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Chapter 1: Conservative and Surgical Management of the Osteoarthritic Hand and Wrist, 3rd Edition 1 [2 Contact Hours] The course offers practitioners in-depth knowledge of several of the most common medical and evidence-based treatments for wrist and hand osteoarthritis and provides instruction for application of techniques in OT evaluation and intervention. Chapter 2: Differential Diagnosis for Headaches and Cervical Spine Pain 26 [3 Contact Hours] When evaluating head and neck pain in physical therapy, we must recognize that many conditions share similar signs and symptoms. This course presents information to help the evaluating clinician determine when a client’s symptoms may be the result of systemic or viscerogenic causes and when referral to another healthcare provider is indicated. In addition, this course presents a framework for differentiating and assigning the appropriate diagnosis for neuromuscular and/or musculoskeletal conditions. Chapter 3: Frozen Shoulder Management and Manual Treatment Strategies 68 [2 Contact Hours] Shoulder dysfunctions causing painful stiffness are endemic issues, causing clinical challenges and conflicting treatment guidelines. Common terminology of frozen shoulder and adhesive capsulitis share significant and long duration impairments. This advanced course reviews pathophysiology of these conditions, the natural history associated with idiopathic frozen shoulder and essential assessment findings. Based on updated scientific evidence, a review and compilation of available interventions of conservative, medical and invasive options is presented. The role of manual therapy methodology is featured. Due to variability in patient progress and manual therapy approaches, specific guidelines on type, timing, position and amplitude are investigated to standardize joint mobilization efforts. Finally, treatment program principles of patient education, suggested number of visits, daily clinical visit structure, management of plateaus and beneficial integration with medical/invasive procedures are discussed. The purpose of this course is to provide clinicians with an evidenced- based approach on treating frozen shoulder and associated conditions. Chapter 4: Therapeutic Exercise and the Older Adult: An Evidence-Based Approach, 3rd Edition 81 [2 Contact Hours] This intermediate-level course is designed to educate occupational and physical therapy practitioners on the implementation of exercise prescriptions in older adults. This course will review the multiple age-related systemic changes that take place in the cardiovascular, respiratory, endocrine, interstitial and musculoskeletal systems and describe how exercise may mitigate these changes. This course will also provide recommended exercise programs according to the most recent American College of Sports Medicine guidelines for older adults and discuss common barriers for exercise participation in older adults. It will also describe how changes after an exercise intervention can be measured by providing several clinical measures that can routinely and easily be implemented in clinical practice. Finally, this course will discuss special concerns, such as the need for medical screening prior to establishing a new exercise program, and special considerations when recommending exercise for individuals with comorbid conditions common in older populations, such as osteoarthritis, chronic pain, diabetes, dementia, and obesity. At the end of this course, practitioners should be able to comfortably recommend, implement, and evaluate a comprehensive exercise program for older adults. Chapter 5: Therapeutic Yoga after Knee Replacement 110 [1 Contact Hour] Knowledge of safe and effective evidence-based yoga poses for knee rehabilitation can assist physical therapists in prescribing therapeutic exercises after Total Knee Replacement. Final Examination Answer Sheet 124
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PHYSICAL THERAPY CONTINUING EDUCATION
Book Code: PTNY1024
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Book Code: PTNY1024
PHYSICAL THERAPY CONTINUING EDUCATION
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PHYSICAL THERAPY CONTINUING EDUCATION
Book Code: PTNY1024
Chapter 1: Conservative and Surgical Management of the Osteoarthritic Hand and Wrist, 3rd Edition 2 Contact Hours
By: Erin K. Peterson, DHSc, OTR, CH Learning objectives After completing this course, the learner will be able to: Recognize the etiology and pathophysiology of osteoarthritis (OA) of the hand and wrist. Explain the process and criteria for reaching a clinical diagnosis of OA. Identify the goals and treatment options for managing OA. Course overview This intermediate-level course provides rehabilitation practitioners with a detailed overview of the pathophysiology and mechanics of the joints of the hand of those diagnosed with osteoarthritis (OA). Both occupational therapists (OTs) and physical therapists (PT) are trained initially as generalists in understanding the signs and symptoms of OA, the functional implications of the condition, and basic methods of intervention. An intimate knowledge of this condition and its treatment, typically reserved for those who specialize in hand therapy, will become paramount for generalists, too. With an aging American population, and based on the percentage of older adults affected, will come an increase in the number of individuals Implicit bias in healthcare Implicit bias significantly affects how healthcare professionals perceive and make treatment decisions, ultimately resulting in disparities in health outcomes. These biases, often unconscious and unintentional, can shape behavior and produce differences in medical care along various lines, including race, ethnicity, gender identity, sexual orientation, age, and socioeconomic status. Healthcare disparities stemming from implicit bias can manifest in several ways. For example, a healthcare provider might unconsciously give less attention to a patient or make assumptions about their medical needs based on race, gender, or age. The unconscious assumptions can lead to delayed or inadequate care, misdiagnoses, or inappropriate treatments, all of which can adversely impact health outcomes. Addressing
