UNIVERSITY OF CAPE TOWN

DIVISION OF OCCUPATIONAL THERAPY – AHS3107W

ARTHRITIS

Rheumatoid Arthritis (RA) is a systemic disease that affects the joints and
sometimes the major organs of the body.
 It is characterised by inflammation of joints
 Connective tissue disease, of which there are 2 main types, namely
rheumatoid arthritis and osteoarthritis and gout.
 Less than 2% of the world’s population suffers from this disease
 More common in females than in males
 Seen more in urbanised communities
 Onset is between 20-40 years unless as child - named Juvenile Arthritis
 Severe restriction of occupation occurs with after 10 years of illness only
50% of patients with disease are still in employment

In RA, the synovial membrane becomes thickened and inflamed with the erosion
of the cartilage. The synovial membrane invades the joint space whereupon the
whole joint becomes swollen and painful with movement.
The cause of RA remains unknown, although the following causal factors are
considered
 lowering of the immune system
 genetic factors
 certain hormones
 infectious agents
Extensive efforts to identify an exogenous infectious agent such as a bacterium,
mycobacterium, mycoplasma, fungus or virus have been unsuccessful.

Any joint may be affected, but those commonly involved are the second and third
MCP joints of the hand, second and third PIP joints, metatarsophalangeal joints
of the foot, wrists, knees, elbows and less commonly, the shoulder, hip and DIP
joints.

Signs and symptoms include

 symmetrical polyarticular joint pain and inflammation that persists for more
than 60 days
 morning stiffness that may last for several hours after arising
 malaise
 fatigue
 increase in skin temperature
 feelings of exhaustion
 decrease in weight
Primary changes associated with inflammation are joint tenderness and swelling
in at least three joints, including one hand joint. Over long periods, joint
tenderness and swelling may improve while progressive deformity and disability
develops. Disease progression results in joint space narrowing as a result of
cartilage destruction and erosion. Further progression may result in radiographic
evidence of joint malalignment. More than half the patients with RA develop
radiographic abnormalities within 2 years of onset. Muscle weakness and
neurological problems may also occur.

Classification criteria for RA suggest that there are at least 3 types of disease.
 Type I exhibits a self-limited polyarthritis, which often resolves.
 Type II is characterised by persistent disease that does not lead to long
term consequences.
 Type III is a progressive disease with radiographic changes and decline in
function and reported work disability.

Phases of treatment:
 Acute – hot, swollen, red, painful joints with loss of movement, possible
systematic manifestations.
 Sub-acute – inflammation diminishing
 Chronic active – low grade inflammation, stable condition.
 Chronic inactive – inflammation controlled, stable condition.

Assessment
The patient with RA is assessed according to his or her own goals in the context
of his or her environment. It is necessary for the OT to obtain as much
information as possible through observation, interview and assessments of the
physical components. It is also important that the file is read, and collateral
information acquired.
 Medical history – date of onset, course of disease, response to treatment,
surgery, sleep patterns etc
 Pain – an assessment of joints involved and visual analogue scale to
quantify pain is helpful in establishing priorities. Subjective.
 Presence of synovitis – signs of inflammation - redness, swelling, warmth
 Range of Motion – record time of assessment. Possible causes for limited
range: joint synovitis, tenosynovitis, muscle spasms, tendon rupture,
oedema, soft tissue contractures, bony erosions, ankylosis. ROM lag
refers to a difference between active and passive movement, a
consequence of tendon damage, adhesions or muscle weakness. Assess
functional ROM if time does not permit a detailed ROM assessment.
 Observe for subluxation common at the wrist and in the joints of the hand
especially MCP joints. Ligamentous instability caused by chronic synovitis
may result in abnormal lateral movement. Joint contractures may also be
present causing a fixed limitation in joint motion.
 Muscle strength – assess grip strength as well as group muscles.
Resistance should be applied within the patient’s pain free range and not
at the end of the active range.
 Extrinsic and intrinsic muscle tightness may be observed. Here the
motion of the distal joint is affected by the position of the proximal joint.
  Observe for tendon rupture – caused by tenosynovitis (lining becomes
inflamed with fluid getting trapped within walls).
 Hand function including grip strength must be assessed.
 Psychological considerations: patients response to chronic illness/disease
and disability – evidence of denial, depression, need for control,
dependency and acceptance. Patients knowledge about his condition, its
treatment, course and prognosis and his ability to accept responsibility for
his treatment.
 Daily activities and occupations – level of independence is most important
factor. The following questions should be addressed:
*Is the patient performing any daily tasks that are causing needless or potentially
deforming stresses to the joints?
*Are there assistive devices or adaptive methods that could minimise or eliminate
joint stress in these activities?
*Is the patient limited in performing daily tasks as a result of physical limitation?
*Are there adaptive methods or assistive devices that could increase
independence in these tasks?
*Can the physical condition be improved in any way to facilitate independence?
 Social network – does the patient have social support, community
involvement, leisure activities or interests? If not determine the limiting
factors.

