Gout, Infectious Arthritis, Lyme Disease, Reiter’s Syndrome, Rheumatoid Arthritis, Scleroderma, Still’s Disease and Juvenile Rheumatoid Arthritis, Systemic Lupus Erythematosus Flashcards
What is Gout?
A group of disorders in which crystals of monosodium urate are deposited in the tissues, accompanied by attacks of acute arthritis
The metatarsophalangeal joint of the big toe is the area most commonly attacked by gout, with the tarsal area and ankle also frequently involved
Pseudogout, a similar condition, is caused by calcium pyrophosphate dihydrate crystals. Joints attacked are usually ankles, knees, shoulders and wrists, with the big toe rarely being affected
It is much more common in men between the ages of 40-50 years
The cause of gout is a malfunction of the normal chemical process that breaks down purines. These substances are found in all the body cells, as well as in certain foods such as meat and fish
People who develop gout either have an overproduction of uric acid or an underexcretion of uric acid, or in some cases, both abnormalities
The excess uric acid accumulates in the extracellular fluid, eventually changing to needle-shaped urate crystals which collect in synovial tissue and eventually precipitate into the synovial fluid where they trigger an acute attack of gout
An acute attack usually affects a single joint
The initial onset is sudden and extremely painful
The gnawing intense pain may be such that the person is unable to bear the weight of the bed sheets on the joint
The affected joint is red, hot and swollen
The skin over the joint is shiny and taut
Gout can be an inherited condition, but attacks can also be precipitated by excessive alcohol consumption, obesity, certain foods and medications, trauma, surgery and “crash” diets
Gout stages
- In the early stages:
An acute attack may last for a few days, followed y a symptom-free period of several months or years
If untreated, attacks are more frequent and severe as the disease progresses
Repeated flare-ups cause joint stiffness and reduced range of motion and eventually cartilage and subchondral bone destruction leading to joint deformation
- In the chronic stage:
Inflammation spreads to other peripheral joints
This stage occurs on average 10 years after the initial attack
It is marked by subcutaneous deposits of urate crystals called “tophi”
These lumps occur outside the joints
Tissues commonly affected include the olecranon bursa, subcutaneous tissue along the forearm extensors, skin over joints, the helix of the ear and tendon sheaths in the hands and around the Achilles tendon
If left untreated, tophi can break through the skin and lead to infection or carpal tunnel syndrome or trigger finger
Over time, uric acid crystals may form kidney stones
Medically, gout is diagnosed through identification of urate crystals in synovial fluid
The inflammation and pain of acute attacks are treated with NSAIDs and colchicine
Uric acid production is reduced using allopurinol
Some foods such as liver and sardines can raise blood levels of uric acid, while alcohol can trigger attacks
Once medication stabilizes uric acid levels, most people with gout can consume these substances in moderation
What is Infectious Arthritis?
Joint inflammation resulting from infection by bacteria, viruses or fungi
In most cases, infectious arthritis involves one joint, such as the knee, hip, shoulder, elbow and small joints in the hand or foot
The affected joint(s) is red, hot and swollen with reduced range of motion due to pain
During the inflammatory response, fibrin is deposited on the cartilage and synovial lining leading to ischemia and necrosis
If untreated, as the inflammation resolves, relative capsular fibrosis or a reduced flexibility of the joint capsule is present
Infectious arthritis may be caused by a number of organisms
Bacteria reach joints both directly, as a result of trauma or surgery and indirectly through the bloodstream from other sites of infection
With bacterial infections, the onset is usually sudden with symptoms such as fever, shaking and chills
Medically, it is important to treat bacterial arthritis quickly with a full course of antibiotics
Normal compressive forces of joints reduce the diffusion of medication from the bloodstream into the joint (so rest)
Arthritic reactions may follow a viral infection. Joint inflammation usually lasts 1-2 weeks and resolves on its own
Fungal arthritis develops very slowly over weeks or months. The fungi enters the skin through cuts. The fungi that cause arthritis are found in soil and bird droppings. Antifungal medications are used to treat this arthritis
What is Lyme Disease?
