Week4 6671/6611 Flashcards
Small, non palpable rash
Macule
Raised palpable rash
Papule
Rash contains pus
Pustule
Large palpable rash
Plaque
Rash- small with clear fluid
Vesicles
Allergic- raised edges, migratory
Urticaria
Allergic- watery edema
Angioedema
Thick swollen synovial membrane with granulation tissue (fibroblasts, myofibroblasts, and inflammatory cells)
Pannus
RA
Photo sensitivity can be caused by what meds?
Antibiotics
Diuretics
NSAIDS
Oral hypoglycemics
RA - joints?
Symmetrical
Multiple- usually 5 or more
Common:
Small joints first: MCP, PIP, MTP
As progresses…
Large joints: shoulders, elbows, knees, ankles
Unusual itching- skin disease screening
Liver disease
Renal disease
Elderly population
Dry skin
Specific RA deformities - hands
- Ulnar deviation
- Boutonnière deformity
Extensor tendon splits- PIP flex, DIP hyper-ext - Swan neck deformity
PIP hyper-ext , DIP flex
Baker cyst
Popliteal cyst
Synovial sac of knee bulges posteriorly
(RA)
Felty syndrome
RA, Splenomegaly, and Granulocytopenia
Risk of life threatening infections
ABCDE mole/lesion
Asymmetry Border Color Diameter Evolve
Atopic dermatitis/Eczema
Chronic inflammatory skin disease
Usually children, but can affect adults
Flexor surfaces most involved
Dry skin, erythema, oozing and crusting
Scaling often present in adults
Very itchy
Often associated w/ other allergic conditions such as asthma and food allergy
Herpes zoster
Very common rash
Often in elderly
UNILATERAL distribution is hallmark
Can be triggered by stress, immunocompromise, illness
“Dew drop on a rose petal”
Effective vaccination is available
Post herpetic neuralgia is a significant complication
Abscess
Treatment is always drainage
Antibiotics may be needed for surrounding cellulitis
MRSA is an increasing problem
Any lesion with obvious purulence/pus should be referred for incision and drainage
Post op infection-
Physical exam
Sinus tract to joint is a definite infection
Warmth, redness or swelling
Low grade fever
Limited ROM due to pain and swelling
Err on side of caution
Post op infections- history
Persistent pain and stiffness at site of arthroplasty is associated w/ infection >90% of patients
Acute onset w/ swelling, tenderness, drainage
Chronic infections show pain and more subtle symptoms- function deteriorates and pain worsens over time
Vascular exam
Pulse palpitation
Capillary refill
Edema
Turgor
Dermatomyositis
Idiopathic inflammatory myopathy w/ proximal skeletal muscle weakness and muscle inflammation
Pink cheeks, purple “violaceous” hue over eyelids, rash along elbows, knuckles and knees
Rash classically does NOT spare nasal labial fold
Similar to polymyositis- but polymyositis does not have skin changes
Good prognosis, rarely recurrent
SLE -
Epidemiology
African-American, Latino and Asian women
Women 9-10:1
Typical onset 15-45
Chronic inflammatory disease
Can affect virtually every organ
Develop large number of antinuclear antibodies
Common pattern: constitutional complaints w/ skin, MSK, mild hematologic, and serologic involvement
Avoid sunlight, smoking, stress. Get Regular exercise and prolonged rest
SLE- constitutional symptoms
Fatigue
Fever
Myalgia
SLE- vascular
Raynaud’s phenomena
Vasculitis
Thromboembolic disease
SLE- skin changes
Butterfly rash
Photosensitivity
SLE- overview of affects
Constitutional (Fever, fatigue and myalgia) Arthritis and arthralgia Skin changes Renal and cardiac disease Pulmonary disease Vascular disease
SLE - medical therapy
Corticosteroid creams, pills and/or IV
NSAIDS
Anti malarial drugs
Drugs targeting B-cells
SLE- medical dx
Blood test - measure anti-nuclear antibodies
Tissue biopsy
Scleroderma
Hardening of skin
Affects different body parts
Prompt and proper referral may minimize symptoms, and reduce chances of irreversible damage
No cure or known cause
Localized- more common in children
Systemic- more common in adults
Women predominant (4:1)
Onset 25-55
May be genetic.
