GENERAL-MEDICAL-CONDITIONS-1.docx

GENERAL MEDICAL CONDITIONS **GENERAL MEDICAL CONDITIONS** **Course Syllabus** **1.Rheumatic disorders** **a.General considerations** **b.Rheumatoid arthritis** **c.Osteoarthritis** **d.Spondyloarthropathies** **1.d.Ankylosing spondylitis** **2.d.Reiter's disease** **3.d.Psoriatic arthritis** **e.other Connective tissue diseases** **1.e.Systemic sclerosis(Scleroderma)** **2.e.Dermatomyositis-Polymyositis(DM-PM)** **3.e.Systemic Lupus Erythematosus(SLE)** **4.e.Sjogren's disease** **f.Crystal-induced Arthritides** **1.f.Gouty arthritis** **2.f.Septic arthritis** **3.f.Vascular syndromes** **4.f.Sarcoidosis** **g.Rehabilitation of Total Hip and Total Knee Replacements** **h.Chronic Pain** **i.Myofascial Pain Syndrome** **j.Chronic Fatigue Syndrome** **k.Fibromyalgia** **l.Immobilization Syndrome** **m.Cumulative Trauma Disorder** **1.m.Performing Artists Occupational Disorders** **n.Low back And Spinal Pain** **o.Miscellaneous Disorders:** **1.o.Diabetes Mellitus** **2.o.Thoracic Outlet Syndrome** **3.o.Reflex Sympathetic Dystrophy** **4.o.Hypotension** **RHEUMATIC DISORDERS** **General considerations** **Mediators of joint inflammation** : prostaglandins, leukotrines,& thromboxanes : substances released by mast cells, basophils & platelets such as serotonin, histamine, bradykinin & arachinate metabolites : plasma proteins of the complement system **Types of cells involved in joint inflammation:** 1\. neutrophils- recognize, ingest, and destroy particulate matter 2\. basophil-cause increased vascular permeability for the development of immediate hypersensitivity 3\. eosinophil-have enzymes that degrade mediators released by basophils and mast cells 4\. monocytes and macrophages-phagocytosis 5\. 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 and degree of inflammation **Laboratory & X-ray findings suggestive of inflammation** : increased peripheral white blood cell count : elevated erythrocyte sedimentation rate with 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 have not been shown to be the cause : effects of serial casting and splinting directly related to severity of joint destruction(the better the x-ray appearance the better the result) : casts applied in position of maximum extension without excessive force and are removed for hygiene everyday : at end of 5-7 days replaced and more extension noted : last 10 degrees of extension most difficult to achieve ,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 the various asymmetrical arthritic conditions** OA AS Reiter's PSA Septic Gout -------------------------------- ------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------- --------------------- ------------------------- Pathology Cartilage degeneration Enthesopathy; synovitis (Reiter's/PSA) Joint infection Crystal arthritis Lab tests HLA-B27; SI joint x-rays Joint fluid culture Serum uric, Joint fluid Most frequently affected joint Hip,knee,DIP,1^st^ CMC, cervical spine SI, Heel, Vertebral column, Hip, Shoulder, Knee, Ankle, MCP, PIP, DIP,MTP Knee, ankle, wrist, hip, small joints 1^st^ MTP, small joints. knee Less frequently affected Ankle, shoulder, Types of changes seen Joint space narrowing; Marginal osteophytes; Cortical sclerosis & cyst Soft tissue swelling, New bone formation, Fluffy periosteal bone, Syndesmophytes, Enthesopathic ossification or erosion, Bony ankylosis, Sausage finger(reiter's,PSA) Soft tissue swelling, Joint space enlargement, Periosteal elevation, Bony destruction Soft tissue swelling, Soft tissue calcification, Tophi, Erosion of bone with marginal overhangs System involvement CVS, Eye, NAsopharynx & ear, skin CVA Skin dermographica Men before 45;females after 45 15-45;60:1 men 15-45 Basic pathology in various arthritis RA, PSA, Reiter's Synovitis AS, PSA, Reiter's Enthesopathy OsteoarthrItis Cartilage degeneration Gout, pseudogout crystal arthritis Bacterial , viral ,fungal arthritis joint infection Trauma, reactive arthritis ,metabolic ,endocrine Disorder joint effusion Scleroderma, dermatomyositis , polymyositis, SLE ,polymyalgia rheumatic vasculitis Frequent signs & symptoms of rheumatic diseases & possible causes SIGNS/SYMPTOMPS LIKELY 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 Drugs Pleuritis SLE Drug-induced or spontaneous Raynaud's phenomenon Color changes PSS vs. CREST DM/PM ,RA ,local trauma(e.g.from playing tennis or air hammer) Red eyes Reiter's conjunctivitis Uveitis Rash Psoriasis Drug eruption(ibuprofen ,d-penicillamine, SLE, drug-induced or spontaneous, rheumatic fever) Weakness on arising from chair or bathtub DM/PM Steroid-induced proximal myopathy Frequent physical findings in rheumatic disease and possible causes PHYSICAL FINDINGS LIKELY CAUSES Boutoniere deformity RA,SLE,Parkinsonism ,MCT disease MCP subluxation Ulnar deviation Swan neck deformity RA Bouchard's nodes PIP joint, OA Finger drop Tendon rupture Foot drop Mononeuritis multiplex Heberden's nodes DIP joint ,OA Joint effusion Ballottable patella ,bulge sign Lhermitte's sign Occipital paresthesia thesia as a sign when flexed with 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(place Finger beneath MCP joint to Detect small amounts of syno Vitis ) Telangiectasia CREST syndrome Tendon rubs PSS Tender points Fibromyalgia, tendinitis, bursitis Trigger points Referred pain of fibromyalgia Summary of major radiographic findings & other association RA Marginal erosion of bone with juxtaarticular osteoporosis OA Non-uniform joint space loss in association with bony sclerosis Marginal osteophytes; articular cartilage degeneration. AS Symmetrical sacro-iliac joint involvement; syndesmophyte; Periosteal new bone formation; ankylosis Gout Soft tissue deposits; marginal erosions with large bony over Hangs 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 Sjogren's (+)Shirmer's test Some therapeutic modalities: : use of superficial heat vs.deep heat in rheumatic disease patients are both incomplete and inconclusive : trial and pattern prereference should direct the prescription of heat or cold for rheumatic disease : before exercising, superficial heat and deep heat if available should be applied ; the dose is determined by costs, custom and convenience rather than by scientific data. : nylon spandex compression gloves-helpful If finger stiffness is excessive; also found to reduce finger circumference. : topical irritant ointments; topical capsaicin : TENS-recent study that effect of treatment not very remarkable. : 1kg. weight loss results in a 3-4 g decrease in load across the hip joint : forearm crutch more effective in unloading weight to limb; elbow should be in 30 degrees. Orthotic devices in arthritis: DEFORMITY/INDICATION PRESCRIPTION : periods of inflammation functional wrist splint : CMC & IP pain from OA thumb post splint : carpal tunnel syndrome functional wrist cock-up splint : MCP replacements, radial dynamic outrigger splint Nerve neuropraxia pulls finger into extension :control excessive pronation in bring calcaneus perpendicular Subtalar joint to the floor Principles of joint protection: 1\. preservation of muscle strength and joint ROM 2.prevention of positions of deformity especially in the hands 3\. utilization of the strongest joint(bigger joints) for the heavier jobs 4\. use each joint in its most stable anatomic and functional plane 5\. maintain muscle balance and correct patterns of motion 6\. adaptation of tasks requiring static positioning.it is best to alternate rest with activities 7\. elimination of activities that cannot be halted immediately 8\. application of scientific management principles to each tasks.scientific management embodies work simplification and time and motion economy.plan ahead and do not overdo or undertake too much. 9\. respect pain and stop activities that cause it. 10\. provide support for inflamed joints Basic guidelines in joint protection 1\. respect pain 2.pace the activities properly : take frequent rest breaks : have the rest breaks before beginning to get tired : on good days pace the work to avoid end-day tiredness : maximize lunch and coffee breaks as rest periods in work 3. plan each day's activities : plan only small amounts of work each day\] : : never overdo a day's schedule : follow heavy tasks with less demanding tasks : break down long duration or complex tasks 4\. prioritize desired tasks/accomplishments : make a list of chores in order of importance : schedule most essential tasks during best periods : reschedule