Arthritis and Lower Extremity Joint Replacement

Pima Medical Institute OTA 215: Phys Dys Notes Outline

Chapter 28: Arthritis and Lower Extremity Joint Replacement

Definition of Arthritis

  • Arthritis: "joint inflammation"

    • Affects the joints and the tissue surrounding the joints

    • Causes increased pain and decreased Range of Motion (ROM) due to damaged body tissue

    • Can be localized or systemic, affecting multiple joints

I. Primary/Most Common Forms of Arthritis

A. Rheumatoid Arthritis (RA)

  • Definition: Autoimmune dysfunction that is chronic and systemic in nature.

    • Joint capsule membranes become thickened and scarred;

    • Synovial fluid is over-produced but becomes less effective as the condition progresses.

    • RA primarily damages joints but can also affect blood vessels, the heart, lungs, or eyes in severe cases.

RA Demographics and Etiology

  • Demographics:

    • Affects women at a ratio of 3:1 compared to men.

    • Onset occurs typically between the ages of 30-40 (not to be confused with juvenile form, JRA).

  • Etiology:

    • Considered idiopathic.

    • Various environmental factors and a genetic predisposition have been identified.

RA Signs and Symptoms

  • There is considerable variation in signs and symptoms among individuals.

    • Signs and symptoms can result from the disease process itself or as side effects of medication.

  • Flare-ups and Remissions:

    • Exacerbations (periods of heightened disease activity) and remissions (inactive periods during which the disease is still present).

  • Systemic Symptoms:

    • Primary systemic effect is inflammation, which leads to various complications:

    • Eyes: Inflammation of the sclera; symptoms include dryness, gritty feeling, and pain.

    • Digestive System: Experiences dry mouth, ulcers, and colitis due to inflammation.

    • Cardiopulmonary System: Inflammation can affect heart membranes (e.g., peri-, myo-, endocarditis) and the pleura of the lungs, leading to chest pain and shortness of breath.

    • Vascular System: Inflammation of blood vessel linings can weaken and overstretch vessels, cause narrowing (stenosis), contribute to reduced vascular efficiency, and lead to skin ulcers.

      • Significant but rare incidents of vascular problems affect approximately 1 in every 100 patients.

  • Characteristic Symptoms:

    • Fatigue, loss of appetite, fever, achiness/stiffness, and weight loss.

  • Synovitis: Inflammation and overactivity of synovial joint membranes leading to hypertrophy, alongside production of poor-quality synovial fluid containing T-cells, B-cells, and fibroblasts.

    • Smaller joints, usually affected bilaterally, include wrists, hands, feet, and intervertebral joints of the cervical spine.

  • Up to 80% of individuals with RA develop deformities:

    • Hands and Wrists: Common deformities include ulnar drift, subluxation, swan-neck deformity, Boutonniere deformity.

    • Feet: Deformities such as bunions and hammer toes are prevalent.

    • Rheumatoid nodules may develop over time, with a higher occurrence in smokers with RA.

Medical Management for RA

  • Medication Interventions: Refer to pg. 518 for drug therapies.

  • Surgical Interventions: Options include:

    • Synovectomy

    • Tenosynovectomy

    • Tendon surgeries

    • Arthrodesis

    • Arthroplasty

Occupational Therapy Treatment Process for RA

  • Decreased function is not automatically implicated with the presence of deformities as these typically evolve over time.

  • Evaluate functional status closely.

  • Consider psychosocial and emotional aspects and potential medication side effects.

  • Employ pain rating scales for assessment.

Specific OT Treatment for RA

  • Refer to PAMs (Physical Agent Modalities) per MD orders; assist in pre and post-treatment OT interventions.

  • Therapeutic Exercise (Ther Ex) and Therapeutic Activities:

    • Refer to clinical pearls on pages 525 and 527.

    • Remission Phase: Focus on resistive exercises and activities with joint protection, avoiding strengthening in positions of deformity.

    • Exacerbation Phase: Contraindicates resistive exercises and activities.

    • Recommended to perform gentle passive range of motion (PROM) without stretching twice daily.

    • Isometric exercises help preserve muscle strength.

  • Rest Strategies:

    • May involve resting affected areas (using splints) or rest for the whole limb or body (using props/pillows to accommodate fixed deformities).

    • Engage in quiet activities, meditation/breathing exercises, or sleep as needed.

    • Nurses and OT can assist patients with planning proactive activity rests to avoid fatigue.

  • Positioning: Avoiding positions of deformity during rest and activity is crucial.

  • Orthotic Interventions: Assist in maintaining proper joint position.

  • ADL Training and Education: See pages 525-527, Figures 28.17-28.18 for detailed assistive device recommendations covering topics:

    • Energy conservation

    • Joint protection

    • Aids in daily living (ADs)

B. Osteoarthritis (OA)

  • Definition: Commonly referred to as degenerative joint disease (DJD).

    • The articular cartilage decays leading to bone-to-bone contact in joints.

  • Demographics: Typically affects individuals as they age or suffer trauma to the affected area.