Determine an occupational therapy intervention plan for management and treatment of OA of the proximal and distal finger joints. Differentiate an occupational therapy intervention plan for the management and treatment of OA of the carpometacarpal thumb joint. Construct an occupational therapy intervention plan for the management and treatment of OA of the wrist. experiencing the signs, symptoms, and occupational disruptions associated with OA. The focused content on hand and wrist OA offered in this course provides the practitioner with the tools needed to assist clients in decreasing pain and deformity, while enhancing function. The course offers practitioners in-depth knowledge of several of the most common medical and evidence-based treatments, and it provides instruction for the application of techniques in evaluation and intervention. These include specific interventions, physical agent modalities, orthoses (splints), adaptive equipment, and joint protection to allow clients to engage in meaningful daily occupations. implicit bias in healthcare is crucial for achieving equity in medical treatment. Strategies to combat these biases involve education and awareness programs for healthcare professionals. These programs help individuals recognize and acknowledge their biases, fostering a more empathetic and unbiased approach to patient care. Additionally, implementing policies and procedures prioritizing equitable treatment for all patients can play a pivotal role in reducing healthcare disparities. Ultimately, confronting implicit bias in healthcare is essential to creating a more just and equitable healthcare system where everyone receives fair and equal treatment regardless of their background or characteristics.
Occupational Therapy Association [AOTA], 2020), similarly, PT is focused on improving quality of life through prescribed exercise, hands-on care, and patient education. (American Physical Therapy Association [APTA], n.d.). To help clients with OA achieve their highest level of function within these areas of occupation, practitioners use a range of treatment approaches that affect a variety of underlying factors and skills. Both physical/occupational therapists (PT/OTs) and physical/ occupational therapy assistants (PTA/OTAs) are trained initially as generalists in understanding the signs and symptoms of OA, the functional implications of the condition, and basic methods of intervention. An intimate knowledge of this condition and its treatment, typically reserved for those who specialize in hand therapy, will become paramount for generalists, too. With an aging American population, and based on the percentage of older adults affected, there will be an increase in the number of individuals experiencing the signs, symptoms, and occupational disruptions associated with OA. The focused content on hand and wrist OA offered in this course provides the practitioner
Osteoarthritis (OA), also known as degenerative joint disease (DJD), is the most common form of arthritis found in the hand and upper extremity (Arthritis Foundation, n.d.; Lubahn et al., 2011). As many as 54.4 million Americans—or approximately 28% of the adult population—are affected, most of whom are over the age of 45 (Guglielmo et al., 2019). Characterized by loss of the articular cartilage of a joint, OA can lead to stiffness, bony sclerosis, capsular thickening, pain, and disability. Impaired movement of the joints, as well as disuse and weakness resulting from pain, can lead to significant limitations in occupations such as self-care, work, leisure, and social participation (Taylor et al., 2011). Physical and occupational therapy (PT/OT) practitioners are instrumental members of any healthcare team seeking to facilitate quality of life for individuals experiencing the signs and symptoms of OA. Offering a holistic approach to client care, OT is concerned with the ability of the client to engage in all desired life occupations, including self-care, care of others, work, play, leisure, social participation, rest, and sleep (American
Book Code: PTNY1024
with the tools needed to assist clients in decreasing pain and deformity, while enhancing function. This intermediate-level course provides therapists with a detailed overview of the pathophysiology and mechanics of the joints of the hand of those diagnosed with OA. The course offers practitioners in-depth knowledge of several of the most common
medical and evidence-based treatments, and it provides instruction for application of techniques in OT evaluation and intervention. These include specific interventions, physical agent modalities, orthoses (splints), adaptive equipment, and joint protection to allow clients to engage in meaningful daily occupations.
