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Ortho > RA > Flashcards

RA Flashcards

1
Q

What are criteria to be diagnosed with RA?

A 
needs score of 6
- Joint involvement
0 = 1 large joint
1 = 2-10 large joints
2 = 1-3 small joings
3 = 4-10 small joints
5 = >10 joints
- Serology (at least 1 test result is needed for classification)
0 = neg RF and neg ACPA
2 = low + RF or low + ACPA
3 = high + RF or high + ACPA
- acute phase reactants (at least 2 test needed)
0 = normal CRP and normal ESR
1 = Abnormal CRP or abnormal ESR
- duration of sx:
0 = < 6 weeks
1 = > or equal 6 weeks
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2
Q

What are systemic manifestations of RA?

A
  1. Morning stiffness - Difficulty in moving upon awakening
  2. Anorexia
  3. Weight loss
  4. fatigue
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3
Q

What joints are typically involved in RA?

A
  1. Hands
  2. Wrists
  3. Elbows
  4. shoulders
  5. Knees
  6. Ankles
  7. Feet
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4
Q

What does hand involvement of RA look like?

A
  • Swelling of PIP joints
  • Fusiform or sausage like appearance
  • 3rd and 4th PIP affected
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5
Q

What does swan neck deformity look like?

A

PIP hyperextension and flexion of DIP

  • Hypermobility at chronically inflamed PIP- volar subluxation and PIP hyperextension
  • Volar capsule of PIP is stretched, lateral bands move dorsally- tension on FDP by the PIP flexes the DIP
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6
Q

What does boutonniere deformity look like?

A

flexion of PIP and hypertension of DIP

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7
Q

What are characteristics of RA in ankles and feet?

A
  1. Synovitis of MTP joints-metatarsalgia
  2. Hallux valgus
  3. Bunion - painful bursitis of medial aspect of 1st MTP joint
  4. Hammer toes
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8
Q

What are characteristics of RA in knees?

A
  1. Large amount of synovium- commonly involved
  2. Chronic synovitis- distension of joint capsule
  3. Destruction of joint surfaces
  4. Painful knees- flexion contractures
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9
Q

What is m involvement in RA?

A
  1. Atrophy of intrinsic muscles of the hand

2. Quadriceps atrophy - Disuse atrophy, Myositis, Steroid induced myopathy, or Peripheral neuropathy

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10
Q

Most common extra articular manifestation; 25% of patients with RA; Extensor surface of elbows, forearms, dorsum of hands, Achilles tendon

A

Rheumatoid nodules

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11
Q

Redness in the eye due to systemic inflammation in the eye from RA

A
  1. episcleritis

2. scleromalacia

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12
Q

non healing ulcers that appear when RA is chronic

A

vasculitis

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13
Q

Is RA benign?

A

no:

  1. severe functional disability
  2. substantial morbidity
  3. Increases mortality: most common cause of death with RA = heart disease due to ongoing inflammation
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14
Q

Why does chronic inflammation happen?

A

pro-inflammatory cytokines overwhelm anti-inflammatory cytokines
- IL-6, TNF alpha, IL-1

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15
Q

Why is early treatment important with RA?

A

results in easier remission with less joint damage

- damage occurs within first 2 years

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16
Q

What are lab tests for RA?

A
  1. Elevated Erythrocyte sedimentation rate (ESR)
  2. Elevated C reactive protein (CRP)
  3. Rheumatoid factor
  4. Cyclic citrullinated peptide antibodies (Anti CCP)
  5. CBC - Anemia; Thrombocytosis (increased platelet count)
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17
Q

Marginal erosions of the bone; close to the sides and joint line

A

peri articular osteopenia

  • detected by US longitudinal and coronally
  • MRIs more sensitive, but more expensive
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18
Q

Mothed of scoring severity of joint space narrowing (normal, focal, >50%, < 50% and ankylosing) and bone erosion (discrete to complete collapse)

A

Modified sharp scoring method

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19
Q

Name the classes of RA according to the global functional status of RA (I-IV)

A 
I = completely able to perform usual everyday life
II = Able to perform self-care and vocational activities, but limited to avocational activities
III = able to perform ADLs, but limited in ability to perform vocational and avocational activities
IV = Limited ADLs, vocational and avocational activities
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20
Q

What is the first line of drugs for managing RA?

A

Methotrexate

- if does not control inflammation, need to adjust medications

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21
Q

Analog of dihydrofolic acid; Inhibits dihydrofolate reductase; Immunomodulatory effects at low doses; GI complaints, mucositis, alopecia, LFT elevations, infections; Injectable form improves bio availability

A

Methotrexate

  • most common complication is ulcers - folic acid helps
  • Methotrexate induced pneumonitis, teratogenicity
22
Q

Hydroxychloroquine is administered orally; approximately 75% of the drug is absorbed. Gastrointestinal toxicity is relatively common should preferably be given with food; extensively tissue bound and has a long elimination half-life of the order of 40 days.; preferentially stored in melanized tissue and hence has a propensity to concentrate in the skin and retinal pigment.

