Arthritis & Orthopedic conditions

Normal Bone Health 

• The body maintains healthy bone by a process of repair (called remodeling) 

• Driven by two types of bone cells:

  • Osteoclasts:

    • Responsible for removing (resorption) of old existing bone 

  • Osteoblasts:

    • Responsible for forming new bone 

• A balance between the activities of osteoclasts keeps the overall mass of bone in the body constant 

Arthritis = inflammation of a joint 

• Several types, most common is osteoarthritis or wear-and-tear arthritis 

• Pennis = 

• SYMPTOMS:

  • Affects various joints in the body 

    • Common to have initial onset symptoms at the joint at the base of the thumb

  • Common symptoms of arthritis/osteoarthritis include:

    • Joint pain that often gets worse after exercise or excessive pressure on a joint 

    • Joint stiffness particularly in the morning

    • Cracking or grinding noise with joint movement 

    • Decreased function of the joint 

• Causes & risk factors:

  • Over 40 years can affect people of all ages 

  • Most common cause is wear-and-tear, and as you age, you are more prone to develop arthritis 

  • Traumatic injuries, fractures, & joint dislocation make you more susceptible to develop arthritis 

  • Certain types of arthritis are more common in women than men (such as arthritis in the thumb) 

  • Some people have congenital abnormalities of the joints-for example. Perthes’ disease of the hips, that cause early degeneration & subsequently can cause osteoarthritis 

Rheumatoid Arthritis (RA)

• RA is an auto-immune disease in which the body’s immune system (the body’s way of fighting infection) attacks healthy joints, tissues, & organs – heart, lungs, gastrointestinal system 

• Most often in women of childbearing age, the disease inflames the lining (or synovium) of joints (2-3x more women) 

• Can happen at any age, primarily between 25-45 years crippling disability that impairs a person’s ability to stay active & independent & may shorten a person’s lifespan 

• Pain, stiffness, swelling, & loss of function in joints 

• Severe RA can deform/change a joint

• Affects mostly joints of the hands & feet & tends to be symmetrical (no other form of arthritis is symmetrical)

• RA is one of more than 100 forms of arthritis affecting millions of Americans 

Deformities:

• Swan neck 

  • PIP hyperextension 

  • DIP flexion 

    • Dorsal migration of the lateral bands 

• Boutonniere deformity 

  • PIP flexion 

  • DIP hyperextension 

    • Lateral bands migrate volar 

Diagnosis:

• 2 main tests:

1. Rheumatoid Factor 

2. Anti-cyclic citrullinated peptide (anti-CCP)

• Medical history - patient narrative; physical exam; blood test, imaging tests 

• Medications: pain-relieving medications such as NSAIDs, DMARDS, COX-2 inhibitors & opioids may be prescribed. 

  • Topical medications such as ointments can be applied over the skin where there is pain 

    • If the pain is very severe, corticosteroid injection can be given directly into the affected joint to ease pain 

• Surgery:

  • joint replacement 

• Therapy 

  • Exercise to keep joints flexible & improve muscle strength 

  • Applying heat to affected joints for temporary pain relief 

  • Lifestyle modifications to control weight & avoid extra stress on the weight-bearing joints 

  • AE

• RA is a systemic disease which damages more than joints, can also affect internal organs such the heart, lungs, liver, or vascular system 

• RA has been associated with cardiovascular disease, heart failure, lung disease, eye disorders, fibromyalgia, depression, & more 

• Patients with RA need to attend to their cardiovascular health by controlling high cholesterol, eating a heart-healthy diet, & getting regular exercise 

• Heart disease is the leading cause of death among people diagnosed with RA 

****can increase the risk of cardiovascular disease (RA is a systemic disease that can damage more than joints) 

Rheumatoid Arthritis = bone loss 

• The inflammatory process that occurs in RA increases the risk of bone loss & fractures 

  • Severity of inflammation 

  • Duration of disease 

GOALS for RA:

