ARTHRITIS AND ITS RELATED CONNECTIVE TISSUE DISEASES

SEROPOSITIVE ARTHROPATHIES
Rheumatoid Arthritis
I. Definition
A chronic, inflammatory, systemic disease that produces its most common and
most prominent manifestations in the diarthrodial oints.
II. Epidemiolo!y
A!e Predilection" #$%&$ years old 'maority is (et)een *+%,$ y.o.-
Se. Predilection" /01 '*"2- 'after &+ y.o., there is e3ual distri(ution-
III. Etiolo!y
4n5no)n
6elie7ed to (e autoimmune (ecause indi7iduals )ith RA produces
anti(odies to their o)n immuno!lo(ulin.
Rheumatoid /actor 'R/- auto anti(odies )ith specificity for the /8
fra!ment of I!9 are found in :$; of RA pts.
IV. Pathophysiolo!y
Syno7ial inflammation 7enous distention, capillary o(struction,
neutrophilic infiltration of arterial )alls, areas of throm(osis and
hemorrha!e
As a conse3uence of inflammation, the syno7ium (ecomes hyper%
trophic from proliferation of (lood 7essels and syno7ial fi(ro(lasts
and from multiplication and enlar!ement of syno7ial linin! layers
These leads to formation of !ranulation tissue called PA<<4S
Pannus
% e.tends to the articular cartila!e as it dissol7es the colla!en
% acti7ely in7ades and destroys the periarticular (one and the
cartila!e at the mar!in (et)een syno7ium and (one
% )ill e7entually result in adhesions and fi(rous or (ony an5y%
losis of the oint
% the destructi7e element of RA
% responsi(le for most of the deformities in RA
% the hallmar5 of RA
V. 8linical 1anifestation
Extra-Articular
2. Rheumatoid <odules
% most common e.tra articular manifestation
% all are R/ positi7e
% common in e.tensor surfaces of /A, olecranon, Achilles tendon,
ischial area, o7er 1TP oints, fle.ion or surface of fin!ers
#. Vasculitic =esions
% most common are leu5ocytoclastic 7asculitis and palpa(le purpura
*. Peripheral neuropathies
% usually found in elderly RA pt.
,. Ocular in7ol7ement
% 5eratoconuncti7itis sicca in association )ith so!rens s.
% Scleritis has )orse pro!nosis
+. Hematolo!ic
% Anemia is most common
% /eltys syndrome characteri>ed (y splenome!aly, neutropenia,
throm(ocytopenia and anemia in lon! standin! RA
Systemic Manifestation
2. malaise and lo) !rade fe7er
#. anore.ia
*. )ei!ht loss
#?
,. fati!ue
Articular Manifestation
% al)ays 6I=ATERA= S@11ETRI8A=
% can affect any diarthrodial t.
2. 1ornin! stiffness
% uni7ersal feature of syno7ial inflammation
% last for more than # hours
#. Tenderness
*. Structural Dama!e and 8repitus
%caused (y cartila!e loss and erosion of periarticular (one
,. /le.or contractures
+. /in!er deformities
a. S)an nec5 deformity more common
(. 6outonniere deformity
&. usually affects the hands, )rists, shoulder, 5nee, 82%8# t and
midcer7ical t.
VI. Dia!nostic 8riteria
2?A: Re7ised 8riteria for the 8lassification of RA"
2. mornin! stiffness
#. arthritis of * or more ts.
