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Osteoarthritis
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Osteoarthritis (OA), or degenerative joint disease, is the most common form of arthritis. It most often affects middle-aged and older people, involving the neck, lower back, knees, hips and fingers. Nearly 70 percent of people over the age of 70 have x-ray evidence of the disease, but only half of these people ever develop symptoms. It may also occur in joints that have suffered previous injury, been subjected to prolonged heavy use, or damaged by prior infection or inflammatory arthritis. Patients with OA experience pain and loss of function.
 
OA results from degeneration of the joint cartilage. The causes of cartilage loss are multiple. Some kinds of OA are known to be hereditary, including the common form that causes enlargement of the knuckles. Current research focuses on this genetic abnormality as well as new methods studying cells, chemistry and function of cartilage. These efforts are creating rapid progress in our understanding of OA. In most people, cartilage breakdown is due to both mechanical ("wear and tear") effects and biochemical effects.
 
OA affects more than 21 million Americans. OA is the most common type of arthritis and a leading cause of disability in the U.S. Virtually everyone over the age of 75 is affected in at least one joint. Women are generally affected at a younger age than men.
OA is suspected when pain develops in the commonly involved joints. It may be confirmed by a physical examination, x-rays and by ruling out other types of arthritis. Since it is so common, it may be present simultaneously with other types of arthritis.
 
Therapy for OA includes both medication and other treatments that help to relieve pain and improve joint function. Drug therapy should begin with simple pain relievers (acetaminophen) and progress to nonsteroidal anti-inflammatory drugs and/or intermittent corticosteroid injections. Recently, several thick liquids that resemble normal joint fluid have been approved for use by repeated injection in the knee joints. In addition, there is some evidence suggesting that some dietary constituents may have a beneficial effect.
 
Other therapies include patient education, occupational and physical therapy to restore joint movement and increase strength and aerobic capacity, reduction of weight on painful joints and application of heat and cold to relieve pain. Joint surgery to repair or replace seriously damaged joints may be required to end pain and restore functional mobili

Patient's will seek the advice of their doctor in a joint that is insidious in onset, mild to moderate in severity,worsened with use,and relieved with rest. In general,inflammation is not a common presenting factor in OA,but some patients may have synovial swelling of the affected joint.
 
Stiffness is not severe, but some patients may experience joint stiffness for as long as 15 to 30 minutes when awakening in the morning. Signs associated with OA include crepitus or the sound of bone rubbing against bone,bony hypertrophy,and tenderness.
 
With more advanced disease and joint destruction, patients may experience limited range of motion,joint malaignment, and altered gait (usually localized).
 
Osteoarthritis may be confused with rheumatoid arthrits,particularily when O.A. affects more than one joint in the body.
 
RA begins in the synovial membrane rather then the cartilage. It usually occurs earlier in life than O.A.--30's and 40's--many joints are affected,and often occurs symmetrically on both sides of the body.People generally have morning stiffness that lasts for at least an hour.( Stiffness from O.A. usually clears up sooner.)
 
X-rays show changes in the bones that differ from those occurring in O.A. In RA,blood tests often show a specific antibody,(rheumatoid factor) that is usually not present with O.A. patients.
 
E.S.R. (blood test) are often elevated in RA,but they are generally normal in O.A. RA usually do not show up in the fingertips where in osteoarthritis it is common.
 
Physical Examination--The doctor will check the patient's general health.Joints bothering patient will be examined,including checking reflexes,and muscle strength.The doctor will also observe the patient's ability to walk,bend,and carry out activities of daily living.
 
Doctors take x-rays to see how much joint damage is done.X-rays can show such things as cartilage loss,bone damage, and bone spurs.But there is often,a big difference between severity that the x-rays shows and what the patient actually have. And x-rays may not show early OA.(before much cartilage loss has taken place).
 
The doctor may take blood tests to determine the cause of symptoms and rule out other causes of arthritis like RA. Blood tests for osteoarthritis alone,are not useful. Synovial fluid may be examined with radiographic pictures of the affected joint.
 
It is usually not difficult to tell if a patient has OA. Hot,red,or tender? probabily not OA.Check with your doctor about other causes such as RA. Not everyone with OA feel pain. In fact,only a third of people with OA in their x-rays report pain or other symptoms.
 
