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Arthritis

QuestionAnswer
Genu valgum Deformity in which the lower extremities curve inward with knees close together: knock knees.
Genu varum Deformity marked by medial angulation of the leg in relation to the thigh, an outward bowing of the legs, giving the appearance of a bow.
Calcaneal valgus Condition where the foot surface which is in the contact with the floor is more than the normal feet.
Pes planus A flattening of the longitudinal arch of the foot
Cock-up (claw) toes Deformity with hyperextension of the metatarsophalangeal joint and flexion of the proximal and distal interphalangeal joints.
Hammer toe Deformity with hyperextension of the metatarsophalangeal joint, flexion of the proximal interphalangeal, and hyperextension of the distal interphalangeal joints.
Bunion Hallux valgus with a painful bursitis over the medial aspect of the first metatarsophalangeal joint.
Hallux valgus Valgus deformity at the first metatarsophalangeal joint of the great toe.
Splayfoot Transverse spreading of the forefoot.
Protrusio acetabuli Condition in which the head of the femur pushes the acetabulum into the pelvic cavity.
Swan Neck deformity Finger deformity involving hyperextension of the proximal interphalangeal joint and flexion of the distal interphalangeal joint.
Mutilans Deformity (opera-glass hand) Severe bony destruction and resorption in a synovial joint; telescopic shortening in the fingers.
Mallet finger deformity Deformity involving only flexion of the distal interphalangeal joint; secondary to disruption of the insertion of the extensor tendon into the base of the distal phalanx.
Heberden’s nodes Bony enlargement of the distal interphalangeal joint; characteristic of osteoarthritis.
Bouchard’s nodes Osteophyte formation around the proximal interphalangeal joint.
Boutonniere deformity Contracture of hand musculature marked by proximal interphalangeal joint flexion and distal interphalangeal joint extension.
Zigzag effect Ulnar drift at the metacarpophalangeal joints associated with radial deviation of the wrist.
Volar subluxation of the wrist Dislocation of the wrist.
Bursitis Inflammation of a bursa that can be due to frictional forces, trauma, or rheumatoid disease.
Metatarsal heads The expanded distal end of a metatarsal bone that articulates with the proximal phalanx of the same digit.
Corn (on toe) Also referred to as clavi, are painful, hyperkeratotic papules of the skin that develop in response to excess pressure on the bony prominences of the feet and toes.
Metatarsalgia Pain over the metatarsal head on the plantar aspect of the foot.
Subluxation Incomplete or partial dislocation.
Carpometacarpal (CMC) Five joints in the wrist that articulates the distal row of carpal bones and the proximal bases of the five metacarpal bones.
Osteophytes Bone growths at joint margins.
Tenosynovitis Inflammation of the tendon and tendon sheath.
Odontoid process(dens) Vertical projection that lies just posterior to the anterior arch of C1, has ligamentous attachments to the skull base, and articulates with C1 (atlas).
link between rheumatoid factors (RF) and RA They are found in the sera of approx 70% of patients with RA. RF are antibodies specific to IgG. Arise as antibodies to altered autologus (the patient’s own) IgG. Changes in IgG renders it an autoimmunogens, stim the production of RF.
triggers or causative factors for RA d) perhaps viral e) genetics f) other factors include geographic, occupational, psychosocial, nutritional, and metabolic
triggers or causative factors for RA a)aberrant functioning of cell mediated immunity and defective T lymphocytes may trigger the autoimmune response of RA b)rheumatoid factors (RF) c)perhaps bacterial organisms
Why RA is considered an autoimmune disorder Based on the fact that individuals with RA produce antibodies to their own immuoglobulins.
epidemiology of RA a)0.3-1.5% of poplation b)women 2 to 3 times more than men at all ages c)increases with age-can occur at any age d)white American more than black
rheumatoid arthritis (RA) A systemic disease characterized by bilateral, symmetrical pattern of joint involvement and chronic, inflammation of the synovium.
osteoarthritis (OA) Also known as degenerative joint disease (DJD), the most common rheumatic disease, characterized by the progressive loss of articular cartilage and the formation of bone at the joint margin.
epidemiology of RA a) 10 cases per 1000 people or 2.1 million people 0.3-1.5% b) women 2 to 3 or 4 times more than men at all ages c) increases with age-can occur at any age d) white American more than black, native American more
Flatfoot (pes planus) abnormal flatness of the sole and arch of the foot.
