Disorders of motor activity Flashcards
What is the most common form of arthritis?
Osteoarthritis. Prevalence increase w age. 1/3 adults > 60 demonstrate radiographic OA
What is the typical history of OA?
- joint pain worse w activity
- morning stiffness lasting no more than 30m
- stiffness after periods of immobility
- impairment or function
What is found on PE in OA?
- bony swelling
- crepitus
- jointline tenderness
- limitation of joint mobility
- joint instability
- periarticular muscle atrophy
What is primary OA?
Idiopathic, occurs in previously undamaged joints. Can be classified as localized (1-2 sites) or generalized (3 or more sites)
What is secondary OA?
Ass w well -recognized causes
- Inflammatory arthritis eg RA, psoriatic
- Crystal arthropathy eg gout, calcium pyrophosphate deposition disease
- septic arthritis /TB
- prior joint trauma or surgery
- endocrinopathy eg acromegaly, hyperparathyroidism
- metabolic disorder eg hemachromatosis, ochronosis
- neuropathic arthropathy eg DM, tabes dorsalis
- prior bone disease eg Pagets, osteonecrosis
- hemophilia
- cong. / development eg dysplasia, slipped femoral epiphysis, Marfan sd
What are the risk factors for OA?
- Older age
- Obesity
- female gender
- joints malalignment
- occupational activity, kneeling, stooping
- presence of hand OA
What is the clinical ACR clinical radiographic DX criteria for OA in the knee
Knee pain + osteophyte + at least 1 of the following
- age > 50 y
- stiffness < 30 min
- crepitus
ACR criteria for OA in hip?
Hip pain and at least 2 of the following
- ESR < 20 mm/h
- radiographic femoral or acetabular osteophytes
- radiographic joint space narrowing, superior / axial / and or medial
What is the incidence of RA?
Peak btw 35 - 50, but can happen from 20 y. Higher incidence in women, 3,6% lifetime risk ( 1,7% in men)
What are the systemic features of RA?
- Fatigue
- Malaise
- Weight loss
- Weakness
- Low grade fever
What are the ACR/ EULAR criteria for RA
- Definite RA is based on the confirmed presence of synovitis in at least 1 joint, absence of an alternative dx better explaining the synovitis, and achievement of a total score of 6 or greater of possible 10
How are the points counted in ACR/EULAR criteria for RA w joint involvement?
Joint involvement
- 0pt for 1 large joint
- 1 pt for 2-10 large joints
- 2 pts for 1-3 small joints
- 3 pts for 4-10 small joints
- 5 pts for > 10 joints, at leas 1 small
How are the points counted in ACR/EULAR criteria for RA w serology?
0 pt w RF and ACPA
2 pt w RF or ACPA positive at low titer < 3 times ULN
3 pts w ACPA positive at high titer, > 3 ULN (upper limits than normal)
ACPA = anti citrullinated peptides antibody
How are the points counted in ACR/EULAR criteria for RA w duration of synovitis and acute phase reactants?
Duration:
0pt < 6w
1 pt > 6w
Acute phase reactants
0 puts if normal ESR/CRP
1 pt if abnormal ESR/CRP
What is ankylosing spondylitis? (AS)
Bekhterevs sykdom
What is prevalence of AS?
0,2-0,5% in the US. More often in women. Age of onset peaks at 2nd and 3rd decade of life. 80% experience sx before 30 y
What are the new york clinical criteria of AS?
- Low back pain and stiffness > 3 months that improves w exercise, but not relieved by rest
- Limitation of motion of the lumbar spine in the sagittal (sideways) and frontal (forward and backward) planes
- Limitation of chest expansion relative to normal values, correlated for age and sex
What are the new you radiological criteria?
- sacrolitis grade 2 bilaterally or grade 3-4 unilaterally or bilaterally
- grades
1. some blurring of joint margins
2. minimal sclerosis w some erosions ( mild sacrolithis)
3. severe erosions w widening of joint space +/- some ankylosis
4. complete ankylosis
When can you say that it is definite AS?
Radiological + 1 clinical criteria
What are the spectrum og spondyloarthritis disorders?