PATHOPHYSIOLOGY OF OSTEOARTHRITIS
Cartilage is a stiff connective tissue that covers the articular bony surfaces in joints, providing a nearly frictionless, gliding surface. In addition to reducing friction during movement, cartilage functions to disperse forces of compression during mechanical loading of the joint. Cartilage cells fit snugly within a fibrous matrix made up of collagen fibers and are embedded in a stiff, water-based ground substance. In addition to water, the ground substance contains dissolved salts, proteins, lipids, and interwoven proteoglycan molecules. The collagen fibers, which account for nearly 50% of the cartilaginous matrix, are strengthened and held in place by long proteoglycan molecules (Wang & He, 2018). In adulthood, cartilage cells (i.e., chondrocytes and chondroblasts) become relatively inactive metabolically and have a limited vascular supply. As a result, the cartilage cells have difficulty healing, which can lead to arthritic joint changes. OA results when changes within joint cartilage lead to a reduction in both joint lubrication and the cushion that protects bone ends (Figure 1). Risk factors for OA in the hands and wrists are multiple and include overuse, genetic predisposition to collagen breakdown, prior fractures, significant disuse of a joint, prior surgical intervention, and congenital defects (Dewing et al., 2012). Individuals who have congenital joint abnormalities or joint hypermobility have increased incidences of OA, as do individuals employed in highly repetitive work, particularly work involving resistance. Systemic conditions such as hemochromatosis and Wilson’s disease can contribute to development of OA of the hand or wrist (Dewing et al., 2012). Other conditions, including hemophilia and sepsis, create trauma within the joint, disrupt the collagen matrix, and can lead to development of OA (Dewing et al., 2012). Figure 1: Joint Structure
research also suggests that breakdown of the articular cartilage in OA results from biochemical and cellular changes in addition to mechanical factors (Sovani & Grogan, 2013). Genetics have also been shown to play a role in the occurrence of OA, with a higher prevalence noted in those who have positive family histories for the condition (Tschon et al., 2021). Women have higher susceptibility and prevalence than men, particularly women older than age 50, due to the onset of menopause and bone density changes (Tschon et al., 2021). Results from recent studies emphasize the association of OA with obesity. Although obesity is understood universally to impact load- bearing joints, metabolic factors associated with obesity can also cause development of OA in the non-load-bearing joints of the hand and wrist (Gabay & Gabay, 2013; Wang & He, 2018). The joints most commonly associated with painful and function- limiting OA are the load-bearing joints of the hip and knee and the small joints of the hand. The distal interphalangeal joints (DIP) and the carpometacarpal (CMC) joints of the thumb are the most symptomatic when OA develops (Figure 2). It is difficult for individuals who have OA in the hands to avoid constant trauma to the joints because of the inevitable need to use the hands for most daily functions. For example, if a person with OA of the lower body and the hand requires use of a walker, cane, or crutch due to pain or weakness, forces generated on the arms and hands by use of the assistive device can put excessive stress on the upper extremities and lead to greater degrees of hand and wrist pain and disability (Beasley, 2012). Figure 2: Hand Osteoarthritis
Note . “Erosive osteoarthritis” by Mikael Häggström, used under Creative Commons License CC0 1.0. Identifying the cause of OA continues to be elusive despite its long diagnostic history and extensive research. There is no known cure, and symptom management—including surgical, pharmacological, and therapy approaches—are the primary means of alleviating discomfort and preserving occupational participation. The culprit in the development of OA is defective collagen (Heinegård & Saxne, 2010). When the proteoglycans that give articular cartilage its stiffness are compressed, collagen becomes brittle and more susceptible to injury, especially from forces of mechanical loading. According to Heinegård and Saxne (2010), molecular processes elicited in the cartilage might then initiate a cycle in which the quality of the matrix is downgraded
Note . “Arthritis” by OlafJanssen, used under Creative Commons License BY-SA 3.0 / Cropped from original. In the literature, OA is known by several names, including osteoarthrosis, degenerative joint disease (DJD), and hypertrophic OA. Lubahn and colleagues (2011) point out that the term osteoarthropathy might be most accurate for the condition, since OA does not involve the amount of inflammation typical of other arthritic conditions. OA is thought to be a condition associated exclusively with aging and wear, but
Book Code: PTNY1024
by proteolysis, along with removal of matrix components. Although this increases sensitivity to mechanical load, fragments of the released molecules might induce or worsen inflammation, furthering cartilage breakdown. Progressive articular cartilage deterioration slowly causes increasing pain, stiffness, disuse, and disability. Due to thinning cartilage, decreased cartilage integrity, and bone erosion, joint space narrows and osteophytes form (i.e., osteophytosis). Osteophytes are a pattern of bony outgrowth, usually branched in form. Subchondral bone changes such as osteophytes, microfractures, and cyst formation result in abnormal bony contours. These are visible during examination on the outer surface of the hand, and they present as Bouchard’s nodes on the proximal interphalangeal joints (PIP) or Heberden’s nodes on the distal interphalangeal joints (DIP) (Kalichman &
Hernández-Molina, 2010). Aging also influences collagen health. With aging, chondrocyte cells do not respond readily to growth factor stimulation 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 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).
