March 11 lecture Flashcards
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?
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.
- that if you Rx it early you can stop a lot of the disease
1) when Ax for RA what are some key points to remember in making a diagnosis
- labs do not = diagnosis Hx and physical exam do
* age; sex; race; Fx; presentation (febrile, acute, chronic, or widespread)
What are key questions to consider when screening Ra
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
What are 4 Red Flags you must consider when ax for Ra, what action do you take with them (FSMN)
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
What are the 7 differences between Inflammatory conditions and Non-inflam conditions
(KNOW THIS SLIDE)
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
Once you know if there is an inflame condition or not what is the next step?
You need to determine if the swelling is articular or periarticular
What is the difference between articular and periarticular swelling
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
What is the Ax algorithm for Ra?
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
What are some inflammatory and non-inflammatory non-articular conditions
Inflammatory: bursitis; enthesitis; polymyositis
Non-inflamm: Fibromyalgia; #; carpal tunnel
What is RA and what does it cause?
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)
-
RA is only minor aches and pains and never happens in womenF!
NO it can be serious health problem if untreated
- no women > men (about 1%)
- usually 35-50 yrs (presentation more severe in first nations)
-
What happens at the joint in RA?
- 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
What is the most common autoantibody in RA
HLA-DR4 (80%) cases
Could you use RF as a diagnostic indicator for RA?
No, its present in most ppl
- -ve RF W. clinical symptoms = Senonegative arthritis (30%)pt.s
- use it as a confirmatory agent NOT diagnostic
What other conditions does RF present with?
lupus, mixed connective tissue disease, syphillis, chronic hepatitis, PFribrosis
What are key questions to take into account in subjective Hx?
- twins?
- FHx (does a sister have one??)
True/false - decreased risk of RA post baby
False - increased risk d/t prolactin
True/false - Oral contraceptive reduces risk for RA?
True (postpone vs. prevent)
what food factors can increase or decrease your risk?
Reduce: olive oil >3x/wk, drinking tea >3cups and antioxidants
INcreased: decafe coffee > 4cups
more import. then genetics are…
the environmental factors which are modifyable and we can help them with..smoking, occupation, pollution…
What are the criteria for RA as per 1987
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
What are the clinical features of RA
Pain ** Fatigue Stiffness decreased ROM Swelling Jt deformity instability muscle atrophy decreased strength (d/t P and deconditioning) general conditioning extraarticular features
A patient has had RA for a number of years how do you tell how fast the jt damage is happening?
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 ***
There are 4 main Rx for Ra what are they?
1) medication
2) Rehab
3) lifestyle modification
4) surgery
Describe the Rx for RA using Medication
- 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
Describe the PT aspect of RA including the goal
GOAL: control/decrease inflam and P **
- balance, rest & activity
- Ice
- splinting, positioning
- ROM exercises **very impt ppl will just stop
A pt with RA comes in to your clinic with an active bout of RA and tight hamstrings, do you stretch him?
No b/c the jt will already be inflamed and stretched out you could cover stretch the jot
What is the goal of PT for chronic RA
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..When considering physical activity for RA you should consider all of the following.
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
Outside of non medical options what else can you do for Rx of RA?
Education key
- self management - active roles - problem solving - self monitoring - communicating
What are the 4 R’s in surgical manage. of RA
Remove
Re align
Rest
Replace
