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BPT 17 - Geriatric > 4 - AUTOIMMUNE DISEASES & FIBROMYALGIA > Flashcards

4 - AUTOIMMUNE DISEASES & FIBROMYALGIA Flashcards

1
Q

Autoimmune disease: def

A
  • Could be systemic or single organ
  • Systemic = Scleroderma, Psoriasis, Systemic lupus erythematosus, Celiac disease, Multiple sclerosis, Myasthenia gravis, Ankylosing spondylitis & Rheumatoid arthritis
  • Organ specific = Diabetes mellitus, Hashimoto’s thyroiditis, Grave’s diseases & Crohn disease
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2
Q

Autoimmune disease: pathogenesis

A
  • Exact mechanism unknown
  • Disruption of immuno regulatory mechanism
  • Antibodies directed against body’s own cells
  • Body’s fails to distinguish self from non self
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3
Q

Autoimmune disease: risk factors

A
  • Hormones
  • Environment
  • Genetics
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4
Q

Rheumatic disease: description

A
  • Systemic diseases affecting any & all body systems
  • Characterized by periods of exacerbation & remission
  • Chronic conditions with long term rehab needs
  • Heavy burden for health care system & economy
  • Prevalence in general population: 9,8 - 33,2%
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5
Q

RHEUMATOID ARTHRITIS: definition

A
  • Chronic systemic inflammatory disease affecting synovial lining of joints & other connective tissue
  • Presents with wide range of articular & extra-articular findings
  • Systems that may be involved: cardiovascular, pulmonary & gastrointestinal
  • Extra-articular manifestation: affect bones, skin & lungs. Eye lesions, infection & osteoporosis also possible
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6
Q

Rheumatoid arthritis: epidemiology

A
  • 2nd most prevalent form of Arthritis after OA
  • 1-2% of US adult population has RA
  • Higher incidence for females (x3 times)
  • Onset: any age
  • Peak onset: around age of 60y
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7
Q

Rheumatoid arthritis: risk factors & multifactorial etiology

A

RF
- Age
- Decaffeined coffee
- Female gender

ME
- Unknown
- Possible due to genetics, environmental factors
- In some cases, gene HLA-DR4 identified
- 80% of patients with RA positive, rheumatoid factor (autoantibody)

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8
Q

Rheumatoid arthritis

A
  • RA begins attacking joint in synovium
  • Multiply of cells in synovial lining + stream of leukocytes —> edema of synovium
  • Thickened synovium & pannus tissue formation
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9
Q

Hypertrophic joint, thickened synovium: description

A

Schema

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10
Q

Rheumatoid arthritis: manifestation: description of subjective, objective & joints symptoms

A
  • Insidious onset with slow progression
  • Most frequently involved joints: wrist, knee & joints of fingers, hands & feet
  • Early involvement hand joint with MCPJ and PIJ
  • Have periods of remission & relapse / flare ups
  • Remission period: absence of joint symptoms for 2 consecutive months

Subjective
- Fatigue
- Weight loss
- Weakness
- General, diffuse MSK pain - Decondition
- Depression
- Localized symptoms to specific joints
- Multiple joints presentation (& symmetrical)

Joints symptoms
- Edema, warm joint, pain
- Morning stiffness > 30 min up to several hours
- Gradual joints deformity (ulnar deviation, swan neck deformity, boutonnière deformity) - Characteristic: RA nodule in skin

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11
Q

Rheumatoid arthritis: objective cont.: soft tissue symptoms & spine

A

Soft tissue symptoms
- Symptoms of Synovitis
- Bursitis
- Tendinitis
- Fasciitis
- Neuritis
- Vasculitis

Spine
- Deep aching cervical pain
- Frequent occipital headaches
- C1 & C2 mostly affected
- Increased risk for atlanto-axial (C1-C2) subluxation

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12
Q

Rheumatoid arthritis: prognosis

A
  • No cure or condition with irreversible joint changes
  • Difficult to make accurate prognosis, depends on number of factors
  • 70% of RA patients may have varying degrees of disability
  • 10% severely disabled
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13
Q

Rheumatoid arthritis: classification of functional capacity

A

1) Class I: completely able to perform usual activities of ADLs (self care, vocational, avocational)
2) Class II: able to perform usual self care & vocational activities, but limited in avocational activities
3) Class III: able to perform usual self-care activities but limited in vocational & avocational activities
4) Class IV: limited in ability to perform usual self-care, vocational & avocational activities

