Arthritis Overview and Treatments

Rheumatoid Arthritis

• Chronic, systematic autoimmune disease
• Characterized by synovitis (inflammation of joint lining)

Osteoarthritis

• Degenerative joint disease
• Caused by cartilage breakdown and wear-and-tear

Rheumatoid Arthritis Symptoms

• Systemic symptoms (body-wide)
• Joint pain, swelling, and deformity
• Weight loss, fatigue

Osteoarthritis Symptoms

• Localized joint pain, swelling, and stiffness
• Deformity, weakness (especially CMC joints)

Rheumatoid Arthritis Course

• Acute (flare-ups) and chronic (remissions) phases

Osteoarthritis Course

• Progressive disease

Arthritis Medical Treatments

• NSAIDs (non-steroidal anti-inflammatory drugs)
• DMARDs (disease-modifying antirheumatic drugs)
• BRMs (biologics response modifiers)
• Analgesics (pain relievers)
• Steroids
• Surgical options (synovectomy, tenosynovectomy, tendon surgery, arthroplasty, arthrodesis)

Joint Nodes

• Bouchard's nodes: PIP (proximal interphalangeal) joints
• Heberden's nodes: DIP (distal interphalangeal) joints

De Quervain's Tenosynovitis

• Inflammation of tendon sheath

OT Treatment Goals for Arthritis

• Joint protection
• Energy conservation

Joint Protection Aspects

• Respect pain
• Use larger joints
• Avoid positions of deformity
• Avoid unnecessary joint loading

Energy Conservation/Work Simplification Aspects

• Pre-planning
• Rest
• Good posture and mechanics
• Avoid extremes, diaphragmatic breathing

Adaptive Equipment for Arthritis

• Button hooks, zipper pulls, jar openers, enlarged/lever handles, reachers, dressing sticks, tub seats, grab bars, raised toilet seats

Splinting

• Used for rest, hand function support, and deformity prevention

Splint Types and Uses

• Silver ring splint: swan neck or boutonniere deformities
• Soft splint: ulnar drift
• Wrist splint: De Quervain's

OT Treatment Phases for Arthritis

• Acute: ROM only, no resistance
• Chronic: ROM, gentle stretching, isometric strengthening

Modalities

• Heat: decreases stiffness, increases ROM
• Cold: decreases inflammation, swelling

Pain Definitions

• Acute pain: lasts less than 6 months
• Chronic pain: lasts 6 months or longer

Acute Pain Characteristics

• Signals tissue damage
• Identifiable cause, well localized, accompanies objective signs

Chronic Pain Characteristics

• Occurs after tissue heals
• No identifiable cause, poorly localized, lacks/fluctuates objective signs

Chronic Pain Additional Characteristics

• Multiple failed interventions
• Psychological effects (anxiety, anger)
• Potential legal issues (lawsuits)

Chronic Pain Conditions

• Cancer, arthritis, fibromyalgia

Complex Regional Pain Syndrome (CRPS)

• Miscommunication with sympathetic nervous system causing increased pain response (potentially reversible with early intervention)

Pain Etiology (No One Thinks So Funny Dad)

• Nociceptors (pain receptors)
• Thalamus (pain signal dispersal)
• Somatosensory cortex (pain localization)
• Frontal cortex (pain response coordination)
• Descending analgesic pathways (pain suppression)

Pain Cycle

• Pain -> Muscle Guarding -> Inactivity

Acute Pain Precautions

• Calm pain (modalities, exercises, massages)

Abnormal Pain Response Theories

• Misinterpretation of pain signals
• Centralized pain theory (brain "ownership")
• Gate control theory (blocking signals)

Chronic Pain Precautions

• Break pain cycle in areas of inactivity
• Avoid inactivity

OT Intervention: Acute Pain

• Establish trust
• Early intervention (splinting, ADLs, joint protection, soft tissue techniques)
• Strengthened return to ADLs

OT Intervention: Chronic Pain

• Establish trust
• Avoid focusing on pain
• Focus on function and activity (ADL modification, body mechanics, risk reduction techniques)

Pain Documentation

• Location, description, intensity, pain triggers, and relievers

Fracture Definition

• Break or crack in a bone

Fracture Types

• Closed (no skin break), open (skin break)

Fracture Lines

• Transverse, oblique, spiral, comminuted, segmental, avulsed, impacted, torus, greenstick

Specific Fracture Types (Upper Extremity)

• Colles: distal radius (falling)
• Mallet: distal phalanx (avulsion)
• Boxer's: 5th metacarpal (pinky)
• Scaphoid: carpal bone

Fracture Etiology

• Trauma (falls, accidents) or disease (cancer, osteoporosis)

ORIF Definition

• Open reduction internal fixation (surgery to fix bone)

Fracture Healing Times

• Upper Extremity: 6-12 weeks
• Lower Extremity: 12-30 weeks

OT Intervention: Upper Extremity Fractures

• Maintain integrity of unaffected joints
• Splinting
• Control pain, edema, scarring
• ROM (once stable)
• Strength and control
• Psychosocial adjustment
• ADL training, adaptive equipment

