Arthritis

Question 1

What is osteoarthritis (OA)?

Answer 1

AKA degenerative joint disease

Causes the cartilage in joints to break down, which results in joint pain and stuffness

Question 2

What are common joints affected in OA? (8)

Answer 2

Neck, spine, hips, knees, MTPs, DIPs, PIPs, thumb CMCs

Question 3

What is the disease process of OA?

Answer 3

Not inflammatory - Primary OA has no known cause & is typically associated with aging & overuse of joints. Secondary OA is related to an identifiable cause such as trauma, anatomic abnormalities, infection, or aseptic necrosis.

Question 4

How long does morning stiffness typically last in OA?

Answer 4

<30min

Question 5

Signs & symptoms of OA (7)

Answer 5

1. Pain
2. Stiffness
3. Tenderness
4. Limited mvmt
5. Variable degrees of inflammation
6. Crepitus
7. “Gelling” after inactivity (stiffness)

Question 6

What is crepitus?

Answer 6

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

Question 7

What is rheumatoid arthritis (RA)?

Answer 7

Chronic, autoimmune inflammatory condition, which develops suddenly over a period of weeks-months

Question 8

What are common joints affected in RA? (11)

Answer 8

1. Neck
2. Jaw
3. Hips
4. Knees
5. Ankles
6. MTPs
7. Shoulders
8. Elbows
9. Wrists
10. PIPs
11. MCPs
12. Thumb CMCs

Question 9

What is the disease process of RA?

Answer 9

Inflammatory, characterized by synovitis & a polyarticular & symmetrical presentation. Characterized by flare-ups and periods of remission.

Question 10

How long does morning stiffness typically last in RA?

Answer 10

1-2+ hours

Question 11

Systemic features of RA?

Answer 11

Fever, malaise, fatigue

Question 12

Mechanism of RA disease process

Answer 12

Synovitis (inflammation of synovial membrane) - degrading enzymes, swelling due to too much synovial fluid, enlargement of the synovium, & thickening of joint capsule

Question 13

What are common deformities due to RA? (4)

Answer 13

1. Wrist radial deviation
2. MP ulnar deviation
3. Swan neck deformity
4. Boutonniere deformity

Question 14

OT Eval Process for Arthritis: (5)

Answer 14

1. Client hx (dx, onset, meds, etc.)
2. Occupational profile (roles, activity, typical occ’s)
3. Occupational performance status (ability to participate in meaningful roles & occupations)
4. Cognitive, psychologic, & social status
5. Clinical status (inflammation, ROM, strength, hand function, stiffness, pain, sensation, joint instability & deformity, physical endurance & functional mobility)

Question 15

Procedures for MTT with arthritis (4)

Answer 15

1. Resistance is applied in the pain-free range (not the hard/soft end-feel)
2. Use joint protection principles
3. Discontinue resistance if there is pain
4. Use functional motions when use of resistance is contraindicated (in acute or active phase of arthritis)

Question 16

What are Bouchard’s nodes?

Answer 16

Osteophyte formation (enlarged bony nodule) of the PIP

Question 17

What are Heberden’s nodes?

Answer 17

Osteophyte formation (enlarged bony nodule) of the DIP

Question 18

What is anklyosis?

Answer 18

Fusion of the bones of a joint, characterized by lack of joint mobility.

Question 19

What is multilans deformity?

Answer 19

Characterized by floppy joints with redundant skin - bones shorted & renders the joint completely unusable.

Question 20

Overarching goal of OT intervention with arthritis

Answer 20

1. Decrease pain
2. Protect joints
3. Increase function

Question 21

General OT objectives include (6)

Answer 21

1. Maintain or increase ability to engage in meaningful occupations
2. Maintain or increase joint mobility & strength
3. Maximize physical endurance
4. Protect against or minimize deformity
5. Increase understanding of disease & how to deal with it
6. Assist with adjustment to disability

Question 22

Stage of Disease: Acute.
Name Symptoms (6), Objectives (2), & Tx considerations (9)

Answer 22

Symptoms: Pain, inflammation, hot red joints, tenderness, overall stiffness, limited motion
Objectives: Decr. pain & inflammation, & maintain ROM, strength & endurance
Tx Considerations: Splinting for localized rest day & night, incr. bedrest, joint protection, AD, PAMs, gentle AROM or PROM to point of pain (no stretch), proper positioning, functional activities to tolerance, isometric exercise

