Rheumatology: Understanding Arthritis, Diagnosis, and Treatment - PDF

RHEUMATOLOGY Bouchard nodes: hard, bony outgrowths at the proximal interphalangeal (PIP) joints due to osteoarthritis (OA). Boutonnière deformity: joint deformity characterized by flexion of the PIP joint and hyperextension at the distal interphalangeal (DIP) joint. Cachexia: loss of muscle mass as...

RHEUMATOLOGY Bouchard nodes: hard, bony outgrowths at the proximal interphalangeal (PIP) joints due to osteoarthritis (OA). Boutonnière deformity: joint deformity characterized by flexion of the PIP joint and hyperextension at the distal interphalangeal (DIP) joint. Cachexia: loss of muscle mass as the inflammatory processes affects muscles and the metabolism in rheumatoid arthritis (RA). Chondropenia: loss of cartilage faster than the rate of repair in the osteoarthritic joint. Crepitus: feeling or sound of crunching, creaking, or grating coming from the articular surface during range of motion. Disease-modifying antirheumatic drugs (DMARDs): drugs that affect the immune response or suppress the disease process (e.g., methotrexate). Fibrillation: the initial degenerative changes in OA, marked by softening of the articular cartilage and development of vertical clefts between groups of cartilage cells. Heberden nodes: hard, bony outgrowths at the DIP joints caused by OA. Joint protection techniques: the application of ergonomic principles in daily activities, work, and leisure to reduce internal and external stress on the joints and soft tissues. Mallet finger deformity: deformity resulting from damage to the extensor tendon at the DIP joint. Swan-neck deformity: hyperextension of the PIP joint and flexion at the DIP joint. Synovitis: inflammation of the synovial membrane (which lines synovial joint capsules, the function of which is to produce synovial fluid, which lubricates joints). Volumetry: a water displacement measure of hand volume, conducted by inserting the hand to a specified depth in a measuring cylinder containing a specified amount of water. Z deformity of OA thumb: carpometacarpal (CMC) joint adduction, metacarpophalangeal (MCP) joint hyperextension, and interphalangeal (IP) joint flexion. Z deformity of RA thumb: excessive hyperextension of the IP joint and flexion of the MCP joint of the thumb. Objectives - Create an awareness of the prevalence and seriousness of both inflammatory and non-inflammatory arthritis. - Increase your knowledge of the more common rheumatic diseases. - Provide you with basic tools and resources for assessing and treating individuals with rheumatological disease and understand the role of Occupational Therapy. Intro - It can be easy for some of us to overlook arthritis as a serious chronic condition. It’s not a silent killer like heart disease and it doesn’t get the publicity that breast cancer does. And yet, its seriousness is often downplayed. We dismiss and diminish the toll that is taken by arthritis. Unlike fatal diseases, arthritis takes lives in pieces, killing dreams, relationships, and even livelihoods. - Arthritis is a term used to describe a group of over 100 diseases characterized by inflammation in the joints or other areas of the body. Inflammation is a medical term that describes pain, stiffness, redness and swelling. Left unchecked, inflammation can lead to significant and often irreparable damage to the affected areas, resulting in loss of function and disability. o Osteoarthritis, rheumatoid arthritis, gout, scleroderma, lupis, PMR – all common o Less common one–>in consultation with physician that specializes in rheumotology  - Arthritis (arthro= joint, itis= inflammation) can involve almost any part of the body, most often affecting the hip, knee, spine or other weight-bearing joints, but also found in the fingers and other non-weight-bearing joints. Some forms of arthritis can also affect other parts of the body. o It attacks the body–>damages the body o Can affect joints, muscles, bones, eyes, skin internal organs - Arthritis is a chronic condition: it affects people on an ongoing, constant or recurring basis over months, years, even a lifetime. - Doesn’t the recognition it deserves on how disabling it is - Host of diseases Joint Anatomy Review - Joint Complex- Purpose- motion, distribute forces and dissipate load, allow for low friction load bearing, and is optimized by interaction of intact, associated joint structures - Diarthroses–Contain synovial membrane and fluid and are most commonly referred to as synovial joints o Know what synovial joint looks like - Component of articular joint tissues o Articular cartilage o Joint capsule o Synovial fluid/tissue o Subchondral bone Inflammatory Process - Local tissue reaction to injury - Micro vs macro trauma o Micro trauma adds up over time–>may not perceive at the time but can set off cascade of cytokines o Hyperextending MCPs may set off micro inflammatory response - Cytokines are important in intercellular interactions between WBCs o Set of response - Cytokines are molecules that are secreted from one cell to interact with another cell at receptor sites - Important role in immune responses including inflammatory reactions seen as: o Heat, Redness, Swelling, Pain, Loss of function Pattern of Inflammation - Acute Inflammation- Short duration (hours to days) - Chronic Inflammation- Longer duration (days to years) - In practice these 2 patterns often overlap - Never want inflammation - Flares=acute exacerbations Prevalence of Arthritis in our Society - About 6 million Canadians aged 15 or older o About 1 in 5 - Expected to increase to 9 million by 2040 - >4 million people living with Osteoarthritis- 1/ 7  - >272,000 people living with Rheumatoid Arthritis- 1 in 100 or 0.9% of the Canadian adult population - Predicted to grow to 1.3% over next 30 years - 1 in 8 workers has OA (11.93% of Canadian workforce) - 1 in 136 workers has RA - OA – 3.9 million Canadians 20 and over living with OA - RA most commonly diagnosed type of inflammatory arthritis Osteoarthritis and Rheumatoid Arthritis Osteoarthritis - Consensus Definition: “when clinically evident...characterized by joint pain, tenderness, limitation of movement, crepitus, occasional effusion, variable degrees of inflammation without systemic effects.” o Localized at joint or cluster of joints o Traumas affects ECM of cartilage o Assault on cartilage on articular surface, result can also be boney spurs–>affects articulation further and further deranges joint o Joint pain linked with degenerative joint changes o OA is the most common form of arthritis and the leading causes of pain and disability worldwide. o a metabolically active, dynamic process involving all joint tissues (cartilage, bone, synovium, capsule, ligaments, and muscle). o primarily affects the cartilage in the hands (thumb carpometacarpal [CMC], PIP, and DIP joints) and weight-bearing joints specifically, cervical and lumbar spine, hips and knees o can affect one joint or multiple o onset gradual but progression can vary depending on if it is the result of an injury o knee OA–>typically progresses to knee replacement o IP joint OA–>become asymptomatic after a few years o Hip OA–>more need hip replacement after 1-5 years, poorest outcome Presentation of OA - Hand- 1st CMC joint (base of thumb), DIP and PIP joints o Very common in thumb o Small joints of hand–>thumb - Knee- Medial compartment (75%), Lateral compartment (26%), and Patellofemoral compartment (48%), Malalignment o 70+ walking–>medial aspect of knee is varus o Often why need knee replacement o Patellofemoral–>destruction of cartilage behind patella–>cant squat, do stairs etc. Bone on bone arthritis - Hip- Superior migration > Medial migration o Change biomechanics of joint so wear unevenly - Foot- 1st TMT, Talonavicular joint, and 1st MTP joint May be primary or secondary Pain - Pain, Stiffness, and Functional impact are primary symptoms - Pain increases with activity and improves with rest - Stiffness < 30 minutes o After that, feels better o Stiffness occurs after sleep or prolonged inactivity o postactivity flare-ups of edema and pain are common symptoms. - Bone can one the most painful things in body - Joint guarding and decreased willingness to move the painful joint contributes to muscle weakness and limitations in range of motion (ROM). o Crepitus can occur in advance cases during ROM - Hip OA presents as groin pain - Pain is persistent and can disrupt sleep - Pain is caused by the stretching of nociceptors in the joint capsule due to focal synovitis, increased vascular pressure in subchondral bone, and from spasm of muscles surrounding the involved joints Pathology of OA - Gradual loss of articular cartilage - Thickening of subchondral bone - osteophytes at joint margins - mild, chronic, non specific synovial inflammation - any synovial jpint can develop OA - damage of joint cartilage attributed to multiple risk factors: genetic (heritability accounts for 40% to 60% of hand, knee, and hip OA), constitutional factors (more common in women, with age, and with higher body weight), and biomechanical factors (e.g., joint injury, greater occupational or leisure use of a joint, reduced muscle strength, joint laxity, or misalignment). - Pathophysiology changes: o Fibrillation, loss of articular cartilage, and remodeling of adjacent bone with new bone formation (osteophytes) o Focal synovial membrane inflammation can occur because of irritation from osteophytes and other joint changes. o suggest that OA is a repair process, which is initially effective, resulting in a structurally altered but symptom-free joint. However, continued damage or ineffective repair or chondropenia means symptomatic OA results Cartilage - Normal cartilage o Extracellular matrix, rich in collagens and proteoglycans (capable of retaining molecules of water). o Matrix- responsible for tensile strength and resistance to loading of the articular cartilage o Type 2 collagen - Aging Cartilage o Structural and biochemical changes