Lecture 19 - Rheumatology Flashcards
RA diagnosis - pts should be tested for RA if __?
- they have at least 1 joint with definite clinical synovitis (swelling)
- the synovitis is not better explained by another disease (e.g. systemic lupus erythematosus, psoriatic arthritis, gout)
RA diagnosis/classification is based on what?
1) Joint involvement
- Large joints = shoulders, elbows, hips, knees, ankles
- Small joints = MCP, PIP, thumb IP, wrists, 2nd – 5th MTP
N.B. DIP, 1st CMC and 1st MTP are not included here as they are often involved in OA
2) Lab testing
- Serology: rheumatoid factor (RF) & anti–citrullinated protein antibody (ACPA)
- Acute Phase Reactants: C-reactive protein (CRP)& erythrocyte sedimentation rate (ESR)
3) Duration
*Diagnosis of RA:
New (acute) patients: ≥ 6 points
or
Patients with erosive disease typical of RA and Hx of prior fulfillment of criteria (i.e. ≥ 6 points)
•including pts whose disease is inactive (with or without treatment)
what are the differences btw RA and OA?
RA – General management (for all rheumatic conditions)?
Elements of comprehensive management
–Interdisciplinary approach
–Early intervention, ongoing care and systemic reassessment (follow-up)
–Pt and family involvement
–Ecosystemic approach (Home/work evaluation; recommendations when possible)
RA – PT evaluation
Hx
–current and pass illnesses
–previous surgeries
–previous rehab services
–Medication
–last/next appt with rheumatologist
–social hx
Physical and Functional status
–ROM & MMT
–Neurological exam
–Posture
–Balance
–Endurance
–Transfers
–Gait
- Stairs
RA – Medical management
Drug therapy
–NSAIDs
–Glucocorticosteroids (Corticosteroids)
–Disease-modifying antirheumatic drugs (DMARDs) (Traditional DMARDs, Biologics, Biosimilars)
Surgery
–Jt replacements
RA – Goals of PT Rx
•Educate pts and caregivers
–disease processes
–self-management
- Control inflammation
- ↓ pain and stiffness
- ↓ rate of damage and preserve jt integrity
- ↑ & maintain jt mobility and ms strength
- Preserve or restore function
RA – PT interventions
Education (in collaboration with OT)
–Dx
–Jt protection techniques
–Energy conservation techniques
•4 “P”s: plan, posture, prioritize, pace
–Body mechanics & postural (positioning) hygiene
–Exercises
–Use of ice/heat
–Proper footwear/insoles
–Self-management strategies
–Links to further information
Walking aids & gait training
Other assistive device, splinting/ bracing (OT)
Referrals
–Rheumatologist
–OT
–Psychology
–Social worker
RA- ACSM exercise prescription guidelines (2014)
Goal: Minimise pain but gradually progress towards levels that provide health benefits
In general, consistent with those for healthy adults: take into consideration individual’s pain, stability and functional limitations
Special considerations
–Avoid strenuous ex’s during acute flare-ups/ inflammation (ROM ex’s are appropriate- Parameters for acute/painful/irritable condition)
–Adequate warm-up and cool-down are important to minimize pain
–Incorporate functional ex’s
Clinical practice guidelines for RA - there is a total of 6 recomende dor strongly recomended guidelines
Exercise Therapy (included in 5/6)
–Recommended (5/5)
–Aerobic (3/5)
–Muscle strength (1/5)
–High-intensity exercise (2/5)
–Low-intensity exercise (1/5)
Education (included in 3/6)
–Recommended (3/3)
–Jt protection techniques, E conservation, problem-solving skills (2/3)
–Pain disability coping and maintenance of work ability (1/3)
U/S, electrical stimulation, LLLT (laser), thermotherapy (included in 4/6)
–TENS for short-term pain and stiffness relief (2/4)
–TENS or thermotherapy as adjunct to pharmacological treatment (1/4)
–U/S and laser recommended (1/4) and as an adjunct only to pharmacological treatment(1/4)
Massage, manual therapy, balneotherapy (included in 1/6)
–Massage recommended, but not on its own (1/1)
–Passive mobs recommended to maintain or restore ROM (1/1)
–Balneotherapy as adjunct to active and passive PT interventions (1/1)
Cochrane reviews on treatment interventions in RA - exercises and thermotherapy
Cochrane reviews on treatment interventions in RA - ultrasound and TENS
Cochrane reviews on treatment interventions in RA - E-stim and LLLT
Cochrane reviews on treatment interventions in RA - splints/orthoses and thai chi
Would you prescribe wrist and hand ROM exercises to this person with RA? If so, which one(s)?
–Yes
–You can prescribe any painfree or non irritable exercises except you should avoid exercises that promote the pt’s deformity.
–For this case you should avoid: UD exercises of the MCPs, Be careful if do UD exercises of the wrist that there is no compensation at the MCPs also going in that UD direction
Systemic Lupus Erythematosis (SLE) - evaluation and treatment
Evaluation
- Similar to RA
- Need to look more closely at all the systems during the evaluation.