*. arthritis of the hand
,. symmetric arthritis
+. rheumatoid nodule
&. serum R/
:. radio!raphic chan!es
B RA C D least , out of E criteria
B2%, must ha7e (een present for # least & )ee5s
B#%+ o(ser7ed (y physician
B&E:% la(oratory findin!s
VII. D.
=a(oratory"
a. ESR
(. R/
c. 868% R68 %dec.F G68%<ormal
d. Syno7ial fluid analysis
<ormal%transparent, yello)ish, 7iscous )ith clots
Gith inflammation%cloudy, less 7iscous, )ill clot
Radio!raphy
o 1ar!inal erosion )ith u.ta%articular osteoporosis
o 8lassification of pro!ression of RA"
Sta!e I%early
Sta!e II% moderate
Sta!e III% se7ere
Sta!e IV% terminal
VIII. Pro!nosis
indi7iduals )ith RA may li7e less
almost +$; )ill e7entually ha7e mar5ed restrictions in AD= or )ill (e
incapacitated
elderly onset, (etter functional outcome than those )ith early onset
BAmerican 8olle!e of Rheumatolo!y Re7ised 8riteria for 8lassification of
/unctional Status in RA "
8lass I % independent
8lass II % a(le to perform )ith pain
8lass III % a(le to do some
8lass IV % una(le to perform
IH. 1edicalISur!ical 1!t.
*$
salicylates
<SAIDS%2
st
line of defense
Anti%malarial dru!s
D%penicillainine
Steroids%e.o!enous !lucocorticoids
H. PT 1!t.
superficial heatin! IR and H1P
deep heatin! modalities e.!. 1GD, SGD, E 4S.
Systemic Lupus Erythematosus
I. Definition"
a systemic immune%mediated dIo char. (y presence of a num(er of anti(odies to
nuclear components.
II. Epidemiolo!y"
females 'A"2-, increase in )omen of child (earin! a!e
2+%,+ y.o.
#%, times !reater in (lac5s and Hispanics than in )hites
may (e hereditary or !enetically determined, !reater in identical t)ins.
III. Etiolo!y"
un5no)n
'J- of re!ulatory mechanisms in immune response
IV. 8linical 1anifestations"
the 22 criteria" SHI< ROAD 1AP
o Serosiris% pericarditis E pleuritis
o Hematolo!ic% feltys syndrome
o Immunolo!ic
o <eurolo!ic% psychosis E epilepsy
o Renal% lupus nephritis
o Oral% ulcers
o Arthritis% non%erosi7e non%deformin! 'KA88O4D-
o Discoid rash% ant. <ec5 E scalp area
o 1alar rash% a5a (utterfly rash
o Anti%nuclear anti(ody 'A<A-% la(. Hallmar5 of S=E
o Photosensiti7ity% cant tolerate li!ht
V. 1edicalISur!ical 1!t.
immunosuppressi7e dru!s may (e helpful
salicylate
corticosteroids
Juvei!e Rheumatoid Arthritis "Sti!! s dse#
I. Definition
an uncommon cripplin! dse of children associated )ith fe7er and enlar!ement of
lymph nodes and spleen.
II. Epidemiolo!y
L(oysC!irls
Lmost common in childhood
L2
st
de!ree relati7es and ,$; of mono>y!otic t)ins may (e affected
III. 8linical 1anifestastion
!ro)th retardation
La(n speech
Lrapid loss of RO1 E contractures
small mandi(le 'microa!nathia-
IV. Types
a. systemic onset
*2
o L'J- of e.traarticular manifestations in addition to arthritis
o (oys L !irlsF median a!e of onset" + y.o
o 'J- casrdiac in7ol7ement
o pt. may e.perience polyarthritis, anemia, leu5ocytosis
o 'J- hi!h fe7er esp. in the afternoon and e7enin!
(. pauciarticular arthritis
o *$; of KRA pts.
o 1ost fre3uent type
o 9irls L (oysF early a!e of onset is #%, y.o
o In7ol7ement of 2 or fe) ts. 8ommon in 5nees E an5les
o Has mild arthritisF !ood pro!nosis
o 1ay lead to cataract irritation, loss of 7ision and (and 5eratopathy
c. polyarticular arthritis
o #+; of pts.
o Predominantly !irls at youn!er a!e
o Has relati7ely !ood pro!nosis
o Onset is insidious
o Initial in7ol7ement of small ts.
