4 - AUTOIMMUNE DISEASES & FIBROMYALGIA Flashcards
Autoimmune disease: def
- 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
Autoimmune disease: pathogenesis
- Exact mechanism unknown
- Disruption of immuno regulatory mechanism
- Antibodies directed against body’s own cells
- Body’s fails to distinguish self from non self
Autoimmune disease: risk factors
- Hormones
- Environment
- Genetics
Rheumatic disease: description
- 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%
RHEUMATOID ARTHRITIS: definition
- 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
Rheumatoid arthritis: epidemiology
- 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
Rheumatoid arthritis: risk factors & multifactorial etiology
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)
Rheumatoid arthritis
- RA begins attacking joint in synovium
- Multiply of cells in synovial lining + stream of leukocytes —> edema of synovium
- Thickened synovium & pannus tissue formation
Hypertrophic joint, thickened synovium: description
Schema
Rheumatoid arthritis: manifestation: description of subjective, objective & joints symptoms
- 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
Rheumatoid arthritis: objective cont.: soft tissue symptoms & spine
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
Rheumatoid arthritis: prognosis
- 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
Rheumatoid arthritis: classification of functional capacity
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
Rheumatoid arthritis: aims of treatment, outcomes on PT, patient education & aims of exercise intervention
- 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
Rheumatoid arthritis: types of therapeutic exercises
- Functional strengthening exercises
- Aerobic & resistance exercise
- Balance, coordination, posture & ROM exercises
- Hydrotherapy
Rheumatoid arthritis & rehab: description & osteoporosis
- 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
Rheumatoid arthritis: thermotherapy & electrotherapy: description of each level
Tableau
Ankylosing spondylitis: def & epidemiology
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
Ankylosing spondylitis: etiology & pathogenesis
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
Ankylosing spondylitis: risk factors + signs & symptoms
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
Ankylosing spondylitis: pulmonary function & diagnosis
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
Ankylosing spondylitis: red flags & implications for PT + BASMI description
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
Ankylosing spondylitis: therapeutic exercise, exercise prescription & type of exercises
- 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
Fibromyalgia syndrome: def + epidemiology
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
