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Week 1: Common Orthopaedic Conditions: Osteroarthritis - Coggle Diagram
Week 1: Common Orthopaedic Conditions: Osteroarthritis
Osteoarthritis (OA)
Definition of Osteoarthritis
A non-inflammatory degenerative joint disease characterised by loss of articular cartilage
What occurs leading to osteoarthritis
When chondrocytes cells fail to repair damaged cartilage, the joint capsule thickens and it scars
Associated with new bone formation by the body and capsular fibrosis that results when chondrocytes fail to repair damaged cartilage
in an attempt to repair the damage to the joint
Etiology of osteoarthritis
1. Primary/Idiopathic
Where there is no obvious cause
2.Secondary - identifiable cause
Previous trauma
eg Overuse
Congenital deformity
Infection
Metabolic disorders
Pathology of osteoarthritis
OA is progressive and results in pain and stiffness in the joint involved
What osteoarthritis leads to
Alteration of limb length: Situation where one limb is slightly shorter than the other
Fixed deformity in the joint limiting movement: eg knee contracture
Progressive wasting of muscles as the limb is used less
People who experience symptoms and signs of non-inflammatory arthritis have the clinical diagnosis confirmed with XRAYs
Radiological signs of osteoarthritis
Joint space narrowing - initially at maximal load area before progressing to the entire joint
Maximal load where there is more pressure applied around that area
Development of osteophytes as the join endeavors to repair itself
[Development of bone spurs]
Subcortical/subchondral sclerosis indicated by thickening of the bone below the joint surface
Subchrondral pseudo-cyst formation
Subchondral cyst is a fluid-filled space inside a joint that extends from one of the bones that forms the joint. This type of bone cyst is caused by osteoarthritis.
https://www.hss.edu/condition-list_hip-cysts.asp
Treatment for Osteoarthritis
Initial treatment: should always be conservative/non-operative options
Protection of joint overload by losing weight and using walking aids
Strengthening and stretching of supporting muscles to avoid wasting and preventing stiffness
Pain relief using analgesics, anti-inflammatory drugs and sometimes physical modalities like hot packs
Intra-articular corticosteroid and hyaluronic acid injections
Locations at which these intra-articular hyaluronic acid or viscosupplementation injections should take place
Intra-articular hyaluronic acid
[C] When there is break down of joint fluid: Inject around the lateral or medial meniscus closer towards the centre/anterior cruiciate ligament area
[B] When Bone spurs develop: inject around the medial meniscus region
[A] When cartilage wears away: inject around the cartilage area
Viscosupplementation injection
[D] To occur at the medial section around ACL area
Taking oral glucosamine and chondroitin
For people with persistent pain and symptoms despite conservative measures surgery can be considered
Operative/surgical methods to consider
Realignment osteotomies (for younger persons)
Arthroplasty (usually for older adults)
Surgical reconstruction or replacement of a joint
Types of arthroplasty
Hemiarthroplasty
Locations:
Hip: Hip fractures and arthritis
Shoulder joints: Eg Fracturs of the glenohumeral joint
Only one articular surface is replaced
Unicompartmental arthroplasty
Locations: Keee joint
When there are denegerative changes are confined to either the medial or lateral half of the joint
and in these cases good results can be achieved by only replacing the degenerative part
Total joint arthroplasty/Replacement
Gold standard of joint replacement and the most commonly performed type of arthroplasty
Both sides of the articular surface is removed and replaced with a prosthetic
Locations:
Hip: Total Hip Replacements (THRs)
Knee: Total Knee Replacements (TKRs)
Ankle joints
