OA & RA Flashcards
1
Q
Q: How is arthritis the following things?
- Complicated
- Highly prevalent
- Not just for old people
- Getting worse
A
- Consists of 100+ diseases/conditions
- affects 1 in 5 americans; 52.5 million
- 2/3 with condition are < 65
- Projected 67 mill by 2030
2
Q
Q: What type of arthritis is typically in younger individuals?
A
RA
3
Q
Defn: Rheumatoid Arthritis (RA)
A
a systematic inflammatory disease primarily affecting **joint synovium **
4
Q
Defn: Osteoarthritis (OA)
A
A **localized **process involving desctruction of cartilage tissue - “wear and tear”
5
Q
Q: What is another name for OA?
A
Degenerative joint disease (DJD)
6
Q
Diagram: Identify the condition
A
OA/DJD of knee affecting the medial WB surface
7
Q
Diagram: Identify the condition
A
OA/DJD of hip affecting superior WB surface
8
Q
Diagram: Identify the condition
A
Normal right wrist
9
Q
Diagram: Identify the condition
A
RA of the right wrist
yellow = inflammation
red/green = joint erosion
blue = joint space narrowing
10
Q
Q: How would you describe the unique feature of an OA xray?
A
Areas of OA “Light Up” due to thickening of the bone
11
Q
Q: How would you describe the unique of a RA xray?
A
Washed out appearance - bones turn to “Mush”
12
Q
Q: OA is a _____________ process that is __________ to the affected joints
A
localized, confined
13
Q
Content: Two pathologic characteristics of OA
A
- Progressive desctruction of articular cartilage
- Formation of bone/osteophytes at the margins of the joint
14
Q
Defn: Osteophytes
A
Formation of bone
15
Q
Q: How is a OA diagnosis determined? (3)
A
- Signs/symptoms
- Distribution of involvement
- Imaging
16
Q
Content: Diagnostic Criteria for OA (4)
A
- Asymmetrical joint involvement
- Lack of generlaized symptoms
- Morning/post inactivity stiffness (shorter duration)
- Variable pain that occurs/worsens with motion
17
Q
T/F: Radiographic tests always match the severity of the condition.
A
False, may not match
18
Q
Q: OA affects > ______ million people in the US, with common onset in those over ____ years old, and widespread in those over _______ years old.
A
27, 40, 65
19
Q
Q: What is the distribution of men and women with OA?
A
Men > women until 5th decade, then reverses
20
Q
T/F: OA is more common in the hip than the knee.
A
False, knee
knee = 13.8% in those 55-74 yo
hip = 3.1% in those 55-74 yo
21
Q
Content: Etiology of OA (3)
A
- No single predisposing factor has been identified
- Primary or Idiopathic (unknown etiology)
- Secondary (trauma, congential malformation, musculoskeletal disease)
22
Q
T/F: OA is a normal part of aging.
A
False: not normal
23
Q
Content: Risk Factors for OA (5)
A
- Increased age
- Trauma (early/repetitive microtrauma)
- Occupational/functional tasks
- Obesity
- Infection
24
Q
Content: Pathophysiology of OA (4)
A
- Initial increase in articular cartilage H20 content
- **Proteoglycan ** and collagen synthesis increase (Shift from type2>1, fibrillation and fraying of articular cartilage)
- Later, **proteoglycan loss **reduces compressive stiffness/elasticity
- Begins to affect subchondral bone and periarticular surfaces
25
Q: What effect does proteoglycan loss during OA have on function? (3)
1. Decreased joint loading capacity
2. Increased friction forces
3. Decreased shock absorption
26
Q: What part of the pathophysiology of OA leads to joit replacement?
When the subchondral bone and periarticular structure become affected
27
Q: What 3 things does the Kellgren & Lawrence scale (0-4) evaluate?
1. Presence of osteophytes
2. Joint space narrowing
3. Deformity
28
Q: What things are ruled out in a differential diagnosis of OA? (3)
1. RA
2. Infection
3. Other rheumatic conditions
29
T/F: A differential diagnosis for OA should look at joint ditribution/symmetry, radiographic findings, and laboratory findings.
