OTA 215: Ch. 28_Arthritis and LE Joint Replacement Flashcards

Overview and Prevalence of Arthritis

• Definition: Arthritis refers to conditions affecting the joints and the tissue surrounding the joints; the literal term translates to "joint inflammation."

• Localization: Can present as a localized condition or a systemic condition affecting multiple joints throughout the body.

• Varieties: The Centers for Disease Control and Prevention (CDC) has identified over $100$ distinct types of arthritis.

• Prevalence: Affects more than $54\text{ million}$ individuals.

Classifications and Clinical Features of Arthritis

• Rheumatoid Arthritis (RA):

  • Disease Nature: A chronic, systemic, autoimmune disorder.

  • Affected Structures: Most commonly damages joint structures, but can also cause damage to blood vessels, the heart, lungs, or eyes.

  • Demographics and Onset: Onset is most common between the ages of $30$ and $40$; affects women $3\times$ more frequently than men.

  • Pathophysiology: The immune response causes synovitis (inflammation of the joint capsule or lining), which leads to stretching of the joint capsule, tendons, and ligaments, ultimately weakening the joint structures.

  • Disease Course: Characterized by chronic inflammation and continuous disease progression, though some individuals experience periods of remission. Acute pain occurs during exacerbations.

  • Clinical Features:

    • Joint swelling resulting from an abundance of synovial fluid.

    • Reductions in range of motion (ROM), muscle strength, and endurance.

    • Scar tissue formation caused by chronic inflammation, which can lead to joint fusion.

    • Bilateral involvement across joints, though not always symmetrical; the dominant hand is frequently affected more severely.

    • Specific hand deformities resulting from poorly managed disease, including swan-neck deformity, boutonniere deformity, and ulnar drift.

    • Joint laxity, characterized by ligamentous instability due to stretching or lengthening of the collateral ligaments.

• Osteoarthritis (OA) and Degenerative Joint Disease (DJD):

  • Disease Nature: Occurs when the protective cushioning provided by joint cartilage breaks down, causing joint stiffness and pain.

  • Primary Causes and Mechanisms: Commonly designated as a "wear-and-tear disease" due to progressive degeneration from age, overuse, or injury. Primary structural damage stems from mechanical forces acting on the joint due to excessive body weight, weak musculature, or joint misalignment.

  • Risk Factors: Prior history of joint injury, genetic predisposition, obesity, and female gender (specifically over the age of $50$).

  • Clinical Features:

    • Softening and loss of elasticity in the smooth cartilage covering bone ends, leading to direct bone-on-bone friction.

    • Development of osteophytes (bone spurs resulting from abnormal bone growth).

    • Crepitus, defined as an audible or palpable noise or grinding sensation within the joint.

    • Formation of fluid-filled subchondral cysts within the bone.

    • Pain characteristics ranging from acute post-surgical pain to chronic pain that progressively worsens over time.

    • Finger deformities resulting from cartilage damage and osteophyte formation in the digital joints.

• Gout:

  • Pathophysiology: Results from an accumulation of excess uric acid in the body. Uric acid crystallizes and deposits in and around joint tissues, inducing severe inflammation and acute pain.

  • Demographics and Prevalence: Affects over $8\text{ million}$ individuals, occurring with a higher prevalence in men than in women.

  • Risk Factors: Genetic predisposition, advanced age, hypertension (HTN), high alcohol consumption, and elevated body mass index (BMI).

  • Four Stages of Progression:

    1. Asymptomatic Stage: Elevated uric acid blood levels lead to early crystal deposition without associated pain.

    2. Symptomatic Stage: Characterized by the rapid onset of acute joint pain.

    3. Hot, Red, Painful Joint Stage: Acute inflammatory flare-up typically originating in the first metatarsophalangeal joint (big toe); manageable via pharmacological intervention.

    4. Chronic Gout Stage: Persistent crystal deposits cause progressive erosion of joint cartilage, synovial membranes, tendons, and surrounding soft tissues, resulting in permanent joint deformities.

Pharmacological and Surgical Management

• Medical Interventions:

  • Disease-Modifying and Biologic Response Modifiers: Administered individually or in combined regimens to suppress the autoimmune response and slow down progressive joint damage.

  • Anti-Inflammatory Therapies: Targeted local inflammation is managed through systemic steroids or targeted corticosteroid injections.

  • Gout Pharmacotherapy:

    • Primary Strategy: Lifelong maintenance therapy aimed at decreasing serum uric acid concentrations.