Crest syndrome
Hands... Calcium deposits Puffy fingers Raynaud’s Digital ulcers/scars
Form of scleroderma (systemic- limited)
Psoriatic disorder
Skin hyperproliferation as well as a complex immune mediated condition
Characterized by: well-demarcated, erythematous plaques w/ silver scale; dry cracked skin may bleed
Thickened, pitted or ridged nails
Assoc w/ comorbidities such as autoimmune thyroid disease, DM, metabolic syndrome and psoriatic arthritis
Psoriatic arthritis
Characteristic early nail separation (onycholsis) w/ erythema of fingers
Nail pits can develop into separation of lateral nail plate from nail bed
Clinical manifestations of psoriasis
Discomfort and pain
Routine tasks are difficult when hands involved
Concern about appearance of skin
Mgmt incl diet, exercise, weight control, avoid smoking and treat for signs of depression
Medical therapy- psoriasis
Topical corticosteroids and emollients for skin rash and plaques
Moderate to severe plaque disease can be treated with phototherapy
Systemic therapy w/ immunosuppressant or immunomodulatory drugs (MTX or retinoids)
SLE- prognosis
No cure
Self-management: Avoid sunlight Avoid smoking Stress management Prolonged rest at night (12 hours) Regular exercise
SLE- common s/s
Joint inflammation Kidney disease Skin rashes Fatigue Muscle pain Unexplained fever Loss of hair Raynaud’s phenomenon Seizures Sensitive to sun Swelling- edema in legs or around eyes May affect: heart, lungs, blood and brain
PT considerations for SLE and RA-
Treatment sought for?
Seek treatments related to:
Arthritis
Weakness/Fatigue
Pain reduction
PT considerations for SLE and RA-
Education?
Education: skin care, prevention of breakdown (limit sun exposure); energy conservation techniques (avoid excessive bed rest)
PT considerations for SLE and RA-
Other?
Assistive devices (consider hand deformities)
Infection control
PT considerations for SLE and RA-
Acute inflammation
ROM and MMT testing
May be Contraindicated
PT considerations for RA-
AA?
Atlanto-axial Instability in RA = contact MD immediately
Neuro signs Progressive neck pain Paraplegia Spasticity Hyperreflexia Ataxic gait
PT considerations for SLE and RA-
Exercise?
Exercise in short, frequent sessions throughout day (vs 1 long session)
Avoid fatigue
Alternate activities
Stop activity when fatigue and pain begin
Decrease level or remove activity if pain lasts for more than 1-2 hrs after end of activity
PT considerations for SLE and RA-
Other recommendations
Change positions every 20-30 min throughout day to avoid static positioning
Avoid high-impact and contact sports
During inflammation flare ups, avoid excessive bending and stooping
Aerobic exercise- evidence SLE
Reduce fatigue
Increase QOL
Improve functional testing scores
No aggravation of symptoms
3x per week, 12 weeks
65-75% HRR
Cardio better than resistance for improved QOL
Does not demonstrate a change in disease activity
Aquatics vs Land- evidence RA (RCT)
30 min week- 6 sessions
Aquatic vs land
Aquatic: 87% “much better or very much better”
No significant differences in 10 m walk, functional scores, QOL or pain scores
Evidence- RA (RCT)
Person-centered PT on fatigue
12 weeks
Self care plan development with focus on balance of physical and life activities
Reduced general fatigue
Less anxiety
Commonalities among chronic pain syndromes
Chronic widespread pain
Often with fatigue, sleep, memory and mood disturbances
May represent a central pain syndrome: doesn’t r/o peripheral nociceptive input or neuropathic conditions; makes id of pain source less clear leading to treatment difficulties
Dx often overlap and assoc with anxiety and depression
Similarities between MPS, FMS, and CFS increases risk of misdiagnosis
The pain continuum
Nociceptive Centralized
______ Pain related to damage of somatic or visceral tissue, due to trauma or inflammation
Nociceptive
_____ Pain related to damage of peripheral or central nerves
Neuropathic
___ Pain without identifiable nerve or tissue damage; thought to result from persistent neuronal dysregulation
Centralized
Key characteristic-
Acute pain
First time event
Key characteristic-
Recurrent pain
Relapsing/Remitting
Episodic vs Constant
Key characteristic-
Chronic pain
Neural adaptation
Sympathetic alterations
Bio psychosocial consequences
Acute vs Recurrent vs Chronic Pain (global and local)
Myofascial example
Acute: strain
Recurrent:
Global-Myofascial pain syndrome
Local- Epicondylalgia; Impingement; Recurrent tension HA
Chronic:
Global-Fibromyalgia; Chronic Fatigue Syndrome
Local-Chronic tension HA
Increased pain response to normally painful stimulus
Hyperalgesia
Painful response to a normally innocuous stimulus
Allodynia
Pain caused by a lesion or disease of the somatosensory nervous system
Neuropathia
Pain that is enhanced or maintained by a functional abnormality of the SNS
Sympathetically maintained pain
Progressive increase in frequency and magnitude of firing of dorsal horn neurons by the repetitive activation of C fibers above a critical threshold, leading to a perceived increase in pain intensity
Windup
CMP: Chronic myofascial pain
Characterized by?
