Rheumatoid Arthritis and Related Conditions

Question 1

Rheumatoid Arthritis (RA) (Def)

Answer 1

Is an inflammatory, systemic, connective tissue, and autoimmune disease characterized by bilateral, symmetrical arthritis.

Affects many body organs, including heart, liver, eye, skin, bones, and lungs.

Question 2

Articular Pathological Changes (Process)

Answer 2

RA involves synovitis, and hypertrophy and thickening of the synovium, and an excessive production of synovial fluid.

Pannus (abnormally invasive layer of tissue that forms in the internal surface of the synovial membrane) destroys the hyaline cartilage and the bone beneath.

This results in a reduced joint space and rubbing of bone ends on each other. Some joints may become ankylosed.

Question 3

Articular Pathological Changes (Injuries)

Answer 3

Inflammation can cause breakdown of adjacent ligs → subluxation.

Pressure on the muscle tendons can lead to rupture.

OP can develop in the distal ends of the bones.

Question 4

Articular Pathological Changes (Onset)

Answer 4

RA usually begins as symmetrical arthritis in the distal joints of the UL and LL, especially the hands and feet.

Some individuals experience an acute onset: sudden, unexplained severe pain and stiffness, whereas others have a more gradual onset over several months.

The early stages of RA are mainly inflammatory, therefore the main signs of inflammation are apparent. Joints are: swollen with joint effusion, soft tissue edema around the joint, acutely painful, hot to touch, erythema.

Question 5

Articular Pathological Changes (Signs)

Answer 5

> Pain can be acute and severe. Identifying feature is pain at rest, at night, and in the early morning.

> Spindle fingers, or fusiform-shaped fingers: swelling of PIP joint.

> Early morning stiffness (that can last several hours).

> Muscle atrophy from disuse.

Question 6

Articular Pathological Changes (Joint Deformities in UL)

Answer 6

> Trigger finger: finger flexor tenosynovitis that results in snapping type motion.

> Boutonniere’s deformity: hyperext of DIP, flex of PIP, and hyperext of MCP.

> Swan-neck deformity: flex of DIP, and hyperext of PIP.

> Ulnar drift (aka Z deformity): disruption of the collateral ligs of the MCP joints.

Question 7

Articular Pathological Changes (Joint Deformities in LL)

Answer 7

> Cock-up toes: deformity with subluxation of MTP joints.

> Claw toes: flex DIP, flex PIP, and hyperext MTP.

> Hallux valgus (bunion).

> Hammer toes: hyperext DIP, flex PIP, and hyperext MTP.

> Mallet toes: flex DIP, neutral PIP and MTP.

> Genu valgus and knee flexion deformities: atrophied quad and HS muscles.

Question 8

Articular Pathological Changes (Joint Deformities in Cx spine)

Answer 8

> Atlantoaxial joint: 83% people with RA have ant atlantoaxial subluxation within 2 y of onset of disease.

> Symptoms can range from:

• Quadriparesis, quadriplegia or tetraplegia (in severe cases), and even death.
• HAs, radicular pain (in less severe cases).
• Pressure on blood vessels can cause Transient Ischemic Attacks (TIA).
• Vertebral artery insufficiency (aka vertebral basilar insufficiency): ataxia, dizziness, motor and sensory changes, vertigo and visual deficits.

Question 9

Nonarticular Pathological Changes (Si and Sy)

Answer 9

> Severe fatigue: which may be related to anemia.

> Anorexia.

> Felty’s syndrome: in people with severe or long-standing RA. Causes splenomegaly → pt become prone to infections, vasculitis, and skin lesions (skin nodules).

> Weight loss.

> Eye problems.

> Pulmonary complications: pleural effusion and lung nodules, interstitial lung disease, bronchiolitis, bronchiectasis, and respiratory infections.

> OP.

> Vasculitis.

Question 10

Rheumatoid Arthritis (Pharmacology)

Answer 10

> Aspirin: anti-inflammatory, analgesic, ↓ fever, ↓ clotting.

> Acetaminophen: analgesic, ↓ fever.

> NSAIDs: anti-inflamatory, analgesic, ↓ production of prostaglandina, and ↓ inflammation.

> DMARDs (Disease-Modifying AntiRheumatic Medications): anti-inflammatory, and immunosuppressive.

Question 11

Rheumatoid Arthritis (PT intervention)

Answer 11

Requires a full system approach.