True
30
T/F: RA presents with bone formation and OA presents with bone erosion.
False, flip it
31
Content: Patterns of Joint Involvement for OA in the UE
1. DIPs, PIPs, thumb CMC
32
Q: What type of arthritis are Heberden's nodes more common in?
OA
33
Defn: Heberden's nodes
Osteophyte formation at the DIP
34
Q: RA presents more _____________ (\_\_\_\_\_ and \_\_\_\_) while OA presents more ___________ (\_\_\_\_/\_\_\_\_)
proximally, wrist, CMC/MCP, distally, DIP, PIP
35
Content: Patterns of Joint Involvement for OA at the Hip (2)
1. Protective position (Hip flex, abd, ER)
2. Decreased hip ROM correlated to decreased walking speed and funcitonal limitations
36
Q: What is the most prevalent location for OA?
OA of the knee
37
Content: Kellgren and Lawrence System for OA - Grade 0
Normal
38
Content: Kellgren and Lawrence System for OA - Grade 1
Possible osteophytes, questionable joint narrowing; very early stage
39
Content: Kellgren and Lawrence System for OA - Grade 2
Definite osteophyte formation
40
Content: Kellgren and Lawrence System for OA - Grade 3
Moderate osteophytes, narrowing, possible deformity
41
Content: Kellgren and Lawrence System for OA - Grade 4
Large osteophytes, marked narrowing, severe sclerosis, definite deformity
42
Q: Pharmacologic therapy for OA is focused on ______ \_\_\_\_\_\_\_\_\_, traditional drugs ______ affect the disease progression.
pain, control, don't
43
Content: Pain Control Strategies for OA (4)
1. Medications (NSAIDS)
2. Pt. Education (low level activities)
3. Joint protection (support/stability, i.e. knee sleeve)
4. Exercise
44
Content: Pharmoacolgical Therapy Options for OA (4)
1. Oral Analgesics/NSAIDS
2. Corticosteroid injections (temporary effect of 2-3 mo, no more than 2-3 injections)
3. Viscosupplementation
4. Topical analgesics (gate control theory)
45
Q: How many criteria are there for RA and how many must be met to be diagnosed with RA?
7, 4
46
T/F: 1-4 of the criteria must be met for \< 6 weeks duration to be diagnosed as RA.
False, 6+ weeks
47
Content: Diagnostic Criteria for RA (7)
1. Morning stiffness (at least 1 hr)
2. Arthritis of 3+ joint areas (PIP, MCP, wrist, elbow, knee, ankle, MTP)
3. Arthritis of hand joints (wrist, PIP, MCP)
4. Symmetry
5. Rheumatoid nodules
6. Positive serum rheumatoid factor
7. Radiograpic evidence of erosion, bondy de-calcification
48
Content: Epidemiology of RA
1. Distribution
2. W:M ratio
3. Peak incidence
4. Lower prevalence in...
5. % of death due to arthritis/rheumatism
1. 1.5 mil in US
2. 2-3:1
3. 60-70 yo
4. African americans, Japanese, Chinese vs, Caucasian, (increased in native american)
5. 22%
49
Content: Etiology of RA (5)