A

Hydroxychloroquine (plaquenil)

  • needs eye evaluation
  • can cause skin rash, in which case it needs to be stopped
23
Q

What are the ADRS of antimalarials?

A
  1. Gastrointestinal tract-Nausea, abdominal discomfort, diarrhea
  2. Skin- Rash, depigmentation
  3. Eye- Blurring of vision, rarely retinopathy
  4. Central nervous system- Tinnitus, headache
  5. Muscle- Myopathy** = m weakness
  6. Pregnancy-Crosses placenta and risk of fetal abnormalities
24
Q

Inhibits dihydro orotate dehydrogenase; Decreases T & B cell proliferation; Lack of renal toxicity; Diarrhea- improves with dose reduction; Elevation of LFTs, hypertension, transient leukopenia; Contraindicated in pregnancy and lactation

A

Leflunomide

25
Q

Antibiotic (sulfapyridine)+ anti inflammatory agent (5-ASA)
30% of SSZ is absorbed from the GI tract; Remainder degraded in the gut to sulfapyridine and 5-ASA; Most of sulfapyridine is absorbed from GI tract, most 5-ASA is excreted in feces; suppresses lymphocyte and leucocyte functions; Inhibits AICAR transformylase=> release of extracellular adenosine

A

Sulfasalazine (SSZ)

26
Q

What are the TNF alpha antagonists used to treat RA?

A
  1. Adalimumab (humira)
  2. Etanercept (enbrel)
  3. Infliximab (remicade) – chron’s disease
  4. Certolizumab pegol (Cimzia)
  5. Golimumab (Simponi)
    $10k-25k per year
27
Q

What is the IL1 antagonists used to treat RA?

A

Anakinra (kineret)

$18k per year

28
Q

What is the IL6 antagonists used to treat RA?

A

(Actemra)Tocilizumab

29
Q

What is the T cell inhibitor used to treat RA?

A

Abatacept ( Orencia)

30
Q

What is the Anti B cell monoclonal antibody used to treat RA?

A

Rituximab (rituxan)

– used in moderate to severe RA; failed to respond to other medications

31
Q

What is the JAK inhibitor used to treat RA?

A

Tofacitinib (Xeljanz)

32
Q

What are common ADRs of RA medication?

A 
Target related:
- Infections
- Opportunistic infections- TB
- Malignancies- lymphoma, skin cancer, lung cancer
- Demyelinating conditions
- Congestive heart failure
- Autoantibodies
Agent related:
- Immunogenicity, administration reactions
33
Q

What are relative contraindications to RA medication?

A
  1. Multiple sclerosis
  2. Active serious infections
  3. Chronic or recurrent infections
  4. Lymphoproliferative disease within 5 yrs
  5. History of TB or positive PPD (untreated)
  6. Congestive heart failure (Class III or IV)
  7. Pregnancy
34
Q

Most common in males 18-30 years; HLAB27
Sacroiliitis (FABER test); Inflammatory back pain - worse in the morning, gets better with movement; anterior longitudinal lig gets calcified

A

Ankylosing spondylitis

35
Q

Gradual loss of articular cartilage; Thickening of subchondral bone; Bony outgrowths at joint margins (osteophytes); dificulty instating joint movement after inactivity; Mild, chronic non specific inflammation caused by aspirated joint fluid; responds to steroid injections; Risk factors = Increasing age, Female, Genetic, Obesity, Trauma, Occupation, malalignment

A

OA

  • hip pain
  • femoral and/ or acetabular osteophytes on radio graphs or ESR < 20 mm/h and axial joint-space narrowing on radiographs
36
Q

In OA, Herbendens nodes appear on the ____ and bouchens nodes appear on the ____

A

DIP joint

PIP joint

37
Q

What joints are most commonly affected by OA?

A
  1. Lumbar spine
  2. Hip
    - Superior pole of the hip
  3. knee
    - Medial tibiofemoral – narrowing 1st here
    - Lateral patellofemoral
  4. foot
  5. hand
38
Q

What is the pathogenesis of OA?

A
  1. In a normal joint, healthy cartilage, lubricated by synovial fluid, cushions the bones and allows them to move easily
  2. the cartilage begins to break down, first making it thinner and then creating cracks in its surface
  3. gaps in cartilage can expand until they reach the bone itself
  4. synovial fluid leaks into cracks which can form in the bones surface when this replacement wears away; this causes further damage and in some cases can lead to cysts in the bone or other deformities
  5. if not treated, damage can progress to the point where the bones in the joint becomes seriously and permanently deformed
39
Q

What are non-steroidal agents to treat OA?