–Heart/lung involvement (Can limit ability to work on improving endurance)
–Neurological involvement (Balance can be affected)
Treatment
•Similar to RA
–Advices specific for skin rash (Avoid exposure to sun, Use sun block & protective clothing)
Scleroderma - PT treatment
•Mainly supportive interdisciplinary approach
PT Role
–ROM ex’s for the affected jts (gentle)
–Facial and mouth exercises
–Strengthening ex’s
–Hot pack or wax bath
–Close monitoring of skin integrity with ROM/ stretching necessary
–Education: Avoid exposure to cold, monitor closely with heat (Raynaud’s phenomenon )
Gout (Crystal-Induced Arthritis) - pt role
•PT Role: similar to other rheumatic conditions
Ankylosing Spondylitis - PT evaluation
Five screening questions:
- Is there morning stiffness?
- Is there improvement in discomfort with exercise?
- Was the onset of back pain before age 40 years?
- Did the problem begin slowly?
- Has the pain persisted for at least 3 months?
Interpretation
4 or 5 positive answers provides:
- sensitivity ≤0.95
- specificity ≤0.85
- PLR ≤6.3
- PPV = 0.04 (Ankylosing spondylitis is RARE)
OTHER
- Duration of morning stiffness
- Posture: Loss of Lx lordosis, ↑ Tx kyphosis, compensatory ext of Cx spine
- Spinal mobility (using tape measure)
–Finger-to-floor
–Occiput-to-wall
–Cx spine: all mvts
–T1-to-wall, T7-to-wall
–Lx spine: Modified Schober’s test
- Chest expansion at xiphoid process
- Active jt count as needed (if peripheral jt involved)
Ankylosing Spondylitis - PT management goals
- Maintain a good posture and avoid stiffening in a flexed position
- Optimize spinal and chest mobility
- Optimize general ms strength
- Optimize CV function
- Maintain and improve general functioning and HR-QOL
- Design lifelong health and rehabilitation programs with the patient
Ankylosing Spondylitis - cochraine review
Example of exercises
–Cx retraction AROM
–Tx extension AROM
–Tx rotation AROM
–Lx extension AROM
–Breathing exercise (diaphragmatic)
–Postural awareness: e.g. being pulled by an imaginary cord on the head
Ankylosing Spondylitis - PT evaluation - spinal mobility tests
Ankylosing Spondylitis – PT management
- Postural correction exercises / Global postural reeducation
- Spine & Chest wall mobility exercises
–Should include all planes of movement with a rotational component
- General trunk stretching
- Soft tissue mobilization
- Deep breathing exercises & breathing control, incentive spirometry, coughing maneuvers
- ROM exercises
- Strengthening exercises
- Gait reeducation
- Aerobic exercise
what Pharmacological agents are used in rheumatology conditions?
NSAIDs
Glucocorticosteroids (Corticosteroids)
Disease-Modifying Antirheumatic drugs (DMARDs)
–Traditional DMARDs
–Biologics
–Biosimilars
NSAIDS: Implications for rehabilitation
Corticosteroids: Implications for rehabilitation
Traditional DMARDs implications for rehab
•Considerations for rehabilitation listed in the rheumatology course notes
Biologics & Biosimilars:
Implications for rehabilitation
1) The cause of the skin changes and muscle wasting is likely the prednisone meds (corticosteroids).
- Primary side effects: break down proteins (proteins catabolism) such as collagen in ms, skin, bone and other tissues
- In addition, she might not have been as active due to her RA symptoms.
- The combination of the catabolic effects of the drugs combined with a more sedentary lifestyle are both likely contributing factors to her ms loss.
2) Traditional DMARDs, biologics or biosimilars
•These drugs do not typically cause the catabolic effects associated with corticosteroids. Also, they provide a more specific inhibition of the autoimmune response related to RA as opposed to the corticosteroids which virtually inhibits all aspects of inflammation.
3) Gradual strengthening exercise program to restore ms strength, ms mass and bone density tailored to her current level of strength and function.
•You might want to start with an aquatic exercise program if possible and progress to land-based exercises
define arthritis - reading
p 1
what is Raynaud’s phenomenon / syndrome? -reading
p 1
describe RA - general presentation, epidemiology, etiology
- p2
describe RA inflammatory process, symptoms, general course
p 2-3
RA - describe: Swan neck deformity, Boutonniere deformity, Zig Zag deformity, Synovitis, deviations (hand)
p 4
RA describe: Mallet toe, hammer toe, claw toe, Hallux valgus, knee, and neck deformities
p 5
desribe ra RA - Extra-articular manifestations
p 6
describr ra lab tests
p 6-7
what is Systemic Lupus Erythematosis (SLE) - system involvement, general course, tests, management, etc
p 8-9
what is Scleroderma - types, system involvement, tx, smptoms
pg 10-11
what is gout?
p 12
describe Ankylosing Spondylitis (AS) - pathology, clinical presentation, tests, management, etc
p 13-14
reading - nsaids
p 15
reading - Glucocorticosteroids (Corticosteroids)
p 15
reading - Traditional Disease-Modifying Antirheumatic drugs (DMARDs)
p 16
*Many traditional DMARDs also put the patient at increased risk of infection due to their immunosuppressive effects. Refer to the Rheumatology lecture ppt section on Biologics and Biosimilars: Implications for rehabilitation regarding precautions related to the increased risk of infection.
reading - Biologics
p 17
The common side effects of biologic agents are:
Risk of severe allergic reactions during administration
Risk of infections
Risk of certain cancers
Risk of demyelinating disorders
Change in mental status
reading - Biosimilars
p 18
