Arthritis

Clinical Features

OA is characterized by joint pain, stiffness, tenderness, limited movement, variable degrees of local inflammation, and crepitus (an audible or palpable crunching or popping in the joint caused by the irregularity of opposing cartilage surfaces).⁴⁷ It can affect both axial and peripheral joints. The most common joints are the distal interphalangeal (DIP), proximal interphalangeal (PIP), and first carpometacarpal (CMC) joints of the hand; the cervical and lumbar apophyseal joints; the first metatarsophalangeal (MTP) joints of the feet; and the knee and hip joints.^4,29,54 Symptoms are usually gradual and may begin as a minor ache with motion. Pain and stiffness typically occur with activity and are relieved by rest, but eventually they become present at rest and at night. Morning stiffness (lasting less than 30 minutes) and stiffness after periods of inactivity (known as gelling) may develop. With advanced disease, patients may complain of the “bony” appearance of their joint, which is a result of osteophyte formation and possibly muscle atrophy.^29,54

Diagnostic Criteria

The diagnosis of OA is initially made on the basis of the patient’s history and physical examination, with a lack of systemic symptoms ruling out inflammatory disorders such as RA. The cardinal symptoms are use-related pain and stiffness or gelling after inactivity. The clinical diagnosis is typically confirmed with radiographs of the affected joint, which will show osteophyte formation at the joint margin, asymmetric joint space narrowing, and subchondral bone sclerosis.²⁹ Magnetic resonance imaging (MRI) may be used to improve diagnostic imaging; MRI is able to more sensitively detect loss of cartilage, osteophytes, and subchondral cysts. The American College of Rheumatology classification criteria for osteoarthritis of the hand are listed in Box 38-1.

Medical Management

OA currently has no cure. Goals in the treatment of OA are to relieve symptoms, improve function, limit disability, and avoid drug toxicity.^54,81 Pharmacologic treatment may be systemic or local. Commonly prescribed systemic medications include analgesic agents and anti-inflammatory agents (Table 38-2).³ Analgesic agents provide relief to painful joints and may be non-narcotic or narcotic for advanced and severe OA that fails to respond to other measures. Anti-inflammatory agents provide pain relief, with the added benefit of decreasing local joint inflammation. Because of the risk for gastrointestinal and renal toxicity, these drugs are typically used when analgesics are ineffective. Nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 (COX-2) inhibitors fall into this category. Though proved effective in treating OA, NSAIDs must be chosen and monitored carefully to minimize potentially serious side effects. COX-2 inhibitors are thought to provide clinical benefits similar to NSAIDs but with a lower incidence of gastric problems; however, more experience by prescribing physicians and longer-term use will help better define their role. The withdrawal of two popular COX-2 inhibitor drugs from the market (Vioxx in 2004 and Bextra in 2005) because of links with an increased risk for heart attack and stroke points to the need for further study. The remaining COX-2 inhibitor (Celebrex) now carries a black box warning.³ Local pharmacologic treatment of OA includes topical agents and intra-articular corticosteroid injections, alone or as an adjunct to systemic medications. Among topical agents are aspirin and capsaicin creams, as well as the first topical NSAID approved for treating OA pain (Voltaren gel).³ Cortisone injections in a joint are often limited to fewer than three per year because of the possible risk for progressive cartilage damage.¹⁹

Use of nonpharmacologic agents, also known as nutraceuticals, is extremely common in persons with OA as alternative or complementary treatments and seems to be gaining favor in the general public.^51,54,74,81 These agents include nutritional supplements such as glucosamine sulfate and chondroitin sulfate. Although they may have some effect in improving symptoms or slowing the progression of OA, studies citing their efficacy have not yet been of optimal quality.⁵⁴ However, even if their benefits have not been proved convincingly, use of nutraceuticals typically carries little risk. Even so, patients should be aware that supplements are not regulated like prescription medications. Use of complementary and alternative treatments should be discussed with one’s physician to minimize potential negative effects.⁵¹

Surgical Management

Operative intervention may be performed to slow joint deterioration, improve joint integrity, restore joint stability, or reduce pain, with the overarching goal of improving the patient’s overall function. Common surgical procedures for OA include arthroscopic joint débridement, resection or perforation of subchondral bone to stimulate the formation of cartilaginous tissue, use of grafts to replace damaged cartilage, joint fusion, and joint replacement.^19,54