Question 23

Stage of Disease: Subacute.
Name Symptoms (4), Objectives (2), & Tx considerations (10)

Answer 23

Symptoms: inflammation subsiding, warm pink joints, decr. tenderness & pain, stiffness limited to morning
Objectives: Decr. pain & inflammation, & maintain ROM, strength & endurance
Tx Considerations: Less restrictive splinting during day, splinting con’t at night, joint protection, AD, PAMs, AROM or PROM w/ gentle stretch, proper positioning, incr. functional activities to tolerance, isometric exercise

Question 24

Stage of Disease: Chronic Active. 
Name Symptoms (4), Objectives (2), & Tx considerations (8)

Answer 24

Symptoms: minimal inflammation, less tenderness & pain, incr. activity tolerance, low endurance
Objectives: Decr. pain & inflammation, & INCREASE ROM, strength & endurance
Tx Considerations: splinting as needed, joint protection, AD as needed, PAMs as needed, AROM or PROM w/ stretch, incr. functional activities, cardiovascular exercise, resistive exercise (but don’t over stretch joint)

Question 25

``` Stage of Disease: Chronic Inactive. Name Symptoms (3), Objectives (3), & Tx considerations (10) ```

Answer 25

Symptoms: No inflammation, pain & stiffness from disuse, low endurance Objectives: Decr. pain, & increase or maintain ROM, increase strength & endurance Tx Considerations: splinting as needed, joint protection, AD as needed, PAMs as needed, AROM or PROM w/ stretch, incr. functional activities, cardiovascular exercise, resistive exercise (but don't over stretch joint)

Question 26

General treatment precautions related to arthritis (6)

Answer 26

1. Respect pain 2. Avoid fatigue 3. Avoid placing stress on inflamed or unstable joints 4. Use resistive exercise or activity w/ caution 5. Be aware of sensory impairments 6. Be cautious with fragile skin resulting from system disease or pharmacologic side effects.

Question 27

Primary categories of OT Tx for Arthritis

Answer 27

1. Rest & Sleep 2. PAMs 3. Therapeutic Exercise 5. Therapeutic Activity 6. Splinting 7. Assistive Devices 8. Client & family education

Question 28

OT Tx for Arthritis: SLEEP & REST

Answer 28

Rest & relaxation can effectively break the cycle of pain, stress & depression by allowing the body time to heal itself. Recommendation: 8-10hrs sleep per night, 1/2-1hr rest breaks in morning & afternoon OUTCOMES: less joint swelling, pain, & fatigue

Question 29

OT Tx for Arthritis: PAMs

Answer 29

Helpful in relieving pain or increasing/maintaining ROM Modalities: superficial heat & cold agents *Note heat has risk of incr. inflammation - not recommended for acutely inflamed joints. In subacute or chronic phases, heat & cold may be equally effective

Question 30

Contraindication of Raynaud's phenomenon?

Answer 30

COLD is contraindicated for this vasospastic disorder of the digits

Question 31

OT Tx for Arthritis: THERAPEUTIC EXERCISE

Answer 31

Purpose is to keep muscles joints functioning as normally as possible by maintaining muscle strength, preventing disuse atrophy, & maintaining/improving ROM

Question 32

What's a sign modification of exercise program is needed?

Answer 32

Pain lasting more than 1-2hrs

Question 33

General guidelines for exercise for a ct with Arthritis

Answer 33

1. Avoid undue stress on joints 2. Avoid pain & swelling 3. Work within ct's comfortable ROM

Question 34

Contraindication in exercise program for Active Phase arthritis

Answer 34

If in active phase, never STRETCH the joint. PROM & AROM may be used, but only within pain limits/comfy ROM

Question 35

When can resistive exercised be used?

Answer 35

NEVER IN ACUTE PHASE | May be appropriate at later phases

Question 36

OT Tx for Arthritis: THERAPEUTIC ACTIVITY

Answer 36

Both physical & physiological benefits - Discussing past & present hobbies will help determine a beneficial activity, graded appropriately for safe engagement

Question 37

What activities do you have to be careful with RA?

Answer 37

Activities that require use of hand in prolonged static positions (e.g. knitting & crocheting) *NOTE: Only truly contraindicated if there is active MCP synovitis, a developing swan neck deformity, or thumb CMC involvement

Question 38

OT Tx for Arthritis: SPLINTING (6 indications)

Answer 38

``` Fundamental goal = maximize function Indications: 1. reduce inflammation 2. decr. pain 3. support unstable joints 4. proper positioning 5. limit undesired motion 6. incr. ROM. *Primarily beneficial during acute phase ```

Question 39

Common splints for arthritis (7)

Answer 39

1. Resting hand splint 2. Wrist splint 3. MCP ulnar deviation splint 4. Swan neck splint 5. Boutonniere splints 6. Hand-based short thumb spica splint 7. Opponens splint

Question 40

When is a resting hand splint used? Functions?

