Rheumo Case Review

Patient details

Male, 28years

Lives with Wife and One Year old Child

He use to work as a chef, but cannot work at the moment due to pain and immobility

His wife works and studies

Diagnosis: Polyarticular Gout

Polyarticular Gout. If more than one joint is affected, it is known aspolyarticular gout. Multiple joints are affected in only 10 - 20% of first attacks. Older people are more likely to have polyarticular gout. The most frequently affected joints are the foot, ankle, knee, wrist, elbow, and hand. The pain usually occurs in joints on one side of the body and it is usually, although not always, in the lower legs and feet. People with polyarticular gout are more likely to have a slower onset of pain and a longer delay between attacks. People with polyarticular gout are also more likely to experience low-grade fever, loss of appetite, and a general feeling of poor health.

An untreated attack will typically peak 24 - 48 hours after the first appearance of symptoms, and go away after 5 - 7 days. However, some attacks last only hours, while others persist as long as several weeks.

Reason for admission - Methylprednosone Pulses 3x

Reason for Referral Assessment - Splinting, Education, RTW, equipment/aids

• Intial Hand Assessment
• ADL tasks sheets- self report of difficulties
• Assessment of Hands

Presenting Problems/Complains

• Pain and reduced ROM in R) Wrist - also decreased strenght in R) hand
• Swan neck deformity in R) LF
• Pain in TMC/CMC joint - thumb
• Difficulties with multiple ADLS
• Reduced mobility due to pain in L) knee; both ankles and feet.
• Poor sleep and fatigue

Current/Pre admission occupational performance/mobility

• Mobilising with gutter crutch L) arm
• Independent with personal ADL's on ward, concerns re: showering at home
• Unable to carry heavy items or carry items in R) hand
• No completeing heavy housework tasks
• Difficulty with but independant with multiple actions/tasks at home relating to hand function, strenght, pain and immobility

Intervention

• Education re: sleep cycles, factors linking to poor sleep, strategies and use of relaxation, sleep diary and routine/environmental setup
• Wrist splint - D ring splint for stability
• Issued a BB and K-trolley

Plan

• Book in O/P clinic to review splinting of R) LF - swan neck deformity, and resting slint for wrist.

Case review

Case Review

Patient details: Female, 56

Event leading to admission: Prolonged hypoglycemia - unconcious episode, lowered GCS

Pre-admission occupational performance

- Independent with grooming, and personal care tasks

- Independent mobility

Social Situ

- Lives with Husband - primary carer

OT input - Assessments:

Basic cognitive assessments - orientation, attention, object naming/use, working memory

Basic tasks - writing, reading,

Joint session with SLT - ruled out language problem - more cognitive problems

AMPS observation of grooming - combing hair and brushing teeth

Observations from AMPS

• Prompt to start task
• Indep with manipulating toothpaste - fine motor
• Chose appropriate tools and used them appropriately
• Assistance gathering and organising task environment - therapist intitated
• Sitting in chair, stabilising body on table
• Assistance to position table appropriately to perform task
• Coordinating bilateral hand tasks effectively
• Reduced grip strength ? due to arm positioning akwardly
• Obtaining and holding task objects effectively
• Poor endurance throughout task
• Pace slow, however ? due to difficulty with terminating task
• Attends to task, however distracted by others talking, however contiunes with tasks indep
• Handles task objects appropraitely
• Sequencing task appropriately
• Repeats steps ? difficulty terminating task
• Searches and locates objects

Overall minimal assistance with task and safe performing task with environment set up

Next step:

Further assessment of ADL's - showering and dressing

Determining a good understanding of prior level of cognition - mixed reports

Goal setting with rehab team - realistic goals

JESS

Complex case QOL

I have had a patient who is very unsafe to return home. She is falling alot and has fallen on the ward numerous times, she often doesnt use her walking frame and she fluctuates between being lucid and being very very confused. She often talks about living in the past with her mother as it is happening presently or will happen in the future. She needs constant direction on the medical ward and she needs 24/7 supervision due to her cognition, and falls risk.

We had a family meeting with the Son and Daughter last week, and we each communicated how concerned we were that they had decided it be best for her to return home. I understand that they want the best for her (i.e. quality of life and the patients wish to not go into a RH). I also know that they are aware of the concerns, but really what can we do? The patient has been deemed incompetent, and the EPA wants her to remain at home. I wonder about her quality of life, and whether the patient can experience a quality life remaining at home and not having any awareness of where she is, what day it is, what year it is and why she was in hospital. She also doesnt show any awareness of how she is managing.