Clinical Features

RA is characterized by symmetric polyarticular pain and swelling, prolonged morning stiffness, malaise, fatigue, and low-grade fever. Joints most commonly affected are the PIP, metacarpophalangeal (MCP), and thumb joints of the hands, as well as the wrist, elbow, ankle, MTP, and temporomandibular joints; the hips, knees, shoulders, and cervical spine are also frequently involved.^94,96 Even though joint involvement is bilateral, disease progression may not be equal on both sides. For instance, a patient’s dominant hand may show more severe involvement and different joint changes or deformities than the other hand. Clinical features vary from patient to patient and also in individual patients over the course of their disease. Pain can be acute or chronic. Acute pain occurs during disease exacerbations, or flare-ups. Chronic pain results from progressive joint damage. Synovial inflammation is manifested as warm, spongy, and sometimes erythematous, or red, joints. This is seen in active phases of the disease process. Rheumatoid nodules, a cutaneous manifestation of RA, develop in 25% to 30% of persons with RA during periods of increased disease activity. These soft tissue masses are commonly found over the extensor surface of the proximal end of the ulna or at the olecranon.^94,96 Morning stiffness is an almost universal feature of RA. Unlike the shorter-duration stiffness seen with OA, RA morning stiffness can last 1 or 2 hours. It frequently disappears during periods of disease remission. The duration of morning stiffness tends to correlate with the degree of synovial inflammation, and its presence and length are useful measures for monitoring the course of RA.⁷⁰ Feelings of malaise, fatigue, and depression also fluctuate, with many patients experiencing worse symptoms in the afternoon. These nonspecific symptoms may precede other typical signs of RA by weeks or months.⁹⁴

The inflammatory process has been described as having four stages: acute, subacute, chronic active, and chronic inactive.⁶⁴ Stages may overlap, and patients may move back or forward through them, depending on the course of their disease. Clinical symptoms seen in the acute stage include limited movement; pain and tenderness at rest that increase with movement; overall stiffness, weakness, tingling, or numbness; and hot, red joints. In the subacute stage, the limited movement and tingling remain. A decrease in pain and tenderness indicates that the inflammation is subsiding. Stiffness is limited to the morning, and the joints appear pink and warm. The chronic active stage is characterized by less tingling, pain, and tenderness and increased tolerance of activity, although endurance remains low. No signs of inflammation are present in the chronic inactive stage. The patient’s low endurance and pain and stiffness at this stage result from disuse. Overall functioning may be decreased as a result of fear of pain, limited range of motion (ROM), muscle atrophy, and contractures.⁶⁴

The characteristic joint deformities will develop as late manifestations of the disease in more than 33% of patients with RA. Deformity of the small joints of the hand will develop within the first 2 years in more than 10%.⁹⁶ Wrist radial deviation, MP ulnar deviation, and swan neck and boutonnière deformities of the digits are the joint changes most often seen. Joint changes, or deformities, can result from a variety of mechanisms, including joint immobility, destruction of cartilage and bone, and alterations in muscles, tendons, and ligaments.⁹⁷ Tenosynovitis (inflammation of the tendon sheath) and the presence of nodules within the flexor tendon sheaths can cause trigger finger. Patients may also exhibit symptoms of nerve compression of the median or ulnar nerves at the wrist. Tendon rupture may also be seen, usually in the extensor tendons of the fifth, fourth, and third digits. Stages of the disease based on joint deformity and radiographic changes are defined in Box 38-2.

Diagnostic Criteria

No single test leads to a definitive diagnosis of RA. Diagnosis is based on clinical evaluation of characteristic signs and symptoms, laboratory findings, and radiologic findings.^70,94,96 The American College of Rheumatology criteria for the classification of RA require that the patient demonstrate at least four of seven criteria for a diagnosis of RA to be made (Table 38-3). A positive laboratory test is not necessary to establish a diagnosis of RA, but such tests may help confirm the clinical impression. Rheumatoid factor is an antibody found in the blood serum of approximately 85% of persons with RA, but it can also be found in other inflammatory diseases associated with synovitis. The presence of rheumatoid factor correlates with increased severity of symptoms and increased systemic manifestations. The erythrocyte sedimentation rate correlates with the degree of synovial inflammation and is useful in ruling out noninflammatory conditions such as OA and tracking the course of inflammatory activity.^94,96 Radiographs may show nothing other than soft tissue swelling early in RA, but in more than half of patients, radiographic changes will develop within the first 2 years after onset of the disease.^70,94,96

Medical Management

RA currently has no known cure. The major goals in the treatment of RA include (1) reducing pain, swelling, and fatigue; (2) improving joint function and minimizing joint damage and deformity; (3) preventing disability and disease-related morbidity; and (4) maintaining physical, social, and emotional function while minimizing long-term toxicity from medications.^70,96 Maintaining normal joint anatomy can be accomplished only by controlling the disease before irreversible damage occurs. Major advances in the treatment of RA have occurred over the past several years as a result of improved understanding of the pathogenetic mechanisms of the disease, development of therapies that more specifically target the pathophysiologic processes, and recognition that early initiation of aggressive drug therapies can alter the outcome and reduce the severity and disability of RA.^70,96

Drug categories used for RA include NSAIDs, corticosteroids, and disease-modifying antirheumatic drugs (DMARDs; see Table 38-2).³ Because the fast-acting NSAIDs can decrease joint pain and swelling but cannot alter progression of the disease, they are rarely, if ever, used alone for the treatment of RA. The anti-inflammatory effects of the large number of medications in this category are about equal. COX-2 inhibitors show no evidence of greater efficacy than other NSAIDs but are thought to pose a lower risk for serious gastrointestinal side effects.⁹⁴ Corticosteroids have a long history in the medical management of RA and still remain a key element. They produce rapid and potent suppression of inflammation with improvement in joint pain and fatigue. Because of the significant adverse effects of corticosteroids, they are frequently used on a temporary basis in patients with active disease and significant functional decline while awaiting the full therapeutic effect of DMARDs. DMARDs lack a pain relief effect, but they may actually affect the course of the disease. Because of their slow-acting nature, weeks or months of drug therapy may be necessary before a clinical benefit is recognized. The potency of these drugs requires that patients be closely monitored for side effects.

