OCCTH 584 Midterm Study - Activities of Daily Living (ADLs) - Occupational Therapy PDF

**OCCTH 584 Midterm Study** **Readings** Dirette & Gutman (2021) - Ch. 27 Restoring Activities of Daily Living. \[The information in these 3 chapters are used throughout the course.\] - Ch. 32 The Biomechanical Frame of Reference - Ch. 33 The Rehabilitation Frame of Reference - Ch....

**OCCTH 584 Midterm Study** **Readings** Dirette & Gutman (2021) - Ch. 27 Restoring Activities of Daily Living. \[The information in these 3 chapters are used throughout the course.\] - Ch. 32 The Biomechanical Frame of Reference - Ch. 33 The Rehabilitation Frame of Reference - Ch. 41 (Orthopedic Conditions) - Ch. 44 (Amputations & Prosthetics) - Ch. 45 (Diabetes) - Ch 42 (RA & OA) - Ch 25 (Wheelchair and Seating Selection) **Ch. 27 Restoring Activities of Daily Living** **Assessment of Activity of Daily Living Performance (Need to know for short answer) pg.1483** A critical component of evaluation is ADL observation and analysis. Therapists can evaluate ADL performance by asking clients to provide a self-report of their performance or use performance-based ADL assessments. It is often important to assess client factors and skills such as ROM, strength, sensation, balance, and cognition prior to beginning ADL assessments. Ideally, ADL performance should be assessed in the environments in which they are typically done, or the environment should closely simulate clients' natural environments. ADL tasks to be assessed should range from simple to complex and should be based on the information obtained from the referral, chart review, and occupational profile. Therapists may use standardized ADL assessments such as the Functional Independence Measure (FIM); the Klein-Bell Activities of Daily Living Scale; the Katz Index of Independence in Activities of Daily Living; Performance Assessment of Self-Care Skills (PASS); Disabilities of the Arm, Shoulder, and Head (DASH) Assessment; and the Barthel ADL Index; or nonstandardized measures such as ADL checklists.8--13 These standardized assessments can be used for re-evaluation to measure outcomes and to determine whether clients met their goals. **Other Factors to Consider in Activities of Daily Living Evaluations** It is important to consider the contextual and environmental factors that might impact client performance. Physical environmental factors such as clutter, barriers to access, rugs, steps, or stairways should be eliminated or adapted for safe ADL performance. Cultural and social factors also impact ADL performance and should be incorporated in evaluation and intervention when possible and desired by clients. Therapists should determine whether clients desire family and caregivers to be present and should comply with Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations. Therapists working in acute or intensive care settings must consider the client's medical complexity. When evaluating and intervening with clients in these settings, therapists should understand and monitor lab values, vital signs, and code status repeatedly, as well as documented precautions for clients. Therapists should be familiar with equipment typically encountered in this setting, including electrocardiogram (EKG) monitors, ventilators, lines, catheters, tubes, dialysis equipment, pacemakers, mechanical circulatory devices, and respiratory care equipment. Isolation precautions, if applicable, should be reviewed and followed. This information is usually available in client charts and posted on hospital room doors. **Activities of daily living (ADLs):** activities oriented toward taking care of one's body and include bathing and showering, toileting and toilet hygiene, dressing, swallowing and eating, functional mobility, personal device care, personal hygiene and grooming, and sexual activity. They are also referred to as personal activities of daily living (PADLs) or basic activities of daily living (BADLs).1 **Adaptive equipment:** devices, tools, or products that are used to assist individuals with disabilities to engage in occupations within their natural contexts and environments; also referred to as assistive technology, assistive devices, or adaptive devices. **Client-centered approach:** an approach to service delivery that includes respect for and collaboration with clients (individuals, groups, agencies, governments, or corporations). Therapists involve clients in decision-making, advocate for and with clients to meet needs, and recognize clients' experience and knowledge.2 **Durable medical equipment (DME):** supplies that provide therapeutic benefit to clients experiencing difficulty or functional deficits resulting from medical conditions or illnesses. DME must be prescribed by physicians or health care providers authorized by state law. DME must be reusable and primarily used in the home. **Occupational profile:** a component of the occupational therapy evaluation that provides information about clients' occupational histories and experiences, daily living patterns, interests, values, needs, reasons for seeking services, and concerns related to occupational performance and disruption.1 **Occupations:** activities that individuals, groups, or populations engage in that are meaningful and include activities of daily living, instrumental activities of daily living, rest and sleep, education, work, play, leisure, and social participation. **Bed Mobility**: the ability to bridge in bed, roll from supine to side-lying, scoot up and down in bed, move from supine to sitting and sitting to supine, and sit at the edge of the bed. If, after screening, it is determined that an evaluation is needed, therapists complete **occupational profiles** to gain information about client factors, performance skills and patterns, contexts, and occupations.1 Occupational profiles help therapists to understand client abilities, capacities, interests, values, roles, habits, routines, environments, and needs related to occupational engagement. It is important to ask the following questions: What is the client's current lifestyle?