March 11 lecture

Question 1

Does Ra happen to everyone?
What are the stats on OA, RA, gout and alkyl. spond.
Despite the prevalence, what is a key fact about arthritis?

Answer 1

Yes, 2/3 ppl over 65 get the disease. 
1/10 have OA 
1/30 have Gout 
1/100 have RA 
0.5-1 in 100 have ankloysing spon. 

3. that if you Rx it early you can stop a lot of the disease

Question 2

1) when Ax for RA what are some key points to remember in making a diagnosis

Answer 2

• labs do not = diagnosis Hx and physical exam do

* age; sex; race; Fx; presentation (febrile, acute, chronic, or widespread)

Question 3

What are key questions to consider when screening Ra

Answer 3

1) R there red flags
2) intra vs peri articular inflammation
3) inflam vs non-inflam
4) focal (3jts)
5) acute (6wks)
RF = rehumatoid factor more severe in ppl with RA sensitivity

Question 4

What are 4 Red Flags you must consider when ax for Ra, what action do you take with them (FSMN)

Answer 4

1) Fracture 2) Septic Arthritis (infec in jt. severe condition b/c it can cause jt damge) 3) malignancy 4) neurological signs and symptoms (focal/diffused muscle weakness; turning, numbness, parasthesia)
* These may present like Ra but require immediate referral or additional apts to rule them out

Question 5

What are the 7 differences between Inflammatory conditions and Non-inflam conditions
(KNOW THIS SLIDE)

Answer 5

Feature Inflam conditoin non inflam condition
Pain Yes (morning) Yes (after use)
Swelling mod to severe Mild
Erthema Sometimes absent
Warmth Sometimes absent
Morning stiffness Yes > 1hrs <30min
Systemic features sometimes absent
Increse ESR * Frequent uncommon
Examples RA OA
** Erthrocyte sedimentation rate

Question 6

Once you know if there is an inflame condition or not what is the next step?

Answer 6

You need to determine if the swelling is articular or periarticular

Question 7

What is the difference between articular and periarticular swelling

Answer 7

Articular swelling: deep diffuse pain; pain w. A/PROM all planes; swelling is common

Periarticular: localized tenderness (bursitis, tendinitis); P. w. movt only in active few planes; swelling is uncommon

Question 8

What is the Ax algorithm for Ra?

Answer 8

MSK condition

RED FLAGS
 
YES NO
Immediate Rx/Dx is this Articular condt?
(#, Septic arth; Cancer; Neuro)

 
YES (articular) NO (pericart)
Is jt inflamed? Non-articular condt.
(septic arth; gout; RA; PS) (bursit; enthesitis; polymyositis)

 
YES NO
>3jts Suspect OA

Question 9

What are some inflammatory and non-inflammatory non-articular conditions

Answer 9

Inflammatory: bursitis; enthesitis; polymyositis

Non-inflamm: Fibromyalgia; #; carpal tunnel

Question 10

What is RA and what does it cause?

Answer 10

Autoimmune disease
Synovitis (inflam of synovial membrane)
- hyperplasia
- increased vascularity
- infiltration of inflam cells = production fo enzymes that causes inflam (cytokine and TNF)
- Articular damage caused by pannus (layer of fibrovascular tissue or granulation tissue)
-

Question 11

RA is only minor aches and pains and never happens in womenF!

Answer 11

NO it can be serious health problem if untreated
- no women > men (about 1%)
- usually 35-50 yrs (presentation more severe in first nations)
-

Question 12

What happens at the joint in RA?

Answer 12

• immun factors cause synovium to swell cells proliferate
• pannus (dense articular membrane) spread over articular cartilage and erodes underlying cartilage and bone
• pannus normally on one side can extend to other side too causing fibrous scar tissue or adhesions or analysis
• bone = osteopenic
• ligaments /tendons = damaged or rupture
• muscles around jt decrease leaving unstable

Question 13

What is the most common autoantibody in RA

Answer 13

HLA-DR4 (80%) cases

Question 14

Could you use RF as a diagnostic indicator for RA?

