Gout (Inflammatory Arthritides) Flashcards
- What are Inflammatory Arthritides?
- What is Gout?
- A group of inflammatory diseases affecting connective tissue including joints
- 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 giả bệnh gút, 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 bài tiết kém 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 kết tủa 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 gặm nhấm 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 thừa hưởng condition, but attacks can also be precipitated by excessive alcohol consumption, obesity, certain foods and medications, trauma, surgery and “crash” diets
Symtoms
- 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 dưới sụn bone destruction leading to joint deformation sự biến dạng
- 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
diagnosed
treated
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
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 ADL’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: Rheumatoid Arthritis & Other Inflammatory Arthritides
- 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
Self-Care
Exercise to the client’s pain tolerance
Between flare-ups, self-stretching is used to prevent contractures
Submaximal isometric exercise to maintain strength of muscles crossing affected joints is progressed to low impact or water aerobics
Stress reduction exercises and diaphragmatic breathing are important
Splints to protect joints, orthotics and devices to help with ADL’s may be helpful
Larger objects are easier to grip than small ones
During flare-ups, cool hydrotherapy applications may relieve pain
Between flare-ups, heat is used on affected joints