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14
Q

Rheumatoid arthritis: aims of treatment, outcomes on PT, patient education & aims of exercise intervention

A
  • Requires interdisciplinary approach & long term planning

Treatment aims to:
- Maintain state of remission
- Reduce pain
- Maintain mobility
- Minimize stiffness, edema & joint destruction
- Restore function

Outcome based on PT interventions
- PT assessment should include overall assessment of ADLs
- Assess activities & tasks that are also noted limited by patient
Gives attention to feet assessment
- Look for uneven or pathological weight bearing patterns
- Check shoes
- Is there need to provide assistive device or orthotics?
Adaptations may be necessary: types of crutches, adaptive equipment….

Patient education
- Self management strategies: learning of acing, joint protection, symptoms monitoring
- Minimize trauma to joint: unload joints & reduce mechanical stress
Consider stage of disease: acute, subacute or inactive
Balance between rest & exercise. Some patients might need about 2h of bed rest during day Know when to modify program: acute pain during exercise, post-exercise pain lasting > 1h

Exercise intervention
Aiming to
- Prevent contractures
- Improve strength
- Enhance cardiorespiratory or aerobic conditioning

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15
Q

Rheumatoid arthritis: types of therapeutic exercises

A
  • Functional strengthening exercises
  • Aerobic & resistance exercise
  • Balance, coordination, posture & ROM exercises
  • Hydrotherapy
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16
Q

Rheumatoid arthritis & rehab: description & osteoporosis

A
  • ROM exercises: start with low reps several times throughout day. Can be increased up to 8-10 reps in subacute phase
  • Isometric exercises: short holds (4-6 secs) with low reps (start wit h1-2 & gradually increase to 4-6)
  • Strength training: low load & moderate to high intensity shown benefits & training effects on muscle strengthening in RA
  • 30 min of moderate exercise, 4-5 times/week recommended

Osteoporosis
- Patients with RA have higher risk of developing osteoporosis

Why?
- RA medication (glucocorticoid medication triggers bone loss) - Bone loss as direct result of disease
- Inactivity secondary to pain & disability caused by disease

17
Q

Rheumatoid arthritis: thermotherapy & electrotherapy: description of each level

A

Tableau

18
Q

Ankylosing spondylitis: def & epidemiology

A

Definition
= inflammatory arthropathy of axial skeleton
- Systemic rheumatic disease that affects entire body

Epidemiology
- Prevalence: 0,1 - 0,2% in USA (nearly 2 million people)
- Whites > African, Americans, Asians or other non whiter groups - Men > Women (2 to 3 times higher rate
- Age: 15-30 y.o

19
Q

Ankylosing spondylitis: etiology & pathogenesis

A

Etiology
- Still unclear
- Genetic
- Environmental factors
- HLA-B27 antigen positive

Pathogenesis
- Progressive fusion of zygapophyseal joints & disc spaces of axial skeleton, resulting to rigid hypnotic deformity of thoracic spine & positive sagittal balance
- Morphology alterations make spine vulnerable to injury following minor or unrecognized trauma
- Spine unable to adequately accommodate normal mechanical forces
- Possible fractures at any level of spine

Enthesitis: inflammation for:
> Ligaments attachments
> Tendons attachments
> Cartilage attachments

=> Decrease ROM, tenderness, pain, stiffness in various joints

Spine effects:
Healing with reactive bone formation, secondary to disruption of ligaments vertebral junction/attachment Outer annular fibers of intervertebral disk replaced by bone —> bones fused

20
Q

Ankylosing spondylitis: risk factors + signs & symptoms

A

Risk factors
- Men
- Age

Signs & symptoms
- Gradual onset of low back pain/buttock/hip & stiffness > 3 months
- Morning stiffness > 1h
- Poorly localized pain at beginning. In general, becomes bilateral & persistent
- Pain with rest/inactivity which gets better with active movement
- Pain that wakes you up at night
- Tenderness in different body parts (GT, spinous process, ligaments attachments at calcaneus, heel pain
common)
- Bowel irritation
- Fatigue doesn’t improve , eyes inflammation
- Loss of spine mobility
- Loss of lordosis, development of kyphosis
- Loss of chest wall excursion

