Pathophysiology II Flashcards
test 1
T or F?
RA is a systemic autoimmune disorder (abnormal antibodies attack your own body) that affects the joints and connective tissues of the body
True
Who does RA mostly affect?
Young and middle-aged women, usually in the small joints of hands and feet
What does RA overall do?
Produces chronic inflammation and thickening of the synovial membrane of joints
T or F?
RA can often cause sx’s of chronic illness by affecting the blood vessels, heart, and lung
True
What are some other conditions that RA includes under its umbrella?
Juvenile arthritis, lupus, scleroderma, polymyositis, and dermamyositis
T or f?
The pathophysiology of RA is not fully understood
True
How does RA being?
Begins as a state of persistent cellular activation, leading to autoimmunity and immune complexes in joints and other organs
Where is the initial disease site of RA? What happens there?
Synovial membrane (synovitis) - swelling and congestion results in immune cells coming in, leading to pain, stiffness, and limited ROM. Synovitis leads to hypertrophy and excessive synovial fluid
What is the vascular granulation tissue called that dissolves collagen as it extends over the articular cartilage, destroying joint tissues?
Pannus - the dissolved cartilage can lead to adhesions, fibrosis, or bony anklyosis (stiffness/fixation of jt)
What are the three phases of progression of RA and what are they caused by?
- Initiation phase - caused by non-specific inflammation
- Amplication phase - caused by T cell activation
- Chronic inflammatory phase - tissue injury occurs from cytokines, interleukins 1 and 6, and tumor necrosis factor - alpha
Ra is highest in women at what percent?
69%
What is the mean age of diagnosis of RA?
56 yo
In affected pts, RF is present in what percent of them?
66%
What percent of affected patients show evidence of erosions in the first year?
20%
What is the rate of people being diagnosed with RA in the US?
41 per 100,000 people
How many people are estimated to have RA in the US?
1.5 million
What provokes our immune system into action, causing it to respond directly or by production of antibodies?
Antigens
What makes RA an autoimmune disease?
People who have RA produce antibodies to fight their own antibodies like RF or ACPA
T or F? RA is believed to be hereditary and can be triggered by viral infections
True
What greater risk are you at if a first degree family member is diagnosed with RA?
4x higher risk of developing RA
What are some environmental factors that can predispose you to RA?
Chemicals, pollution, secondhand smoke, and trauma
In women, can hormonal changes trigger RA?
Yes
What is the most strongly associated risk factor of RA and by what % does it increase your risk?
Smoking increases risk of RA by 2. 4%
T or F?
RA produces no noticeable deformities and destruction of the MCP joints
False - there is noticeable deforming and destruction of the MCP joints
Where can nodules appear in the body?
Hands, feet, and elbow
What are some other sx’s that can occur with RA?
- Pleuritis: inflamed pleura layer of the lungs
- Anemia: when blood does not have enough healthy RBC’s (this is why CBC is a test for RA)
- Valvulitis: inflammation of valves of the heart
- Lung fibrosis: scarring of lungs causing SOB
- Kidney problems
- Cardiovascular problems
- Glaucoma: eye disease causing vision loss and blindness due to damage of optic nerve
What can happen with RA and the neck and spinal cord?
It can affect the neck and spinal cord causing damage, which can lead to paralysis or even death
Clinically, what are we going to see in an RA pt?
C/O fatigue and weight loss, symmetric joint swelling, pain, and stiffness (which is more prominent in the morning)
Between what ages of women is onset of disease highest?
20-40 yo
T or F? RA can produce spontaneous atlantoaxial subluxation due to laxity of ligaments and TMJ issues
TRUE - don’t have RA pt’s be jumping or intensely running, bobbing their head
Specifically in the hands, what can we see occur with RA?
- Ulnar drift of MCP’s
- Volar subluxation
- PiP swelling
Swan neck or Boutonniere deformity of fingers? PiP hyperextension and DiP flexion
Swan neck
Swan neck or Boutonniere deformity? DiP extension and PiP flexion
Boutonniere
How does mallet finger occur of the DiP joint occur?
The extensor digitorum tendon ruptures, pulling DiP into flexion
Rheumatoid nodules are present in what % of people with RA?
20-25%
What is the term for inflammation of lining of the sheath surrounding a tendon that can be found in a pt with RA?
Tenosynovitis
T or F?
Muscle atrophy doesn’t happen until later after diagnosis and is mostly in the knees and feet?
FALSE - muscle atrophy around affected joints can be present early and mostly in the intrinsic hand muscles and quads
Can pts with RA have a lot of de-conditioning that results in decreased cardiorespiratory status, muscle strength, and flexibility?
YES
When it comes to cardiopulmonary complications of pts with RA, what has greatest prevalence?
Ishemic heart disease (accelerated atherosclerosis)
What is first evaluated when trying to diagnose?