• Stop inflammation (put disease in remission) 

• Relieve symptoms

• Prevent joint & organ damage 

• Improve physical function & overall well-being 

• Reduce long-term complications 

• Control inflammation 

• Increased amount of calcium 

RA = Osteoporosis 

• Osteoporosis, with increased risk of fracture, commonly affects women with RA

  • This is especially true as this group reaches menopause & during the post- menopause years, when the risk for osteoporosis is normally the highest 

  • Osteoporosis is a condition in which the bones become less dense & more likely to fracture 

  • In the US, more than 53 million people either already have osteoporosis or are at high risk due to low bone mass 

Gout

• Metabolic syndrome 

• Most common form of arthritis 

• Crystalline form of inflammatory arthritis 

• First appearance = significant pain in MTP of big toe 

• Related to how the body metabolizes food 

• Will have periods of flare ups & remissions 

• Associated with “rich man’s diet”

• AMAB are 3x more likely to develop gout 

• African AMerican AMAB more likely than caucasian AMAB

• Signs & symptoms 

  • Reddish purple tone 

• Increased with age 

• Increases medication utilization & cost 

• Interconnected to other diseases 

• Maintained by medication but not well controlled by US  

• Diagnosed through physical exam, medical history, and lab/blood work

  • Imaging can also be used for more severe & chronic forms of gout 

• Presence of uric acid crystals in synovial fluid & elevated leukocytes & neutrophils 

• Episodic & chronic components 

• A form of inflammatory arthritis, & some people have high levels of uric acid in the blood 

  • The acid can form needle-like crystals in a joint and cause sudden, severe episodes of pain, tenderness, redness, warmth, & swelling 

• Stages of gout:

  • Asymptomatic hyperuricemia

    • The period prior to the first gout attack

  • Acute gout, or gout attack 

    • Happens when something (such as a night of drinking) causes uric acid levels to spike or jostles the crystals that have formed in a joint, triggering the attack

  • Interval gout 

    • The time between attacks 

  • Chronic gout 

    • Develops in people with gout whose uric acid levels remain high over a number of years 

• Prevalence: occurs in about 4% of American adults – about 6 million men & 2 million women. Experts believe natural estrogen protects women up to that point 

• Risk factors:

  • Genes: if family members have gout, you're more likely to develop it 

  • Other health conditions: high cholesterol, high blood pressure, diabetes & heart disease may increase your risk 

  • Medications: diuretic medications of “water pills” taken for high blood pressure can raise uric acid levels; so can some drugs that suppress the immune system taken by rheumatoid arthritis & psoriasis patients, as well as transplant recipients 

  • Diet: eating red meat and shellfish increases your risk   

  • Alcohol: for most people, more than two liquor drinks or two beers a day can increase the risk of gout 

  • Sodas: the fructose in sweet sodas has recently been shown to increase gout risk 

  • Obesity: obese people are at higher risk for gout, & they tend to develop it at a younger age than people of normal weight 

  • Bypass surgery: those who have undergone gastric bypass surgery have an increased risk 

Lupus 

• A chronic, autoimmune disease, with an overactive & misdirected immune system 

• Lupus is systemic, meaning that it affects a wide part of the body, including the joints, kidneys, skin, blood, & other organs 

• Systemic lupus erythematosus (SLE)

  • Accounts for about 70% of all lupus cases

  • Considered most serious form of lupus but range from very mild to severe

  • SLE affects various parts of the body and can cause joint pain, fatigue, hair loss, sensitivity to light, fever, rash, & kidney problems 

• Prevalence: 

  • More than 1.5 million Americans have lupus 

  • Across all ethnic, age, and sexes; 9 out of 10 adults with the disease are women between ages 15 and 45 

