Rheumatoid Arthritis and Joint Health Quiz

Musculoskeletal I: Introduction to the Patient Management Model and Upper Extremity

• This course introduces the patient management model and upper extremity anatomy.
• The course is for the Doctor of Physical Therapy program, Summer 2024.

Bones

• Dynamic tissues that remodel, capable of withstanding compressive and tensile forces.
• Anatomical structures with a rigid framework, withstand mechanical loads.
• Levers for the locomotor function of muscles.
• Protect important organs.
• Hemopoietic tissue.
• Storage or reservoir for calcium, magnesium, and sodium.
• Osteoblasts - calcitonin
• Osteoclasts - parathyroid hormone (PTH).
• Woven bone: low mineral content, initial phase of fracture healing, random collagen arrangement; mechanically weaker.
• Lamellar bone: mature, organized collagen arrangement; mechanically stronger.
• Tensile force: elongation, easy fracture
• Compressive force: shortening, osteoporotic fracture
• Shear force: angulation, fracture more frequent in areas with more cancellous bone
• Fracture: single load or repetitive low load exceeds repair rate.
• Wolff's law: bone remodeling in response to stress.

Bone Growth

• Endochondral ossification: most bones.
• Membranous ossification: sutures of skull and a few other bones.

Cartilage

• Viscoelastic tissue
• Withstands shear and compressive forces.
• Aneural (no nerves) and avascular (no blood vessels).
• Chondrocytes and intracellular substance.
• Sponge-like behavior.

Synovial Membrane

• Large functional surface
• Synovial fluid: viscous, pale, yellow, clear fluid that nourishes the cartilage
• Nourishes the cartilage (cushioning and lubrication role).

Tendons and Ligaments

• Tendons transmit loads to bones.
• Ligaments prevent excessive motion and guide joint motion; give passive stability.
• Closed packed position is maximum bony congruency.
• Fibroblasts + matrix
• Aging causes collagen, changing mechanical properties.
• Sprains: 1st degree = microfailure of fibers, minimal pain, no instability; 2nd degree = partial rupture, ~50% strength, pain, some instability; 3rd degree = almost complete rupture, intense pain initially less after, severe instability.

Physical Tissue Stress Model

• Adaptation to stress: too little stress or too much stress.
• Stress on tissues necessary for health (for tissues to remain healthy).

Skeletal Muscles

• 600 muscles, 50% of body weight.
• 3 types of contraction: I – slow twitch, low load, high repetition; II – fast twitch, high load, low/high repetition types.
• Muscle fiber structure (thick and thin filaments of sarcomeres).
• Relationship of tension to muscle length.
• Optimal muscle length results in maximum tension.

Optimal Loading

• The load applied to structures maximizes physiological adaptation.
• Variables influencing optimal loading: tissue type, pathological presentation.
• Loading goals include: increased tensile strength, collagen reorganization, increased muscle-tendon unit stiffness, and neural reorganization.

Diagnostic Work-Up

• History and physical exam are the most important aspects of patient interaction.
• Establishes rapport with the patient.
• History provides important clues for guiding the clinical exam.
• Imaging studies (e.g., X-rays, CT, MRI, ultrasound) and educating patients about findings and treatment options are essential parts of the work-up.

Red Flags

• Cancer: night pain, constant pain, weight loss, appetite loss, fatigue, and history of cancer
• Cardiovascular: shortness of breath, dizziness, chest pain
• Gastrointestinal/Genitourinary: abdominal pain, heartburn, nausea, vomiting
• Neurological: problems with hearing, swallowing, speech, severe headache, blurry vision, balance problems
• Miscellaneous: fever, night sweats, severe emotional disturbances, joint swelling without injury, pregnancy (consider trimester-dependent contraindications).

Introduction to Imaging

• Physical therapists have a history of successful use of imaging in the US military system.
• Imaging reduces unnecessary procedures.
• Imaging improves client satisfaction and decreases costs.

