Joint Diseases PDF

Joint diseases  objective -Define Osteoarthritis and rheumatoid arthritis -Identify the different signs and symptoms of osteoarthritis and rheumatoid arthritis and the problems that affect patient functions. -Recognize the different risk factors associated with osteoarthriti...

Joint diseases  objective -Define Osteoarthritis and rheumatoid arthritis -Identify the different signs and symptoms of osteoarthritis and rheumatoid arthritis and the problems that affect patient functions. -Recognize the different risk factors associated with osteoarthritis -Design PT program for osteoarthritis and rheumatoid arthritis to help the patient return to the active functional state without any impairments -Describe the different surgical procedures in the treatment of joint arthritis -Progress the treatment program after surgery without any side effects to regain normal function soon after surgery  arthritis It is inflammation of a joint. The most common types are rheumatoid arthritis and osteoarthritis.  Clinical Signs and Symptoms of inflamed joint 1. Impaired mobility (called a capsular pattern), 2. Decreased and painful joint play. 3. Joint swelling (effusion). 4. Muscular contractures limiting ROM. 5. Impaired Muscle Performance. 6. Joint malalignment 7. Muscle inhibition 8. Impaired balance 9. Functional Limitations  Osteoarthritis (OA) is a chronic degenerative disorder primarily affecting the articular cartilage of synovial joints, with bony remodelling and overgrowth at the margins of the joints (spurs and lipping). There is also progression of synovial and capsular thickening and joint effusion.  Characteristics of OA 1. Pain 2. Weight-bearing joints are the most involved (hips and knees), the cervical and lumbar spine, the DIPJ (distal inter phalangeal joint) of the fingers and the CMCJ (carpometacarpal joint) of the thumb. 3. Capsular laxity  Cause of OA 1. Mechanical injury to the joint 2. Repeated minor stresses 3. Joint deformity 4. Soft tissue injuries (ACL- MM- MCL- LCL) 5. Poor movement of synovial fluid during joint immobilization.  Risk factors 1. Genetics 2. Obesity 3. Weakness of the quadriceps muscles, 4. Repetitive microtrauma 5. Occupational activities: such as jobs that require kneeling and squatting with heavy lifting.  Pathophysiology 1. The cartilage splits and thins out 2. Subchondral bone becomes exposed as increased density of the bone along the joint line (sclerosis), with cystic bone loss 3. capsular laxity as a result of bone remodeling leading to hypermobility or instability in some ranges of joint motion. 5. The affected joints may become enlarged in later stages The radiological features The radiological features Osteoarthritis Knee Osteoarthritis of The Knee I. Overview ❖ Epidemiology ❖ Definition ❖ Risk Factors II. Clinical Approach to Knee Pain III. Differential Diagnosis IV. Diagnosis of Knee OA V. Management ❖ Lifestyle ❖ Medical ❖ Surgical  Overview: Epidemiology Knee OA most common cause of disability in adults Decreased work productivity, frequent sick days Highest medical expenses of all arthritis conditions Symptomatic Knee OA – More than 10 million Americans – More than 11% of persons > 64yo  Overview: Definition Arthritis vs. Arthrosis Gradual loss of articular cartilage in the knee joint 3 articulations: 1) Lateral condyles of the femur and tibia 2) Medial condyles of the femur and tibia 3) Patellofemoral joint Damage caused by a complex interplay of joint integrity, biochemical processes, genetics, and mechanical forces Anatomy of The Knee Anatomy of The Knee Overview: Risk Factors Age Female Obesity Previous knee injury Lower extremity malalignment Repetitive knee bending High impact activities Muscle weakness Clinical Approach to Knee Pain “Hey Doc, my knee’s been hurting!” History SOCRATES pain questions Inflammatory sx e.g. fever, hot joint History of trauma or surgery Instability Functional loss Prior treatment  Clinical Approach to Knee Pain Physical Exam Vitals, BMI Palpation: isolate tenderness, effusion, crepitus ROM: measure degree of flexion Stability: ligaments, menisci Alignment: genu varus