Arthritis and Rheumatological Conditions Lecture PDF

Arthritis and rheumatological conditions Dr Brooke Coombes Acknowledgement of Ramona Clarke Meet our guest Learning outcome At the end of this lecture, you should be able to 1. Describe the pathophysiology and presentation of arthritis and other rheumatological conditions 2. Compare and contras...

Arthritis and rheumatological conditions Dr Brooke Coombes Acknowledgement of Ramona Clarke Meet our guest Learning outcome At the end of this lecture, you should be able to 1. Describe the pathophysiology and presentation of arthritis and other rheumatological conditions 2. Compare and contrast inflammatory and non-inflammatory arthritis 3. Describe the medical and physiotherapy management of patients with rheumatological conditions What is rheumatology? • Study of arthritis, other musculoskeletal conditions and other autoimmune diseases • Physiotherapists typically see conditions affecting the musculoskeletal system which have a major impact on the individual’s function • Autoimmune conditions may also affect the rest of the body • E.g eyes, skin, internal organs and nervous system Arthro- = “joint” -itis = “inflammation” Arthritis • 100+ types of arthritis are broadly categorized into two types: Inflammatory Non-inflammatory (also ‘degenerative’) Immune-driven process à pain, stiffness, swelling No systemic immune response à pain, little/no swelling Rheumatoid arthritis (11.5%, ~2% pop) Osteoarthritis (58.5%, 4% pop) Gout (~5%, 0.8% pop) Ankylosing Spondylitis (~1%, 0.2% pop) https://www.aihw.gov.au/reports/chronic- musculoskeletal-conditions/arthritis-snapshot/ contents/impact-of-arthritis Osteoarthritis (OA) Osteoarthritis –Risk factors • Age biggest risk factor (typically in over 50-60 year olds) • ↑ Females > Males (>postmenopausal) • Obesity – associated with knee OA • Joint malalignment and trauma • Genetics – especially nodal OA (typically hands) Osteoarthritis - Clinical presentation • Typical onset in 50’s or 60’s (articular changes may have occurred for 10-20 years prior) • Pain (difficult to localise, tenderness on palpation) • Stiffness, Swelling*, ↓ ROM • +/- crepitus • Muscle wasting • Aggravated by WB/activity, eased by rest • In severe OA à pain not eased by rest • +/-numbness/tingling/prickling Osteoarthritis – Clinical presentation Joints commonly affected are: • Hips • Knees Sinusas et al (2012) • C-spine and Lumbosacral spine • 1st MTP (base of big toe) • Hands – DIPs, PIPs and 1st MCP (base of thumb) © Healthwise, Inc Osteoarthritis - Pathophysiology Primary features • Loss of articular cartilage • Hypertrophy of bone at the margins (osteophytes) • Subchondral sclerosis Secondary features • Synovial inflammation may occur • not a defining feature and inflammatory markers may not be elevated www.boneandspine.com Chp 21, p542 Radiological features of osteoarthritis • Loss of joint space • Osteophytes at margins (bone outgrowth) • Subchondral sclerosis (increased bone density) • Deformity • +/- subcortical cysts (geodes) • Erosions are not a feature of OA https://www.msk.org.au/osteoarthritis/ Grading of radiological features– Kellgren-Lawrence Grading Scale Grade Description 0 No radiographic features of osteoarthritis 1 Possible joint space narrowing and osteophyte formation Mild 2 MildMod 3 Mod 4 Severe Definite osteophyte formation with possible joint space narrowing Multiple osteophytes, definite joint space narrowing, sclerosis and possible bony deformity Large osteophytes, marked joint space narrowing, severe sclerosis and definite bony www.ncbi.nlm.nih.gov/pmc/articles/pmc2703468 deformation Management of osteoarthritis - Guidelines 1. Comprehensive assessment 5. Medicines used to manage symptoms 2. Diagnosis 6. Patient review 3. Education and management 7. Surgery 4. Weight loss and exercise Osteoarthritis of the Knee Clinical Care Standard (2017) Surgery – Joint replacement • 100 patients with moderate to severe knee osteoarthritis • RCT compared TKR (+12 wks non-surgical treatment) vs 12 wks nonsurgical treatment • TKR had greater pain relief & improvement in function KOOS (Knee osteoarthritis outcome score) but higher number of serious adverse events • Both groups had substantial improvement and only 26% of patients assigned to receive nonsurgical treatment alone underwent TKR in the following year Skou (2015) New England J of Medicine Surgery – Joint replacement Skou (2015) New