When a client presents with arthritic involvement in several joints, other conditions should be ruled out first, including fracture, tumor, metabolic bone disease, bursitis, tendinitis, rheumatoid disease, internal derangement, soft tissue injury, Criteria Following criteria established by the American College of Rheumatology 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 other 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 entire body) are uncommon with OA, whereas local symptoms are more typically present and often recur with prolonged activity, extensive use, and weather changes (Hunter & Lo, 2008). Joint locking or instability can occur and might indicate fragments of bone or cartilage, internal derangement, or soft- tissue weakness. Although hands and wrists are not usually affected bilaterally, there might be occasional symmetry of signs and symptoms. Inflammation, 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
and viral infection (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 “classifying 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 investigators 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 mechanics, gymnastics, and playing musical instruments might cause such tissue damage to the hand and wrist. management plans. For example, the medication routine of a client cannot 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, phenobarbital, 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., furniture, 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 movements? ● 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?
Book Code: PTNY1024
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 inspected for bony alignment, redness, swelling, and bony asymmetries. Proximally, Bouchard’s nodes, which are bony nodules on the PIP joints, might be found (Figure 3). Distally, Heberden’s nodes, presenting 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). Limited joint range of motion and pain in response to movement are reliable indicators of OA. Physicians, OTs, and PTs can administer the following examinations during the diagnostic process: ● Active range of motion (AROM) measurements should be taken using appropriately sized wrist and finger goniometers. A surface- or dorsal-based goniometer provides more expedient assessments in comparison to taking lateral measurements of the wrist and fingers (MacDermid, 2015). When measuring AROM of a digit, the proximal joint should be stabilized to give accurate measures of the distal joint. When measuring DIP flexion, the PIP can be stabilized either in extension or in flexion to encourage full gliding of the flexor digitorum profundus (FDP; see Figure 6). Figure 3: Bouchard’s Node
Figure 5: Enlarged Joints in Diffuse Osteoarthritis of the Hand
Source: Erin Peterson
FIGURES 6a-g: ACTIVE RANGE OF MOTION MEASURES OF SELECTED JOINTS Figure 6a: DIP Flexion
Source: Erin Peterson
Note . “Heberden-Arthrose” by Drahreg01, used under Creative Commons license BY-SA 3.0 / Circle added. Figure 4: Heberden’s Node
Figure 6b: PIP Flexion
Source: Erin Peterson
Source: Erin Peterson. Note: Heberden’s nodes at radial and ulnar index DIP and ulnar long DIP.
Book Code: PTNY1024
Figure 6c: MCP Flexion
Figure 6f: Wrist Radial Deviation
Source: Erin Peterson
Figure 6d: Wrist Flexion
Source: Erin Peterson
Figure 6g: Wrist Ulnar Deviation
Source: Erin Peterson
Figure 6e: Wrist Extension
Source: Erin Peterson
● Passive range of motion (PROM) should be tested gently. Although this assessment might appear similar to testing active motion, the therapist is providing the movement and assessing the point at which the end feel is evident (Figure 7). The clinician should check for normal capsular end feel and pain.