\ What was the client's ADL status prior to injury, disease, or illness?\ What are the client's current occupational challenges?\ What comprises the client's typical day-to-day routines?\ What occupations are meaningful to the client?\ In what environments does the client currently navigate to complete occupations? **Levels of Independence** ***Independent:*** Clients can perform the activity independently; without modification of technique, assistive devices, or aids; and within a reasonable time frame. ***Modified independence:*** Clients either require an assistive device to complete the activity, the activity takes more than a reasonable time, or safety considerations exist. ***Supervision (standby assistance):*** Clients require a therapist to stand by for safety in case of balance loss. Therapists may provide verbal cues for safety. ***Contact guard:*** Therapists place one or two hands on the client's body to maintain balance, dynamic stability, or safety; however, they do not assist in task performance. ***Minimal assistance:*** Therapists provide 25% of assistance (physical or verbal), and clients are able to perform 75% or more of the activity.\ ***Moderate assistance:*** Therapists provide 50% of assistance (physical or verbal), and clients are able to perform 50% to 74% of the activity. ***Maximal assistance:*** Therapists provide 75% of assistance (physical or verbal), and clients are able to perform 25% to 49% of the activity.\ ***Dependent:*** Therapist provides more than 75% of assistance (physical or verbal), and clients are able to perform less than 25% of the activity. ** Ch. 44 (Amputations & Prosthetics)** **Body-powered (BP) prosthesis:** an upper limb device that operates from an individual's proximal motions (typically the muscles of the shoulders, neck, and back). **Externally powered (EP) prosthesis:** an upper limb device that operates through external power. **Functional envelope:** the area of space in which the patient can effectively operate an upper extremity prosthesis. **Heterotrophic ossification:** bone that abnormally grows in soft tissue where it should not exist and it commonly occurs after trauma to the musculoskeletal system, brain, or spinal cord. **Hybrid prosthesis:** an upper limb device that combines two prosthetic options into one; the most common combination is with a transhumeral prosthesis with a BP elbow and EP terminal device. **Musculoskeletal pain:** discomfort that occurs in other areas of the body, such as the back, neck, shoulder, or contralateral limb, as a result of overuse or poor body mechanics. **Myodesis:** surgical technique that involves directly suturing muscle or tendon to amputated bone in order to provide optimal distal muscle stabilization. **Myoplasty:** surgical technique that involves suturing muscle to muscle and then placing it over the end of the amputated bone before closing the wound; more commonly used in patients with poor vascular health. **Neuroma:** an injured nerve in which severed nerve fibers form a disorganized mass of nerve cells (neuroma) that is painful with direct pressure. **Terminal device (TD):** an upper limb prosthetic component that is inserted at the distal end of an upper limb prosthesis and is used to grasp and release objects; may be a hook or hand. **Major limb amputation(s**) are proximal to the wrist or ankle, whereas **minor limb amputation(s)** are distal to the wrist (hand and fingers) or ankle (foot and toes). A diagram of a human arm AI-generated content may be incorrect.  - The main causes of amputation are dysvascular disease (54%), trauma (45%), and cancer (less than 2%) - Most common cause if lower limb dysvascular is complications from diabetes, arteriosclerosis or smoking. - Almost 70% of upper limb is due to trauma in males aged 15 to 45 at work - There are a number of secondary health effects that may occur after amputation, which may include poor nutritional intake, reduced exercise, obesity, tobacco use, hypertension, hypercholesterolemia, skin issues, diabetes, and cardiac disease. - Patients can be fitted for a prosthetic once All wounds are healed, sutures are removed, the patient the patient has been medical cleared and has maximized independence in self-care ADL using adaptive strategies, assistive technology, or durable medical equipment. - Phases of rehabilitation are perioperative, pre prosthetic training, and prosthetic training - Postoperatively, **residual limb management** includes wound healing, limb protection, edema control, residual limb shaping, pain management, and decreasing