Answer 14

No, its present in most ppl

• -ve RF W. clinical symptoms = Senonegative arthritis (30%)pt.s
• use it as a confirmatory agent NOT diagnostic

Question 15

What other conditions does RF present with?

Answer 15

lupus, mixed connective tissue disease, syphillis, chronic hepatitis, PFribrosis

Question 16

What are key questions to take into account in subjective Hx?

Answer 16

• twins?

- FHx (does a sister have one??)

Question 17

True/false - decreased risk of RA post baby

Answer 17

False - increased risk d/t prolactin

Question 18

True/false - Oral contraceptive reduces risk for RA?

Answer 18

True (postpone vs. prevent)

Question 19

what food factors can increase or decrease your risk?

Answer 19

Reduce: olive oil >3x/wk, drinking tea >3cups and antioxidants
INcreased: decafe coffee > 4cups

Question 20

more import. then genetics are…

Answer 20

the environmental factors which are modifyable and we can help them with..smoking, occupation, pollution…

Question 21

What are the criteria for RA as per 1987

Answer 21

need to have 4 of 7 of these

• morning stiffness > 1hr (>6wks)
• arthritis of >or = 3jts (>= 6wks)
• Arthritis of hand jts (> 6wks)
• Rheumatoid nodules (extra articular feat. granulated)
• Serum rheumatoid factor
• radiographic changes
• • use meds to help delay disease but need most symptoms to be there for 6wks

Question 22

What are the clinical features of RA

Answer 22

Pain ** 
Fatigue
Stiffness
decreased ROM 
Swelling
Jt deformity
instability 
muscle atrophy decreased strength (d/t P and deconditioning) 
general conditioning 
extraarticular features

Question 23

A patient has had RA for a number of years how do you tell how fast the jt damage is happening?

Answer 23

1) swelling no erosion
2) thinning cortex on radial side and min jt space narrowing
3) marg erosion at radial of MChd W. jt space narrowing
* * nodules often in elbow dont know why they happen ; dont have to be symmetric ***

Question 24

There are 4 main Rx for Ra what are they?

Answer 24

1) medication
2) Rehab
3) lifestyle modification
4) surgery

Question 25

Describe the Rx for RA using Medication

Answer 25

• Standar is “TREAT TO TARGET”
• if just diag. = maintain remission
• if long term = then achieve & maintain low disease activity
• b/c RA overactive immune want to TREAT this, drugs take 6-8 wks to take effect
• biologics faster but more $
• *DMARD (Disease modifying antiRheumatic Drugs) (methotrexate) **need this EARlY
• • biologics to halt disease process
• b/c DMARD take long time give NSAIDs.. to deal w. P
• ramp meds till target reached then back off

Question 26

Describe the PT aspect of RA including the goal

Answer 26

GOAL: control/decrease inflam and P **

• balance, rest & activity
• Ice
• splinting, positioning
• ROM exercises **very impt ppl will just stop

Question 27

A pt with RA comes in to your clinic with an active bout of RA and tight hamstrings, do you stretch him?

Answer 27

No b/c the jt will already be inflamed and stretched out you could cover stretch the jot

Question 28

What is the goal of PT for chronic RA

Answer 28

GOAL: improve pain and stiffness 
- mods: TENS, ice, heat 
- positioning, supports, splints 
- exs (functional / balance / proprioception) 
      (decreased balance incr. osteopenia inc. chance falls and breaks >> fall prevention))
- pool activity - endurance 
- ROM 
- leisure and occupational activities 
** Prevent deformity - positioning..

Question 29

When considering physical activity for RA you should consider all of the following.

Answer 29

Rec activity 
Occupational acti
daily living act. 
GENERAL RECOMMENDATIONS: 
- whole body 
- most days of the wk 
- mildly increase HRT 
- slightly out of breath 30min accumulation 
- (flexibility: ROM VS stretch/ strength/ cardio

Question 30

Outside of non medical options what else can you do for Rx of RA?

Answer 30

Education key

- self management - active roles - problem solving - self monitoring - communicating

Question 31

What are the 4 R’s in surgical manage. of RA

Answer 31

Remove
Re align
Rest
Replace