A

traditional NSAIDs-inhibit COX-1 & COX-2

  1. Ibuprofen
  2. Naproxen

Selective COX-2 inhibitors

  1. Celebrex
  2. Mobic
  3. nabumetone

ADRS:
Gastrointestinal bleeding, Nausea, Diarrhea, Fluid retention, Hypertension, Skin rash

40
Q

What are topical agents to treat OA?

A
  1. Methyl salicylate
  2. Capsaicin
  3. Voltaren gel- diclofenac
  4. Lidocaine patch
  5. Flector patch
41
Q

What are intra articular injections to treat OA?

A
  1. Corticosteroid
  2. Viscosupplementation
  3. Hyaluronate- synvisc, euflexxa, hyalgan
42
Q

What is surgical management to treat OA?

A
  1. Synovectomy
  2. Osteotomy
  3. Prosthetic arthroplasty
  4. arthrodesis
43
Q

What are red flags when evaluating someone with joint pain?

A
  1. Trauma
  2. Hot swollen joint
  3. Weakness- focal or diffuse
  4. Neurogenic pain-
    - Asymmetric (radiculopathy, entrapment neuropathy)
    - Symmetric (myelopathy, peripheral neuropathy)
44
Q

What does PT intervention of arthritis consist of?

A
  1. Pain relief
  2. Heat and cold
    - Superficial heat- moist hot pack, dry heating pads, paraffin, hydrotherapy
  3. Orthoses
    - Hand and wrist- functional wrist splints
    - Patellofemoral taping
    - Load shifting knee braces
  4. endurance training: reg CV conditioning, walking, stationary bike
  5. ROM - gentle PROM, AROM with slow/ careful stretching and isometrics, stretching throughout ROM
  6. Fxn’l training - long handled appliances and devices for grasp, raising bed/ chairs, aids for dressing, railings
45
Q

Strategies for foot joint protection?

A
  1. Foot orthotics
    - Relieves biomechanical stresses
    - Enhances function
  2. Rocker sole
  3. Extra depth orthopedic foot wear
46
Q

What is cervical spine management?

A
  1. No manipulations in RA!!
  2. Protective devices
    - Halo device
    - Cervicothoracic brace
    - Soft cervical collar
47
Q

Multisystem autoimmune rheumatic disease that causes fibrosis, vascular damage, and inflammation; more common in Native American population

A

systemic sclerosis

  • Interstitial fibrosis of lung
  • Pulmonary hypertension
  • Renal disease
48
Q

What is CREST syndrome/

A 
Calcinosis
Raynaud’s
Esophageal dysmotility
Sclerodactyly
Telangiectasia
49
Q

skin thickening proximal to the elbows and/or knees in addition to distal extremity involvement; Rapid onset of disease following the appearance of Raynaud’s phenomenon; Significant visceral disease: lungs, heart,GI, kidneys; Absence of anticentromere antibodies; Variable disease course- poor prognosis; Survival 40-60% at 10 yrs

A

Diffuse cutaneous (dcSSc)

  • diffuse = tightness above elbow
  • Face can be involved in both and has no bearing on classification
50
Q

Symmetrical skin thickening limited to the areas below the elbows and knees and involving the face and neck; Progression of disease over months or years after the onset of Raynaud’s phenomenon; Later or less severe development of visceral disease; Late development of PAH; Assoc with anticentromere antibodies Good prognosis with survival >70% at 10 yrs

A

Limited cutaneous (lcSSC)

51
Q

What are PT interventions for systemic sclerosis

A
  1. Emphasize jaw opening
  2. Elbow flexion/ extension
  3. Finger flexion/extension
  4. Knee extension
  5. Low level aerobic program at 60% maximum
52
Q

Diagnostic criteria for _____:

  1. Malar rash – butterfly rash
  2. Discoid rash – causes scarring
  3. Photosensitivity
  4. Oral ulcers
  5. Arthritis (inflammatory)
  6. Serositis
  7. Kidney disorder
  8. Neurological disorder
  9. Blood disorder – anemia (low red blood cell count), leukopenia (low white blood cell count), lymphopenia (low level of specific white blood cells), or thrombocytopenia (low platelet count)
  10. Immunologic disorder –anti-DNA or anti-Sm or positive antiphospholipid antibodies
  11. Abnormal antinuclear antibody (ANA)
A 
SLE
PT intervention:
- Strengthening
- Aerobic endurance exercises
- General ROM exercises

Ortho (10 decks)

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