Radiography

• Most cost-effective initial test in orthopedics.
• Used to assess bone and joint pathology, fracture, healing, and progression.
• Minimum of two views (90 degrees) needed.
• Provides patient exposure to radiation.
• Structures are shaded in ways for different tissues (metal=white, contrast media=bright white, bone=white, water=grey, fat=gray/black, air=black).
• Must look for proper size, shape, cortex thickness, continuity, and relationships with other bones.

Bones of the Elbow

• Humerus: capitellum, radial fossa, trochlea, coronoid fossa, olecranon
• Radius: head of radius, articular fovea, neck of radius, radial tuberosity
• Ulna: trochlear notch, coronoid process, radial notch, ulnar tuberosity
• Lateral epicondyle, lateral supracondylar ridge, medial epicondyle, medial supracondylar ridge.

Joints of the Elbow

• Humeroulnar: hinge joint (flexion/extension)
• Humeroradial: modified hinge (pronation/supination)
• Proximal and distal radial-ulnar

Muscles of the Elbow/Forearm

Magnetic Resonance Imaging (MRI)

• Primarily used for soft tissue lesions (rotator cuff tears, meniscal tears, ACL tears, osteomyelitis, osteonecrosis, stress fractures).
• False positive rates – at times over diagnosis

Computed Tomography (CT)

• Provides 3-D info, especially cortical margins of bone.
• Extremely useful for certain fractures (e.g., tibial plateaus, scapula fractures, ankle fractures, talus, spine).
• Now optimal method for detection of pulmonary emboli.

Bone Scan

Absorptiometry (DEXA)

• Best way to measure bone density and bone health.
• Upper lumbar spine and femurs are ideal for measurement.

Diagnostic Ultrasound

• Revealing as MRI but much less costly
• Useful for muscle and tendons

Important Concepts to Musculoskeletal Patient Management

• Sackett's Model of Evidence-Based Practice (EBP)
• Guide to PT Patient Management Model (rehab cycle).
• International Classification of Functioning, Disability, and Health (ICF) Classification

Examination for Musculoskeletal Disorders

• Typical sequence of examination for musculoskeletal disorders.
• Elements and the sequence may be modified, depending on various environmental or patient factors.

Patient Reported Materials and Initial Observation

• Review of intake forms and functional outcome measures (e.g., Oswestry, Neck Disability Index)
• Gather history and identify potential red flags. Review of body chart and pain scale.
• Establish a rapport (warm, confident, in charge but polite).
• Observe movement, affect, posture, and communication.

History

• Location, nature, severity, irritability, mechanism of injury/symptoms.
• How have symptoms (or complaints) changed?
• Review all systems (physical, neurological, psychological aspects associated with the complaint).
• Ask about red flags.

Diagnostic Workup

• Includes taking the patient's history, examining them physically, and ordering any necessary tests.

Screening Exam

• To identify possible issues quickly, especially painful or neurological issues related to the complaint.
• A comprehensive exam (e.g neck and spine, symmetry, etc.)

Movement Analysis

• Demonstrating patient's selected movement
• Watch for: pain, symmetry, efficiency of movement.

Active Range of Motion (AROM)

• Quantity of range of motion.
• Quality: grimacing, difficulty, lack of control, reports of pain.

Passive Range of Motion (PROM)

• Osteokinematic and arthrokinematic motions to consider the quality and quantity of motion, any pain, and the presence/absence of any blocking.

Resistive Tests

• Muscle selective tissue-tension testing.
• Manual muscle testing (MMT).

Muscle Length

• Muscle length testing.

Special Tests

• Specific tests for specific joint/muscles/structures. Must consider sensitivity, specificity, likelihood ratio.

Palpation

• Soft tissue and bone.

Evaluation

• Gather all known information into general categories and make basic initial assessments about the problem.

Test your knowledge on inflammatory arthritis, joint degeneration, and the role of therapies in managing these conditions. This quiz covers essential aspects of bone growth, cartilage health, and the significance of synovial fluid. Ideal for students or professionals interested in rheumatology and orthopedics.