- Axial SpA: 1) Ankylosisng spondylitis 2) Nonradiographic ax-SpA
- Peripheral SpA:
1) Arthritis ass w inflammatory bowel disease
2) Reactive arthritis
3) Psoriatic arthritis
4) Undifferentiated SpA
What is the criteria for axial SpA ?
- 3 or more months of back pain and age at onset < 45y
- Sacrolitis on imaging + 1 or more SpA feature
OR
HLA- B27 + 2 or more other SpA features
How can you see sacrolitis on imaging
- Acute/ active inflammation on MRI highly suggestive of sacrolitis ass w SpA
- Definite radiographic sacrolitis according to modified NY criteria
What are the SpA features?
1) inflammatory back pain 2) enthesitis (heel) 3) dectylitis 4) Crohns /UC 5) family history w SpA 6) increased CRP 7) arthritis 8) uveitis 9) psoriasis 10) good response to NSAIDs 11) HLA - B27
Prevalence of lower back pain
Affect 8-10/10 people at some time in life. Is 2nd (behind common cold) cause of lost work time. Most common disability in people under 45y. Serious causes are uncommon, < 1%
What are the causes of lower back pain?
- Muscle / tendon sprain
- Degenerative disc disorder
- Disc herniation
- OA of spine
- Axial spondyloarthritis
- NPL tumors or metastasis
- discitis
- vertebral osteomyelitis
- spondylodiscitis
- compressive fracture
- congenital malformations
What is the Px in lower back pain ?
- 60% recover in 1-3 w
- 90% recover in 6-8w
- 95% recover in 12w
What is the (typical) cause in age 30-60?
Lumbar disc herniation, degenerative disc disorder and muscle and other soft tissue strain
What is the (typical) cause in age > 60?
OA, compression fracture, metastasis
What are the red flags for cauda equine sd?
1) Saddle (perianal/perineal) anesthesia or paresthesia (numbness around passage and/or genitals)
2) Bladder disturbance: inability to urinate / difficulty, loss of sensation when passing urine, inability to stop/ control urination, loss of full bladder sensation
3) Bowel disturbance: inability to stop a bowel movemnet, constipation, loss of sensation when passing stool
4) Sexual problems: inability to achieve an erection or ejaculate, loss of sensation during intercourse
5) Nerve root pain: severe or progressive deficit in the lower extremities
What are the red flags of spinal fracture?
- Sudden onset of severe central pain in the spine, which is relived by lying down
- Major trauma such as road accident or fall from hight
- Minor trauma such as strenuous lifting, in people w osteoporosis
- Structural deformity of the spine
What are the red flags of infection or cancer in spine?
- Onset >50 y or < 20y
- history of cancer
- constitutional sx: fever, chills, unexplained weight loss
- recent bacterial inf
- immune suppression
- IV drug abuse
- pain that remains when supine, aching night time pain that disturb sleep
- structural deformity of spine
What are the red flags for spondyloarthropathy?
- early morning stiffness lasting > 45/60 min
- night pain
- easier w movement, worse at rest
Red flags suggesting risk of permanent damage to the compressed nerve
- significant muscle weakness or wasting
- loss of tendon reflex
What are the orange flags for back pain ?
Psychiatric sx.
- clinical depression
- personality disorder
What are the yellow flags for back pain ?
Increased risk of having chronic back pain
- Beliefs and judgement:
1. Unhelpful beliefs about pain, indication of injury as uncontrollable or likely to worsen
2. Expectations of poor tx outcome, catastrophisation, delayed return to work - Emotional response
1. distress not meeting criteria for dx of mental disorder
2. worry, fears, anxiety - Pain behavior
1. avoidance of activities due to expectations of pain and possible rein jury
2. over reliance on passive tx ( hotpacks, cold packs, analgesics)
What are the blue flags of back pain?
Perceptions about relationship btw work and health
- belief that work is stressful, excessively demanding and likely to cause further injury
- belief that workplace supervisor and workmated are unsupportive
What are the black flags of back pain ?
Context, environment, system obstacles
- Conflict w insurance staff over injury claim
- Overly supportive family and health care providors
- heavy work w little opportunity to modify duties