of the matrix occur during aging. o reduced capacity of molecules to retain water. Lose tensile strength of cartilage–>more likely to get damaged o Biomechanical properties altered- fissures develop in cartilage. o Difficult to make cartilage when older May take supplements–>need to research before recommending it OA Joints - Different ways to classify OA o May be better to look at what functional problems they are having than focusing on what stage they are at - Abnormal cartilage and bone - Synovial and capsular lesions - Phase I: edema o Surface largely intact o May be some abrasions o Edema puts some pressure on joint so may be some fibrillations - Phase II: fissuring and pitting of cartilage o Cell death o Over proliferation in clusters of cartilage o Fissures all the way down through the middle - Phase III: fragments of cartilage detach and “fall” into the articular cartilage and uncover subchondral bone where osteophytes form. o Fragments rip off and are floating in joint capsule–>osteophytes can now produce bone where they shouldn’t be OA Hand - the repair process can lead to osteophyte formation at joint margins and focal synovitis in affected joints - most commonly affects DIP and CMC - Should be spaces between joints but there aren’t - Cartilage loss with narrowing of interphalangeal joints - B: Bouchard nodes (osteophytes PIP joints) o PB–>peanut butter - H: Heberden nodes (osteophytes DIP joints) - Only difference of the location of the nodes - Mallet finger deformity results at the DIP joint if the distal extensor digitorum communis tendon attachment is disrupted by bony enlargement. - classic thumb deformity in OA consists of squaring at the CMC joint, with Z deformity of the OA thumb, which results from CMC joint adduction, MCP joint hyperextension, and IP joint flexion. - Muscle wasting is noticeable in the thenar eminence, and finger, thumb, and wrist movement reduces. OA Treatment Recommendations - Non-Pharmacologic Treatment: o Weight reduction (knees and hips–less stress on these joints), Physiotherapy, Footwear (kinetic chains), Orthotics, Knee Brace (to stabilize medial compartment), Splint, Assistive and Ambulatory Devices, Occupational therapy for joint protection education - Pharmacologic Treatment: o Decrease pain and stiffness and improve joint mobility and physical activity o Topical, Intraarticular treatment, Acetaminophen, NSAIDs, Duloxetine, Opioid Analgesics o Cymbalta–>off label use for pain relief - If conservative treatment doesn’t work o Common surgical interventions include joint replacements, such as total hip arthroplasty (THA) and partial and total knee arthroplasty (TKA) o most common procedure of the CMC joint of the thumb is arthroplasty with ligament reconstruction with tendon interposition (LRTI). o Arthrodesis, or joint fusion, is reserved for only the most painful joints that have not responded to all other interventions. - Consult: Rheumatologist and Orthopedic Surgeon OA Functional Impairments - People with combined finger and CMC OA have the poorest function - May have difficulties with ADL - May have to retire early Research - Improving joint protection for people with hand osteoarthritis (Ontario) - Development of a set of biomarkers to predict clinically relevant knee osteoarthritis progression (Duke University) Rheumatoid Arthritis - Chronic, systemic inflammatory disease - Symmetric polyarticular pain, swelling, morning stiffness, malaise, and fatigue - Progressive joint damage resulting in significant disability if not treated - Autoimmune disease - Cause or etiology unknown - Genetic and environmental factors have been linked with onset o disease process is initiated by an interaction between genetic, hormonal, environmental, and lifestyle factors. - Joints can be damaged within months of symptom onset - Unknown event or stressor thought to trigger abnormal activity in the body’s immune system, causing synovial tissue and adjacent structures to be affected. - Cigarette smoking increases the risk of developing RA, as well as the risk of increased disease activity and mortality Features of RA - Pain o Painful as it progresses o Difficult to diagnose when it starts - Fatigue- 40- 80 % of patients, contributing factors anemia, inflammatory cytokines, pain, sleep disturbance, and depression  o Disrupted sleep, everything more difficult–>fatigue, leads to depression which can be fatiguing o Say they are tired or fatigued –> ask if they mean mentally, physically or both - Morning stiffness- > 30 minutes; often one of the first signs of disease o Prolonged beyond 30 min - Pain and stiffness improves with activity and is worse with inactivity o Opposite of OA - Onset: 3-1 female to male ratio with primary onset between ages of 35 and 50. Most individuals (70%) experience an insidious onset of symptoms over weeks to months. 