Are women or men more likely to have RA
women
When is the onset for RA
35-50
Which populations have the highest levels of RA? The lowest?
Aboriginal
Asian
What is the pathophysiology of RA
Autoimmune disease
- In response to immunologic factors synovial membranes become inflamed
What triggers RA
Genetic susceptibility and environmental triggers
What are the characteristics of synovitis
- Hyperplasia (synovial cell proliferation)
- Increased vascularity
- Infiltration of inflammatory cells - resulting in the production of enzymes that causes inflammation
- Articular damage cased by pannus
what is pannus
granulation tissue formed within synovium
What is the difference between joint damage in OA and RA
In an RA affected joint damage is throughout the joint surface (unlike OA where you see the most damage near site of stress)
- In RA there can also be bone damage leading to osteoporosis
What happens when a joint is affected by RA
- In response to immunologic factors, the synovium becomes swollen and cells begin to proliferate
- A densely cellular membrane )pannus) spread over the cartilage and erodes the underlying cartilage and bone
- Pannus can cause fibrous scar tissue, adhesions, and ankylosis on opposite articular surfaces
- Bone becomes more osteopenic, ligaments and tendons are damage, surrounding muscle deteriorates
What is the response of the synovium to immunologic factors
becomes swollen and cells begin to proliferate
What is the result of pannus spreading over the articulare cartilage
erodes the underlying cartilage and bone
What is the result of pannus spreading to the opposite articular surface
creates fibrous scar tissue, adhesions, and ankylosis
What is the result of tendon and ligament damage in RA
increased risk of rupture
What is the result of ligament damage and deteriorating musculature
leaves joints unstable and prone to deformity
Familial history of RA increases overall risk by ___
2x
What is the genetic marker for RA
Rheumatoid factor HLA-DR4
Rheumatoid factor (RF) HLA-DR4 is present in ___% of people with RA
80%
Rheumatoid factor (RF) HLA-DR4 accounts for ___% of the genetic risk in RA
30%
High RF can also be present in people with what conditions?
Lupus, syphilis, chronic or idiopathic pulmonary fibrosis
when else might you see elevated levels of RF
in aging population - 5-10% of healthy people>60yrs have it
What are the risk factors for RA
- Genetics
- Pregnancy & hormonal factors
- Environmental factors - Smoking, occupation, diet,
What occurs to your risk of RA following child birth
increases
What may be a reason for why risk of RA increases following child birth
breast feeding - associated with increased prolactin
Oral contraceptive use Increases or decreases you risk of RA
decreases by postponing disease onset
What are the findings for risk of RA in those using postmenopausal hormones
inconsistent
smoking use Increases or decreases you risk of RA
increases - especially in men
What type of RA is smoking associated with
seropositive RA
Which occupations are associated with a risk in RA
Miners (silica exposure)
Farmers (pesticide exposure)
Which dietary choices are associated with decreased risk of RA
- Olive oil consumption
- Fish consumption (>3times/week)
- Drinking tea (>3cups/day) - antioxidants
What are the 7 criteria for RA
- Morning stiffness >1 hours (>6 weeks)
- Arthritis of > 3 joints (>6 weeks)
- Arthritis of hand joints (>6 weeks)
- Symmetric arthritis (>6 weeks)
- Rheumatoid nodules
- Serum rheumatoid factor positive
- Radiographic changes
How many RA criteria need to be met for a diagnosis
4 or more
Clinical features of RA
- Pain
- Fatigue
- Stiffness
- decreased ROM
- often involves small joints
- often symmetrical
- swelling
- joint deformity
- Instability of the joint
- Muscle atrophy, general deconditioning
- Extraarticular features
When the disease is quieted down - what are acceptable training levels
you can train at high intensities
Where do rheumatoid nodules develop?
subcutaneously in elbow, finger, wrist, hip joints, lower back and achilles tendon
Occasionally in heart and lung tissue
rheumatoid nodules are found in ___% of people at the time of diagnosis
7%
Rheumatoid nodules affect __% of patients are some point during their disease
30%
What sensations occur during the warming or stress relief of raynauds patients
- Numb, prickly feeling or stinging pain
Raynauds is present is ____ of RA patients
17%
What are the 4 major management areas for RA
- Medications
- Rehabilitation interventions
- Lifestyle modification/self-management
- surgery
What are 5 types of medications for RA
- Traditional DMARD
- Biologiv DMARD
- NSAID
- Tylenol
- Corticosteroid
Which medication is the first line of treatment
DMARD
What are DMARDs used for
to halt the disease process - prevent irreversible joint damage
What is the consequence of not using DMARD
premature death
What is the downside to DMARDs
very expensive
What is the target of treatment for people with a new RA diagnosis
Achieve and maintain remission
What is the target of treatment for people with establish long-standing RA diagnosis
achieve and maintain low disease activity
When is medication escalated
until the target is reached and promptly modified when the target is no longer
Is typical or biological DMARD more effective
Biological
What is the goal of rehabilitation interventions in the acute phase of RA
Control/decrease inflammation, control pain
What are the modes of rehabilitation intervention in the acute phase
- Balance rest & activity
- ICe
- Splints
- ROM exercises
Should you stretch an acutely inflamed joint? why?
No because the synovial membrane is already distended
What are the goals of rehabilitation interventions in the chronic phase of RA
- Improve knowledge of RA and active self management
- Improve pain and stiffness
- Increase function & activity level
- Prevent deformity
- Address muscle imbalances
What are the 4 Rs of surgical management
- Remove - synovectomy, MTP resection
- Re-align - tendon rupture repairs
- Rest - Arthrodesis (surgical fusion) of the ankle, wrist, C1-C2
- Replace - Arthroplasty hip, knee, ankle, shoulder, MCP joints
