OTH 5430 – Exam 2 Study Material: Osteoarthritis (OA) and Rheumatoid Arthritis (RA)

Rheumatic diseases are commonly referred to as ______.

"arthritis" = joint and inflammation

more than 100 conditions are classified as rheumatic diseases

What are rheumatic diseases characterized by? What part of the body does it affect?

chronic pain, progressive physical impairment

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

T or F: Rheumatic diseases are the leading causes of disability.

true

What are the different types of rheumatic diseases?

OA

RA

Lupus

Ankylosing spondylitis

Scleroderma

Gout

Fibromyalgia

T or F: OTs are more likely to see clients with rheumatic diseases as a primary or secondary condition. To recognize problem areas and plan effective intervention strategies, the occupational therapist should know the unique features of each disease, its underlying pathology, and its typical clinical findings; the therapist should also be familiar with commonly prescribed medications and their adverse reactions.

true

Osteoarthritis (OA): Etiology

-most common RD

-affects 33% of working adults in the US

-affects all races and ethnic groups

-blacks and hispanics report twice the prevalence of work limitation and pain vs whites

-risk increases with age!!! (onset later in life)

-number one reason for physician visits for individuals 65 years and older

OA vs RA

Osteoarthritis

-individual joints

-non-inflammatory

-21 million

-incidence increases with age

-slow onset

-morning stiffness resolves in 20-30 mins

-NO redness, warmth

-responds to heat

-asymmetrical

Rheumatoid arthritis

-systemic

-inflammatory

-2 million

-40-60 years, females

-sudden onset

-morning stiffness persists for ~1 hr

-redness, warmth

-does not respond to heat

-symmetrical

What is gelling?

Stiffness and limited motion after inactivity

morning stiffness

OA vs RA: Joint damage

Osteoarthritis

-bone on bone (bone rubs together)

-thinned cartilage

-fusiform swelling of joints

-heberden's nodes

Rheumatoid arthritis

-bone erosion

-swollen inflamed synovial fluid

-ulnar drift of MCPs, boutonniere deformity of thumb, swan neck deformity of fingers

is OA inflammatory or non-inflammatory?

non-inflammatory

is RA inflammatory or non-inflammatory?

inflammatory

What is osteoarthritis?

-most common type of degenerative joint disease (DJD)

-strongly correlated with age (almost everyone over 65 has some cartilage damage)

-also associated with heredity, obesity, anatomical joint abnormality, injury, overuse, and repetitive movements

-non-inflammatory

-breakdown of cartilage in the joints leading to joint pain and stiffness

-affects specific joints (hands, hips, knees, spine) and may arise on both sides of the body

-minimal or not present warmth, swelling, and joint redness

-morning stiffness for ~20 mins

-absent systemic symptoms

What are the clinical features of OA?

pain

stiffness

tenderness

limited movement

variable degrees of local inflammation

crepitus

reduced ROM (with crepitus and hard end feel)

OA affects which joints

-hand: DIP, PIP, thumb CMC

-cervical and lumbar spine

-feet: MTP

-knees, hips

Is OA a 2-part process?

yes

1) deterioration of articular cartilage

2) new bone formation

steps

-cartilage softens, loses elasticity

-large sections wear away

(reduced spaces, bone-on-bone contact)

-osteophytes from as ends of bones thicken

-cysts may form, cartilage particles float in joint space

T or F: OA is classified as either primary or secondary

true

What is primary OA?

-no known cause (idiopathic)

-may be localized (involvement of one or two joints) or generalized (diffuse involvement, three or more joints)

more common

What is secondary OA?