10% acute severe onset and 20% subacute onset. - Extraarticular symptoms- pericarditis, pericardial effusion, rheumatoid nodules (bits of flesh, growth under the skin, moveable), anemia, osteoporosis o Usually around olecranon of elbow or IP joints in hands - Diagnostic Tests- laboratory tests provide support for diagnosis Pathological changes - Synovitis: Thickening of the synovial membrane with increased synovial fluid causes edema around the joint. Edema-related pressure stretches nociceptors in surrounding tissues, causing pain. - Pannus: Protein-degrading enzymes released from inflammatory cells lead to hypervascularization and thickening of synovial membrane to form pannus (inflammatory tissue) that invades the bone and cartilage at the joint margins, leading to chondral and subchondral erosions. - Cachexia: Loss of muscle mass as the inflammatory processes affects muscles and metabolism. - Joint instability: Prolonged joint swelling stretches and weakens joint ligaments and capsules, thereby disrupting the stability of the joint. - Joint deformity: Abnormal movement in the joints with weak ligaments and disrupted structures leads to deformities. - Fatigue: Inflammatory proteins (e.g., tumor necrosis factor alpha) that are released lead to marked fatigue. Course and Prognosis - Most people have periods of exacerbations and remissions - Three distinct disease courses of RA: o Monocyclic: About 20% have one episode ending within 2 to 5 years of initial diagnosis without any recurrence. Early diagnosis and/or aggressive treatment with disease-modifying antirheumatic drugs (DMARDs) can arrest disease progression. o Polycyclic: About 75% experience fluctuating disease activity over the course of the condition, which can last for many years. o Progressive: About 5% RA continues to rapidly increase in severity and is unremitting. Classification Criteria - Target population (Who should be tested?): o Patients who have at least 1 joint with definite clinical synovitis (swelling* with the synovitis not better explained by another disease) o If symmetrical–>think RA - Classification criteria for RA (score-based algorithm of following categories: Joint involvement; serology- rheumatoid factor and anti cyclic citrullinated peptide, CRP/ESR; and duration of symptoms) Joints Affected and Type of Joint Damage - Lots of wrist, PIP, MCP (not DIP) - Wrist looks deranged  - Ankylosis–>restriction of mov’t at articular surface Signs and Symptoms of RA - Signs and symptoms of RA include symmetrical presentation of polyarticular pain, edema, early morning stiffness, malaise, and fatigue. - four stages of the inflammatory process: o acute characterized by red, hot swollen joints with pain, tenderness, and stiffness o subacute associated with morning stiffness but less pain and tenderness o chronic active and chronic inactive with reduced pain and increased tolerance but low endurance - can also affect the eyes, skin, lungs, heart, gastrointestinal system, kidneys, nervous system, and blood. - gradual onset, with symptoms appearing first in the hands and feet. - in about 20%, the onset is rapid, and clients wake one morning with multiple painful, stiff, and swollen joints, requiring emergency care - no cure but early diagnosis can slow disease progression Hands - In women with early RA (irreversibke - Arthritis can alter movement–>stiffness and instability Muscle Weakness  - Secondary to joint inflammation and pain - Muscle weakness happens slowly and is reversible - Varied disease process with periods of increased disease activity. - Flare ups can also occur due to the individual’s approach to activity management and psychosocial factors such as stress. o Try to avoid flare ups Normal Joint Movement - Finger function to maintain: o Fist, tuck, tip to tip, key grip, thumb flexion/extension, abduction - Wrist function to maintain: o Bending, straightening, side to side movements o Tend to lose ulnar and radial deviation quickly - Try to maintain those movements Hand Deformities - Piano Key: bump on wrist due to raised, loose ligaments between ulna and radius o Ulnar head pops up - Ulnar Deviation: tendons shift off of MCP joint, causing fingers to shift towards the little finger o Hallmark feature of RA in hands o Usually can still do ADLs with ulnar deviation o Digits go ulnar and carpals radial o Hand strength isn’t affect but hand function is - Boutonniere deformity o DIP hyperextended o PIP flexed o Volar plate under DIP irritated - Swan neck deformity o Could just be relaxed tendons o DIP flexed, PIP hyperextended o Volar plate under PIP irritated - Wasting in interossei and between carpals  - Hand radiograph of a patient with rheumatoid arthritis. Imaged is the hand of a patient with advanced rheumatoid arthritis with severe destruction of the joint architecture. Asterisks indicate bone erosion. - Lipping–>severe bone destruction RA Medical Management - Pharmacology–reduce inflammation to prevent or limit joint damage o Start earlier = better outcome - Common surgical procedures of the wrist and hand joints include synovectomy, tenosynovectomy, tendon repair and transfers, joint arthroplasty, and