Rheumatological Conditions Lecture PDF

Rheumatoid arthritis – General Advice • Rest during acute attacks helps recovery • Fatigue - short rest periods during day • Joint protection eg. wrist splints, activity modification, aids for ADLs • Appropriate exercise important to maintain physical function What is the role of physiotherapy? ...

Rheumatoid arthritis – General Advice • Rest during acute attacks helps recovery • Fatigue - short rest periods during day • Joint protection eg. wrist splints, activity modification, aids for ADLs • Appropriate exercise important to maintain physical function What is the role of physiotherapy? Physical training and rheumatoid arthritis • Physical activity increases fitness and muscle strength, and may have some effect on disease activity and pain • No studies have found worsened disease activity as a result of physical training (limited studies in people with severe RA) • Recommend supervised and individually tailored exercise • Cycling, swimming or hydrotherapy Pedersen 2015 Exercise as medicine Physical training and rheumatoid arthritis Possible mechanisms: • Exercise training induces anti-inflammation and suppresses TNF production (which causes cachexia and loss of muscle strength) • Exercise has benefits on other CV disease risk factors Pedersen 2015 Exercise as medicine Physical training and rheumatoid arthritis Contraindications/ Precautions: • Consult with rheumatologist if severe RA • Not advisable if pericarditis or pleurisy • Caution with exercises involving the neck • Caution with high intensity and weight bearing exercise if joint destruction Pedersen 2015 Exercise as medicine Gout Gout – Risk factors • male >female • >30years, peak 40-60 years • Lifestyle factors may increase your risk, including: • Overweight or obese • high cholesterol, • high blood pressure, or • glucose intolerance • kidney disease • taking diuretics Gout – Clinical presentation • Severe pain, rapid onset • Swelling, usually 1st MTP (big toe) • Redness • Tenderness • +/- white nodules “tophi” Gout - Pathophysiology • Defect in uric acid metabolism àmonosodium urate crystals form in the synovial fluid à tissue damage and inflammation What is the role of physiotherapy? Rheumatological conditions of the spine From the Greek language spondylo, means vertebrae Rheumatological conditions of the spine Spondylo= “spine” -itis = “inflammation” Inflammatory Non-inflammatory (also ‘degenerative’) Immune-driven process à pain, stiffness, swelling No systemic immune response à pain, little/no swelling Spondyloarthritis Ankylosing spondylitis (2%) Psoriatic arthritis Reactive arthritis Enteropathic arthritis Spondylosis Spondylolisthesis Non-specific LBP Inflammatory vs mechanical low back pain Spondyloarthritis Ankylosing spondylitis Spondylosis Spondylolisthesis Non-specific LBP Duba et al 2018 Spondyloarthritis (SpA) • ~1% population • Group of chronic inflammatory rheumatic conditions that cause arthritis • Affects the spine & pelvis (axial spondyloarthritis), arms/legs (peripheral arthritis), tendon/ligament insertions (enthesitis) and other extra-articular manifestations Spondyloarthritis (SpA) – Risk factors • Strong genetic risk • 80-95% have positive HLA-B27 allele • But, less than 5% of HLA-b27 positive population develops the disease, hence routine testing for HLA B27 isn’t valuable Spondyloarthritis (SpA) – Clinical presentation • Inflammatory back pain + early morning stiffness >30 mins + night pain • Improvement with movement but not rest, favourable response to NSAIDs • Extra-articular manifestations • psoriasis • Colitis or Crohns’ • uveitis, dry eyes • Dactylitis – swelling of digits • Enthesitis – e.g Achilles insertional pain Spondyloarthritis (SpA) – Clinical screening Ankylosing Spondylitis Ankylos = “bent” spondylo = “vertebrae” itis = “inflammation” • Men > women (2-3x) • Develops in late adolescence and young adulthood (Peak ~20yo) • Affects sacroiliac joints and axial skeleton • +/- peripheral joints and other organs (heart/lung/eyes) Ankylosing Spondylitis - Pathology • Systemic, autoimmune disease • Inflammation of fibrocartilage of SIJ & vertebrae • Inflammatory cells infiltrate jointà damage bone and joint structures • Repair by fibroblasts à forms scar tissue • Becomes calcified over time à joints fuse https://www.msk.org.au/ankylosing-spondylitis/ Ankylosing spondylitis – Clinical presentation • Inflammatory low back and buttock pain • Decreased