1. Considered autoimmune
2. Unknown, likely multi-factorial
3. Genetic predisposition (HLA-DR genes)
4. Potential bacterial/viral component
5. Smoking may contribute
50
Content: Rhuematoid Factor
1. Autoantibody against IgGFc
2. Present in about 70% of RA pts.
51
Content: Pathophysiology of RA
1. Infiltration of synovium by CD4+ T cells, B cells, and monocytes/macrophages
2. Production of inflammatory cytokines and chemokines
3. Hyperplastic synoium (pannus) invades and erodes cartilage, subchondral bone, articular capsule, and ligaments
4. Neutrophil infiltration of the synovial fluid, venous distention, capillary obstruciton, thrombus, and hemorrhage may also occur
52
Content: Differential Diagnosis for RA (10 - general idea)
1. Osteoarthritis
2. Reactive Arthritis (Reiter’s Syndrome)
3. Inflammatory bowel disease
4. Gout
5. Psoriatic arthritis
6. Polymyalgia rheumatica
7. Infection
8. Fibromyalgia
9. SLE
10. Sarcoidosis
53
Content: RA Clinical Presentation (7)
1. Insidious onset
2. Symmetrical morning stiffness \> 60 min
3. Generalized fatigue/malaise
4. Low grade fever
5. Anorexia/weight loss
6. Depression
7. Progression most rapid in 1st 6 years
54
Content: Disease Course for RA (3)
1. Monocyclic - 20%
- One episode which abates within two years of initial presentation
2. Polycyclic - 70%
- Fluctuating level of disease activity
3. Progressive and unremitting - 10%
55
Content: RA Patterns of Joint Involvement (4)
1. Bilateral and symmetrical
2. Most commonly hands and wrists
3. Joint inflammation and Crepitus
4. Permanent joint abnormalities within 10 years of diagnosis (80%)
56
T/F: The axial skeleton and DIP are often involved in RA
False, rarely
57
Q: What may accompany and be affected by RA?
Accompanied by joint ankylosis or ankylosing spondylitis
C-spine may be affected - can cause symptoms of cord compression
58
Diagram: Review of ABCs of Radiology
59
Content: RA Wrist Involvement (3)
1. Volar subluxation and ulnar displacement of carpals in relation to radius
2. Frequent development of flexion contractures
3. DeQuervain's and CTS are common due to synovitis
60
Content: RA Hand Involvement
1. MCP
2. PIP
3. Thumb
4. DIP
1. volar subluxaiton and ulnar drift
2. Swan neck and Boutonniere deformities with osteophyte formation, Bouchard's nodes
3. IP hyperextension and MCP flexion, with progressive CMC involvement
4. Usually uninvolved
61
Q: What is often the first clinical feature of RA?
Symmetric MCP and PIP joint involvement
62
T/F: Profound deformity and bone erosion is not associated with RA.
False, associated
63
Defn: Mutilans Deformity
Severe deformity with profound instability and funcitonal impairment
64
T/F: Hip involvement is more common in RA.
False OA
65
Content: RA Hip Involvement (2)
1. Joint space narrowing with intact articular cortex
2. No sclerosis
66
Content: RA Knee Involvement (5)
1. Commonly involved due to large amount of joint synovium
2. Flexion contracture are common due to pain, muscle guarding
3. Joint collapse
4. Absense of osteophytes
5. Diffuse osteopenia
67
Content: RA Foot and Ankle Involvement (5)
1. Pronated hindfoot
2. Collapse of longitudinal and transverse arches
3. Hallux valgus
4. MTP joint subluxation
5. Hammer/claw toes
68
Content: RA Muscle Involvement (5)
1. Occurs at affected joints
Things that may contribute:
2. Disuse atrophy
3. Myositis
4. Steroid induced myopathy
5. Peripheral neuorpathy
69
Content: RA Tendon/Ligament Involvement
1. Altered biomechanics due to chronic inflammatory process
2. Tenosynovitis interrupts gliding at tendon sheath, causing damage and potential for rupture
3. Flexor tenosynovitis is considered a poor prognostic factor
70
Content: Radiographic Feaures of RA during the following stages
1. Early
2. Moderate
3. Severe
4. Terminal
1. No radiographic evidence, possible osteoporosis
2. OP with slight cartilage destruction, muscle atrophy, no joint deformity
3. OP and destruction of cartilage/bone, joint deformity w/o anklyosis, extensive atrophy
4. Stage 3 + fibrous or bony ankylosis
71
Content: RA Laboratory Tests (5)
1. Rheumatoid factor (RF) - Negative in up to 30% with RA, ca be + in absence of RA
2. Erythrocyte sedimentation rate (ESR) - often ^ in RA/other rheumatic diseases
3. C-reactive protein - ^ indicates actue inflammation
4. Complete blood count - decreased RBC, norm WBC, ^ platelets
5. Synovial fluid analysis - usually turbid with neutrophils culture to rule out infection
72
Content: Complication of RA - Deconditioning (2)
1. Loss of lean body mass
2. Elevated resting energy expenditure
73
Content: Complication of RA - Vascular (3)
1. CHF
2. GI Bleeding
3. Hemorrhage
74
Content: Complication of RA - Neurological
Usually associated with compression/entrapment
75
Content: Complication of RA - Cardiopulmonary (2)
1. Impaired fitness
2. Pericarditis - rare
76
Content: Complication of RA - Ocular compromise
Sjogren's Syndrome - inflammatory disorder of lacrimal and salivary glands
77
Q: What is the goal of RA pharmacologic therapy?
