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Multi Systems > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

1
Q

Rheumatoid Arthritis

A

Systemic inflammatory disease characterized by symmetrical polyarthritis

AUTOIMMUNE DISEASE

Primarily a disease of the synovium - inside layer w/in the joint capsule
- Synovial cells will proliferate & caus this thick swollen membrane

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2
Q

RA: Epidemiology

(2)

A

F>M (2-4x)

30-45 most common age of onset

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3
Q

Rheumatoid Factor

A

Are antibodies with are found in the sera of approximately 70% of patients affected with RA
- RA (+) often have a more severe or aggressive form of RA
- RA can also occur in patients who are RF negative

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4
Q

Laboratory Tests

(4)

A

Acute phase reactants
- INC Erythrocytes (RBC) Sedimentation Rate (ESR) = RBC drop to the bottom - sediment @ the bottom of the test tube (how long it takes for that to occur)
- INC C-reactive Protein (CRP)
- Indication of active inflammation

Prescence of autoantibodies
- Rheumatoid Factor (RF) - (+) is associated with a more severe/aggressive disease

Complete Blood Count (CBC)
- RBC count often decreased (anemia) in approx 20% of RA patients

Synovial Fluid Analysis
- Normal synovial fluid: transparent, yellowish, absent of clots, and viscous
- Synovial fluid from inflammed joint: Cloudy, will clot, less viscous

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5
Q

Radiographic Findings

(3)

A

Joint Space
Cartilage erosion (inflammation/chrondrocytes/osteoclasts) -> narrowing joint space (unevenly)

Bone
- Erosion
- Peri-articular osteopenia - less white, DEC bone density around the joint
* Indication of a PAST inflammed joint (may still be there) BUT what originally lead to the osteopenia

Soft Tissue
- Rheumatoid nodules - firm, noticable lumps under the skin
- Swelling

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6
Q

Diagnosis Criteria
ACR 1987 Criteria for the Classification of Acute Rheumatoid Arthritis

List & Need How Many!!

A

Need at least 4 of 7 criteria
Criteria 1 to 4 must have been present for at least 6 weeks

  1. Morning stiffness lasting at least 1 hour
  2. Soft-tissue swelling or fluid in at least 3 joint areas simultaneously
  3. At least one area swollen in a wrist, MCP, or PIP joint
    Somewhere in the HAND! - DIP is rarely involved w/ RA (Could be invovled d/t a deformities BUT it is NOT active)
  4. Symmetrical arthritis
  5. Rheumatoid nodules - typically around joints
  6. Abnormal amounts of serum rheumatoid factor (RF) - Lab value
  7. Erosions or bony decalcification on radiographs of hand and wrist - Radiograph

Knowing these as a criteria & ALSO HOW RA presents. Seen in later stages

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7
Q

How do they define RA remission?

A

Remission is defined as < 15 minutes of morning stiffness & no joint tenderness or effusion for at least 3 months

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8
Q

RA: Systemic S/S

(5)

A
  1. Morning Stiffness
    Lasting > 1 hr
    Generalized stiffness
    Severity & duration of morning stiffness are directly related to the degree of disease activity
  2. Extreme Fatigue
    INC resting energy expenditure (REE) - d/t chronic immune activiation - working overdrive = energy deficit
    Leads to “rheumatoid cachexia” = loss of lean body mass as a result of RA
  3. Weight loss / loss of appetite
  4. Fever
  5. Malaise
    All 3 are common w/ other diseases that are SYSTEMIC
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9
Q

RA: Articular S/S

(8)

A
  1. Bilateral & symmetrical pattern
  2. Effusion (swelling)
  3. Arthralgia (joint pain)
  4. Crepitis - joint noise as a result of the uneven surfaces (can be symptomatic or asym)
  5. Deformity - d/t erosion & mm imbalances
  6. Loss of function
  7. Pseudo-laxity
  8. Eventually progressing to ankylosis/fusion leading to immobility
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10
Q

RA: Articular: C/S

What joints are impacted most? What mvmts?