A complex rheumatic disease that affects many systems of the body
Lyme disease mimics other diseases including the flu and several other rheumatic conditions
It is caused by the spirochete borrelia burgdorferi, which is transmitted to humans by tick bites
Ticks live outdoors in wooded or marshy areas and are most active in the spring and summer months. They spend part of their life cycle living on birds and other animals, then develop to their next stage were they bite humans
Lyme disease begins after an incubation period of up to 32 days
In most cases, a large expanding skin rash (erythema migrans) is noticed around the site of the tick bite, although the person may not have noticed the bite itself
In some people, the rash is ring-shaped
In others, there is a raised, vesicular area in the centre
Several days after the onset of erythema migrans, severe headache, fever, chills, stiff neck, swollen lymph nodes, fatigue, muscle ache and joint pain occur
These symptoms are usually intermittent and changing
Brief, sporadic attacks of arthritis may affect large joints, especially one knee. These episodes may become longer after the second year of Lyme disease, lasting for months instead of weeks
Other more serious manifestations of Lyme disease are neurological abnormalities developing months after the initial symptoms, including meningitis, bilateral facial palsy, memory impairment and distal paresthesia. Cardiac involvement can include irregular or slow heartbeat
Medically, Lyme disease is treated with antibiotics and is curable if treatment is begun early
Preventative measures to avoid tick bites include wearing protective clothing that covers the legs and arms
After being in wooded areas, people should check for ticks on themselves, children and pets
Typically, ticks are attracted to warmer skin areas such as the axilla, inguinal area and trunk
If a tick is found attached to the skin, tweezers are used to carefully remove the tick without squeezing the tick’s body
After wiping the skin over the tick bite with an antiseptic, the tick may be saved in a jar for later identification
What is Reiter’s Syndrome?
A triad (3) of arthritis:
non-gonococcal urethritis (an infection of the urethra)
conjunctivitis (pink eye)
following inflammation of the intestine or urinary tract
It is only one manifestation of reactive arthritis, an inflammatory joint response to an infection distant to the inflamed joint(s)
While the bacteria that caused the infection are not directly found in the inflamed joint, antigens and RNA from the bacteria are present
The cause is idiopathic, but associated with an initial infection of a genetically susceptible person by salmonella, shigella, campylobacter or yersinia bacteria in the GI tract or by chlamydia trachomatis in the urinary tract
Most cases are seen in adults after an episode of gastroenteritis
Early symptoms include joint stiffness, myalgia and low back pain
Arthritis develops up to 3 weeks after the initial infection
Typically, joint involvement is asymmetric ( 1side)
The feet, ankles, knees and wrists are commonly affected
Those with severe or chronic Reiter’s syndrome are more likely to have the spine affected as well, including the SI joints
Inflammation occurs mostly at the insertion of a tendon to a bone, rather than or in addition to the synovium (ex. Plantar fascia and the Achilles tendon attachments at the calcaneus)
In the toes and fingers, this presents as a uniformly swollen digit, termed “sausage digit”
In the majority of cases, the arthritis does not lead to permanent disability or joint deformity
Some people have repeated attacks of arthritis lasting from 3-6 months
Successive flare-ups are similar in terms of severity, although different joints may be affected each time
Conjunctivitis is experienced by some with Reiter’s syndrome, while urethritis and cystitis affect both men and women who have the syndrome
Associated skin problems are a rash on the plantar surface of the foot and small, painless sores in the mouth or on external genitalia
Reiter’s syndrome is hard to diagnose
Medications such as NSAIDs and remedial exercises are used to control arthritis, combined with treatment of other presenting symptoms as needed
It is associated with HIV but it is thought that the drugs used to treat Reiter’s syndrome may increase the suppression of the body’s immune response
What is Rheumatoid Arthritis?