Aggressive early disease managment to limit long term joint destruciton
78
Content: RA Pharmacologic Therapy (3)
1. NSAIDs - analgesic, antiinflammatory, usually COX2
2. Disease Modifying Anti Rheumatic Drugs (DMARD) - early prolonged use, methotrexate
3. Biological Response Modifiers (BRM) - DMARDs with block TNF-alpha or interleukin-1, Humira
79
Content: Primary Indications for Surgical Management (3)
1. Intractable pain
2. Loss of function
3. Progression of deformity
80
Content: Soft tissue Procedures (3)
1. Synovectomy
2. Soft tissue release
3. Tendon transfer
81
Content: Bone/Joint Procedures (3)
1. Osteotomy
2. Arthroplasy
3. Arthodesis
82
Content: Red Flags (3)
1. Recent trauma
2. Constitutional signs
3. Unusual pain or weakness, etc
83
Content: OE ROM (4)
1. Goni assessment
2. Functional ROM
3. Influence on ADLs
4. Biomechanical impact on surrounding joints
84
Content: OE Strength (2)
1. Caution with MMT
2. Modify or use funcitonal test
85
Content: OE Joint Stability
Don't want to do too much mobilization, use caution
86
Content: Functional Assessment (4)
1. Ideally should be standardized
2. Functional status index
3. Arthritis impact measurement scale
4. WOMAC
87
Content: Psyhological Status
Pain correlates more strongly with depression than function
88
Content: Goals and Outcomes for Arthritis (7)
1. Decrease pain, mechanical joint stress
2. Increase or maintain ROM and strength
3. Improve joint stability
4. Increase functional endurance
5. Maximize independence in ADL
5. Improve gait efficacy and safety
6. Establish exercise and conditioning programs
7. Educaiton to increase capacity for self management
89
Q: What directs the evulation and intervention for arthritis?
Stage of Inflammation
90
Content: Acute Phase Rehab (4)
1. Reduce pain and inflammation
2. Rest affected joints
3. Modalities
4. Maintain ROM, strength, endurance, functional independence
91
Content: Sub-Acute Phase Rehab (3)
1. Progress ROM, strength, endurance and functional training
2. Improve performance and range of ADL’s
3. Joint protection
92
Content: Chronic Phase Rehab (3)
1. Independence in ADLs
2. Return to vocation, recreation
3. Pt. education
93
Content: Modalities (5)
1. Used to reduce pain and facilitate actvity
2. Superficial head - dry heat pads, paraffin, etc
3. Deep heat - US, diathermy (contraindicated for acute, usefulness for arthritis is questionable)
4. Cold - for acute edema
5. TENS
94
Content: Joint Mobility (3)
1. Positioning and self ROM
2. Lengthen shortened muscle groups
3. MT is usually not indicated for RA
95
Content: Strengthening (4)
1. Isometric or submax
2. Add dynamic, concentric/eccentric
3. Use resistnace with caution (pain free, monitor for exacerbation, incorporate functional activities)
4. Exercise induced discomfort should subside within one hour
96
Content: Gait and Functional Training (3)
1. Improve walking speed and normalize gait
2. AD selection
3. Cane may unload hip by up to 60%
97
Content: Joint Protection (4)
1. Splints/Orthoses
2. Maintain ROM
3. Biomechanical support
4. Reduce pain
98
Content: Endurance Training
Consider NWB modes if possible
99
Content: Education (4)
1. Disease process
2. Joint protection
3. Pain management
4. Resources