any areas of hypersensitivity. **Ch. 45 Diabetes** **Diabetes distress:** emotional burdens and worries that are part of the person's experience when he or she needs to manage a severe and demanding chronic disease like diabetes. **Diabetes mellitus:** a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine. There are two main types of diabetes: type 1 and type 2. People with type 1 diabetes don't produce insulin. People with type 2 diabetes don't respond to insulin as well as they should and later in the disease often don't make enough insulin. **Glycated hemoglobin (HbA1c):** any derivative of hemoglobin in which a glucose molecule is attached to the hemoglobin molecule. The most abundant form of glycated hemoglobin is hemoglobin A1c (HbA1c), levels of which are significantly increased in diabetes. **Hyperglycemia:** high level of blood glucose caused by the body's inability to properly use or make the hormone insulin that leads to symptoms such as increased urination, extreme thirst, and unexplained weight loss. **Insulin:** a protein hormone, produced in the pancreas, that is crucial in regulating the amount of sugar (glucose) in the blood. Lack of this hormone results to diabetes mellitus. **Nephropathy:** a kidney disease that affects the ability of the kidney to excrete any waste products and to regulate the water and acid--base balance of the body. **Neuropathy:** a disease of the peripheral nerves, usually causing weakness and numbness. When blood glucose levels stay high for an extended period of time, it can damage the nerves, particularly the nerves in the lower limbs. **Retinopathy:** disease of the retina resulting in impairment or loss of vision. In the most serious cases, retinopathy can lead to blindness. **Self-management:** a person's ability to manage the symptoms, treatment, physical and psychosocial consequences, and lifestyle changes inherent in living with a long-term disorder. **In type 1 diabetes**, the body does not produce insulin. Type 1 diabetes occurs most often in children, adolescents, or young adults and represents only 10% of people with diabetes. The exact causes of type 1 diabetes are still unknown, but the body's immune system destroys the beta cells in the pancreas that produces insulin. Hypothesis is that it would be related to a genetic predisposition or certain environmental factors **Type 2 diabetes** is the most common form of diabetes, accounting for 90% of cases.3 In type 2 diabetes, the body either does not produce enough insulin or does not use it properly, leading to a **hyperglycemia**. This phenomenon is called insulin resistance: the pancreas produces extra insulin to compensate, but over time is not able to produce sufficient insulin to keep blood glucose levels normal.3 The body, then, cannot effectively use glucose as an energy source. The chronic hyperglycemia of diabetes is associated with relatively specific long-term microvascular complications affecting the eyes, kidneys, and nerves, as well as an increased risk for cardiovascular disease The American Diabetes Association (ADA) recommends that individuals are diagnosed with diabetes when their fasting levels of glucose in the blood reaches 7.0 mmol/L or higher, and/or the level of **glycated hemoglobin** (HbA1c) in the blood is 6.5% or higher.3 The term prediabetes is used for people whose HbA1c levels are between 6.0% and 6.4%.3 These individuals are at high risk of developing diabetes and the diabetes-related complications. People with this syndrome present some or all of the following abnormalities: high blood glucose, abdominal obesity, hypertension, dyslipidemia, high triglycerides, and insulin resistance.4 The **single strongest risk factor for type 2 diabetes** is a high body mass index (BMI), with up to 61% of cases attributed to BMI \>25.2 Physical activity level can also predict the development of type 2 diabetes **Complications** These complications can be categorized in two types: microvascular (small blood vessels) and macrovascular (large blood vessels).7 Microvascular complications include **retinopathy** (eye damage), **nephropathy** (kidney damage), and **neuropathy** (nerve damage). Macrovascular complications include stroke, heart attack, and circulatory disease. Individuals with diabetes also have a high level of psychosocial stress with higher rates of anxiety and depression. people living with diabetes can experience a wide range of difficulties in their daily occupations, such as difficulty performing activities of daily living (ADLs), limited community mobility, decreased energy, social isolation, poor time usage, poor daily planning, lack of meaningful leisure activities, and diminished healthy habits. Managements is complex and requires both medical monitoring and lifestyle management. **Self-management** impacts occupations across the lifespan. Self-managements recommendations include; adopting healthy eating habits, monitoring blood glucose levels, doing regular physical activity, taking medication daily, taking care of feet, and accessing psychosocial resources and support. **Behavioural Change Models** 1. **Self-Regulation Theory**: This emphasizes the ability to monitor and adjust one\'s actions based on personal standards, goals, and feedback. Higher self-regulation helps people resist impulses, but competing demands can diminish it. 2. **Goal Setting and Goal Striving Theory**: Goals serve as motivating drivers of behavior. Effective goals should be achievable, moderately challenging, and aligned with personal motivations. Goals should also be specific and feasible to encourage continued progress. 