Goals of treatment
 Reduce pain and inflammation – rest, splinting of inflamed joints,
elimination of any joint stress.
 Maintain ROM – positioning to avoid deformity, splinting to maintain ROM.
 Psychological support
 Maintain strength and endurance – introduction of light ADL as
inflammation subsides and considering patients tolerance. Joint
protection principles may be taught as well as work simplification and
energy conservation techniques. Isometric exercise is preferable.
Assistive devices or adaptive methods may be brought in to assist the
patient in fulfilling their tasks.
 Maintain joint integrity – joint protection principles, assistive devices,
splinting.
 Promote a sense of control in the patient’s life – education about the
condition, prognosis etc, teach techniques of stress management, time
management, relaxation. Education is especially valuable in the early
years of the diseases but should be an ongoing process as the patient
learns to handle and cope with problems experienced.
 Improve function in daily activities – seek alternative methods of
performance or train in use of assistive devices. Assist patient in having
realistic expectations especially with regards to leisure activities.
 Facilitate the greatest level of independence possible and realistic –
splinting and assistive devices.
  Investigate the patient’s social network and assist in the establishment of
social outlets to prevent loneliness and depression from entering the
patient’s world.

Joint protection
In empowering joint protection principles, the OT will seek to achieve the
following:
1. Explain the rationale for joint protection based on the damaging effects of
the inflammatory process.
2. Teach the patient to recognise that joint pain, warmth, redness and
swelling are signs of inflammation.
3. Impress on the patient the necessity of reduction of stress to joints that
are or have been inflamed.
4. Encourage the patient to evaluate disease activity level through
recognition of inflammatory signs, symptoms and joint stiffness.
5. Stimulate awareness for need to modify activities based on disease
activity level.
6. Teach patients to balance activity with rest. Exacerbation may occur if
joint is not rested.
7. Help patient to recognise that pain should be respected at all time as joint
damage may occur. True joint pain hurts even when resting. Muscle
aches when movement occurs – it is harmless.
8. Describe the alternatives available to the patient or pacing activities.
 rest during chores and between tasks
 adapt methods and equipment
 rest of specific joints through splinting
 systemic or whole-body rest
 emotional rest
9. Affirm that function is best preserved by maintaining muscle strength and
ROM – encourage exercise and the participation in activity
10. Identify proper joint alignment during rest and activity.
 Explain what correct alignment looks like
 Describe how disalignment encourages disability and deformity
 Encourage and practice movements in good planes
11.Identify situations in patient’s life where improper stress is exerted on
joints and recommend alternatives
12.Stimulate problem solving for other situations.

Splinting
Purpose: to rest the inflamed joints,
reduce stress on the capsule
allow muscles to relax
relieve pain
maintain position
minimise deformity – cannot correct
prevention of deformity from incorrect positioning
 postoperative splinting to maintain surgical gains and good
alignment
postoperative splinting to strengthen and to prevent adhesions
promote functional ability

Common splints are a resting splint for the wrist to be in 10-20 degrees of flexion,
wrist extension splint, 3-point finger splints for Swanneck and Boutonniere Also want to
deformities and ulnar drift splint. Other splints are neck collar, knee and elbow maximize
gutter splints and insoles for the patient’s shoes. functionality
Boutonniere deformity is involvement of the PIP joint, where the patient has an eg wrist in
inability to straighten this joint. Poor grip and function arise. most func
Swan-neck deformity is the hyperextension of the PIP joint where the finger position
concerned becomes stiff and poor grips and function arises.

Activity should have minimal resistance and should encourage rhythmical

movement. It should allow for the application of joint protection principles e.g. it
should not require long periods of static positioning or small static grips, it should
allow rest periods. It should make use of isotonic exercise. Should be able to be
performed within pain tolerance. Pain following activity should not last longer
than one hour otherwise it is excessive. It should be highly motivating and have
strong ability to divert the patient from pain and negative feelings.