Likely warning signs steady or intermitten pain in a joint.Stiffness after getting out of bed. Joint swelling or tenderness in one or more joints. A crunching feeling or sound of bone rubbing against bone. Pain often disappears after a short rest (non-activity) in O.A. 
 
In RA activity of the affected joints helps pain relief. Sometimes numbness or tingling in an extremity (If the arthritis had led to pressure on a nerve, e.g., in the neck or lower back.) Limited flexibility,especially after not moving for a while may be another symptom ("gelling").
 
People with OA may have non-medical ways to relieve pain such as warm towels,hot packs,or a warm bath or apply moist heat to the joint which can relieve pain and stiffness.For OA of the knee a well fitting shoe helps.
 
Many NSAIDs are used to treat OA. The two new Cox-2 inhibitors are excellent choices for OA treatment. Acetaminophen--(Tylenol) -this drug does not irrate the stomach,and less likely than NSAIDs to cause long-term side effects.Research has shown that in many patients with OA it was equal to NSAID in treatment.Doctors may recommend topical pain-relieving creams, rubs,and spray.
 
Injected corticosteriod may be injected to relieve pain temporarily.This is a short term measure for extreme pain,not recommended more than 2 or 3 times a year. Unlike RA disease modifying drugs is not employed in OA therapy. 
 
Hyaluronic acid,a new joint injection medication is used to treat OA. This substance is a normal compound of the joint,involved in joint lubrication and nutrition. Many patients experience pain relief after a series of three to five injections.
 
They are of a  temporary nature of relief,lasting 12-52 weeks and may have harmful effects on joint integrity. Irrigation of the OA knee,poses minimal local and systemic risks. For some people surgery helps relieve the pain or disability of OA.
 
Some patients seek alternative therapy for their pain and disability. Such as wearing copper bracelets,drinking herbal teas,and taking mud baths. While these practices are not harmful,some can be expensive. They also cause delay in seeking medical treatment.
 
To date,no scientific research shows these approaches to be helpful in treating OA.Nutritional supplements are often reported as helpful in treating OA. Such reports should be viewed with caution, however, since very few studies have carefully evaluated the role of nutritional supplements in OA.
 
Researchers at the University of Virginia in Charlottesville studied osteoarthritis and recently published the top treatments in The journal of Family Practise. The top treatments for reducing pain (and consequently physician visits) were exercise, physical therapy,transcutaneous nerve stimulation (TENS),patient self-education.
 
Medications recommended for reducing pain for OA,although further research comparing these therapies must be undertaken,are codeine, acetaminophen, NSAIDs and selective cyclooxygenase-2 inhibitors (coxibs).
 
Surgery for OA of the hip and knee was found to be both cost-effective and beneficial, Studies found some evidence in favour of the complementary treatments glucosamine, chondroitin,avocado/soybean unsaponifiables and acupuncture.
 
The effectiveness of other therapies,such as ultrasound,spa therapy,low-level laser therapy,therapeutic touch and electromagnetic fields, could not be determined for this study. Oddly enough, regular scheduled appointments with physicians for education purposes were found to have a worsening effect on a patient's physical functioning,rather then a beneficial one---most physicians are poor educators..
 
While intra-articular steriods for OA of the knee are recommended (so is acetaminophen) by the American College of Rheumatology,there was no evidence supporting any long-term benefit of steriod  injections (used for short-term pain relief benefit).
 
When the presence of OA is unknown such as degenerative it is referred to as Type 1. If the cause of OA is the result of injury or of a known cause it is often referred as Type 11. Several risk factors are implicated in the development of OA.
 
In addition to aging,obesity,previous joint injury,female gender (OA of the hip is found more in males),and repetitive occupational use,predisposition of genetic factors,and developmental abnormalities have been in implicated in the development of osteoarthritis.
 
The exact mechanism of OA is currently unknown,but more research studies are now being done then in the past.
 
Osteoarthritis is often described as "wear-and-tear "type of arthritis,and is more associated with older citizens. This is true of the degenerative type of arthritis. The coined phrase "live long enough and everyone will have some form of arthritis is quoted by many doctors. But (OA)osteoarthritis of the hip,for example can happen to people in their 30's and 40's.
 