RA is an inflammatory, destructive, chronic autoimmune disease of multiple joints and connective tissue throughout the body
The cause of RA is unknown
In genetically predisposed individuals, a diminished immune response to bacteria and viruses may play a part
The immune system likely plays a role in this disease, since rheumatoid factor (an antibody) is present in many of those with RA
The onset is often gradual over several months, with symptom-free periods following for several months or years. There are periods of flare-ups and remission
Prognosis is uncertain. The disease can be mild, attacking a few joints for brief periods
RA begins with activation or injury of the synovial microvasculature of the endothelial cells
Edema and inflammation result and the synovial cells multiple and grow, capillaries proliferate among the newly grown synovial cells within a few weeks
The affected joints are hot, puffy and swollen, the skin over the joint is shiny and tight
ROM is reduced due to pain and stiffness, especially after a period of immobility such as sleeping
Stiffness persists for at least 1 hour and may be relieved by a hot shower
The duration of morning stiffness gives an indication of the severity of the inflammation
The disease often starts in the hands and wrists and joints are usually affected symmetrically
Most commonly involved are the PIP joints, MCP joints, wrist, knees, MTP joints, subtalar joints and C1-C2
The person also experiences systemic symptoms such as generalized aching, stiffness, fatigue and weight loss
As RA progresses, synovitis occurs and the synovial membrane thickens and folds in a process similar to granulation which occurs with wound healing
The inflammatory process liberates proteolytic enzymes, which attack and erode the cartilage, eventually exposing subchondral bone
Pannus develops between the joint margins, forming adhesions which restrict ROM
The surrounding joint capsule, ligaments, bursae and bones are affected as the joint structure erodes and crumbles
Joint deformities occur as the joint capsule swells and thickens
The fingers may become spindle-shaped
Tendons and muscles crossing the affected joints develop spasms leading to imbalances which move the joint further out of alignment
Subluxations may develop and the joint capsule and surrounding tendons can rupture
In the hand, common joint deformities include:
Swan neck deformity due to intrinsic hand muscle contracture (PIP joint hyperextended, DIP joint flexed)
Boutonniere (buttonhole) deformity resulting from ruptures of the central slip of the extensor tendons (PIP joint flexed, DIP joint hyperextended)
Severe loss of function occurs with a swan neck deformity as the person can no longer make a fist
Knee valgus deformity is quite common. Swelling is pronounced and the normal contours of the patella disappear
A Baker’s cyst, enlargement of the posterior knee bursa may form in the popliteal space
Knee flexion contractures may eventually develop if the person is unable to weight bear and uses a wheelchair
Neck pain is common. In severe cases, erosion of the alar ligaments and the odontoid process of C2 may lead to cervical instability and neurological symptoms
As RA is a systemic disease, there are several extra-articular symptoms
During flare-ups, pain, fatigue, low-grade fever, weight loss and anemia are likely experienced
Rheumatoid nodules can be present and develop where skin and subcutaneous tissues are subject to pressure
Sjorgren’s syndrome of dry eyes and dry mouth is present in some with RA. The eyes feel gritty and the person feels thirsty
More serious symptoms include pericarditis, pleurisy and eye lesions
Medically, diagnosis of RA is made with laboratory tests and x-rays and in the presence of the following: morning stiffness for at least one hour, involvement of at least three joints for 6 weeks, symmetrical joint swelling and rheumatoid nodules
NSAIDs, methotrexate (an immunosuppressive), antimalarial drugs, penicillamine or gold salts may be prescribed
A short course of corticosteroid treatment will dramatically improve the joint symptoms but will not alter the course of the disease
People with RA are often referred for physiotherapy to maintain ROM and strength
What is Scleroderma?
