Conditions in Occupational
Therapy
5th edition
Ben J. Atchison and
Diane Powers Dirette
_____________________________________________________________________
Chapter 23:
Rheumatic Diseases
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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
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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
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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
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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
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Rheumatic Diseases Etiology
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Rheumatic Diseases Etiology
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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
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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
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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
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Rheumatic Diseases Etiology, cont’d
•
Systemic lupus erythematosus

Unclear etiology

Autoimmune disorder

Impact on joints similar to RA
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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
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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%
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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
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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
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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
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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)
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Rheumatic Diseases Signs and Symptoms, cont’d
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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
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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
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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
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Rheumatic Diseases Signs and Symptoms, cont’d
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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
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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
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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
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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)
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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)
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Rheumatic Diseases Medical / Surgical Management, cont’d
•
Fibromyalgia

NSAID

Opioids

Most effective: antidepressants / neuromodulating
antiepileptic medications
•
Gout
 NSAIDs
 Xanthine oxidase inhibitors (XOI) tx hyperuricemia
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Rheumatic Diseases Impact on Occupational Performance
•
Mobility
•
Gripping feeding utensils
•
Loss of leisure participation
•
Sexual activity
•
Pet care
•
Work performance
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