3. **Self-Efficacy Theory**: Self-efficacy is the belief in one's ability to succeed in specific tasks. This belief, central to Bandura's Social Learning Theory, affects motivation and behavioural change. Mastery experiences, observing others\' success, social encouragement, and self-appraisal all boost self-efficacy, which is critical for successful health behaviour change. Key concepts are competence mastery, vicarious learning, social persuasion, and self-appraisal. 4. **Transtheoretical Model**: This model outlines stages of change: precontemplation (no intention to change), contemplation (awareness but ambivalence), preparation (intention to act), action (modifying behavior), and maintenance (sustaining changes and confidence). People progress through these stages before maintaining long-term behavior change. 5. **Chronic Care Model**: A framework for managing chronic conditions like diabetes, focusing on collaborative care between informed patients and proactive healthcare providers. It emphasizes self-management support, system design, decision support, and information technology, highlighting the importance of sustained, individualized care and client involvement in goal setting and decision-making **Primary Role of OT** is to support individuals in engagement in healthy lifestyles to manage diabetes **The Resilient, Empowered, Active Living with Diabetes (REAL**) intervention65 is an evidence-based occupational therapy--led diabetes intervention and is an adaptation of Lifestyle Redesign intervention **Ch 25 (Wheelchair and Seating Selection)** **Manual wheelchair (MWC):** a mobility base consisting of a frame, rear wheels, and front casters designed for self-propulsion or dependent mobility. **Power assist add-ons:** additions to a manual wheel chair that are placed under and behind the wheelchair and can be activated to assist in propulsion as needed for longer distances. **Power assist wheels:** alternative to standard wheels on a manual wheelchair to increase the force of the client's propulsion stroke for increased distance and speed. **Power-operated vehicle (POV):** (aka scooters) mobility bases that have three or four wheels, a driving tiller, and a consumer-style seat. **Power wheelchair (PWC):** a mobility base consisting of a frame, drive wheels, and casters designed for independent mobility through a driving method such as a joystick. **Pressure injury:** a breakdown of the skin and sometimes underlying tissues owing to unrelieved pressure in conjunction with other contributing factors. **Primary support surfaces:** the seat, back, footplates, and arm pads of the wheelchair and seating system. **Secondary supports:** anterior (e.g., pelvic positioning belt or anterior trunk support), posterior (e.g., calf strap), or superior (e.g., foot straps) supports. **Secondary support surfaces:** anterior (e.g., anterior lower leg support aka knee block), lateral (e.g., lateral trunk support), posterior (e.g., posterior head support), and medial (i.e., medial knee support) support surfaces designed to keep the client aligned with the primary support surfaces. **Shear:** forces created when body tissues and seating surfaces move laterally in relation to each other. **Wheelchair seating Screen** A checklist with text and images AI-generated content may be incorrect. **Wheelchair seating systems** fall into the categories of sling upholstery, captains seat, linear seating, generic contoured seating, aggressively contoured seating, and molded seating. **Seating assessment:** - Identifies pressure injury risks and makes related recommendations to mitigate this risk - Determines the appropriate angle of support surfaces and components - Identifies specific seating challenges - Develops intervention strategies and matches this to appropriate products. These interventions can be applied to multiple seating system categories. **Wheeled Mobility Categories** - Augmented Mobility Devices: Walking aids such as canes, crutches, walkers and gait trainers - Dependent Mobility Bases: Not designed for self-propulsion and can include adaptive strollers, transport chairs and MWCs - Manual Mobility Bases: Standard wheelchair, standard hemi wheelchair, lightweight wheelchair(less than 36lbs), lightweight wheelchair (less than 34lb), custom lightweight and ultra lightweight, pediatric wheelchair, bariatric wheelchair, and specialty wheelchair - Manual Wheelchairs with power assist: power assist wheels replace standard wheels on MWC, increasing the force of clients propulsion stroke for increased distance and speed - Power Mobility Bases: Can be power overated vehicles (scooters) or power wheelchair **Ch. 32 The Biomechanical Frame of Reference** **Edema:** the swelling of soft tissues as a result of excess fluid accumulation. **Endurance:** the ability of muscles to exert their effort or force for extended periods of time. Is highly correlated to OPIs **Functional range of motion:** the amount of range of motion that is required, at joints of the arm for instance, to enable an individual to