-related to an identifiable cause

-due to trauma, anatomic abnormalities, infection, or aseptic necrosis

less common

How is OA diagnosed?

patient history

x-rays

MRI

What characteristics are noted in the hands with OA?

heberden's nodes - DIP

bouchard's nodes - PIP

thumb CMC

How is OA medically managed? What are the treatment goals?

treatment goals = relieve symptoms, improve function, limit disability, avoid drug toxicity

medications may target system or local joints

-pain relievers: narcotics, non-narcotics (can affect tx i.e. drowsy, nauseous, constipated)

-anti-inflammatory meds: provide pain relief, decrease local joint inflammation

-risk of GI and kidney complications

-nonpharmacological agents (herbal remedies)

How is OA surgically managed?

arthroscopic joint debridement, grafting, fusion, replacement

How is OA treated?

positioning - splints (static splints for rest and support)

pain management

joint protection techniques

increase function

What is rheumatoid arthritis?

-chronic, systemic inflammatory condition with an onset earlier in life

-develops suddenly or within weeks or months (insidious onset)

-affects many joints: wrists, elbows, shoulders, mainly smaller joints on both sides of the body

-warmth, swelling, and joint redness is common

-morning stiffness lasts longer than OA (longer than 1 hr

-systemic symptoms are present

Rheumatoid arthritis (RA): Etiology

-onset is earlier

-yet-unknown trigger causes an autoimmune inflammatory response in the joint lining of a genetically predisposed host.

-peak incidence occurs between 40 and 60 years of age

-rate of disease two to three times higher in females

T or F: RA manifests itself as synovitis, which is inflammation of the synovial membrane that lines the joint capsule of diarthrodial joints.

true

Is RA symmetrical or asymmetrical?

symmetrical

What are the clinical features of RA?

-symmetric pain and swelling, prolonged morning stiffness (1 hr +), malaise, fatigue, and low-grade fever

-PIP, MCP, and thumb joints, wrist, elbow, ankle, MTP, and temporomandibular joints (jaw); the hips, knees, shoulders, and cervical spine

What are the classic external S&S of inflammation (in RA)?

heat

edema

erythema (redness)

pain

___________, a cutaneous manifestation of RA, develop in 25% to 30% of persons with RA during periods of increased disease activity.

rheumatoid nodules

With RA, pain can be acute or chronic. When do these occur?

Acute pain occurs during disease exacerbations, or flare-ups. Chronic pain results from progressive joint damage.

What is the diagnostic criteria for RA?

-morning stiffness greater than 1 hour

-arthritis of 3 or more joint areas

-arthritis of hands

-symmetrical arthritis

-rheumatoid nodules

-RH factor

-x-ray changes

Edema and no deformities noted are indicative of what stage of RA?

RA early stages

Ulnar drift and joint deformities are indicative of what stage of RA?

RA late stages

How many stages are in the inflammatory process of RA?

1) acute stage

2) subacute

3) chronic active

4) chronic inactive

What are the signs and symptoms of the acute stage in RA?

inflammation

red, hot joints

pain and tenderness at rest that increase with movement

weakness, tingling, or numbness

overall stiffness

limited motion

What are the signs and symptoms of the subacute stage in RA?

inflammation subsides

warm, pink joints

decreased pain and stiffness

limited movement and tingling remain

stiffness limited to the AM

What are the signs and symptoms of the chronic active stage in RA?

minimal inflammation

less pain and tenderness

increased activity tolerance

low endurance

stiffness remains

What are the signs and symptoms of the chronic inactive stage in RA?

no inflammation

pain and stiffness – result from disuse

low endurance – result from disuse

overall functioning may be decreased as a result of fear of pain, limited range of motion (ROM), muscle atrophy, and contractures

Which of the following symptoms is characteristic of the acute stage of rheumatoid arthritis (RA)?

A) Crepitus

B) Hard end feel with reduced ROM

C) Red, hot joints

D) Pain that decreases with movement

C) Red, hot joints

Which of the following symptoms is characteristic of the subacute stage of rheumatoid arthritis (RA)?

A) Red, hot joints

B) Severe pain and stiffness throughout the day

C) Warm, pink joints with decreased pain

D) Hard end feel with reduced ROM

C) Warm, pink joints with decreased pain

Which of the following symptoms is characteristic of the chronic active stage of rheumatoid arthritis (RA)?