Tendon Rupture the tearing of a tendon. Can cause mallet finger (slide 25)
Metatarsals the bones in the foot that articulate with the tarsals and the phalanges.
Radioulnar the joints formed by either the distal or proximal ends of the radius and the ulna.
Radiocarpal the joint formed by the distal end of the radius and the proximal end of the scaphoid (carpal bone).
Carpals eight bones located at the wrist wedged together between the distal radius and ulna and the metacarpals.
Interphalangeal the joint in between two phalangeal bones (DIP or PIP)
Metacarpophalangeal the joint formed by the proximal end of the phalange and the distal end of the metacarpal.
Volar (palmar) relating to the palm of the hand or sole of the foot.
Acromioclavicular joint formed by the lateral end of the clavicle and the acromion of the scapula.
Sternoclavicular joint formed by the medial end of the clavicle and the sternum.
Glenohumeral joint formed where the humerus articulates with the glenoid fossa of the scapula.
Costovertebral joint formed by the posterior ends of the ribs and the thoracic vertebrae.
Spinal Facet small smooth area on a vertebrae where the vertebrae articulate with one another.
Sacroiliac the immovable joint formed by the lateral surfaces of the sacrum and ilium.
Atlantoaxial the joint between C1-C2 (atlas and axis, respectively)
Bow-stringing of the Flexor Tendons of the Fingers with Zigzag Deformity results from moving the fulcrum of the flexor tendons distally which places an ulnar and volar pull on the proximal phalanges.
link between rheumatoid factors (RF) and RA RA occurs in the absence of RF but the presence of RF shows an increased frequency of subcutaneous nodules, vasculitis, and polyarticular involvement.
pathology of the RA joint and surrounding tissue early events-micovascular injury (causes less O2/nutrients to tissue=tissue death), edema of subsynovial tissues, mild synovial lining cell proliferation, and phagocytosis is prominent, obliteration of small blood cells
pathology of the RA joint and surrounding tissue established RA-synovium is grossly edematous and protrudes into joint cavity with slender villous/hair-like projections into the joint cavity, hyperplasia and hypertrophy of the synovial lining cells (normal 1-3 cells with RA 6-10 cells)
pathology of the RA joint and surrounding tissue PANNUS-(most prominent destructive element in RA) can eat away at cartilage and bone. Dissolves collagen as it extends over the cartilage joint. Eventually results in adhesions, fibrosis, and bony ankylosis of the joint.
established RA vascular-venous distension, cap obstruction, areas of thrombosis and hemorrhage
established RA fibrous or joint ankylosis (stiffness or fusion of a joint)
established RA joint capsule weakening-involves ligamentous structures, alters joint structure and function, tendon rupture and fraying will produces deformities
pathogenesis (development / progression) of RA during periods of inflammation and are not easily cleared. Because the cartilage is avascular, antigen-antibody complexes may be sequestered within the joint cavity and may facilitate a process of phagocytosis and further development of pannus
determine whether an exact mechanism of synovium destruction has been found In established synovitis, polymorphonuclear (PMN) leukocytes are chemotactically drawn into the joint cavity and contribute to the inflammatory destruction of the synovium, although the exact mechanism of this destruction is unknown
seven criterion for classifying RA 1. Morning stiffness 2. Arthritis of three or more join areas 3. Arthritis of hand joints 4. Symmetric arthritis 5. Rheumatoid nodules 6. Serum rheumatoid factor 7. Radiographic changes
systemic manifestations of RA Difficulty in moving upon awakening and generalized stiffness despite morning activity help to differentiate this s sign from the stiffness of a particular join seen in osteoarthritis following inactivity.
systemic manifestations of RA Morning stiffness lasting more than 60 minutes us a hallmark symptom of R.A.