Source: Erin Peterson
Book Code: PTNY1024
Figure 7: Passive Range of Motion: Hyperextension of the Metacarpophalangeal Joint
Figure 8b: Using a Pinch Meter
Source: Erin Peterson
Source: Erin Peterson ● Strength testing should be performed using manual muscle test techniques and/or a handheld dynamometer and pinch meter to determine grip and pinch strength of the hand and fingers. The standard position of the client should be client seated, shoulder at zero degrees flexion and abduction, elbow flexed at 90 degrees, and forearm in neutral; client instructed to squeeze dynamometer as pictured (Figure 8; MacDermid, 2015). ● Palpation should be done for any other swelling that might be present, such as in the palmar fascia (Figure 9). ● Gentle pressure should be applied simultaneously on two sides (i.e., medial/lateral and/or volar/dorsal) of the joint (Figure 10) to determine the presence of pain or discomfort, which is a positive sign of joint swelling (Cooper, 2020). When performing the physical examination, the therapist should remember that the inflammation that is often present in rheumatoid arthritis is not necessarily found in OA. Typical joints affected by rheumatoid arthritis include the MCPs, wrists, elbows, shoulders, and ankles, often in a symmetrical pattern not always seen in OA. During range of motion testing and other functional assessment tests of the physical examination, the therapist might observe crepitus as bony surfaces move against each other in the joint. Crepitus is a grinding, grating, clicking, or cracking noise. In the case of OA, crepitus can be heard when the joint or bone ends come together and grind against one another. If crepitus is not accompanied by pain or limitation of movement, it is of no clinical significance. FIGURES 8a-b: STRENGTH MEASUREMENTS Figure 8a: Using a Dynamometer
Figure 9: Palpating Palmar Fascia
Source: Erin Peterson
Figure 10: Palpating a Joint Using Lateral Pressure
Source: Erin Peterson
Source: Erin Peterson
Book Code: PTNY1024
Radiology Diagnosis of OA of the hands and wrist is determined primarily by clinical presentation. However, radiological tests can confirm a diagnosis in questionable cases, and are helpful in ruling out other conditions. Plain x-rays showing the presence of asymmetric joint space narrowing, increased subchondral density (that appears white on film), new bone cell formation, marginal bony growths (i.e., bone spurs), or joint subluxation can be helpful when there is a diagnostic question (Khorashadi et al.,2012). Laboratory tests No laboratory tests can pinpoint a diagnosis of OA, but joint fluid aspiration can be used to rule out other conditions that
Joint space narrowing and the presence of marginal osteophytes on an x-ray are key diagnostic features in OA. Although imaging might confirm an OA diagnosis or evaluate its severity, a normal radiograph does not rule out OA in its early stages, just as a standard x-ray might not reveal evidence of a suspected fracture until it is reevaluated a week or so later when evidence of fracture healing is observed (Khorashadi et al., 2012). Only one-third of those who have x-ray evidence of decreased joint cartilage exhibit pain or limited range of motion (Khorashadi et al., 2012; O’Neill & Felson, 2018).
create joint pain. When no other disease is present, the synovial fluid of an osteoarthritic joint is clear (Khorashadi et al., 2012).
GOALS AND TREATMENT OPTIONS IN MANAGING OSTEOARTHRITIS
When working with clients experiencing the signs and symptoms of OA, each health professional will establish goals pertinent to their specialty in concert with the goals of the client. Generally, all health professionals have goals that include: ● Maintenance or restoration of daily function. ● Reduction or elimination of pain. ● Maximization of joint function. ● Diminishment of stiffness and improvement in dexterity. ● Improvement in mobility. ● Client empowerment through education and environmental adaptations. As with any treatment team approach, the physician, OT, or PT working with a client who is experiencing hand and wrist OA must coordinate management, goals, and content to capitalize on the teaching principle of repetition of information and avoid giving the client conflicting information. Client education is critical and should be a priority for all health professionals. Helping a client understand that there are ways to improve their functional ability is a large part of any management program. The Arthritis Foundation publishes a web page dedicated to OA that can be recommended to clients and can be used by professionals. The Agency for Healthcare Research and Quality developed its Chronic Disease Self-Management Program for Conservative medical management As with OA in other joints, OA of the hand has multiple causes and leads to deformities and limitations that vary from client to client. The medical management approach must be tailored to each individual. Depending on the localization of the OA, the erosive/nonerosive pattern, the degree of pain and disability, and the client’s perception of pain and functional impact, various therapeutic approaches can be used (Gabay & Gabay, 2013). As described by Gabay and Gabay (2013), the management of hand OA includes both pharmacological and nonpharmacological methods. Nonpharmacological methods include: ● Education such