39 Questions
What are the basic guidelines in joint protection?
Respect pain, pace activities properly, plan each day's activities, prioritize desired tasks/accomplishments, practice proper joint positioning
Which type of medication is used to control inflammatory signs and symptoms in Rheumatoid Arthritis?
NSAIDs
_____ guidelines suggest limiting intra-articular corticosteroid injections to no more than 4 times a year for a given joint.
Guidelines for intra-articular steroid injection
Moist heat treatments for pain relief provide a long-lasting effect compared to NSAIDs. True or False?
False
Infiltration of muscle also leads to ____
weakness
Which of the following are clinical features of Progressive Systemic Scleroderma (PSS)?
Skin thickening pulmonary fibrosis
Match the following conditions with their associated features:
Dermatomyositis/Polymyositis (DM-PM) = Inflammation of muscles with or without rashes Sjogren's Disease = Connective tissue disorder affecting exocrine glands Systemic Lupus Erythematosus (SLE) = Systemic immune-mediated disorder
Jacoud's arthritis is characterized by bony erosion.
False
What is the most common cause of death in patients affected by a vasculitis and resultant disease?
Kidneys
What are some types of cells involved in joint inflammation?
neutrophils, basophil, eosinophil, monocytes, lymphocytes
Which clinical features suggest inflammation in joints?
Fever
Laboratory & X-ray findings suggestive of inflammation include increased peripheral white blood cell count, elevated erythrocyte sedimentation rate with shift to the left, and group II or III joint fluid. Additionally, soft tissue swelling on radiographs and evidence of periostitis, bony erosions, or uniform loss of __________.
cartilage
Match the following types of arthritis with their associated pathology:
RA = Synovitis AS = Enthesopathy Osteoarthritis = Cartilage degeneration Gout = Crystal arthritis Septic arthritis = Joint infection
Joint contractures in rheumatic disorders are caused by adhesion across the joint surfaces.
False
What is one of the frequent signs/symptoms of rheumatic diseases and its likely cause?
Morning stiffness - RA or spondylitis
What is the most common type of injury in weight lifters?
back pain
What are possible crystal deposits in crystal-induced arthritides?
Calcium oxalate
Which lifestyle factors are associated with an increased risk of back pain? (Select all that apply)
Low job satisfaction
A focal extension of a disc beyond the vertebral end plate is known as disc ___.
herniation
What disorder is characterized by hyperuricemia and acute monoarticular inflammatory arthritis?
Gouty arthritis
Match the spine structures with their innervated structures:
Lumbar z(zygopophyseal) joints = Richly innervated joint capsule Joint capsule = Clavicle Outer annulus of IV disc = Erector spinae and multifidi muscles
What is the typical sequence seen in gouty arthritis?
Asymptomatic hyperuricemia - Acute gouty arthritis - Intercritical gout - Chronic tophaceous gout
Tophi primarily contain calcium crystals.
False
What is the prevalence range of gouty arthritis?
3-7%
What are the factors that increase susceptibility for Osteoarthritis?
body built, heredity, reproductive variables, osteoporosis, hypermobility, smoking
Which of the following mechanical factors increase the risk for Osteoarthritis?
Repetitive use
Main symptoms of Osteoarthritis include use-related pain, stiffness after inactivity, and ____________.
coarse crepitus-cracking or locking
Match the OA treatment approaches with their corresponding steps:
Education, counselling, dietary advice, reassurance = 1 ROM and strengthening exercises = 2 Joint protection techniques = 3 Orthotic/assistive devices = 4 Simple analgesics = 5 Short course NSAID = 6 Other physical techniques = 7 Intra-articular injections = 8 Joint lavage debridement, medical synovectomy = 9 Surgery = 10
Ankylosing Spondylitis is also known as Marie-Strumpell disease.
True
What is the characteristic triad associated with Reiter's Disease?
arthritis, urethritis, conjunctivitis
Which autoimmune disease is characterized by skin thickening in both proximal and distal limbs, face, and trunk?
Systemic Sclerosis
What is the definitive diagnosis for gout?
Synovial fluid analysis
Which of the following are major criteria for Chronic Fatigue Syndrome (CFS)?
Severe fatigue that does not resolve with bed rest
Chronic gouty arthritis is characterized by shorter intercritical periods.
