Conditions in Occupational Therapy 5th edition Ben J Conditions in Occupational Therapy 5th edition Ben J. Atchison and Diane Powers Dirette _____________________________________________________________________ Chapter 23: Rheumatic Diseases

Rheumatic Diseases Description and Definitions Rheumatoid Arthritis Usually impacts same joint on both sides Erosions/ periarticular sinuses in affected joints Subchondral cysts Severe periarticular bone fragmentation Osteoarthritis Degenerative joint disease Copyright © 2017 Wolters Kluwer • All Rights Reserved

Rheumatic Diseases Description and Definitions, cont’d Osteoarthritis, cont’d Inflammation of bone / joints Primary OA: wear / tear over time Secondary OA: injury / insult to joint Fibromyalgia Widespread pain / tender points Copyright © 2017 Wolters Kluwer • All Rights Reserved

Rheumatic Diseases Description and Definitions, cont’d Gout Primary impact: 1st metatarsophalangeal joint “unwalkable disease” Also impacts: elbows / interphalangeal joints of hands Systemic Lupus Erythematosus Autoimmune disease Skin rash Copyright © 2017 Wolters Kluwer • All Rights Reserved

Rheumatic Diseases Etiology RA Genetic + eviromental factors Formation of synovitis / tenosynovitis if left untreated Infectious agents into synovial tissues = chronic inflammation Formation of pannus; substance that destroys soft tissue Copyright © 2017 Wolters Kluwer • All Rights Reserved

Rheumatic Diseases Etiology Copyright © 2017 Wolters Kluwer • All Rights Reserved

Rheumatic Diseases Etiology Copyright © 2017 Wolters Kluwer • All Rights Reserved

Rheumatic Diseases Etiology, cont’d OA Polygenic hereditary + environment General aging Chondropenia Degradative enzymes in synovial fluid Fibromyalgia Disabling pain / tenderness; muscles, joints, tendons Unclear etiology Copyright © 2017 Wolters Kluwer • All Rights Reserved

Rheumatic Diseases Etiology, cont’d Fibromyalgia, cont’d Theory: genetics + immunological + hormonal Without joint inflammation Gout Crystallization of uric acid in joints Diet high in purines, rise in blood uric acid Hyperuricemia Copyright © 2017 Wolters Kluwer • All Rights Reserved

Rheumatic Diseases Etiology, cont’d Fibromyalgia, cont’d Theory: genetics + immunological + hormonal Without joint inflammation Gout Crystallization of uric acid in joints Diet high in purines, rise in blood uric acid Hyperuricemia Copyright © 2017 Wolters Kluwer • All Rights Reserved

Rheumatic Diseases Etiology, cont’d Systemic lupus erythematosus Unclear etiology Autoimmune disorder Impact on joints similar to RA Copyright © 2017 Wolters Kluwer • All Rights Reserved

Rheumatic Diseases Incidence and Prevalence RA Affects 1% of world pop Prevalence increases with age Dx between age 40 – 70 Equally affects all races, ethnic groups, gender Juvenile rheumatoid arthritis = onset < age 16 OA 10% - 15% world pop Copyright © 2017 Wolters Kluwer • All Rights Reserved

Rheumatic Diseases Incidence and Prevalence, cont’d OA, cont’d ~ 27 million in US Knee most common site 47% women vs 40% men Hands 9.7% women vs 4% men Hip OA African American men 32.2% (highest) Knee OA Chinese women 46.6% Hand + hip OA Caucasians 47% Copyright © 2017 Wolters Kluwer • All Rights Reserved

Rheumatic Diseases Incidence and Prevalence, cont’d Fibromyalgia Often accompanied with RA / OA 1% - 4.7% worldwide More common in women US: .5% men vs 3.4% women Gout Most common form of inflammatory arthritis 1% - 4% worldwide Copyright © 2017 Wolters Kluwer • All Rights Reserved

Rheumatic Diseases Incidence and Prevalence, cont’d Gout, cont’d 8.3 million in US Men and African Americans mostly affected Systemic lupus erythematosus Frequency decrease of new cases Northern Ireland highest prevalence Caribbean descent highest incidence / prevalence Females 6x > males Copyright © 2017 Wolters Kluwer • All Rights Reserved

