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Chapter 57 Occupational Therapy

Manual of Rheumatology and Outpatient Orthopedic Disorders

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Chapter 57 Occupational Therapy

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Toni Golin

Evaluation
Splinting
Activities of daily living
Dressing
Bathing
Homemaking
Patient education
Hand

Occupational therapy provides assistance to persons whose functional level of performance has been affected by physical, psychological, or developmental disabilities . The role of occupational therapy in the treatment of rheumatoid arthritis is to improve or maintain the patient's maximum level of functioning. The overall goal of the treatment is to minimize the effects of pain, decreased mobility, and decreased endurance on a person's ability to perform activities of daily living (ADL). To achieve this goal, a variety of strategies are employed to:

1. Maintain or increase range of motion (ROM), strength, and endurance in the upper extremity .
2. Correct and prevent the development or progression of hand deformity.
3. Improve functional abilities in ADL.
4. Explore adaptation or alternatives in vocational or avocational interests.
5. Provide patient education, specifically in the area of joint protection and energy conservation.

I. Evaluation. The first step in treatment is the evaluation. Careful observation of the extremity for heat, redness, edema deformity, pain, and stage of disease process helps determine treatment plans and goals. Active and passive ROM of the upper extremity and muscle strength are evaluated by means of goniometry and individual and functional muscle testing. Objective means of measuring strength include the dynamometer, sphygmomanometer, pinch gauge, and computer-assisted equipment. Based on findings, an exercise program can be prescribed. A hand evaluation is performed to assess grasp and prehension patterns, strength, deformities, and pain. Joint and tendon crepitus, joint stability, tendon integrity, and muscle imbalance should be noted. This information is necessary also when a patient's splinting needs are being determined. An ADL evaluation is performed to determine the patient's past and present ADL skills and level of independence. ADL include feeding, writing, dressing, grooming, hygiene, homemaking, and work- related skills as appropriate. Noted in this evaluation is the ease with which a task is accomplished, any pain associated with performing the task, and potentially deforming stresses to the involved joints.

The goals of exercise are to strengthen muscles and increase ROM and endurance, all of which contribute to an improved overall level of functioning. Modalities such as heat, cryotherapy, paraffin, and fluidotherapy are often used to augment treatment. Active, active assisted, and passive ROM, along with resistive exercises, are employed depending on the amount of disease activity present.

1. In the acute stage, when the joints are swollen and inflamed, rest accompanied by splinting is generally indicated. Active and gentle passive ROM is employed to maintain joint mobility. Isometric exercises can be performed. No stretching or resistive exercises are attempted in this phase.
2. In the subacute stage, gentle passive stretch and active isotonic exercises with minimal joint stress can be added to the passive or active ROM exercise program. Their purpose is to regain lost active ROM and improve endurance.
3. In the chronic stage, stretch at the end of ROM, active ROM, and isometric exercises is employed. Patients are encouraged to maintain general conditioning by performing ADL to tolerance.

II. Splinting is frequently used as part of the treatment program.

1. Indications for splinting include the following:
   1. Immobilizing painful, inflamed joints.
   2. Preventing contractures by maintaining proper joint alignment.
   3. Preventing repetitive stress in a joint during activities.
   4. Improving function by increasing support and stability.
   5. Maintaining surgical correction.
2. Choice of splints. Static splints contain no moving parts and maintain the affected part in the desired position. Dynamic splints assist movement in specific directions by the application of a nearly constant force. They may utilize hinges , springs, or outriggers with elastic tension. When determining the type of splint to be fabricated for a particular patient, it is important to keep in mind that splints can be awkward to wear. Despite some gains, they somewhat limit function. A functional splint that the patient can easily manage is a wiser choice than a more complicated splint that attempts to accomplish many goals at once but is cumbersome and unmanageable for the patient. Also, immobilization of one joint alters the biomechanical forces in adjacent joints, causing increased stress and possible inflammation .

   Common problems that may require splinting, the types of splints used, and the rationale are listed in Table 57-1.

   
   

   Table 57-1. Common problems requiring splinting

   
   
   

   
   

   FIG. 57-1. Volar wrist cock-up.

   
   
   

III. Activities of daily living. At any stage of disease, the patient can experience functional limitations resulting from pain, decreased ROM, decreased muscle strength, deformity, or fatigue. ADL treatment includes instruction in alternate methods to perform a task and in the use of assistive devices to maintain independence and preserve joints.

Limited ROM in an upper extremity may make it difficult to bring food to the mouth. Weakness and deformity may make it difficult to manipulate utensils and cut food. Adapted utensils with enlarged or extended handles can compensate for decreased ROM and poor grip. Swivel or curved forks and spoons can compensate for lack of supination and wrist radial deviation. An insulated mug allows a patient to use two hands to bring cup to mouth when weakness or poor pinch is a problem. A long straw can eliminate the need to lift a glass from the table. A universal cuff can be used to hold utensils when hand use is severely limited. Rocker knives and Swedish-design knives make cutting foods easier.

