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