A

ROM limited in all planes (especially ROTATION)
- C1-2 = more affected joint in neck & half of C/S ROT comes from this joint ~45

C0-1, C1-2, and mid-cervical region are all common sites of inflammation leading to DEC ROM & potential instability
- C1-2 may lead to life-threating situation should the transverse ligament of C1 (atlas) weaken or rupture allowing herniation of odontoid process of C2 (axis) into the SC, or the odontoid process of C2 should # and herniated into the SC
- Life threatening - Diaphragm is knocked out
- RA patients presenting w/ neurological signs & cervical radiculopathy should be referred immediately to a physician

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11
Q

RA: Articular: Temporomandibular Joint

(3)

A
  • Commonly one of the last joints involved
  • Inflammation results in pain, swelling, and limited ROM
  • In advanced RA may progress to ankylossi - fuses = big issue b/c cannot open jaw
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12
Q

RA: Articular: Shoulder

(3)

A
  • Glenohumeral, sternoclavicular, or acromioclavicular joints may be involved
  • Chronic shoulder inflammation causes distension and thinning of the capsule and ligaments
  • Joint surface erosion leads to shoulder instability and potential for shoulder subluxation
    ~ INC risk of subluxation / dislocation
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13
Q

RA: Articular: Elbows

(6)

A
  • Bilateral olecrannon bursitis (most common in severe RA)
  • Effusion between lateral epicondyle and olecranon prominence
  • Ulnar nerve entrapment - sensory disturbutions & motor impairments
  • Rheumatoid nodules on the olecranon or posterior surface of proximal ulna
    Most common area to have nodules
  • Flexion contractures d/t patient posturing to DEC pain & spasms
  • Inflam > capsular & ligament distention & joint erosion > instability
    Consideration: If they do require a gait aid - they can NOT push off - can NOT use normal gait aids like canes or crutches
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14
Q

Where is the most common area to have rheumatoid nodules?

A

Elbow

On the olecranon or posterior surface of proximal ulna

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15
Q

RA: Articular: Wrist

(6)

A
  • Wrist affected in almost all RA patients
  • VOLAR subluxation of the wrist & hand on the radius (Piano key sign) > may cause extensor tendon rupture
  • Proximal carpal row ULNAR subluxation & distal carpal row RADIAL subluxation = loss of ulnar deviation and compensatory ULNAR DRIFT of MCP
  • Carpal bone erosion
  • Carpal tunnel syndrome comon
    1. Space is encroached on - carpal tunnel area
    2. Soft tissue swelling = DEC space
  • Decreased grasp and pinch strength
    Very important for hand function = significantly impacts ADLs
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16
Q

RA: Articular: MCP

(4)

A
  • Commonly affected (almost all RA patients)
  • Joint effusion especially in the index and long fingers is common
  • Trigger finger may be present d/t flexor tenosynovitis, friction with mvmt or tendon nodules

ZIG-ZAG Effect
Proximal row ULNAR subluxation & distal row RADIAL subluxation > loss of ULNAR deviation > compensatory ULNAR DRIFT of MCPs as the phalanges try to compensate back into normal functional position which creates the zig-zag effect

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17
Q

Bunnel-Littler Test

A

Test for instrinsic mm tightness
1. Perform passive PIP flexion w/ MCP held in flexion
2. Perform passive PIP flexion w/ MCP held in extension

(+) = PIP joints are limited in flexion when MCP is held in extension BUT not when held in flexion = intrinsic mm
- If PIP is limited w/ MCP flexion & extension = capsular retriction (not intrinsic mm tightness)

18
Q

RA: Articular: PIP

(1) + 2 Deformities

A

Effusion common and easily palpable - will feel the fluid move

2 common deformities:
1. Swan Neck Deformity - PIP hyperext & DIP flexion, MCP flexion
2. Boutonnierre Deformity - PIP flexion & DIP ext, MCP extension

19
Q

Swan Neck Deformity

Position & Causes

A

DIP flexion, PIP hyperextension, MCP flexion

Develop 3 distinct ways:
1. Reflex mm spasm of intrinsics d/t the pain of chronic MCP synovitis in addition to hypermobility d/t structural changed PIP

  1. Volar capsule of PIP is stretched > lateral bands move dorsally > tension on the flexor digitorum profundus by the hyperextened PIP flexes the DIP
    Passive insufficiency
  2. Rupture of the extensor digitorum communis (at DIP insertion) causing the flexor digitorum profundus to pull the DIP into flexion (unrestrained by extensor digitorum communis)
    **Muscular imbalance - FDP > EDC
20
Q