activities if paid or fatigue sets in. 5\. practice proper joint positioning : use stronger & bigger joints for heavy tasks : avoid positions of deformity : use each joint in its most stable and anatomic plane : change position frequently : use assistive/adaptive devices to prevent joint stress Anti-inflammatory drugs in arthritis: Types of NSAIDS Salicylates Aspirin Propionic acid Fenoprofen Flurbiprofen ( Ansaid, Ocufen) Ibuprofen (Alaxan,Muskelax, Midol 200, Motrin,Brufen, Skelan forte) Ketoprofen(Orudis,Oruvail) Naproxene(Naprosyn,Flanax) Oxaprozin Fenemates Meclofenamate Mefenamic acid ( Ponstan, Dol Fenal , Revalan) Acetic acids Diclofenac(Cataflam,Voltaren) Etodolac(Lodine) Indomethacin(Indocid) Ketorolac(Toradol) Nabumetone(Relifex) Sulindac(Clinoril) Tolmetin Oxicams Piroxicam(Feldene) Tenoxicam(Tilcotil) Patients at high risk for NSAID-induced ulcer: : 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 Risks of corticosteroids: : Ignore underlying disorder when feeling better\>\>\>only mask the inflammation associated with the disease; not effect a cure : Steroid-induced crystal arthropathy : Tendon rupture : Precaution with diabetics taking in 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 Guidelines for intra-articular steroid injection : Limit intra-articular corticosteroid injections to no more than 4 x a year and 20 x in a lifetime for a given joint. : Never inject directly to a tendon and avoid peritendinous injection of the Achilles and patellar tendon as tendon rupture can occur due to the catabolic effect of corticosteroids on proteins and inhibition of collagen synthesis. Contra-indications of intra-articular injections : overlying soft tissue sepsis : bacteremia : anatomic anaccessibility : uncooperative patient : articular instability : septic arthritis : avascular necrosis : osteonecrosis : neurotrophic joints : charcot joints : unstable joint : traumatic arthritis secondary to fracture : severe osteoporosis : surgical implants : non-diarthrodial joints due to absence of synovial sac Complications of intra-articular injection : infection : post-infection inflammation : issue atrophy especially if corticosteroid leaks outside of joint space Frequency of giving intra-articular injection: : large joints-3-4 x/ year ,maximum of 10 : small joints-2-3 x/year, maximum of 4 : inflamed weight bearing joints-every 3-4 months only : post-injection care: : icing for 1^st^ 24 hours : care with frequently injected joints ,ligaments, tendons : have period of joint immobilization, rest & protection from further injury After injection RHEUMATOID ARTHRITIS Description : Systemic rheumatic disease which primarily affects the synovial lining of diarthrodial joints. : Classic clinical picture is that of a chronic inflammatory arthritis involving symmetric small joints particularly the PIP,MCP,& MTP joints. : Often of insidious onset with pain ,swelling and morning stiffness in multiple joints : Bony erosions pathognomonic of RA. : Fatigue prominent element : Rarely affect axial spine except at atlantoaxial joint : Other organ systems frequently involved : Felty's syndrome seen in 15% of patients : Characteristic deformities :MCP ulnar deviation and subluxation, boutoneire and swan neck of PIP, DIP, ruptured tendons : Other deformities & predisposing factor: : radial deviation of wrist due to weakness of ECU & ulnar ligaments : ulnar deviation of fingers due to increased ulnar torque of finger flexors following wrist radial deviation : swan neck deformity due to intrinsic tightness in patients with hyperextensible PIP joints : boutonneire deformity due to weakening of central extensor attachment and volar slip of the lateral bands : cocked toe deformity with MTP pain due to swelling of the MTP joints with dorsal subluxation of the proximal phalanges : increased splay of the forefoot : hallux valgus : Rehab.goals: pain relief ,increased ROM, increased strength and endurance, prevention and correction of deformities, counselling and education. Pain relief: : moist heat-15 min. twice daily(depth of penetration 1-1.5 cm) : moist heat-pain reliever ,reduce stiffness and serves as preparation to an exercise program : most painful joints are treated first : moist heat treatment temporary effect and inconvenient compared to NSAID : splinting for wrist and hands Prevention and correction of deformities: : protective splints : joint immobilization(gentle manipulation of joints past the range normal reach by active ROM) not beneficial to RA patients : molded shoe insoles, extra depth shoes to provide support and spread pressure\>\>\>relieves pain extends walking range and slow progression of such deformities as protruding metatarsal heads :joint preservation and work simplification techniques promulgated by Cordery and colleagues : Increasing strength and endurance: : patients feel fatigue and are chronically tired : studies on short term effect of isometric exercises, treadmill/cycle ergometer and water exercise all sho increased strength and endurance : no long term follow up yet on the effect of exercise : moderation is watchword : suppress inflammation thoroughly before exercising : e xercise done under careful, controlled conditions with monitoring of exercised joints : Psychosocial counselling-job history and modification Epidemiology: : F\>M(3:1) : 80% onset between 35-50 y/o : prevalence: 1-2 % : higher in white ;lower in Japanese Pathophysiology: : etiology-unknown : pathological changes :chronic inflammation synovial tissue : acute inflammation synovial fluid :bone and cartilage destruction Presentation: : constitutional symptoms: fatigue, anorexia, generalized weakness, vague musculoskeletal symptoms : localized, symmetric joint pain and swelling aggravated by movement; hyperthermic but erythema uncommon : morning stiffness : weakness and atrophy common : affected joints : PIP,MCP : DIP rarely involved : upper cervical involvement(usually C1-C2; thus immobilization with a rigid cervical orthosis is important) :lumbar spine involvement rare Course and outcome: : by 3 years 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 & deformity in 10-12 years Potential deformities: :"Z" deformity (wrist radial deviation with MCP ulnar deviation and palmar subluxation of proximal phalanges : swan neck and boutoniere : hindfoot eversion : widening of forefoot : hallux valgus : loss of medial arch : loss of subtalar movement : excessive pronation subtalar joint : plantar subluxation of metatarsal heads : lateral deviation & dorsal subluxation of toes FELTY'S SYNDROME : is the combination of:1.chronic rheumatoid arthritis :2.splenomegaly :3. neutropenia or leukopenia(occasionally anemia & thrombocytopenia) : other features: high titers of rheumatoid factor : more likely to have systemic manifestation of RA including subcutaneous nodules : uncommon in African Americans : increased susceptibility to infection. 1987 Revised Criteria for the Classification of Rheumatoid Arthritis(Braunwald1998) 1. Guidelines for classification (+) RA -- at least 4 criteria present Patients with 2 or more clinical diagnosis are not excluded 2. Criteria (7 in all ) Lastly, laboratory findings: F.(+) serum Rheumatoid factor G.