V. 1edicalISur!ical 1!t.
Salicylates% 2
st
dru! of choice
9old salts (e !i7en if salicylates is not effecti7e
Antimalarials
Systemic !lucocorticosteroids
VI. PT 1!t E Assessment
!oal is relief of pain and maintenance of function
splintin! of ts.
proper e..
ade3uate rest
$ro%ressive Systemic Sc!erosis
(scleroderma or systemic sclerosis)
I. Definition
An uncommon connecti7e tissue dse )ith the most prominent feature )hich
is THI8ME<I<9 OR /I6ROSIS of the s5in. It is hetero!enous, (oth in7ol7in! the
internal or!ans and oints.
II. Epidemiolo!y
8ommon in /emales '*"2-
Rare in children and in men under *$ y.o.
Sli!htly more common in (lac5 )omen in child(earin! years
III. Etiolo!y
Etiolo!ic a!ent is o(scure and no stron! hypotheses e.ist to its nature
IV. Pathophysiolo!y
The a(normal deposition of colla!en in the 8T of the micro7essels
causin! o(literation, 7asomotor'7asospasm- and permea(ility chan!es
'edema-, platelet acti7ation and perimuscular mononuclear cell
infiltration leadin! to inflammation. The inury to endothelial cell linin!
of the 7essels ma5es the or!an dama!ed since there is the
distur(ance )hich acti7ates the clottin! system releasin! 7asoacti7e
peptides. Thus smooth ms mi!rate in, proliferate and deposit 8T to a
proliferati7e 7ascular lesion of PSS.
V. 8linical 1anifestation
Raynauds Phenomenon
% caused (y a spastic (lood 7essel in the e.tremities especially
in the di!its
*#
% presence of pain and num(ness especially on toes and fin!ers
of the in7ol7ed e.tremity
% ulcerations
% )e((in! conditions
% compromised (lood supply to the di!its
S5in
% early disease s)ollen fin!ers and hands, forearm,
feet, lo)er le!s and face are affected.
9IT
%esopha!eal hypomotility leads to dyspha!ia or heart (urn.
%!astric hypomotility leads to (loatin! E a(dominal pain.
Pulmonary
%e.ertional dyspnea often accompanied (y a non% producti7e
cou!h
cardiac
%pericarditis )ith or )ithout effusions, heart failure, and 7aryin!
de!rees of heart (loc5s or arrythmias.
Renal
%)ill manifest encephalopathy, se7ere hIa, retinopathy, sei>ures
VI. 8omplications
pleuritis, interstitial fi(rosis, pulmonary Htn, )t. loss, constipation,
dyspha!ia
may result to crest syndrome
a. su(cutaneous phenomenon
(. raynauds phenomenon
c. esopha!eal dysfunction
d. sclerodactyly
e. telan!iectasia
VII. 1edicalISur!ical 1!t.
dru! therapy" e.!. penicillamine, antoplatelet, !lucocorticoid
for Raynauds phenomenon" reserpine, pheno.y(en>amine
Dermatomyositis $o!ymyositis "D&'$&#
I. Definition
It is an inflammatory disease of muscle and s5in often associated )ith
profound )ea5ness of s5eletal muscle, includin! the heart, )ith or )ithout the presence
of rash.