Myofascial pain syndrome
Pain caused by facial constrictions and multiple trigger points
Non-symmetrical pain pattern
May be in response to tissue injury
Possible progression to FMS or CFS with chronicity and central sensitization
CMP: Chronic myofascial pain
Mechanisms of development?
Persistent load from…
Low-level muscle contractions
Uneven intramuscular pressure distribution
Unaccustomed eccentric contractions, eccentric contractions in unconditioned muscle
Maximal or submaximal concentric contractions
CMP: Chronic myofascial pain
Persistent skeletal muscle ____
Nociceptor activity
Trigger point (TrP) -
Taut, palpable bands
Pain with palpation
Can be active or latent:
-Active: “jump sign” on palpation
-Latent: nodular/taut band w/o pain on palpation
-2ndary: hyper irritable point that becomes active as muscular overactivity in another muscle occurs
Possible non-radicular, referred pain w/ consequences
CMP: Chronic myofascial pain
Myofascial pain syndrome
Pathophysiology
Abnormal ACh release-> Increased tension in muscle fiber-> Blood flow constriction and hypoxia-> Disrupted mitochondrial metabolism-> Release of sensitizing substances-> Pain and tenderness
(Cycle repeats through Autonomic modulation)
CMP: Chronic myofascial pain
Myofascial pain syndrome
Diagnostic criteria
- Taut band within muscle
- Exquisite tenderness at point on taut band
- Reproduction of pt pain
^ essential for dx
Local twitch response Referred pain Weakness Restricted ROM Autonomic signs (skin warmth or erythema, tearing, piloerection)
CMP: Chronic myofascial pain /
Myofascial pain syndrome
Perpetuating factors
Mechanical:
Scoliosis, leg length discrepancies, joint hyper mobility, muscle overuse
Psychosocial: stress, anxiety
Systemic/Metabolic: hypothyroidism, iron insufficiency, Vit C, D or B12 deficiency
Other: infectious disease, parasitic (Lyme), polymyalgia rheumatica, Statins
CMP: Chronic myofascial pain /
Myofascial pain syndrome
Medical therapy
NSAIDS alone have limited effectiveness (injected may help)
Muscle relaxants not effective (TrPs NOT a spasm)
Invasive:
Anesthetic injections (lidocaine)
Botulism toxin A injections (if resistant to conventional rx)
CMP: Chronic myofascial pain /
Myofascial pain syndrome
PT
Invasive: dry needling
Non-Invasive: US TENS Stretching (spray and stretch) Post-isometric relaxation Trigger point pressure release Massage
Multi-modal protocols show good results
Correction of perpetuating factors
CMP: Chronic myofascial pain /
Myofascial pain syndrome
PT: correction of perpetuating factors
Abnormal posture
Incorrect muscle activity or movement patterns
Anatomical defect correction (ie leg length)
Sleep hygiene
CMP: Chronic myofascial pain /
Myofascial pain syndrome
PT- multimodal protocols
Combo: myofascial TrP dry needling, spray and stretching, kinesio-tape, eccentric exercise, and pt education
Low visits stretched out over long duration (ie 5 visits over 4 weeks)
Fibromyalgia
Definition/Description
Syndrome of central sensitivity
Generalized soft tissue syndrome caused by limbic and/or neuroendocrine dysfunction
Systemic involving biochemical, neuro endocrine and physiological abnormalities
Leads to disorder of pain processing and perception (allodynia, hyperalgesia)
Heightened/augmented sensitivity to pain and other stimuli (sounds, smell, heat)
Fibromyalgia
Clinical dx
Widespread pain at least 3 months AND Presence of all the following: 11 out of 18 Tender points Pain above and below waist Pain on bilateral side of body
Fibromyalgia tender points
- Occiput
- Trapezius
- Supraspinatus
- Gluteal
- Greater trochanter
- Low cervical
- Second rib
- Lateral epicondyle
- Knee
One per side of body for 18 total
11 out of 18 for dx
Fibromyalgia
Clinical presentation
Widespread chronic, unrelenting pain Fatigue Insomnia Impaired thought processes Altered sensation Poor physical function and balance Oral and ocular problems HA Sexual dysfunction Psychological effects
Common symptoms of FMS and CMP/MPS
Mild to severe soft tissue pain HA, migraines Disturbed sleep Balance problems/dizziness Tinnitus Memory problems Unexplained swelling Worsening symptoms from stress, changes/extremes in weather, physical activity
Differentiating FMS and CMP/MPS
Tender points in fibromyalgia NOT same as TrP (trigger points) in CMP/MPS
CMP/MPS- pain generally confined to TrPs (but may refer); TrPs CAN be eliminated
FMS can be a progression from CMP/MPS
FMS- pain widespread and around tender points and DOES NOT refer
FMS (fibromyalgia) pathophysiology
Uncertain
Suspected... Low serotonin Increase in Substance P Elevated levels of nerve growth factor Dysfunction of HPA-axis Central sensitization phenomena
FMS (fibromyalgia)
Co-morbidities
Sleep disturbance/apnea Depression Anxiety PTSD May need labs to rule out other conditions
Fibromyalgia
Medical management
Local anaesthetics- reduction of peripheral deep tissue pain
Anti-epileptics/Antidepressants-
Improve/prevent central sensitization
GABA agonists- normalization of sleep abnormalities
Antidepressants- esp Tricyclics- treatment of negative effect, particularly depression
Fibromyalgia
PT interventions
Improve physical fitness and function
Reduce fibromyalgia symptoms
Optimize overall health and well-being
Minimize effect of illness and injury on fibromyalgia symptoms
Fibromyalgia
PT interventions
Exercise considerations
Sedentary lifestyle and general deconditioning assoc w/ FMS increases risk of chronic disease
Greater levels of FMS symptoms assoc w/ lower aerobic fitness (but don’t assume!)