lumbar lordosis • Increased thoracic kyphosis • Assessment of spinal mobility used to grade severity of AS Ankylosing spondylitis – Clinical presentation – Onset before age 40 – Insidious onset – Persistence for at least 3 months – Morning stiffness – Improvement with exercise • Other features – Worse at night. Does the patient wake and what do they do to relieve their pain? – Responds to NSAIDS Ankylosing spondylitis – Diagnosis • Based on clinical features and X-ray findings Radiological findings of ankylosing spondylitis • Changes in sacroiliac joints • Erosions, fibrosis, fusion • Calcification of outer layer of vertebral disc • Syndesmophytes (bone spurs between adjacent vertebra) • Multi-level spinal fusion • Bone remodelling results in vertebral body becoming square in shape • Bamboo-like appearance https://radiopaedia.org/cases/ankylosingspondylitis-2?lang=us Ankylosing Spondylitis - Management • Aims to reduce pain, improve function and decrease complications • NSAIDs are 1st line therapy • DMARDs or biologics e.g anti TNF therapy • Physical therapy to maintain spinal mobility and strength • Smoking cessation • Treat and monitor for osteoporosis Disease-modifying antirheumatic drugs (DMARDs) • Alter the function of the immune system, slowing progression of inflammatory joint conditions such as RA, ankylosing spondylitis • Goal is to reduce or prevent joint damage and dysfunction • May eliminate/reduce need for NSAIDs, pain relief or corticosteroids • 2 groups • Non-biological e.g Methotrexate • Biological agents – block the effects of TNF Rheumatological conditions of the spine Spondylo= “spine” -itis = “inflammation” Inflammatory Non-inflammatory (also ‘degenerative’) Immune-driven process à pain, stiffness, swelling No systemic immune response à pain, little/no swelling Spondyloarthritis Ankylosing spondylitis (2%) Psoriatic arthritis Reactive arthritis Enteropathic arthritis Spondylosis Spondylolisthesis Non-specific LBP Spondylosis - Pathophysiology • Akin to OA of the spine (age-related wear & tear affecting IV discs) or “degenerative disc disease” • Degeneration of the intervertebral discs of the spine à loss of disc height à narrowing of disc space • Vertebral body endplate surfaces become sclerotic • Facet joints become loaded à osteoarthritis of this synovial joints • Narrowing of spinal foramen à can lead to nerve root impingement losis = “problem” Radiological features of spondylosis • Loss of disc space • Osteophytes • Endplate irregularity and sclerosis https://radiopaedia.org/cases/cervical-dege spondylosis?lang=us Spondylolysis - Pathophysiology • Defect of pars interarticularis (part of the neural arch that connects superior and inferior articular facts) “pars defect” • Oblique x-ray may show Scotty Dog sign – break in pars interarticularis • Can be unilateral or bilateral • Commonly asymptomatic • Can be developmental or acquired e.g. repeated microtrauma e.g cricket bowlers lysis= “to loosen” Radiological findings of spondylolysis www.thenursedoctor https://radiopaedia.org/cases/spondylolysis-1?lang=us Spondylolisthesis - Pathophysiology listhesis = “slip, slide or movement” • Spondylolisthesis is a consequence of spondylolysis • The instability caused by the crack in the pars interarticularis allows the affected vertebra to shift position • One vertebra slips forward relative to the vertebra beneath it Radiological findings of spondylolisthesis • <50% slippage= low-grade spondylolisthesis • >50% slippage = high-grade spondylolisthesis https://radiopaedia.org/cases/spondylolist hesis-grade-iii-1?lang=us Spondylolisthesis – Clinical presentation • Occurs in about 4-6% of adults • Not all cases cause symptoms • Symptoms may include: • low back pain ± leg pain • muscle spasm (hamstrings) • pain with bending • numbness/weakness (if nerve root impingement) Management of non-inflammatory back pain • Non-surgical treatments include • Rest (short periods only) • NSAIDS • Physical therapy – exercises for spinal stability and pain relief • Brace • Surgery may be needed to relieve nerve pain or stabilise spine in high grade spondylolisthesis Rheumatology and arthritis summary • Individuals with inflammatory arthritis who are referred to a rheumatologist early (within 3 mths of start of symptoms) and who are managed with appropriate medications have better outcomes • Physiotherapists can help distinguish inflammatory and noninflammatory conditions QUESTIONS???