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| CASE REPORT |
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| Year : 2019 | Volume
: 51
| Issue : 4 | Page : 151-154 |
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Occupational therapy for knee osteoarthritis: A case study
Karthik Mani
External and Regulatory Affairs, NBCOT Inc., Gaithersburg, MD, USA
| Date of Submission | 05-Dec-2019 |
| Date of Acceptance | 12-Dec-2019 |
| Date of Web Publication | 3-Jan-2020 |
Correspondence Address:
Dr. Karthik Mani
335, W Side Dr, Gaithersburg 20878, MD
USA
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijoth.ijoth_34_19
Osteoarthritis (OA) is a prevalent condition in India. It can cause functional limitations and affect the quality of life (QoL). This case study describes the occupational therapy (OT) services implemented for a female patient diagnosed with bilateral knee OA. The patient described in this case study experienced pain and fatigue. Further, the suboptimal performance in instrumental activities of daily living tasks affected her subjective well-being. The patient was consulted for seven sessions in total, including the follow-up. The treatment techniques used were patient education, home modification, activity modification, and assistive device prescription and training. The patient verbalized improvement during the follow-up visit after 6 months. The improvement was also evident through improved fatigue and QoL scores. The implications of the case for OT practice in India were highlighted.
Keywords: Activities of Daily Living, Fatigue, India, Quality of Life, Self-Help Devices
How to cite this article:
Mani K. Occupational therapy for knee osteoarthritis: A case study. Indian J Occup Ther 2019;51:151-4 |
| Introduction | |  |
Osteoarthritis (OA) is a chronic degenerative disorder characterized by the breakdown of cartilage, hypertrophy of bone margins, and subchondral sclerosis. The overall prevalence of OA in India was reported to be 28.7%.[1] The symptoms of OA vary between patients. Depending on the joints involved, OA can cause a variety of functional impairments and affect the quality of life (QoL). Occupational therapy (OT) plays a critical role in the management of arthritis, including OA.[2] This case study illustrates the OT management of a patient diagnosed with bilateral knee OA in the Indian context of practice.
| Patient Information | | |
In early 2019, a 67-year-old female (Mrs. B) with chronic pain in both knees due to OA was referred to an occupational therapist (therapist) by an orthopedist. The referral indicated “evaluate and treat as needed.” The only significant diagnosis in her past medical history was Type II noninsulin-dependent diabetes.
| Clinical Findings | | |
Radiological findings revealed joint space narrowing and osteophytes on both sides (Grade 2 on the Kellgren-Lawrence Scale). Mrs. B was under physical therapy for pain management and strengthening when she consulted the therapist. The presenting complaints were pain, morning stiffness, and fatigue.
| Timeline | | |
[Table 1] presents the timeline with session outlines.
| Assessment | | |
The occupational profile[1] identified Mrs. B as a widow and retired clerk, who lives alone in an own, independent, and single-story house. Her daughter lives in a different city and visits Mrs. B once every few weeks. Her son lives abroad and calls her a few times a week.
Mrs. B is a Hindu by religion and had strong cultural beliefs and values. Her strengths included intact cognitive skills, normal vision, self-confidence, ability to follow instructions, and her desire to lead an independent life. When asked about her goals, Mrs. B reported that she wants to (i) live pain-free, (ii) age in place (does not want to go to an old-age home), and (iii) complete all her activities independently (does not want to depend on others for any activities).
The analysis of occupational performance showed that Mrs. B was independent in basic self-care activities and most of the instrumental activities of daily living (IADL) [Table 2]. However, she reported feeling very tired after engaging in activities for an hour. She experienced difficulties getting up from low surfaces (floor and sofa), especially when feeling stiff. Mrs. B also used cross-legged sitting during her prayers and while completing some kitchen tasks and found it difficult to maintain that posture for a longer time. | Table 2: Preintervention Instrumental Activities of Daily Living Performance of Mrs. B
Click here to view |
Mrs. B rated her pain as 7/10 and 5/10 for the right and left knees, respectively, on the visual analog scale during the assessment. Standing and walking for a longer time aggravated the pain. Rest, pain killers, and self-massage relieved the pain. Mrs. B's range of motion at both the knees was within the functional limits. She demonstrated 3/5 for knee extension and 3+/5 for knee flexion during manual muscle testing. Her body mass index was 27.2 (overweight; range 25-29.9). Mrs. B scored 27 on the Fatigue Assessment Scale (FAS)[3],[4] and 75/112 on the QoL Scale (QoLS).[5] The FAS was translated by the therapist in the Tamil language during the administration. The QoLS was administered using an interview format in Tamil. The patient was provided with a copy of the 7-point response scale during the administration.[6]
The home assessment revealed (i) clutter with many furniture contributing to extra energy expenditure, (ii) difficult to access kitchen cabinets causing Mrs. B to assume unsafe postures when retrieving things, (iii) shorter stone platform (used for handwashing clothes) in the backyard causing her to stoop and assume unsafe posture, and (iv) no handrails in the bathroom.
| Intervention | | |
The therapist collaborated with Mrs. B to identify pain reduction and improved ability to perform IADL tasks with less fatigue as goals. The person-environment-occupation model and rehabilitation frame of reference guided the intervention plan. The following sections describe the intervention.
