Rheumatoid Arthritis Flashcards
Rheumatoid Arthritis
Systemic inflammatory disease characterized by symmetrical polyarthritis
AUTOIMMUNE DISEASE
Primarily a disease of the synovium - inside layer w/in the joint capsule
- Synovial cells will proliferate & caus this thick swollen membrane
RA: Epidemiology
(2)
F>M (2-4x)
30-45 most common age of onset
Rheumatoid Factor
Are antibodies with are found in the sera of approximately 70% of patients affected with RA
- RA (+) often have a more severe or aggressive form of RA
- RA can also occur in patients who are RF negative
Laboratory Tests
(4)
Acute phase reactants
- INC Erythrocytes (RBC) Sedimentation Rate (ESR) = RBC drop to the bottom - sediment @ the bottom of the test tube (how long it takes for that to occur)
- INC C-reactive Protein (CRP)
- Indication of active inflammation
Prescence of autoantibodies
- Rheumatoid Factor (RF) - (+) is associated with a more severe/aggressive disease
Complete Blood Count (CBC)
- RBC count often decreased (anemia) in approx 20% of RA patients
Synovial Fluid Analysis
- Normal synovial fluid: transparent, yellowish, absent of clots, and viscous
- Synovial fluid from inflammed joint: Cloudy, will clot, less viscous
Radiographic Findings
(3)
Joint Space
Cartilage erosion (inflammation/chrondrocytes/osteoclasts) -> narrowing joint space (unevenly)
Bone
- Erosion
- Peri-articular osteopenia - less white, DEC bone density around the joint
* Indication of a PAST inflammed joint (may still be there) BUT what originally lead to the osteopenia
Soft Tissue
- Rheumatoid nodules - firm, noticable lumps under the skin
- Swelling
Diagnosis Criteria
ACR 1987 Criteria for the Classification of Acute Rheumatoid Arthritis
List & Need How Many!!
Need at least 4 of 7 criteria
Criteria 1 to 4 must have been present for at least 6 weeks
- Morning stiffness lasting at least 1 hour
- Soft-tissue swelling or fluid in at least 3 joint areas simultaneously
- At least one area swollen in a wrist, MCP, or PIP joint
Somewhere in the HAND! - DIP is rarely involved w/ RA (Could be invovled d/t a deformities BUT it is NOT active) - Symmetrical arthritis
- Rheumatoid nodules - typically around joints
- Abnormal amounts of serum rheumatoid factor (RF) - Lab value
- Erosions or bony decalcification on radiographs of hand and wrist - Radiograph
Knowing these as a criteria & ALSO HOW RA presents. Seen in later stages
How do they define RA remission?
Remission is defined as < 15 minutes of morning stiffness & no joint tenderness or effusion for at least 3 months
RA: Systemic S/S
(5)
- Morning Stiffness
Lasting > 1 hr
Generalized stiffness
Severity & duration of morning stiffness are directly related to the degree of disease activity - Extreme Fatigue
INC resting energy expenditure (REE) - d/t chronic immune activiation - working overdrive = energy deficit
Leads to “rheumatoid cachexia” = loss of lean body mass as a result of RA - Weight loss / loss of appetite
- Fever
- Malaise
All 3 are common w/ other diseases that are SYSTEMIC
RA: Articular S/S
(8)
- Bilateral & symmetrical pattern
- Effusion (swelling)
- Arthralgia (joint pain)
- Crepitis - joint noise as a result of the uneven surfaces (can be symptomatic or asym)
- Deformity - d/t erosion & mm imbalances
- Loss of function
- Pseudo-laxity
- Eventually progressing to ankylosis/fusion leading to immobility
RA: Articular: C/S
What joints are impacted most? What mvmts?