II. Epidemiolo!y
most common in ,$ &$ years old
children of a!es + 2+ may ac3uire it
malesCfemales
III. Etiolo!y
un5no)n cause
theories" due to 7iral infection and autoimmune distur(ances
IV. Pathophysiolo!y
there is a(normal reco!nition of the self in )hich anti(odies of the
indi7idual attac5s its o)n self causin! dama!e to the muscle and s5in
leadin! to )ea5ness in s5eletal and articular muscles
V. 8linical 1anifestation
profound )ea5ness of s5eletal muscle
)ea5ness of respiratory and s)allo)in! muscles
oint diseases are rare (ut (ony erosions are common
VI. Types of D1%P1
Type 2 Primary, Idiopathic P1
**
insidious onset, mod%se7ere arthritis, Raynauds
phenomenon is present
pel7ic !irdle L shoulder !irdle and nec5 muscle L dyspha!ia
and dysphonia
Type # Primary, Idiopathic D1
acute onset, pro.imal muscle )ea5ness and heliotropic rash
and !rottrons papules
muscle tenderness, systemic%fe7er, malaise, )t. loss
Type * D1%P1 associated )ith mali!nancy
more common in 1L,$ y.o., muscle )ea5ness usually
pro!ressi7e
dyspha!ia and respiratory )ea5ness
death due to pneumonia or respiratory failure
Type , D1IP1 associated )ith 7asculitis
disease of childhood
rapid and pro!ressi7e muscle )ea5ness )ith dyspha!ia,
dysphonia and respiratory )ea5ness
contracture and atrophy is hi!h
calcinosis is present
Type + Associated )ith other colla!en 7ascular diseases
RA, S=E, PSS
/unctional pro(lems associated )ith the indi7idual colla!en
diseases often dominates the clinical picture
Type & Inclusions (ody myositis
VII. 8omplications
Aspiration pneumonia
lun! dysfunction
VIII. Dia!nosis
e7aluation of serum muscle en>ymes
muscle (iopsy
E19
Steroids not effecti7e
S(o%re s Sydrome
I. Definition
A chronic, slo)ly pro!ressi7e inflammatory autoimmune e.ocrinopathy )hich
is characteri>ed (y dry eyes '5eratoconuncti7itis sicca- and dry mouth ' .erostomia-F
the second most common immune%mediated disorder
II. Epidemiolo!y
1ost common in females, +$ yrs old, ?"2
III. Etiolo!y
un5no)n
associated )ith other autoimmune diseases such as RA, S=E and
PSS
IV. Pathophysiolo!y
t)o main autoimmune phenomena are" lymphocytic infiltration of
e.ocrine !lands and 6%lymphocyte hyperacti7ity
V. 8linical 1anifestation
Meratoconuncti7itis sicca dryness of the eyes
.erostomia dryness of the mouth
arthritis
dyspareunia pain durin! se.ual intercourse
parotid !land enlar!ement
raynauds phenomenon
*,
fe7erIfati!ue
lymphoma and Galdenstroms macro!lo(ulinemia
VI. 8omplication
dry nose, throat, and trachea
esopha!eal mucosal atrophy
atrophic !astritis
fati!a(ility
renal in7ol7ement
nephritis, 7asculitis
VII. Tests
Schirmers Test test for 5eratoconuncti7itis sicca
Rose 6en!al Test
Test for Herostomia
VIII. 1edicalISur!ical 1ana!ement
9oal
aimed at symptomatic relief and limit dama!in! effects of chronic
.erostomia and 5eratoconuncti7itis sicca
1ana!ement
fluid replacement
a7oid diuretics, antihypertensi7e and anti%depressant dru!s
eye patchin! and (oric acid ointments
!lucocorticoids and immunosuppressi7e a!ents
SERO<E9ATIVE ARTHROPATHIES
A)y!osi% Spody!itis
I.Definition"
systemic, chronic, inflammatory disorder of the a.ial s5eleton, affectin! SI
oints and spine
a5a 7on 6echtere)s Disease, Strumpell%1arie Disease, Rheumatoid
Disease
prototype of the Spondyloarthropathies
II.Epidemiolo!y
more common in males '*"2-
#$ ,$ yrs. Old
?$; )ith H=A%6#: positi7e '!enetic predisposition-
III.Etiolo!y
un5no)n
hereditary
IV.Pathophysiolo!y
no specific e.o!enous a!ents has (een identified to tri!!er the disease
implicate immunomediated mechanisms
inflammatory processes tend to start or ori!inate in li!ametous and
capsular sites of attachment to (ones 'enthesitis-, u.ta%articular
li!amentous structures, and the syno7ium, articular cartila!e and
su(chondral (ones of in7ol7ed oints
V.8linical 1anifestation
a. Sacroilitis
Hallmar5 of AS
2
st
initial symptom
dull pain felt in the lo)er lum(ar )ith (ac5 mornin! stiffness
(. =o) 6ac5 Pain
c. 6ony Tenderness
*+
d. Enthesitis
Inflammation of li!amentous tendinous insertions
e. Peripheral Arthritis
usually in the shoulder and hip oints
f. =oss of Spinal 1o(ility
!. =O1 in hip and shoulder oints
h. E.tras5eletal manifestation
VI.Dia!nosis
Dia!nostic criteria"
h. of inflammatory (ac5 pain
'J- sacroilitis
=O1 of lum(ar spine
=imited chest mo(ility
VII.8omplications
spinal fracture most serious complication
VIII.1edicalISur!ical 1ana!ement
Indications for sur!ery"
hip pain and stiffness
Dru!s
indomethacin most common
<SAIDS
=ocal corticosteroids
IH.PT Assessment
E.ercises
early mornin! )arm%ups to facilitate AD=s
nec5 and (ac5 e.ercises 1cMen>ies e..