    • Acute Flare Management: Nonsteroidal anti-inflammatory drugs (NSAIDs) are utilized to reduce pain and acute systemic inflammation.

• Surgical Interventions:

  • Synovectomy: Surgical excision of diseased, inflamed synovial tissue.

  • Tenosynovectomy: Surgical removal of an infected or diseased tendon sheath.

  • Tendon Surgery: Includes tendon relocation, tendon repair, tendon transfer, and tendon release for specific hand impairments; performed most frequently on the extensor tendons of the hand and wrist.

  • Arthrodesis: Surgical fusion of joint surfaces using permanent hardware such as pins or rods.

  • Arthroplasty / Joint Replacement: Prosthetic joint reconstruction; total hip arthroplasty (THA) and total knee arthroplasty (TKA) represent the most frequent procedures.

  • Hip Precautions Following Arthroplasty:

    • Anterior Approach: Avoid hip external rotation, adduction, and extension.

    • Posterior Approach: Avoid hip flexion beyond $90^\circ$, internal rotation, and adduction.

  • Prosthetic Fixation and Weight-Bearing Status:

    • Cemented Prosthesis: Typically allows immediate Weight Bearing As Tolerated (WBAT).

    • Non-Cemented Prosthesis: Typically requires Non-Weight Bearing (NWB) status during initial healing.

Occupational Therapy Evaluation and Treatment Framework

• Assessment of Occupational Performance:

  • Primary Objective: Maximize functional independence in daily occupations and enhance overall quality of life.

  • Evaluative Components: Formulation of an occupational profile, detailed review of medical and client history, evaluation of daily routines, personal values, and pain standardizations using pain scales.

  • Assessment Tools: Utilization of standardized and non-standardized assessment measures to evaluate performance in Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs), complemented by environmental home assessments as indicated.

• Intervention Modalities and Methods:

  • Preparatory Methods and Physical Agent Modalities (PAMs): Applied as preparatory interventions to minimize pain, mitigate local tissue inflammation, and enhance functional ROM. Modality selection must comply with state-specific regulatory scope-of-practice guidelines.

  • Therapeutic Exercise and Activities:

    • Designed to preserve and promote joint function, muscle strength, and physical endurance.

    • Requires interprofessional communication to avoid physical overexertion or overworking specific muscle groups.

    • Incorporates individualized aerobic and resistive exercise protocols tailored to patient status.

    • Employs passive range of motion (PROM), active-assistive range of motion (AAROM), or active range of motion (AROM) based on client condition.

  • Rest and Activity Modification:

    • Rest serves as a structured activity modification technique, with specific rest requirements varying between individuals.

    • Extended periods of bed rest may be indicated during acute disease exacerbations.

    • Activity modification strategies are integrated to grant periodic physiological rest to affected joints.

  • Positioning Strategies:

    • Implementation of positioning protocols reduces joint pain, rests localized structures, and prevents progressive deformities.

    • Intermittent prone lying is utilized to facilitate hip extension.

    • Raised toilet seats and armrests on chairs reduce mechanical load on the upper extremities (UEs) while maintaining mandatory hip precautions.

  • Orthotic Interventions:

    • Splints, braces, and orthoses are applied to support affected joints in anatomically optimal positions.

    • Orthotics assist in preventing contractures and deformities, reducing joint pain, and improving overall functional grip strength.

  • Energy Conservation and Task Modification:

    • Maximizes functional performance through structured education on work simplification techniques and balancing activity with rest.

    • Employs activity grading and adaptive equipment (AE) to adapt task requirements in response to reduced strength, impaired dexterity, or limited activity tolerance.

• Principles of Joint Protection Education:

  1. Respect pain: Modify or cease activities that provoke severe joint discomfort.

  2. Maintain muscle strength and joint ROM: Perform gentle functional movements regularly within safe limits.

  3. Avoid positions of stress: Refrain from joint alignments that promote persistent stress and structural deformity.

  4. Avoid static positioning: Prevent joint stiffness by avoiding prolonged maintenance of any single position.

  5. Utilize optimal biomechanics: Employ the largest and strongest available joints and muscle groups for manual tasks.

  6. Distribute operational loads: Spread mechanical workloads evenly across multiple joints.

• Discharge Planning and Long-Term Program Continuity:

  • Active client engagement throughout the continuum of care ensures improved compliance and functional follow-through post-discharge.

  • Customized home programs are developed and prescribed to maintain functional gains made during therapy.