(+) radiograph changes in hand & wrist\>\>\>erosions, unequivocal bony decalcification adjacent or localized to involved joint. Prediction of deformities in Rheumatoid Arthritis Medications in RA: : NSAID : control inflammatory sign & symptoms : minimal effect on disease progression : DMARDS(Disease modifying anti-rheumatic drugs) : decrease elevated levels of acute phase reactants so thought to modify the destructive process of the disease : include: gold compounds, d-penicillamine, anti- malarials, sulfasalazine : minimal effect on symptom relief : high toxicity : not retard erosion nor facilitate healing : Glucocorticoid therapy : control symptoms : symptomatic relief only : has toxic effects : Immunosuppressive & cytotoxic drug therapy : ameliorate disease process in some patients : includes:azathioprine,cyclophosphamide,methotrexate : used if DMARDs fails : also with 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 nly 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 : +) bony erosions on x-ray : (+) rheumatoid nodules : white females tend to have more persistent synovitis and progressive erosions : persistent synovitis : high titers of RhF, C-reactive protein,haptoglobin : (+) erosion,subcutaneous nodules on initial level : sustained disease activity\>1 year OSTEOARTHRITIS Description : most common form of arthritis : prevalence increases with age : less than 45 years old ;ÓA more common in males : greater than 45 year old; more common in females : females tend to have more severe disease than men : predisposed joints in women:DIP,PIP,1^st^ CMC,1^st^ MTP : predisposed joints in men :hip(but at 55-64 y/o hip involvement becomes twice more prevalent in women than men) : knee involvement :equal prevalence from 55-64 y/o ,but beyond 65 y/o severe knee OA is more common in women. : cartilage degeneration is the hallmark of OA. : etiology of degeneration is unknown : predisposed areas of more severe OA: apex of femoral head ,lateral or central lesion of patella : pathological process begins with histological changes and end in frank destruction of joint cartilage : have increased density of bone adjacent to joint and bony excresence called osteophytes can occur at the margins of the joint. : most common in older patients : associated with conditions of previous joint damage or excessive wear or obesity : factors that increase susceptibility for OA: \>body built \>heredity \>reproductive variables \>osteoporosis \>hypermobility \>smoking : mechanical factors that increase risk for OA: \>trauma \>joint shape \>repetitive use \>occupation \>recreational activities Main symptoms: : use-related pain(rest and night pain; tenderness) : stiffness after inactivity; early morning stiffness usually \\>\>pathology in trauma, reactive arthritis, metabolic/endocrine disorders) : coarse crepitus-cracking or locking : signs of mild inflammation(cool effusion) : restricted painful movements : tightness of joint : instability Pyramidal approach to treatment of OA: 1\. education,counselling,dietary advice, reassurance 2\. ROM and strengthening exercises 3.joint protection techniques 4\. orthotic/assistive devices 5\. simple analgesics 6\. short course NSAID 7\. other physical techniques 8\. intra-aricular injections 9\. joint lavage debridement,medical synovectomy 10 surgery OA in specific joints 1. Shoulders : older patients : associated with excessive joint destruction or rotator cuff tear or rupture 2. Elbows : occur after trauma, joint overuse or inflammatory joint disease : injections provide symptomatic relief : full ROM not necessary : neoprene sleeves help reduce pain 3.Hip : common : generally idiopathic : initially relieved by having patient walk with a cane in contralateral hand : isometric gluteus maximus and medius exercises increase pain : steroids difficulty to inject : associated with obesity : quads weakness noted : knee braces not generally successful but feel improved proprioception stability and strength and decreased pain : cane crutches relieve weight bearing : cane may be ipsilateral or contralateral : soft soled shoes : multiple angle isometrics throughout knee ROM relieve pain 5\. Base of thumb : common cause of pain : thumb spica awkward and interferes with ADL but provide consistent relief of pain 6\. Cervical spine : common in older persons : cause radiculopathy due to osteophytes impinging on nerve roots and myelopathy due to bony overgrowth causing cord compression :if osteophytes cause of radiculopathy ,treat with collar holding neck in neutral position or flexion since placing neck in extension will reduce interforaminal space and exacerbate symptoms 7\. lumbosacral spine and spinal stenosis : common cause of polyradiculopathy and myelopathy : epidural injections and brace hold spine in slight lumbosacral flexion to provide temporary relief : NSAIDS : exercises small part to play in treatment but extension of spine increases symptoms : OA of lumbosacral spine almost universal in middle-aged and elderly : myelopathy and radiculopathy rare in above group : back pain of spinal stenosis increased by extension and relieved by flexion; resembles radiculopathy especially in L3 to L4 dermatomes; aggravated by walking and relieved by rest. 8\. Foot : hallux valgus of great toe and cock-up deformity of digits 2-5 most common expression of OA in foot. : deep toe box shoe(extra depth) Radiograph grading system for OA: Grade 0 -- normal\-\-\-\-\--no features of OA Grade 1-doubtful\-\-\-\-\-\--minute osteophyte, doubtful significance Grade 2-minimal\-\-\-\-\-\--definite osteophyte, unimpaired joint space Grade 3-moderate\-\-\-\--moderate diminution of joint space Grade 4-severe\-\-\-\-\-\-\-\--joint space greatly impaired with sclerosis of subchondral bone SPONDYLOARTHROPATHIES Definition: a group of clinical conditions that have\>\>\> (+)spondylitis & inflammatory peripheral arthritis :(+) HLA-B27 antigen :(-) Rheumatoid factor (seronegative) ANKYLOSING SPONDYLITIS :traditionally refers to the idiopathic spondyloarthropathy (because in contrast psoriatic arthritis, inflammatory bowel disease and Reiter's all have known secondary causes; however in more recent books ,AS is used synonymously with the general group name spondyloerthropathy and is just subdivided into primary(idiopathic) and secondary( ankylosing spondylitis) : also called Marie- Strumpell disease.Bechterew disease Rheumatoid spondylitis Classification of Spondyloarthropathy 1\. Primary Ankylosing Spondylitis 2\. Secondary Ankylosing Spondylitis a\. Reactive artritis(Reiter's disease)-acute arthritis associated with an infection. B Psoriatic arthritis-chronic ,inflammatory arthritis seen in 5-42% of psoriasis patients c\. Enteropathic arthritis-associated with inflammatory bowel disease : is combined synovitis and inflammation of the enthesis : Enthesis is the tissue attaching tendons and joint capsules to bone. : healing is by ossification which leads to progressive stiffening and rigidity of the spine. : spine usually stiff in flexion : I ritis(inflammation of uveal tract) and aortic valve disease common ; Different from Reiter's and Psoriasis because confined to spine : Goal of rehab :keep patient functional as long as possible : prescribe exercises aimed at maintaining erect posture or stiffness in extension : exercise found to help maintain aerobic capacity : in females involvement of hip common : arthroplasty done in AS commonly develops post-op heterotopic ossification 1984 New York Criteria for AS :History of inflammatory back pain \>onset \insidious \>duration\>3 mo. before medical consult \>morning stiffness \>improve with exercise & activity : LOM lumbar spine in both sagittal & frontal planes : limited chest expansion94RTH ics;N=5 cm or more) : definite radiographic sacroillitis Epidemiology: : affect young adults\F(3:1) : gradual onset Clinical manifestations Skeletal findings Axial arthritis( saroillitis & spondylitis) Arthritis of girdle joints Peripheral artritis uncommon Enthesopathy Extraskeletal findings Acute anterior uveitis Cardiovascular involvement Pulmonary involvement Cauda equine syndrome Enteric mucosal lesion Other findings Loss of lumbar lordosis, increased thoracic kyphosis, forward stoop cervical spine, hip flexion contracture, secondary knee flexion contracture (+) Shober's Increased occiput (or tragus)-to --wall distance Course and Outcome: : generally with a variable course : good prognosis-females : poor prognosis: onset in adolescence : severe early disease : presence of extraarticular complications : complete cervical ankylosis with kyphosis : lifespan usually normal : potential complications: cervical spine fracture : cauda equine : pulmonary fibrosis : prostatitis : aortic insufficiency : heart block REITER's Disease : classic triad of arthritis, urethritis & conjunctivitis now uncommon : varied presentation from monoarthritis to severe multisystem disease : (+) history of antecedent infection or new sex partner : constitutional symptoms: fatigue, malaise, low grade fever ,weight loss : asymmetric ,additive arthritis Manifestations: : often affects: knee, ankle, subtalar joint, MTP, toe, IP : dactylitis or sausage digit-diffuse swelling of one finger or toe(distinctive feature of both Reiter's & psoriatic arthritis) : tendinitis & fasciitis(plantar fascia) : low back pain : urogenital lesion : prostatitis : ocular:conjunctivitis,uveitis : muscolo-cutaneous lesions: oral ulcers, keratoderma blenorrhagica (characteristic skin lesion of Reiter's seen in palm & soles) : circinate balanitis (lesion of glans penis) : nail changes( onycholysis, distal yellowish discoloration, hyperkeratosis Course & Outcome : 30-60%have persistent joint symptoms : 25% will have disabilities : (+)tendency for recurrence : chronic heel pain : Yersinia infection-better prognosis PSORIATIC ARTHRITIS : arthritic problem may present as tendinitis, enthesitis, synovitis : affect both peripheral and spinal joint : often asymmetric but symmetric involvement not uncommon : spinal involvement usually asymetrical so more responsive to exercise : prescribe high toe box if with involvement of toes : heel lift and arch support helpful for associated plantar fasciitis : for spinal involvement-injections for costochondral joint pain,superficial heating,spine extension exercises : Koebner or isomorphic phenomenon is a finding seen in dermatologic psoriasis where traumatized areas of the skin are the same areas that will develop psoriatic skin lesions(the skin lesions of psoriasis are erythematous,sharply demarcated papules and rounded plaques covered by silvery micaceous scales) : X-ray findings \*similar to RA: soft tissue swelling loss of the cartilage space, erosion, bony ankylosis of fingers, subluxations, and subchondral cysts \*but less demineralization \*unique ,highly suggestive findings -erosion at DIP joints -base of terminal phalanx-expanded -proximal phalanx-tapered -distal terminal phalanx-cup-like erosions and bony proliferation (pencil-in-cup appearance) \*proliferation of the bone near osseous erosions \*terminal phalangeal osteolysis, bone proliferation and periostitis (especially of phalanges) Outcome: asymmetric and spondylitic subgroups-better prognosis : symmetric type-50% develop arthritis mutilans 3 major types of psoriatic arthritis INFLAMMATORY BOWEL DISEASE (IBD) -Refers to the enteropathic type of spondyloarthropathy -Equal male and female predilection -Present as symmetric, migratory, polyarthritis affecting mainly the large joints -Predominant spondylitis is more common in males -May be seen in Cronh's disease, colitis & other inflammatory bowel diseases. OTHER CONNECTIVE TISSUE DISEASES Autoimmune diseases : condition in which host immune response against self components contributes to pathogenesis of the disease : are of 2 types: organ-specific (antibodies attack only cells of parts of particular organ) : systemic (various organ cells can be attacked) Organ-specific Multiple sclerosis Insulin dependent DM Myasthenia Gravis Grave's disease Addison's disease Systemic Rheumatoid arthritis SLE Sjogren's Scleroderma Dermatomyositis Polymyositis Mixed CTD Common characteristics of auto-immune diseases 1\. have autoantibodies-markers(ANA, rheumatoid factor) 2..often associated with genetic and viral and environmental factors 3.female predisposition SYSTEMIC SCLEROSIS : Diffuse cutaneous scleroderma \- rapid progression \- symmetric skin thickening in proximal and distal limbs,face and trunk \- visceral involvement likely especially renal. : Localized cutaneous scleroderma \- skin thickening limited to distal limbs and face \- often has features of CREST syndrome( calcinosis, Raynauds syndrome, esophageal dysmotility, sclerodactyly, telangiectasia) Description : Epidemiology \- rare \- 30-40 y/o \- F\>M(3:1) \- increased risk: blacks, pregnancy, stone masonry, coal/gold/uranium exposure -In PSS have excessive amounts of abnormal collagen causing thickening of the skin and difficulty in moving the joints. -Usually LOM noted in fingers, shoulders and knees -Fibrosis also affects GIT motility, lung air exchange ,pericardial expansion and motion resulting in associated systemic manifestations. -Infiltration of muscle also leads to weakness -Kidneys affected by a vasculitis and resultant disease most common cause of death of patient -May also have Raynaud's phenomenon -CREST syndrome variant of PSS: subcutaneous calcinosis : Raynaud's phenomenon : esophageal dysfunction : sclerodactyly : telangiectasia often of lips and fingers Hand splints not as helpful in maintaining hand function; casts used to cover ulcers Clinical features of Progressive Systemic Scleroderma(PSS) : Raynaud's phenomenon esophageal dysmotility : Skin thickening pulmonary fibrosis : Subcutaneous calcinosis isolated pulmonary arterial hypertension : telangiectasia congestive heart failure : arthralgia and arthritis renal crisis : myopathy DERMATOMYOSITIS/POLYMYOSITIS (DM-PM) \- inflammation of muscles with or without rashes \- etiology: unknown but abnormal immunoregulation and viral causes suspected \- auto-immune disease \- polymyositis-skeletal muscle damaged by a non- suppurative inflammatory process characterized by lymphocyte infiltration \- dermatomyositis-polymyositis plus skin rash(diffuse erythema, maculopapular eruption, dermatitis) \- insidious onset \- findings:polymyositis \>proximal limb weakness(hip & thigh)-presenting with difficulty in squatting, kneeling, climbing \>pain in buttocks and thigh \>heliotrope rash(classic lilac colored rash in eyelids, nose bridge & cheek),itching \>periorbital edema \>subcutaneous calcification -5 subtypes or groups: I-primary,idiopathic PM II-primary,idiopathic DM III-DM/PM associated with malignancy or neoplasia IV-DM/PM of childhood associated with vasculitis V-DM/PM associated with other collagen vascular disease(SLE,RA,PSS) Group I:Primary,Idiopathic PM -insidious onset -begin with pelvic girdle weakness later involving shoulder girdle -moderate arthritis,Raynaud's disease,dysphagia and dysphonia may be present -remission and exacerbations common Group II:Primary,Idiopathic DM -acute onset with proximal shoulder and pelvic girdle involvement and an erythematous heliotropic rash on the sin of theeyelids and dorsum of the hands. -muscle tenderness in 25% -subacute joint findings,fever,malaise and weight loss common Group III:DM/PM associated with malignancy -more common in males more than 40 y/o -weakness may precede onset of malignancy by 1-2 years -dysphagia and repiratory muscle weakness common -death usually due to pneumonia or respiratory failure Group IV:DM/PM associated with vasculitis -disease of childhood -characterized by rapid and progressive muscle weakness and frequent dysphagia,dysphonia and respiratory weakness -severe joint contractures develop easily -have cutaneous and muscle calcification over bony prominences Bohan criteria for diagnosis of PM/DM: 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 weak ness -Joint LOM if with subcutaneous calcinosis(more common in children) Most common sites of pain in polymyositis:buttock,thighs,calves,lower back Factors that influence prognosis: :adults fair better than children :higher mortality rate if with associated carcinoma :severe affectation at onset---poorer prognosis :late treatment---poorer outcome :Group I and II can recover completely or have residual muscle weakness and fatgue that responds to rehab. :Group III poor prognosis Efficacy of treatment and course of the disease monitored through measurement of muscle strength and serial serum enzyme measurement. SYSTEMIC LUPUS ERYTHEMATOSUS(SLE) -systemic,immune mediated disorder -present with a mild but painful synovitis that weakens tendons and capsule -result in hand deformities similar to RA but without bony erosion called Jacoud's arthritis or non-erosive deforming arthritis. -2^nd^ form of joint disease seen in SLE:avascular necrosis frequently in knees,hips,shoulders -pain relief in avascular necrosis mainly by reducing weightbearing -patellar and Achilles tendon ruptures may occur -systemic manifestations include:wolf-like skin rash :renal failure :central & peripheral nervous system abnormalities :hematologic problems :systemic cutaneous vasculitis :pleurisy Epidemiology: :onset any age but often 15-25 y/o :F\>M(3:1 to 8:1) :blacks,Asians Manifestations: :systemic-fatigue,malaise,fever,anorexia,nausea,weight loss :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),pleral effusions ,lupus pneumonitis ,interstitial fibrosis ,pulmonary HPN, ARDS, haemorrhage :renal-proteinuria nephrotic syndrome ,renal failure :GIT-non-specific GI symptoms ,vasculitis ,abnormal liver enzymes ,ascites :venous and arterial thrombosis : fetal loss :ocular -retinal vasculitis ,conjunctivitis , episcleritis, Sicca syndrome 1982 Criteria for SLE: -malar rash -renal disorder -discoid rash -neurologic disorder -photosensitivity -hematologic disorder -oral ulcers -immunologic disorder -arthritis -antinuclear antibodies \- serositis SJOGREN'S DISEASE Manifestations: ;XEROSTOMIA(dryness of the mouth)-difficulty swallowing dry food ,inability to talk continuously burning sensation ,increase in dental caries, problems with dentures :dry eyes-gritty feeling,(+) Shirmer'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 :is a connective tissue disorder affecting the exocrine glands Diagnostic criteria: Criteria Definitions 1.Ocular symptoms.dry eyes everyday for more than 3 months.recurrent sensation of sand or gravel in the eyes.or, any use of tear substitutes for more than 3 x a day 2.Oral symptoms.daily feeling of dry mouth for more than 3 months.recurrent or persistently swollen salivary glands.or, use of liquids to aid in swallowing dry food 3.Ocular signs.