A) Severe inflammation with red, hot joints

B) Less pain and tenderness with minimal inflammation

C) High endurance with no stiffness

D) Severe pain and limited activity tolerance

B) Less pain and tenderness with minimal inflammation

Which of the following symptoms is characteristic of the chronic inactive stage of rheumatoid arthritis (RA)?

A) High levels of inflammation with red, hot joints

B) Pain and stiffness, limited range of motion (ROM), muscle atrophy, and contractures due to disuse

C) High endurance and full range of motion (ROM)

D) Severe pain and increased muscle strength

B) Pain and stiffness, limited range of motion (ROM), muscle atrophy, and contractures due to disuse

What is the clinical course of RA? From best to worst.

-single episode of acute inflammation (best)

-periodic episodes of exacerbations

-low-grade symptoms

-progressive with exacerbation and remission (deformities continue to develop)

-rapid unrelenting (worst - chronic, extreme pain)

What deformities are associated with RA?

1) swan-neck

2) boutonniere

3) mallet finger

4) ulnar drift

5) thumb

-impaired pinch

-loss of fingertip pick-up

-prominent proximal phalangeal head

What is swan neck deformity?

PIP hyperextension and DIP flexion

dorsal displacement of lateral bands

When a person has a __________ deformity, the function of the finger is compromised by an inability to flex the PIP joint, with loss of the ability to make a fist or hold small objects.

swan neck deformity

What is a boutonniere deformity? When does it occur?

PIP flexion and DIP hyperextension

occurs because of synovitis

grasp is preserved

When a person has a _________, the function of the finger is compromised by the inability to straighten the finger and the loss of flexion at the fingertip for pinching.

boutonniere deformity

What is mallet finger? Why does it occur?

DIP flexion (and PIP extension)

occurs bc of rupture of extensor tendon as it crosses the DIP joint

the finger loses the ability to extend the distal phalanx

What type of splints can be used for mallet finger and swan neck or hyperextension deformity?

tripod splint

In (1)_______, the most common pattern of deviation is (2)______ deviation of the wrist and (3)______ deviation of the MCP joints. Deviation is caused by ligament weakening or disruption.

1) RA

2) radial deviation of wrist

3) ulnar deviation of MCPs

(1)_____________ are granulomatous and fibrous soft tissue masses that are sometimes painful. They usually occur along weight-bearing surfaces such as the ulna or at the olecranon and can be prognostic of the severity of (2) _______.

1) nodules

2) RA

What are nodules? What should we be sure to note when documenting?

granulomatous and fibrous soft tissue masses found on bony prominences exposed to pressure but can occur in other areas

be sure to note:

-location

-size

-sensitivity

-number

-consistency

What two thumb deformities are common in RA?

type I - boutonniere deformity of thumb

type III - swan neck deformity of thumb

Type I - boutonniere deformity of thumb (RA)

CMC not involved

MCP flexion

IP hyperextension

Type III - swan neck deformity of thumb (RA.....and OA)

CMC subluxed, flexed, and adducted

MCP hyperextension

IP flexion

What is subluxation?

-partial dislocation of a joint (volar or dorsal displacement of joints)

-S&S: reduced range of motion, feeling of the joint being "out of place" or "slipping.

dorsal subluxation: the bone moves towards the back side

volar subluxation: the bone moves towards the palm or front side

What are the most common sites of subluxation for RA?

most common sites of subluxation are the wrist and MCP joints

(volar subluxation of the MCP joints occurs frequently and is often accompanied by ulnar drift and lateral displacement of the extensor tendons)

What is ankylosis?

abnormal stiffening and immobility of a joint due to the fusion of the bones

fusiform inflammation

Tendon involvements

flexor tenosnyovitis

extensor tenosnyovitis

trigger finger

DeQuervains

Tendon ruptures

What is flexor tenosynovitis? How do you evaluate?