21
Q

Ankylosing spondylitis: pulmonary function & diagnosis

A

Pulmonary function
- Pulmonary function compromised
- Patient might report ribs tenderness & shortness of breath after gentle activity
- Ossification results in Kyphosis, reduced thoracic mobility & chest wall immobility
—> Reduced lung volumes secondary to mechanical limitation
—> Patients show significantly impaired pulmonary function compared to healthy population

Diagnosis
Usually via rheumatologist considering several elements
- History / symptoms experienced
- Physical examination
- Blood tests
- X-ray or MRI
- Age
- Fatigue

22
Q

Ankylosing spondylitis: red flags & implications for PT + BASMI description

A

Red flags
- Sudden onset of lower back, SIJ or hip pain with no trauma or overuse & non-mechanical causes of back pain
- Signs & symptoms of systemic disease: fever, fatigue, respiratory compromise

Implications for PT
- Assess spine & peripheral joints ROM & strength —> Schober test: assessment of lumbar spine flexion
- Chest expansion
- Hip flexion contractions (30-50% of patients wit hAS will develop hip deformities, need total hip arthroplasty)
- Hip internal rotation ROM indicative of hip involvement

Bath Ankylosing Spondylitis Metrology Index (BASMI)
- Cervical rotation
- Travis to wall
- Lumbar side flexion
- Lumbar flexion (modified Schober’s)
- Inter-malleolar distance

23
Q

Ankylosing spondylitis: therapeutic exercise, exercise prescription & type of exercises

A
  • Avoid hit-impact activities & contact spots, high-velocity exercises especially trunk flexion / rotation

Exercise prescription
- Not clear recommendations
- Encourage cardiopulmonary fitness - Encourage physical activity
- Consistency = key factor

Type of exercises
Mobility exercises: major role
- Spinal mobility
- Peripheral joint mobility

Other types of exercises
- Stretching
- Strengthening
- Cardiopulmonary
- Functional fitness exercises
- Hydrotherapy: excellent type of exercise
- Modified Pilates
- Tai chi

24
Q

Fibromyalgia syndrome: def + epidemiology

A

Definition
= syndrome characterized by chronic widespread pain at multiple tender points, joint stiffness & systemic symptoms

Epidemiology
- Incidence rate: > 6 million people in USA, more women than men
- Prevalence in healthy population: 2-8 %
- Age: 20-55y
- Affects more female than males
- Onset symptoms: between age of 20-55y

25
Q

Fibromyalgia syndrome: multifactorial etiology + risk factors

A

Multifactorial etiology
- CNS
- ANS
- Genetic factors
- Neuroendocrine dysfunction

Risk factors
- Rheumatoid arthritis
- Lupus
- Age

26
Q

Fibromyalgia syndrome: pathogenesis + signs & symptoms

A

Pathogenesis
- Not clearly understood
- Malfunction of CNS
- Complex interaction of pain & inflammation
- Central sensitization: mechanism of CNS resulting in greater perception of pain
- Change in level of various inflammatory cytokines
- Imbalance of neurotransmitters
Patients have lower pain threshold. Hypersensitivity to painful stimuli. Reduced pain inhibition Abnormal pain modulation

Signs & symptoms
- Muscle pain (major symptoms)
- Diffuse pain
- Tender points bilaterally
- Sleep disturbances, fatigue
- Diaphragm muscle = significantly affected (accessory muscles of neck & upper chest take over) - Wind up response (central sensitization of pain)
- High level of muscle activity present during activities (ADLs)

27
Q

Fibromyalgia syndrome & rheumatoid arthritis

A
  • High prevalence of FM in RA:
  • 12-48% of confirmed RA patients
  • Appears within 1y after RA diagnosis
  • RA & FM patients have increased pain, fatigue & disability
28
Q

Fibromyalgia syndrome: management

A
  • MDT approach
  • Exercise
  • Physical activity (150 m/week)
  • Education
  • Self management & coping strategies
29
Q

Fibromyalgia syndrome: therapeutic exercises (exo recommendations + intensity)

A

Exercise recommendations
- Strengthening exercises
- Aerobic exercises
=> Reduced symptoms, improved quality of sleep & improved function
- Tai chi
- Yoga
- Nordic walking
- Hydrotherapy => for pain relief

Intensity
- Gradual progression to moderate-intensity aerobic exercises
- Low resistance strengthening to begin with 10% intensity increase after 2 weeks without symptoms exaggeration

BPT 17 - Geriatric (11 decks)

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