Causes of the arthritic sx’s. Rule out and test for things like lupus, cancer, scleroderma, hormone disorders, Sjorgen’s syndrome, etc
Can diagnosis of RA be based on family history, physical exam, and lab tests? What labs tests are done?
YES! RF is tested, CBC, ESR (which will be +), synovial fluid analysis, and serum protein electrophoresis
What is the prognosis of RA?
It is really poor because there is no way to reverse it. The damage cannot be undone, so the goal of treatment is to prevent further damage and manage the RA
What is our role in treating pt’s with RA?
- Joint function and muscle strength is priority!!!
- Low impact aerobic (conserve energy)
- Aquatic therapy (takes off stress of gravity on joints)
- Heat or ice packs and massage
- Assisting pt with maintaining strength, tone, and fitness
- Stretching, flexibility exercises, and strength training
- Minimize stiffness and swelling
- EDUCATE THEM!!
- Manage flare-ups
What 2 things are used for pain management of RA?
Anti-inflammatory meds and analgesics (pain-killers)
What are used in the short term for acute attacks of RA?
Corticosteroid
Penicillimine is a drug in what class of treating RA?
Anti-rheumatic drugs
When treating an RA pt, do you want to conserve their energy and protect their joints with things like splints if needed?
yes
Do some RA pts get to a point where joint replacements surgically are needed to improve quality of life?
Yes
Between Stage 1-4 of RA, which is characterized by maybe having radiographic evidence of osteoporosis and no destructive changes on an X-ray?
Stage 1, early
Between Stage 1-4 of RA, which is characterized by having radiographic evidence of osteoporosis, with or without subchondral bone destruction and slight cartilage destruction, no joint deformities and possibly limited ROM, adjacent muscle atrophy, and extra-articular soft tissue lesions like nodules and tenosynovitis?
Stage 2, moderate
Between Stage 1-4 of RA, which is characterized by having radiographic evidence of cartilage and bone destruction and osteoporosis, joint deformity, extensive muscle atrophy, and extra-articular soft tissue lesions, nodules, and tenosynovitis?
Stage 3, severe
Between stage 1-4 of RA, which is characterized by having radiographic evidence of cartilage and bone destruction and osteoporosis, joint deformity, extensive muscle atrophy, extra-articular soft tissue lesions, nodules, and tenosynovitis, and fibrous or bony ankylosis?
Stage 4, terminal
T or F? OA is also known as degenerative joint disease and is joints wearing out from use
True
Is osteoarthritis the leading cause of disability in the US?
Yes
Zooming in on joints wearing out, what specifically is degenerating make the surface more rough than normal?
The articular cartilage is the primary change - it is degenerating and is more rough than normal (with this, bone spurs can occur)
What are some triggers of OA?
- Tissue damage from injuries
- Transmission of inflammatory mediators from the synovium into cartilage
- Defects in cartilage metabolism
T or F? Eventually with OA, there is subchondral sclerois with bone spurs on the edges of the joint, then synovial inflammation and thickening. Contractures and tendinitis can develop
True
With OA, can the surrounding muscles of a joint and menisci of the knee be weakened and damaged?
Yes
T or F? Articular cartilage has nerves and blood vessels and lymphatic vessels
False - in articular cartilage there are no nerves, blood vessels, or lymphatic vessels
How does articular cartilage receive nutrition and eliminate waste?
Diffusion through synovial fluid and by facilitated imbibition (absorption of fluid by a solid body)
What is the first osteoarthritic change to occur when OA starts?
Increase in water content
T or F? As articular cartilage is being destroyed, the joint space narrows and can be seen on x-rays
True
What is the first notable change in cartilage characterized by?
Mild fraying or “flaking” of superficial collagen fibers
After the initial fraying and flaking of superficial collagen fibers of articular cartilage, what does it proceed to?
Deeper flaking or fibrillation occurs in greater areas of weight bearing
T or F? The articular cartilage in a joint can degenerate to a point that the exposed subchondral bone can become necrotic
True
T or F? Osteophytes may be fibrous, cartilaginous, or bony, and this process is very well understood
FALSE - the process is not well understood, but osteophytes CAN be fibrous, cartilaginous, or bony
How many people in the US are believed to have OA?
20 million
OA affects women __% of the time, and later in life than men
60% of the time
_____ out of every _____ people have some form of OA
1 out of every 13 people have some form of OA
By what age does 50% of the population have x-ray evidence of OA in at least 1 joint?
Buy age 65, 50% of the population has some x-ray evidence of OA in at least 1 joint
T or F? OA is relatively common in adults in their 40s
True
Can osteoarthritis affect younger people who have had bad joint injuries?
Yes
Is OA the most common form of arthritis?
Yes
What is the etiology of OA?
It has an unknown origin - it depends on the amount of wear and tear on joints and the severity
What are some risk factors of OA?
