Rheumatoid arthritis Flashcards
what is rheumatoid arthritis?
it is autoimmune condition that causes a chronic inflammation of the synovial lining of joints,tendon sheath and bursa.
and it is systematic inflammatory joints
what is synovitis?
the inflammation of synovial
does rheumatoid arthritis tend to be symmetrical and not?
The rheumatoid arthritis are tend to be symmetrical & affect multiple joints
which gender are more effected?
three time are more common in women than male
age?
middle age
but can affect at any age
What are the genetic associations?
HLA DR4
HLA DR1
what gene often present in RF positive patients?
HLA DR4
what gene occasionally present in RA patients?
HLA DR1
which antibody found in ra?
rheumatoid factor (70%) cyclic citrullinated peptide antibodies
Presentation?
- symmetrical distal polyarthropathy
- stiffness
- pain
- swelling
- pt. usually complain pain in the small joints of the hands and feet, typically the wrist, ankle ,mcp and pip joints in the hand.
- they can also affected larger joints such as the knees, shoulder and elbows.
- the onset can be very rapis (i.e overnight) or over months to years.
other associates symptoms: fever weight loss flu like illness muscle aches and weakness
difference between RA & OA?
In RA pain get worse at rest & improve with movement
In OA pain get worse with activity and improve with rest
what is palindromic rheumatism?
this involves slef limiting short periods of inflammatory arthritis with joint pain, stiffness and swelling typically affecting only a few joints.this episode only last 1-2 days and then completely resolve.
does palindromic rheumatism has RF antibodies and Anti ccp antibodies?
yes & may indicate it will progress to full rheumatoid arthritis
what joints are more commonly affected?
Proximal interphalangeal joints metacarpophalangeal joints wrist and ankle metatarsophalangeal joints cervical spine large joints can also be affected such as the knee hips and shoulders
which part of joint never affected in ra?
distal interpahalngeal joints
if affected that’s mean they have likely to be heberden nodes due to osteoarthritis
How ppl with get ra without any family history?
becoz of low immunity
Why it is affect small joints?
unknown reason
clinical features
affects synovial lining of joints and tendon sheath
affect ligament joint
compress nerve
deformity no fix pattern ( we can’t stop but we can progress slowly deformity)
bisymmetrical involvement (first dominant affected then non dominant (which is gradually progress after 1 year but it is bound to happen)
intrinsic weakness and tightness,contracture
mcp and wrist affected early
later ip involvement
why mcp joints affect earlier?
there is no exact causes unknown but we can say becoz of synovial joint (it has classical synovial joint of the hand)
how many tendon are there in carpal tunnel?
9 tendon
what is difference between oa and ra?
OA is degenerative disease
RA is inflammatory disease
In OA cartilage destruction
& both rub each other
In RA the cartilage is intact
the bone are not coming each other
but it showing erosion
early Ra
swelling
redness
why ulnar shift in deviation towards ulnar?
our fingers deviate radial to ulnar
in any kind of activities
that’s why they are more prone to deviate in ulnar shift.!
Avoiding ulnar deviation in RA
pt education
Avoid ulnar deviate
changes equipment
deformities
boutonnière deformity swan neck deformity mallet finger button hole deformity of the thumb swan neck deformity of thumb adducted retropositioned thumb palmar subluxation of distal radio ulnar joint ulnar dift at mcp dorsal wrist involvement carpal tunnel syndrome, De Quervains is common hourglass swelling due to constriction of middle part by doral carpal ligament subluxation of distal ulna ulnar shifting of carpals volar subluxation of wrist
what is trigger finger?
pain while extension
what is de quervains?
it is overuse injury
& inflammation of tendon sheath
between at the snuff box resulting in pain
finklestien test
short term gaol?
30 days of goal
& every day therapist has to give goal & see improvement & this will become their habit
Deformities?
boutonnière deformity swan neck deformity button hole deformity swan neck deformity of thumb Z thumb (Hitchhiker’s thumb) Rheumatoid nodules ulnar drift
Hitchhiker’s thumb
Hitchhiker’s thumb occurs when the thumb flexes at the metacarpophalangeal joint (connecting the thumb to the palm of the hand) and hyperextends at the interphalangeal joint (the one just below your thumbnail).
