Arthritis Quiz: Symptoms and Risk Factors

Joint Diseases Overview

• Joint diseases are characterized by inflammation of a joint.
• Common types include osteoarthritis and rheumatoid arthritis.

Objective of Study

• Define osteoarthritis and rheumatoid arthritis.
• Identify the different signs, symptoms of osteoarthritis and rheumatoid arthritis, and the problems affecting patient functions.
• Recognize various risk factors associated with osteoarthritis.
• Design physical therapy programs for osteoarthritis and rheumatoid arthritis to help patients return to active function without impairments.
• Describe surgical procedures for treating joint arthritis.
• Design treatment programs after surgery, ensuring no side effects to quickly restore normal function.

Arthritis

• Arthritis is inflammation of a joint.
• Common types are rheumatoid arthritis and osteoarthritis.

Clinical Signs and Symptoms of Inflamed Joints

• Impaired mobility (capsular pattern)
• Decreased and painful joint play
• Joint swelling (effusion)
• Muscular contractures limiting range of motion (ROM)
• Impaired muscle performance
• Joint malalignment
• Muscle inhibition
• Impaired balance
• Functional limitations

Osteoarthritis (OA)

• A chronic degenerative disorder primarily affecting articular cartilage in synovial joints.
• Characterized by bony remodeling and overgrowth at joint margins (spurs and lipping).
• Includes thickening of synovial and capsular tissues and joint effusion.
• Weight-bearing joints (hips, knees), cervical and lumbar spine, distal interphalangeal joints (DIPJs) of fingers, and carpometacarpal joints (CMCJ) of the thumb are commonly involved.
• OA often results from a complex interplay of joint integrity, biochemical processes, genetics, and mechanical forces.
• Mechanical injuries, repeated minor stresses, joint deformity, and soft tissue injuries (e.g., ACL, MCL, LCL) can contribute to OA development.
• Poor synovial fluid movement is problematic during joint immobilization.

OA Characteristics

• Pain in weight-bearing joints is typical.
• Capsular laxity is observable.

Risk Factors for OA

• Genetics
• Obesity
• Weakness of the quadriceps muscles
• Repetitive microtrauma
• Occupational activities (e.g., jobs requiring kneeling, squatting, heavy lifting)

Pathophysiology of OA

• Cartilage splits and thins out.
• Subchondral bone becomes exposed with increased density and cystic bone loss along the joint line (sclerosis).
• Capsular laxity results from bone remodeling, leading to some joint motion instability or hypermobility.
• Affected joints may enlarge in later stages.

Radiological Features of Knee Osteoarthritis

• Radiographs display progressive stages of OA in the knee.
• Stages are often graded from 0-4, with higher stages showing more significant cartilage loss and bone changes.

OA of the Knee: Overview

• Knee OA is a primary cause of disability among adults.
• It causes decreased work productivity and frequent sick days.
• It incurs the highest medical expenses among all arthritis conditions.
• Over 10 million Americans suffer from symptomatic knee OA.
• The prevalence is elevated in people over 64.

OA of the Knee: Definition

• OA involves a gradual loss of articular cartilage within the knee's three articulations: the lateral and medial femoral condyles with the tibia, and the patellofemoral joint.
• Damage results from a combination of joint integrity, biochemical processes, genetics, and mechanical force interplay.

Anatomy of the Knee

• The knee is a complex joint with multiple ligaments (LCL, MCL, ACL, PCL) and cartilage (menisci) that stabilize and cushion the joint.
• Ligaments limit sideways and rotational movements, while also controlling forward movement of the tibia.

Risk Factors for Knee OA

• Age
• Female gender
• Obesity
• Previous knee injury
• Lower extremity malalignment
• Repetitive knee bending
• High-impact activities
• Muscle weakness

Clinical Approach to Knee Pain

• Comprehensive patient history assessment using SOCRATES pain questions.
• Examination of inflammatory indicators (e.g., fever, hot joint).
• Assessment of past trauma or surgical history.
• Evaluation of knee instability.
• Evaluation of functional loss.

Knee Pain Assessment

• Physical exam includes observing patient vitals and Body Mass Index (BMI).
• Knee palpation for tenderness, effusion, and crepitus.
• Range of motion (ROM) measurement.
• Assessment of ligament, meniscus, and overall alignment.
• Observation of gait or movement patterns (e.g., duck waddle).