-inflammation of the tendon and synovial sheath that causes the finger to swell and become painful to move on the volar side

-S&S: heat, swelling, pain or tenderness over the tendon sheath

evaluate

-evaluate the digits between MCP and PIP

-gently pull all digits into hyperextension at MCPs at one time to test simultaneously

-describe location and what motion, if any, increases pain

What is extensor tenosynovitis? How do you evaluate?

inflammation of the tendon and synovial sheath that causes the finger to swell and become painful to move on the dorsal side

evaluate

-place fingers in full flexion (fist), then gently move the wrist into full flexion

-describe location and what motion, if any, increases pain

What is trigger finger?

-caused by a nodule or thickening of the flexor tendons of the finger or thumb as they pass through the digital pulleys

-hinders gliding motion, resulting in catching or "triggering" during flx/ext

What motions are seen in trigger finger?

can actively flex, but not actively extend

can passively extend

What is DeQuervain's tenosynovitis? How is it tested?

-tenosynovitis involving the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) (("Apple and Peanut butter"))

-tenosynovitis of tendons on radial side

tested through the Finkelstein Test

-patient grasps thumb with fingers and gently deviates wrist ulnarly

What are tendon ruptures?

-most commonly occur with extensor tendons

-result in a loss of active MCP extension with inability to palpate tendon during attempts to extend digit

-rupture can be complete or partial

OT Evaluation of OA and RA involves gathering information on the patient's clinical status including......

1) pain level (throughout day)

2) inflammation or synovitis

3) AROM and PROM

4) strength

5) endurance

6) hand function (grip and pinch)

7) joint deformities

8) joint stiffness and morning stiffness (how long does it last?)

9) crepitus (location, cause, audible and/or palpable)

10) fatigue

12) sensation

12) functional mobility

13) medication

14) joint instability (laxity)

T or F: MMT is contraindicated when a patient with arthritis has inflammation.

true

in the case of an acute or active phase of arthritis, resistance may be harmful to inflamed tissue and joints

joint protection principle!!!

T or F: It is important to understand that strength testing in clients with arthritis differs from normal testing procedures. Resistance is applied at the end range of pain-free motion rather than at the true end of the ROM.

true

when resistance is applied within the pain-free range, inhibition of muscle strength by pain will be avoided.

How is the severity of a mallet finger deformity determined?

determined by DIP flexion with incomplete active extension

mild = partial active extension of DIP

moderate = no active extension of DIP

severe = fixed DIP contracture in flexion

How is the severity of a boutonniere deformity determined?

determined by the loss of active PIP extension

mild = loss of 5-10°

moderate = loss of 11-30°

severe = loss of 31° or more

How is the severity of MCP ulnar drift deformity determined?

determined by degree of ulnar deviation present (without correction)

mild = 0-10°

moderate = 11-30°

severe = 31° or more

How do you evaluate ligamentous instability (laxity) of the PIP / DIP joints?

to evaluate PIP / DIP

-hold joint in neutral (full passive extension)

-stabilize proximal bone while moving the distal bone from side to side

will be noted as:

-mild (5 to 10 degrees in excess of normal)

-moderate (10 to 20 degrees in excess)

-severe (20 or more degrees in excess)

How do you evaluate ligamentous instability (laxity) of the MCP joints?

to evaluate MCP

-hold joint in full passive flexion

-move proximal phalanx

will be noted as:

-mild (5 to 10 degrees in excess of normal)

-moderate (10 to 20 degrees in excess)

-severe (20 or more degrees in excess)

Composite finger flexion to palm

-measures the distance of the finger pulp from the palm when finger joints are flexed simultaneously

-if flexion is near normal, the finger pulp will lie over the distal palmar crease

-if flexion is restricted, the finger pulp will lie over the mid or proximal palm area

-composite finger flexion can be assessed with a ruler that measures the distance from the pulp of the finger to the palm

(tip of index to palmar crease)

-hard end feel - bony blockage

-firm end feel w/ some give - limited by ligament or capsule

How is OA and RA treated?