This is sometimes also called the Z-shaped deformity.
Rheumatoid nodules
Rheumatoid nodules are hard lumps that form under the skin near the joints. These are another common symptom of RA in the hands.
They can also occur in multiple areas, most commonly near your elbows. The nodules usually aren’t painful or debilitating, but some people might not like how they look.
Less common among people with RA are Heberden nodes and Bouchard nodes. These are visible bumps at the joints that are more typical of osteoarthritis.
Boutonniere deformity
- extension of DIP
- Mcp joints with flexion of PIP joints
- capsular distension of pip joints
- capsular & bony attachment of central tendon are weakened
- relatives lengthening of central tendon
- lengthening of transverse fiberes
- lateral tendon palmar subluxation
- increased extensor tendon full on distal phalanx
- hyperextension deformity of DIP
- collapse of the 3 level system
- joint disorganisation
Swan-neck deformity
Swan-neck deformity, the most common change in people with RA, occurs when there’s weakness or tearing of a ligament due to inflammation.
This results in laxity of the middle joint of the finger and flexion of the distal joint.
cause - contracture of intrinsic muscle
synovitis of the flexor tendon sheath
increase flexion pull on mcp
imbalance to the extensor central slip through the long extensor tendon and intrinsic muscle
stretch of palmar plate of pip joint
hyper extension of pip joint
stretching of transverse fibers of retinacular ligament
dorsal subluxation of lateral tendon
relatives lengthening of lateral tendon
flexion of dip due to pull of fdp
joint disorganisation
button hole deformity
flexion of mcp joint with extension of ip joint
synovitis of mcp joint
epl & adductor exapansion displaced ulnarly
attachment of EPB to the base of proximal phalanx is lengthened & become ineffective
extensor tendon & extensor insertion of intrinsic muscle apply force to DIP
swan neck deformity of thumb
flexion of CMC & IP with extension of mcp joint
synovitis of cmc joint
contracture of adductor pollicis
ulnar drift
Ulnar deviation is also known as ulnar drift. This hand condition occurs when your knuckle bones, or metacarpophalangeal (MCP) joints, become swollen and cause your fingers to bend abnormally toward your little finger.
What are the symptoms?
Swelling in your knuckles is one of the most noticeable symptoms of ulnar deviation. You may also find that your fingers, especially your middle and index fingers, bend toward your pinky finger.
As the condition progresses, you may experience:
abnormal heat around your wrist, hand, and finger joints
pain or tenderness around your wrist, hand, and finger joints, especially when you move or flex your fingers
inability to fully flex your fingers or make a fist
tightness of your hand muscles
inability to pick up objects or do certain tasks with your index finger and thumb, such as using zippers or squeezing objects
Ulnar deviation is often linked to types of arthritis, especially rheumatoid arthritis.
Other symptoms that go along with these conditions include:
abnormal weight loss
stiffness in your hand joints and similar joints, such as your toe joints
feeling of exhaustion
What causes ulnar deviation?
One of the most common causes of ulnar deviation is rheumatoid arthritis (RA). RA is an autoimmune disorder that causes your immune system to target your joint tissue.
With RA, inflammation can cause damage to both the MCP joint and the areas surrounding the joint. Over time, this can cause your joints to wear away and your bones to erode. This may eventually make your hands look distorted.
RA doesn’t have a specific known cause. It’s thought that your genes can trigger the condition when you’re exposed to certain environmental factors, such as infection.
Osteoarthritis (OA) is also known to cause ulnar deviation. Unlike RA, OA isn’t caused by your immune system. It’s caused by your joint cartilage gradually wearing away due to overuse or age. When the cartilage has worn away significantly, your bones start to rub together in the joint. This damages the joints and can cause them to become distorted and bend.
