Arthritis Flashcards
Define arthritis
A chronic joint disorder characterised by degeneration of joint cartilage and adjacent bone that can cause joint pain and stiffness
The most common form of arthritis is …
Osteoarthritis
Prevalence of osteoarthritis … with age
Increases
Which joints does osteoarthritis commonly affect?
Knees
Hips
Hands
Describe process of osteoarthritis
- Collagen/proteoglycan producing cells become abnormal
- An increase in cartilage growth initially and bone density (osteosclerosis) reducing joint space
- Cartilage thins and cracks, roughening causes pain during movement
- Bone erosion with bone on bone movement
- Compensation occurs with development of bone spurs leading to deformation and pain
- Inflammation thickens synovium
- Increase in synovial fluid –> joint swells –> overstretching of muscles causes weakness
Clinical features of osteoarthritis
Bone hypertrophy
Bone spurring
Fusiform swelling of joints (Bouchard’s nodes)
Heberdens nodes
Rheumatoid arthritis is an … disease affecting the … …
Autoimmune
Whole body
Rheumatoid arthritis affects … of the population
1%
RhA is … times more common in …
3
Women
Process of RhA
- T-cells in synovial fluid become unable to distinguish between foreign and normal body cells
- Excessive production of immunoglobulins and inflammatory cytokines (TnF alpha)
- Excessive Ig causes abnormal division and growth of synovial cells
- Leukocytes migrate to joints, release enzymes causing synovitis –> increases swelling, stretching of ligaments, enzyme release attacks hyaline cartilage
4 stages of RhA
- Synovitis (synovial membrane inflammation)
- Pan us (extensive cartilage loss, exposed and pitted bones)
- Fibrous ankylosis (invasion of joint with fibrous connective tissue)
- Bony ankylosis (fusion of bones)
What may blood tests reveal in RhA? Why does this happen?
Presence of rheumatoid factor (RF) antibody (80% sensitivity)
RF is produced to try and lower levels of other antibodies
(However some people with RF don’t have RhA and vice versa)
RhA usually affects joints …
Symmetrically
Joints commonly affected in RhA
Wrists Hands Knees Elbows Shoulders Ankles
Major aetiology of RhA
60% genetic plus environmental involvement
Non-genetic factors causing RhA
Age Hormonal factors Infection Smoking Obesity
What does ankylosing spondylitis cause?
Acute spinal pain and stiffness without significant decrease in mobility
Why is osteoarthritis joint specific but RhA whole body?
RhA is an autoimmune disease so affects multiple organs
Why do ligaments become lax in later stage arthritis?
Chronic inflammation causes over-stretching
What is TNF-alpha?
An inflammatory cytokines produced my macrophages
Name some extra-articular manifestations of RhA
TNF-alpha causes weakness, fatigue, loss of appetite, muscle pain, weight loss
Myocardial damage and pericarditis
Pleural fluid accumulation in lungs
In 1 out of 6 people can shorten life
Why is there increased prevalence of arthritis in older people?
Natural decline in glucosamine and chondroitin sulphate production (so less durable cartilage is produced)
Men have more … OA
Hip
Women have more …/… OA
Hand/knee
In general … develop RhA more frequently than …
Women
Men
What hormone is protective of OA?
Oestrogen - increased OA prevalence post menopause
Weakness of which muscle is a risk factor for OA?
Quadriceps (from inactivity)
Top … for BM increases risk of hip and knee OA by … times
20%
7-10
Modest weight loss … OA
Reduces
History of joint damage … to OA
Predisposes
True or false, there is conclusive evidence that overuse increases risk of OA
False - inconclusive data on athletes
Moderate levels of physical activity … increase risk of OA
Doesn’t
True or false, infection can predispose to arthritis
True - both OA and RhA
There is a …-…% influence of genetics on development of arthritis
30-60%
Arthritis symptoms (general)
Pain and crepitation on movement Enlarged and deformed joints Inflammation of joints Stretched ligaments - instability Decreased ROM or complete freezing of joints
3 movements most affected by arthritis
Stooping/bending
Standing
Walking
Exercise limitations in people with arthritis
Less muscular strength/endurance
Less flexibility and ROM
Lower peak VO2 (20-30%)
Increase in oxygen demand of movement due to movement inefficiencies
Why do you get exercise limitations with arthritis?