Traditionally, the approach to treatment of RA began with less toxic medications such as NSAIDs and progressed to the stronger drugs needed later in the disease course. The approach is now more aggressive, with early use of DMARDs to control the disease process as soon as possible, as completely as possible, and for as long as possible.^70,103 Drug therapy constantly changes, depending on the patient’s needs and response to treatment, as well as the physician’s treatment philosophy. This uncertainty can be frustrating for the patient, who may have to experiment with myriad new medications when current drugs become ineffective or side effects too severe. It is important for the occupational therapist and other team members to know the specific medications that the patient is taking and what adverse reactions may arise.

Surgical Management

Because of the extensive joint damage caused by RA, surgical intervention is frequently indicated to relieve pain and improve function. Several surgical procedures may be of benefit to patients with RA. Synovectomy (excision of diseased synovium) and tenosynovectomy (removal of diseased tendon sheaths) are performed to relieve symptoms and slow the process of joint destruction, but they do not prevent progression of the disease. These procedures are most commonly performed in the wrist and hand. Tendon surgery, including relocation of displaced tendons, repair of ruptured tendons, and release of shortened tendons, may be performed to correct hand impairments. Tendon surgery occurs most frequently on the extensor tendons of the wrist and hand. Tendon transfers and peripheral nerve decompression (such as carpal tunnel release) are also performed to optimize function. Arthroplasty (joint reconstruction) and arthrodesis (joint fusion) are options when joint restoration is not possible. These procedures may be performed to relieve pain, provide stability, correct deformity, and improve function. Common sites for arthroplasty include the hip, knee, and MCP joints. Common sites for arthrodesis include the wrist, thumb MCP and interphalangeal (IP) joints, and cervical spine.^19,64

Client History

A thorough history should be obtained through review of the client’s report and medical record. Important details include diagnosis, dates of onset and diagnosis, secondary medical conditions, current medications and medication schedule, alternative or complementary therapies, and surgical history.⁸⁵ Asking the client questions such as “What type of arthritis do you have?,” “How long have you had it?,” “What medications are you currently taking?,” and “What other things are you doing to manage your arthritis?” can provide helpful insight regarding the client’s level of understanding about his or her condition, medical treatment, and health habits. Previous experiences with OT and physical therapy should also be ascertained to build on them. The therapist must ask and actively listen to the client’s current primary complaints through questions such as “What is bothering you most about your arthritis?,” “How is your arthritis limiting your ability to do things right now?,” and “What are you hoping therapy can help you with?”

This was Nina’s first referral to OT. She was knowledgeable about her diagnosis and medications but uncertain about the potential benefits of therapy. Through her responses to key questions, Nina was able to clearly state that her pain and difficulty performing household and work activities were her main priorities.

Occupational Profile

It is helpful to begin the process of assessing occupational performance with an occupational profile. Obtained through an open-ended interview, the profile yields important details about the client’s previous and current roles, occupations, overall activity level, and ability to participate in meaningful activities. It can also provide insight into the client’s sense of self-efficacy, adjustment to disability, and themes of meaning in his or her life.^55,62 An effective method to obtain a client’s occupational profile is to have the client describe how he or she spends a typical day. This typical-day assessment allows the therapist to become familiar with the client’s routines, use of time, sleep/wake habits, energy and fatigue patterns, important people and environments, activity contexts, and other details that may not otherwise come up in conversation. Because arthritis involves fluctuant symptoms, the client should be asked to describe how time is spent on a good day and a bad day so that the therapist can compare the two and understand how arthritis affects the client’s daily life and how effectively the client is able to balance activity and rest. It is helpful to ask the client to estimate the percentage of good versus bad days per week or month. It may also be advantageous to explore time spent on weekend days versus weekdays; the client may reveal other occupations, such as those involving spirituality, social participation, and leisure. This fluid dialog also serves to develop rapport, establish the client as the valued expert in his or her occupations and lifestyle, and frame the role of OT in the client’s rehabilitation.

Occupational Performance Status

Once the client’s typical and preferred occupations are identified, his or her level of independence engaging in these functional activities can be assessed by interview or by observation. If observation is used, the activity should occur as close as possible to the time that it is normally performed because the client’s abilities may fluctuate at different times of the day. For instance, stiffness and pain may make dressing very difficult in the early morning, but if this task is assessed in the afternoon, the client’s status may appear much better. Ideally, the activity should also be done in the client’s own home, community, or work contexts.⁷ In addition to assessing the client’s level of independence during activities of daily living (ADLs), instrumental activities of daily living (IADLs), school, work, sleep and rest, play, leisure, and social engagements, it is important to note any assistive devices (e.g., mobility aids or adaptive equipment) and compensatory techniques that the client may use. The activity demands of the occupation performed (e.g., tools, equipment, and skills required), as well as the specific contexts in which it is performed (e.g., the client’s living situation, others in the home, and architectural set-up relative to occupational performance), should be detailed in tandem with existing physical, environmental, or social barriers. Finally, the amount of time required to complete certain activities should be explored. A client who experiences significant morning stiffness or limited endurance often chooses to accept assistance in an activity such as dressing to save time or conserve energy to participate in a more meaningful occupation later in the day. This strategy may contribute to the client’s overall satisfaction with and participation in life, and it should be respected as such.