About Total Knee Replacement (TKRs) Surgery
Video of how Total Knee Replacement Surgery is done
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Effectiveness and complications of doing TKR on an OA knee
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Post Total Knee Replacement Function
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Occupational therapy for TKR
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Rheumatoid Arthritis
Why it is covered together with other orthopedic conditions: As RA involves the joints
Medical attention received: A patient with RA who is not seen by an orthopaedic doctor likeley to be seen by a rheumatologist
As cause of RA is not biomechanical like many other orthopaedic conditions
Definition of Rheumatoid Arthritis
Chronic systemic autoimmune disease with unclear aetiology and a number of joint sequelae
Chronic disease in which the
body produces antibodies that attack its own joints,
leading to joint deterioration and destruction
In some people, condition can also damage a wide variety of body symptoms (eg skin, eyes, lungs, heart and blood vessels)
Symptoms of Rheumatoid Arthritis
Like an inflammatory arthritis - typically the person experiences acute or chronic episodes throughout their life
Series of ups and downs
Joints can feel good on some days but some days swelling and pain can be so bad that you can barely get out of bed
Different types of symptoms
Systemic
Fatigue
Early morning stiffness or stiffness after rest
Flu-like symptoms
Pain during rest
Flares in symptoms followed by disease inactivity
Rheumatoid nodules where there are firm tissue lumps (Occur in one-fifth of patients)
Loss of appetite, anaemia, weight loss
Sjögren's syndrome - involvement of the glands around the eyes and mouth causes decreased production of tears and saliva
Local
Location of joint symptoms
Any joints can be affected
Joint symptoms are symmetrical (on both sides)
Most commonly in the smaller joints of the fingers, hands, and wrists
People with RA are more susceptible to infection
Potential causes are not clear, and there are a number of joint complications following each flare up
Cure and treatment for RA
There is currently no cure for RA
Treatments can improve symptoms and slow progress of the disease
Much of the treatment aimed at controlling the condition and preventing the chronic changes usually associated with RA
Disease-modifying treatment has the best results when started early and aggressively
Early aggressive medical treatment can control the condition and limit joint damage and thus prevent or limit chronic disability typically associated with rheumatoid arthritis in the past
Pathology of Rheumatoid Arthritis
[Stages]
Stage 1 [ Early Stage ]
: Involves initial inflammation in the joint and swelling of the synovial tissue/lining of the joint
Inducing clear symptoms of warmth, redness, joint swelling and pain and stiffness
However generally no XRAY evidence of joint destruction
Stage 2 [Moderate stage]:
Thickening of synovial tissue causes cartilage damage and narrowing of the joint space
Rapid division and growth of cells resulting in pannus formation/thickened synovium
In this stage, symptoms of loss of mobility and range of motion become more frequent
Stage 3 [Severe Stage]:
Inflammation in the synovium is now destroying the cartilage of the joint and the bone
Potential symptoms of this stage include increased pain and swelling and a further decrease in mobility and even muscle strength
Stiffness, pain, deformity experienced at the end stage
Stage 4 [Terminal/End Stage]:
The inflammatory process stops and formation of fibrous tissue or fusing of bone results in ceasing in joint function
Pain, swelling and stiffness and loss of mobility are primary symptoms in this stage
Stage associated with formation of subcutaneous nodules
What is the definition of subcutaneous nodules?