- Excessive wear or injury to joints
- Family history
- Female gender (higher onset)
- Obesity
- Increasing age
T or F? Age it self causes OA and is considered normal with the aging process
FALSE - aging itself does not cause OA and should not be considered synonymous with “normal” aging processes
T or F? Many OA related changes seen at the cellular and tissue level are opposite those seen with normal aging
True
Genetic factors account for ___%-___% of radiographic OA at the hand, hip and knee and as much as ____% at the spine
Genetic factors account for 39% - 65% of radiographic OA at the hand, hip and knee and as much as 70% at the spine
Repetitive microtrauma involved with kneeling and heavy lifting are relating to development of OA at the ____
Knees
What 2 things are associated with greater prevalence of knee and hip OA with varus being the strongest predictor of disease progression
Malalignment (varus and valgus)and LLD (leg length descrepancy)
T or F? There can be femoroacetabular impingement (FAI) at the hip if OA develops there
True
What joints does OA usually affect?
Weight bearing joints like hands, hips, knees, and spine (one of the main difference between RA and OA)
Does OA affect MCP joints?
No - just DIP and PiP, which will appear crooked
In hips and knees, where does the articular cartilage degeneration occur and what forms there? What might a pt need at this point to improve quality of life?
In hips and knees, articular cartilage degeneration occurs at the end of long bones and bone spurs will form, limiting movement. A pt at this stage might need a THA or TKA
What are the most common signs and symptoms that lead to diagnosis of OA?
Pain and swelling, loss of ROM, and bony deformity
Does OA have a bilateral, symmetrical presentation?
NOOO! Only RA does
Is OA a systemic disease with systemic complaints?
No, only RA is
T or F? OA affects the CMC, DiP, PiP, neck, lumbar spine, hips, knees and MTP of big toe
True
What is common clinical finding in OA that is another word for a pop?
Crepitus - can progress from a painless grating feeling to a really painful, high pitched sound as a result of bone on bone
T or F? Cartilage degeneration is the cause of pain
FALSE - Cartilage degeneration is NOT the cause of pain since it is aneural.
In the hands and fingers, what does OA look like?
Reduced ROM, poor grip strength, bony nodes. Usually tender in the early stages and restricts fine skills later in the disease
OA can also affect the CMC joint of the thumb leading to decreased function, what does that lead to?
Decreased gripping and grabbing function
In the hips, how does OA present?
Sx’s are usually insidious at onset and can include a limp and decreased ROM
With hip OA, how is the leg have a tendency to be situated as?
Flexed, ER, and abducted, with IR really painful and hard
If you have decreased hip ROM because OA, what does this affect?
Slower walking speed, decreased stride length, poor balance leading to falls, and you’re having to use a lot more energy to walk
In knees with OA, how does it present as in the early stages?
There is pain with weight bearing activities
Ex. climbing stairs or squatting
With knee OA, does prolonged sitting cause pain and stiffness?
Yes
Does knee OA more commonly affect the medial or lateral joint?
Medial joint - there is a higher weight bearing load placed on this compartment (results in pseudolaxity of the MCL, strengthening of the LCL, and gene varus)
If there is patellofemoral compartment OA, what is the hallmark for this?
Anterior knee pain
T or F? With knee OA, joint locking and buckling due to damage of menisci and ligaments can lead to increase falls.
True
What is the most common site of OA in the feet?
MTP joint of big toe
Can OA affect our walking?
YES! - It can disrupt forefoot involvement, leading to poor push off while walking and gives poor balance
Can hammer toes occur in OA and how?
YES! Extensors become shortened and pull toe up
What parts of the spine are most susceptible to OA?
Lower cervical and mid to lower lumbar
What is the only true synovial joint in the spine?
Facet joints
What positions give relief to someone with OA?
Lying and spinal flexion
Can the facet joints of the spine have bone spurs?
Yes - this contributes to lateral and central lumber stenosis and thus nerve impingement
Pain is increased in what motions with a pt who has spine OA?
Extension, rotations, and when standing or sitting
What ways is OA diagnosed
X-ray, physical exam, pt history
What is typically shown on an x-ray of someone with OA
Narrowing of joint spaces, bone spurs, cyst formation, and subchondral sclerosis
What two ways can OA be diagnosed?
- Primary - idiopathic/no known prior event
A. localized - one or two joints affected
B. generalized - 3+ joints affected - Secondary - etiology can be identified
A. Trauma
B. Biomechanics factors
C. Congenital malformation
D. Other musculoskeletal disease
What is treatment for OA?
-Non weight bearing exercise like biking or swimming
- Rest
- Heat (only when sx’s are not flared)
- Meds - analgesics and anti-inflammatories
- If severe: steroid injections into joint capsules
- Joint replacement: hips, knees, shoulders
- Arthroscopic procedure preceding these d/t bone spurs and torn cartilage
What are some things the PTA can assist the pt with?
General fitness, low impact aerobics,
cardiovascular exercise, strengthening, and ROM exercise
What is the prognosis of OA?
It varies: sx’s can start and go away randomly. Most pts can maintain daily functions unless hips or spine are severely involved