True
The 7 Ds of chronic pain include Duration more than ____ months.
6
Match the following pain interventions with their types:
NSAIDs = Pharmacologic Acupuncture = Non-pharmacologic Anti-depressants = Pharmacologic Guided visual imagery = Non-pharmacologic
What are the predisposing factors for orthostatic hypotension?
- Prolonged bed rest, 2. Drug therapy, 3. Salt restriction, 4. Autonomic dysfunction
Which medications can cause hypotension?
Diuretics
Match the following genetic disorders with their characteristics:
Hurler's syndrome = Autosomal recessive lysosomal storage disease with alpha L-iduronidase deficiency Ehler-Danlos = Hyperelasticity of the skin and hypermobile joints Marfan's = Deficiency of a glycoprotein, long thin extremities, aortic aneurysm, dislocated lenses Klippel-Feil = Congenital fusion of cervical vertebra with triad of low posterior hairline, short neck, and head and neck limitation Sprengel's = Congenital high scapula due to failure to descend
Study Notes
General Medical Conditions
Rheumatic Disorders
- Mediators of joint inflammation:
- Prostaglandins, leukotrienes, and thromboxanes
- Substances released by mast cells, basophils, and platelets (e.g. serotonin, histamine, bradykinin, and arachidate metabolites)
- Plasma proteins of the complement system
- Types of cells involved in joint inflammation:
- Neutrophils: recognize, ingest, and destroy particulate matter
- Basophils: cause increased vascular permeability for the development of immediate hypersensitivity
- Eosinophils: have enzymes that degrade mediators released by basophils and mast cells
- Monocytes and macrophages: phagocytosis
- Lymphocytes: initiate, control, and terminate cellular and humoral immune system
- Clinical features suggesting inflammation:
- Acute, painful onset
- Fever
- Erythema of the skin over the joint or joints involved
- Increased warmth over the affected joint
- Tenderness that parallels the degree of inflammation
- Laboratory and X-ray findings suggestive of inflammation:
- Increased peripheral white blood cell count
- Elevated erythrocyte sedimentation rate with a shift to the left (more immature form)
- Group II or III joint fluid
- Soft tissue swelling on radiographs
- Evidence of periostitis, bony erosions, or uniform loss of cartilage
Joint Contractures in Rheumatic Disorders
- Adhesion across the joint surfaces has not been shown to be the cause
- Effects of serial casting and splinting are directly related to the severity of joint destruction
- Casts are applied in a position of maximum extension without excessive force and are removed for hygiene every day
- At the end of 5-7 days, the cast is replaced, and more extension is noted
- The last 10 degrees of extension are the most difficult to achieve and are often impossible
- Total ROM usually does not change, but the ROM shifts toward the extension limits rather than the flexion limits of joint motion
Comparison of Asymmetrical Arthritic Conditions
- Characteristics of Rheumatic Disorders:
- OA: cartilage degeneration, joint space narrowing, marginal osteophytes, cortical sclerosis, and cysts
- AS: enthesopathy, synovitis, soft tissue swelling, new bone formation, fluffy periosteal bone, syndesmophytes, enthesopathic ossification or erosion, bony ankylosis, sausage finger
- Reiter's: enthesopathy, synovitis, soft tissue swelling, new bone formation, fluffy periosteal bone, syndesmophytes, enthesopathic ossification or erosion, bony ankylosis, sausage finger
- PsA: enthesopathy, synovitis, soft tissue swelling, new bone formation, fluffy periosteal bone, syndesmophytes, enthesopathic ossification or erosion, bony ankylosis, sausage finger
- Gout: crystal arthritis, soft tissue swelling, joint space enlargement, periosteal elevation, bony destruction
Basic Pathology in Various Arthritis
- RA: synovitis
- PSA: synovitis
- Reiter's: synovitis
- AS: enthesopathy
- OA: cartilage degeneration
- Gout: crystal arthritis
- Bacterial, viral, fungal arthritis: joint infection
- Trauma, reactive arthritis, metabolic, endocrine: joint effusion
- Scleroderma, dermatomyositis, polymyositis: connective tissue disease
- SLE: vasculitis
Frequent Signs and Symptoms of Rheumatic Diseases and Possible Causes
- Alopecia: adrenocorticosteroid, cyclophosphamide therapy, SLE
- Morning stiffness: RA, Spondylitis
- Morning back pain: Ankylosing spondylitis