 It can be painful,disabling and affect quality of life profoundly. Some will require hip replacement and some will have to have surgery more than once on the same body part.--This may apply to other body parts affected by OA in different patients as well.
 
Severity,pain and disability will depend on individual case-history. This fact also applies to many rheumatic diseases. Younger patients are often associated with sports or work-activity injury,but this is not absolute or common in that group of people.
 
 

Cartilage:
 
The primary enzymes responsible for the degradation of cartilage are the matrix metalloproteinases (MMPs) These enzymes are secretated by both synovial cells and chondrocytes and are categorized into three categories:
 
a)collagenases.
 
b)stromelysins.
 
c) gelatinases.
 
Under normal conditions, MMP synthesis and activation are tightly regulated at several levels. They are secreated as active proenzymes that require enzymatic cleverage in order to become activated.
 
Once activated,MMPs become susceptible to the plasma-derived MMP inhibitor,alpha-2-macroglobulin,and to tissue inhibitors of MMPs (TIMPs) that are also secreted by synovial cells and chondrocytes.
 
In OA,synthesis of MMPs is greatly enchanced and the available inhibitors are overwhelmed,resulting in net degradation. Stromelysin can serve as an activator for its own proenzyme,as well as for procollagenase and prostromelysin,thus creating a positive feedback loop of proMMP activation in cartilage.
 
One factor responsible for inducing metalloprotease synthesis is interleukin-1--capable of inducing chondrocytes and synovial cells to synthesize MMPs. Also,IL-1 suppressess the synthesis of type II collagen and proteoglycans,and inhibits transforming growth factor-alpha stimulated chondrocyte proliferation.
 
 The presence of IL-1 RNA and protein have been recently confirmed in OA joints. IL-1 may not only promote cartilage degradation,but may also suppress attemps at repair,in OA. Il-1 induces nitric oxide  production,chondrocyte apoptosis,and prostaglandin synthesis,which further contribute to cartilage deterioration. Under normal conditions,an endogenous IL-1 receptor antagonist regulates IL-1 activity.
 
MMPs and pro-inflammatory cytokines (e.g., IL-1) appear to be important mediators of cartilage destruction in OA. Synthesis and secretion of growth factors and of inhibitors of MMPs and cytokines are apparently inadequate to counteract these degradive forces. Progressive cartilage degradation and OA result. New therapies,focused on reducing MMP activity and on stimulating matrix synthesis,are in development.
 
Glucosamine and chondroitin sulfate, both of these niutrients are found in small quantities in food and are natural components of cartilage. Scientific studies on these two nutritional supplements have not yet shown that they affect the disease. The NIH is currently supporting a clinical trial to determine this. Patients using this therapy are cautioned to seek medical advice.
 
Many medications used in alternative therapies are unregulated and hence the danger of purity , and advertised quantity of the actual medication in manufacture. Drug interaction is also a important consideration often overlooked.
 
Vitamins C and D.Reports that vitamins C and D affect progression of the disease with high intake of vitamin C and D. More studies are needed to confirm these reports.
 
Fish Oils--Rheumatoligists say the high level of intake necessary for benefit is a major-safety- concern.More longer clinical trials are needed,despite so called , "reported  benefits".They recommend natural fish high in omega 3 content--re-safe intake.
 
A commercial testing company did some tests on some tablets sold by commercial drug companies and they concluded the amount of omega 3 content was lacking in the tablets itself. They tested numerous brands. (Currently the problem seems to be in manufacturing)
 
Patients suffering from arthritis or cartilage degeneration may soon have a minamally-invasive solution available to them in Europe. Medical device developer,SaluMedica,was recently granted authorization to apply the CE mark to its SaluCartilage product intended for cartilage repair. Th CE mark allows SaluCartilage to be distributed throughout th European Union.
 
SaluCartilage is the company's first product for use in cartilage repair applications,designed as a less invasive and more cost-effective alternate to current therapies for patients suffering from O.A.,RA,and sports injury
 
The product,a purely synthetic implant offered in a range of sizes,is made from the Company's proprietary Salubria biomaterial. Using standard arthroscopic techniques and instrumentation,damaged articular cartilage may be cored out and replaced with the synthetic cartilage to provide a smooth,load-bearing joint surface.
 