or valgus Function: gait, duck waddle Clinical Approach to Knee Pain Valgus Test (MCL) Varus Test (LCL) Lachman Test (ACL) McMurray Maneuver Duck Waddle (menisci) (stability)  Clinical Approach to Knee Pain Tests CBC, ESR, RF Arthrocentesis X-rays (3 views) – Weight-bearing AP – Lateral – Tangential Patellar (Sunrise) MRI Differential Diagnosis of Knee Pain Medial Pain Lateral Pain OA OA MCL LCL Meniscus Meniscus Bursitis Iliotibial band syndrome Diffuse Pain Anterior Pain OA OA Infectious arthritis Patellofemoral syndrome Gout, pseudogout Prepateller bursitis RA Quadriceps mechanism  Diagnosis of Knee OA Classic Clinical Criteria – established by ACR, 1981 – sensitivity 95%, specificity 69% knee pain plus at least 3 of 6 characteristics: > 50 yo Morning stiffness < 30 min Crepitus Bony tenderness Bony enlargement No palpable warmth  Diagnosis of Knee OA Classification Tree Clinical symptoms Synovial fluid 1. WBC functional gain ACL sacrificed PCL also may be sacrificed Prosthesis 10-yr survival: 90% Rheumatoid arthritis  Definition ▪ Chronic systemic autoimmune inflammatory disease with symmetric polyarthritis and synovitis ▪ Progressive chronic inflammation leads to large and small joint destruction, deformity, decline in functional status, and prematur morbidity/mortality. ▪ System(s) affected: musculoskeletal, skin, hematologic, lymphatic, immunologic, muscular, renal, cardiovascular, neurologic, pulmonary ▪ It is characterized by a fluctuating course, with periods of active disease and remission  EPIDEMIOLOGY ▪ Incidence ✓25 to 30/100,000 cases for males ✓50 to 60/100,000 cases for females ▪ Peak age is 35 to 50 years. ▪ Prevalence ✓General population: 0.3-1%  ETIOLOGY AND PATHOPHYSIOLOGY ▪ An insult (e.g., infection, smoking, trauma) precipitates an initial autoimmune reaction where antibody-complement complex activation ultimately results in endothelial activation, synovial hypertrophy, and joint inflammation. ▪ RA is a systemic disorder. ▪ Pathogenesis is mediated by abnormal B- and T- cell interactions and overproduction of cytokines such as TNF and IL-6. ▪ Multifactorial disease with genetic, host (hormonal, immunologic), and environmental (socioeconomic, smoking) factors  Risk factors ▪ Family history: First-degree relatives have 2- to 3-fold increased risk. ▪ Smokers have elevated relative risk of 1.4-2.2% ▪ Pregnancy and breastfeeding for 24 months lowers risk. ▪ Women affected 3:1, difference diminishes with age. Diagnosis  History ▪ Symmetric polyarthritis most commonly affecting the hands and feet. ▪ Constitutional symptoms: fatigue, malaise, weight loss, low-grade fevers. ▪ Articular symptoms: tender/swollen joints, early morning stiffness (at least 60 minutes), and difficulty with activities of daily living. ▪ Extra-articular involvement: skin, pulmonary, cardiovascular, and ocular symptoms ▪ Onset is typically insidious. ▪ Patients rarely present with abrupt onset of symptoms and extra-articular manifestations. Clinical pictures  General signs & symptoms ▪Fever ▪Weakness ▪Fatigue ▪Tiredness  Articular mamifestation Arthralgia OR arthritis Synovitis Swelling(effusion) Tenderness Boggy Deformities and rheumatoid nodules in late stage.  “Joints involved” JOINT PERCENT JOINT PERCENT MCP 90-95 % ANKLE/SUBTALAR 50-60 % PIP 75-90 % CERVICAL SPINE(ESP.C1-C2) 40-50 % WRIST 70-80 % ELBOW 40-50 % KNEE 60-80 % HIP 20-40 % SHOULDER 50-70 % TEMPROMANDIBULAR 10-30 % MTP 50-60 % NB: DIP JOINT IS SPARED swelling in RA= fusiform=spindle-shaped Deformities Extra Articular Manifestations of RA General manifestation Cardiac Fever Pericarditis Lymphoadenopathy Myocarditis Weight loss Nodules on valves fatigue Dermatological Neuromuscular Palmer erythema Entrapment neuropathy Subcutaneous nodules Peripheral neuropathy Vasculitis Occular Haematologic Episcleritis lymphoma Scleritis Choriod and retinal nodules Pulmonary Others Pleuritis Osteoporosis Nodules atherosclerosis Interstitial lung disease ✓Sjögren syndrome DD ✓Systemic Lupus Erythematosus (SLE) ✓Systemic sclerosis ✓Psoriatic arthritis ✓Polymyalgia Rheumatica (older) ✓Osteoarthritis ✓Crystal arthropathy ✓Viral-induced arthritis (parvovirus B19, hepatitis C [with cryoglobulinemia] ✓Behçet syndrome INVESTIGATION  Radiological finding ✓Radiographic findings help establish diagnosis and monitor treatment ✓MRI of hands and wrists looking for erosions, pannus, synovitis ✓Diagnostic ultrasound: to assess for synovial thickening/erosions. ✓Plain film radiographs are preferred for RA: ✓Initial radiographs of the hands, wrists, and feet Larsen score Radiographic changes 0 Normal joint, no changes 1 Osteoporosis and swelling 2 Joint space narrowing and erosion 3 Significant erosion, moderate destruction 4 Loss of joint space, severe destruction 5 Mulrilation or ankylosis DEFORMITIES TREATMENT  General measures ✓Target treatment to achieve remission or minimize disease activity, prevent structural damage and disability. ✓Early, aggressive treatment prevents structural damage and disability ✓Periodic evaluation of disease activity and extent of synovitis is important ✓Arthritis self-management education PHYSICAL THERAPY Management of active/acute RA  PROBLEM LIST ✓Tenderness and warmth over the involved joints with joint swelling ✓Muscle guarding and pain on motion ✓Joint stiffness and limited motion ✓Muscle weakness and atrophy ✓Potential deformity and ankylosis from the degenerative process and asymmetric muscle pull ✓Fatigue, malaise, sleep disorders ✓Restricted ADLs and IADLs PLAN OF CARE INTERVENTION 1. Educate the patient. ▪Inform the patient on importance of rest, joint protection, energy conservation, and performance of ROM. ▪Teach home exercise program and activity modifications that conserve energy and minimize stress to vulnerable joints. 2. Relieve pain and muscle ▪Gentle massage guarding and promote relaxation. ▪Immobilize in splint ▪Relaxation techniques ▪Medications as prescribed by physician PLAN OF CARE INTERVENTION 3. Minimize joint stiffness and ▪Passive or active-assistive ROM maintain available motion. within limits of pain, gradual progression as tolerated. ▪Gentle joint techniques using grade I or II oscillations. 4. Minimize muscle atrophy. ▪Gentle isometrics in pain-free positions, progression to ROM when tolerated. 5. Prevent deformity and protect ▪Use of supportive and assistive the joint structures. equipment for all pathologically active joints. ▪Good bed positioning while resting. ▪Avoidance of activities that stress the joints.  Principles of Joint Protection and Energy Conservation ❑Monitor activities and stop when discomfort or fatigue begins to develop. ❑Use frequent but short episodes of exercise (three to five sessions per day) rather than one long session. ❑Alternate activities to avoid fatigue. ❑Decrease level of activities or omit provoking activities if joint pain develops and persists for more than 1 hour after activity. ❑Maintain a functional level of joint ROM and muscular strength and endurance. ❑Balance work and rest to avoid muscular and total body fatigue. ❑Increase rest during flares of the disease. ❑Avoid deforming positions. ❑Avoid prolonged static positioning; change positions during the day every 20 to 30 minutes. ❑Use stronger and larger muscles and joints during activities whenever possible. ❑Use appropriate adaptive equipment.  CLINICAL TIPS Therapeutic exercises cannot positively alter the pathological process of RA, but if administered carefully, they can help prevent, retard, or correct the mechanical limitations and deforming forces that occur and therefore, help maintain function  “Precaution” Secondary effects of steroidal medications may include osteoporosis and ligamentous laxity, so use exercises that do not cause excessive stress to bones or joints.  