Boutonniere Deformity

Position & Cause

A

DIP extension, PIP flexion, MCP extension

Cause:
1. Chronic synovitis > central slip (insertion of extensor digitorum communis into middle phalax) lengthens & volar slip of lateral bands > PIP forced into flexion

Remember: Boutonniere flower @ prom - pushing the doorbell to pick up your date - position your finger goes into

21
Q

RA: Articular: Thumb

Types of deformities (4)

A
  1. Flail IP: loss of ability to flex the IP joint
  2. Type 1 Deformity: IP hyperextension & MCP flexion (w/o involvement of CMC)
    MOST common
    Also know as Z-deformity
  3. Type 2 Deformity: CMC subluxation & IP hyperextension
    Least common
  4. Type 3 Deformity: CMC subluxation and MCP hyperextension
22
Q

RA: Articular: Knee

A
  • Commonly involved in RA (knee has large amount fo synovium)
  • Accumulation of fluid in the knee may lead to a Baker’s cyst
  • Chronic Synovitis leads to:
    1. Distention & laxity of joint capsule & collateral and cruciate ligaments
    2. Erosion of joint surfaces
    3. Flexion contractures second to flexed posturing to avoid increase pain

2 Tests:
- Knee Ballottement Test
- Bulge Test/ Brush Test

23
Q

RA: Knee: Tests

A

Knee Ballottement Test - used for excess fluid
Therapist: presses down on the patella with index finger
(+) Sensation of “bogginess” indicating excessive effusionn in the knee

Bulge Test / Brush Test
Therapist: strokes w/ an upward motion on the medial aspect of the knee then places pressure or downwards on the lateral aspect of the knee
(+) A wave-like mvmt of fluid returning to the medial aspect of the knee indicated excessive effusion in the knee

24
Q

RA: Articular: Ankle

(2 + 3)

A
  • Chronic synovitis may lead to:
    1. Hindfoot pronation
    2. Forefoot planus & flattening of medial longitudinal arch
    3. Possible instability in subtalar joint requiring fusion
  • Tarsal tunnel syndrome may develop - involvement of tibial nerve & may get some S/S of tibial sensory or neuropathy
25
Q

RA: Articular: Feet

(4)

A
  • Synovitis of MTP joints is very common (may lead to Metatarsalgia)
  • Calcaneus may erode or develop exostoses (spurs)
  • Hallux valgus & bunions may develop along with other deformities: Hammer toe, Claw Toe, Mallet Toe
  • Morton’s neuroma may develop
26
Q

RA: Foot: Deformities

(3)

A
  1. Hammer Toe:
    Volar subluxation of the MTP w/ flexion of the PIP & hyperextension of the DIP joint
  2. Claw Toe
    Volar subluxation of the metatarsal head w/ flexion of the PIP & DIP
  3. Mallet Toe:
    Flexion contracture of the DIP joint. PIP & MTP remain in neutral
27
Q

Extra-Articular: Muscle

A
  • Muscle atrophy may be present around affected joints d/t:
    1. Disuse - pain, deformity
    2. Nerve impairment - CTS, tarsal tunnel - LMN
    3. Myositis - inflammation of the muscle
    4. Steriod-induced myopathy - disease of mm
    5. Selective attrition of unknown mechanism related to disease proccess
  • Atrophy common in hand intrinsics and quadriceps
  • Selective attrition of Type II muscle fibers - FAST twitch
  • Rheumatoid cachexia: loss of body mass (predominantly skeletal mm) due to RA
  • MM weakness which develops may be d/t to atrophy or reflex inhibition secondary to pain
28
Q

Extra-Articular: Tendon

A
  • Tenosynovitis may occur with an active disease
    Common sites: wrist flexion, thumb flexors, patella, & achilles tendon
  • Chronic inflammation may damage a tendon, which may ultimately cause the tendon to rupture
29
Q

Extra-Articular: Rheumatoid Nodules

A
  • Occurs in approx 20-25% of RA patients
  • Associated with seropositive RF
  • Found in subcutaneous tissue or deeper connective tissue
  • Common in areas subjected to repeated mechanical pressure or pressure bearing areas
    Olecranon bursae, extensor surface of forarms, and achilles tendon