 "One of the greatest benefits of the SaluCartilage implantation is that it does not necessitate the sacrifice of healthy cartilage from the patient, although it could be used in conjunction with such a technique," explains Dr. Ku. "Even more importantantly,we expect that SaluCartilage could provide an option to those patients requirring a total joint replacement,postponing the need for this traumatic surgery."
 
The Company plans to engage one or more distribution partners with a strong presence in the European Union and other markets outside the United States to assist with the product launch.
 
 

Joints are marvellous biomechanical systems whose health is maintained by a sophisticated chemical feedback loop. Problems in any part of the joint can produce a domino effect that throws the whole system out of kilter. As we age,this remarkably resilient system loses its ability to absorb stresses it easily handled in earlier stages of life
 
Cartilage will roughen,fray,develop ulcers,and allow joint fluid to leak into subchondral bone,causing cysts to form in the marrow.
 
Subchondral bone (i.e.,bone to bone to which cartilage is attached ) may develop tiny fractures,sprout jagged spurs,form calluses,and harden.
 
Synovial cells may begin to form tiny pellets of bone and connective tissue called osteophytes. These collect in synovial fluid and peripheral areas of the joint,causing further damage and pain..
 
Synovial membranes thicken,reducing the joint space.In later stages, inflammation  occurs in the synovial membrane,causing cartilage cells (chondrocytes ) to manufacture the wrong kind of collagen (Types I and III,instead of the normal Type II )
 
This troubling picture reflects a finely tuned bio-chemical system that is out of control
 
When joint damage results from an injury,infection,or rheumatic disease,such as Ra ,it's called secondary osteoarthritis. While.osteoarthritis is generally  classified as non-inflammatory arthritis,in some patients,there is evidence of erosive-inflammatory  content involved,but in most people,it is not. Scientist are taking a closer look at osteoarthritis cause,prevention,knowledge and therapy. There is more to osteoarthritis then "wear and tear".
 
The joint pain and stiffness caused by osteoarthritis often starts with a minor annoyance. typically,the first symptom is morning stiffness in one or more joints,which lessens in about in a half--hour or less,generally. stress on affected joints can cuse pain,and range of motion may be diminished. Affected joints can stiffen into a bent position,feel tender,and become difficult to fully flex without pain. In some cases,including secondary arthritis,symptoms may "flare: suddently and then recede for a time.
 
Later,arthritic joint(s) may begin to grate,crackle,and vibrate because degenerated cartilage no longer smooths the passage of bone over bone. bonu,pelletlike osteophytes may begin to block the motion of joint. Fluid may build up,and the joint may swell and distort. These distortions start to stretch anchoring ligaments,causing joint to loosen,destablize,and produce pain. If pain discourages movement of the joint,muscles will begin to atrophy from lack of use,further destablizing the joint.

Coping Skills:
 
Custom-fitted or store-bought splints may rest an active joint or provide support to a damaged joint, and patients are willing to wear these when they are well fitted.
 
Of paramount importance is the patient's understanding of the need to adhere to a regimen over a long period. Education, delivered when the patient is receptive, is effective; this is rarely at the time of diagnosis. Typically, denial and anger precede the optimum teaching moment.
 
Physical and occupational therapists expect to be provided with the primary diagnosis for the problem they are going to treat (in practise this pattern is not usually followed ). They do not expect specific instructions or treatment recommendations but generally prefer to be allowed some discretion in developing a treatment plan based on their findings.
 
These therapists also expect the primary care physician or specialist to have achieved control of inflammation and pain through pharmacologic means where possible. A patient with ankylosing spondylitis, for example, is less likely to adhere to a daily exercise regimen if he or she has not achieved some degree of pain management with an appropriate anti-inflammatory medication.
 
The services of physical and occupational therapists will be enhanced if supporting information is forwarded to them at the time of referral. Copies of radiologic reports or radiographs, for example, can help them tailor treatment and education to the individual patient ( usually not done).
 