CONTRAINDICATIONS ❑Do not perform stretching techniques across swollen joints. ❑When there is effusion, limited motion is the result of excessive fluid in the joint space. ❑Forcing motion on the distended capsule overstretches it, leading to subsequent hypermobility (or subluxation) when the swelling abates. It may also increase the irritability of the joint and prolong the joint reaction. PRECAUTIONS: Respect fatigue and increased pain; do not overstress osteoporotic bone or lax ligaments. CONTRAINDICATIONS: Do not stretch swollen joints or apply heavy resistance exercise that cause joint stress. Principles of Management: Subacute and Chronic Stages of RA ❑As the intensity of pain, joint swelling, morning stiffness, and systemic effects diminish, the disease is considered subacute. ❑Often medications can decrease the acute symptoms, so the patient can function as if in the subacute stage. ❑The chronic stage occurs between exacerbations. This may be very short in duration, or it may last many years. ❑Treatment approach. The treatment approach is the same as with any subacute and chronic musculoskeletal disorder, except appropriate precautions must be taken because the pathological changes from the disease process make the tissues more susceptible to damage.  Joint protection and activity modification. Continue to emphasize the importance of protecting the joints by modifying activity, using splints, asssistive devices, and environmental adaptations for safe function. Flexibility and strength. To improve function, exercises should be aimed at improving flexibility, muscle strength, and muscle endurance within the tolerance of the joints. Cardiopulmonary endurance. ❑Nonimpact or low-impact conditioning exercises—such as aquatic exercise, cycling, aerobic dancing, and walking/running—performed within the tolerance of the individual with RA, improve aerobic capacity and physical activity and decrease depression and anxiety. ❑Group activities, such as water aerobics, also provide social support in conjunction with the activity. One randomized review suggested that aerobic training also has a positive impact on the cardiovascular status of patients with RA.  “PRECAUTIONS” The joint capsule, ligaments, and tendons may be structurally weakened by the rheumatic process (also as a result of using steroids), so the dosage of stretching and joint mobilization techniques used to counter any contractures or adhesions must be carefully graded. “CONTRAINDICATIONS” Vigorous stretching or manipulative techniques.  Evidence-based PT ✓ Patient with active but medically controlled RA who shared in a carefully supervised intensive exercise program showed greater improvement in function and muscle strength, a greater decrease in the number of clinically active joints, and a faster rate of diminished disease activity compared to the control group of patients who participated in a program of ROM and isometric exercise. ✓ The intensive exercises included isokinetic resistance to the knees at 70% maximum voluntary contraction and angular velocity at 60°/sec, isometric exercises at 70% maximum voluntary contraction, bicycling at 60% of the age-predicted maximum for 15 minutes, and ROM exercises. ✓ All exercises were adjusted to the pain tolerance of the individual when needed. ✓ The primary conclusion of this study was that there is no evidence that patients with active disease should be prevented from vigorous exercise so long as fatigue and pain are respected. ✓ The study did not look at joint erosion or cartilage damage. ✓ studies of various strength do support that therapeutic exercise, including functional strengthening and aerobic exercise are beneficial for patients with RA demonstrating relief of pain, improved muscle strength, and functional status. ✓ In one of the reviews,27 investigators found that moderate- or high-intensity exercise in patients with RA has a minimal effect on disease activity and radiological evidence of damage in the hands and feet, but that there is insufficient radiological evidence to determine the effect in large joints. ✓ The reviewers also reported that long-term moderate- or high-intensity exercises (individualized to protect radiologically damaged joints) improve aerobic capacity, muscle strength, functional ability, and psychological well- being inpatients with RA  Surgical ttt ▪ Surgical treatment including ▪ synovectomy ▪ tendon reconstruction ▪ joint fusion ▪ joint replacement may be considered to prevent disability in RA unresponsive to therapy or in advanced RA Joint selection for synovectomy and arthrodesis