In RA, functional status may be classified according to the American College of Rheumatology’s revised criteria for the classification of functional status in clients with RA (Table 38-4). This system was devised for rapid, global assessment of functional status by health professionals.⁴⁷ The therapist should be familiar with this system because it is often used in clinical research and can provide a general framework for defining advancing disability.^43,106 Nina would be considered class III because of limitations in her work activities.

A decrease in occupational functioning in clients with arthritis may be due to pain, joint changes or instability, loss of motion, weakness, fatigue, change in the living environment, or change in social support, among other contributing circumstances. The effects of medication can also limit performance. The challenge for the therapist is not only to identify deficits in occupational performance but also to determine the factors that are causing them. Asking the client why an activity cannot be done yields the important client perspective.⁷ Nina was having difficulty with many occupations, including sleeping, playing actively with her grandchildren, managing her home, and performing her job to her level of satisfaction. She reported having to give up or cut back on activities because of increased pain, stiffness, and fatigue from her recent flare-up.

Cognitive, Psychologic, and Social Status

The effects of arthritis are not merely physical and functional. Clients with arthritis should be screened for cognitive and psychosocial deficits. Although arthritis does not directly affect cognition, pain, sleep disturbances, depression, and medication can all have profound effects on attention span, short-term memory, and problem-solving skills.⁶⁴ People with a chronic illness must develop coping strategies to deal with the disability. Coping strategies are particularly crucial for persons with arthritis, who may face serious changes in physical function, life roles, and appearance because of deformity and pharmacologic side effects. Because arthritis is both unpredictable and painful, normal responses to the disability include depression, denial, need to control the environment, and dependence. Psychosocial adaptation is affected by the complex interplay of physical, psychologic, and situational factors.^55,72 Approximately 20% of persons with RA are estimated to suffer from major depression.²⁸ About half of individuals with RA or OA may experience loss of social relationships.¹⁰⁵ Constant pain and fear of pain, changed body image, perception of self as a sick person, continuous uncertainty about the course and progression of the disease, sexual dysfunction, altered roles, and loss of income resulting from inability to work can lead to significant psychologic stress.^55,72 Evidence has shown that the disability associated with RA relates to psychosocial factors almost to the same extent as to biomedical factors.³² Occupational therapists must understand the ways in which their clients manage stress in their lives because these stressors may exacerbate the disease.⁵⁵ Family relationships and cultural backgrounds also affect the client’s health care behavior and response to disability.⁷⁶ The therapist should be sensitive to all factors that will influence rehabilitation. Referral to other health professionals (such as psychiatrists, psychologists, and social workers) should be made if needed.⁷²

Nina reported that she had increasing difficulty concentrating on tasks because she was unable to get adequate restful sleep. She expressed frustration about her inability to keep her house in order and anxiety about losing income because she was unable to work her customary hours. She was also fearful about her health because her arthritis had been adequately controlled for the past few years and she had not experienced any flares.

Clinical Status

For clients with arthritis, the elements of inflammation, ROM, strength, hand function, stiffness, pain, sensation, joint instability and deformity, physical endurance, and functional mobility should be included through either brief screening or detailed evaluation. As with assessment of function, the time of day and anti-inflammatory or analgesic medications taken should be noted because these factors may influence the results. In addition, future re-evaluations should be performed under the same conditions.⁶⁴ When the client’s functional deficits are identified first, assessment of client factors can be much more focused. Additionally, asking the client a question such as “What joints are you having the most problems with?” can help prioritize assessment needs. Given Nina’s initial findings, the detailed evaluation focused primarily on synovitis, pain, stiffness, ROM, strength, physical endurance, and functional mobility. Even though joint deformities were not immediately evident, the therapist was careful to search for signs of instability that would place Nina’s joints at risk for deformity.

The clinical evaluation may take considerable time. It should be approached in a systematic manner with the results clearly documented. The occupational therapist may need to perform assessments over several sessions, especially if the client is experiencing significant pain or fatigue. Intervention can begin immediately and does not necessarily depend on completion of the evaluation. The evaluation actually begins with a general observation of the client’s posture, willingness to move, and pain behavior during the initial interview.