As the primary care physician, the general practitioner should also determine what treatment is being carried out by the therapist and whether it is successful. Ideally,regular communication will facilitate the development of a rapport between physician and therapist and will improve treatment for the patient.
 
The physical therapist will assess the musculoskeletal status of the patient by taking a history and examining ranges of motion, muscle strength, joint status (e.g., stability, alignment), posture and gait.
 
Physical therapists who have additional training in rheumatic diseases will also evaluate the acuteness of the disease. This is necessary in inflammatory diseases, such as ankylosing spondylitis and rheumatoid arthritis, because it relates directly to the extent of physical activity that the patient can tolerate.
 
Exercise can exacerbate the acuteness of disease if it is not delivered at a level consistent with the condition of a particular joint. An appropriate level of exercise may be followed by a short period (up to 2 hours) of moderate discomfort; however, significant exacerbation of the condition for a longer duration may occur if the assessment of the disease stage was inadequate or the patient has been overzealous or is exercising incorrectly.
 
Physical therapists trained in the evaluation of rheumatic diseases can be located in some provinces through the Arthritis Society. A single toll-free number (800 321-1433) allows people to contact their local Arthritis Society office for referrals to community care providers.
Physical therapy consists of exercises to improve muscle strength, joint mobility and cardiovascular function.
 
Heat, cold, electrical treatments or hydrotherapy may also be used to achieve temporary relief of pain and reduction of muscle spasm, but these techniques are used to prepare the patient with arthritis for exercise and should not be viewed as the treatment. The emphasis should be on exercise and education, with the goal of enabling the patient to continue an independent home program after discharge.
 
Gait training may be required to change poor habits, identify muscle weakness and imbalance and increase strength and walking range. For example, following total hip arthroplasty, patients often have a "Trendelenburg gait" with a lateral shift toward the operated leg in stance phase. This may be because of shortness of the leg, weak hip abductors or habit.
 
An assessment of the strength of the hip and knee musculature, measurement of leg length and observation of gait will allow the therapist to identify which problems need to be corrected and how to do so.
 
A physical therapist uses posture training and counselling to help patients reduce stress on joints or soft tissue during regular movement, work and recreational activities. For example, a dentist with ankylosing spondylitis who spends a large part of his or her day stooped over the chair is increasing the likelihood of fixed postural deformities.
 
It may be possible to encourage this patient to work from a sitting position, so that the spine is maintained in a more erect position for most of the workday. A person with osteoarthritis of the hip may not want to use a cane held in the opposite hand unless the therapist spends time demonstrating leverage and how forces on the hip joint can be unloaded when a cane is used properly.
 
As most forms of arthritis are chronic, the patient will usually be instructed in a program of exercise that can be carried out at home. In addition to learning the exercises, the patient should also understand the rationale behind them and be given guidelines for progression.
 
Long-term adherence to a regimen, particularly one as time-consuming as an exercise program, will only occur if the patient understands the reasons for doing the exercises and believes that they will be useful.
Role and function of the occupational therapist
 
The occupational therapist's role is to improve patients' ability to perform daily tasks, help them adapt to disruptions in lifestyle and prevent loss of function. Principles of energy conservation and joint protection, as well as techniques for stress management, are taught to minimize fatigue, reduce stress on joints, reduce pain and increase performance in the activities of daily life.
 
Patients are trained in alternative methods and the use of adaptive equipment for performing daily self-care, work, school, leisure and recreational tasks. Emphasis is placed on evaluating the patient within the context of his or her home, work or school setting so that appropriate, acceptable interventions will enhance the patient's capabilities.
 
Environmental modifications may be necessary to promote independent functioning. For example, a grab rail fixed to the wall or bathtub can facilitate entry and exit from the tub. The toilet is often the lowest seat in the house and may be difficult for patients with hip or knee problems to use; a raised toilet seat may mean the difference between independence and institutional care for some patients. Ergonomic positioning of desks, chairs and computer monitors may be important for patients in sedentary jobs.
 
An occupational therapist may also help the patient adjust to new or changed roles in the family or community.
 
Symptom management for patients with osteoarthritis:
Osteoarthritis is perhaps the most common rheumatology problem that the family physician sees, and physical and occupational therapy play an important role in relieving the symptoms associated with this disease.
 