Back Injury Precautions

• NWB (non-weight bearing)
• PWB (partial weight bearing)
• TTWB (toe-touch weight bearing)
• FWB (full weight bearing)

Post-Surgery Movements to Avoid (Hip Posterior/Anterior Approaches)

• Posterior: Flexion, internal rotation, adduction
• Anterior: External rotation, adduction, extension

OT Goals for Fracture Recovery

• Maximize ADLs while maintaining safety,functional mobility, transfers, IADL’s

Muscle Strain

• Tearing, bruising, bleeding, or irritation of muscle fibers (tendon)

Facet Joint Sprain

• Tearing or inflammation of facet joint ligament/capsule (avoid twisting)

Slipped Disc

• Bulging or herniated disc compressing nerves, blood vessels, and ligaments (avoid forward bending)

Spinal Stenosis

• Narrowing of spinal canal

Spondylolisthesis

• Superior vertebra sliding over inferior vertebra (avoid spinal extension)

Orthopedic Spinal Conditions Symptoms

• Localized pain, radiating pain, muscle guarding, weakness, numbness, tingling, restricted mobility

Macrotrauma

• Sudden, major injury

Microtrauma

• Microscopic tissue injury (cumulative effects lead to major injury)

Cumulative Back Injury Factors

• Poor posture, poor mechanics, decreased flexibility, poor fitness

Amputations (Upper Extremity)

• Forequarter: humerus, scapula, clavicle removal
• Shoulder disarticulation: humerus-glenoid fossa separation
• Transhumeral: humerus amputation (loss of elbow)
• Wrist disarticulation: forearm-hand separation
• Transradial: below-elbow amputation
• Elbow disarticulation: lower arm removed at elbow
• Transcarpal: amputation through hand bones
• Finger/phalangeal: finger amputation
• Transmetatarsal: foot amputation at metatarsal bones
• Hemipelvectory: through the pelvis

Amputations (Lower Extremity)

• Transfemoral: above-knee amputation
• Knee disarticulation: lower leg separated from femur at knee
• Transtibial: below-knee amputation
• Symes: foot amputation at ankle joint

Amputation Interventions

• Muscle strength: cuff weights, bands
• Residual limb hygiene: adaptive techniques
• Phantom limb pain: mirror therapy
• Prosthetic training: specific exercises
• Edema control: wrapping, positioning
• Change of dominance: hand coordination
• Psychological support: active listening
• ROM: prevent soft tissue contractors
• Recreational activities: activity-specific adaptations

Amputation Types

• Congenital: present at birth
• Acquired: due to trauma or surgery

Upper Extremity Prostheses

• Passive mitts
• Body-powered
• Myoelectric (muscle-powered)
• Brain-powered

Body-Powered Prosthesis

• TD operation through shoulder flexion/protraction

Myoelectric Prosthesis

• TD controlled by electrodes on muscles

Preoperative Amputation Care

• Psychological support, prosthetic options, postoperative exercise programs, one-handed ADLs

Postoperative Amputation Care

• Emotional support, prosthesis benefits, active listening

Lower Extremity Amputation Interventions

• Positioning, transfers, strengthening, ADLs, IADLs, balance, driving, vocational activities, community reintegration

Upper Extremity Amputation Interventions

• Stump care, wrapping, ROM, desensitization, prosthesis schedule, skill training

Types of TD (Terminal Device)

• Voluntary opening: TD closes, amputee opens
• Voluntary closing: TD opens, amputee closes

UE Prosthesis Components

• Stump sock, harness, cables/components, socket

Neuroma

• Benign tumor at the proximal end of a severed nerve

Phantom sensations

• Sensations felt in the missing limb

Phantom limb pain

• Pain felt in the missing limb

Lower Extremities Amputee Positioning

• Daily ROM, neutral hip alignment, reduced contractors, edema and ulcers

Burn Definitions

• Tissue damage (heat, radiation, electricity, chemicals)
• Eschar (dead tissue)
• Hypertrophic scar (raised, borders)
• Keloid scar (raised, beyond borders)
• Contracture (shortened tissue)
• Debridement (removing tissue)

Burn Types

• Superficial (1st degree, epidermis)
• Partial thickness (2nd degree, dermis)
• Full thickness (3rd/4th degree, subcutaneous/bone)

Burn Assessment

• Rule of Nines
• Lund and Browder chart

Burn Complications

• Infection, temperature regulation, shock, scarring, contractors, psychosocial issues (PTSD, depression, anxiety)

Acute Phase Burn OT Interventions

• Edema control, contracture prevention

Rehabilitation Phase Burn OT Interventions

• PROM/AROM, edema control, scar management, ADLs

Scar Management Techniques

• Wraps, compresses, silicone products, stretching, ultrasound, massages

Post-grafting Burn OT Interventions

• Positioning, immobilization depending on graft

Acute Care Burn OT Interventions

• Medical management, edema management, splints

Rehabilitation Phase Burn OT Interventions (general)

• Achieving independence while preventing deformities

Wrist/Hand Burn Splint Positioning

• Wrist extension 30 degrees
• Thumb abduction/extension
• MCP flexion (50-70 degrees)
• IP extension