Common hand deformities in persons with RA
1. Boutonniere Deformity
Flexion of the PIP joint and hyperextension of the DIP joint
What are the differences between the deformities
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2. Swan Neck Deformity
Hyperextension of the PIPJ and the flexion of DIP
3. Joint Deviation
Deviation is a change in normal joint position
It is typically described as radial or ulnar
Most common pattern of deviation: radial deviation of the wrist and ulnar deviation/drift or the MCPJs
Causes of joint deviation
Caused by ligament weakening or disruption
Small joints are especially vulnerable to deviation because ADLs involving gripping and pinching apply strong forces to them
Rheumatoid Arthritis (RA) Treatment
Current focuses/Treatment plans
Pain relieving
Reducing inflammation
Preventing joint damage
Functional improvement
Symptomatic treatments
Medication/therapeutic categories are based on those that are aimed at controlling the progression of disease and those aimed at symptomatic relief
Different types of symptomatic treatments
1. Non-steroidal anti-inflammatory drugs (NSAIDs)
Reduce inflammation, pain and fever
Side effects: is an increase in bruising and bleeding so care should be taken when handling
2. Analgesic drugs:
to relieve pain
3. Corticosteroids
low doses to reduce inflammation and to prevent joint damage. These may be administered systematically or as injections to the joints
Pharmacological treatments
Disease control treatment
(Medications that control the progression of RA)
1. Disease-modifying anti-rheumatic drugs (DMARDs)
Used with other drugs to slow joint destruction over time
eg methotrexate, penicillamine, azathioprine
care needs to be taken due to known side effects and drug interactions
2.Immunotherapies
eg anti-tumour necrosis factor (TNF) drugs
Biological agents and immunoactive drugs, which principally inhibit cytokines in the immune system to control inflammation
No long-term studies that have looked at the effects of these on disease outcome
3. About Alternative Therapies
Many people may have been given device, or may have done their own research, on alternative strategies
Although there may not be good evidence to support many of these, an open mind should be kept regarding those which people choose to take
Medical practitioners should be careful not to advise on alternative therapies unless they are knowledgeable or trained in this field
We now know that combination therapy is usually most effective in controlling the disease and therefore a person will usually be on more than one form of medication
Surgical RA Treatment
1. Synovectomy
To reduce the amount of inflammatory synovium in the joint
2.Joint Replacement/arthroplasty
Used when pain is not controlled by medication alone, and a person is limited in heir movement
Partial joint replacement not suitable (e.g unicompartmental knee replacement or hemiathroplasty of the hip) as the whole joint is involved in he rheumatoid arthritis
3. Arthrodesis/fusion
Can be used to control pain
Although it does prevent movement in the joint
This is more commonly employed in the foot and ankle rather than the hand
Rheumatoid Arthritis Pain
Symptoms
Stiffness
Shooting pain
Joints can lock for a long time (ie trigger fingers)
Having to learn how to pry them open by herself
RA: Cause a painful inflammation of the joints
Have about 30 degree ROM and right arms start to feel pain and couldn't breath all the time as it was inflammed
Occupations such as getting dressed was very hard for her
Inflammation could actually eat at the bone and the architecture of the joint and there could be deformities at the joint --> People lose their ability to do thing, therefore it could be a crippling disease left untreated
Possible causes Rheumatoid Arthritis Pain
Doctors say that they know that cells from the immune system invade the joint tissues causes a reaction that results in inflammation and extreme pain, which affects more than 1 million americans mostly women
Early diagnosis and drug therapies can control the progression of disease, but pain management can be tricky
Parts that may be affected
Feet, ankles and knees: used for walking
Hand and wrists are what people use the most during the day for manipulating working on computer etc
Doctors Recommendation
Starting with pain relief such as Ibruprofen to relief the stiffness and swelling.
Heat can also help tight muscles relax, and also help cool down swollen joints and reduce swelling.
Smoking can make RA worse
Exercise is crucial in minimizing carrying excess weight
Preventive methods
When you are not having any pain and swelling in your hands, it is a good time to make those joints as strong as possible
Reason: there is a component of wear and tear always when we exercise (often ask patients to exercise and walk)
Some people find if they cut back on carb and sugar it may help with their artihritis
people often times feel like an apple cider vinegar help their arthritis, sometimes black cherries too
Eg Spice some people find tumeric, cucumin or garlic helps
Learning how to do the simplest things without causing further damage to the joints is also key
Learning to do things with bigger joints such as elbow joints to push cabinets and drawers shuts
OT Intervention
1. Rest
During RA flares
At least 8-10 hours of sleep at night and half-hour to 1-hour morning and afternoon rest periods are recommended
Localised rest of joints may include wearing a splint, avoiding or modifying activity, or positioning to prevent joint stress
About 30 mins to an hour morning and afternoon rest periods is recommended
2. Therapeutic exercises and activity
Therapeutic exercises
Regular physical activity can also be helpful in alleviating depression
However in a flare, cut down on exercises but do not discontinue them entirely
Purpose of exercises the treatment of RA is to
keep muscles and joints functioning as normally as possible
by maintaining muscle strength, preventing disuse atrophy and maintaining or improving ROM
Therapeutic activity
Activities should be non-resistive, avoid patterns of deformity, and not overstress joints
Activities should offer enough repetition of movement to help improve ROM and strength
The effect of the activity on all joints should be considered
3.Occupational performance training
(ADL Training)
An effective means of maintaining functional motion and strength is to have clients perform ADLs and IADLS
Limited to simpler tasks during RA flares --> these may be limited to simpler tasks such as feeding and hygiene.