Education:
The therapist will explain the use of heat or ice and which to use first. Ice has been shown to have more lasting benefit, but heat is often preferred by the patient. This therapy is used before exercise; its purpose is pain relief.
 
Although exercise can improve mobility, strength and endurance, overdoing it can aggravate symptoms (pain and inflammation). The therapist will emphasize the need to begin an exercise program slowly and to limit first the weight used and then the number of repetitions if the patient experiences pain.
 
Education will also include emphasizing the benefits of a regular exercise program.
 
Education is important to reduce stressful activity, such as stair climbing and the inappropriate use of an exercise bicycle (i.e., with the resistance set too high), and to explain the benefits of using a cane and controlling weight.
 
For the obese patient, losing weight is essential for a satisfactory long-term outcome.
 
Pain relief;Physical therapy
If the joint is warm and swollen, ice may be used, otherwise the choice of heat or ice depends on patient preference. Mild to moderate heat is applied for 15 minutes, ice for 10-15 minutes.
 
Electrical treatments, such as interferential therapy and ultrasound, are of limited value because they cannot be continued in the long term by the patient independently and can be seen as a passive alternative to exercise.
 
Occupational therapy
Splinting can provide rest and support and may be useful in pain relief .
 
Assistive devices will help relieve joint pain .
 
Exercise program;Physical therapy
Daily walking, outside or inside on a treadmill, for 20-30 minutes a day is encouraged. If joint pain is acute, this activity will have to be started slowly.
 
Range-of-motion exercises should be carried out daily, using a slow motion, with the joint as close to full range as possible without resistance or weight. These exercises should be repeated up to 5 times in each direction.
 
Isometric exercise should be used to increase strength. Some motion is acceptable when the joint is loaded: for example, resting the leg above the knee on a shallow block and moving the joint through.
 
Quadriceps exercise to strengthen muscles acting on the knee joint. The leg above the knee is rested on a shallow block, and the joint is moved .
 
An exercise bicycle may aggravate the patient's condition. If it is used at all, the tension should be reduced to minimum resistance. It may be useful for osteoarthritis in the hip but may be harmful in the presence of patellofemoral joint disease. It is also to be avoided in the presence of synovitis.
 
Aquatic exercise is invariably safe and acceptable, and the availability of community programs for people with arthritis is increasing. Warm water is more beneficial than cold. The breaststroke kick is best avoided by those with arthritis affecting the knee joint and after hip arthroplasty.
 
Cane use;Physical therapy
A cane may be used for extended outdoor activity but not necessarily for routine activity.
 
The cane is held in the hand opposite the affected hip or knee.
The top of the cane should be level with the proximal wrist crease when the patient is standing erect . (A good rubber cane tip should be in place for safety.)
 
The correct height for a cane, with the top of the cane level with the proximal wrist crease .
 
For bilateral joint problems, 2 canes may be used. Crutches or a walker provide greater support and allow partial weight bearing. Severe problems of this nature probably require surgery.
Occupational therapy

The therapist should ensure that the cane tip is in good repair for safety reasons, particularly in winter. A spike tip is available for patients walking in icy conditions.
 
A simple wooden cane provides the same support as an adjustable metal cane and can be obtained from a pharmacy or medical supplier at minimal cost.
 
Weight control;Physical therapy
Weight Watchers may be a useful resource because the program is supervised and provides a weekly incentive.
 
Patients need to be informed of the relation between symptoms in their weight-bearing joints and their weight. This understanding will increase their motivation to lose weight. (The Framingham Study3 has demonstrated that obesity is a causative factor in osteoarthritis of the knee in women.)
 
Patients may be encouraged to participate in an aquatics program. In water, buoyancy relieves stress on the weight-bearing joints and is well tolerated. The ability to swim is unnecessary.
Joint protection
 
Occupational therapy
Many assistive devices for reducing stress on joints are commercially available . Devices to assist in the kitchen, including electric can openers, jar openers and extended tap turners, can reduce stress on the first carpometacarpal (CMC) joint by reducing the gripping force required.
 
Thumb splints restrict movement, decrease pain and allow use of the hand.
 