Narrow therapeutic window: too little exercise = no benefits; too much exercise = exacerbations
Minor injuries/illness may sustain process of central sensitization
Fibromyalgia
PT interventions
1- Education Self-efficacy Trusting therapeutic relationships Stress management Activity management
Multi-modal multidisciplinary approach:
combo of aerobic, strength and flexibility
Aquatics (not better than land for FMS)
Alternative: tai chi, Nordic walking, Pilates, relaxation/visualization
“Increased home based physical activity”- pedometer step counts etc
Fibromyalgia
“Start low, go slow”
Gradual progression low-intensity->
Aerobic: Start just below capacity and gradual increase to 20-30 min 2-3x/wk
HR not specific, be able to “speak fluently w/ another”
Duration of at least 4 weeks
Strength: start at lower levels than age-predicted norms. Reduce intensity/duration w/ post-exertion pain/fatigue
Intensity increased 10% after 2 weeks w/o exacerbation
CFS: Chronic Fatigue Syndrome
Definition/description
Debilitating and complex disorder
Intense fatigue not improved by bed rest and may be worsened with physical activity/mental exertion
Substantially lower level of function than prior to illness
May have flu-like symptoms at onset, w/ progression to muscle pain and forgetfulness
Often disturbance in autonomic regulation of BP and HR (lower)
Varies person to person; May be cyclical
Hallmark- post-exertional malaise
Multitude of immune and neuro symptoms
CFS: Chronic Fatigue Syndrome
And FMS: Fibromyalgia
Shared symptoms
Chronic pain Fatigue, sleep difficulties Stiffness Anxiety/Depression Frequent HA Sensitivity to light Cognitive issues Exertional malaise
CFS: Chronic Fatigue Syndrome and FMS: Fibromyalgia
Differences
FMS: Pain is dominant symptom
CFS: Fatigue is dominant symptom
FMS: May be triggered by trauma
CFS: May be preceded by flu-like or infectious illness
FMS: Substance P elevated (is not in CFS)
CFS: Greater exercise intolerance
CFS: Chronic Fatigue Syndrome
Pathophysiology
Mostly unknown etiology
No biomedical tests for dx - must be clinical dx and one of exclusion
Common pathological processes in both FMS and CFS:
HPA suppression
Autonomic dysfunction
Disturbed Stage 4 sleep
Decreased serotonin/suppression of growth hormone
CFS: Chronic Fatigue Syndrome
Dx criteria
Fatigue 6 or more months Substantial reduction in work, personal, school, social... Unrelieved w/ rest Other medical/psychiatric conditions excluded AND 4 or more of following.... Post-exertion malaise lasting > 24hra Impaired memory or concentration Non refreshing sleep Muscle pain Pain in multiple joints w/o inflammation HA PF new type or severity Sore throat Tender cervical or axillary lymph nodes
CFS: Chronic Fatigue Syndrome
Medical management
Symptom relief, improved function, and sleep disturbance
No specific approved drug therapies
Many similar meds as FMS
NSAIDS May be more beneficial for CFS
Antidepressants- more for assoc between depression and CFS, and assist w/ sleep
SSRI/SNRI May help w/ neuropathic pain assoc w/ CFS but do not address immune system dysregulation
CFS: Chronic Fatigue Syndrome
GET- Graded Exercise Therapy
Best clinical evidence in combo w/ strategies of pacing to promote energy conservation and rest
Best outcomes when in combo w/ cognitive-based therapies
Once maintenance achieved, progress slowly to graded aerobic exercise
Graded exercise guidelines for
CFS: Chronic Fatigue Syndrome
- Time contingent (not symptom)
- Home exercise:
5x/week starting at 5-15 min per session, gradual increase to 30 min - Number of sessions, length and duration:
10-11 sessions over 4-5 months (excluding home exercise sessions) - Aerobic exercise- walking, swimming or cycling