  • Etiology: Frequently described as a “wear and tear” disease resulting from repetitive impacts or forces degrading the joint space.

OA Signs and Symptoms

  • Localized pain that intensifies over time but is not systemic.

  • Associated symptoms include redness, edema, and pain in the affected area.

  • Formation of osteophytes (bone spurs) in and around the joint space.

  • Usually affects larger joints and tends to present unilaterally.

Medical Management and Occupational Therapy Treatment for OA

  • Refer to the treatment protocols for RA concerning management and interventions.

C. Gout

  • Definition: Localized accumulation of uric acid crystals (a by-product of kidney function) in or around joints.

  • Demographics: Most commonly seen in males over the age of 50, with increased incidence in women post-menopause.

  • Etiology: Generally considered idiopathic with some genetic predispositions.

Gout Signs and Symptoms

  • Characterized by exacerbations and remissions, with sudden onset of pain, redness, heat, and edema surrounding the affected area.

  • Most commonly affects the hallux (big toe) at the MTP joint.

  • If untreated, may lead to deformity but generally responds well to medications.

Medical Management and Occupational Therapy Treatment for Gout

  • Medical Management: Primarily focused on pain management and educating about dietary changes and weight loss.

  • Occupational Therapy: Provide support, reinforce education for dietary adjustments, and encourage increased physical activity to promote a healthy weight, compliance with medications, and protection of joints.

Introduction to Lower Extremity Fractures and Joint Replacement

  • Older populations are at greater risk for hip fractures due to falls and conditions such as osteoporosis.

  • Analysis of falls:

    • Question: Does a fall lead to a fracture, or does a fracture lead to a fall?

  • Elderly individuals who have suffered a fracture may undergo procedures like hip replacement or ORIF (Open Reduction and Internal Fixation).

  • Rehabilitation can be complicated by multiple comorbidities present in these patients.

LE Joint Replacements

  • Joint Replacements:

    • Also known as arthroplasties, performed due to fractures, arthritis, congenital malformations, and other conditions.

    • Hip and knee replacements are the most frequently performed surgeries.

Weight Bearing Precautions

  • Weight bearing precautions are prescribed by physicians and can apply to either upper or lower extremities.

  • Types of Weight Bearing Precautions:

    • NWB: Non-weight bearing; no weight may be applied.

    • TTWB: Toe touch weight bearing; patients may only touch toes for balance.

    • PWB: Partial weight bearing; a specific percentage of weight may be applied (e.g., 25%, 50%, etc.).

    • WBAT: Weight bearing as tolerated; encourages full weight bearing to tolerance.

    • FWB: Full weight bearing; encourages patients to fully bear weight to tolerance.

A. Total Hip Arthroplasty (THA/THR)

  • Goal: To alleviate pain, restore joint motion, or replace fractured components.

  • Wound Care: Issues surrounding wound care and a significant risk of infections exist.

1. THA: Posterior Approach

  • Precautions:

    • NO hip flexion > 90º on the affected side.

    • NO internal rotation of the affected hip.

    • NO adduction of the affected lower extremity.

    • Adhere to established weight-bearing precautions.

  • Risk of Non-Adherence: Identify functional activities that may lead to non-adherence.

2. THA: Anterior Approach

  • Precautions:

    • NO extension past neutral on the affected hip.

    • NO external rotation of the affected hip.

    • NO adduction of the affected lower extremity.

    • Follow established weight-bearing restrictions.

  • Risk of Non-Adherence: Identify functional activities that may threaten adherence to anterior hip precautions.

3. Open Reduction with Internal Fixation (ORIF)

  • Surgical insertion of hardware (pins, plates, screws, etc.) to reduce fractures.

  • May involve posterior or anterior hip precautions and potential weight-bearing restrictions.

OT Intervention and Total Hip Arthroplasty

  • OT Framework: Determine the frame of reference most applicable.

  • Emphasis on:

    • ADLs (Activities of Daily Living)

    • Adaptive Equipment (such as a Hip Kit)

    • Durable Medical Equipment (DME)

    • Strengthening

    • Functional mobility, therapeutic exercise, standing activities

    • Enhance activity tolerance/endurance

    • Implement joint protection strategies, work simplification techniques, and education.

B. Total Knee Arthroplasty (TKA/TKR)

  • Comparison between Healthy Knee and Arthritic Knee; participation in “Pre-hab” for weight optimization and overall health improvement may happen before joint replacement.

  • TKA Surgery: Illustrated via surgical slides and post-operative X-ray views.

  • TKA Precautions:

    • Weight bearing as per physician orders.

    • Use of Continuous Passive Motion (CPM) machines as scheduled and directed.

    • NO rotation at the knee joint.

    • NO kneeling on the affected side.

OT Intervention and Total Knee Arthroplasty

  • Similar to intervention protocols for THA, emphasizing:

    • ADLs, adaptive equipment, DME

    • Strengthening, functional mobility, therapeutic exercise, standing activities

    • Activity tolerance/endurance strategies

    • Joint protection, work simplification, education, and facilitate the use of CPM machines, knee immobilizers, or braces as directed.