arthrodesis RA Functional Impairments - 60% of those diagnosed with RA from the early stages have difficulty with hand function and challenges completing activities of daily living (ADL) - 20% to 70% of working adults stop working within 7 to 10 years of initial diagnosis - Although physical activity is known to decrease pain, improve physical function, and reduce 40% of health care costs, one in three adults with arthritis are inactive RA vs OA RA OA - Chronic - Chronic - Joint and systemic - Joints only o Affects multiple organs besdies the - Degenerative or wear and tear joints - Only symptom treatments - Autoimmune or inflammatory - Cartilage is abnormal - Symptom and disease controlling treatments - Body can’t keep up with cartilage repair after - Joints Lining (Synovium) is abnormal microscopic or regular trauma causing - Infection fighting cells start fighting normal destruction tissue in synovium causing destruction - What they tell you  - What you observe - RA is a systemic, progressive condition that affects synovial joints and other body systems. - Associated with substantial personal and societal burden. - Early diagnosis and appropriate medical treatment reduces disease activity, improving long-term outcomes. - As primary contact practitioners, there is a role in identifying early features of RA and referring individuals for diagnosis and medical management. Role of the Occupational Therapist Management of the Rheumatic Diseases - Early intervention - Individualized approach - Team approach - Continuity of care - Patient education - Family involvement - Therapeutic interventions What is the Role of OT in Rheumatology - Assess and address issues related to activities of daily living - Explore the physical, psychosocial and environmental impacts of disease on meaningful activities - Help people learn about their diseases and how to manage them - Splint to protect damaged joints, reduce pain, limit deformity and enable function. - Help people identify and liaise with community resources and support systems OT and Disease-Specific Management Strategies - Understanding disease process - Joint protection - Posture / positioning - Pain management - Fatigue management / energy conservation - Relaxation / stress management - Footwear recommendations - Activity adaptations and aids - Environmental adaptations - Fall prevention - Problem-solving strategies - Personal goal setting / motivation Joint Protection - Joint protection aims to reduce loads on joints and reduce deforming forces, thus minimizing risks of injury. - The strategy that is used to teach people a different way to do activities that decreases or changes the joint stressors on joints that lead to pain, fatigue, deformities, and loss of function is: joint protection - Avoidance of positions of deformity o Primarily refers to positions of flexion, ulnar deviation, and poor biomechanics Example: tight grip leads to increased risk of ulnar deviation and ligamentous stretch  Leaning on MCP’s may contribute to pain and volar subluxation Sleeping with pillows under the knees may lead to flexion contracture - Fatigue management–guidelines to help maximize energy day to day –>joint protection o Add grips to tools you use everyday–toothbrush, brush, fork Foam rubber tubbing o Switch from dishcloth to sponge Squish with flat hands instead of wring it out o Distribute load across larger and more joints Instead of grabbing jug of milk with one hand, support bottom with other hand o Drag things instead of lifting o Pivot to pour instead of lifting to pour o Anything with handle–>distribute across bigger joints o Neutral joint positions whenever possible o Get electric toothbrush to decrease repetitive motions and use big cylinder grasp Fatigue Management - Fatigue o Physical and/or mental exhaustion o Profound lack of energy o Mental ‘fuzziness’ o Difficulty concentrating - Best management: rest o Total Body Rest Acute inflammation  8- 10 hours of sleep per night  30-60 minute rest period during the day o Localized Rest Specific joint or area May involve the use of splint and/or joint protection techniques - Activity planning and pacing Energy Maximization -...a group of strategies used to: o Manage day-to-day tasks in the face of fatigue, in order to achieve a balance between rest, work and leisure. The goal of energy maximization is to help you participate in your most important activities which includes those that give you joy and enable you to optimize quality of life. - Clients don’t know how much energy they will have each day - If they can identify what contributes to fatigue, it will be helpful o Figure out have tos (eat, sleep etc.) o Want to bank energy to have it available for what you want to - Energy busters/Energy boosters o STEP ONE: Identify CONTRIBUTING FACTORS to fatigue: eg. your arthritis, other health concerns, medications, nutrition and diet stress / anxiety, pain, sleep, exercise, posture, other people, your environment (noise, lighting, temperature) Dealing with concerns related to these contributing factors may also help reduce your fatigue levels.  