Rheumatoid and Osteoarthritis Overview

Rheumatoid Arthritis

• Chronic, systemic autoimmune disease
• Characterized by synovitis (inflammation of the fluid around joints)

Osteoarthritis

• "Wear and tear" arthritis
• Causes cartilage damage in joints

Rheumatoid Arthritis Symptoms

• Systemic (throughout the body)
• Joint pain, swelling, and deformities
• Weight loss, fatigue

Osteoarthritis Symptoms

• Localized joint pain, swelling, and stiffness
• Deformities, weakness
• CMC (carpo-metacarpal) joint involvement

Rheumatoid Arthritis Course

• Acute (exacerbation) and chronic (remission) phases

Osteoarthritis Course

• Progressive

Arthritis Medical Treatments

• NSAIDs, DMARDs, BRMs
• Analgesics, steroids
• Synovectomy, tenosynovectomy, tendon surgery, arthroplasty, arthrodesis

Joint Nodules

• Bouchard's nodes at PIP (middle) joints
• Heberden's nodes at DIP (distal) joints

De Quervain's Tenosynovitis

• Inflammation of tendon sheath

Occupational Therapy (OT) Goals for Arthritis

• Joint protection and energy conservation

Joint Protection

• Respect pain
• Use larger joints for tasks
• Avoid positions of deformity and unnecessary loading

Energy Conservation/Work Simplification

• Pre-plan, organize
• Rest, good posture
• Avoid extremes, diaphragmatic breathing

Adaptive Equipment for Arthritis

• Button hooks, zipper pulls
• Jar openers, enlarged handles
• Shoe horns, bath sponges, reachers, dressing sticks, tub seats, grab bars, raised toilet seats

Splinting

• Rest, support, prevent deformities

Splinting Applications

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

OT Treatment Phases for Arthritis

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

Modalities for Arthritis

• Heat: Decrease stiffness, increase ROM
• Cold: Decrease inflammation, swelling

Pain Definitions

• Acute Pain: < 6 months
• Chronic Pain: > 6 months

Acute Pain Characteristics

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

Chronic Pain Characteristics

• Occurs after tissue damage and healing
• Lack of identifiable cause, poorly localized, fluctuating subjective signs
• Multiple failed treatments, psychological effects (anxiety, anger), litigation

Chronic Pain Associated Conditions

• Cancer, arthritis, fibromyalgia

Complex Regional Pain Syndrome (CRPS)

• Sympathetic nervous system miscommunication, increasing pain response
• Reversable with early intervention

Pain Etiology (Nociception)

• Nociceptors: Pain receptors
• Thalamus: Disperses pain signals
• Somatosensory cortex: Pain localization
• Frontal cortex: Response coordination
• Descending analgesic pathways: Opioid suppression

Pain Cycle

• Pain -> Muscle Guarding -> Inactivity

Acute Pain Precautions

• Calm pain with modalities, exercises, massages

Pain Mechanism Theories

• Misinterpretation: Nerve fibers outside CNS
• Centralized pain theory: Brain "ownership"
• Gate theory: Pain signal inhibition (rubbing stubbed toe)

Chronic Pain Precautions

• Break pain cycle, avoid inactivity

OT Intervention with Acute Pain

• Trust building
• Early intervention (splinting, PAMs, soft tissue, ADLs)
• Strengthening and graded return to ADLs

OT Intervention with Chronic Pain

• Trust building
• Avoid focus on pain
• Focus on function, ADLs, body mechanics, compensation

Pain Documentation

• Location, description, intensity, aggravators, relief

Fracture

• Break or crack in a bone

Fracture Types

• Closed, open

Fracture Lines

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

Specific Fracture Examples (UE)

• Colles fracture: Distal radius, fall
• Mallet finger fracture: Distal phalanx avulsion
• Boxer's fracture: 5th metacarpal
• Scaphoid fracture: Specific carpal bone

Fracture Etiology

• Trauma, disease (cancer, osteoporosis)

ORIF

• Open reduction internal fixation

Fracture Healing Times

• UE: 6-12 weeks
• LE: 12-30 weeks

OT Intervention Steps for UE Fractures

1. Maintain non-immobilized joints
2. Splinting
3. Control pain, edema, scarring
4. ROM (as prescribed)
5. Strength and control
6. Psychosocial adjustment
7. Achieve highest function (ADL, adaptive equipment)

Back Injury Precautions

• NWB, PWB, TTWB, FWB

Back Surgery Precautions (Hip Approach)

• Posterior: No flexion, internal rotation, adduction
• Anterior: No external rotation, adduction, extension