Rheumatic Diseases Signs and Symptoms RA 1 joint or polyarticular Symmetrically / asymmetrically Fatigue / generalized weakness Loss of ROM Joint edema Joint guarding Contractures, subluxation, ankylosis Copyright © 2017 Wolters Kluwer • All Rights Reserved

Rheumatic Diseases Signs and Symptoms, cont’d RA, cont’d Swanneck deformity Boutonniere deformity Abnormal gait pattern, (hip involvement) OA Localized pain at particular joint Edema / tenderness Joint stiffness post prolonged inactivity (sleeping) Copyright © 2017 Wolters Kluwer • All Rights Reserved

Rheumatic Diseases Signs and Symptoms, cont’d Copyright © 2017 Wolters Kluwer • All Rights Reserved

Rheumatic Diseases Signs and Symptoms, cont’d OA, cont’d Postactivity flare-up (pain / edema) Crepitus ROM guarding Fibromyalgia Chronic widespread pain Point tenderness Lower abdomen cramps Copyright © 2017 Wolters Kluwer • All Rights Reserved

Rheumatic Diseases Signs and Symptoms, cont’d Fibromyalgia, cont’d Depression Poor sleep, fatigue, headaches Signs can occur unilaterally / bilaterally Chest, upper back, neck, buttocks, arms, shoulders Gout Joint inflammation Copyright © 2017 Wolters Kluwer • All Rights Reserved

Rheumatic Diseases Signs and Symptoms, cont’d Gout, cont’d Symptoms: more intermittent vs progressive Left untreated = quite destructive Edema, erythema, increased localized temp Most often big toe affected Feet, ankles, wrist, hands, elbows, knees Copyright © 2017 Wolters Kluwer • All Rights Reserved

Rheumatic Diseases Signs and Symptoms, cont’d Copyright © 2017 Wolters Kluwer • All Rights Reserved

Rheumatic Diseases Course and Prognosis RA Function declines with severity 20% adults remission 1st yr Majority will dev chronic progressive disease 70% - 90% of JRA satisfactory recovery; small chance of recurrence as adult Women dx prior age 50 worst prognosis dev severe / chronic form of RA Copyright © 2017 Wolters Kluwer • All Rights Reserved

Rheumatic Diseases Course and Prognosis, cont’d OA Faster progression in distal joints Greater BMI = rapid progression Osteophytes and sclerosis = greater progression Joint replacement improves prognosis Fibromyalgia Non-progressive Can begin widespread or unilaterally to bilaterally Copyright © 2017 Wolters Kluwer • All Rights Reserved

Rheumatic Diseases Course and Prognosis, cont’d Gout Untreated = very progressive / destructive to joints Tx early = long-term effects can be eliminated Episodic and chronic Copyright © 2017 Wolters Kluwer • All Rights Reserved

Rheumatic Diseases Medical / Surgical Management RA Managing factors: Pain / joint stiffness Reduce edema Preserve normal joint function Min medication side-effects Maintaining ADL independence Disease-modifying antirheumatic drugs (DMARD) Copyright © 2017 Wolters Kluwer • All Rights Reserved

Rheumatic Diseases Medical / Surgical Management, cont’d RA, cont’d Glucocorticosteroids Tumor necrosis factor (TNF) inhibitor OA Nonsteroidal anti-inflammatory drugs (NSAIDs) COX-inhibiting nitric oxide donators (CINODs) Copyright © 2017 Wolters Kluwer • All Rights Reserved

Rheumatic Diseases Medical / Surgical Management, cont’d Fibromyalgia NSAID Opioids Most effective: antidepressants / neuromodulating antiepileptic medications Gout NSAIDs Xanthine oxidase inhibitors (XOI) tx hyperuricemia Copyright © 2017 Wolters Kluwer • All Rights Reserved

Rheumatic Diseases Impact on Occupational Performance Mobility Gripping feeding utensils Loss of leisure participation Sexual activity Pet care Work performance Copyright © 2017 Wolters Kluwer • All Rights Reserved