cardinal signs of inflammation pain, redness, swelling, and heat
Joint Involvement-Neck (RA symptoms)  Atlanto-axial and midcervical region • may lead to subluxation at C1-2  cord compression  neurologic manifestations  vertebral artery insufficiency • decreased ROM • headaches
Joint Involvement-Shoulder (RA symptoms)  common in late part of dz process  glenohumeral involvement may cause joint capsule rupture and subluxation  LOM  pain  tendinitis & bursitis
Joint Involvement-Elbow (RA symptoms)  common early signs of RA  flexion contractures and swelling  erosion and loss of joint space can lead to dislocation  pain  LOM
Joint Involvement-Wrist (RA symptoms)  early sign of RA is a painless swelling at ulnar styloid area  limitation of wrist extension  radial deviation  volar subluxation (of wrist on radius)  compression of median nerve (carpal tunnel syndrome)
MCP joints (RA symptoms) • soft tissue swelling is common • ulnar drift  zig-zag deformity  bowstringing of flexor tendons • decreased grip/pinch grip
PIP and DIP Joint (RA symptoms) • Swan neck deformity (also w/ OA)  Due to synovitis, tendon rupture, capsule stretching… • Boutonniere deformity  Due to synovitis, tendon rupture, capsule stretching • Bouchard’s nodes  bony formations at PIP joint (osteophyte)
PIP and DIP Joint (RA symptoms) • Heberden’s nodes  Bony formations at DIP joint (osteophyte)  May also be seen in OA  uncommon in RA but does occur • Mallet finger (DIP) (also w/ OA) • Volar subluxation of phalanges
Thumb (RA symptoms) • various combinations of joint deformities  Loss of ability to oppose thumb  Z-deformity • Mutilans Deformity  opera glass hand  Bone resorption, shortening, erosion
Joint Involvement-Hip (RA symptoms)  Patients in early stages present with groin pain  May progress with destruction of the femoral head and acetabulum • loss of joint space • protrusio acetabuli • severe pain, difficult ambulation  Also seen w/ OA
Joint Involvement-Knee (RA symptoms)  synovial effusion common • destruction of joint surfaces • Baker’s cyst  fixed flexion deformity is common  genu valgum / genu varum deformities also common • Also commonly seen w/ OA
Joint Involvement-Ankles/Feet (RA symptoms)  Deformities which may occur: • hind-foot pronation • flat feet • bony spurs • splayfoot • hallux valgus • hammer toes • claw toes • Dropped (subluxed) metatarsal heads  callous formation
activities of daily living (ADL) that are affected by RA -self-care (dressing, feeding, bathing, grooming and toileting) -avocational (recreational/leisure) -vocational (work, school, homemaking)
why the knee joint is most frequently affected by RA because of the large amount of synovium
why patients may consciously maintain a flexed position of the knee to avoid the pain
identify the consequences of maintaining a flexed knee position (consider ADLs). This can cause flexion contractures, causing functional and community mobility problems.
normal synovial fluid transparent, yellowish, viscous and without clots, acts as a lubricant for the joint.
inflamed synovial fluid cloudy, less viscous, and with clot, causes a loss of space in the synovial cavity.
Gout chronic disorder of uric acid metabolism. It forms hard nodules and kidney impairment.
impairments and secondary complications of RA Deconditioning, Rheumatoid nodules, Vascular complication, Neurologia manifestation, Cardiopulmonary complications and ocular manifestations.
Stage I, Early RA 1. No destructive changes on radiographic examination. 2. Radiographic evidence of osteoporosis may be present.
Stage II, Moderate RA 1. Radiographic evidence of osteoporosis, with or without slight subchondral bone destruction; slight cartilage destruction may be present. 2. No joint deformities, although limitation of joint mobility may be present.
Stage II, Moderate RA 3. Extensive muscle atrophy. 4. Extra-articular soft tissue lesions, such as nodules and tenosynovitis may be present.
Stage III, Severe RA 1. Radiographic evidence of cartilage and bone destruction, in addition to osteoporosis. 2. Joint deformity, such as subluxation, ulnar deviation, or hyperextension, without fibrous or bony ankylosis.
Stage III, Severe RA 3. Extensive muscle atrophy. 4. Extra-articular soft tissue lesions, such as nodules and tenosynovitis may be present.
Stage IV, Terminal RA 1. Fibrous or bony ankylosis. 2. Criteria of stage III.
Class I Ra Completely able to perform usual activities of daily living (self-care, vocational, and avocational)
Class IV RA Limited in ability to perform usual self-care, vocational, and avocational activities.
two pathological features of OA 1. the progressive destruction of articular cartilage 2. the formation of bone at the margins of the joint
Kellgren and Lawrence ordinal scale as a reference Grade 2 grade 2- (definite osteophytes and absent or questionable narrowing of the joint space) More pain and morning stiffness. Deep aching joint pain that gets worse after exercising. Have joint pain in rainy weather. Joint swelling with LOM.
