Lecture 19: Rheumatology Flashcards
(40 cards)
What is arthritis?
Inflammation w/in a joint that can have many causes. It is associated w/ pain, stiffness, edema/swelling.
-May appear as acute episodes w/ periods of remission or chronic symptoms.
What are the common rheumatic/arthritic conditions?
- Rheumatoid Arthritis
- Osteoarthritis
- Juvenile Idiopathic Arthritis
- Diffuse Connective Tissue Diseases: Systematic Lupus Erythematous, scleroderma, polymyositis and dermatomyositis.
- Crystal-induced arthritis: Gout
- Spondyloarthropathies: ankylosing spondylitis, Reiter’s syndrome, psoriatic arthritis.
- Fibromyalgia
What is Raynaud’s Phenomenon?
- Episodic vasoconstriction of the arteries of the hands or feet leading to cyanosis or blanching, burning or tingling.
- Usually associated w/ cold or stress.
- Erythema (redness of the skin) can be seen after vasospasm as a result of vasodilation.
- What is RA?
- Epidemiology of RA.
- Etiology
- Chronic, systemic, inflammatory disorder. Inflammation of joints w/ associated damage. Often progressive.
No cure, medication slows progress of the disease. - 1% population. Women>men. Age onset 25-50yo.
- Cause=unknown, combination of factors.
- Genetics (HLA-D)
- Environment
- Multiple cell types involved
- Auto-immune involvement: Immune system attacks healthy tissue of the body especially joints and periarticular surfaces.
- High levels of autoantibodies.
What is the clinical course of RA?
Typically manifests in small joints of the hand and feet.
Insidious or sudden onset. Type 1: Self-limited Type 2: Minimally progressive Type 3: Progressive -Flare ups and remission common
What are symptoms of RA?
- Fatigue
- General malaise
- Low grade fever during active phase
- Anemia
- Weakness
- Depression
- Weight loss
What are the articular manifestations of RA?
- Symmetrical pattern
- Pain
- Swelling
- Stiffness (usually after periods of inactivity)
- Joint deformities
What are common hand and wrist deformities?
Neck?
- Swan neck
- Boutonniere
- ZigZag deformity thumb
- UD MCPs
- ZigZag wrist and fingers (RD of wrist w/ UD MCPs)
- Synovitis
-C1-2 subluxation
What are common feet and toe deformities?
Knees?
- Mallet Toe
- Hammer Toe*
- Hallux Valgus*
- Claw Toes
- Most common
Genu Valgus or Varum
Must look at different factors to confirm RA diagnosis, not one single test:
- Who should be tested for RA?
- What is the diagnosis based on?
- What are the criteria for diagnosis of RA?
- Why is early diagnosis important?
- 1 joint w/ clinical synovitis.
- Synovitis is not better explained by another disease.
2.
-Joint involvement: Large joints, small joints.
-Lab Tests:
Serology: RF and ACPA
Acute Phase Reactants: CRP, ESR (general swelling/inflammation factors)
-Duration (< or > than 6 wks)
See table in slides
- New (acute) pts: > 6 points
Pt w/ erosive disease typical of RA and hx of prior fulfillment of criteria (>6pts)- including pts whose disease is inactive. - To get medication early, slow the disease process. To minimize inflammation causing joint deformity and laxity.
What are the differences b/w RA and OA
Systemic: RA-Yes OA-No
Morning Stiffness Duration: RA- longer >30 min OA-Shorter as when the move it gets better <30 min
Extra-Articular Manifestation: RA-Yes (Rash, Raynaud) OA-No
Symmetrical: RA-Usually OA-No (sometimes can have symmetry w/ wb joints)
Joint involvement: RA- Mainly small hands, wrists, elbow, shoulders, hip, knees, neck and feet.
OA- hip, knee WB joint, Usually DIP, PIP, 1st IP, MCP, 1st CMC.
Inflammatory process:
RA- Primary (auto-immune) Inflammation then jt degradation and laxity.
Secondary- Jt degeneration then inflammation, crepitus, osteophytes.
What are the general management strategies for rheumatic conditions?
- Interdisciplinary approach
- Early intervention (delay deformity)
- Ongoing care
- Systemic reassessment
- Pt and family involvement
- Ecosystem approach (home/work eval)
PT sees pt over a long period of time, especially during periods of flare up or after jt replacement.
What is involved in the medical management of RA?
Drug Therapy:
- NSAIDS
- Corticosteroids
- Disease-modifying anti rheumatic drugs (DMARDs): Traditional, biologics and biosimilars.
Surgery: Jt replacement.
What are the components of a PT evaluation for RA?
Hx: Can be extensive depending on how long they have had the disease. Current/past illness, surgeries, rehab services, medication, appt w/ a rheumatologist, social hx.
Disease activity and damage:
1) Inflammation: duration morning stiffness, grip strength, active joint count, VAS, ES rate, RF, X-ray.
2) Damage: Damage jt count
3) Extra-articular features (Raynaud’s)
Physical and functional status: ROM, strength, endurance, transfers, gait, posture, balance, neuro.
What are the goals of PT Rx for RA?
- Educate pt and caregiver (disease process and self-management)
- Control inflammation
- Decrease pain and stiffness
- Decrease rate of damage and preserve jt integrity
- Increase and maintain jt mobility and ms strength. It is a progressive disease so there will be deterioration over time-try to maintain as much as possible.
- Preserve or restore function.
What PT interventions are used for RA?