Assistive devices and adaptive methods are used to modify the environment
or make the patient more functional. Some examples of changing the physical
environment are as follows:
 Remove doors of cabinets or attach loops to door handles
 Lower above-counter cupboards
 Replace shelves in low cupboards with swivel or pullout shelves
 Replace door knobs with lever handles
 Use remote devices to automate on-off switching
 Use trolley or pushcart to move items from room to room.

Criteria when choosing assistive devices

 Lightweight, durable, compact, attractive in appearance
 Multipurpose use to prevent need to search for multiple devices
 Simplicity of operation
 Reduce stress to all multilinked joints involved in operating the device
 Suitable for individual patient’s gadget tolerance
 In accord with self image of user.

Some common assistive devices that are utilised are the buttonhook, a dressing
stick, sock or tights cone, long-handled sponge for bathing of back or toes, easy-
reacher to pick up items at a distance on the floor, trolley for transporting many
items, tap turner, cutting board with spikes to peel potatoes, high kitchen stool,
adapted key holder and electrical equipment.
Management of non-inflammatory arthritis: Refers to degenerative arthritis
(osteoarthritis) and traumatic arthritis.
It is characterised by the absence of inflammatory signs such as pain on
motion/weight-bearing; joint stiffness particularly after a period of static
positioning; residual deformity; muscle weakness; disuse atrophy; muscle spasm
secondary to pain; poor endurance related to inactivity. Goals:
 Improve functional independence
 Improvement of functional independence through instruction in work
simplification and energy conservation. Minimise ambulation, static
positioning and stress to the joint.
 Assessment and treatment pre and post surgery e.g. THR
Prognosis for functional use is excellent for the upper limb, fair for the knees and
poor for the hips, hence common need for THR.

Rheumatic Disease in Childhood:

Limb pain in childhood is common, but serious rheumatic disease is rare. Very
young children affected have naturally severe implications for their growth and
development. One or many joints may be involved and there may/may not be
systemic manifestations. Onset may be early (under 5 years) or late in childhood.
Prognosis – the younger the child at onset, the more difficult to prevent deformity.
Death may be due to infections.
 Pauci – articular disease – growth anomalies often seen; serious eye
involvement possible.
 Polyarthritis – growth is usually less retarded than those systemically
affected.
Presence of a positive rheumatoid factor indicates a more severe arthritis that
may persist into adulthood characterised by deformity and disability. Disease
may persist over many years and is characterised by exacerbations and
remissions. In many cases the disease goes into remission by adolescence,
although permanent joint damage has already occurred. Correct early
management is therefore essential.

Anticipated problems:
1. Limited ROM together with postural deviations and compensatory
movements.
2. Pain and stiffness.
3. Muscle weakness, secondary to joint problems, immobility and disuse.
4. Poor endurance.
5. Poor gait and ability to balance – often fear movement and anticipate pain.
6. Visual problems.
7. Considerable side effects from drugs.
8. Psychological/social factors:
 Repeated hospital admissions - need for therapy, surgery interrupts
normal schooling.
 Frustration, depression, withdrawal from peers.
 Overprotectedness from parents and resulting resentment.
  Poor decision making and social skills.
 Poor body and self image due to physical appearance and inability
to partake in normal occupations.
 Behavioural problems due to chronic nature of the illness, e.g.
manipulation.
 Trauma of repeated separation from family and peers.
 Socially these children are very immature.
9. Future planning is often limited, and children often have misconceptions
about their conditions and the possibilities for the future.
10. Play and recreational activities and opportunities may be severely limited.
11. Independence maybe slow/impossible creating a delayed overall
development.

Intervention:
Focus on dealing with the above-mentioned problems and treating the child
within the context of his/her particular family and social setting. These
children benefit from group interventions and should be encouraged to
understand their treatment and assume responsibility for their treatment from
an early age. Realistic goals of treatment need to be established with all the
major role players to ensure that the child has the best opportunity to function
as best they can within the normal school and home environment. Children
should be encouraged to express their feelings and activity should be geared
not only to gross motor function but also to the very important need for
developing a positive self image and a feeling of ‘ability’ rather than
‘disability’. The need for experiencing the joy of activity participation is very
great in these children. Age appropriate handling and expectation is essential
as these children often appear much younger than their peers physically.