as teaching methods for pain reduction, joint protection, and work simplification. ● Exercise and yoga to maintain strength and flexibility, as well as joint health. ● Nutrient/herbal supplements such as glucosamine, chondroitin sulfate, and curcumin—despite mixed evidence concerning their effectiveness (Sawitzke et al., 2008; Zeng et al., 2021). Physical rehabilitation OTs work with clients diagnosed with OA who are experiencing limitations in occupational participation in several ways. OTs assist the client (and the client’s family, as indicated) to use tools, establish realistic goals, and retain a lifestyle despite the presence of disease or disability. OTs also assist clients by designing adaptive equipment, assistive devices, and orthoses to decrease pain and prevent stress on weakened joints. Like
people with chronic conditions (Agency for Healthcare Research and Quality [AHRQ], 2020). Both programs include techniques for stress reduction, pain control, and exercise; offer instruction in self-help strategies; and should be shared with clients as part of a comprehensive program. See the Resources section of this course for more information. Confirmation of an OA diagnosis and determination of the extent of the disease and disability are the responsibility of all team members. Treatment efficacy and impact on participation are paramount to the management of OA of the wrist and hand. Methods of management include conservative medical management, PT/OT, pharmacological treatments, physical agent modalities, physical therapy interventions, and appropriate medical or surgical interventions. Team members must help their client cope with the symptoms of the condition to the fullest extent possible and may advise use of available self-help programs, if appropriate. It is the responsibility of the client—the one who must live with OA and its impact—to follow through with suggested treatment options. To enable client follow- through, education is the core of all management programs—the client must understand what OA is and what it does. The roles of interventions and professionals are described below. ● Transcutaneous electrical nerve stimulation (TENS), an electrical stimulation unit used to increase comfort in those with chronic or intractable pain (Knight & Draper, 2013). ● Therapeutic touch, including massage, as a means of reducing muscular spasms and increasing circulation for pain reduction (Knight & Draper, 2013). ● Low-level laser or high-intensity laser therapy, which can help decrease pain and reduce inflammation (Akaltun et al., 2021). Pharmacological approaches include paracetamol/ acetaminophen, conventional nonsteroidal anti-inflammatory drugs (NSAIDs), COX-2 selective inhibitors, topical NSAIDs, topical capsaicin, symptomatic slow-acting drugs for OA (SYSADOA), intra-articular corticosteroids, and intra-articular and hyaluronic acid preparations (Gabay & Gabay, 2013). The use of topical NSAIDs such as diclofenac gel yields significant improvement of pain and function compared to placebo trials (Wolff et al., 2021). physical therapists, OTs focus on the client-centered, long-term goals of reducing pain and improving function. The role of the OT also involves prevention of future deformity, future pain, and further occupational dysfunction. The OT evaluates all aspects of functional performance in context to design treatment plans that prevent future difficulties.
Book Code: PTNY1024
OTs have special knowledge of assistive devices that can be used to simplify work, reduce energy expenditures, and provide creative solutions to enhance client independence. (See Appendix A.) OTs can also assist the client with managing any psychological symptoms associated with having a chronic, painful condition. Clients might exhibit depression and limited motivation for engagement if they are in chronic pain or believe engaging in the community exacerbates painful symptoms. Evaluation of client abilities, family and social support systems, financial needs, and the home environment makes it possible to tailor OA management to each situation. Individualized treatment involves obtaining a detailed assessment of a client’s hands and wrists; their pain; the impact of OA on their ADL, home, and work environments; and any specialized tasks they need to perform. Helping a client focus on abilities and strengths, rather than disabilities and weaknesses, is an essential component of the OT’s role (AOTA, 2020). Hand and wrist OA might make it difficult for a client to get dressed, tie shoelaces, handle clothing during toileting, make beds, prepare meals, open jars, and handle money. Use of reachers, buttonhooks, elastic shoelaces, and other items enables a client to perform ADL without additional assistance, and enables the client to retain dignity and independence. Creative modification of kitchen, gardening, and work utensils by building up handle thicknesses or improving ergonomic alignment can greatly diminish stresses on the hand and wrist. OTs work with clients to fabricate custom orthoses to ensure that joints are positioned neutrally and avoid further irritation when functioning or sleeping. Some OTs and PTs specialize in the treatment of the hand and wrist. Hand therapy is a combined specialty of both OT and PT, each providing similar treatments that include physical agent modalities to