• Systemic lupus erythematosus 

• Pain & inflammation in any part of the body 

• Autoimmune disease 

• Symptoms can come & go and vary in severity 

• Autoimmune disease that does not have an etiology but has contributing factors 

• More common in AFAB (a lot of research being done with the association with estrogen) 

• Runs in families 

• Health disparities can impact severity of disease presentation and reduced QoL 

Symptoms include:

• Severe & prolonged fatigue

• Stiffness & pain in hands, wrists, elbows, & knees 

Other symptoms:

• Butterfly rash across nose & cheeks 

• Fever

• Sunlight sensitivity 

• Raynaud’s phenomenon 

• Mouth sores

• Swollen glands 

• Trouble breathing 

• Kidney issues 

• Cognitive deficits (memory issues) 

• Blood disorders

• Vaginal dryness 

• Swelling in legs & around eyes 

• Cough 

• Lupus Nephritis 

• Inflammation of NS

• Inflammation of blood vessels 

• Hardening of arteries 

• Skin inflammation

• Diagnosing lupus can take an average of 6 years to be diagnosed

• Typically requires:

  • Review of symptoms

  • Medical history 

  • Family history 

  • Lab tests

• 3 categories of classifications of lupus 

1. Quiescent 

2. Stable 

3. Serious 

Juvenile Idiopathic Arthritis (AKA Juvenile RA) 

Types of JIA

• Oligoarticular or pauciarticular JIA (most common type of arthritis in children under 16 y/os) 

• Polyarticular JIA

• Enthesitis-related arthritis (ERA) 

• Psoriatic JIA 

• Systemic JIA (still disease) 

• Some types can cause complications with growth, joint damage, and eye inflammation 

• Many other forms of juvenile inflammatory arthritic conditions 

• Has genetic & environmental factors play a role in JIA 

• Affects AFAB more than AMAB

• More common in caucasian populations than African American populations 

• Signs & symptoms:

  • Fever

  • Joint swelling & stiffness 

  • Swollen lymph nodes

  • Rash 

• Diagnosis = rule out method 

Fractures 

• Caused by trauma or disease of bone or joint 

• 2 factors to determine a fracture:

  • Amount of force applied to bone 

  • Strength of the bone 

• As you age = bone mass will decrease

• Force applied can be from high energy, low energy, and/or chronic stress 

• Stress fractures most often result from overuse or repetitive stress on the bone

  • They often result from any increased amount or intensity of activity that occurs too rapidly to give the bone a chance to adjust 

    • More common in lower extremities 

Osteoarthritis = most common 

• Also a degenerative joint disease 

• Older adults 

• Affects cartilage (the tissue that cushions & protects the ends of bones in a joint) 

  • With osteoarthritis, the cartilage wears away over time 

• Bone-on-bone contact 

• Bones may also bulge, or stick out at the end of a joint = bone spur 

• Joint pain can limit ROM (the ability to freely move and bend a joint) 

• Disability most often happens when the disease affects the spine, knees, & hips 

Osteopenia:

• Reversible bone weakness 

• Decrease in bone density 

• Precursor to osteoporosis 

Heterotopic Ossification: 

• Abnormal bone formation in soft tissues 

• Associated with traumatic injuries 

• Can be painful & debilitating depending on the severity 

Types of fractures:

• Hairline 

• Greenstick 

• Closed 

• Open

• displaced/unstable 

• nondisplaced/stable 

• Comminuted 

• Spiral 

Occupational Therapy: Arthritis 

• Joint protection 

• Adaptive techniques/equipment

• Conditioning programs/exercise 

• Education 

• Community mobility/driving 

• Splints 

• psychosocial/ coping/ sleep 

• Pain reduction 

• ADL/IADL

• vocational/ workplace assessments 

Key Principles for Prevention of Joint & Protection of Joints 

• Avoid forceful activities 

• Avoid tight grasps 

• Avoid using pressure side of thumb 

• Always use your largest joints 

• Use 2 hands for lifting instead of 1 

• Slide heavy items instead of carrying