A systemic disorder affecting collagen, characterized by slowly
spreading fibrosis and collagen deposits throughout the body
Scleroderma is an autoimmune disorder
The cause is unknown, however, occupational exposure to vinyl chloride, silica and organic solvents may be connected
It is a rare disease, usually affecting adults between 30-50 years of age
Often the first symptom is Raynaud’s phenomenon, swelling or puffiness of the digits and arthritis of the digits. The skin thickens and indurates
There are two forms of scleroderma:
Localized
Generalized
types of scleroderma?
- Localized scleroderma:
- Affects the skin, fascia, muscles and sometimes bone
- It strikes children and young adults, mostly females
- Fibrotic lesions, composed of abnormal fibroblasts form hard oval patches on the skin’s surface or extend from the skin deep into muscles and bones of the limbs and forehead
- ROM is reduced in the affected joints and collagen deposits in the synovial lining give rise to joint pain
- On the face, lips pucker and there is difficulty in opening the mouth
- Generalized scleroderma:
- Affects multiple systems of the body: the skin, capillaries, GI tract, lungs, heart and kidneys
- It is further divided into two categories:
- Limited and diffuse
- The onset of limited is over a period of 5-10 years. The skin is affected first, followed later by contractures of the digits and dilated superficial skin capillaries
- The onset of diffuse is more sudden with the skin affected first. Later, stiffness, flexion contractures, tendon involvement, CTS (carpal turnel sympltom) and arthritis of large and small joints are present. Muscle weakness occurs due to restricted ROM. more serious symptoms result from visceral involvement. Collagen can build up and narrow the esophagus and small intestine
treatment for scleroderma?
Medically, there is no cure for scleroderma, certain drugs such as penicillamine may slow its progression
NSAIDs are also used to treat arthritis pain
Raynaud’s phenomenon is treated by keeping the extremities warm
What is Still’s Disease and
Juvenile Rheumatoid Arthritis (Viêm khớp dạng thấp thiếu niên)
Common conditions of chronic synovial inflammation in children
The cause of these conditions are unknown
JRA may develop at any stage of childhood
Pauciarticular onset describes arthritis of four or fewer joints, that usually manifests during the first six months of the disease. This condition comprises about half of the children affected with JRA
Polyarticular onset is arthritis of more than four joints. Onset is between 1-3 years of age as well as between 8-10 years of age. The hands, feet and TMJ are often affected, usually symmetrically (bilatery). Mild fever, malaise, adenopathy anemia and stunted growth may occur. This onset affects about 40% of children with JRA
Still’s disease has a systemic onset and is more rare. Symptoms include a high, spiking fever, pink rash, hepatosplenomegaly (enlarge) and anemia. Later, polyarthritis develops. Symptoms usually diminish after 12 months
The prognosis for most children with JRA is good with many experiencing remission with little or no residual disability. Aspirin is the most common medication. Exercise is important, as is encouraging the child to lead as normal a life as possible
Adult onset Still’s disease can affect young adults of both genders. It is a polyarthritis identical to childhood-onset Still’s disease with the additional symptoms of lymphadenopathy and less commonly, pericarditis
What is Systemic Lupus Erythematosus?