help with pain relief or stiffness. When joints are stiff and painful, OTs assist clients with using paraffin baths, fluidized therapy units, and warm-water baths to help improve range of motion (ROM). OTs and assistants do not need to be specialized to work with those experiencing OA, but should be well versed in the condition and competent in all techniques and modalities. This section discusses the role of the OT—from both a conservative and a postsurgical viewpoint—when working with clients with OA of the proximal and distal finger joints, thumb CMC joint OA, and wrist OA. Therapeutic evaluation The first step in the treatment of OA is to determine the occupations in which the client needs or wants to engage and to identify those that are difficult due to OA. This part of the assessment is known as the occupational profile (AOTA, 2020). As mentioned in the physical examination section, the therapist should assess pain, ROM, strength, and the presence of deformities of the hands/wrists. Several psychometrically sound tools (i.e., outcome measures) are available on the market or otherwise freely available for assessments of these areas. Some of the more popular tools include the Canadian Occupational Performance Measure (COPM), used to assess a client’s perceived performance and satisfaction in all areas of occupation (Law et al., 2014); the Disabilities of Arm, Shoulder, and Hand assessment (DASH), which allows a client to identify areas in which the pathology is limiting function (Kennedy et al., 2011); and the Manual Ability Measure-20 (MAM-20), which allows a client to choose their level of function within 20 predetermined areas (Chen & Bode, 2010). MAM- 20 also includes a pain scale. The therapist must next determine the cause of the challenges from a client factor or skill perspective. The OT assesses the factors and/or skills either separately or in the context of occupations themselves to determine the best course of treatment. This assessment is known as analysis of occupation (AOTA, 2020). A number of tools are used to assess client factors (e.g., ROM and strength) and their effect on impaired occupational participation. For example, goniometry
assesses ROM; a visual analogue pain scale determines degree of discomfort; and tools to assess strength, including dynamometers and pinch meters, determine whether muscle weakness contributes to dysfunction. When assessing motion, the therapist should know whether a subluxed joint is reducible or if the deformity is fixed. Severe joint destruction with fusion and/or osteophytes can create lack of joint movement and give a bone-on-bone end feel when passive movement is attempted. Pain scales are also effective at determining a client’s response to treatment by getting a before and after assessment of pain. These measures are also effective tools for the client to use at home to gain better understanding of the factors that influence pain, both positively and negatively. Provocative tests are another way for the PT or OT to determine the extent of joint damage or pain, and to make a differential clinical diagnosis. The grind test, shown in Figure 11, provides both objective and subjective data in the form of client reports of pain and the feel or auditory phenomenon of crepitus experienced by the therapist (Badia, 2011). The test is performed as the therapist securely places the forearm of the client in neutral rotation and grasps and secures the wrist from a radial approach. The therapist holds the MCP and proximal phalanx of the thumb with the opposite hand. While pressing the metacarpal into the trapezium, the therapist moves the joint in a rotary motion—to grind the joint. The client is asked to report pain; the presence of pain indicates that the grind test is positive for joint cartilage change (Badia, 2011). Figure 11: The Grind Test
Source: Erin Peterson Finkelstein’s test assists with a differential diagnosis to ensure De Quervain’s stenosing tenosynovitis is not the reason for pain at the base of the thumb. Symptoms of De Quervain’s can be similar to CMC OA, but CMC OA does not typically include pinpoint pain at the base of the thumb, radiated proximally, or present with swelling at the base of the wrist in the area of the radial styloid. Finkelstein’s test (Figure 12) is typically positive for De Quervain’s but negative for OA. Finkelstein’s
Book Code: PTNY1024
test is performed by having the client hold a flexed thumb in their palm with the digits fisted (Cooper, 2020). The wrist is then ulnarly deviated while keeping the thumb in the palm. A sharp pain extending along the thumb and into the radial wrist is a positive result, and could indicate De Quervain’s stenosing tenosynovitis. For some individuals, pain is naturally present during this maneuver, but is typically experienced to a lesser degree than in the presence of tenosynovitis. It is advisable to compare a client’s pain levels with pain levels on the noninvolved side, if possible, to determine whether the pain is indicative of an inflammatory condition. Figure 12: Finkelstein’s Test