(+) Schirmer's test or a rose Bengal score of \> or = to 4 according to van Bijsterveld's scoring system 4.Histopathology.focus score 1 in a minor salivary gland biopsy 5.Salivary gland.positive result in one of the ff. tests: salivary scintigraphy, parotid sialography, salivary flow(1.5 or less in 15 min.) 6\. Autoantibodies.antibodies to Ro(SS-A) or La(SS-B),anti-nuclear antibodies or RhF Comparison of SLE, Sjogren's and Scleroderma +-----------------+-----------------+-----------------+-----------------+ | | Systemic lupus | Sjogren's | Systemic | | | erythematosus | | sclerosis | +=================+=================+=================+=================+ | Distinctive | Multisystem | Lymphocytic | Sclerotic | | feature | chronic | infiltration of | changes due to | | | inflammatory | salivary and | collagen | | | disease | lacrimal | | | | | glands(exocrine | Endothelial | | | Defects in | glands) | cell damage | | | humoral and | | | | | cellular | | | | | immunity | | | +-----------------+-----------------+-----------------+-----------------+ | Autoantibody | Antinuclear | RF,ANA,anti-SS | ANA | | | antibodies(ANA) | | (90%),anti-Scl | +-----------------+-----------------+-----------------+-----------------+ | Prevalence | 15-50/100,00 | | Less common | | | | | than SLE | +-----------------+-----------------+-----------------+-----------------+ | Sex | Females(3:1 to | Female(9:1) | Female(3:1) | | | 8:1) | | | +-----------------+-----------------+-----------------+-----------------+ | Onset | Childbearing | Begin in | 3^rd^ to 5^th^ | | | years(may occur | childhood but | decade | | | at any age) | mean age 50 y/o | | +-----------------+-----------------+-----------------+-----------------+ +-----------------+-----------------+-----------------+-----------------+ | Predisposing | | | Pregnancy | | factor | | | | | | | | Stone | | | | | masonry,coal | | | | | and gold | | | | | mining.uranium | | | | | exposure | +=================+=================+=================+=================+ | Race | Blacks,Asians | | | +-----------------+-----------------+-----------------+-----------------+ | Etiology | Unknown | Unknown | Unknown | +-----------------+-----------------+-----------------+-----------------+ | Most common | Symmetric | Dry eyes | Skin changes in | | clinical | polyarthralgias | (keratoconjunct | fingers | | presentation | and | ivitis) | | | | polyarthritis | | Raynaud's(95%) | | | affecting small | Dry mouth | | | | joints of | (xerostomia) | Polyarthralgia | | | hands,wrists,kn | | | | | ees | | Skin | | | | | indurated,edema | | | Cutaneous | | tous | | | lesions:butterf | | then sclerotic | | | ly | | and contracted | | | rash,discoid | | | | | lesion | | Initially | | | | | distal limbs | | | Hematologic:lym | | then later | | | phopenia | | affect proximal | | | | | limbs | | | | | | | | | | Myopathy | +-----------------+-----------------+-----------------+-----------------+ | Constitutional | Fever,weight | | | | symptoms | loss,fatigue | | | +-----------------+-----------------+-----------------+-----------------+ | Musculoskeletal | Joint | 10% with | | | findings | pain,synovitis, | lymphocytic | | | | rarely | infiltrates | | | | erosive and | | | | | deforming | | | +-----------------+-----------------+-----------------+-----------------+ | Cardiovascular | Carditis | | CHF | | system | | | | | | Pericarditis(30 | | Arrythmias | | | -50%) | | | | | | | | | | Valvulitis | | | | | | | | | | Secondary heart | | | | | disease(CAD,HPN | | | | | ) | | | +-----------------+-----------------+-----------------+-----------------+ | Blood vessels | Vasculitis | vasculitis | | +-----------------+-----------------+-----------------+-----------------+ | Hematologic | Lymphopenia | | | | | | | | | | Anemia | | | +-----------------+-----------------+-----------------+-----------------+ | Pulmonary | Pleurisy | Dryness---trach | Diffuse | | manifestation | | eobronchitis | interstitial | | | Pleural | or pneumonia | pneumonia | | | effusion | | | | | | Dessication of | Pulmonary HPN | | | Diaphragmatic | nose,mouth,trac | | | | dysfunction | heobronchial | Aspiration | | | | tree | pneumonia | | | Pulmonary HPN | | | | | | Pleurisy,pleura | Pulmonary | | | Diffuse | l | neoplasm | | | interstitial | effusion | | | | disease | | | | | | Diffuse | | | | Acute lupus | interstitial | | | | pneumonitis | disease | | | | | | | | | Massive | Lymphocytic | | | | pulmonary | interstitial | | | | haemorrhage | pneumonia | | +-----------------+-----------------+-----------------+-----------------+ | Brain | Neuropsychiatri | | | | | c | | | | | symptomps(70%) | | | +-----------------+-----------------+-----------------+-----------------+ | Kidneys | Lupus nephritis | 10% with | Obliterative | | | | lymphocytic | vasculopathy | | | | infiltrates | | | | | | Renal failure | +-----------------+-----------------+-----------------+-----------------+ | Liver | Usually normal | Biliary | Cirrhosis rare | | | | cirrhosis or | | | | | sclerosing | | | | | cholangitis | | +-----------------+-----------------+-----------------+-----------------+ | Gastrointestina | | | Esophageal | | l | | | dysmotility | | tract | | | | | | | | Hiatal hernia | | | | | | | | | | Peptic | | | | | esophagitis | | | | | | | | | | Mucosal atrophy | +-----------------+-----------------+-----------------+-----------------+ | Lymph node and | Enlarged | 10% with | | | spleen | | lymphocytic | | | | | infiltrates | | +-----------------+-----------------+-----------------+-----------------+ | Treatment | No cure | No cure | No cure | | | | | | | | NSAIDs if mild | Symptomatic | supportive | | | | treatment | | | | Antimalarials | | | | | for cutaneous | Moisture | | | | and arthritic | replacement | | | | manifestations | | | | | | | | | | Glucocorticoids | | | | | for life | | | | | threatening | | | | | complications | | | | | and severe | | | | | disabling | | | | | disease | | | +-----------------+-----------------+-----------------+-----------------+ | Course | Usually one or | | Variable but | | | few organ sites | | relentless | | | followed by | | | | | chronic | | | | | remissions and | | | | | relapses with | | | | | new sites | | | | | | | | | | Progressive | | | +-----------------+-----------------+-----------------+-----------------+ | Prognosis | More severe in | Better | Only skin | | | younger | prognosis | involvement---s | | | patients | unless | lower | | | | carcinoma | progression | | | CNS,renal | develops | | | | involvement | | (+) visceral | | | more in young | | disease---worst | | | | | prognosis | | | Cerebritis,neph | | | | | ritis | | Poore prognosis | | | worst prognosis | | for white | | | | | males,black | | | Leading cause | | females and | | | of death:renal | | onset\>45 years | | | failure and | | old | | | infection | | | | | | | Death due to | | | 10 year | | renal,cardiac,o | | | survival | | r | | | | | respiratory | | | | | complications | +-----------------+-----------------+-----------------+-----------------+ +-----------------------+-----------------------+-----------------------+ | -- -- -- -- | | | | | | | | -- -- -- -- | | | +-----------------------+-----------------------+-----------------------+ CRYSTAL-INDUCED ARTHRITIDES Possible crystal deposits: :monosodium urate crystals (gout) :calcium pyrophosphate dehydrate(pseudogout) :calcium hydroxyapatite :calcium oxalate GOUTY ARTHRITIS- a group of disorder 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% :prevalence of hyperuricemia:2-13% :peak age at onset:40-60 for males; post-menopause for females :benchmark feature: acute monoarticular arthritis :prevalence :1.3-3.7% :prevalence of hyperuricemia:2-13% :multiple joint involvement in first attack;more common in women :occasionally acute attacks occur without hyperuricemia :75% with 2^nd^ attack within 2 years :presumptive diagnosis-acute monoarticular arthritis, hyperuricemia, dramatic response to colchicine. TOPHI aggregates