ROM limited in all planes (especially ROTATION)
- C1-2 = more affected joint in neck & half of C/S ROT comes from this joint ~45
C0-1, C1-2, and mid-cervical region are all common sites of inflammation leading to DEC ROM & potential instability
- C1-2 may lead to life-threating situation should the transverse ligament of C1 (atlas) weaken or rupture allowing herniation of odontoid process of C2 (axis) into the SC, or the odontoid process of C2 should # and herniated into the SC
- Life threatening - Diaphragm is knocked out
- RA patients presenting w/ neurological signs & cervical radiculopathy should be referred immediately to a physician
RA: Articular: Temporomandibular Joint
(3)
- Commonly one of the last joints involved
- Inflammation results in pain, swelling, and limited ROM
- In advanced RA may progress to ankylossi - fuses = big issue b/c cannot open jaw
RA: Articular: Shoulder
(3)
- Glenohumeral, sternoclavicular, or acromioclavicular joints may be involved
- Chronic shoulder inflammation causes distension and thinning of the capsule and ligaments
- Joint surface erosion leads to shoulder instability and potential for shoulder subluxation
~ INC risk of subluxation / dislocation
RA: Articular: Elbows
(6)
- Bilateral olecrannon bursitis (most common in severe RA)
- Effusion between lateral epicondyle and olecranon prominence
- Ulnar nerve entrapment - sensory disturbutions & motor impairments
- Rheumatoid nodules on the olecranon or posterior surface of proximal ulna
Most common area to have nodules - Flexion contractures d/t patient posturing to DEC pain & spasms
- Inflam > capsular & ligament distention & joint erosion > instability
Consideration: If they do require a gait aid - they can NOT push off - can NOT use normal gait aids like canes or crutches
Where is the most common area to have rheumatoid nodules?
Elbow
On the olecranon or posterior surface of proximal ulna
RA: Articular: Wrist
(6)
- Wrist affected in almost all RA patients
- VOLAR subluxation of the wrist & hand on the radius (Piano key sign) > may cause extensor tendon rupture
- Proximal carpal row ULNAR subluxation & distal carpal row RADIAL subluxation = loss of ulnar deviation and compensatory ULNAR DRIFT of MCP
- Carpal bone erosion
- Carpal tunnel syndrome comon
1. Space is encroached on - carpal tunnel area
2. Soft tissue swelling = DEC space - Decreased grasp and pinch strength
Very important for hand function = significantly impacts ADLs
RA: Articular: MCP
(4)
- Commonly affected (almost all RA patients)
- Joint effusion especially in the index and long fingers is common
- Trigger finger may be present d/t flexor tenosynovitis, friction with mvmt or tendon nodules
ZIG-ZAG Effect
Proximal row ULNAR subluxation & distal row RADIAL subluxation > loss of ULNAR deviation > compensatory ULNAR DRIFT of MCPs as the phalanges try to compensate back into normal functional position which creates the zig-zag effect
Bunnel-Littler Test
Test for instrinsic mm tightness
1. Perform passive PIP flexion w/ MCP held in flexion
2. Perform passive PIP flexion w/ MCP held in extension
(+) = PIP joints are limited in flexion when MCP is held in extension BUT not when held in flexion = intrinsic mm
- If PIP is limited w/ MCP flexion & extension = capsular retriction (not intrinsic mm tightness)
RA: Articular: PIP
(1) + 2 Deformities
Effusion common and easily palpable - will feel the fluid move
2 common deformities:
1. Swan Neck Deformity - PIP hyperext & DIP flexion, MCP flexion
2. Boutonnierre Deformity - PIP flexion & DIP ext, MCP extension
Swan Neck Deformity
Position & Causes
DIP flexion, PIP hyperextension, MCP flexion
Develop 3 distinct ways:
1. Reflex mm spasm of intrinsics d/t the pain of chronic MCP synovitis in addition to hypermobility d/t structural changed PIP
- Volar capsule of PIP is stretched > lateral bands move dorsally > tension on the flexor digitorum profundus by the hyperextened PIP flexes the DIP