What is a quality life??

I have found a few definitions: and picked out a few key terms...

Quality of life: An important consideration in medical care, quality of life refers to the patient's ability to enjoy normal life activities. Some medical treatments can seriously impair quality of life without providing appreciable benefit, while others greatly enhance quality of life.

The best way of approaching quality of life measurement is to measure the extent to which people's 'happiness requirements' are met - ie those requirements which are a necessary (although not sufficient) condition of anyone's happiness - those 'without which no member of the human race can be happy.'

- McCall, S.: 1975, 'Quality of Life', Social Indicators Research 2, pp 229-248

‘‘Quality of life’’ (QOL) subsumes two distinct domains in gerontological research. One is health-related quality of life (HRQOL); the other, nonhealth or environment-based quality of life (Spilker and Revicki).

http://www.novelguide.com/a/discover/eoa_04/eoa_04_00344.html

This website, discusses these two domains - and i think it helps me understand that perhaps the family of the client

above are thnking of her environment based quality of life and not her health based quality of life. HOwever QOL does mean different

things to different people.

Anyway, the medical and AH team essentially have concerns about the choice the family have made, and the wellbeing of the patient in mind. The SW has put a referral through to elder support to ensure that we have done all we can to protect the wellbeing of the patient. But essentially, all we can do is advise the patient (which we have done) of our concerns and the risks of the patient remaining at home and support them as much as we "can" towards a safe discharge, whilst knowing that the patient is going to fall again and will also most prob end back up in hospital (which we have also discussed with the family).

Learning about Fibromyalgia

Fibromyalgia is a long term condition characterised by widespread muscle pain and fatigue. It is thought to affect 3-5% of the population. It can affect anyone at any age but is more common in women.

Fibromyalgia is a chronic condition characterised by widespread muscle pain and fatigue. The term 'fibromyalgia' literally means pain in muscles and fibrous tissues (ie: tendons and ligaments).

For many years it was thought that fibromyalgia was psychologically based but is now recognised as a medical condition in its own right and research into the condition has increased.

Approximately 80% of fibromyalgia sufferers are women and the condition is most commonly diagnosed in the 30 to 45 year age group.

The cause of fibromyalgia is unknown. There are indications that an injury, infection or illness may trigger the condition. There are also indications that hereditary factors are involved in the development of fibromyalgia as sometimes it occurs in several members of one family.

It is thought that fibromyalgia may be due to a malfunction in the way the central nervous system processes pain signals. This leads to people with fibromyalgia experiencing as pain, sensations that other people might perceive as uncomfortable.

Two brain chemicals, Serotonin and Substance P, are thought to play a role in the condition.

Serotonin is a neurotransmitter (a chemical that enables the transmission of nerve impulses) that influences mood, appetite, pain perception, sexual function, anxiety, temperature control and sleep. Studies have indicated that levels of this chemical are lower than usual in people with fibromyalgia.

Substance P, another neurotransmitter, is involved in transmitting pain sensations to the brain and also regulates the way we perceive pain. Some studies have found substantially elevated levels of this substance in people with fibromyalgia.

A person with fibromyalgia can experience a wide range of symptoms but the main ones are muscle and joint pain, stiffness and fatigue.

The one symptom experienced by everyone with fibromyalgia is pain. This pain can be described in various ways, such as an ache, a sharp pain, a throbbing or a burning feeling. The pain is felt throughout the body and on both sides of the body. The pain can move from one part of the body to another. The amount of pain experienced can vary throughout the day and can also worsen with a change in weather, increase in stress, noise, activity and lack of sleep.

Stiffness of muscles and joints is most noticeable in the morning and after a period of rest. This can interfere with work and daily activities such as driving. Keeping moving is the best way to prevent stiffness. If a person has to sit for long periods, he or she can reduce stiffness by regularly getting up to move around and stretch.

Fatigue is experienced by up to 90% of people with the condition. The level of fatigue can vary from person to person, from being barely noticeable to severe. As with the amount of pain experienced, the degree of fatigue can vary throughout the day, from day to day, and may even be absent on occasion.

Many people with fibromyalgia experience sleep problems. There are a number of stages of normal sleep ranging from light to deep sleep. It seems that people with fibromyalgia often lack the deep restorative stages of sleep and often wake feeling unrefreshed.