The presence and location of inflammation or synovitis should be noted because these signs indicate an active disease process. Several types of swelling may be present and should be described. An effusion (excess fluid in the joint capsule) is seen as fusiform swelling that is spindle shaped and conforms to the shape of the joint. Boggy swelling is thin and full of fluid. Puffy, spongy, and soft to the touch, boggy swelling is seen in the early active stages of synovitis. Chronic synovitis feels firm because the joint fills with synovial tissue.⁶⁴

Active and passive ROM can be measured. Depending on the reason for referral and the client’s complaints, the therapist may not find it necessary to obtain goniometric measurements of all joints but instead focus only on the joints of most concern. Active motion will allow the therapist to see the amount of mobility that the client has available for function, whereas passive motion will elicit the joint’s capacity to move. The client’s range of active motion may be significantly less than the range of passive motion; this is known as lag and is caused by pain, weakness, or the mechanical inefficiencies attributable to joint damage. Goniometric measurement of hand joints may be difficult in the presence of deformity. Assessment of composite (combined motion of all joints) flexion, composite extension, and thumb opposition can provide more functional information.¹¹ Active opening and closing of the hand can be measured by the distance from the fingertips to the tabletop in maximal extension (opening) when the dorsal side of the hand is resting on the table and by the distance from the fingertips to the distal palmar crease (closing). While performing the ROM assessment, the therapist should note whether the client’s joints feel stiff or unstable. A hard end-feel in the presence of contracture indicates bony blockage.⁶⁵ A firm end-feel that still has some give indicates that the joint capsule or ligaments are limiting motion.⁴⁵ The presence and location of crepitus, along with the motions that cause it, should also be noted because crepitus often indicates extensive joint damage. The source of crepitation may be bony, synovial, bursal, or tendinous (see Chapters 20 through 22 for additional information).^11,64

Gross strength should be assessed with more specific manual muscle testing as indicated. One important detail to understand is that strength testing in clients with arthritis differs from normal testing procedures. Resistance is applied at the end range of pain-free motion rather than at the true end of the ROM. It is not unusual for clients with arthritis to have pain in the last 30 to 40 degrees of joint motion. When resistance is applied within the pain-free range, inhibition of muscle strength by pain will be avoided. It is also important to consider joint protection principles when applying resistance and to discontinue resistance if the client experiences pain. If use of resistance is contraindicated (as may be the case in an acute or active phase of arthritis, in which resistance may be harmful to inflamed tissue and joints), functional muscle or motion testing may be substituted.⁶⁴

Hand strength and function are important to test, but care must be taken to not stress painful or vulnerable joints during assessment. Grip and pinch may be measured by standard meters, but in the presence of severe weakness or hand deformity, adapted methods, such as use of a blood pressure cuff to measure force in millimeters of mercury, may be indicated.^11,64 Although it is more comfortable for the client, the results of strength testing in this manner are less reliable, with no established norms. Other specific devices for measuring grip strength in hands with arthritis, including pneumatic bulb dynamometers, are commercially available. As a result of joint deformity, the client may not be able to assume the standard testing positions for lateral and palmar pinch. Because it is important to assess pinch strength relative to function, pinch should still be tested, with notation made of the client’s prehensile pattern (e.g., “4 pounds of pinch with meter placed in web space between thumb and second metacarpal”). The presence and location of muscle atrophy should be recorded because it indicates severe weakness and possible nerve compression that may require further investigation. Intrinsic atrophy can be seen as flattening of the thenar and hypothenar eminences and as hollowing between the metacarpals on the dorsal aspect of the hand.

Hand function can be assessed through standardized tests (e.g., the Jebsen-Taylor Hand Function Test)⁵⁰ or observation of the client performing common functional tasks that involve various grasp and prehensile patterns. These tasks can include opening a medication bottle, writing, holding a glass, picking up small pins, turning a doorknob and key, cutting with a knife, and fastening buttons. In addition to noting whether the client is able to perform each task, the value of this testing lies in observation of how the client uses his or her hands and determination of which factors interfere most with activity: instability, lack of motion, deformity, pain, weakness, or something else. The therapist cannot predict function solely on the basis of the hand’s appearance. Deformities caused by arthritis often develop slowly, and many clients learn how to adapt their hand function gradually over time. It may be surprising to see significantly deformed hands performing tasks with relatively good function. The therapist should remember this when planning an intervention because it might eliminate a problem that is actually functional for the client.

Joint stiffness is a distinct feeling of excessive stiffness that eventually wears off.⁶⁴ It can occur as a result of low-grade inflammation, effusion, synovial thickening, muscle shortening, or spasm.^12,65 The therapist can determine the extent of joint stiffness by asking the client which joints experience stiffness, under what conditions, and for how long. Morning stiffness and gelling should be considered separately and can be measured in hours or minutes. The duration of morning stiffness is often used as an objective indicator of the degree of disease activity present. The gelling phenomenon, stiffness after prolonged periods of inactivity, is so named because fluid in the joint and surrounding tissues sets up like gelatin.⁶⁵

Because pain is often the primary clinical manifestation of arthritis, it should be closely evaluated. Pain that interferes with the client’s ability to engage in occupations should be of primary concern. The presence and location of joint pain should be noted. To elicit important details, the therapist should ask questions such as “When does the pain occur?,” “What tends to make the pain worse?,” and “What seems to make the pain better?” An attempt should be made to distinguish between articular (joint) pain and periarticular (soft tissues surrounding the joint) pain. Secondary conditions such as tendonitis and bursitis are frequent causes of pain. Pain has different meanings for individuals and is often difficult to describe.⁸⁶ The therapist can obtain measurements of pain intensity by asking the client to rate the pain on a numerical scale of “1” (no pain) to “10” (greatest pain) or on a visual analog scale in which the client places a mark along a 10-cm line.⁴⁹ These scales can also be used to measure other subjective symptoms, including fatigue and degree of stiffness.⁴² Because pain related to arthritis is fluctuant, the client may be asked to rate pain at its current level, at its best, at its worst, and at various times of the day or to compare pain at rest versus pain with motion or activity. Interestingly, pain caused by acute inflammation in the early stages of RA tends to be greater than pain at the end stages, when severe deformities are present.¹¹ The presence and location of joint tenderness should also be noted. Tenderness is assessed by applying manual compression to the medial/lateral aspects of the joint (see Chapter 28 for additional information).⁶⁴

