Rheumatic Disease

Question 1

RA

Answer 1

Systemic auto-immune disease characterized by pannus that destroys articular cartilage

Chronic inflammatory polyarthritis (5+ joints)

Primarily affects synovial joints (blood vessels, heart, lungs, etc)

MOST COMMON OF THE INFLAMMATORY DISEASES

Question 2

Three disease courses

Answer 2

Monocyclic
Polycyclic
Progressive

Question 3

Monocyclic

Answer 3

One episode which ends within 2-5 years of initial diagnosis and did not reoccur

May result from early diagnosis and/or aggressive treatment

Question 4

Polycyclic

Answer 4

The levels of disease activity fluctuate over the course of the condition

Question 5

Progressive

Answer 5

RA continues to increase in severity and is unremitting

Question 6

RA: Natural History

Answer 6

Radiographic erosion typically fastest in the first year of disease

75% of people with RA experienced remission within 5 years of dx

Question 7

Female hormones

Answer 7

Appear to influence development of RA

Question 8

RA Incidence

Answer 8

Peak onset 60 years of age

Decrease incidence with the use of oral contraceptives; remission of symptoms during pregnancy

Increase in symptoms after menopause

Question 9

RA Primary Pathological Event

Answer 9

Takes place in synovium

^^^ Suggesting the offending agent is carried to the joint via the bloodstream

Question 10

RA Etiology

Answer 10

Pannus production

Catabolic enzymes produced which causes collagen break down

Joint effusion further stresses articular cartilage

Effusion stretches the capsule and causes ligamentous instability

Question 11

RA Characteristics

Answer 11

Rheumatoid factors

Insidious development of symptoms

Symmetric early involvement in hands, wrist, feet, and ankles

LATER - develop joint deformities, contractures, which affect WB and NWB joints

Question 12

Who should be tested?

Answer 12

Patients that have at least 1 joint with definite clinical synovitis with it not being explained by another disease

Question 13

Classification criteria for RA

Answer 13

> 6/10 needed for definite RA classification

Question 14

RA Differential dx

Answer 14

Systemic lupus erythematosus
Psoriatic arthritis
Gout

Question 15

Comorbidities

Answer 15

CVD (ischemic heart disease)
Infections (TB)
Mental health conditions (anxiety and depression)
Malignancies (leukemia and multiple myeloma)

Question 16

RA Clinical Features

Answer 16

Morning stiffness at least 1 hour

Arthritis in at least 3 joint areas with swelling or fluid

Arthritis of hand joints (1 wrist, MCP, PIP joint swollen)

SYMMETRIC joint swelling and involvement

Positive Rh factor

Radiographic changes typical of RA

Subcutaneous nodules

Question 17

RA Radiologic Features

Answer 17

Soft tissue changes EARLIEST sign of disease

Articular erosions within first 2 years

Osteoporosis

Joint space narrowing

Question 18

RA Joint Deformities

Answer 18

Subluxations and dislocations occur secondary to capsular and ligamentous laxity, destruction of joint surfaces, and tendon ruptures

Flexion contractures result

Swann neck/boutonniere deformity

Hallux valgus, hammer toe

Joint ankylosis

Question 19

Boutonniere deformity

Answer 19

DIP extension

PIP flexion

Question 20

Swan neck deformity

Answer 20

PIP hyperextension

DIP flexion

Question 21

RA Changes in Cervical Spine

Answer 21

Narrow facet joints

Narrow intervertebral joints

Subluxation of atlanto-axial joint from laxity of transverse ligament

Question 22

RA treatment

Answer 22

Initially - education, protection, splinting

PT indication depends on whether acute exacerbation or period of remission

Medications

Orthopedic surgeries

Question 23

RA Medications

Answer 23

Traditionally NSAIDs

DMARDS within 3 mos

Question 24

DMARDs

Answer 24

Disease-modifying

Slow the progression of RA and save the joints and other tissues from permanent damage

SE - liver damage, bone marrow suppression, severe lung infections

Question 25

Biologic agents

Answer 25

Newer class of DMARDs Can target parts of the immune system that trigger inflammation that causes joint and tissue damage Also increase the risk of infections

Question 26

Pannus

Answer 26

Inflammatory synovitis An invasive granulation tissue that invades and erodes subchondral bone and cartilage

Question 27

Steroids

Answer 27

Reduce inflammation, pain, and slow joint damage SE - thinning of bones, weight gain MDs may prescribe a corticosteroid to relieve acute symptoms, with the goal of gradually tapering off the medication

Question 28

NSAIDs

Answer 28

Side effects may include ringing in your ears, stomach irritation, heart problems, and liver and kidney damage

Question 29

Deep heat

Answer 29

NOT RECOMMENDED DURING ACUTE INFLAMMATION

Question 30

Pain post exercise

Answer 30

Should not have > 1 hour post-exercise

Question 31

Acupuncture for RA

Answer 31

Limited studies have shown it can help

Question 32

Fish Oil

Answer 32

May be as effective as NSAIDs

Question 33

Juvenile RA

Answer 33

Juvenile Ideopathic Arthritis Onset before age 16 Symptoms last from 6 weeks to 3 mos One or more joints Often accompanied by fever, rash, eye inflammation

Question 34

ARA list of criteria for dx

Answer 34

Chronic synovial inflammation of unknown cause Onset in children younger than 16 Evidence of arthritis in 1 or more joints for 6 consecutive weeks ``` Exclusion of other diseases... Lyme disease Lupus Bone disorders Cancer ```

Question 35

RA Sx/sy

Answer 35

``` Limping Stiffness upon wakening Reluctance to use arm or leg Reduced activity level Fever Joint swelling Difficulty with fine motor activities ```

Question 36

Pauciarticular/oligoarticular JRA

Answer 36

4 or fewer joints after 6 mos of symptoms 1/2 cases of JRA Most common pattern onset before 4 yo Morning stiffness, reluctance to play Begins at one joint - knee, ankle, wrist, fingers May span multiple joints and go into adulthood

Question 37

Polyarticular JRA

Answer 37

5 or more joints Symmetric involvement of knees, wrist, fingers, ankle More common in girls Seronegative 1-3 Seropositive in adolescence (indistinguishable from adult RA)

Question 38

Systemic JRA

Answer 38

Illness begins with high spiking fevers likely complicated by pericarditis, pleural effusions, enlargement liver, spleen, lymph nodes 10% all cases Onset between 4-9 years Salmon pink rash that comes and goes Joint swelling until months after fevers begin Arthritis may persist after other symptoms resolve

Question 39

Psoriatic JRA

Answer 39

Arthritis with psoriasis

Question 40

Overall treatment goals

Answer 40

Control symptoms Prevent joint damage Maintain function Maintain activity and participation levels

Question 41

Medication Lines

Answer 41

1st - NSAIDs 2nd - DMARDs Caution with steroids

Question 42

Ankylosing Spondylitis

Answer 42

Chronic progressive inflammatory arthritis characterized by joint sclerosis and ligamentous ossification Men affected 7x greater that women Begins in 20s Early dx confirmed by lab studies elevated ESR

Question 43

Sx/sy Ankylosing Spondylitis

Answer 43

Early state have LBP and morning stiffness Spondylitis and marked limitation of LS motion ***Skin distraction test to confirm Will spread to thoracic and cervical spines later on Decreased lumbar lordosis Increased thoracic kyphosis Immobile cervical spine

Question 44

Radiographs with Ankylosing Spondylitis

Answer 44

Bamboo spine

Question 45

Ankylosing Spondylitis Treatment

Answer 45

``` Psychological considerations Pharmacology Orthopedic appliances PT Possible orthopedic surgery ```