Usual life activities should be resumed with improvement of condition
This also promotes physical status and psychological well-being
Assistive devices
Assistive devices can be prescribed to help patients with RA to maintain independence
Commonly used assistive devices in RA
Extended handle devices: compensate for loss of proximal ROM and strength
Built-up handle: Compensate for limited hand function
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
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 the devices to promote strength and mobility
6.Client education on joint protection techniques
1. Respect Pain
Pain is a signal from the body that something is wrong and disregard and working through the pain may lead to more pain and may cause joint damage as a result
Client should be encouraged to be aware of their limits and stop activities before pain occurs
Client education has been shown to empower patients and lead to changes in disease management behaviours and self-efficacy
2. Maintain muscle strength and Joint ROM
Joints that are less stiff and have balanced strength will be less susceptible to further injury
Limited motion at one join
t transmits force to another
and may require exaggerated motions at other joints to accomplish a task. For example, loss of MCPJ motion will affect the PIPJs
3.Use each joint in its most stable anatomical and functional plane
This plane is where the resistance to motion is provided by muscle rather than the ligament
An example is to avoid leaning to either side when rising from a seated position to lessen rotational forces on the knees
4. Avoid positions of deformity
The usual way of performing tasks may cause forces to be applied in directions of deformity
Tasks involving tight squeezing, pinching or twisting motions are especially stressful
Opening a jar lid and turning a door knob are activities promoting MP ulnar deviation. The client can be encouraged to open lids with a jar opener, or to turn a doorknob with an adapted lever
Static positions of deformity should be avoided. The client should be discouraged from leaning his/her chin on the back of fingers because this applies considerable forces to the flexed MPJs
5.Use the strongest joints available
Using larger, inherently stronger joints reduces the stress of smaller joints
Carrying bags on the shoulder or elbow lessens the strain on the wrist and hand
The palms rather than the fingers should be used to lift, push, or take weight to better distribute the forces
6. Avoid Prolonged Static Positions
This can lead to joint stiffness and muscle fatigue
Positional stress is then transmitted to the joint ligaments, which amy already be in a weakened state
Changing body positions, taking frequent breaks and integrating exercises during activities such as typing on the computer can prevent fatigue and stiffness
7. Avoid starting an activity that cannot be stopped immediately if it becomes too stressful
To prevent load from going to the joint capsule and ligament if muscles tire
Continuing a task that causes sudden or severe pain is likely to cause joint damage and safety risks
Realistic planning of options can help prevent such situations
Examples
Clients can keep a shower bench available in case they need to rest while standing in the shower
Can also not the location of benches in a mall in relation to teh stores where they plan to stop
8. Balance rest and activity
The key to increasing functional endurance is to rest before becoming overfatigued
Some clients with RA take advantage of "good days" by trying to complete as many tasks as possible but end up with several "bad days" as their bodies struggle to recover
Balancing activities during the day and longer-term across the week or month can be accomplished through planning and establishing priorities
9.Reduce the force and effort
Less force and effort equates to less joint stress, pain and fatigue
Using assistive devices and other joint protection techniques can help towards this end
Keep commonly-used items within easy reach
Sit on a perching stool for tasks normally done in standing
Joint protection principles can be applied to all ADLS and IADLs. If you are able to teach these to the client and client is able to internalize them, they will be able to function more independently