Sensation should be evaluated if the potential for peripheral nerve damage or compression caused by swelling exists. The therapist should obtain a subjective report from the client with regard to the presence of numbness or tingling. This report can be followed by screening of the touch/pressure threshold of the fingertips with monofilaments.⁸ If sensory impairment is noted, further assessment may be indicated. This may include provocative tests to replicate or aggravate symptoms so that areas of compression can be localized. Examples of these tests are the Phalen and Tinel tests in individuals with suspected median nerve compression at the carpal tunnel.⁶ When cervical spine involvement is known or suspected, dermatomal light touch, sharp-dull sensation, and proprioception should be evaluated (see Chapters 23 and 39 for additional information).

The examiner assesses joint laxity (instability) by applying stress to individual joints in the medial/lateral and anterior/posterior directions. When testing medial/lateral stability of the MCP joints, the examiner must first place the MCP joints in flexion to tighten the collateral ligaments, which are naturally loose during MCP extension. Unstable joints should be noted. Ligamentous laxity can be described as slight (5 to 10 degrees in excess of normal), moderate (10 to 20 degrees in excess), or severe (20 or more degrees in excess).⁶⁴ In the hand joints, instability with medial/lateral motion indicates laxity of the collateral ligaments, whereas excessive anterior/posterior motion is caused by laxity of the joint capsule and volar plate. Normal joint stability is highly variable, and whenever possible, it is helpful to compare it to the client’s uninvolved joints.⁶⁴

Evaluation of joint deformities is done primarily by observation and palpation. The location and type of deformity should be noted. Comparison with previous evaluations, if available, allows the therapist to see how the deformities have progressed over the course of the disease. If a deformity is correctable, either actively or passively, it is considered flexible; if the deformity cannot be reduced, it is considered fixed. Patterns of deformity can be different in a client’s two hands, and a person with RA can also exhibit deformities caused by osteoarthritic joint damage.

Common hand deformities in persons with arthritis include the following:

Physical endurance can be evaluated by observation during the assessment process and by client report. Pain, weakness, deconditioning, lack of sleep, and emotional stress can all lead to decreased stamina. The pattern and severity of fatigue should be noted.⁸⁵ Functional mobility, including ambulation, sitting, and standing tolerance and ability to transfer, should be assessed relative to occupational performance.

Sleep and Rest

Rest should be considered an active means of reducing inflammation and pain. Rest and relaxation can effectively break the vicious cycle of pain, stress, and depression by allowing the body time to heal itself. Rest can be either systemic or local. Whole-body general rest, including recuperative sleep, is necessary for health. However, individuals with arthritis are at risk for sleep problems because of pain and depression.⁸³ During periods of active systemic inflammatory disease, at least 8 to 10 hours of sleep at night and half-hour to 1-hour morning and afternoon rest periods are recommended.^9,83 The amount of systemic rest needed varies by individual, from complete bedrest to an extra nap during the day. Localized rest of joints with symptoms of RA and OA may include wearing a splint, avoiding or modifying activity, or positioning during the day or at night to prevent joint stress.²³ Repetitive joint loading or motion with activity should be alternated with rest. The effectiveness of rest will be seen as an improved energy level with less joint swelling, pain, and fatigue.

Nina required both general rest for her body and localized rest for her inflamed wrists and hands. It was important to help her realize the physiologic need for rest during recovery from her flare-up. This assurance permitted her to feel less guilty about tasks left undone and enabled her to understand that taking care of herself in the short term would allow her to return to activity in the long term.

Physical Agent Modalities

PAMs may be helpful in relieving pain or in maintaining or improving ROM. Although modality use alone has not been shown to provide sustained benefits in rheumatic disease, clients do report less pain and stiffness from a clinical standpoint.^9,11 The most commonly used PAMs are superficial heat and cold agents. Benefits of heat in clients with arthritis include increased blood flow, pain relief, and increased tissue elasticity, with a negative effect of increasing inflammation also possible.^16,44 Benefits of cold include reduced inflammation and decreased pain threshold, with possible negative effects of increased tissue viscosity and decreased tissue elasticity causing more joint stiffness.^16,44 Heat can be delivered through hot packs, paraffin, fluid therapy, hydrotherapy in a heated pool, and even a warm shower or bath; cold can be delivered through ice packs or gel packs. When selecting the proper modality, the therapist must consider the activity and stage of the disease process. Acutely inflamed joints may be exacerbated by heat, whereas ice may be more helpful in reducing pain and inflammation. In the subacute or chronic stages, heat or cold may be equally effective.¹⁶ Nina preferred the use of heat and found it helpful in loosening her joints and lessening her pain. Even though she was in the subacute phase, some inflammation was still present; therefore, her response to heat was closely monitored so that it did not worsen her inflammation. She was educated in the safe use of warm baths and microwave packs at home.