Passive insufficiency - Rupture of the extensor digitorum communis (at DIP insertion) causing the flexor digitorum profundus to pull the DIP into flexion (unrestrained by extensor digitorum communis)
**Muscular imbalance - FDP > EDC
Boutonniere Deformity
Position & Cause
DIP extension, PIP flexion, MCP extension
Cause:
1. Chronic synovitis > central slip (insertion of extensor digitorum communis into middle phalax) lengthens & volar slip of lateral bands > PIP forced into flexion
Remember: Boutonniere flower @ prom - pushing the doorbell to pick up your date - position your finger goes into
RA: Articular: Thumb
Types of deformities (4)
- Flail IP: loss of ability to flex the IP joint
- Type 1 Deformity: IP hyperextension & MCP flexion (w/o involvement of CMC)
MOST common
Also know as Z-deformity - Type 2 Deformity: CMC subluxation & IP hyperextension
Least common - Type 3 Deformity: CMC subluxation and MCP hyperextension
RA: Articular: Knee
- Commonly involved in RA (knee has large amount fo synovium)
- Accumulation of fluid in the knee may lead to a Baker’s cyst
- Chronic Synovitis leads to:
1. Distention & laxity of joint capsule & collateral and cruciate ligaments
2. Erosion of joint surfaces
3. Flexion contractures second to flexed posturing to avoid increase pain
2 Tests:
- Knee Ballottement Test
- Bulge Test/ Brush Test
RA: Knee: Tests
Knee Ballottement Test - used for excess fluid
Therapist: presses down on the patella with index finger
(+) Sensation of “bogginess” indicating excessive effusionn in the knee
Bulge Test / Brush Test
Therapist: strokes w/ an upward motion on the medial aspect of the knee then places pressure or downwards on the lateral aspect of the knee
(+) A wave-like mvmt of fluid returning to the medial aspect of the knee indicated excessive effusion in the knee
RA: Articular: Ankle
(2 + 3)
- Chronic synovitis may lead to:
1. Hindfoot pronation
2. Forefoot planus & flattening of medial longitudinal arch
3. Possible instability in subtalar joint requiring fusion - Tarsal tunnel syndrome may develop - involvement of tibial nerve & may get some S/S of tibial sensory or neuropathy
RA: Articular: Feet
(4)
- Synovitis of MTP joints is very common (may lead to Metatarsalgia)
- Calcaneus may erode or develop exostoses (spurs)
- Hallux valgus & bunions may develop along with other deformities: Hammer toe, Claw Toe, Mallet Toe
- Morton’s neuroma may develop
RA: Foot: Deformities
(3)
- Hammer Toe:
Volar subluxation of the MTP w/ flexion of the PIP & hyperextension of the DIP joint - Claw Toe
Volar subluxation of the metatarsal head w/ flexion of the PIP & DIP - Mallet Toe:
Flexion contracture of the DIP joint. PIP & MTP remain in neutral
Extra-Articular: Muscle
- Muscle atrophy may be present around affected joints d/t:
1. Disuse - pain, deformity
2. Nerve impairment - CTS, tarsal tunnel - LMN
3. Myositis - inflammation of the muscle
4. Steriod-induced myopathy - disease of mm
5. Selective attrition of unknown mechanism related to disease proccess - Atrophy common in hand intrinsics and quadriceps
- Selective attrition of Type II muscle fibers - FAST twitch
- Rheumatoid cachexia: loss of body mass (predominantly skeletal mm) due to RA
- MM weakness which develops may be d/t to atrophy or reflex inhibition secondary to pain
Extra-Articular: Tendon
- Tenosynovitis may occur with an active disease
Common sites: wrist flexion, thumb flexors, patella, & achilles tendon - Chronic inflammation may damage a tendon, which may ultimately cause the tendon to rupture
Extra-Articular: Rheumatoid Nodules
- Occurs in approx 20-25% of RA patients
- Associated with seropositive RF
- Found in subcutaneous tissue or deeper connective tissue
- Common in areas subjected to repeated mechanical pressure or pressure bearing areas
Olecranon bursae, extensor surface of forarms, and achilles tendon