If wearing the orthosis causes difficulties with tasks requiring a tight pinch or grasp pattern, adapted devices should be issued or recommended to the client. Such devices might be large-diameter pens or the addition of plastic or foam tubing to increase the diameter of a pen or pencil. The handles of devices and utensils such as hairbrushes, toothbrushes, and kitchen tools can be modified easily in this way to increase functionality. In cases in which acute inflammation and edema are present, edema management techniques such as light retrograde massage, wearing compression gloves and sleeves, and gentle lymphatic stimulation exercises (e.g., diaphragmatic breathing, active trunk and cervical rotation exercises) can help to reduce and manage subsequent edema (Priganc et al., 2020). Compression gloves and sleeves made of nylon/spandex can be used in conjunction with an orthosis during wear as needed, especially because the neutral warmth of the glove or sleeve may reduce morning joint stiffness and decrease pain (Hammond et al., 2016). When acute pain subsides, the client in the subacute stage of OA can continue to experience stiffness and pain with overuse or straining of the joint. For this reason, it is important for the client to be educated on joint protection techniques and to use orthoses as needed due to the likelihood that pain will reoccur on return to heavy use of hands for daily activities. Clients with known subacute OA should consider the use of adaptive equipment and convenience tools when possible. Examples of adaptive equipment include built-up handles; lighter-weight cookware; and devices that reduce the need to pinch, such as spring-loaded scissors. Convenience tools reduce time and exertion, and are available commercially. Examples include mini electric food choppers, electric knives, electric can openers, electric screwdrivers, and light handheld electric mixers. The evaluation and intervention for specific joints for conservation and postsurgical management are discussed further in the sections on OA of proximal and distal finger joints, thumb, and wrist. Physical therapy provides a way to reduce pain, improve flexibility, strengthen muscles, increase endurance, and improve functional mobility. PTs also assist clients in improving body mechanics and posture, and develop strategies to manage OA daily, particularly OA in the larger joints of the body such as the hip, knee, and shoulder. Practitioners assess flexibility, muscle strength, physical functioning, mobility, and ambulation. Treatment might include instruction in exercises to improve joint ROM, endurance, and muscle strength, as well as gentle oscillatory joint mobilization, which can ease painful joints and enhance pain-free joint mobility. Low-impact aerobic conditioning exercises such as walking, bicycling, and swimming help decrease pain and functional disability, and help establish correct body weight, which is important to managing OA of hips and knees (Katz et al., 2021). When joints are inflamed, clients can perform isometric exercises designed to strengthen muscles while avoiding joint motion. PTs also work with the hand and wrist, but typically do so in the specialty practice of hand therapy. Hand therapy is a subspecialty of both physical and occupational therapy. Both disciplines contribute to the knowledge base of those who identify as hand specialists, and each discipline learns and uses the theories and techniques of the other for best client outcomes. According to the Hand Therapy Certification Commission (HTCC), approximately 87% of hand therapy specialists are occupational therapists (HTCC, 2022). Information specific to occupational therapy of the hand and wrist is expanded further in a subsequent section.
Source: Erin Peterson Tools that assess hand skills include the Jebson Hand Function Test, the Purdue Pegboard Test, and the Moberg Pick-Up Test (Cooper, 2020). These tools each have a structured method of administration and demonstrate reliability and validity (Cooper, 2020). In addition to known assessment tools, the therapist should use clinical observation skills. The therapist should observe the client during functional activities and note how they use the thumb and fingers. The therapist should perform cursory assessment of other joints of the hand and the more proximal upper extremity joints to determine their status and functional abilities. For example, the presence of thumb CMC joint deformity should be noted and might indicate the degree of joint involvement. The arthritic CMC joint typically has a squared appearance to the base of the thumb as it articulates with the wrist. In more advanced cases, the CMC joint may become subluxed or fused and cause the metacarpal to become fixed in an adducted position. Therapeutic intervention General treatment of OA includes the provision of custom- fabricated or prefabricated orthoses (splints), which immobilize or support the affected joint during use of the wrist and hand. When an orthosis is applied to an acutely inflamed joint, the client should be instructed to wear the device during sleep hours to reduce pain and prevent deformity. The orthosis should also be worn during daily tasks involving force or repetitive movement. The orthosis can be removed several times during the day for ice, massage, and gentle exercise to prevent contractures, and can be removed for bathing if that activity does not aggravate the joint. See Appendix B for an example template of how to document and provide patient education to a client with an orthosis.
Book Code: PTNY1024
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