of monosodium urate monohydrate crystals surrounded by giant cell :form in extraarticular and articular structures and cause deformity and destruction of hard and soft tissue :in joint, tophi lead to destruction of cartilage and bone ,triggering secondary degeneration Diagnosis: 1.Synovial fluid analysis-definitive diagnosis 2.Presumptive diagnosis-acute monoarticular arthritis ,hyperuricemia, dramatic response to colchicine. Management: 1.Antihyperuricemic and uricosuric agents-most important -essential for patients with Recurrent attacks Chronic gout Tophi Gouty arthritis and nephrolithiasis present 2.NSAID for symptomatic relief Rehabilitation management: 1.advise to patients on NSAID 2.guidelines for intraarticular injection 3.joint protection techniques Acute gouty attack characterized by: -agonizing pain with intense inflammation (swelling,erythema,warmth,exquisite tenderness and occasionally low grade fever) -peak attack 24-48 hours and last 7-10 days if untreated -usually only one joint affected in 1^st^ attack -multiple joint involvement in 2^nd^ attack more common in women -mainly affect peripheral joints of LE -may also affect periarticular sites such as: plantar fascia ,Achilles tendon insertions ,Heberden's nodes or other tenosynovitis -1^st^ MTP involved in over 50% of 1^st^ attacks and in 90% of cases overall -sacroiliac, sternomanubrial and spinal involvement rare -attacks best correlated with rapid decreases in serum urate but may also be triggered by abrupt increases. -other provocative factors:stress :trauma :infection :hospitalization :surgery :starvation :weight reduction :hyperalimentation :excessive food intake :alcohol and medication -75% with 2^nd^ attack within 2 years Chronic gouty arthritis: -shorter intercritical periods -increased frequency of acute attack -period of attack lasts longer -polyarticular -intensity of attack less -persistent polyarticular low-grade pain with acute or subacute inflammation -tophi present on PE -cartilage and bone destruction by x-ray SARCOIDOSIS -chronic multisystemic disorder of unknown cause -characterized by accumulation of T-lymphocytes & mononuclear phagocytes -result in granuloma formation & derangement in normal tissue architecture -affects all body parts especially lungs,skin,eyes,lymph nodes -bone and joint involved in only 5% CHRONIC PAIN Slow vs. Fast pain Fast pain Slow pain Onset Immediate Delayed Foremost purpose protection;associated with poten- associated with tissue Tially harmful stimulus destruction Distribution skin only skin,deep tissue and Not felt in deeper tissues of body organs Nature/description sharp,pricking,acute,electric pain slow burning,aching, Throbbing and chronic Pain Type of peripheral Nerve type A delta fibers type C fibers Conduction velo- City rapid,6-30 m/sec slow,0.5-2 m/sec Termination in Spinal cord lamina I(lamina marginalis) & V lamina II & III(collectively Called substantia gelati Nosa Major termina- Tion of spinal Tract thalamus brainstem reticular area Localization easier or more accurate poorly localized Initiators of pain: 1. Thermal: temperature\>45 degrees C :temperature \postulated that nociceptive transmission cells in the marginal layer of the cord are postsynaptically inhibited by the large diameter primary afferents via gelatinosa cells. \>in contrast, nociceptive afferents exert an opposite effect directly on yhese transmission neurons and have relatively little feedback activity via the gelatinosa cells. Definition of terms: Pharmacologic & Non-pharmacologic pain interventions Pharmacologic Non-pharmacologic -NSAIDs -behaviuor modifiers(relaxation,biofeedback, -Anti-depressants guided visual imagery,music therapy, -Anti-convulsants distraction,hypnosis) -Invasive pain modulators(spinal opiods -pain modulators(TENS,acupuncture) Peripheral nerve stimulators,epidural, -conditioning exercises(stretching,flexibility, & deep brain stimulators) myofascial release,spray & stretch) -Invasive pain relievers(sympathetic nerve Nerve blocks,epidural anesthetics/steroids, Root sleeve & trigger point injections TENS in Chronic Pain :TENS given at rates of 50-100 Hz produces analgesia not reversible by naloxone :3 routes of neuromodulation 1.presynaptic inhibition of spinal cord 2.direct inhibition of abnormally firing sensory nerve 3.restoration of afferent input :recommend use in early part of pain program :better effects seen in neurogenic & musculoskeletal pain compared to psychogenic pain :applied over or near area of pain with dipole parallel to major nerve trunks :optimal placement & intensity determined by trial and error :may adjust amplitude,rate,pulse,width,electrode placement :no single mode known to be advantageous :adverse reactions uncommon :common complaint-skin hypersensitivity :avoid use over carotid sinus,patients with demand-type pacemakers and pregnant patients :pain conditions known to respond to TENS: -RA pain symptomatically mediated pain -oa pain tension headache -myofascial pain acute pos-op pain -dysmenorrhea -visceral pain -phantom limb The 7 Ds of chronic pain: -Duration more than 6 months -Dramatization exaggerated behaviour;emotionally charged description -Diagnostic dilemma extensive history;doctor shopping,diagnostic Results not compatible with clinical Presentation -Drugs dependence or abuse -Depression impaired coping and low-self-esteem -Disuse effect of inactivity -Dysfunction socially withdrawn and unable to work MYOFASCIAL PAIN SYNDROME(MPS) -a syndrome characterized by diffuse aching musculoskeletal pain associated with multiple discrete predictable tender points or trigger points associated with stiffness. -in rheumatology however,the diagnosis is based on the following criteria: :widespread aching of more than 3 months :local tenderness at 12-14 specific sites :skin roll tenderness over the upper scapular region :disturbed sleep with morning fatigue and stiffness -unknown etiology -may be present in any age but is most frequently seen at 20-50 y/o -women frequently affected -affected patients tend to have a typical personality :is a worrier :has many real or perceived responsibilities :has difficulty relating Clinical features: :trigger points-characteristic feature :"jump sign"-refers to the tendency of some patients to move or cry out if minimal pressure is applied to the trigger points. :tender points :palpable muscle bands which may have a ropy consistency :commonly involves the neck muscles specifically the cervical paraspinals and upper trapezius muscle :waxing and waning pain in the neck and posterior shoulder :may have a previous history of trauma such as cervical strain :some patients may have visual disturbances and vague neck pain that cannot be localized associated with autonomic disturbances including nausea,vomiting and fainting. Clinical Criteria Diagnosis:5 major + 1 minor criteria MAJOR criteria: 1.regional pain complaint 2.pain or altered sensation in expected area of reffered pain 3.taut band 4.exquisite spot tenderness(trigger point) at one point along length of tait band 5.some degree of LOM MINOR criteria: 1.reproduction of clinical pain complaint or altered sensation by pressure on tender spot 2.local twitch of taut band with rolling or needle insertion 3.pain relief with stretching or injection of trigger point. CHRONIC FATIGUE SYNDROME(CFS) Definition: 1.both major criteria and at least 6 minor symptoms plus at least 2 minor physical criteria OR 2.both major criteria and at least 8 symptom criteria MAJOR criteria: 1.persistent or relapsing fatigue or easy fatigability that -does not resolve with bed rest -is severe enough to reduce average daily activity by at least 50% 2.satisfactory exclusion of other chronic conditions including pre-existing psychiatric disease MINOR criteria: -mild fever -sore throat -lymph node pain,cervical or axillary -unexplained generalized muscle weakness -muscle discomfort,myalgia -proloned generalized fatigue following exercise -new,generalized headache -migratory non-inflammatory arthralgia -neuropsychological symptoms:photophobia,transient visual scotoma,forgetfulness,excessive irritability,confusion,difficulty thinking,inability to concentrate or depression -sleep disturbance -patient's description of initial onset of symptoms as acute or subacute PHYSICAL findings -low-grade fever -non-exudative pharyngitis -palpable or tender cervical or axillary lymph nodes Suggested new working definition of CFS: 1.fatigue for more than 6 months causing significant