- Joint crepitus: OA
- Joint damage: Soft tissue inflammation
- Diarrhea: Ulcerative colitis with spondylitis or arthritis
- Dysuria: Reiter's syndrome
- Genital sores: Reiter's syndrome
- Nephritis: SLE
- Numb thumb: Carpal tunnel syndrome
- Palpable purpura: Systemic cutaneous vasculitis
- Photosensitivity: SLE
- Pleuritis: SLE
- Raynaud's phenomenon: Color changes
- Red eyes: Reiter's conjunctivitis
- Uveitis: SLE
- Rash: Psoriasis
- Weakness on arising from chair or bathtub: DM/PM
Frequent Physical Findings in Rheumatic Disease and Possible Causes
- Boutonnière deformity: RA, SLE, Parkinsonism, MCT disease
- MCP subluxation: Ulnar deviation
- Swan neck deformity: RA
- Bouchard's nodes: OA
- Finger drop: Tendon rupture
- Foot drop: Mononeuritis multiplex
- Heberden's nodes: OA
- Joint effusion: Ballottable patella, bulge sign
- Lhermitte's sign: Atlanto-axial joint
- Occipital paresthesia: Atlanto-axial joint
- Mouth ulcers: Reiter's syndrome
- Skin ulcers: Venous stasis, arteritis, pressure sores
- Subcutaneous nodules: Gouty tophi, RA, Rheumatic fever
- Synovitis: Joint pain only vs. inflammation
- Telangiectasia: CREST syndrome
- Tendon rubs: PSS
- Tender points: Fibromyalgia, tendinitis, bursitis
- Trigger points: Referred pain of fibromyalgia
Summary of Major Radiographic Findings and Other Associations
- RA: marginal erosion of bone with juxtaarticular osteoporosis
- OA: non-uniform joint space loss in association with bony sclerosis and marginal osteophytes
- AS: symmetrical sacro-iliac joint involvement, syndesmophytes, periosteal new bone formation, ankylosis
- Gout: soft tissue deposits, marginal erosions with large bony overhangs
- Pseudogout: calcinosis in fibrocartilage
- Joint infection: If early, negative or (+) joint space widening
- Osteomyelitis: periosteal reaction
- SLE: malar or butterfly rash
- Psoriasis: pencil-in-cup (on x-ray) and opera-glass deformity
- Sjögren's: (+) Shirmer's test
Therapeutic Modalities
- Heat and cold therapy: use of superficial heat vs. deep heat in rheumatic disease patients
- Orthotic devices: helpful in reducing finger circumference
- TENS: recent study that effect of treatment not very remarkable
- Weight loss: 1 kg weight loss results in a 3-4 g decrease in load across the hip joint
- Forearm crutch: more effective in unloading weight to limb
- Orthotic devices: e.g. functional wrist splint, thumb post splint, radial dynamic outrigger splint
Principles of Joint Protection
- Preservation of muscle strength and joint ROM
- Prevention of positions of deformity especially in the hands
- Utilization of the strongest joint (bigger joints) for the heavier jobs
- Use each joint in its most stable anatomic and functional plane
- Maintain muscle balance and correct patterns of motion
- Adaptation of tasks requiring static positioning
- Elimination of activities that cannot be halted immediately
- Application of scientific management principles to each task
Basic Guidelines in Joint Protection
- Respect pain
- Pace activities properly
- Plan each day's activities
- Prioritize desired tasks/accomplishments
- Practice proper joint positioning
Anti-Inflammatory Drugs in Arthritis
- Types of NSAIDs:
- Salicylates (Aspirin)
- Propionic acid (Fenoprofen, Flurbiprofen)
- Acetic acids (Diclofenac, Etodolac, Indomethacin, Ketorolac, Nabumetone, Sulindac, Tolmetin)
- Oxicams (Piroxicam, Tenoxicam)
- Contra-indications of NSAIDs:
- History of previous NSAID-induced ulcer complication
- Prior ulcer disease
- Advanced age (>75)
- Concomitant corticosteroid or anti-coagulant use
- Smoking in combination with any of the above
- Prolonged use
Corticosteroids
- Risks:
- Ignore underlying disorder when feeling better
- Steroid-induced crystal arthropathy
- Tendon rupture
- Precaution with diabetics taking insulin or hypoglycemic agents
- Osteoporosis
- Cushing's syndrome
- Behaviour and mood alteration, fluid retention, HPN
- Adrenal atrophy, amenorrhea, appetite increase, glucose tolerance impairment, electrolyte problems
- Aggravation of peptic ulcer
- Avascular necrosis, bone demineralization, steroid myopathy
- Acne, buffalo hump, moon face, hirsutism, skin thinning
Intra-Articular Steroid Injection
-
Rheumatoid Arthritis (RA)
- Definition: Chronic inflammatory disease characterized by joint inflammation, pain, and stiffness, leading to deformity and disability.