1) Education: Dx, ice/heat, Jt protection (ex: use splints, avoid maintaining same position for prolonged periods), energy conservation, exercise, body mechanics, links other info, self-management, footwear/insoles.
2) Exercise: ROM, stretching, balance, land and water based CV, HEP.
3) Thermal modalities: Use ice during flare-up, do not use heat this will increase inflammation.
May use hot and cold same time at different joints.
Active-cold
non-Active-hot to help w/ pain
4) Electrotherapy
5) Manual therapy: limited role b/c of jt instability especially spine.
6) Walking aids
7) Referral
What are the ACSM guidelines for RA?
What is the goal of ACSM guidelines?
Special Consideration?
ROM/Flexibility: Daily all major ms groups
Resistance: 2-3d/wk , light to high, if jt damage lower intensity recommended.
Aerobic: 3-5 d/wk, light to mod, >150 min. Activities low jt stress.
Generally these guidelines are similar as for healthy adults, just have to consider pain and status- during active flare up activity may be contraindicated.
Goal: Minimize pain but gradually progress towards a level that provide health benefits.
Special Consideration:
- Functional Ex
- Adequate WU/CD to min pain
- Avoid strenuous Ex during acute flare-up (ROM are appropriate- parameters for acute/irritable condition 5-10 reps no hold 2-5 times per day).
What are the recommended clinical practice guidelines for RA?
Cochrane?
- Ex therapy
- Education
- US, Estim, LLT, thermotherapy
- Message, manual therapy, balneotherapy.
Cochrane:
- Exercise
- Thermotherapy
- US
- TENS
- E-stim
- LLLT
- Split and orthoses
- Tai-chi
Systemic Lupus Erythematosis (SLE)
- Epidemiology
- General Presentation
- Clinical Course
- System involvement
- Lab tests
- Medical Management
- 1 per 2000, women>men b/w age 15-40yo.
- Chronic, systemic, inflammatory auto-immune disorder with multi-organ involvement. Genetics factors play a role. Antibodies attack healthy tissue resulting in inflammation of many tissues in body.
- No characteristic pattern. Initial presentation can be linked to fever, weakness, fatiguability and weight loss. Usually periods of active flare-ups and remission.
- Joints:
-Symmetric
-Inflammatory but non-erosive. Deformities are rare and ca be reversible
-Small>larger joints
-mainly capsule/supporting structures.
Sling: photosensitivity rash, butterfly rash, ulcers.
Muscles: myositis.
Kidneys, lungs, Gi, cardiac, vascular, neuro and neuropsych also involved. - Antinuclear Antibodies (ANA)
Hematological abnormalities: low WBC, RBC, platelets or combination
High ERS - Drugs: NSAIDs, Glucocovrticosteroids and DMARDs.
PT evaluation and treatment for SLE?
Eval: Similar to RA, but more close examination of all systems. Heart/lung->endurance
Neurological->balance
Treatment: Advice for skin rash (avoid sun, sun block and protective clothing)
Scleroderma:
- Epidemiology
- General Presentation
- Types
- System involvement
- Specific Changes
- Rare 5-15 per 1 million. Female>male 30-50
- Genetic and environmental causes.
Systemic, auto-immune, connective tissue disease characterized by fibrosis of the skin and internal organs.
Inflammation, vasculopathy and fibrosis (collagen deposits).
Sclera=Hardening Derma=Skin Fibrotic changes in the skin characteristic feature.
Early symptoms: muscle pain and stiffness.
3. Limite Scleroderma C-Calcium deposits R-Raynaud E-Esophageal dismotility S-Thickening skin toes and fingers T-small dilated blood vessels
-Skin involved distal to elbow and knees. Less organ involvement. Neck and face are not involved. Better prognosis.
Diffuse Scleroderma
- Trunk and proximal limbs
- Sever organ involvement
- Peak after 5-6 hrs then regression
- Skin: Thickening/rigidity of skin and ca deposits
MSK: Erosive arthritis and myositis.
GI, Lung, Cardiac, Renal - Hand Involvement: Edema (sausage fingers), Thickening of skin, bonds resorption, contractors, Ca deposits. Raynaud common 90%.
Mauskopf Facial Change: Contractors and hardening of facial tissue: muscle atrophy, absence skin folds, pursed lips, poor oral aperture, expressionless.
PT interventions for Scleredoma
- ROM for affected jts
- Facial and mouth ex
- Strengthening
- Hot pack or wax bath
- Monitor skin integrity w/ ROM/stretching
- Education re cold exposure, monitor w/ heat
Mouth Exercises:
2X/day, 15 min each over 18 wk improve mouth opening 10 mm.
Improve eating, speaking, oral hygiene and insertion dentures.
1) Finger exercise
2) Splint
Gout (Crystal-Induced Arthritis)
- Epidemiology
- Etiology
- Most commonly affected joint
- Clinical presentation
- Medical Management
- 1% population, male>female, peak 40-50 yo.
- Acute inflammatory condition resulting from hyperuricemia: excess of uric acid in the blood, leading to the formation of hard uric acid crystals in one joint which can lead to joint degeneration.
- 1st MTP, may also affect heels, ankles and knees. (Kidneys as well).
- Rapid onset of swelling and redness of a joint, combined w/ pain. Feet or LE involvement and inability to WB. Fever and chills. Flare-up lasts 1-2 wks.
- NSAIDs for acute attack and Allopurinol to reduce uric acid production.
Role of PT for Gout?
Similar to other rheumatic conditions.
Possibly assistive devices if walking is affected.
Fairly rare.