perform requisite functional tasks. **Impairment:** a state of reduced quality or function in a physical characteristic of the body, such as strength, motion, and endurance; can be partial or complete. **Kinematics:** the science of describing the positions and motions of the body in space. **Kinetics:** the study of forces that affect motion and the results they have on a body. **Physical agent modalities (PAMs):** procedures and interventions that are applied to modify specific client factors that may be limiting occupational performance; using various forms of energy to modulate pain, modify tissue healing, increase tissue extensibility, modify skin and scar tissue, decrease edema and inflammation, or decreased function secondary to musculoskeletal conditions; are used as adjunctive or preparatory methods to engagement in occupation. **Range of motion (ROM):** the pathway of movement possible at a joint; typically measured in degrees of motion. **Strength:** the ability of a muscle or group of muscles to create a contractile force against a resistance in a single contraction or effort. Measured in pounds of force exerted **Therapeutic activities:** tasks, including arts, crafts, sports, self-care, home management, and work-related, that are used or adapted to meet a functional objective. **Therapeutic exercise:** body movement or muscle contraction used to prevent or correct a physical impairment or improve musculoskeletal function; typically repetitive in nature. **The Biomechanical Frame of Reference Theoretical Base** Biomechanics is the study of mechanical laws relating to the movement or structures of living bodies. The FOR is applied to individuals who demonstrate limitations in moving freely, with adequate strength or in motion. Sustained over time. These limitations can be due to problems with the musculoskeletal system, PNS, CNS, injury, surgical procedure, etc... **Ch. 33 The Rehabilitation Frame of Reference** **Adaptation:** the process of modifying items, activities, and environments to promote function. **Assistive technology:** items, equipment, and systems designed to promote function; may be commercially available, modified, or customized. **Compensation:** the use of techniques that allow an individual to complete a desired activity in a modified way. **Compensatory techniques:** intentional ways of performing an activity differently; also called *compensatory strategies*. **Continuum of care:** a comprehensive range of health-related services provided over time and across levels of intensity. **Environmental modification:** a change to the physical or human environment designed to promote function. **Orthotic:** a device designed to stabilize a body part, prevent deformity, protect against injury, or assist with function. **Prosthetic:** a device designed to replace the function of a missing body part. **Remediation:** the process of improving or correcting a deficit. The Rehabilitation Frame of Reference aligns with the "modify" approach to intervention outlined in the third edition of the Occupational Therapy Practice Framework (OTPF-3), which also emphasizes **compensation and adaptation**. The biomechanical frame focuses on restoring by addressing impairments in body functions. Clinical question faced is whether to focus on remediation, compensation, or adaptation. Dutton identified the following five assumptions underlying the Rehabilitation Frame of Reference: 1. Individuals can regain independence using compensation when underlying deficits cannot be remediated. 2. Regaining independence is closely tied to the individual's motivation, which is influenced by values, roles, preferences, and sense of purpose. 3. Motivation for independence cannot be separated from the environmental context, which includes characteristics of the setting, the individual's previous life, family and social support and resources, and cultural background. 4. Certain psychosocial and cognitive skills are needed for the individual to achieve independence because implementing adaptive techniques requires motivation and understanding. 5. The therapist's clinical reasoning should follow a top-down approach. Function--dysfunction continua in the Rehabilitation Frame of Reference include: 1.ADLs\ 2. IADLs\ 3. Work and education 4\. Play and leisure\ 5. Social participation 6\. Rest and sleep **Function/Dysfunction** These indicators of function apply to each of the six continua identified earlier. 1. The client is able to engage in activities of choice in a way that she or he finds satisfying and meaningful. 2. The client is able to complete activities with an acceptable level of independence. 3. The client is able to complete activities with an acceptable level of safety. 