** All the same areas suspectible to pressure sores
RA: Neurological
Peripheral neuropathy may develop secondary to mechanical compression of nerves or vasculitis of vessels supplying the nerves
- inadequate blood to those nerves = not working in the same fashion - starved
Spinal cord compression may arise d/t inflammation in the C/S
*** Cord compression signs require immediate medical attention (ER)
RA: Cardiopulmonary Complications
(4)
- INC morbidity & mortality risk d/t CV disease in RA patients
- Accelerated Atheroscleorsis > ischemic heart disease
- Pleuritis & pulmonary nodules may be present & affect gas exchange (SOB, inadequate O2, may not be expeling CO2)
- Pulmonary nodules are related to rheumatoid nodules elsewhere in the body & found in seropositive patients (RF)
RA: Ocular
(3)
Epicleritis may be present (bengin, self-limiting inflammatory disease of part of the eye)
Scleritis may be present (a serious condition that may lead to blindness)
RA patients should have an annual eye exam
Disease Modifying Anti-Rheumatic Drugs (DMARDS)
(5)
Primary class of drugs to manage RA
- Reducse disease progression, do NOT provide analgesic effects
- Slow acting (takes weeks to months to take effect)
- Risk of toxicity/ side effects
- New class of DMARDS known as Biological Response Modifers (BRMs) have been created to mimic activities of selective immune cells to reduce or block the inflammation process (immunosuppression)
REd Flags (Urgent Referral)
(6)
- Claudification pain pattern
DDx: PVD - intermittent claudification could be d/t other CVD issues, stenosis (L/S) - Constitutional signs (fever, wt loss, malaise)
Systemic &/or infection S/S - Focal or diffuse weakness
Focal - nerve lesion
Diffuse - degeneration, NMD, myositis/myopathy - Significant history of trauma
Fractures or internal derangement - Hot, swollen joint
Infection/ systemic - Neurogenic pain (burning, numbness, paresthesia)
** Could be radiculopathy = INC risk of SCI d/t instability & inflammation process
Standardized Assessment of Joint Inflammation (SAJI)
4 Objective Measures
Four objective measures of general level of inflammation:
- Duration of morning stiffness (minutes) - >60 mins
- Bilateral grip strength testing (mmHg) - blood measure cuff squeeze
- Number of “active joints”
- Erythrocyte Sedimentation Rate - blood values
Standardized Assessment of Joint Inflammation (SAJI): Assess
Active & Damaged
Active Joint Count (one of the following must be present)
- Effusion
Use two thumb technique, four finger technique, or palpation - Joint Line Tenderness
Pain from pressure being placed over the joint - Stress pain
Pain with passive over pressure at end range
Damaged Joint (one of the following must be present)
- Subluxation or deformity
- Bone on bone crepitus
- Loss of more than 20% of passive ROM
- Ligament instability
Active Joint Count: Acronym
STOP signs
S = swelling
~ Two thumb OR 2. 4 fingers
T = tenderness (joint line)
O-P = overpressure (stress pain)
** At any point you get a (+) for symptoms= STOP! that joint is active
What do you not apply on inflammed, hot or swollen joints?
Superficial heat
Deep heat
- Contraindicated in acute stages of inflammation
What can be applied during a period of active joint inflamm?
Cold!
Contraindicated in patients with Raynaud’s disease or cryoglobulinemia
Rest: Yes or No?
Complete bed rest is rarely recommended
- Short rest breaks throughout the day & quality sleep is recommended
- Inactivity leads to other problems such as:
Deconditioning, depression, DEC bone & tissue health, and INC risk for CV disease
Main Interventions
Summary (3)
Most important tasks initally are:
- DEC pain & swelling
- Optimize ROM & strength
NO stretching for active inflammed joints - capsule & lig are already on stretch
NO strengthening exercises for active inflammed joints - tendons could be compromised w/ chronic swelling
- Optimize function