1) maintain or increase ability to engage in meaningful occupations

2) maintain or increase joint mobility

3) maintain or increase joint strength

4) maximize physical endurance

5) protect against or minimize deformities

6) decrease pain

Pain management includes........

-positioning

-splinting

-thermal modalities

-rest

-pharmacological therapy

-energy conservation

-relaxation techniques

-TENs

-joint protection

-exercise

OA and RA treatment: Rest

-considered an active way of reducing inflammation

-can break the cycle of pain

if have systemic symptoms = whole body rest

if have localized symptoms = splinting, avoiding/modifying task

OA and RA: PAMs - Superficial thermal agents (heat vs cold)

heat can provide

-increased blood flow, pain relief, increased tissue elasticity

-BUT may increase inflammation! (bad)

cold can provide

-reduced inflammation, decreased pain

-BUT may reduce tissue elasticity and increase stiffness

When are the use of cold PAMs contraindicated for RA?

use of cold is contraindicated in clients with Raynaud's phenomenon

-excessively reduced blood flow in response to cold

-skin turns pale, grey, or white

T or F: Clients with RA often have unstable vascular reactions to heat and cold that cause greater than normal heat retention with heat agents or increased coldness and stiffness with cold exposure. Therefore, careful monitoring of client responses to PAMs is crucial.

true

What is the goal of therapeutic exercise for patients with arthritis?

goal = to keep muscles and joints functioning as normally as possible

-exercise programs are individualized

-when pain lasts greater than 1-2 hours post-exercise, then OT should decrease exercise intensity

-avoid undue joint stress, pain, joint swelling

-work within client's comfortable ROM

Therapeutic exercise: Active RA

eliminate stress on inflamed joints (joint protection)

work on AROM (or PROM with stretch at end range)

work on isometric exercises

-resistance if no risk of overstressing joints, and if so, only functional activities like canned foods

Chronic active RA: Treatment objectives

decrease pain and inflammation

Increase ROM

increase strength and endurance

T or F: Rigid splints provide maximal immobilization or stability.

true

T or F: Soft splints allow more freedom of motion.

true

T or F: Semirigid splints combine elements of both.

true

RA Stage I: Early - Splints

Resting splints to decrease acute inflammation, decrease pain, protect joints

RA Stage II: Moderate - Splints

Day splints to provide comfort

Night splints to relieve pain or protect joints against potential deformity

Splints to increase ROM

RA Stage III: Severe and Stage IV: Terminal – Splints

Day splints to improve function (decrease pain, provide stability, limit undesired motion, properly position joints)

Night splints to provide positioning and comfort

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

Joint protection principles: External forces

outside forces placed on joints such as:

-odd-shaped objects

-slippery surfaces

-tight-fit objects (lids, covers)

-small handles

-cold objects

Joint protection principles: Internal forces

internal forces placed on joints such as:

-grasping objects tightly

-poor placement of hand

-poor placement of joints

most joints become stressed in flexion

What movements cause ulnar deviation and should be avoided (or modified)?

holding knives

lifting plates

opening jars

turning a doorknob

pushing in a drawer

wringing out a cloth

Joint protection: Avoid activities involving tight grasp. How can we modify?

use tools with large/rounded handles

use a spike board to stabilize vegetables when cutting them

grasp objects between the palms of both hands instead of using handles (using larger joints over smaller joints)

Joint protection: Avoid sustained positions

maintaining grasp or sustaining a position fatigues muscles easily

-have patient check in with themselves to ensure they don't reach fatigue

STOP sustained activities BEFORE muscles fatigue

Joint protection: Lever arm

increasing the lever arm will decrease the torque

use tongs, reacher, grip wrench

Joint protection: Circumference

increasing the circumference of the tool decreases the force needed

bigger objects easier to manipulate

Joint protection: Diameter

increasing the diameter will decrease the amount of grip required

-preserves the smaller joints

-reduces fatigue from static holding

i.e. thick handles for utensils