impairment of normal activities not resolving with bed rest. 2.neurocognitive and neuropsychiatric symptoms 3.musculoskeletal symptomps-most common meeting the criteria for fibromyalgia. FIBROMYALGIA Epidemiology: -73-88% are females -prevalence:5-8% -usually 34-57 y/o Cardinal features:chronic widespread pain and tender points on examination Characteristic findings: Fatigue irritable bowel syndrome Sleep disturbance Raynaud's like syndrome Stiffness depression Paresthesia anxiety Headaches(tension or migraine) Other findings: Difficulty in localizing the pain;generalized Profound fatigue on waking up and at mid-afternoon Dizziness,difficulty concentrating,dry eyes,dry mouth,palpitations,sensitivity to food,medications and allergens Physical exam: Appears well No obvious systemic or aricular abnormalities Complaints of weakness but MMT is normal Complaints of numbness and tingling but neurological exam is normal Multiple tender points Muscle spasm or taut bands Skin sensitivity in form of skin roll tenderness or dermatographism or purplish mottling of skin when exposed to cold 1990 Criteria for Classification of Fibromyalgia(by the American College of Rheumatology) 1.pain of at least 3 months in upper and lower body,right and left sides and axial skeleton 2.pain in at least 11 out of 18 tender points on digital examination :occiput-suboccipital muscle insertion :low cervical-anterior aspect of intertransverse spaces at C5-7 :trapezius-mid-point of upper border :supraspinatus-origin above the scapular spine near medial border :2^nd^ rib-2^nd^ costochondral junctions just lateral to junctions on upper surfaces :lateral epicondyle-2 cm.distal to epicondyle :gluteal-upper outer quadrants of buttocks in anterior fold of muscle :greater trochanter-posterior to trochanteric prominence :knee-medial fat pad above joint line Fibromyalgia vs.Myofascial Pain Syndrome Fibromyalgia Myofascial Pain Syndrom Examination tender points trigger points Location generalized regionalized Response to local Therapy not sustained curative Gender F\>M(10:1) equal Systemic findings characteristic ? Muscles distant to Tender/trigger points generalized sensitivity normal sensitivity Basic mechanism systemic neurotransmitter neuromuscular condition Dysregulation;many bioche- mechanical causes Mical causes. LOW BACK PAIN & SPINAL PAIN :leading cause of disability :3^rd^ leading cause of disability in individual \25 lbs. -dysrhythmic or racheting lifting -asymmetrical load lifting(ex.one hand lifts or lifting out of the sagittal plane) 4.vibrational trauma-5 Hz frequency 5.lifestyle factors such as smoking,low job satisfaction,educational level,monotonous or repetitious work 6.heavy work-driving 7.sporting activities:most common injury in weight lifters :sport activities highly associated-gymnastics,weight lifting,dancing,football,wrestling,rowing Pain-sensitive structures: :lumbar facet joint joint capsule :ligamentum flavum muscles and tendons :outer 1.3 of annulus fibrosus posterior aspect of disc :anterior longitudinal ligament posterior longitudinal ligament Erector spinae,multifidi On treatment: :prolonged absolute bed rest for more than 3 days not necessary :classical William's flexion exercises decrease compressive load to posterior disc and open intervertebral foramen and may be better tolerated in central disc herniations :acute dural tension aggravated by flexion :contraindications to flexion exercises: -segmental hypermobility of instability -increase in LBP -peripheralization of pain to LE :muscular stabilization of spine :intersegmental muscles(multifidi,rotatores,interspinalis) :abdominal muscles(transversus abdominis and internal oblique) :latissimus dorsi :erector spinae :iliopsoas :quadratus lumborum Manifestations of related back conditions 1.spinal stenosis-pseudocalcification 2.spondylolisthesis-back pain radiating to the posterior aspect of thigh;(+) stiffness 3.spondylosis-back pain that increases with motion,(+) LOM & stiffness Nature of back pain in various arthritic conditions :back pain in OA is nocturnal :in LBP strain syndrome due to soft tissue inflammation pain is usually at the end of the day. :in Reiter's back symptoms are not as common since the arthritic involvement is primarily on the peripheral joints :in RA,it is very common for the lower spine to be affected. REHABILITATION OF PATIENTS WITH SPINAL PAIN Related terms: -disc herniation:focal extension of disc beyond vertebral end plate -disc protrusion:contained by outer annulus fibrosis with an intact posterior longitudinal ligament -disc extrusion:non-contained and through the posterior longitudinal ligament -disc fragment(sequestered):free fragment no longer in contact with parent disc -disc bulge:non-focal or circumferential,symmwtric extension of disc beyond the margin of the vertebral end plate. -radiculopathy:radicular pain in a dermatomal distribution and or neurologic symptoms or signs -radiculitis:radicular pain and or radicular symptoms or signs in absence of an obvious compressive lesion Anatomical and biochemical tidbits on the spine :upper cervical spine refers to occiput(Co) to C2 :no IV discs in upper cervical spine :generally accepted levels of maximal motion for cervical spine Head knodding-CO-C1 Rotation-C1-C2 Lateral bending-C3-C4 Flexion-extension-C5-C6 :rotation and lateral bending least in CO-C!\-\--represents protective mechanism for vertebral artery as it enter cranium :thoracic spine with ribcage stiffest and least mobile part of spine but is vital for erect posture :thoracic segmental motion in sagittal flexion and extension occurs mainly in lower thoracic segments(T7-T12) :thoracic axial rotation occurmainly from T1-T6 or upper thoracic segment :above T9 thoracic spine like cervical spine;below T9 like lumbar spine :generally accepted levels of maximal motion for lumbar spine -lateral flexion in upper lumbar spine -flexion-extension:L4 & L5-S1 segment -limited axial rotation at all levels to protect IV discs :segmental spinal stability dependent on IV disc,joints,ligaments,and muscles :cervical spine highly dependent on ligamentum support for spinal stability -ligaments provide main restraint in upper cervical segment where neurovascular protection is vital -posterior longitudinal ligament well developed at middle to lower cervical spine to reinforce posterior disc margin thus protecting spinal cord. -ligamentum flavum reinforces Z-joint capsule -combination of interspinous,supraspinous and nuchal ligaments provide posterior segmental stability,limiting excessive anterior translation. :zygophyseal joints of cervical spine designed for mobility rather than stability. :uncovertebral joints of cervical spine provide both stability to posterolateral aspects of IV disc and guide motion in F-E plane. :normal cervical lordosis places C5-C6 anterior to and further from COG. :rib cage primarily responsible for stability of thoracic spine :in lumbar spine -segmental stability dependent on muscles,ligaments,IV discs and Z joints -midline ligaments(supraspinatus li.interspinous,posterior longitudinal lig.,ligamentum flavum,Z-joint capsule,anterior longitudinal lig., and iliolumbar lig.)form passive restraint system engaged with forward bending -anterior longitudinal lig. And iliolumbar lig. Maintain lumbar lordosis -lumbar lordosis ideal for axial load bearing with ligaments and Z joints assisting in unloading IV disc -orientation of facets parallel to sagittal plane restricts axial rotation in lumbar spine to 3 degrees -IV disc functions in weight bearing,bending,rotation to maintain lumbar stability -brief axial loads resisted by annulus fibrosis;sustained loads redistributed by nuleus pulposus -standing position,stability mainly maintained by ligaments;at 90% lumbar flexion and 60 % hip flexion,erector spinae and hip extensors significantly contribute to lumbar stability. Effect of lifting/bending on IV disc: :bending and lifting increases intradiscal pressure due to muscular compressive forces---pressure increase proportional to distance of load being lifted from body :forward bending\-\--posterior annulus stretches and nucleus pulposus displaced posteriorly which is at risk position :most disc compromised positions-forward bending,rotation,lifting a load away from the body. Forward head postural dysfunction: Muscular Imbalances Shortened & Weakened Lengthened & Weakened Neck capital extensors capital flexors Cervical extensors Sternocleidomastoids Anterior & middle scalenus Shoulder upper traps middle & lower traps Girdle levator scapulae rhomboids Pectoralis minor latissimus dorsi Subscapularis Thoracic extensors Serratus anterior Anterior deltoid :Specific anatomic abnormalities of forward head postural dysfunction: 1.hyperextension of upper cervical segments resulting in hypomobility 2.hyperflexion of lower cervical and upper thoracic segments resulting in hypomobility 3.slackening of nuchal ligament which allows excessive shear through mid-cervical spine promoting hypermobility 4.decrease in size of IV foramen leading to radiculopathy 5.increase in weight bearing load of joints resulting in synovitis and degenerative arthropathy 6.excessive protraction of scapula contributing to increased thoracic kyphosis and impaired scapular stabilization. 