Over half of people with fibromyalgia experience symptoms such as irritability, forgetfulness, lack of concentration, mood changes, anxiety and depression.

Other symptoms that can be experienced by people with fibromyalgia include:

• Migraine and tension headaches
• Recurrent abdominal pain
• Diarrhoea
• Difficulty swallowing
• Irritable bladder leading to frequent or painful urination
• Numbness and tingling of the extremities
• Dry eyes and mouth.

Diagnosis

Fibromyalgia can be a difficult condition to diagnose as the symptoms of fibromyalgia are often similar to those of other conditions, such as rheumatoid arthritis or chronic fatigue syndrome. Blood tests and x-rays usually return normal results in someone with fibromyalgia but they are often performed in order to rule out other conditions.

In order to make a diagnosis of fibromyalgia the doctor will look for the following indicators of the condition:

• A history of widespread pain
• At least 11 of 18 specific tender point sites (as shown below)
• Normal blood tests
• Chronic fatigue
• Sleep disturbances
• Skeletal pain (mainly in the neck and back).

Graphic courtesy of A. Bonsall and MedicineNet.com

Treatment

While there is no cure for fibromyalgia, the condition can be managed using a variety of measures. Optimal management requires cooperation between the patient and various treatment providers.

Exercise is highly recommended even though people with fibromyalgia may be reluctant to exercise because of their pain. Exercise is important to prevent the muscles from losing strength due to lack of use. Other benefits of regular exercise include sleep promotion, aiding digestion, increasing blood flow and improving muscle tone. It is best to start with small amounts of low impact exercise (such as walking) on a daily basis, and gradually increase this as tolerated.

Rest is also important in managing fibromyalgia. People with fibromyalgia often feel exhausted after only small amounts of activity. It is often helpful therefore, to rest regularly during the day and even during activity if it is needed. Even brief periods of rest (such as 5 to 10 minutes) can be helpful.

Stress reduction is important as increased stress can magnify fibromyalgia symptoms. Finding methods of relaxation (such as reading or listening to music) that suit the individual with fibromyalgia can be helpful in stress reduction. Talking about the condition with friends and family can also be helpful. Some people may find it helpful to work with a professional counsellor or psychologist to develop relaxation techniques and strategies to cope with the pain

Sleep is often inadequate in quality for people with fibromyalgia. It is not advisable to use sleeping tablets unless they are absolutely necessary, and then only for brief periods of time. Some methods that may help to gain more restful sleep include avoiding alcohol and coffee in the evening, using the bedroom only for sleep (ie: not for working or eating), ensuring the room is dark when trying to sleep and having a regular time for going to bed.

Alternative therapies such as acupuncture/acupressure, homeopathy, hot and cold packs, massage therapy, nutritional supplements and dietary modifications, herbal preparations, osteopathy or chiropractic treatment, have proved effective for some people in managing the symptoms of fibromyalgia.

Studies have shown that low doses of two different antidepressant medications can be helpful in relieving the pain of fibromyalgia in some people. Amitriptyline (a tricyclic antidepressant) taken at night can help with promoting a restful sleep and reducing muscle pain and spasms. Prozac (fluoxetine) taken in the morning may add to the effects of the Amitriptyline by further controlling the pain during the day. While these medications help some people with fibromyalgia, they are not effective in all cases.

So from learning about this it is important that when initially meeting a person I ask about what symptoms they are experiencing e.g. where the pain is, how they are coping with it, what helps, what doesnt help, how their sleep is, how they manage fatigue, and how they feel within themselves so I can understand their experience of living with this condition.

My intervention could be aimed at education around fatigue management, coping with pain, sleep management, stress management, aids to cope with difficult ADL's when pain/fatigue is a distrubrance,

Jess

Supporting others

Below are some of the activities i wish to do this year, related to my overall objective of: Articulate, negotiate, & demonstrate the role & function of an occupational therapist within a team.

Activity #1: Support the orientation and learning of processes of new staff members by being available to peers for facilitating learning. Seek feedback about support provided to peers and discuss in supervision
Date to complete this activity by: Dec 2010
Added: 24/2/10

Activity #2: Demonstrate and articulate the role of an occupational therapist by modelling and providing support/guidance to peers and OTA
Date to complete this activity by: Dec 2010
Added: 24/2/10

This week we have had two new staff members within our team. I have made myself available to them and they have come to me with questions about a) particular assessments e.g. screening cognition; PTA; intial OT assessments; b) equipment processes and paperwork c) documentation guidance and SOTAP explanation. I have felt confident to talk these through with them, and demonstrate with patients "what i would do with a patient" and how i would document in the notes.