SLE is one type of chronic, attack-remitting autoimmune (can have flare up) inflammatory disease that can affect any system or organ in a variable manner
The cause of lupus is unknown, although there may be a genetic component that is triggered by factors outside and inside the body
Aggravating factors that can trigger an attack include prolonged and severe stress, medications such as chlorpromazine and methyldopa, viral infections and sun exposure. Certain foods such as plant protein found in soybeans and corn may also act as triggers to attacks
The symptoms of SLE are variable from person to person, ranging from mild to severe. There may be periods of remission and exacerbation
Some of the more common symptoms include fatigue, joint and muscle pain, fever, headache, anemia, loss of appetite, nausea, diffuse abdominal pain, skin rash, sun sensitivity and hair loss
Arthritic flare-ups whether transient or chronic can affect any joint but usually the hands and knees are involved. Joint deformities may develop in the fingers
CNS (centrel nerve system) involvement is less common
SLE is the most common form of lupus
Medically, diagnosis may be difficult, it is made through laboratory tests and observation of symptoms over time. Although SLE has no cure, many of the symptoms are controllable
Contraindications
Testing, except for active free ROM is CI’d on acutely inflamed joints
Hot hydrotherapy applications are CI’d during acute inflammation
General massage is CI’d with significant fever (38C, 101.5F)
Lymphatic drainage techniques proximal to the affected joint are avoided with acute infectious arthritis
Local massage is avoided on acutely inflamed joints or over open lesions. Avoid distal techniques that will painfully increase circulation through the joint
Joint play is CI’d on acutely inflamed joints to prevent aggravation of the condition
In tx and self-care, PROM or AROM used as remedial exercise is avoided on acutely inflamed joints
Between flare-ups, deep, vigorous techniques such as frictions and direct fascial techniques may provoke inflammation
With joint laxity and hypermobility, stretching techniques are used with caution
Health History Questions
How is your general health?
What specific inflammatory arthritide do you have?
When was the onset?
Is there a history of this arthritide in your family?
What is the frequency of acute attacks? When was the most recent flare-up?
What are your current symptoms?
What are your AD:’s?
How do you feel first thing in the morning?
Which joints are affected? Is ROM affected? Are there any associated systemic concerns?
Are you taking any specific medication for the arthritide?
Has there been any surgery for affected joints?
Are you doing any other therapies?
Further Assessment
- Health History Questions:
Which inflammatory arthritide do you have?
What stage is the disease?
Is the condition physician diagnosed?
It is important to differentiate an inflammatory arthritide from osteoarthritis, as the treatments are different
- Observations:
Guarded movement to prevent pain and a possibly pained or medicated facial expression may be noted
Depending on the affected joints, gait and postural dysfunctions are likely present due to pain
A postural assessment may be performed to determine sources of muscle imbalance
Affected joints are red and swollen, more so during flare-ups. The skin may be taut and shiny over the joint
- Palpation:
Heat and tenderness of affected joints are palpated, which are worse during flare-ups
Affected joints have a spongy, soft feel due to synovitis
There may be spasm in muscles crossing affected joints. Between flare-ups, HT, TP’s, crepitus (sound cripy), adhesions and disuse atrophy may be palpated
Dense contractured tissue may be present with scleroderma and rheumatoid nodules may be present with RA
- Testing:
During flare-ups, only AF ROM is used with affected joints having reduced ROM due to pain and swelling
Between flare-ups, AF ROM of affected joints is also reduced due to pain and swelling, but not as much as during an attack
PR ROM is restricted due to pain
AR isometric testing is weak and possibly painful for muscles crossing the affected joint
Massage
Tx goals depend on the specific arthritide and whether the client is in remission or active flare-up
- Tx goals can include:
Stress reduction and relaxation
Decreasing pain, edema and spasm
Maintaining joint mobility
Maintaining and increasing strength
Preventing or reducing postural changes and joint deformities
Reducing contractures is especially important with JRA
- During flare-ups:
If massage is tolerated by the client, massage is to the unaffected areas of the client’s body
The massage is limited to 30 mins in duration to avoid exhausting the client
The focus is on relaxation including unforced diaphragmatic breathing
Hydrotherapy is cold applications to the client’s tolerance at the affected joint
Positioning is whatever is comfortable for the client
- Between flare-ups:
The tx should be between 30-45 mins according to the client’s tolerance
Treatment is in the context of a relaxation massage, including diaphragmatic breathing
Positioning is for the client’s comfort
Hot hydrotherapy may be used with chronically arthritic joints as it controls pain and spasm
Specific tx of rhythmic techniques are used. Compensatory structures are treated to reduce HT and TP’s. Gentle fascial techniques are used if soft tissue contractures are present
Gentle joint play techniques may be used with caution on the affected joint capsule