Directed towards:

• Improvement in fx activity.
• Minimization of joint deformity and joint preservation.
• ↑ joint ROM.
• ↓ pain.
• Strengthening the muscles.
• Client education.
• Adaptations to ADLs necessary to promote independence.

Question 12

RA: PT (Hydrotherapy)

Answer 12

Water should be body temp or slightly higher.

Pt should be warmed to limit ex when first starting a program (effect of buoyancy can lead to overexertion without the pt realizing).

Contraindicated in acute exacerbation of RA when joints are acutely inflamed.

Question 13

RA: PT (Passive Stretching)

Answer 13

Best performed through gentle, restricted exercise, positioning, and splinting.

Resting splints to maintain good joint position are an integral part of the treatment approach.

Cx traction or mobilisation techniques are contraindicated for pt with later stage RA (because Cx instability).

Question 14

RA: PT (Active Exercise)

Answer 14

Should be developed concentrating on strengthening weak muscles, improving cardiovascular conditioning, and assisting pt to achieve max fx level.

Emphasis should be placed on quality over quantity.

Discontinue ex if ↑ pain, unexpected side effects, or RA symptoms exacerbate.

Question 15

RA: PT (Electrical Modalities and Thermal Agents)

Answer 15

Neuromuscular electrical stimulation can be combined with active exercises to help build muscle mass and strength, but it’s contraindicated in the acute stage of RA.

Interferential therapy may be helpful for relief of pain and can be used during acute stage.

TENS may be useful, as well as Laser-light therapy (LLT).

Thermal (hot and cold) have been used for many years for relief of pain and inflammation.

Question 16

RA: PT (Orthotics)

Answer 16

May be used to address instability: firm Cx collar, shoe orthotics.

Question 17

RA: PT (Pain Reduction)

Answer 17

Analgesics and anti-inflammatories may ↓ pain.

People with RA usually respond well to warmth, so home programs may include use of heat modalities. Caution with skin sensitivity!

Question 18

Precautions, Contraindications, and Special Considerations for PT intervention for pt with RA

Answer 18

1. NO Cx traction for RA in later stages.
2. NO spinal flex ex if OP.
3. NO forced stretching of RA joints.
4. NO mobs/manip of RA joints.
5. NO use of pillows/rolls beneath knees.
6. Care when using heat, skin is very sensitive.
7. When using electrodes, do NOT use tape.
8. Stop ex’s if pain ↑ or unusual symptoms develop.
9. Instruct pt to check safety of ambulatory assistive devices and suggest regular replacement of rubber cane/walker tips.
10. Skin care: avoid walking into objects, no jewellery that could cause a wound, keep fingernails trimmed, educate pt to do skin self-inspections.
11. Refer pt to occupational therapy for adaptive equipment (bathroom, kitchen, and so on).
12. Suggest use of firm, elevated chair (easier to rise up).
13. Remember that RA pt will fatigue easily (be ready to adapt programs).

Question 19

Ankylosing Spondylitis (AS) (Def)

Answer 19

Is a progressive, inflammatory, rheumatoid-related disease, affecting the joints and ligaments of the spine and occasionally peripheral joints as well as internal organs.

Question 20

Ankylosing Spondylitis (AS) (Si and Sy)

Answer 20

> Ankylosis, mainly of the spine (bamboo spine) and SIJs, but cal also affect sh, hips, and knees.

> Pain and stiffness in the LB: often greater in the morning and alleviated during the day with mvmt and ex.

> Fatigue in early stages of the disease.

Question 21

Ankylosing Spondylitis (AS) (PT intervention)

Answer 21

1. Measurements of spinal mvmt and testing of lung VC.
2. Evaluation of level of fatigue.
3. Pain relief and reduction of muscle spasm.
4. Improvement and/or maintenance of spinal mobility through ex programs:
   > Hydrotherapy/aquatherapy.
   > Breathing ex’s.
   > HEP.
   > Patient education on positioning to include lying prone to stretch hips and spine.
   > Stretching ex’s for spine and extremities.
   > Relaxation ex’s.
   > Reduction of deformity through postural awareness.
   > Strengthening, endurance, and aerobic ex’s.
   > Group activities to benefit pt psychologically and physically.
5. Advice on ADL, use of appropriate assistive devices, and possible referral to other health care providers.
6. Advice to desist participation in contact sports.