I have felt like i have explained everything slowely, and i have asked if they have understood. I have tried really hard not to take over and involve them in the process, however i think they have apprecitated the demonstration and role modelling of what another therapist would do.

I have attended an MDT meeting with one of the therapists and demonstrated, asking questions to clarify if patients need input etc. And communicating current input. The therapist told me she found it very useful observing when to speak up and ask information.

I have made myself available in the office for questions, as they have both approached me in the office to ask questions about processes and talk through patients with me. I have also encouraged them to talk to senior OT's if they have needed more clarification or guidance.

I wish to continue doing this over the next few weeks, to ensure that what ever i can do to support the new staff members thats appropriate i do.

I wish to talk in supervision about what things are appropriate for me to be doing and when i should direct them to a senior OT.

Jess

Finger extension and flexion

Mechanism for finger flexion

• FDP: flexor digitorum profundus (the deeper of the two)
• FDS: flexor digitorum superficialis (the more superficial muscle)

Although the FDP is deep to the FDS over most of its course, it attaches to the skeleton more distally, because it passes through a 'split' in the FDS tendon.

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Mechanism for finger extension

We can extend the PIP and DIP joints without also extending the MP joints.

But we can't extend the PIP joint without extending the DIP joint at the same time.

Flexing only the DIP joint without also flexing the PIP joint is difficult.

Full (active or passive) flexion of the PIP joint prevents active extension of the DIP joint.

We can understand these finding by learning the structure of the EXTENSOR MECHANISM, also known as the:

extensor expansion extensor assembly extensor apparatus

dorsal aponeurosis aponeurotic sleeve

The extensor mechanism is an elaboration of the extensor digitorum comunis (EDC) tendon on the dorsum of each phalanx. The extensor indicis (EI) and the extensor digiti minimi (EDM) insert into the extensor mechanisms of the second and fifth digits, respectively.

Several tendinous structures comprise the extensor mechanism:

The EDC tendon attaches by a tendinous slip to the proximal phalanx, through which it extends the MP joint. The central tendon (or "slip") proceeds dorsally to attach to base of middle phalanx, where tension can extend the PIP joint.

3. the lateral bands proceed on either side of dorsal midline and rejoin before attaching to the distal phalanx. Tension in the lateral bands extends the DIP joint.	4. the extensor hood surrounds the MP joint laterally, medially, and dorsally, and receives tendinous fibers from the lumbricales and interossei.
5. Fibers of the oblique retinacular ligament (ORL) attach at the sides of the proximal phalanx and digital tendon sheaths, and proceed to distal portion of lateral bands. Thus, the ORL's line of application is volar to the PIP joint's lateral axis and dorsal to the DIP joint's lateral axis.
PIP extension (produced by other tissues in the extensor mechanism) elongates the ORL, creating passive tension that extends the DIP. The DIP extension helps open the hand.	DIP flexion (produced by the FDP) elongates the ORL, creating passive tension that flexes the PIP. The PIP flexion assists in finger closure.

1st observation RA, splinting

Today I observed a hand therapist, completing an initial assessment, which included talking about how long the patient had had RA for, and talking about the referral. She then talked about what the main problems were, then went on to assess the hands, joints and tendon placement. She talked through her observations and she interacted with the patient by asking how long a particular joint had been like it was and asked if it was painful and what impact it had on her ADL's.

I have happened to come accross the below guide for taking history, which i think may be very helpful.

1. Evaluation of the history including onset, duration and distribution of joint disease.
2. Assessment of pain, stiffness and function.
3. A full systematic history, as the condition is a systemic disease.
4. A genetic history may be useful in view of the hereditary aspects of disease.
5. Impact of the disease on daily life.

Today, I observed

An example of

a) extensor subluxation - which inhibited the paitents ability to extend her fingers as essentially the tendon had dropped and become a flexor. These tendons on the dorsal aspect are below

The dorsal tendon compartments

Identify the tendons that, encased in synovial tendon sheaths, comprise six numbered dorsal compartments of interests to hand therapists: abductor pollicis longus and extensor pollicis brevis extensor carpi radialis longus and brevis extensor pollicis longus extensor digitorum comunis (four tendons) and extensor indicis extensor digiti minimi extensor carpi ulnaris

b) ulna deviation - as a result of the extensor subluxation

Learning about RA

Rheumatoid Arthritis

- Autoimmune disease – system malfunctions – turns on itself healthy parts come under attack.

