Osteoarthritis & Rheumatoid Arthritis

Question 1

Definitions

Answer 1

OA = LOCALIZED process involving destruction of articular cartilage confined at affected joints

• formation of osteophytes @ margins
• men > women

RA = SYSTEMIC inflammatory disease primarily affecting joint synovium
- women > men

Question 2

Etiology

Answer 2

OA = primary: unknown etiology OR secondary: due to trauma, increased age, occupational/functional tasks, obesity, infection, congenital malformation or other MS disease

RA = autoimmune disorder, specific etiology unknown

Question 3

Pathophysiology

Answer 3

OA = increase in proteoglycan and collagen synthesis –> fraying of articular cartilage –> proteoglycan loss

RA = infiltration by immune cells –> inflammatory response –> hyperplastic granulation invades joint releasing inflammatory factors which erode cartilage and subchondral bone

Question 4

Radiograph Appearance

Answer 4

OA = joint space collapse, sclerosis, osteophyte formations

RA = overall poor bone quality, increased erosion and destruction, inflammation, joint space narrowing

Question 5

Kellgren & Lawrence Grading System for OA

Answer 5

Grade 0 - normal but w/ symptoms
Grade 1 - possible osteophytes & joint space narrowing
Grade 2 - definite osteophyte formation & joint space narrowing
Grade 3 - multiple osteophytes, narrowing & possible deformity
Grade 4 - large osteophytes, marked narrowing, severe sclerosis and definite deformity

Question 6

Stages of RA

Answer 6

Early (I) - no RA evidence, possible OP
Moderate (II) - OP w/ slight cartilage destruction, muscle atrophy and no deformity
Severe (III) - OP and destruction of cartilage and bone w/ deformity and atrophy, no ankylosis
Terminal (IV) - ^^ plus fibrous or bony ankylosis

Question 7

Diagnostic Criteria

Answer 7

OA =

1. hip pain AND hip IR 15 w/ pain AND morning stiffness 50 y/o
2. morning or post-inactivity stiffness about 30min
3. radiographic tests
4. asymmetrical involvement

RA = must rule out other diagnosis, clinical presentation + radiographs

1. morning stiffness at least 1 hour
2. arthritis of more than 3 joints
3. arthritis of hand joints (PIP & MCP)
4. Symmetrical
5. Rhemuatoid nodules
6. positive serum RF
7. radiographic evidence of erosion and bony de-calcification

**must meet 4/7 of criteria & will see systemic signs (fever, malaise, anorexia, wt. loss)

Question 8

Disease Course of RA

- monocyclic, polycyclic or progressive & unremitting

Answer 8

Monocyclic - one episode that will go away and never happen again

Polycyclic - most common - fluctuating levels of disease activity

Progressive and unremitting

Question 9

Patterns of Joint Involvement for OA

Answer 9

1 most common = knee

UNILATERAL

Also affects the hip & UE & axial skeleton (DDD)
- DIPs, PIPs and thumb CMC

**Heberden’s nodes: osteophyte formation on DIPs

Question 10

Patterns of Joint Involvement for RA

Answer 10

BILATERAL & SYMMTERICAL

Most common = hands & wrists

• MCPs: volar subluxation and ulnar drift
• *PIPs: Bouchard’s nodes, swan neck & boutonneire deformity (remember “PBR”)

can also affect the thumb IP, hip, knee, foot/ankle, muscles, tendons/ligaments

Question 11

Pharmacological Interventions

Answer 11

OA = goal is pain control

• oral analgesics/NSAIDS
• corticosteroid injections
• hyaluronic acid (helps build up cartilage & provide lubrication)

RA = goal is aggressive early disease management to limit long-tern joint destruction

• NSAIDS
• DMARD (disease modifying anti-rheumatic drug)
• BMR (biological response modifiers) - impact the disease process (i.e. Humira, Enbril)

Question 12

Rehabilitation Management for OA/RA

• depends on 3 things
• acute, subacute and chronic goals

Answer 12

Depends on:
1. Stage of inflammation, direct evaluation and intervention

Acute = reduce pain and inflammation, rest affected joints, modalities, maintain ROM, strength, endurance and functional independence

Subacute = Progress ROM, strength, endurance; improve performance and range of ADL’s, joint protection

Chronic = independence in ADL’s, return to vocation or recreation, patient education

Question 13

Modalities

Answer 13

reduce pain and facilitate activity

Can use superficial heat, cold packs (acute edema), and TENS (chronic pain)

**DEEP heat CONTRAINDICATED b/c can increase inflammation

Question 14

Joint Mobility

Answer 14

Positioning and self ROM

Lengthen shortened muscle groups

NO manual therapy/mobilizations for RA

Question 15

Strengthening

Answer 15

isometric or sub-maximal; add dynamic when appropriate
use resistance w/ caution in pain free ROM and monitor for exacerbation
- discomfort should subside w/n 1 hour of exercise

Incorporate functional activities

Question 16

Gait and Functional Training

Answer 16

improve walking speed and normalize gait

-assistive device selection (can can unload a hip by up to 60%)

Question 17

Education

Answer 17

disease process, joint protection, pain management, exercise and resources