- Epidemiology:
- F > M (3:1)
- 80% onset between 35-50 years old
- Prevalence: 1-2%
- Higher in white people, lower in Japanese
- Pathophysiology:
- Etiology unknown
- Chronic inflammation of synovial tissue and fluid
- Bone and cartilage destruction
- Presentation:
- Constitutional symptoms: fatigue, anorexia, generalized weakness, vague musculoskeletal symptoms
- Localized, symmetric joint pain and swelling, aggravated by movement
- Morning stiffness
- Weakness and atrophy common
- Affected joints: PIP, MCP, DIP (rarely involved), upper cervical spine (C1-C2)
- Course and outcome:
- By 3 years, 80% have abnormal x-ray findings
- Lifespan shortened by 3-7 years
- Early death often due to GI bleeding and infection
- LE destruction > UE destruction (foot more affected than hand)
- 80% with disability and deformity in 10-12 years
- Potential deformities:
- "Z" deformity (wrist radial deviation, MCP ulnar deviation, palmar subluxation of proximal phalanges)
- Swan neck and boutonniere deformities
- Hindfoot eversion, widening of forefoot, hallux valgus, loss of medial arch, and lateral deviation of toes
FELTY'S SYNDROME
- Definition: Combination of chronic rheumatoid arthritis, splenomegaly, and neutropenia or leukopenia
- Features:
- High titers of rheumatoid factor
- More likely to have systemic manifestations of RA, including subcutaneous nodules
- Uncommon in African Americans
- Increased susceptibility to infection
1987 REVISED CRITERIA FOR THE CLASSIFICATION OF RHEUMATOID ARTHRITIS
- Guidelines for classification:
- At least 4 criteria present
- Patients with 2 or more clinical diagnoses are not excluded
- Criteria (7 in all):
- Morning stiffness
- Arthritis of 3 or more joint areas
- Arthritis of hand joints
- Symmetric arthritis
- Rheumatoid nodules
- Serum rheumatoid factor
- Radiographic changes in hand and wrist (erosions, unequivocal bony decalcification)
MEDICATIONS IN RA
- NSAID: control inflammatory signs and symptoms, minimal effect on disease progression
- DMARDs (Disease-modifying Anti-rheumatic Drugs): decrease elevated levels of acute phase reactants, thought to modify disease process
- Include: gold compounds, D-penicillamine, anti-malarials, sulfasalazine
- Minimal effect on symptom relief, high toxicity
- Glucocorticoid therapy: control symptoms, symptomatic relief only, toxic effects
- Immunosuppressive and cytotoxic drug therapy: ameliorate disease process in some patients, used if DMARDs fail, toxic effects
CLASSIFICATION OF FUNCTIONAL CAPACITY IN RA
- Steinbrocker Classification:
- Class I: completely able to carry out all usual duties without handicap
- Class II: can perform normal activities but with discomfort or limited mobility of 1 or more joints
- Class III: can do only few self-care duties
- Class IV: completely dependent in all aspects of ADL; bedridden
POOR PROGNOSTIC INDICATORS IN RA
- More than 20 inflamed joints
- Markedly elevated ESR
- Presence of bony erosions on x-ray
- Presence of rheumatoid nodules
- White females tend to have more persistent synovitis and progressive erosions
- Persistent synovitis
- High titers of RhF, C-reactive protein, haptoglobin### Polymyositis (PM) and Dermatomyositis (DM)
- Group I: DM (skin rash and muscle weakness)
- Group II: PM (proximal muscle weakness without skin rash)
- Group III: DM/PM associated with malignancy (more common in males > 40 years old, weakness may precede cancer diagnosis by 1-2 years)
- Group IV: DM/PM associated with vasculitis (disease of childhood, characterized by rapid muscle weakness, dysphagia, and respiratory weakness)
