Lecture 7 and 19 - OA and RA Flashcards
What is the definition of osteoarthritis?
progressive loss of articular cartilage
accompanied by
- attempted repair of articular cartilage,
- remodelling, and
- sclerosis of subchondral bone, and
in many instances the formation of
- subchondral bone cysts and
- marginal osteophytes.
T/F Secondary OA: A. can come from a neurological disorder B. Is idiopathic C. Is the most common D. Is explain by age-related dynamic reaction pattern E. joint injuries can be identified
Secondary OA:
A. can come from a neurological disorder - T
B. Is idiopathic - F
C. Is the most common - F
D. Is explain by age-related dynamic reaction pattern - F
E. joint injuries can be identified - T
What can influence the pathogenesis of OA?
- susceptibility of joint damage, repair failure (6)
- site and severity of OA (6)
(name as much as you can)
Age, gender, menopause, genetics, nutrition, bone density
- susceptibility of joint damage, repair failure
Mechanical factors: obesity, injury, surgery, m.weakness
Joint deformity: repetitive joint loading, elite athletics
- site and severity of OA
What are signs and symptoms of OA (5)?
Tips:
type of e/f, subjective, observations (2), sound
joint pain restriction of motion (capsular vs. bony) crepitus with motion joint effusions deformity
What is the typical progression of OA?
- slow or rapid?
- Improvement expected or degeneration until the end of time?
Typically slow, over many years: Occasionally rapid
May spontaneously stabilize or even improve
partial restoration of the articular surface
decrease in symptoms
T/F
In OA, the patients undergoing 2nd non cognate total joint replacement are most likely ipsilateral
Patients undergoing a 2nd total joint replacement of a hip or knee due to OA or RA
RA: 2nd joint “random”
OA: Non-random
Highest: contralateral cognate joint
Non-cognate joint
contralateral more than 2x as likely
Explain a common problem among OA population pre and post op, often leading to deterioration and poor prognosis of the joint?
Patients pre-op for total hip replacement -> Peak knee adduction moment and peak medial compartment load: contralateral > ipsilateral
Patients post-op for total hip replacement-> Persistent asymmetry of knee kinetics
High knee adduction moment during gait is associated with:
- Radiographic severity of knee OA
- Radiographic deterioration of symptomatic knee OA
- Poor surgical prognosis for high tibial osteotomy (repair of varus deformity)
Easy one: Name good exercises to give OA patients
Low impact aerobic exercise, ex: cycling (land-based), quidditch (air-based), aqua-water-based exs.
Individualized
- ROM & flexibility
- Ms endurance and str exs
Describe some modalities that are recommended for OA? Not recommended?
Recommended
- Thermal: hand, knee, hip
- TENS and other electrical
- Acupuncture, balneotherapy
- Manual therapy
Not recommended
- Ultrasound
T/F in OA
1- Joint replacement is recommended for appropriate patients with knee and hip OA
2- Arthroscopy with debridement is recommended for the management of symptomatic knee OA
3- Intra-articular corticosteroids are recommended for knee and hip OA
4- Intra-articular hyaluronans are recommended for knee and hip OA
1- Joint replacement is recommended for appropriate patients with knee and hip OA (T)
2- Arthroscopy with debridement is recommended for the management of symptomatic knee OA (F)
3- Intra-articular corticosteroids are recommended for knee and hip OA (T)
4- Intra-articular hyaluronans are recommended for knee and hip OA (F: not enough evidence)
Pharmacologically in OA, what is recommended
- 1st line
- 2nd line
- Refractory symptoms
- Others
- 1st line: acetaminophen
- 2nd line: topical: capsaicin, topical NSAIDs
- Refractory symptoms: tramadol
- Others: opioids, duloxetine
For obesity-induced OA, what is
- the minimum physical activity recommended
- The recommended phys.activ (extra recommended… like more than minimal)
- Why?
- Minimum ≥150 min/wk of moderate-intensity PA
- ~250 to 300 min/wk (approximately 2000 kcal/wk)
- Why minimal?
o prevent significant weight gain
o reduce associated chronic disease risk factors
o elicit modest reductions in body weight in overweight and obese individuals
Why extra?
o likely to promote greater weight loss and enhanced prevention of weight regained
When patients should be tested for RA?