4. The client is able to complete activities with an acceptable level of timeliness or 5. The client is able to complete activities with an acceptable level of performance or Dysfunction is considered to be present when these indicators are absent or limited. Table 33-1 provides examples of dysfunction and function for each of the six continua. Each example of function incorporates an intervention consistent with the Rehabilitation Frame of Reference. **Ch. 41 (Orthopedic Conditions)** **Abduction pillow brace:** a sling or brace that positions the shoulder in 30° to 45° of abduction to protect the repaired supraspinatus. **Codman's pendulum exercises:** shoulder exercises in which the client stands or sits, bends over at the hips so that the trunk is parallel to the floor, and swings the arm passively or actively in various linear and circular motions.1 **Controlled range of motion:** active or passive movement within a predetermined safe arc. **Scapular plane:** the midpoint between shoulder flexion and abduction. The majority of functional activities occur in this plane. **Shoulder immobilizer:** adjustable elastic band that fits around the waist with two straps that position and secure the arm in a slightly abducted and internally rotated position. **Trendelenburg gait:** ambulation pattern that results from a weakened gluteus medius muscle; the client lurches toward the injured side to place the center of gravity over the hip; it is characterized by dropping of the pelvis on the unaffected side at heel strike of the affected foot. **Volkmann's ischemia:** increased compartment pressure in one anatomic area of the extremity as a result of a fracture or crush injury. The aim of occupational therapy in orthopedic rehabilitation is to help clients achieve maximal musculoskeletal functioning in order to perform their everyday activities. In the acute stage of recovery, the occupational therapist's role is to help relieve pain, decrease swelling and inflammation, assist in wound care, maintain joint or limb alignment, and restore function at the injury site. **UE Fractures** The estimated healing time for uncomplicated upper extremity fractures in adults is as follows: callus formation 2 to 3 weeks, union 4 to 6 weeks, and consolidation 6 to 8 weeks. There are three phases of fracture healing: the inflammation phase, the reparative phase, and the remodeling phase \- The shoulder is considered the most challenging portion of the body to rehabilitate -Shoulder impingement syndrome is a compression of the structures found in the subacromial space cause by repetitive or sustained elevation of shoulder above 90. -Bursitis is the inflammation of the bursa, in the shoulder this happens in the subacromial bursa. ***Neer impingement sign:*** Forced forward flexion with the shoulder internally rotated. If the patient expresses pain, the sign is positive, indicating compression and/or inflammation of the supraspinatus and/or long head of the biceps (Fig. 41-7). ***Hawkins test:*** Shoulder and elbow are flexed to 90° followed by forced internal rotation. If the patient expresses pain (Fig. 41-8), the test is positive, indicating compression and/or inflammation of the supraspinatus and long head of the biceps. ***Jobe's test (empty can test):*** Shoulder elevation to 45° and internal rotation (thumb facing down). Therapist applies resistance to abduction (downward force) (Fig. 41-9). Positive sign is weakness or pain. This test indicates a tear of the supraspinatus tendon. Repeat the same test at 90°. If pain is only experienced at 90° position, suspect bursitis. ***Drop arm test:*** Patient's arm is positioned in 90° of abduction. The patient slowly lowers his or her arm to the side. The test is positive if the patient drops the arm to the side, indicating a supraspinatus tear (Fig. 41-10A and B). ***Biceps Speed's test:*** Shoulder flexed to 90°, forearm supinated, and elbow extended. Resistance is applied to flexion (downward force using a long lever arm). Positive sign is pain over bicipital groove (Fig. 41-11).27--31 **Movement restrictions after hip surgery may include:** -No hip flexion beyond 90°, including movement of the trunk over the thighs\ -No hip rotation (avoid internal rotation for posterolateral approach and external rotation for anterolateral approach)\ -No crossing the operated leg over the unoperated leg (midline)\ -No adduction of the operated leg **Ch 42 (RA & OA)** **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). The goal of pharmacotherapy is to reduce imflimmation to prevent or limit joint damage **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. Rheumatoid arthritis (RA) is an autoimmune, chronic, systemic inflammatory disease affecting the joints. It is the most commonly diagnosed type of inflammatory arthritis. Women are more likely to develop RA. The cause of RA is unknown. It is believed to be an interaction between genetics, hormone, environment, and lifestyle. The pathological changes observed in the joints include the following: ***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. The three distinct disease courses of RA are as follows: 1\. ***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. 2\. ***Polycyclic:*** About 75% experience fluctuating disease activity over the course of the condition, which can last for many years. 3\. ***Progressive:*** About 5% RA continues to rapidly increase in severity and is unremitting. Signs and symptoms of RA include symmetrical presentation of [polyarticular pain, edema, early morning stiffness, malaise, and fatigue]. The four stages of the inflammatory process in RA are: -***acute*** characterized by red, hot swollen joints with pain, tenderness, and stiffness; -***subacute*** associated with morning stiffness but less pain and tenderness; -***chronic active* and *chronic inactive*** with reduced pain and increased tolerance but low endurance In women with early RA (\