List use, mechanism of action, potential side effects for medications used for arthritis: NSAIDs
Use: OA, RA, sprains, inhibition of heterotopic ossification Mech: inhibits COX Side Effects: GI upset, peptic ulcers, renal function, excessive bleeding
List use, mechanism of action, potential side effects for medications used for arthritis: COX-2 inhibitor
Use: OA, RA, sprains, inhibition of heterotopic ossification Mech: inhibits COX-2 Side effects: renal and possibly cardiac function
List use, mechanism of action, potential side effects for medications used for arthritis: glucocorticoids
Use: RA, systemic lupus erythematosus, gout, inflammatory diseases Mech: inhibits many inflammatory mediators Side effects: wt gain, bone/muscle loss, hyperglycemia
List use, mechanism of action, potential side effects for medications used for arthritis: methotrexate
Use: RA, seronegative arthritis Mech: inhibits adenosine metabolism side effect: pneumonitis, leukopenia, liver disease, infection
List use, mechanism of action, potential side effects for medications used for arthritis: Sulfasalazine
Use: RA, seronegative arthritis Mech: inhibits B cell activity side effects: bone marrow suppression, rash, hepatitis
List use, mechanism of action, potential side effects for medications used for arthritis: anti-TNF therapy
Use: RA, psoriatic arthritis, ankylosing spondylitis Mech: inhibits tumor necrosis factor (TNF) Side effects: infection, heart failure, possibly lymphoma
List use, mechanism of action, potential side effects for medications used for arthritis: antimalarials
Use: RA, lupus Mech: inhibits enzyme activity Side effects: eye changes and vision loss
List use, mechanism of action, potential side effects for medications used for arthritis: gold
Use: RA Mech: inhibits WBC activity Side effects: anemia low WBC, count, lung diesase proteinura
List use, mechanism of action, potential side effects for medications used for arthritis: minocycline
Use: RA, reiter syndrome Mech: inhibits metalloproteinase Side effects: hepatitis, lupus like reactions
List use, mechanism of action, potential side effects for medications used for arthritis: colchicine
Use: gout, psuedogout Mech: inhibits microtuble
List use, mechanism of action, potential side effects for medications used for arthritis: leflunomide
Use: RA psoriatic arthritis Mech: inhibits IMP, diarrhea, liver tocidity, HTN
Describe characteristic signs and symptoms of RA:
Symmetric arthritis of small joints of the hands (sparing DIPs), wrists, feet, and knees that is associated with morning stiffness. Rheumatoid nodules as well as serum rheumatoid factor may be evident. X-ray changes. Symptoms >6 wks
X-ray changes present in RA:
- periarticular osteopenia first - erosions may develop at joint margins - loss of joint space, malalignment, and progressive osteopenia
Who may be affected by RA?
1% of population. May begin at any age, most common in women of childbearing years and elderly men/women. Genetic influences
Describe joint pathology in RA:
Chronic thickening and edema of synovial lining; underlying connective tissue cells become activated to invade and destroy cartilage and bone at joint margins - pannus formation
Most common hand and wrist deformities with RA:
1.) swan neck deformity (flexion at DIP, ext at PIP) 2.) boutonniere deformity (ext DIP, flexion PIP) 3.) ulnar deviation at MCPs 4.) flexion, radial deviation, and subluxation at wrist 5.) extensor tendon rupture at wrist
Name the types of juvenile RA
- pauciarticular: involving < = 4 joints
- poly articular: similar in nature to adult RA
- systemic onset with fever, arthritis, rash, and other organ involvement
what is the prognosis for patients with RA?
variable: 50% will be disable from work within 10 yrs, 2/3 have significant trouble with ADLs after 15 yrs; severe may die within 10-15 yrs
Define rheumatoid factor:
Does RA effect the spine?
synovium of odontoid proocess of C2 and the transverse ligament that holds C2 and C1 may become involved and cause erosion leading to instability. Pain and myelopathy may develop
Physical therapy treatments that are helpful for RA?
Acutely inflamed: Heat, rest, splinting to avoid contracture Decreased inflammation: isometric exercise, ROM, strengthening ex, parafin, TENS
Orthopedic procedures that are most often used for RA involving wrist and hand:
- synovectomy - arthrodesis (joint fusion) - soft tissue reconstruction - arthroplasty
What is the Darrach procedure?
excision of the distal ulna often accompanied by synovectomy and extensor tendon repair when needed
What is systemic lupus erthematosus?
multisystem inflammatory disease that may cause fever, fatigue, rash, cytopenia, renal disease, serositis, lung disease, nervous system change, joint pain, and other problems
Is lupus diagnosed by the presence of antinuclear antibodies (ANA)?