Tests for Knee Pain or Arthritis

• Complete blood count (CBC)
• Erythrocyte sedimentation rate (ESR)
• Rheumatoid factor (RF)
• Arthroscopy
• X-rays (3 views - weight bearing and tangential patellar views)
• MRI

Differential Diagnoses for Knee Pain

• Differentiating knee pain necessitates considering various conditions, including osteoarthritis (OA), medial collateral ligament (MCL) issues, meniscus tears, and bursitis. Considerations also include possible iliotibial band syndrome, patellofemoral syndrome, prepatellar bursitis, quadriceps mechanism issues, infectious arthritis, gout, or pseudogout.

Diagnosis of Knee OA

• Diagnostic criteria include age >50, presence of morning stiffness (<30 minutes), crepitus, bony tenderness/enlargement and absence of palpable warmth.

Knee OA Classification Tree

• Classifies symptoms or findings as presenting with or without OA.
• Determines existence of synovial fluid issues (WBC, color, and viscosity).
• Radiographic analysis to determine bone spurs, loss of joint space, subchondral sclerosis, or subchondral cysts.

Treatment of Knee OA Overview

• Management modalities include home exercises, physical aids, pain management, and medical interventions including medication (analgesics or steroids).

Management Guidelines for Knee OA

• Home programs and patient education.
• Pain management.
• Supportive devices (e.g., canes, walkers).
• Joint realignment.
• Mobilization.
• Aerobic exercises and balance training.

Recommendations for Knee OA Management

• Weight management (5-7% loss).
• Land-based exercises (e.g., walking, strengthening).
• Recommend against specific procedures (e.g., debridement, repair, meniscectomy, stem cell injections, viscosupplements).

Moderate Knee OA Management Recommendations

• Hydrotherapy
• Manual therapy
• Stationary bicycles
• NSAIDs and corticosteroid injections (short-term)
• Heat therapy
• Assistive walking aids

Moderate Knee OA Management Recommendations Contraindicated

• Acupuncture
• Kinesiotaping
• Vitamin D
• Omega-3 fatty acids
• Lateral wedge or rocker shoes
• Valgus unloading braces
• Cold therapy, laser, or shockwaves

Knee OA Lifestyle Management

• Weight loss.
• Nutritional guidance.
• Exercise programs with physical therapy referral.
• Quadriceps strengthening.
• Range-of-motion (ROM) exercises.
• Low-impact activities (e.g., swimming, cycling).
• Ambulatory aids (e.g., canes, walkers).
• Insoles.
• Knee braces for unloading.

Knee OA Medical Management

• Analgesics (e.g., acetaminophen).
• Nonsteroidal anti-inflammatory drugs (NSAIDs).
• Intraarticular injections (corticosteroids or hyaluronans).

Surgical Management of Knee OA

• Procedures include arthroscopic irrigation, debridement, high tibial osteotomy, partial knee arthroplasty, or total knee arthroplasty.
• Specific surgical approaches (e.g., high tibial osteotomy) are appropriate for certain OA-related conditions. Surgical steps, recovery durations, and post-operative care vary based on the chosen procedure.

Rheumatoid Arthritis (RA)

• Chronic, systemic, autoimmune inflammatory disease,
• Characterized by symmetric polyarthritis and synovitis.
• Progressive inflammation leads to joint destruction, deformity, reduced function, and increased morbidity/mortality rates.
• Systems affected include musculoskeletal, skin, hematologic, lymphatic, immunologic, muscular, renal, cardiovascular, neurologic, and pulmonary.
• Disease course is fluctuating, exhibiting periods of active disease and remission.

RA: Epidemiology

• Incidence is 25-30 cases per 100,000 for males, and 50-60 per 100,000 for females.
• Peak age of onset is 35-50 years of age.
• Prevalence in the general population is 0.3-1%.

RA: The Rheumatoid Joint

• Key features include inflamed synovial membrane, pannus formation (invading tissue), cartilage thinning, and possible inflammatory synovial fluid.

RA: Etiology and Pathophysiology

• RA is presumed to result from an initial autoimmune reaction precipitated by an insult (infection, smoking, trauma)
• Marked by abnormal B-cell and T-cell interactions and elevated cytokine production (e.g TNF, IL-6).
• RA is a multifactorial disease resulting from genetic, hormonal, immunologic, and environmental (e.g., socioeconomic, smoking) factors interacting to cause an autoimmune response.