RO1 e.. Of cer7ical spine
Positionin!
use of a firm mattress
use of a Kac5son pillo) )hich allo)s lateral cer7ical support in
sidelyin!
prone positionin! of atleast 2 hr daily
Reiter s Sydrome
I.Definition
presents as a clinical triad of non%!onococcal urethritis, conuncti7itis and
arthritis
II.Epidemiolo!y
1ales are more commonly affected
Almost 2$$; H=A%6#: positi7ity
III.Etiolo!y
6elie7ed to (e tri!!ered (y infection of the !enitourinary tract caused (y
8hlamydia, 8ampylo(acter, Salmonella, Shi!ella, and @ersinia
IV.Pathophysiolo!y
The tri!!erin! or!anisms in7ade host cells and sur7i7e intracellularly
Anti!ens of 8hlamydia, @ersinia and Salmonella persist in the syno7ium
for lon! periods follo)in! the acute attac5
8D,Jt cells that respond to anti!erns of the incitin! or!anisms are
typically found in inflamed syno7ium (ut not in peripheral (lood
It remains to (e determined )here the primary process is an
autoimmune response a!ainst anti!ens of tri!!erin! or!anisms that
ha7e disseminated to the tar!et tissue
V.8linical 1anifestation
8onstitutional symptoms" fati!ue, fe7er, malaise and )ei!ht loss
1usculos5eletal symptoms
*&
4rethritis
Dischar!e is mucopurulent, prostatitis is common
8onuncti7itis and iritis
Arthritis )hich (e!ins in the )t. (earin! oints '5nees, an5les, feet and
)rist-
Arthritis of the hands and fin!ers may !i7e a sausa!e di!it appearance
S5in in7ol7ement may include
% Meratoderma 6lenorrha!ica inflammatory hyper5eratotic
lesion of the toes, nails and soles of the feet rese(lin!
pustular psoriasis
% 6alanitis 8ircinata shallo), painless ulcers in !lans penis
and urethral meatus
VI.1edical 1ana!ement
<SAIDS
indomethacin
systemic !lucocorticoids
VII.Sur!ical 1ana!ement
syno7ectomy for se7ere oint pain
e.cision arhroplasty for metatarsal!ia
tenosyno7ectomy
$soriatic Arthritis
I.Definition
a (eni!n inflammatory s5in disease )ith !enetic predisposition
an arhtropathy associated )ith com(ined fearures of (oth RA and
serone!ati7e spondyloarhtropathies
a polyarthritis )ith psoriasis
II.Epidemiolo!y
male C female
2; pre7alence
*$%+$ yrs old onset
III.Etiolo!y
s5in lesions usually antedate the arthritis and e.acer(ation and remissions
of psoriatic arthritis are poorly correlated )ith the course of s5in lesions
IV.Pathophysiolo!y
arthritis may affect one di!it causin! an inflammatory dactylitis
ser7ere osteolysis at the opposin! articular surfaces may occur in
peripheral and in pro.imal oints
tendency to (ony fusion may typically (e seen and may manifest to
patients )ith !enerali>ed psoriatic erythroderma
se7ere resorpti7e arthroplasy in )hich a loss of (onestoc5 and oint
surface is e.tensi7e that the s5in o7erlyin! the fin!ers or )rists may fold
upon itself so called 1ain en =or!enette syndrome
V.8linical 1anifestation
asymmetric oli!oarthritis or monoarthritis
symmetric polyarthritis resem(lin! RA
Auspit> si!n the phenomenon )hre (leedin! occurs )hen the scaly
psoriatic pla3ues are lifted from the s5in
<ail findin!s include stipplin! and onycholysis
Se7erely deformin! arthritis 5no)n as arthritis mutilans causes shortenin!
