

1. Respect pain

2. Maintain strength and ROM

3. Use joint in most stable anatomical plane

4. Avoid positions of deformity

5. Use strongest joint available

6. Ensure correct patterns of movement

7. Avoid staying in one position for long periods

8. Avoid starting an activity that cannot be stopped

9. Balance rest and activity

10. Reduce force and effort

maintaining grasp or sustaining a position ...

fatigues muscles easily

STOP sustained activities .... muscle fatigues

before

... will decrease the torque

increasing the level arm will

circumference and joint protection

increasing the circumference decreases the force

big objects = easier

diameter and joint protection

increasing the diameter will decrease the amount of grip

preserves the smaller joins

reduces fatigue from static holding

ex: knifes, and spoons

what joints should we use whenever possible to reduce risk/pain from OA and/or RA?

use unaffected joints or larger joints whenever possible

joint protection: knives and scissors

make sure that they are sharp

stabilize using dycem

joint protection: stability

use pre-fabricated splints (sports braces)

non-intrusive and look "normal"

joint protection: adapt the environment

- arrangements of objects in environment

ex: place things hip to shoulder height

ex: an electric can opener may seem useful but if its in a cluttered environment it might be more stressful

joint protection: tooth brush

built up handle for bigger grasp which leads to less of an effort to hold

joint protection: correct way to hold a book

place both palms under the book

avoid using fingers

joint protection: key

avoid lateral pinch

use a key grip to hold using a power grip

joint protection: getting up from a chair

Use of palms to push off a chair helps protect finger joints.

For example, the client may use the dorsum of the fingers to push up from a seated position (knuckles). This movement places deforming forces toward MCP flexion. A more suitable pattern is to use the flat surface of the palm.

if unable, place forearms in a nearby table and push up

goals of assistive devices

1) maintain and/or increase independence/participation

2) simplify task

3) decrease pain

4) decrease unnecessary strain in the joints

Commonly used AD in arthritis interventions are

extended-handle devices (eg, reacher, bath sponge, shoe horn, dressing stick, comb) --> to compensate for loss of proximal ROM and strength

devices with built-up handles (eg, hairbrush, toothbrush, writing implement, eating utensil, knob turner) --> to compensate for limited hand function

patient education

• use self-management based on knowledge

• recognize need for assistance

• use members of team appropriately

• use community resources

• incorporate treatment into daily routine

• live as "normally" as possible

*confirm that the patient understood what you are educating them about

Repetition, reinforcement, and real-life application to the client's situation are other keys to education.

Rather than focusing exclusively on providing basic information and generic skills, encouraging ... has been suggested as a helpful part of rehabilitation.

client self-reflection and transformation of client perspectives

The purpose of joint protection is to

reduce internal and external joint stress, pain, and inflammation in the involved joints and preserve the integrity of joint structures during the performance of daily activities.

THR adaptive equipment

1) sock aid

2) reacher

3) easy shoe laces

*extended handled devices

AE for the bathroom after THR

1) elevated toilet seat

2) handrails or grab bars

3) adjustable tub or shower bench (must be higher to avoid flexion)

4) Handheld shower hose,

5) bath bench

6) long-handled sponge

THR Adaptations: environment

avoid scattered rugs

elevate the couch, chair or recliner

(seat height that is at least twenty inches above the floor)

THR adaptations: shelves

avoid excessive bending and lifting

arrange shelves and cupboards with frequently use items at waist to shoulder height

AE for dressing

Dressing stick, shoe horn, sock aid, button hook, zipper pull, elastic shoelaces

AE for toiletting

Raised toilet seat, grab bars, extended perineal hygiene aid

AE for hygiene and grooming

Built-up or extended-handle toothbrush, suction denture brush, extended-handle hairbrush or comb, suction nail brush, mounted nail clipper

AE for feeding

Built-up or extended-handle utensils, lightweight T-handled mug

AE for meal preparation

Electric can and jar openers, adapted cutting board, utensils with built-up handles, ergonomic right-angled knives, rolling utility cart, knob turner for stove, reacher

RA: classic external signs and symptoms of inflammation

- heat

- edema

- erythema

- pain

peak incidence of RA

The peak incidence occurs between 40 and 60 years of age, with the rate of disease two to three times higher in females

synovitis

inflammation of the synovial membrane that results in swelling and pain of the affected joint

present in RA

Joint swelling from RA results from

excessive production of synovial fluid, enlargement of the synovium, and thickening of the joint capsule

this weakens the joint capsule and distends tendons and ligaments.

As the inflammatory process continues, the diseased synovial membrane forms a pannus that actively invades and destroys cartilage, bone, tendon, and ligament.

Scar tissue can form between the bone ends and cause the joint to become permanently rigid and immovable.

Dx criteria for RA

▪Morning stiffness greater than 1 hour

▪Arthritis of 3 or more joint areas

▪Arthritis of hand joints

▪Symmetrical arthritis (involvement on both sides)

▪Rheumatoid nodules

▪RH factor (blood test)

▪X-ray changes

*need at least 4

signs of early stages of RA

edema

no deformity

signs of late stages of RA

joint deformities

ulnar drift

The inflammatory process of RA has been described as having four stages:

1) acute (flares up)

2) subacute

3) chronic active,

4) chronic inactive.

acute stage of RA signs

typically a flare up

▪Pain

▪Inflammation

▪Hot, red joints

▪Tenderness

▪Overall stiffness

▪Limited motion