7.myofascial flexibility and strength imbalances. Innervated Structures of Spine 1.lumbar z(zygopophyseal) joints 2.joint capsule which is richly innervated 3.outer annulus of IV disc(but not rest of annulus and nucleus pulposus) 4.anterior and posterior longitudinal ligament 5.erector spinae and multifidi muscles High risk factors for chronic spine pain: 1.occupational:time off work :job dissatisfaction :patient's perception of heavy work :job availability 2.psychological:poor English proficiency :spouse disabled :anger at system :excessive fault finding :litigation or compensation :physician's conviction of extreme high-risk status 3.medical:history of previous injury and/or substance abuse Role of Manual Therapy\-\-\--Mobilization and Manipulation in Spine Pain :standard grades of mobilization ysed for pain control or to generate motion =Grades I and II-oscillation;low velocity forcesapplied repetitively within resistance-free ROM of a joint;used mainly in pain control : =Grades III and IV-stronger forces that move joint into its restricted range and are useful for producing motion. =Grade V-called manipulation-involves small amplitude,high velocity thrust at or just beyond the normal physiologic range of joint without exceeding its anatomic integrity :key to mobilization is to direct energy at a specific level only. :carack or pop that often accompanies manipulation is due to liberation of gas from synovial fluid as a sudden nrgative pressure is generated with detraction of the joint. :results of studies show that spinal mobilization and manipulation may be beneficial but only to small subgroups of back pain patient's. :patient's more likely to benefit from manipulation are: -acute low back pain of \2C without An open wound. :radiographic stages by Eichenholliz: Stage I :stage of development -acute destructive period -have joint effusion,soft tissue edema,subluxation,bone fragmentation,intra-articular fractures,bone and cartilage debris Stage II :stage of coalescence -period of healing with decreasing edema,absorption of debris,healing of fractures Stage III :Stage of reconstruction -further repair and remodelling;increased bone density and sclerosis with improved joint stability. THORACIC OUTLET SYNDROME :thoracic outlet is an anatomic region containing the following structures: 1^st^ rib clavicle Subclavian artery lung apex Brachial plexus :injury to any of the structures may produce "thoracic outlet" :have 3 subtypes 1.true neurogenic TOC-secondary to compression of lower trunk of brachial plexus by an anomalous band connecting C7 and the !st rib;have hand intrinsic muscle weakness and sensory loss in 4rth and 5^th^ digit palmar area. 2.arterial TOC-due to compression of subclavian artewry by a cervical rib manifesting with reduced blood pressure in affected limb and signs of emboli in hand;no neurologic signs 3.disputed TOC-"wastebasket" group for patients with chronic arm and shoulder pain of unclear cause. :most common clinical manifestation:pain around shoulder and supraclavicular region. :Symptoms -shoulder and arm pain,weakness,paresthesia,claudication,Raynaud's phenomenon,ischemic tissue loss and gangrene -tenderness in supraclavicular fossa :can compress subclavian artery,vein, and nerve (brachial plexus) in thoracic outlet :Site of compression Cervical rib Abnormal scalenus anticus muscle Proximity of clavicle to 1^st^ rib Abnormal insertion of pectoralis minor REFLEX SYMPATHETIC DYSTROPHY 1.CAusalgia :RSD condition characterized by post-traumatic pain which is persistent,diffuse and burning occurring in paroxysm and provoked by various stimuli. :associated with peripheral nerve injuries (often seen in median nerve and tibial nerve injuries) :have excruciating burning pain and hyperalgesia :pain usually begins distally :in 1/3 of cases have onset within one week following injury :pain located in area corresponding to cutaneous distribution of the nerve but not necessarily limited to it :pain preci\[itated or accentuated by emotional and environmental stimuli (touching,tapping,noise, dependent position,emotional disturbances) :may have trophic skin changes :rarely subsides spontaneously 2.Sudeck's atrophy :type of RSD associated with traumatic fracture :primarily diagnosed radiographically :have pain,muscle atrophy,LOM,cyanosis and edema secondary to bone atrophy :characteristic X-ray findings-spotty rarefaction or decalcification in involved bones(ground glass appearance) :usually involved distal part of the extremities---hand and foot :occur 6-8 weeks after onset of symptoms :last weeks to months then gradually subsides leaving a hand or foot which is stiff,cold or slightly cyanotic 3.Shoulder Hand Syndrome :an RSD condition often associated with coronary ischemia and CVA :chief feature---painful,disabled shoulder associated with painful disability of the hand and finger sparing the elbow :severity not proportional to extent of underlying disorder :Stages of RSD I. pain,LOM,and diffuse tenderness in the shoulder;pain and tenderness in the hand;swelling and painful flexion in the fingers;spotty osteoporosis on x-ray. II. Pain and early atrophy in the shoulder induration of the skin in the hand;firm induration and shiny trophic skin in the fingers;vasospasm and hyperhidrosis;progressive diffuse osteoporosis on x-ray III. Slight residual pain and LOM in the shoulder;residual deformity and contractures in the hand and fingers;generalized osteoporosis on x-ray ORTHOSTATIC HYPOTENSION-decline of 20 mmhg or more in systolic BP when rising from supine to standing usually accompanied by symptoms of dizziness or lightheadedness. Predisposing factors: 1.prolonged bed rest 2.drug therapy 3.salt restriction 4.autonomic dysfunction:test pupillary response :abnormal sweating :CNS disease :response to Valsalva Medications that can cause hypotension: 1.nitrates 2.levodopa 3.diuretics 4.phenothiazines 5.tricyclic anti-depressants Management: 1.discontinue drug 2.exercise(ankle dorsiflexion) before arising 3.stand slowly while holding on to a support 4.thogh-high elastic stockings or abdominal binder 5.high sodium diet 6.fludrocortisone acetate for plasma expansion 7.other meds.:NSAID :clonidine or midodrine :propranolol :pindolol :phenylpropanolamine Brief discussions: Hurler's syndrome\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--autosomal recessive lysosomal storage disease;classified as a Mucopolysaccharidoses. Have deficiency of enzyme alpha L-iduronidase Ehler-Danlos\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--characterized by hyperelasticity of the skin and hypermobile joints Possible associated problems:mitral valve prolapse,hernia,pes planus,mild to moderate scoliosis. Genetic disorder Marfan's\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--genetic disorder with a deficiency of a glycoprotein that is a major component of elastin-associated microfibrils. Triad:long thin extremities frequently associated with other skeletal changes :reduced vision secondary to dislocation of the lenses :aortic aneurysm (+)cardiovascular changes\-\-\--mitral valve prolapse Associated change:striae in shoulders and buttocks Klippel-Feil\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--congenital fusion of cervical vertebra manifesting with the triad of:low posterior hairline,short neck,and LOM of head and neck. Crouzon's\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--achondroplasia with craniosynostosis syndrome Sprengel's\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--congenital high scapula due to failure to descend;most common congenital anomaly of the shoulder.

GENERAL-MEDICAL-CONDITIONS-1.docx

Related

Transcript

Tags

Upgrade to continue