Rheumatic Disease Flashcards
RA
Systemic auto-immune disease characterized by pannus that destroys articular cartilage
Chronic inflammatory polyarthritis (5+ joints)
Primarily affects synovial joints (blood vessels, heart, lungs, etc)
MOST COMMON OF THE INFLAMMATORY DISEASES
Three disease courses
Monocyclic
Polycyclic
Progressive
Monocyclic
One episode which ends within 2-5 years of initial diagnosis and did not reoccur
May result from early diagnosis and/or aggressive treatment
Polycyclic
The levels of disease activity fluctuate over the course of the condition
Progressive
RA continues to increase in severity and is unremitting
RA: Natural History
Radiographic erosion typically fastest in the first year of disease
75% of people with RA experienced remission within 5 years of dx
Female hormones
Appear to influence development of RA
RA Incidence
Peak onset 60 years of age
Decrease incidence with the use of oral contraceptives; remission of symptoms during pregnancy
Increase in symptoms after menopause
RA Primary Pathological Event
Takes place in synovium
^^^ Suggesting the offending agent is carried to the joint via the bloodstream
RA Etiology
Pannus production
Catabolic enzymes produced which causes collagen break down
Joint effusion further stresses articular cartilage
Effusion stretches the capsule and causes ligamentous instability
RA Characteristics
Rheumatoid factors
Insidious development of symptoms
Symmetric early involvement in hands, wrist, feet, and ankles
LATER - develop joint deformities, contractures, which affect WB and NWB joints
Who should be tested?
Patients that have at least 1 joint with definite clinical synovitis with it not being explained by another disease
Classification criteria for RA
> 6/10 needed for definite RA classification
RA Differential dx
Systemic lupus erythematosus
Psoriatic arthritis
Gout
Comorbidities
CVD (ischemic heart disease)
Infections (TB)
Mental health conditions (anxiety and depression)
Malignancies (leukemia and multiple myeloma)
RA Clinical Features
Morning stiffness at least 1 hour
Arthritis in at least 3 joint areas with swelling or fluid
Arthritis of hand joints (1 wrist, MCP, PIP joint swollen)
SYMMETRIC joint swelling and involvement
Positive Rh factor
Radiographic changes typical of RA
Subcutaneous nodules
RA Radiologic Features
Soft tissue changes EARLIEST sign of disease
Articular erosions within first 2 years
Osteoporosis
Joint space narrowing
RA Joint Deformities
Subluxations and dislocations occur secondary to capsular and ligamentous laxity, destruction of joint surfaces, and tendon ruptures
Flexion contractures result
Swann neck/boutonniere deformity
Hallux valgus, hammer toe
Joint ankylosis
Boutonniere deformity
DIP extension
PIP flexion
Swan neck deformity
PIP hyperextension
DIP flexion
RA Changes in Cervical Spine
Narrow facet joints
Narrow intervertebral joints
Subluxation of atlanto-axial joint from laxity of transverse ligament
RA treatment
Initially - education, protection, splinting
PT indication depends on whether acute exacerbation or period of remission
Medications
Orthopedic surgeries
RA Medications
Traditionally NSAIDs
DMARDS within 3 mos
DMARDs
Disease-modifying
Slow the progression of RA and save the joints and other tissues from permanent damage
SE - liver damage, bone marrow suppression, severe lung infections
Biologic agents
Newer class of DMARDs
Can target parts of the immune system that trigger inflammation that causes joint and tissue damage
Also increase the risk of infections
Pannus
Inflammatory synovitis
An invasive granulation tissue that invades and erodes subchondral bone and cartilage
Steroids
Reduce inflammation, pain, and slow joint damage
SE - thinning of bones, weight gain
MDs may prescribe a corticosteroid to relieve acute symptoms, with the goal of gradually tapering off the medication
NSAIDs
Side effects may include ringing in your ears, stomach irritation, heart problems, and liver and kidney damage
Deep heat
NOT RECOMMENDED DURING ACUTE INFLAMMATION
Pain post exercise
Should not have > 1 hour post-exercise
Acupuncture for RA
Limited studies have shown it can help
Fish Oil
May be as effective as NSAIDs
Juvenile RA
Juvenile Ideopathic Arthritis
Onset before age 16
Symptoms last from 6 weeks to 3 mos
One or more joints
Often accompanied by fever, rash, eye inflammation
ARA list of criteria for dx
Chronic synovial inflammation of unknown cause
Onset in children younger than 16
Evidence of arthritis in 1 or more joints for 6 consecutive weeks
Exclusion of other diseases... Lyme disease Lupus Bone disorders Cancer
RA Sx/sy
Limping Stiffness upon wakening Reluctance to use arm or leg Reduced activity level Fever Joint swelling Difficulty with fine motor activities
Pauciarticular/oligoarticular JRA
4 or fewer joints after 6 mos of symptoms
1/2 cases of JRA
Most common pattern onset before 4 yo
Morning stiffness, reluctance to play
Begins at one joint - knee, ankle, wrist, fingers
May span multiple joints and go into adulthood
Polyarticular JRA
5 or more joints
Symmetric involvement of knees, wrist, fingers, ankle
More common in girls
Seronegative 1-3
Seropositive in adolescence (indistinguishable from adult RA)
Systemic JRA
Illness begins with high spiking fevers likely complicated by pericarditis, pleural effusions, enlargement liver, spleen, lymph nodes
10% all cases
Onset between 4-9 years
Salmon pink rash that comes and goes
Joint swelling until months after fevers begin
Arthritis may persist after other symptoms resolve
Psoriatic JRA
Arthritis with psoriasis
Overall treatment goals
Control symptoms
Prevent joint damage
Maintain function
Maintain activity and participation levels
Medication Lines
1st - NSAIDs
2nd - DMARDs
Caution with steroids
Ankylosing Spondylitis
Chronic progressive inflammatory arthritis characterized by joint sclerosis and ligamentous ossification
Men affected 7x greater that women
Begins in 20s
Early dx confirmed by lab studies elevated ESR
Sx/sy Ankylosing Spondylitis
Early state have LBP and morning stiffness
Spondylitis and marked limitation of LS motion
***Skin distraction test to confirm
Will spread to thoracic and cervical spines later on
Decreased lumbar lordosis
Increased thoracic kyphosis
Immobile cervical spine
Radiographs with Ankylosing Spondylitis
Bamboo spine
Ankylosing Spondylitis Treatment
Psychological considerations Pharmacology Orthopedic appliances PT Possible orthopedic surgery