Raised toilet seats , grab rails for the bathtub or a bath bench reduce stress on lower limb joints and help patients maintain their independence.
 
A raised toilet seat, available commercially, decreases the required range of motion and force through the hip and knee joints. 
 
A seat cushion or bed blocks can elevate a piece of furniture, making getting up and down possible for those with of arthritis of the hip or knee.
 
Using a riser to adjust seat height makes it easier for those with arthritis of the hip or knee to get up and down. 
 
A running shoe with a wide, supportive heel and a good, cushioned sole may reduce jarring forces through weight-bearing joints.
Splinting
 
Occupational therapy
Some commercial splints are useful and usually economical; however, custom-made splints can be fitted and may be more effective. A splint for the first CMC joint allows pinching and gripping with less pain . A wrist splint will reduce pain during gripping. A leather splint should be used for heavy work; plastic splints allow work in water.
 
Knee bracing should be deferred until after a good trial of the following standard conservative measures: analgesics or nonsteroidal anti-inflammatory drugs, a quadriceps-strengthening program, the use of a cane and possible shoe wedging if valgus (knock-knee) or varus (bowleg) are pronounced. Weight loss is essential if a patient is overweight. Knee bracing is useful where lateral instability is pronounced.
 
A medial wedge (for knock-knee) or a lateral wedge (for bowleg) applied to the outside of the shoe or, less frequently, to an insole in the shoe can be effective in moving the knee alignment into greater or lesser valgus or varus. Minor changes in alignment can produce significant changes in symptoms.
 
A wedge can only be used in a sturdy shoe that is laced and fixed firmly to the foot with a good supportive heel. In a soft, unsupportive shoe, the wedge will not affect the movement of the foot.
 
Physical and occupational therapy for an inflammatory form of arthritis;
The principles outlined here also apply to inflammatory forms of arthritis but require closer patient adherence to instruction because the potential for loss of mobility, flexion contractures and deformity are even greater in chronic inflammatory polyarthritis.
 
Exercise should become part of the daily routine, but the patient should focus on the joints in which the inflammation and pain are most severe. Each active joint should be taken through its full range of motion daily. Isometric exercise may maintain muscle strength without exacerbating the condition of the joint.
 
Exercise should stop short of increasing inflammation in the joint (as observed by an increase in pain and warmth or swelling in the joint). Any activity that increases inflammation in the joint should be avoided.
 
It is important to note that exercises for spondylitis are often the reverse of those recommended for mechanical back pain. Flexion exercise regimens are commonly used for mechanical back pain to improve abdominal strength and flatten the lumbar spine.
 
In spondylitis, pain and inflammation promote a stooped posture with potential deformity in a position of flexion. Therefore, exercise is aimed at maintaining spinal extensor mobility and increasing the strength of the spinal extensor muscles. As spondylitis is less common than mechanical low-back pain (e.g., disc lesions, sprains), there is a danger of applying the standard mechanical treatment rationale to the inflammatory back problem.
 
Custom-fitted or store-bought splints may rest an active joint or provide support to a damaged joint, and patients are willing to wear these when they are well fitted.
 
Of paramount importance is the patient's understanding of the need to adhere to a regimen over a long period. Education, delivered when the patient is receptive, is effective; this is rarely at the time of diagnosis. Typically, denial and anger precede the optimum teaching moment.
 
Physical and occupational therapists expect to be provided with the primary diagnosis for the problem they are going to treat. They do not expect specific instructions or treatment recommendations but generally prefer to be allowed some discretion in developing a treatment plan based on their findings.
 
These therapists also expect the primary care physician or specialist to have achieved control of inflammation and pain through pharmacologic means where possible. A patient with ankylosing spondylitis, for example, is less likely to adhere to a daily exercise regimen if he or she has not achieved some degree of pain management with an appropriate anti-inflammatory medication.
 
The services of physical and occupational therapists will be enhanced if supporting information is forwarded to them at the time of referral. Copies of radiologic reports or radiographs, for example, can help them tailor treatment and education to the individual patient. As the primary care physician, the general practitioner should also determine what treatment is being carried out by the therapist and whether it is successful.
 
Regular communication will facilitate the development of a rapport between physician and therapist and will improve treatment for the patient.