England J of Medicine Surgery – Joint replacement Ackerman et al. BMC Musculoskeletal Disorders (2019) Education and exercises GLAD Good Life with Osetoarthritis Gladaustralia.com.au What is the role of physiotherapy? What is the role of physiotherapy? Rheumatoid arthritis (RA) Rheumatoid arthritis – Clinical presentation • Predominately starts in the joints • Joint signs and symptoms • Pain and stiffness especially in mornings • Heat, swelling, occasional redness over joints • Loss of function • Systemic symptoms also common • Fatigue, weakness, loss of appetite, fever • Reduced muscle strength is partially due to muscle inflammation • Decreased fitness Rheumatoid arthritis – Clinical Presentation • Polyarthritis - small & large joints in a symmetrical distribution – Most common joints: wrists, MCP, PIP, MTP – Large joints typically follow later but not always – Can also involve C-spine, TMJ • Extra-articular features – Skin, eyes, nerves, lungs, heart, malignancy – Nodules under skin Rheumatoid arthritis –Risk factors Cause of RA is unclear despite extensive research • Females > Males • Affects people of all ages but ↑ women of child-bearing age • 2/3 people aged 20-60 years • Genetics (~30% responsible) • Environmental • Smoking, infection (viral/bacterial) • Indigenous people (2x more likely) Rheumatoid arthritis - Pathophysiology • • • • Autoimmune, systemic inflammatory disease Inflammation begins in the synovium Immune system mistakes the synovium for a pathogen Cells of the synovial tissue proliferate (multiply) causing normally smooth synovium to form a rough, grainy tissue (pannus) • Synovial and other cells produce chemicals including cytokines that can destroy all the components of the joint • Pannus grows into the joint cavity and erodes cartilage, bone and tendon à deformity • Scar tissue forms à joint thickening and stiffness Rheumatoid arthritis - Pathophysiology • Inflammation not just localized to joints but also in the bloodstream • People with RA are at increased risk of • Heart disease, pericarditis (inflammation of heart lining) • Skin, eyes • Lungs (fibrosis) • Blood vessels • Carpal tunnel syndrome (compression of nerve at wrist) • 50-60% higher mortality rate due to CV disease • If not treated - reduced life expectancy by 5-7 years & 50% not working within 10 years Hand deformities in RA • Ulnar deviation of fingers • Swan neck – flexion DIP and hyperext of PIP • Boutonniere – flexion PIP, ext DIP • Z-deformity of the thumb Radiological findings of rheumatoid arthritis • Bone erosions at margins (bare areas e.g. MCP) • Soft tissue swelling (joint oedema + tenosynovitis) • Osteopenia • Joint space narrowing • Deformity https://radiopaedia.org/cases/rheumatoid-arthritis-24?lang=gb Rheumatoid arthritis - Diagnosis • No particular blood test, x-ray or biopsy to confirm the diagnosis • Rheumatoid Factor blood test positive in 70% patients & needs interpretation by doctor • Anti-CCP antibody (ACPA) blood test also performed (helpful when positive) • Check blood levels of inflammation (ESR/CRP) • Early manifestations are non-osseous in nature (MRI or ultrasound more sensitive early to look for erosions, synovitis and tenosynovitis) Diagnostic criteria for RA The American College of Rheumatology 1. morning stiffness lasting more than 1 hour 2. arthritis of three or more joint areas 3. arthritis of the hand joints 4. symmetric arthritis 5. rheumatoid nodules over extensor surfaces or bony prominences 6. serum rheumatoid factor 7. x-ray changes (hand and wrist) Aletaha et al. (2010) Rheumatoid arthritis - Course of disease • Usually starts insidiously (>75%) but can be episodic or acute (10-25%) • Polycyclic pattern (80%) - intermittent or continuing activity unless give specific treatment • Monocyclic pattern (10%) – single cycle of activity then a remission for >12 months • Progressive (10%) – increasing joint involvement with time What can precipitate a flare-up? • Most times don’t find a particular cause but part of the natural variability • Infections anywhere & of any severity – flu, colds, urinary infections • Stress • Missing medications or withdrawal of medications Rheumatoid arthritis – Management Principles • Multi-dimensional approach • Careful assessment & monitoring • Education - being knowledgeable about RA & its treatment helps considerably • Physical & occupational therapy • Drug treatment • Surgical intervention (sometimes)