OT Goals for Fracture Recovery

• Max ADL level, safety, functional mobility, transfers, IADLs

Muscle Strain

• Tearing, bruising, bleeding, irritation of muscle fibers

Facet Joint Sprain

• Ligament/joint capsule tear or inflammation
• Avoid twisting

Slipped Disc

• Bulging/herniated disc, nerve/blood vessel compression
• Avoid forward bending

Spinal Stenosis

• Narrowing of spinal canal

Spondylolisthesis

• Superior vertebra slips over inferior
• Avoid spinal extension

Orthopedic Spinal Conditions - Signs/Symptoms

• Localized/radiating pain
• Muscle guarding/tenderness
• Weakness, numbness, tingling
• Mobility impairment

Macrotrauma

• Sudden injury from major force

Microtrauma

• Microscopic tissue injury from cumulative effects

Cumulative Back Injury Factors

• Poor posture, body mechanics
• Decreased flexibility, poor fitness

Amputation Types (UE)

• Forequarter: Humerus, scapula, clavicle removal
• Shoulder disarticulation: Humerus-glenoid fossa
• Transhumeral: Through humerus, no elbow
• Wrist disarticulation: Hand-forearm meeting point
• Transradial: Below elbow
• Elbow disarticulation: Forearm removal, humerus remains

Amputation Types (LE)

• Transcarpal: Through hand bones
• Finger/phalangeal amputation: Passive prosthesis
• Transmetatarsal: Through metatarsals
• Hemipelvectory: Through pelvis
• Transfemoral: Above knee disarticulation; A.K.A.
• Knee disarticulation: Lower leg removal, femur remains
• Transtibial: Below knee; B.K.A.
• Symes: Foot removal at ankle joint

Intervention for Increasing Muscle Strength (Amputation)

• Cuff weights, exercise bands

Intervention for Residual Limb Hygiene

• Adaptive techniques for self-care pre-prosthesis

Intervention for Phantom Limb Pain

• Mirror therapy

Intervention for Prosthetic Training

• Shoulder flexion/bilateral scapular abduction to open/close prosthesis

Intervention for Edema Control

• Reduce residual limb volume to enhance prosthetic fit

Intervention for Change of Dominance (Amputation)

• Increase radial digital coordination

Intervention for Psychological Support (Amputation)

• Active listening, stages of grief

Intervention for Increasing ROM

• Prevent soft tissue contractors

Intervention for Recreation/Leisure (Amputation)

• Activity-specific prosthetic adaptations

Congenital vs. Acquired Amputation

• Congenital: Limb absence at birth
• Acquired: Surgery/trauma

Types of UE Prostheses

• Passive hands/mitts
• Body-powered
• Myoelectric
• Brain-powered

Body-Powered Prosthesis

• TD operated by shoulder flexion/protraction

Myoelectric Prosthesis

• TD operated by muscle electrode activity

Preoperative Amputation Care

• Psychological support, prosthetic options, post-op exercise, ADL techniques

Postoperative Amputation Care

• Emotional/psychological support, prosthesis benefits

LE Amputation Intervention

• Positioning, transfers, strengthening, ADLs, IADLs, dynamic balance, driving, pre/vocational, leisure, community reintegration

UE Amputation Intervention

• Stump care/hygiene, stump wrapping, ROM, desensitization, prosthetic wear schedule, skill training

Voluntary Opening/Closing TD

• Voluntary opening: Closed at rest, opened by action
• Voluntary closing: Open at rest, closed by action

UE Prosthesis Components

• Stump sock, harness, cables/components, socket

Neuroma

• Benign tumor at the proximal end of severed nerve

Phantom Sensation

• Sensations from missing limb

Phantom Limb Pain

• Burning, shooting, squeezing sensations in amputated limb

LE Amputation Positioning

• Daily ROM, avoid pillows, neutral hip alignment, reduce contractures, edema, ulcers

Burn Positioning (Anterior Leg)

• Slight knee flexion

Burn

• Tissue damage from heat, radiation, electricity, chemicals

Eschar

• Necrotic tissue adhering to wound

Hypertrophic Scar

• Raised scar within border

Keloid Scar

• Raised scar beyond border

Contracture

• Shortening of soft tissue around joint

Debridement

• Wound tissue and foreign object removal

Burn Types

• Superficial (1st degree), partial (2nd degree), full thickness (3rd/4th degree)

Burn Depth (Skin Layers)

• Superficial: Epidermis
• Partial: Dermis
• Full Thickness: Subcutaneous/bone

Rule of Nines/Lund and Browder Chart

• Estimated burn area

Burn Complications

• Infection risk, body temperature regulation, shock, scarring, contractures, psychosocial adjustments

OT Treatment - Acute Burn Phase

• Edema control, contracture prevention

OT Treatment - Rehabilitation Burn Phase

• PROM/AROM, edema control, scar management, ADL's

Scar Management Techniques

• Wraps, compression garments, silicone, stretching, ultrasound, massage