o STEP TWO: Take charge of how energy is spent and earned during daily activities. Think of energy like pennies in a jar. ENERGY BUSTERS- take pennies from your jar. ENERGY BOOSTERS- put pennies back into your jar. If energy busters and energy boosters are balanced there will be more success in maximizing energy. For example:  BUSTERS: Errands -7, Studying –4, Vacuuming –5 = -16 pennies  BOOSTERS: Walk +5, Visit with friend +3, Deep breathing +8 = +16 pennies o STEP THREE: Remember the 5 Ps!! Permission–ask for help Plan – Schedule activities for the week. Include both ENERGY BUSTERS and BOOSTERS. Pace – Find times for activity and rest in weekly and daily schedule. Divide large activities into smaller tasks. Notice signs of fatigue and remember to take short rest breaks to replenish your energy. Prioritize – Identify what activities and people are most important. Spend energy on these first. Problem solve – Think about the things that are done each day.  Want flexibility Splinting/Orthoses - Even with changing medical management, orthoses are still a core intervention for many people with arthritis, to reduce hand symptoms and improve hand function alongside hand exercises and joint protection. - How do we make the decision to splint? o The goal is to support self management. Splinting works in combination with other self management strategies such as joint protection and exercise, and assistive devices. o When hand pain and/or altered biomechanics create challenges, frustration, and difficulty doing everyday activities. o Can use it to get through work or to rest joint in neutral postion or to change biomechanics of joint - Hand Splints o Hand splints are effective tools in: Managing local inflammation (at rest) Offering joint stability Improving function - Immobilizes MCP, short spika, resting hand splint, wear it at night o Uncomfortable so client can start with 1 h and build up tolerance  - Working splint, protects CMC, a little bit of ,ovement - Ring splint for swan neck and boutonniere o Could make out of plastic but metal ones have more adherence Adaptive Aids and Equipment - Button hook Assessment - PAS–quantify severity of disease, may need outcome measures o Quantify something we know is going to get worse so careful when telling patients o Don’t expect it to get better so make sure patient knows that Articular Joint Assessment - Joint is assessed for swelling and tenderness. - If the joint is swollen or tender, stress pain is not assessed. - The amount of pressure applied to the joint is equal to the examiner’s fingernails blanching (4 kg/cm2) - Assess most joints in neutral position - Total number of swollen and tender joints is a measure of disease activity- record on homunculus - 3 joints- active disease DAS-28 - Outcome measure o Disease Activity Score for use in individuals with Rheumatoid Arthritis o Outcome Measure that involves the swollen joint count, tender joint count, ESR or CRP, and patient global assessment of wellness o Score- Remission (0-2.6), Low disease activity (2.7-3.2), Moderate disease activity (3.3-5.1), and High disease activity (5.1 and above)  - Know difference btwn RA and OA Evaluation of Functional Deficits as a result of RA and OA Initial Interview - Explore occupational profile - Why problems are occurring (ex. fatigue or pain) - Understand their education on the disease Body Functions and Activity Limitations - Can assess ADLs or use self report questionnaires - Can use activity diary Mobility and Upper Limb Function - Volumetry to assess edema - Circumferential measurement of joints for edema - Record hand appearance on hand chart - Record ROM - Record pinch and grip strength - May need to complete work assessment Interventions for Functional Skill Deficits as a result of RA and OA - In the acute stage of inflammation, the focus of treatment should be on gentle passive and active ROM to the point of pain (without stretch). - In the subacute stage, treatment can include both active and passive ROM, gentle passive stretch, and isotonic and graded isometric exercises with minimal stress to joints. - In the chronic active and inactive stages, treatment focuses on stretch at end range, and resistive isotonic and isometric exercises that do not stress the joints. - key factors to consider when developing treatment plans are to respect pain, avoid fatigue, manage stress, prevent deformities when possible through avoidance of stress to inflamed tissues and joints or excessive activity/exercise during a flare-up or exacerbation, use thermal modalities with caution and limit the application of heat to 20 minutes, use resistive exercise with caution, and be aware of sensory impairments  - Interventions to reduce functional impairments associated with RA and OA in all stages can be broadly classified into five categories: client education, physical agent modalities, edema management, orthotic