Kellgren and Lawrence ordinal scale as a reference Grade 4 grade 4- (large osteophytes, marked narrowing of joint space, severe sclerosis, and definite deformity.) An increase in symptoms. Crepitus, muscle tenderness and tenderness has also increased. Difficult doing ADL, gait etc..
epidemiology of OA is an extremely common condition after 40 years of age, and not always symptomatic when present. It is widespread for adults older than 65. It affects men more than women before the age of 50, but reverses after age 50.
etiology of OA No single factor that predisposes an individual to OA has been identified. Aging is strongly associated with OA.
etiology of OA Trauma prior to adulthood may initiate a remodeling of bone that alters joint mechanics and nutrition in a way that becomes problematic only later in life.
etiology of OA Repetitive “microtrauma”, repetitive knee bending, and obesity has been shown to be a risk factor in the etiology of OA has received attention.
Primary OA diagnosed when the cause is idiopathic
Secondary OA diagnosed when etiology can be identified from an injury, congenital malformation
Treatment of RA NSAIDs have both analgesic (at lower doses) and anti-inflammatory actions (at higher doses).
Treatment of RA DMARDs are used to improve function, reduce inflammation, and prevent structural damage.
Treatment of RA Corticosteroids – most powerful anti-inflammatory drugs available. Since they are too strong, if necessary, they are provided in small doses and patient must be monitored very carefully
Treatment of OA Analgesics- acetaminophen is usually drug of first choice to relieve pain but has no anti-inflammatory effects (as needed for pain).
Treatment of OA NSAIDs- used on those who do not respond to acetaminophen and non-pharmacological measures. May be used in conjunction with acetaminophen
Treatment of OA Corticosteroids – intra-articular corticosteroids injections – for acute episodes with an expected modest response
Hydrolic acid (HA) This contributes to the thickness and viscosity of joint fluid in a healthy knee. In OA, HA levels are lower… which means joint fluid is thinner and less dense (less lubrication)
Counterirritants such as capsaicin reduce pain by the reduction of the neurotransmitter substance P in peripheral nerves. (alkaloid derived from red chili peppers) Reduces pain!!!
Analgesic Acetaminophen, NSAIDs Traditional, and COX-inhibitors.
corticosteroid longterm use consequences osteoporosis, muscle wasting, adrenal suppression, increased susceptibility to infections, impaired wound healing, cataracts, glaucoma, hyperlipidemia, and aseptic bone necrosis
Methotrexate is a common DMARD Common brand name Rheumatrex
Synovectomy surgical procedure to remove the synovial lining of joints or tendon sheaths
Soft tissue release proceedure to correct hallux valgus
Tendon transfers a type of hand surgery that is performed in order to improve lost hand function. A functioning tendon is shifted from its original attachment to a new one to restore the action that has been lost.
Osteotomy surgical cutting of a bone
Prosthetic arthroplasty any surgical reconstruction of a joint; may or may not involve prosthetic replacement
Arthrodesis surgical procedure designed to produce fusion of a joint
Total Joint Arthroplasty (TJA) surgeries of the hip or knee. The primary goals following TJA are to restore function, decrease pain, and gain muscle control to enable the individual to return to previous or improved levels of functioning.
therapeutic exercise Therapists may apply neurophysiological principles of therapeutic exercise to lengthen shortened muscles. Avoid complete bed rest.
gait training with/without assistive device Therapists should address the underlying joint and muscle impairments that contribute to the patient’s deviations in the gait training program.
sensory testing Any indication of peripheral neuropathy or nerve involvement should be investigated using standard examination procedures.
environmental barriers The therapist should be aware of physical barriers in the home and at work that might require specific examinations and recommendations for change.
modalities (physical agents) the purpose is to manage pain and facilitate more comfortable exercise and physical activity
splints / braces Splints may be used to immobilize specific joints and help reduce pain and swelling by providing local rest and support.
posture training patients should be taught proper positioning when resting
health behaviors As in chronic illness, education should include information needed to deal with the condition, self-management skills necessary to carry out important social and vocational roles.