of the fin!ers secondary to e.cessi7e (one resorption pla3ues
Enthesitis
Psoriatic lesions are seen
In radio!raphic features" pencil%in%cup deformity
*:
VI.1edical 1ana!ement
Hydro.ychloro3uine e.cacer(ate psoriasis
9old therapy (ei!n ree7aluated
Immunosuppressi7e therapy '1ethotre.ate- control the disease
Steroids, =ocal s5in treatment
I*!ammatory +o,e! Disease
I.Defintion
9eneral term for a !roup of chronic inflammatory disorders of un5no)n
cause in7ol7in! the !astrointestinal tract
# 1aor 9roups of 8hronic I6D
2. 8hronic non%specific ulcerati7e colitis
#. 8hrohns Disease
II.Epidemiolo!y
Ghites L (lac5s and orientals
1ales C females
Pea5 a!e" 2+ *+ years old
III.Etiolo!y
4n5no)n cause
An immune mechanism may (e in7ol7ed
Psycholo!ical features su!!ested that patients )ith I6D ha7e
characteristic personality )hich renders suscepti(le emotional stresses
)hich may precipitate their symptoms
IV.Pathophysiolo!y
8hronic 4lceritis
Inflammatory reaction in the colonic mucosa and e.tends pro.imal in a
continuous fashion
(ac5)sh ileitis on the entire colon
inflammatory reaction )ith neutrophilic infiltration )hich may cause
e7entual destruction
deeper layers of the (o)el (eneath the su(mucosa usually are not
in7ol7ed
8hrohns Disease
characteri>ed (y chronic inflammation of the intestinal )all and its
mesentery
(o)el )all si plia(le durin! the early sta!e
as pro!resses, it appears !reatly thic5ened and leathery )ith its lumen
narro)ed
mesentery appears )ith fin!erli5e proections
!ranulomas are usually present and is often discontinuous
V.8linical 1anifestation
4lcerati7e 8olitis 8hrohns Disease
2. Diarrhea JJ JJ
#. Rectal (leedin! JJ J
*. A(dominal pain J JJ
,. Palpa(le mass $ JJ
+. /istulas JI% JJ
&. Smal (o)el mo7t JI% JJ
:. Rectal in7ol7ement JJ '?+;- JJ '+$;-
A. To.ic me!acolon J JI%
?. Recurrence after colectomy $ J
2$. 1ali!nancy J JI%
VI.1edicalISur!ical 1ana!ement
9eneral 1easures
(ed rest
*A
proper diet
Dru! Treatment
salicylates ASA is the dru! of choice
<SAIDs
Steroids
9old salts
Anti%malarials
1ethotre.ate
=ocal treatment of Koints
Heat
Acti7e e.ercises
immo(ili>ation
Pre7ention of Deformity
splintin!
e.ercise
VII.Sur!ical 1ana!ement"
2. Syno7ectomy
performed in RA to relie7e pain E inflammation associated )ith
chronic s)ellin!.
To alle7iate or restore RO1 in contracted ts.
#. Tenosyno7ectomy
most fre3uently in e.tensor%fle.or tendons of the hand and TA.