devices, and therapeutic activities and exercises. Physical Agent Modalities - can use heat applications to help reduce pain before therapy exercises - cold application during exacerbation of RA symptoms - Care should be used in selection of heat and cold modalities with attention to the stage of the disease process and monitoring of vascular reactions, and skin and tissue responses - Warm water soaks and baths/showers can alleviate pain and stiffness for people with arthritis. - Ultrasound have help with healing and decreasing inflammatory response - TENS can help with reducing pain - Low-level laser therapy uses a single wavelength of light to produce not a thermal effect but photochemical reactions in the cells to promote soft-tissue healing, reduce inflammation, and reduce acute and chronic pain seen in OA and RA Edema Management - Increased use of the affected limb within pain limits must be strongly encouraged as well as elevation of the involved limb above the heart when at rest - Gentle hand pumping (fisting) combined with elevation should be encouraged to improve circulation - Contrast baths can help reduce edema - Compression - KT tape Orthotics  - Splints are used to reduce local inflammation, reduce soft-tissue and joint pain, correctly position joints, improve joint stability, and improve hand function - During the acute stage in the inflammatory process of RA, splints can be used to support the joints in their open-packed position, allowing the most space in the joint and reducing pain associated with swelling. - Joints should be placed in a functional position - Splint wear regimen should include intermittent removal, gentle ROM, and use of the hand in daily activities. - Static resting splint o reduce pain and inflammation, wear at night or during day rest time - Wrist orthoses o close fit not impeding MCP and thumb, o nighttime pain relief if the person has wrist, but not MCP or IP pain. o main aim is to reduce torque during heavy tasks involving the wrist and to stabilize the wrist in a functionally effective position (i.e., 10°–15° of extension). o more effective in reducing hand pain than improving grip strength or hand function o Supportive wrist splints can be beneficial when worn during heavy activities, such as ironing, gardening, housework, and at work. - MCP splint o Palm based splint to reduce medial force on MCPs o Reduce ulnar deviation of fingers o improve hand function in people with RA with established MCP deformities - Finger splint o Swan-neck splints apply three-point pressure around the PIP joint to prevent PIP joint hyperextension and subsequent DIP flexion Ring splint or thermoplastic - Thumb splints o Short, hand-based splints are designed to immobilize the CMC joint only, the CMC and MP, or a longer hand/ forearm splint if pain extends to the wrist o CMC joint splints can reduce pain, improve function, and avoid or delay surgery in OA Therapeutic Activities and Exercises - RA o physical activity good o short term aerobic exercise good o strength training reduces systemic inflammation o in acute phase of inflammation resistance training contraindicated - OA o Aquatic aerobic programs - Engaging in physical activity for people with arthritis is associated with improved self-esteem, quality of sleep, reduction of pain, and depressive symptoms. - efficacy of home exercise programs is contingent on educating patients about the benefits of physical activity—how it reduces pain, improves fitness, and increases energy levels as muscle strength and aerobic capacity increase, and in RA and OA, how it helps protect joints as stronger muscles compensate for weakened ligaments - Exercise is effective in improving hand strength (grip and pinch) and function and to reduce pain in RA and OA - Exercise must be sustained or benefits lost Ergonomics in Arthritis - Goals of Ergonomics o The goals of the ergonomic approach in RA and OA are to: o Reduce pain during activity, and at rest, resulting from pressure on nociceptive endings in joint capsules, caused by inflammation and/or mechanical forces on joints o Reduce forces on joints: Internal (i.e., from muscular compressive forces, e.g., during strong grip) or external (i.e., forces applied to joints while carrying or pulling/pushing objects) o Reduce secondary inflammation and subsequent strain on soft tissues resulting from excess (i.e., beyond tolerability) force on already inflamed and/or disrupted joints o Reduce loading on articular cartilage and subchondral bone, thus preserving joint integrity and reducing risk of development and/or progression of deformities o Reduce pain resulting from overuse (i.e., beyond tolerability) of deconditioned muscles o Reduce fatigue, by reducing effort required for activity performance, thus improving function - Joint protection o rapid decline of hand function often seen in early RA and hand OA suggests that effective ergonomic education should be provided early to improve and maintain function or prevent problems.