IV. Dressing. Limited ROM in both upper and lower extremities may make it difficult to pull clothing over the head or feet. Poor grip and pinch strength and loss of fine prehension skills create difficulty in zippering, buttoning, and pulling up clothing. A dressing stick can help with putting on and taking off a shirt in cases of shoulder involvement and decreased ROM. A sock aid and a long-handled shoehorn can assist with dressing the lower extremity. A zipper pull and Velcro fasteners to replace buttons or the top button at the neck of a shirt are useful.

V. Bathing. Limitations in ambulation and transfer skills can make getting in and out of the bath or shower hazardous. Loss of strength and range in the upper extremity can make it difficult to reach body parts, manage faucets, and shampoo hair. Grab bars and tub or shower seats can aid in safe transfers. Lever-type faucet handles can replace traditional faucets, or tap-turning devices can be placed on existing faucets when hand strength and ROM are limited. A hand-held shower head can be placed on the side of the tub for easy access and can aid in reaching body parts and washing hair.

VI. Homemaking. Reaching into cabinets , holding and opening containers, handling pots and pans, and chopping food are difficult for the person with arthritis. Many labor-saving appliances, such as a food processor, are useful when lightweight and easy to operate . Roller knives or pizza cutters enable food to be cut with less stress placed on joints. A Zim jar opener easily opens tight lids. Items often used should be kept on low shelves , and small, easily managed food containers should be used. Many devices available to improve ADL are manufactured for people with disability. Many are commercially available appliances that, by the nature of their design, are well suited for an arthritic patient. Devices can be fabricated or adapted by the occupational therapist according to the patient's specific problems and needs.

FIG. 57-2. Resting hand splint.

FIG. 57-3. Forearm-based ulna drift splint. B: Hand-based ulna drift splint.

VII. Patient education

1. Techniques of joint protection are methods of performing daily tasks with a minimum amount of stress on the joints. To preserve the integrity of the joint structures and reduce pain and inflammation, patients must be educated in how particular joints work biomechanically and how forces used during activities can alter their function. Specific principles of joint protection are as follows :
   
   

   
   

   FIG. 57-4. Thumb spica splint.

   
   
   
   1. Avoid deforming positions .
   2. Avoid ulnar deviating pressures in the fingers.
   3. Avoid activities involving a tight grasp.
   4. Avoid holding joints in one position for an extended length of time.
   5. Use the strongest joint available for any activity.
   6. Respect pain.
   7. Follow an ROM home program designed to prevent the development or progression of a fixed deformity.
2. Energy conservation techniques encourage the accomplishment of tasks with the expenditure of a minimal amount of energy. An appropriate balance of work and rest must be determined. Patients tend to try to get everything done on good days, when short rest breaks of 5 to 10 minutes during daily activities can be helpful in increasing overall endurance. Suggestions for conserving energy include the following:
   
   

   
   

   FIG. 57-5. Shorty thumb spica.

   
   
   
   1. Plan work areas so that the most frequently used equipment is easily reached.
   2. Use aluminum foil and other disposable utensils to cut down on dish washing.
   3. Use lightweight equipment and small containers for cleaning and cooking.
   4. Use a wheeled table or cart to move food, laundry, and so on. A cobbler's apron can be useful to carry objects from one room to the next .
   5. Use prepared foods when possible.
      
      

      
      

      FIG. 57-6. Silver ring splints.

      
      
      

VIII. Hand. Specific hand exercises are employed to counteract deforming or potentially deforming forces. Resistive hand exercises, such as squeezing a ball, are contraindicated, as they can add stress to already weak joints and tendons. An adequate grip strength necessary to perform ADL is approximately 20 pounds , as measured by a Jamar goniometer. Below this level, patients may have difficulty lifting a coffee cup or brushing their hair. A pinch strength of 5 to 7 pounds has been found to be adequate in performing most tasks. This is particularly applicable for self-care tasks, such as buttoning, writing, and holding a feeding utensil.

Bibliography

Hicks JE, et al. Handbook of rehabilitative rheumatology. Atlanta: American Rheumatism Association, 1988.

Hunter JM, et al. Rehabilitation of the hand: surgery and therapy, 3rd ed. St. Louis: Mosby, 1990.

Melvin JL. Rheumatic disease in the adult and child. Philadelphia: FA Davis Co, 1989.

Pedretti LW. Occupational therapy practice skills for physical dysfunction. St. Louis: Mosby, 1990.

Books@Ovid
Copyright 2000 by Lippincott Williams & Wilkins
Stephen A. Paget, M.D., Allan Gibofsky, M.D., J.D. and John F. Beary, III, M.D.
Manual of Rheumatology and Outpatient Orthopedic Disorders

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