There are some medical conditions associated with rheumatic disease that contraindicate the use of thermal agents. For example, use of cold is contraindicated in clients with Raynaud’s phenomenon, a vasospastic disorder of the digits.^16,44 Clients with RA often have unstable vascular reactions to heat and cold that cause greater than normal heat retention with heat agents or increased coldness and stiffness with cold exposure.⁴⁴ Careful monitoring of client responses to PAMs is crucial. Client preference and ease of home application should also be considered before choosing an agent to use. Home paraffin units, microwave packs, and continuous low-level heat wraps are increasingly accessible and affordable in community stores and thus provide clients with more options.⁶⁶ Safety should always be a primary concern. Clients and significant others should be carefully instructed in proper application techniques to prevent burns or other tissue damage. Before using any modality, the therapist must fully understand tissue responses and related precautions and be competent in safe delivery of the agent. This typically requires specific education beyond entry-level preparation. Therapists must also adhere to any state licensure or training requirements.

Therapeutic Exercise

The purpose of exercise in the treatment of arthritis is to keep muscles and joints functioning as normally as possible by maintaining muscle strength, preventing disuse atrophy, and maintaining or improving ROM.¹⁰² Regular physical activity can also be helpful in alleviating depression.¹⁰⁰ It is helpful to find out what exercises the client may already be performing and whether these exercises were suggested by a professional or a well-meaning family member or friend; many self-initiated exercises can be harmful to a person with arthritis. There is no universal exercise program suitable for all clients with arthritis. Exercise programs should be designed with regard to individual client needs and tolerances. As a good rule of thumb, pain lasting greater than 1 or 2 hours after completion of exercise signals a need to modify or decrease an exercise.^64,102 General guidelines for exercise in clients with arthritis are to avoid undue joint stress, avoid pain and joint swelling, and work within the client’s comfortable ROM.^11,56,102 The client should be taught to perform exercises slowly, smoothly, and with proper technique. The client must also understand the rationale behind the prescribed exercises.¹⁰² Exercises to maintain ROM should be performed at least once daily, even during a flare. For RA each major joint should be taken through its full comfortable ROM. This includes the neck and possibly the jaw if symptomatic. The stiffest joints require the most attention. The type of ROM exercise selected depends on the disease activity and location of the joint. Active ROM is typically preferred, with assisted or passive ROM if pain or weakness precludes it. In cases of active synovitis, active ROM can exert more stress on a joint than gentle passive ROM, so passive ROM exercises may be safer.⁶⁴ Performing shoulder exercises is often easier in a supine position, which eliminates the effects of gravity. The number of repetitions should be weighed against the potential inflammatory response. On good days, 10 repetitions may be appropriate; on bad days, 3 or 4 repetitions within a smaller arc of motion may be indicated.¹⁰² If the goal of exercise is to increase joint mobility, active or passive stretch can be incorporated. This is appropriate for the subacute or chronic phases of disease but never for the acute phase.⁶⁴ Box 38-4 presents general active ROM exercises for RA.

Exercises for strengthening can be dynamic (isotonic) or static (isometric) and should be aimed toward recovery of function.^26,64,100 Strengthening must be approached cautiously so that pain is not increased, deforming forces are not created, and joint stability is not compromised. Grip-strengthening exercises, even those using light putty, can impart large forces to unstable hand joints.¹⁷ Additionally, this type of dynamic exercise may aggravate joints or pose a risk for potential deformity and in general should be avoided in clients with rheumatoid hand involvement.¹¹ Resistive exercise of any kind should never be performed during periods of acute flare or inflammation but may be used at other stages. Isometric exercises are usually the least painful for clients with RA because they eliminate joint motion and can be as effective or more effective in improving muscle strength and endurance.⁶⁴ Isometric contractions are generally held for 6 to 12 seconds.²⁶ Programs to maintain strength vary depending on the client’s overall activity level. Clients who are sedentary may require a daily program, whereas clients who are active may need to perform only specific exercises once a week.⁶⁴ Gradual progression of repetitions or resistance is recommended.¹⁰⁰

Exercises to promote general health and fitness are recommended for all adults as part of a healthy lifestyle and should be encouraged in clients with arthritis. Current evidence supports the benefits of aerobic and conditioning exercise for people with hip and knee OA, as well as aerobic and strength training in adults with stable RA.¹⁰⁰ Stationary bicycling, walking, and low-impact aerobic dancing, once thought to cause joint damage, have been found to increase flexibility, strength, endurance, and cardiovascular fitness without aggravation of symptoms. T’ai chi has been reported to have positive effects on self-efficacy, quality of life, general health status, pain, stiffness, and physical functioning in older adults with lower extremity OA^41,84 and is being used for clients with RA as well.

