age of 40, but OA is not considered a consequence of aging, nor is aging considered a risk factor (Amoako & Pujalte, 2014). OA is common in an aging population, but studies have shown that it occurs in younger groups, too, particularly among young athletes, who might show evidence of OA by the time they reach their 30s (Amoako & Pujalte, 2014).
Molina, 2010). Aging also influences collagen health. With aging, chondrocyte cells do not respond readily to growth factor stimu- lation for repair, and there is decreased ligament integrity, which results in unstable joints at increased risk for injury. There is also decreased shock absorption secondary to thinning cartilage and increased cartilage vulnerability (Leong et al., 2011). Incidences of OA increase at a rate of approximately 2% each year after the
MEDICAL DIAGNOSIS
When a client presents with arthritic involvement in several joints, other conditions should be ruled out first, including fracture, tu- mor, metabolic bone disease, bursitis, tendinitis, rheumatoid dis- ease, internal derangement, soft tissue injury, and viral infection Criteria Following criteria established by the American College of Rheu- matology for diagnosing OA of the hand and wrist results in a diagnostic accuracy of 94% and an 87% ability to identify the type of arthritis. Criteria include assessing symptoms of pain, aching, or stiffness, and at least three of the following signs (Altman et al., 1990): ● Hard tissue enlargement of two or more of: ○ Third distal interphalangeal (DIP) joints. ○ Second and third proximal interphalangeal (PIP) joints. ○ First carpometacarpal (CMC) joints of both hands. ● Hard tissue enlargement of two or more DIP joints. ● Fewer than three swollen metacarpophalangeal (MCP) joints. ● Deformity of at least one of the above ten selected joints. Client history Client history is an important component of medical diagnostics completed by physicians and treatment diagnoses made by oth- er healthcare providers such as PTs/OTs. Client reports of past injuries, lifestyle choices, vocational interests, and incidences of pain and dysfunction assist with determining the type of arthritic condition present. A client with OA most often seeks treatment when pain, stiffness, and limited movement interfere with usual and desired activities. As the disease progresses, clients report an increase in pain due to joint aggravation resulting from even light activities and pain that continues to be present at rest and during the night (Zhang et al., 2009). Clients with OA typically report stiffness and pain when rising in the morning, usually resolving within 15 to 30 minutes following movement. Constitutional symptoms (i.e., those affecting the en- tire body) are uncommon with OA, whereas local symptoms are more typically present and often recur with prolonged activity, ex- tensive use, and weather changes (Hunter & Lo, 2008). Joint lock- ing or instability can occur and might indicate fragments of bone or cartilage, internal derangement, or soft-tissue weakness. Al- though hands and wrists are not usually affected bilaterally, there might be occasional symmetry of signs and symptoms. Inflamma- tion, as evidenced by fluid collection, warmth, or erythema (i.e., redness), is unusual but can occur following insult or overuse of a joint (Dewing et al., 2012). Many clients presenting with OA have other medical problems that must be evaluated for their potential to complicate manage- Physical examination OA of the hand and wrist is considerably troublesome to clients who have OA because hands are used extensively for daily tasks. It is especially disabling when movement at the base of the thumb and distal fingers is restricted. Pain increases during gripping or pinching movements, which interferes with activities of daily living (ADL), work, and leisure. The hands and wrists should be inspect- ed for bony alignment, redness, swelling, and bony asymmetries. Proximally, Bouchard’s nodes, which are bony nodules on the PIP
(Papadakis et al., 2017). Once eliminated, the following criteria, established by the American College of Rheumatology, establish a medical diagnosis.
OA is classified as Type I (primary) or Type II (secondary). Primary OA is idiopathic, or without known cause, and it might affect the hand or wrist. Based on studies that demonstrate multiple causes of primary OA, Herrero-Beaumont et al. (2009) propose “clas- sifying Primary OA into 3 distinct although interrelated subsets: type I OA, genetically determined; type II OA, estrogen hormone dependent; and type III OA, aging related” (p. 71). Secondary OA results from previous joint damage caused by metabolic, anatomic, traumatic, or inflammatory incidents. Some investiga- tors report that OA occurs in up to 40% of individuals suffering significant joint injury, and might result from the body’s attempts to heal damaged tissues (Tschon et al., 2021). Mechanical forces and repetitive activities such as boxing, carpentry, auto mechan- ics, gymnastics, and playing musical instruments might cause such tissue damage to the hand and wrist. ment plans. For example, the medication routine of a client can- not be overlooked. Drug use, particularly in the elderly, should be examined in terms of its potential effects on sensory systems such as vision, hearing, and balance, as well as functional skills such as executive functions and mobility that, when impaired, can lead to functional decline. Possible interactions of all medications must be considered. For example, neomycin, mineral oil, phenobarbi- tal, and certain cholesterol-reducing drugs diminish absorption of vitamin D, which might increase OA progression (Huang et al., 2012). Questions to ask when taking a client history/occupational profile include: ● What activities do you find hard to do now that you were able to do easily in the past? ● Do you use a cane or walker, or hang on to supports (e.g., fur- niture, walls, handrails) more often than you used to? Does use of these supportive devices increase symptoms in your hands? ● What bothers you most about the changes with your hands that you are experiencing? ● What activity of daily living or job do you do (or did you do in the past) that requires (or required) repetition of similar move- ments? ● Name all medicines you are taking, including those you buy without a prescription. ● Have you ever had a broken bone or surgery on a bone? ● Do you have any other medical problems? joints, might be found (Figure 3). Distally, Heberden’s nodes, pre- senting as hard nodules or enlargements on the DIP joints, might be observed (Figure 4; Kalichman & Hernández-Molina, 2010). The general appearance of a hand with diffuse OA of the PIP and DIP joints can change, even without the presence of large nodes. The joints take on an enlarged appearance when compared to the size of the phalanges (Figure 5).
Page 68
Book Code: PTCA2624
EliteLearning.com/ Physical-Therapy
Powered by FlippingBook