- The faulty system attaches the tissues and other materials in the joints, cartilage, synovial fluid – with fluid to lubricate, ligaments. This causes inflammation and pain, and eventually destroying the joint.

- In some cases patients have organ involvement including the eyes, lungs and membrane around the heart, the damage occurs from inflammation of the vessels supplying the organ or inflammation of the organ issue itself

Drugs

-Release pain as well as prevent damage, reduce inflammation that is causing the damage

2 categogies – 1^st line drugs – pain; 2^nd line that treat the disease

NSEADS – popular – reduce pain and swelling – aspirin, ibuprofen, naproxen

Corticosteroids are used to treat more se3vere inflammation in the body – mimicking the effects of cortisone which is a hormone that is produced by the body to control inflammation. These have profound side effects

Anti rheumatic drugs – disease modifying drugs – DMARDs – slow the diseases progress by modifying the immune system itself – very slow acting – may take 6 – 8 months to reach full

Biological response modifiers - Biologic agents – expensive - can slow or hault/stop destructive progress by targeting the specific molecule involved in the inflammation process, targeting specific proteins compete for the receptor that tells the cells to be inflamed and reduce inflammation that way. These are often combined with DMARDS or corticosteroids.

Learning about Scleroderma

Scleroderma is an autoimmune disease of the connective tissue. Autoimmune diseases are illnesses which occur when the body's tissues are attacked by its own immune system. Scleroderma is characterized by the formation of scar tissue (fibrosis) in the skin and organs of the body. This leads to thickness and firmness of involved areas. Scleroderma, when it's diffuse or widespread over the body, is also referred to as systemic sclerosis.

Patients can have variations of CREST, for example, CRST, REST, ST, etc. Patients can also have "overlap" illness with features of both CREST and the diffuse form of scleroderma. Some patients have overlaps of scleroderma and other connective tissue diseases, such as rheumatoid arthritis, systemic lupus erythematosus, andpolymyositis. When features of scleroderma are present along with features of polymyositis and systemic lupus erythematosus, the condition is referred to as mixed connective tissue disease (MCTD).

Sclerodactyly refers to the localized thickening and tightness of the skin of the fingers or toes. This can give them a "shiny" and slightly puffy appearance. The tightness can cause severe limitation of motion of the fingers and toes. These skin changes generally progress much slower that those of patients with the diffuse form of scleroderma.

The symptoms of scleroderma depend on the type of scleroderma present and the extent of external and internal involvement in the individual affected. Because scleroderma can affect the skin, esophagus, blood vessels, kidneys, lungs, blood pressure and bowels, the symptoms it causes can involve many areas of the body.

Scleroderma affects the skin to cause local or widespread signs of inflammation (redness, swelling, tenderness, itching, and pain) that can lead to skin tightness or hardening. These skin changes can be widespread, but it's most common for them to affect the fingers, feet, face, and neck. This can lead to decreased range of motion of the fingers, toes, and jaw. Tiny areas of calcification (calcinosis), while not common, can sometimes be noticed as hard nodules at the tips of the elbows or in the fingers.

Raynaud's phenomenon (RP) is a condition resulting in a particular series of discolorations of the fingers and/or the toes after exposure to changes in temperature (cold or hot) or emotional events. Skin discoloration occurs because an abnormal spasm of the blood vessels causes a diminished blood supply to the local tissues. Initially, the digit(s) involved turn white because of the diminished blood supply. The digit(s) then turn blue because of prolonged lack of oxygen. Finally, the blood vessels reopen, causing a local "flushing" phenomenon, which turns the digit(s) red. This three-phase color sequence (white to blue to red), most often upon exposure to cold temperature, is characteristic of RP.

Limited scleroderma, or CREST syndrome, is one subtype of scleroderma — a condition that literally means "hardened skin."

The skin changes associated with limited scleroderma typically occur only in the lower arms and legs, and sometimes the face and throat. Limited scleroderma can also affect your digestive tract and can cause serious heart and lung disorders.

While some varieties of scleroderma occur rapidly, signs and symptoms of limited scleroderma usually develop gradually. They include:

• Tight, hardened skin. In limited scleroderma, skin changes typically affect only the lower arms and legs, including fingers and toes, and sometimes the face and throat. Skin can look shiny from being pulled taut over underlying bone. It may become difficult to bend your fingers or to open your mouth.