** All the same areas suspectible to pressure sores

30
Q

RA: Neurological

A

Peripheral neuropathy may develop secondary to mechanical compression of nerves or vasculitis of vessels supplying the nerves
- inadequate blood to those nerves = not working in the same fashion - starved

Spinal cord compression may arise d/t inflammation in the C/S
*** Cord compression signs require immediate medical attention (ER)

31
Q

RA: Cardiopulmonary Complications

(4)

A
  • INC morbidity & mortality risk d/t CV disease in RA patients
  • Accelerated Atheroscleorsis > ischemic heart disease
  • Pleuritis & pulmonary nodules may be present & affect gas exchange (SOB, inadequate O2, may not be expeling CO2)
  • Pulmonary nodules are related to rheumatoid nodules elsewhere in the body & found in seropositive patients (RF)
32
Q

RA: Ocular

(3)

A

Epicleritis may be present (bengin, self-limiting inflammatory disease of part of the eye)

Scleritis may be present (a serious condition that may lead to blindness)

RA patients should have an annual eye exam

33
Q

Disease Modifying Anti-Rheumatic Drugs (DMARDS)

(5)

A

Primary class of drugs to manage RA
- Reducse disease progression, do NOT provide analgesic effects
- Slow acting (takes weeks to months to take effect)
- Risk of toxicity/ side effects
- New class of DMARDS known as Biological Response Modifers (BRMs) have been created to mimic activities of selective immune cells to reduce or block the inflammation process (immunosuppression)

34
Q

REd Flags (Urgent Referral)

(6)

A
  1. Claudification pain pattern
    DDx: PVD - intermittent claudification could be d/t other CVD issues, stenosis (L/S)
  2. Constitutional signs (fever, wt loss, malaise)
    Systemic &/or infection S/S
  3. Focal or diffuse weakness
    Focal - nerve lesion
    Diffuse - degeneration, NMD, myositis/myopathy
  4. Significant history of trauma
    Fractures or internal derangement
  5. Hot, swollen joint
    Infection/ systemic
  6. Neurogenic pain (burning, numbness, paresthesia)
    ** Could be radiculopathy = INC risk of SCI d/t instability & inflammation process
35
Q

Standardized Assessment of Joint Inflammation (SAJI)

4 Objective Measures

A

Four objective measures of general level of inflammation:

  1. Duration of morning stiffness (minutes) - >60 mins
  2. Bilateral grip strength testing (mmHg) - blood measure cuff squeeze
  3. Number of “active joints”
  4. Erythrocyte Sedimentation Rate - blood values
36
Q

Standardized Assessment of Joint Inflammation (SAJI): Assess

Active & Damaged

A

Active Joint Count (one of the following must be present)

  1. Effusion
    Use two thumb technique, four finger technique, or palpation
  2. Joint Line Tenderness
    Pain from pressure being placed over the joint
  3. Stress pain
    Pain with passive over pressure at end range

Damaged Joint (one of the following must be present)

  1. Subluxation or deformity
  2. Bone on bone crepitus
  3. Loss of more than 20% of passive ROM
  4. Ligament instability
37
Q

Active Joint Count: Acronym

A

STOP signs

S = swelling
~ Two thumb OR 2. 4 fingers
T = tenderness (joint line)
O-P = overpressure (stress pain)

** At any point you get a (+) for symptoms= STOP! that joint is active

38
Q

What do you not apply on inflammed, hot or swollen joints?

A

Superficial heat

Deep heat
- Contraindicated in acute stages of inflammation

39
Q

What can be applied during a period of active joint inflamm?

A

Cold!

Contraindicated in patients with Raynaud’s disease or cryoglobulinemia

40
Q

Rest: Yes or No?

A

Complete bed rest is rarely recommended
- Short rest breaks throughout the day & quality sleep is recommended
- Inactivity leads to other problems such as:
Deconditioning, depression, DEC bone & tissue health, and INC risk for CV disease

41
Q

Main Interventions

Summary (3)

A

Most important tasks initally are:

  1. DEC pain & swelling
  2. Optimize ROM & strength

NO stretching for active inflammed joints - capsule & lig are already on stretch
NO strengthening exercises for active inflammed joints - tendons could be compromised w/ chronic swelling

  1. Optimize function

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