Question 22

Psoriatic Arthritis

Answer 22

Another of the group of seronegative spondyloarthropathy diseases.

Is characterized by inflammation of the joints, skin psoriasis, and occasional systemic symptoms.

PT intervention: aimed at reducing symptoms, improve hand and spinal fx, and improve and maintain ROM.

Question 23

Reactive Arthritis (Reiter’s Syndrome or Disease)

Answer 23

Another of the group seronegative polyarticular spondyloarthropathies.

Si and Sy include: polyarthritis, urethritis, conjunctivitis, fever and weight loss, plantar fascitis, SIJ and LBP, and skin lesions on feet, hands, and genitalia.

PT intervention:

• Goals in the acute phase are ↓ pain and inflammation with ice packs, and ↓ or minimize possible deformities through positioning and splinting.
• Goals in the sub-acute phase are ↓ pain and inflammation with modalities, improve joint mobility, strengthen muscles and provide advice to pt for improvement of fx activities.

Question 24

Scleroderma (aka Systemic Sclerosis)

Answer 24

Is a systemic, autoimmune, connective tissue disease.

Si and Sy: thickening and loss of elasticity of the skin with progressive fibrosis involving body organ systems that can lead to hypertension, HAs, and fatigue. Edema of fingers, thickening and tightening of skin, weakness and atrophy of muscles, joint contractures, pursed lip appearance (swallowing difficulties), lung complications, gastrointestinal problems, renal disease.

PT intervention: maintain gentle stretching of joints, providing soft tissue mobs, and massage, and improve of general aerobic fitness.

Question 25

Systemic Lupus Erythematosus (SLE)

Answer 25

Is a rheumatoid-related, systemic, chronic, autoimmune, inflammatory, connective tissue, and collagen disorder.

Si and Sy: butterfly rash across nose and cheeks, arthritis of hands, photosensitivity, raised erythrocyte, cardiopulmonary problems, neurological problems, renal disease, and gastrointestinal symptoms.

PT intervention: very similar as for persons with RA.

Question 26

Fibromyalgia

Answer 26

Chronic pain syndrome characterized by multiple areas of muscle tenderness and frequently joint pain (does not directly affect the joints, tough).

Si and Sy: positive Dx when 11/18 points on the body are hypersensitive to palpation. They may also experience HAs or migraines, fatigue, chest pain, profuse sweating, cognitive deficits (poor memory, inability to concentrate), early morning stiffness, swelling, LBP, neck pain, urinary and bowel symptoms, anxiety, depression, dizziness, and sleep disorders.

PT intervention: stress reduction, adaptation of the workplace environment, aerobic ex’s, and other moderate exercise routines.

Question 27

Myofascial Pain Syndrome

Answer 27

Often confused with polymyalgia rheumatica or fibromyalgia.

Si and Sy: clinically the most significant finding is the presence of trigger points in the muscles involved.

PT intervention: treatment of trigger points.

Question 28

Muscular Dystrophy (MD)

Answer 28

Occurs in many forms, Duchenne MD (DMD) and Becker’s MD (BMD) are the two most common.

Dx in childhood, results in progressive weakness and atrophy of muscles that starts in the proximal muscle groups of pelvic and sh girdles and progresses to the distal extremities and the respiratory muscles.

Si and Sy: delayed gait development, seizures, scoliosis, and susceptibility to respiratory infections.

PT intervention: provide HEP to maintain strength and fx, advice on home adaptations, wheelchair measurement and ordering, and instructions to family for management of the child.

Question 29

Myasthenia Gravis (MG)

Answer 29

Is a chronic autoimmune disease in which the body produces antibodies that destroy the acetylcholine receptors at the synapse in the neuromuscular junctions, resulting in muscle weakness.

Si and Sy: weakness of the eye, skeletal, and respiratory muscles (most evident later in the day because of fatigue of muscles is the main symptom).

PT intervention: providing assistance for ambulation and ADL, and teaching the patient and care providers techniques to assist with transfers and ambulation. Also fx activities that include breathing ex’s.

Question 30

Inflammatory Myopathies

Answer 30

Includes polymyositis and dermatomyositis. This group of diseases cause weakness of skeletal muscles and are considered rheumatoid related diseases.

Si and Sy: weakness of the prox sh, sh girdle, and neck muscles.

PT intervention: exercise programs, manual muscle testing, aquatic therapy, assistance with ADL, and advice regarding HEP and energy conservation.