RA: Risk Factors

• Family history (2-to 3-fold increased risk)
• Smoking (elevated risk, 1.4-2.2%)
• Pregnancy and breastfeeding (reduced risk)
• Female gender predominance (3:1, diminishes with age)

RA: Diagnosis

• History of symmetric polyarthritis (primarily in hands and feet).
• Constitutional symptoms (e.g., fatigue, malaise, low-grade fevers, weight loss).
• Articular symptoms (e.g., tender/swollen joints, early morning stiffness lasting at least 60 minutes, and impact on daily living activities).
• Extra-articular involvement (e.g., skin, pulmonary, cardiovascular, and ocular symptoms).
• Insidious onset is common.
• Typically there's no abrupt onset of symptoms or extra-articular manifestations.

RA: Clinical Pictures

• Patients may experience signs and symptoms such as fever, weakness, fatigue, and tiredness.
• Articular manifestations include conditions such as arthralgia or arthritis, synovitis, swollen joints, and tenderness.

RA: Joints Commonly Involved

• 90-95% of patients have issues with MCP joints, 75-90% PIP joints, 70-80% wrists, 60-80% knees, 50-70% shoulders, and 50-60% metatarsophalangeal (MTP) joints.
• Distal interphalangeal (DIP) joints are often spared.
• Swelling in RA is frequently fusiform (spindle-shaped).

RA: Deformities

• Boutonniere deformity.
• Ulnar deviation of metacarpophalangeal joints.
• Swan-neck deformities.
• Z-shaped thumb deformities.
• Hammer toes.
• Hallux valgus.
• Knuckle Subluxation (partial dislocation).
• Wrist Subluxation

RA: Extra-Articular Manifestations

• General manifestations include fever, lymphadenopathy, weight loss, fatigue, dermatologic issues (e.g., palmer erythema, subcutaneous nodules).
• Vasculitis, related ocular conditions (e.g., episcleritis, scleritis), pulmonary conditions (e.g., pleuritis, nodules, interstitial lung disease), cardiac involvement (e.g., pericarditis, myocarditis), and neuromuscular conditions (e.g., entrapment neuropathy are potential problems.
• Patients may also have hematologic issues (e.g., lymphoma), and possible osteoporosis or atherosclerosis among others.
• Possible differential diagnoses include Sjögren's syndrome, systemic lupus erythematosus (SLE), systemic sclerosis, psoriatic arthritis, polymyalgia rheumatica, crystal arthropathy (gout, pseudogout), and viral-induced arthritis (e.g., parvovirus B19, hepatitis C).

RA: Investigation & Radiographic Findings

• Radiographic findings help establish and monitor RA.
• MRI (hands/wrists) detects erosions, pannus, and synovitis.
• Diagnostic ultrasound assesses synovial thickening/erosion.
• Plain film radiographs are preferred for initial evaluation of RA.
• Initial radiographs generally encompass hands, wrists, and feet.
• Larsen score assesses radiographic changes in RA (grades 0 to 5).

RA: Treatment

• General measures focus on minimizing disease activity and preventing structural damage/disabilities, via early, aggressive treatment.
• Periodic evaluation of disease activity and synovitis is important.
• Arthritis self-management education is vital.
• Treatments should address chronic or subacute phases with similar approaches to other musculoskeletal disorders, with specific precautions applied.

RA: Physical Therapy

• Careful grading of stretching and joint mobilization is crucial since steroids can cause joint laxity.
• Therapeutic exercise helps prevent, retard, or correct mechanical limitations/deforming forces and maintain function.

RA: Surgical Interventions

• Surgical procedures (e.g., synovectomy, tendon reconstruction, joint fusion, or arthroplasty) are often considered for cases unresponsive to other treatments.
• Specific joint choices for synovectomy or arthrodesis procedures are important to consider.

RA: Subacute/Chronic Stage Management

• As the severity of symptoms (pain, swelling) diminishes, the acute stage transitions to subacute.
• Drugs can alleviate symptoms, allowing for functional improvement comparable to the subacute stage.
• The chronic stage involves periods of disease exacerbation that may last for many years.
• Treatment approaches are similar to subacute management, but with special care to avoid undue stress to already weakened tissues.

Considerations for RA Management

• Joint protection and activity modification are essential (splints, assistive devices, environmental accommodations).
• Cardiopulmonary endurance exercises such as aquatic exercise, cycling, dancing, walking/running, maintain or improve aerobic capacity, mitigate the effects of depression. Group activities promote social support.
• Vigorous stretching or manipulative techniques are unsuitable.
• Monitoring exercises is important while exercising individuals with RA as fatigue and pain can compromise the patient's condition.

Test your knowledge on rheumatoid arthritis and osteoarthritis with this quiz. Explore the symptoms, risk factors, and misconceptions about these conditions. Challenge yourself to match features and learn more about the complexities of arthritis.