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)
What is the RA diagnosis based on?
Joint involvement
- Large joints = shoulders, elbows, hips, knees, ankles
Small joints = MCP, PIP, thumb IP, wrists, 2nd – 5th MTP
Lab testing
Duration
What are the joints affected by OA AND RA and not taken into account in the diagnosis of RA?
1st CMC and 1st MTP
With the ACR & EULAR collaborative criteria, how does the RA gets diagnosed?
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 elements of comprehensive management in RA (4)?
Interdisciplinary approach
Early intervention, ongoing care and systemic reassessment (follow-up)
Pt and family involvement
Ecosystemic approach (Home/work evaluation; recommendations when possible)
What are the drug therapy for RA?
NSAIDs
Glucocorticosteroids (Corticosteroids)
Disease-modifying antirheumatic drugs (DMARDs): Traditional DMARDs, Biologics, Biosimilars
What are the 3 MAIN steps in RA PT evaluation?
- Take hx
- Assess disease activity and damage
- Assess physical and functional status
In the RA PT evaluation, what is assessed concerning the disease activity and damage?
Inflammation - Duration of morning stiffness - Grip strength - Active joint count - VAS for pain and fatigue - Tests: Erythrocyte Sedimentation rate (N = <15 mm/hr ♂, <20 mm/hr ♀), RF+, x-rays, etc Damage (deformities) - Damaged joint count Extra-articular features - Raynaud’s - Eye and mouth dryness, etc,…
Give some example of what is assessed when evaluating physical and functional status in RA (tot:8).
ROM & MMT Neurological exam Posture Balance Endurance Transfers Gait Stairs, etc…
What are some goals in the PT treatment in RA (6)?
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
Give some PT interventions for RA (tot:10)?
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 : e.g. The Arthritis Society information line, Arthritis Self Management Program, education and support groups, local programs
Give some joint protection technique principles in RA (tot:13)
Respect pain
Alternate b/w rest and work periods
↓ the qty of effort necessary to accomplish a task
Use stronger & larger jts to accomplish the task
Avoid maintaining the same position for a long time period
Avoid any activities that cannot be stopped
Use splints to protect your jts
Use adaptations to protect your jts
Maintain adequate postural hygiene (sitting position, lying, standing or during leisure activities and work)
Maintain adequate body mechanic
Keep a healthy weight
Maintain strong ms around the jts
Maintain jt alignment
RA - PT interventions.
Give some examples (tot:4)
Exercises
ROM, strengthening ex’s, stretching, balance, whirlpool, land-based CV, water-based CV, HEP
Thermal modalities (Hot/cold packs, wax bath) Electrotherapy as needed
Manual therapy Limited role because of jt instability \+/- gentle accessory mobs (gr I-II) for “inactive” jt C-spine traction rarely used Manipulation techniques not indicated
Walking aids & gait training
Other assistive device, splinting/ bracing (OT)
Referrals: Rheumatologist, OT, Psychology, Social worker
What should you consider when giving exs during RA flare up
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
Suggest that they exercise at the moment during the day that their pain is typically less severe or during peak activity of pain meds
In the PT valuation of SLE, what changes compared 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
Is there any change in the PT treatment of SLE compared to RA?
Similar to RA
Advices specific for skin rash
Avoid exposure to sun
Use sun block & protective clothing
What are the PT interventions in sceroderma?
Mainly supportive interdisciplinary approach
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 )
Give an example of mouth exercise parameters.
What improvements are expected?
Exercises done 2X/day, 15 min each, over 18 wks
Mean improvement in mouth opening
10.7±2.06 mm
Improvements in eating, speaking, oral hygiene, and the insertion of their dentures was easier
What is the joint most affected with gout?
1st MTP
What are the 5 screening questions in AS?
T/F
If more than 50% are positive, the sensitivity and sensibility are high enough to suggest AS
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?
F: 4/5 positive questions