Bohan Criteria for Diagnosis
- Common clinical features:
- Symmetric proximal muscle weakness (UE-67%, LE-84%)
- Muscle pain
- Dysphagia
- Dysphonia
- Raynaud's phenomenon
- Rash
- Joint pain
- Other associated rehab problems:
- Respiratory muscle weakness
- Joint limitation of motion (LOM) with subcutaneous calcinosis (more common in children)
Prognosis
- Factors influencing prognosis:
- Adults fare better than children
- Higher mortality rate with associated carcinoma
- Severe disease at onset has a poorer prognosis
- Late treatment has a poorer outcome
- Group I and II can recover completely or have residual muscle weakness and fatigue that responds to rehab; Group III has a poor prognosis
Systemic Lupus Erythematosus (SLE)
- Systemic, immune-mediated disorder
- Manifestations:
- Musculoskeletal: arthralgias, myalgias, hand deformities, myopathy, myositis, ischemic necrosis of bone
- Cutaneous: malar rash, discoid rash, photosensitivity, oral ulcers, alopecia, vasculitis, panniculitis
- Hematologic: anemia, leukopenia, lymphopenia, thrombocytopenia, splenomegaly, lymphadenopathy
- Neurologic: cognitive dysfunction, organic brain syndrome (psychosis, seizures)
- Cardiopulmonary: pleurisy, pericarditis, myocarditis, endocarditis (Libman-Sachs), pleural effusions, lupus pneumonitis, interstitial fibrosis, pulmonary hypertension, ARDS, hemorrhage
- Renal: proteinuria, nephrotic syndrome, renal failure
- Gastrointestinal: non-specific GI symptoms, vasculitis, abnormal liver enzymes, ascites
- Ocular: retinal vasculitis, conjunctivitis, episcleritis, Sicca syndrome
- 1982 Criteria for SLE:
- Malar rash
- Renal disorder
- Discoid rash
- Neurologic disorder
- Hematologic disorder
- Immunologic disorder
- Antinuclear antibodies
- Serositis
Sjogren's Disease
- Manifestations:
- Xerostomia (dryness of the mouth)
- Dry eyes (gritty feeling, positive Schirmer's test)
- 1/3 of patients with systemic manifestations
- Dry nose, throat, and trachea
- Esophageal mucosal atrophy, gastritis, pancreatitis
- Dyspareunia
- Extraglandular manifestations (rare): easy fatigability, arthralgia, fever, vasculitis, nephritis, interstitial lung disease
- Diagnostic criteria:
- Ocular symptoms: dry eyes, recurrent sensation of sand or gravel in the eyes
- Oral symptoms: daily feeling of dry mouth, recurrent or persistently swollen salivary glands
- Ocular signs: positive Schirmer's test or rose Bengal score
- Histopathology: focus score in minor salivary gland biopsy
- Salivary gland: positive result in salivary scintigraphy, parotid sialography, or salivary flow
- Autoantibodies: antibodies to Ro(SS-A) or La(SS-B), antinuclear antibodies, or RhF
Crystal-Induced Arthritis
- Possible crystal deposits:
- Monosodium urate crystals (gout)
- Calcium pyrophosphate dehydrate (pseudogout)
- Calcium hydroxyapatite
- Calcium oxalate
- Gouty Arthritis:
- Characterized by hyperuricemia
- Acute, monoarticular, inflammatory arthritis
- Urate crystals in/around joints (tophi)
- Urate crystals in kidney
- Renal stones (urolithiasis)
- Typical sequence: asymptomatic hyperuricemia, acute gouty arthritis, interval or intercritical gout, chronic or tophaceous gout
- Prevalence: 1.3-3.7%
- Peak age at onset: 40-60 for males, post-menopause for females
This quiz covers general medical conditions, specifically focusing on rheumatic disorders such as rheumatoid arthritis, osteoarthritis, and spondyloarthropathies. It also explores other connective tissue diseases like systemic sclerosis and systemic lupus erythematosus.
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