Patient Education
The therapist delivered education on the importance of low-impact aerobic exercises and weight reduction, highlighting how they can help decrease stress on the knees.[7],[8] The therapist suggested Mrs. B to use comfortable sneakers, for which she was initially apprehensive. She felt that wearing a sneaker with sarees may look awkward. The therapist showed online images of older women wearing a sneaker with saree to clarify that it is a growing practice in major cities of India. The therapist left the decision to use sneakers with the patient. In addition, the therapist educated the patient on fall prevention, as fall is a major issue among older women with diabetes.[9]
Home Modification
The following recommendations were made: (i) reduce clutter by storing unused furniture and items in a storeroom to reduce home management demands, (ii) install handrails in the bathroom to reduce joint loading when getting up from the toilet seat and minimize fall risk, (iii) replace sofa with sturdy wooden chairs with cushion to avoid low sitting, and (iv) rearrange items to keep often used items nearby to conserve energy.
Activity Modification
The therapist taught the energy conservation and work simplification principles and advised Mrs. B to take rest between the activities. Mrs. B was suggested to use a cutting board and knife for cutting vegetables instead of boti [Figure 1] to minimize floor sitting and getting up, as flexed knee positions can overload the joint and standing up from floor sitting may increase joint loading.[10] However, Mrs. B said that she had always used a boti to cut vegetables, grind coconut, etc., and it would be difficult for her to use a knife. After deliberation, it was mutually agreed that the boti's platform will be stabilized on the kitchen countertop using a long bolt and nut after drilling a hole in boti's wooden platform and the countertop to enable her to complete vegetable cutting while standing. A local mason completed this installation. At unused times, the boti was covered using a wooden sewing machine lid. A wooden chair was placed near the kitchen top so that Mrs. B can rest between the tasks as needed.
The patient declined the suggestion of using a washing machine to wash clothes due to her cultural beliefs and values. She does not want to accumulate dirty clothes in her house for several days to load the washing machine adequately. She believed that God's blessing will be there if the home is clean and tidy. Mrs. B was advised to purchase a wooden stool of suitable height to sit while handwashing clothes.
Assistive Device
The therapist recommended the use of a reacher to easily place and retrieve things in the cabinets and pick up things from the floor. Mrs. B searched for and selected her preferred reacher using an e-commerce platform and ordered it, with assistance from her daughter. The daughter agreed to fill ingredients in small containers during her visits so that it is easy for Mrs. B to safely retrieve containers using the reacher. The use of the reacher eliminated unsafe postures including tiptoe standing to retrieve items that were far in the cabinets. The therapist also provided context-based (home) training in the use of reacher. The therapist suggested the use of a rollator walker, which may help with pain reduction and provide an opportunity to sit and rest irrespective of the places. The patient declined the suggestion as she felt that it may provide her with a handicapped identity. She also refused the suggestion to use a cane.
| Follow-Up and Outcomes | | |
Six months postdischarge, the patient was contacted virtually by the therapist. The patient reported having less fatigue and pain. The patient completed FAS and QoLS the same way she completed prior to the intervention. There was a notable improvement in both the scores. The FAS score went down to 16 and QoLS score increased to 90/122, indicating less fatigue and improved QoL.
| Discussion | | |
The purpose of reporting this case study was to illustrate how OTs could assist patients with OA in the Indian context of practice, as the author believes that case reports may enhance stakeholder understanding of the OT. It was evident through this case study that just a few sessions of OT can improve symptoms and make a meaningful difference in the QoL of a client with OA. In addition, this case study underscores the importance of detailed assessment and client centeredness in OT practice.
Initially, Mrs. B struggled to understand the connection between the therapist's recommendations and her symptoms. However, when the therapist explained how the recommended strategies will alleviate pain and reduce fatigue in the long term, she recognized the connection and gradually became more involved in the therapy.
| Implications of the Case for Practice | | |
- When treating patients with OA, OT evaluation must extend beyond a chart review, interview, and physical assessment
- The patient's life situation, values, and socioeconomic status made this OT intervention possible. Hence, these factors need consideration during treatment planning in the Indian context of practice
- As India's demography and family systems are changing, more elderly people will be in a situation to lead an independent life with quality. This may cause an increased demand for OT services in geriatrics.
| Patient's Perspective | | |
The patient reported, “Now, I am doing well. I don't feel much tired nowadays. I think OT gave me more long-term pain relief than other treatments. It is really a problem-solving therapy."
Informed Consent
The patient provided informed consent to report this case study in a journal with anonymity.
Financial Support and Sponsorship
Nil.
Conflicts of Interest
There are no conflicts of interest.
| References | | |
| 1. | Pal CP, Singh P, Chaturvedi S, Pruthi KK, Vij A. Epidemiology of knee osteoarthritis in India and related factors. Indian J Orthop 2016;50:518-522.  [ PUBMED] [Full text] |
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| 3. | Shahid A, Wilkinson K, Marcu S, Shapiro CM, editors. Stop, that and One Hundred other Sleep Scales. New York: Springer Science; 2012. p. 161-162. |
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| 6. | Burckhardt CS, Anderson KL. The Quality of Life Scale (QOLS): reliability, validity, and utilization. Health Qual Life Outcomes 2003;1:60. |
| 7. | Escalante Y, García-Hermoso A, Saavedra JM. Effects of exercise on functional aerobic capacity in lower limb osteoarthritis: A systematic review. J Sci Med Sport 2011;14:190-198. |
| 8. | Sinusas K. Osteoarthritis: Diagnosis and treatment. Am Fam Physician 2012;85:49-56. |
| 9. | Schwartz AV, Hillier TA, Sellmeyer DE, Resnick HE, Gregg E, Ensrud KE, et al. Older women with diabetes have a higher risk of falls: A prospective study. Diabetes Care 2002;25:1749-1754. |
| 10. | |
[Figure 1]
[Table 1], [Table 2]
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