Other causes of ulnar deviation include:
psoriatic arthritis, a type of chronic arthritis also caused by your immune system attacking your joints
lupus, another autoimmune condition that can cause joint damage associated with arthritis and other symptoms such as fevers and fatigue
Joint Protection Principles
- Planning
Think before starting can the work be more efficient?
Can things be re-organised?
Can certain jobs be delegated, or done less frequently?
Do work when you’re at your best
2. Pacing
Break down tasks to be little and often Take regular breaks to change position Mix heavy and light jobs Start with the more difficult tasks first 3. Respect for Pain
Fear of pain results in inactivity and loss of motion and strength.
Disregard for pain can lead to poor movement patterns and can increase the pain.
Stop activities before reaching the point of discomfort or pain.
Limit activities which cause pain to last more than one hour after you have stopped the activity.
- Balance Activity and Rest
Rest before becoming tired
Plan rest periods during longer or more difficult activities.
By resting 10 minutes during an activity, you will have more energy to continue.
5. Maintain muscle strength and joint range of motion
Achieve full range of each joint while performing daily activities.
Perform specific exercises and range-of-motion activities.
Loss of range of motion and strength leads to a loss of function.
6. Use larger, stronger joints for activities
Instead of using fingers, use wrist; instead of using wrist, use elbow; instead of using elbow, use shoulder.
For example: To lift a bag from a counter, bend knees, hug the bag with both arms. Bend elbows so that the bag is held tightly to chest and straighten knees. Keep hold on the bag by keeping elbows bent. If the load is too heavy, push shopping cart, or get help with groceries - use drive-up service.
7. Avoid staying in one position for extended periods of time.
Plan/set a reminder for when to change position.
Moving/ getting up from your desk when at work regularly will help prevent stiffness
Keep mobile
8. Maintain good movement patterns
If the body moves well it can minimise stress on joints
Proper body mechanics allows use of body more efficiently.
Try to avoid breath holding and jerky movements.
9. Loosing weight[11]
Additional weight leads to increased stress on weight-bearing joints
10. Wear splints/braces to offload joints
Use of a splint or brace can be used temporarily to help offload acutely painful joints.
Splints can also be used to immobilise smaller joints in order for them to rest
It is important to spend time out of a brace in order to maintain full ROM
11. Change the way you move objects
For example: slide pots and pans across stove and counter to sink. Use a kitchen cart to carry foods and dishes and a laundry cart for laundry.
- Avoid tight grasp
Use a relaxed grip.
Enlarge handles.
Place palm of hand on jar lid, and using weight of body, turn arm at shoulder to open jar. A sponge or wet towel under the jar prevents sliding
Hold the knife or mixing spoon like a dagger, with the handle parallel to knuckles. Cutting is then changed from sawing to pulling
Don’t carry heavy handbags, pails, and bags by the handle.
Hold everything no tighter than necessary.
Release tight grasp frequently if you have to use it.
Use built-up handles on writing utensils, pot handles, tools, etc.
Use adaptive equipment such as jar openers.
2. Avoid weight bearing on the knuckles (Metacarpal-phalangeal joints)
Avoid putting weight against the backs of fingers
This occurs while pushing up from a chair using a closed fist or resting chin on the backs of fingers.
Use palms while holding fingers straight.
3. Use both hands when possible
4. Avoid repetitive activities
Take breaks
Change activity regularly, i.e. when doing DIY using screwdriver for a while, change the activity to painting or something different.
5. Avoid pressure to tip or pad of thumb
The thumb is needed for 40% of hand activities
Example: opening car doors, ringing doorbells
To protect thumb joints, open milk containers with heels of the hands rather than thumbs.
6. Avoid pressure against the radial side of each finger
Don’t rest chin on the side of fingers.
Add levers to keys, handles, and knobs.
Hold handles straight across the palm.
7.Avoid prolonged periods of hands in the same position
Re-position yourself often.
Move your hands frequently to ensure they do not get stiff
splint
•swan neck deformity-oval 8 splint, silver ring splint
•boutonnière deformity- splinting the pip joint in extension with dip extension hook
•splinting for mp ulnar drift shift & palmar subluxation- resting splint
hand -based hinged mcp joint splint