Inactivity causing retraining
Structural changes in bone and tendons
Reduced coordination and motor control
What can imposed inactivity with arthritis cause?
Increased risk of CHD, diabetes, osteoporosis
Increased weight exacerbating joint loading and reducing mobility further
Aims of treatment of arthritis (ACSM 2010)
Ease pain and inflammation Improve joint function Lessen joint damage Improve functional capacity Reduce risks of comorbidities
Non exercise treatment of arthritis
Firm beds/chairs
Heat - warm baths
Massage
Drugs: aspirin, ibuprofen, steroids, DMARDs, COX-2 inhibitors (reducing prostaglandins –> reducing inflammation)
Exercise does not stop … … of arthritis, but does not exacerbate … or … …
Pathological process
Pain
Disease progression
How can exercise help arthritis patients?
8
Increase joint mobility
Increase muscle strength around joint (improved stability, shock absorption, lower risk of falls)
Reduces swelling at joints
Reduces body weight
Increased bone density
Reduced pain on movement
Increased peak vo2
Reduced CHD RFs
T or F, cartilage has direct blood vessels and nerves
False - cartilage has no direct vessels or nerves
How does cartilage receive nutrients?
Movement of the joint allows diffusion of nutrients into cartilage
How does movement increase “feeding” of cartilage?
Increased proteoglycan production
Increased glucosamine and chondroitin sulphate secretion from ECM (needed for cartilage production)
Weight loss is important in reducing symptoms of OA, which is most important - body fat or body mass reduction?
Body fat reduction
How does improvement in muscular strength help arthritis?
Quadriceps strengthening cushions force transmission through muscle rather than joint
Improvement in quad:hamstring ratio helps balance load on joint
Exercise may help reduce … … production
TNF-alpha
Aims of exercise in arthritis patients
Increase or preserve ROM and flexibility
Increase muscle strength and endurance
Increase aerobic conditioning
Ameliorate health risks of inactivity
When should exercise be avoided in arthritis pts?
During ‘flares’ or if exercise is particularly painful
Exercise considerations with arthritis pts
Decreased ROM
Work within pain threshold and maximum ROM
Difficulty gripping
Balance problems
Reduce load each joint is taking
Joints stiffer when cold
Stiffer in morning
Considerations when undertaking pre-exercise testing in arthritis pts
Screen for CAD
Joint disease may affect ability to give true maximum effort
Which exercise testing method would you use for a patient with: mild joint impairment, mild to moderate lower extremity impairment, and severe lower extremity impairment?
Mild - treadmill
Moderate - cycle regime try
Severe - arm ergometry
A goniometer is used to test …
ROM
How would you test balance in arthritis pt?
Figure right walking (mild)
Berg balance scale (moderate-severe)
Recommended stretching exercises in arthritis pts
All joints
Static - hold 10-30s
PNF if supervised - 5s stretch followed by 10-30s assisted stretch
3-4 times/session
Recommended strength exercises in arthritis
Isometric: start with isometric, 40-60% MVC, 1-10s, major muscle groups
Isotonic: low weight (40-60% 1RM), build up to high no. of reps, 1-3 sets 1-3 days/week, use fixed weights and bands, work all muscles
Recommended aerobic exercises for arthritis pts
Low impact: 40-80% HRmax, RPE 12-14
Cycling, rowing, swimming, low impact aerobics
Start 5-15 mins every other day, increase to 30-40 mins
Increase in 10% intensity increments
Consider interval training
Do you think that exercise training is worthwhile for people with RA?
Yes - muscle strength and aerobic capacity is vastly improved with exercise in RhA patients without negative effects in disease activity which may be improved
What mechanisms may explain why and how exercise may bring about an improvement in disease activity and does this call for a reappraisal of the 2001 statement of the American College of Geriatricians about exercise and arthritis?
Aerobic exercise seems to reduce joint swelling in RA, strengthening exercise reduces pain reports in RhA patients.
Exercise-related changes in synovial circulation, immune response and inflammatory factors , and neuropeptide levels. General exercise research also may pertain to this population in terms of the benefits of neuromuscular learning and improved elasticity and strength of peri-articular structures