Whether for ROM, strengthening, or overall conditioning, the occupational therapist should work closely with the client to help ensure that any exercise program can be successfully integrated into the client’s typical daily routine with a proper balance of rest and activity. Exercises should ideally be done when the client feels most limber and has the least pain. Community land- and water-based exercise classes specifically designed for people with arthritis are available through the Arthritis Foundation. They offer the added benefits of social interaction and peer support and have been shown to be safe and effective in increasing fitness and strength and decreasing pain and difficulty in daily functioning.^13,88,92

Daily upper body active ROM exercises with gentle stretch and isometric exercises for the shoulders and elbows were prescribed to improve Nina’s motion and strength. It was decided that the best time to perform these exercises was after her morning shower, when she felt less stiff and least fatigued. The therapist recommended that Nina become involved in an Arthritis Foundation exercise class, once her flare subsided, to build her endurance and cardiovascular conditioning. She was interested in joining and planned to attend classes on the days that she worked fewer hours.

Therapeutic Activity

Performance of therapeutic activities offers many benefits, both physical and psychologic. Discussing current and past hobbies or having the client complete an interest survey can help the therapist determine activities that may be most appropriate for the client. New activities may be suggested or previously enjoyed activities reintroduced. A carefully chosen and graded activity can be an effective means of encouraging ROM and strength. When selecting therapeutic activities, the therapist should apply the same principles as with exercise.⁶⁴ Activities should be nonresistive, avoid patterns of deformity, and not overstress joints; instead, they should offer enough repetition of movement to help improve ROM and strength. The effect of the activity on all joints should be considered.

It is typically recommended that clients with RA not engage in activities that require use of the hand in prolonged static positions. However, sometimes the psychologic benefits of doing activities that one enjoys outweigh the risks involved, especially if the risks can be minimized. Examples of activities that are often frowned on include knitting and crocheting. These activities are truly contraindicated only if there is active MCP synovitis, a developing swan neck deformity, or thumb CMC joint involvement.⁶⁴ Potential problems may be averted by having the client wear a hand or thumb splint to support the vulnerable joints while performing the activity. Additionally, educating the client to incorporate frequent rest breaks and stretching exercises for the intrinsic muscles will help limit risks (see Chapter 29 for additional information regarding therapeutic exercise and activity).^27,64

Splinting

Assistive Devices

Numerous assistive devices can be fabricated or purchased commercially. The therapist should be familiar with the types of devices available and sources where they can be obtained at minimal expense. Many devices that were previously available exclusively from medical suppliers can now be found in retail stores at much less cost. Commonly used in arthritis interventions are extended-handle devices (e.g., dressing sticks, sock aids, shoe horns, bath sponges, hairbrushes, toilet aids; Figure 38-20, A), to compensate for loss of proximal ROM and strength, and devices with built-up handles (e.g., eating utensils, button aids, writing implements; see Figure 38-20, B), to compensate for limited hand function (Table 38-8). The therapist should carefully consider the client’s goals, factors, activity demands, and contexts when suggesting assistive devices.⁶⁴ Most relevant to clients with arthritis are the following: Is the client receptive to using a device? Will the device successfully reduce pain, joint stress, energy demands, or time expenditure? Is the device easy to use? Is the device acceptable to the client in terms of appearance, cost, and maintenance needs? Is the device compatible with the physical environment and others in the environment? Is the device likely to cause any negative effects?

Having sample equipment on hand for the client to try can be helpful in finding the best device for each client. In some cases it may be necessary to modify existing devices before the client can use them successfully. For example, the handle of a dressing stick may be built up for a client with limited grasp. Surprisingly little research has been done on assistive devices for clients with arthritis and on the characteristics of device users and nonusers, but clinical experience shows that clients are less likely to use devices that they perceive as not helpful, too complicated, too expensive, or too bothersome to others sharing the environment.^78,91 A study of device use in frail elderly clients, including some with arthritis, demonstrated that they were willing to use the devices but required assistance in identifying sources for devices.^60,61 Some clients may need to use assistive devices only during a flare or on more symptomatic days. On good days, it may be appropriate to encourage clients to perform tasks without them to promote strength and mobility.

Client and Family Education

Providing clients with as much information as possible regarding their conditions and treatment is a crucial component of OT and should be integrated throughout all phases of the program. Whether it is the client’s first visit or one of many therapy encounters, educational needs should always be explored. The client’s estimation of the therapist’s credibility, the quality of the therapeutic relationship, and whether the client’s experience confirms the therapist’s statements are important factors tied to success in changing the client’s knowledge and beliefs.⁵⁸ Client education has been shown to empower clients and lead to positive changes in pain reduction, psychologic status, disease management, self-efficacy, and overall health promotion.^{18,39,57,59,62}

Rather than focusing exclusively on providing basic information and generic skills, encouraging client self-reflection and transformation of client perspectives has been suggested as a helpful part of rehabilitation.³⁰ Repetition, reinforcement, and real-life application to the client’s situation are other keys to education. By focusing on the client’s symptoms and concerns, the therapist can capitalize on “teachable moments” to provide present-oriented and problem-focused learning activities.¹⁴ It may be helpful to provide both verbal and written instructions. The following are some important educational aspects to cover: disease process, symptom management, joint protection and fatigue management, and community resources.

Review Questions

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