99% of lupus patients have this, but there is a 30-40% false positive rate, lupus is a clinical diagnosis
Musculoskeletal problems arising from lupus:
arthralgia and arthritis, osteonecrosis, tendinitis and tendon rupture, fibromyalgia, steroid myopathy, polymyositis
Describe typical lupus arthritis:
- arthralgias are most common, without visible swelling - when inflammation is present it is typically in the small joints of the hand - not erosive but may see some swan neck or jaccound's arthropathy
Name the seronegative arthropathies:
ankylosing spondylitis, reiter syndrome (reactive arthritis), psoariatic arhtritis, arthritis associated with inflammatory bowel disease
List the clinical features that the seronegative arthropathies share:
- enthesitis (inflammation at sites of insertions of tendons and ligaments into bone) - sacroilitis and other axial involvement - Asymmetric, peripheral pauciarticular inflammatory arthritis - extra articular disease involving GI or genitourinary systems, skin, and eye - association with HLA-B27
what is Reiter syndrome?
seronegative arhtritis that is triggered by infection typically chlamydia, shigella, or yersinia
Ankylosing spondylitis vs mechanical LBP?
age of onset: late teens to 20s vs any age Timing of onset: insidious nontraumatic vs sudden/traumatic pain with rest: increased vs decreased pain with activity: decreased vs increased stiffness: ++++ vs + or - less than 15 min
Treatments for ankylosing spondylitis
- education and exercise - extension exercises 3x/day swimming recommended, posture, and sleeping with out a pillow to prevent kyphosis - NSAIDs for pain and inflammation, mexatrexate and sulfasalazine
Describe x-ray changes in ankylosing Spondilitis
- erosion, sclerosis, pseudo widening, ultimate fusion of SI joints, squaring helement pins
what causes gout?
aculumation of uric acid crystals in synovial joints. Polymorphonuclear leukocytes are attracted to the joint, try to engulf the crystals, and release digestive enzymes and proinflammatory mediators
What causes pseudogout?
Calcium pyrophosphate crystals initiate inflammation
How can the crystal types in gout and pseudogout be distinguished?
Examination of synovial fluid under a microsope
Phases of gout:
- asymptomatic hyperuricemia (elevated serum uric acid level) - acute gouty arthritis - intercritical gout (asymptomatic between episodes) - chronic gout (tophi, deposits of uric acid)
Describe a typical episode of acute gout:
sudden onset of severe burning pain often in the middle of the night, usually involving the first MTP. WB'ing or even wt of sheets may be unbearable. Joint is red and swollen, hot to the touch. Resolve in 7-10 days. May be percipitated by alcohol consumption, trauma, surgery, or immobilization
Joints other the first MTP effected by gout:
any joint can be effected, but most commonly affected are the knee, ankle, midfoot, wrist, and hand.
what are tophi?
painless lumps in chronic gout often seen at the olecranon, fingers, toes, or outer ear
How is acute gout treated?
cold packs, NSAIDs, local injection or oral administration of cortiocosteriods. Colchicine is not recommended generally.
Can gout be diagnosed by an elevated serum uric acid level?
No. Made by examination of joint fluid
Differential Dx for a single red hot joint?
infection (most serious) r/o with synovial fluid test, acute gout, hemarthrosis, pseudogout, RA, seronegative arthropathy, tumor, pigmented villodular synovitis
Clinical signs of infected total joint prostheses:
acute infection, wound dehiscence or drainage, inflammation (pain, redness, swelling, heat), loosing of the joint
Infected joint arthoplasties are treated by:
early on with aggressive lavage and intravenous antibiotics, if not caught the joint must be removed and extensive antibiotic treatment ensues before a new replacement can be put in
How common is OA?
prevalence increases with age: >80% of people >75 yrs of age
Pathological changes with OA:
thinning and damage to articular cartilage, subchondral bone sclerosis, marginal bone and cartilage growth as osteophytes, periarticular muscle wasting
Which joints are commonly involved with OA:
DIPs and PIPs, Hips, lumbar spine, knees, feet (first MTP)
Treatments able to stop progression of OA?
No, a few studies suggest minocycline may slow the progression of OA, glucosamine sulfate may increase joint space in OA knees