Answer 40

During acute phase (acute synovitis of the wrist & hand). Primary function: provide localized rest to involved joints Other functions: Decr. pain, decr. muscle spasm, & protect joints vulnerable to contracture

Question 41

Recommended position for resting splint

Answer 41

Slight wrist extension (0-20 degrees) Slight wrist ulnar deviation (10-20 degrees) MCP flexion (20-30 degrees) Slight PIP & DIP flexion (10-30 degrees) Thumb - slight ext., abduct. @ CMC, & flex. @ DIP/PIP

Question 42

What an ideal wearing schedule for a resting splint?

Answer 42

Worn continually for the duration of the flare-up. Removed at least once a day for skin hygiene & gentle ROM exercises. Con't full-time wearing schedule for at least 2 weeks after flare-up, with a gradual decrease in wearing time to allow joints to recover. Eventually only wear at night.

Question 43

What are the benefits/function of a wrist splint?

Answer 43

Provide wrist stability, decrease pain, & improve function

Question 44

What are the benefits/function of a MCP ulnar deviation splint?

Answer 44

Pain relief, stability, alignment, & reduced stress on painful, subluxed, or deviated joints. May slow progression of deformity, but will not prevent it.

Question 45

What are the benefits/function of a swan neck splint?

Answer 45

AKA PIP hyperextension block. Used to restrict unwanted PIP hyperextension. Allows the ct to flex the PIP joint more efficiently

Question 46

What are the benefits/function of a boutonniere splint?

Answer 46

Block PIP in extension & leave the DIP free to flex | Splinting at night in maximal extension can attempt to maintain ROM

Question 47

What are the benefits/function of thumb splints?

Answer 47

Hand-based short thumb spica splint & Opponens splint - used for probs at the MCP or CMC & leave the IPs free Improve pain & function & reduce subluxation

Question 48

Are dynamic splints ever used? Indications? Cons?

Answer 48

Dynamic or serial splints may be used to increase ROM or maximize motion after surgery (e.g. joint arthroplasty). May be indicated if: there is soft-end feel, web space is preserved, & there is minimal inflammation. Static splinting is generally more tolerated due to stress dynamic splinting puts on a joint.

Question 49

Common Assistive Devices for Arthritis (8)

Answer 49

1. Long-handled devices (e.g. dressing stick, sponge, etc.) 2. Devices with built-up handles (e.g. pens, button hooks) 3. Grab Bars 4. Shower chair/bath bench 5. Raised toilet seat 6. Reacher 7. Knob turner 8. Electric can & jar openers

Question 50

What's the purpose of joint protection?

Answer 50

Avoid/reduce internal & external joint stress, pain, & inflammation

Question 51

Principles of Joint Protection (10)

Answer 51

1. Respect pain - it's a signal from the body telling you something's wrong & working through pain can cause joint damage. Stop before it's painful. 2. Maintain muscle strength & joint ROM 3. Use each joint in its most stable anatomic & functional plane 4. Avoid positions of deformity 5. Use the strongest joints available. 6. Ensure correct patterns of mvmt 7. Avoid staying in one position for long periods - change body positions, gripping postures, take frequent breaks & integrate active motion into activities 8. Avoid starting an activity that cannot be stopped immediately if it becomes too stressful 9. Balance rest & activity - the key to increasing functional endurance is to rest before fatigue sets in 10. Reduce force & effort

Question 52

Principles of Fatigue Mgmt (6)

Answer 52

1. Attitudes & emotions - remove yourself from stressful situations, use relaxation techniques 2. Body mechanics - Use your legs when lifting, keep back straight. Avoid reaching. Sit when working. 3. Work pace - get 10-12hrs of rest daily (night + naps), alternate easy & difficult tasks, spread work throughout the week 4. Leisure time - Devote a portion of your day to something to enjoy 5. Work methods - keep items within reach, good light, joint protection, work surfaces @ correct height 6. Organization - plan ahead, don't rush, prioritize, delegate