1aor 8II"
a. 7ery acti7e polyarticular dse
(. poor !eneral medical condition
c. poor moti7ation of the pt.
d. sat!e , in t. destruction
*. Arthrodesis
sur!ical fusion of (ony surfaces of a t.F usually
done in cases of se7ere t. pain E insta(ility in )hich mo(ility of
a t. is a lesser concern.
Indications"
a. relie7e persistent pain
(. pro7ides sta(ility )here there is mechanical
destruction of t ant to halt pro!ress of dse.
8II"
a. si!nificant (ilat. Kt. dse.
,. Tendon transfer
common in RA for the ff"
a. ruptured tendons of the (ody
(. tendon release
+. Osteotomy
help to correct 7al!us deformity in KRA
&. Kt. replacement
indications"
a. persistent pain
(. =O1
c. =oss of function
8omplications of Kt. replacement"
=oosenin!
Early or late infection
Dislocation
/. of (one
Gearin! out of components
*?
<er7e inury
Pulmonary em(olus
Pre%operati7e Reha( m!t"
teachin! the pt. crutch )al5in!
)t. reduction in o(ese indi7idual
stren!thenin! of 3uads (efore 5nee replacement
stren!thenin! of adductors after 5nee replacement
Post%Op Reha( 1!t"
perform pain free RO1 e..
Perform ms stren!thenin! e.. In pain free ran!e
Encoura!e the use of proper assisti7e de7ice
8R@STA=%I<D48ED ARTHROPATHIES.
$seudo%out Arthritis
I. Definition"
The deposition of calcium pyrophosphate dehydrate crystals in the oints
characteri>ed (y acute inflammatory t. disease. This is 5no)n as chondrocalcinosis.
II. Epidemiolo!y"
affects older indi7iduals in their ,
th
%&
th
decade
affects in (oth !ender
pre7alence increases )ith a!e
ratio of psuedo!out )ith !out in incidence is #"*
III. Etiolo!y"
un5no)n
associated )ith meta(olic dIo"
a. hyperparathyroidism
(. hypothyroidism
c. hemochromarosis
d. hypophosphatasia
e. hypoma!necemia
f. !out
!. ochronosis
h. )ilsonNs dse.
IV. Pathophysiolo!y"
* possi(le mechanisms"
a. lo)erin! of either 8a or pyrophosphate ions in the syno7ial fluid may
loosen and shed crystals from cartila!e into the syno7ial fluid.
(. 8rystal may enter syno7ial fluid secondary to mechanical destruction of
cartila!e resultin! from microfractures of su(chondral (one.
c. Release of crystals from de!radation of cartila!e matri. (y en>ymes.
V. 8linical 1anifestation"
patterns of oint in7ol7ement"
a. pseudo!out
occurs #+; of cases
onset is rapidF pea5 in 2# to *& hours
oints are edematous, s)ollen, )arm E painful
usually confined in sin!le oint
may pro7o5e trauma, sur!ery, or medical illness
'J- radio!raphic e7idence of chondrocalcinosis
(. pseudorheumatoid dse.
occurs appro.. +; of cases
multiple t. in7ol7ement
su(acute attac5s last to )ee5s or months
de7elops syno7ial proliferation, =O1, E fle.or deformities.
,$
c. chronic
more in )omen
pro!ressi7e de!eneration of multiple oints
t. in7ol7ement is usually symmetrical
affects mostly in 5nees follo)ed (y )rist, 18P, hips,
shoulders, el(o)s, and an5les
may resem(le neuropathic arthropathy
VI. 8lassifications
hereditary type
8PDDassociated )ith meta(olic dses.
Idiopathic 8PDD
8PDD concomitant )ith OA
VII. 1edicalISur!ical 1ana!ement
phenyl(uta>one
indomethacin
<SAIDS
9lucocorticoids
Salicylates
-outy Arthritis
I. Definition"
a familial dIo of purine meta(olism in )hich uric acid is in7ol7ed.
8harac. (y hyperurecemia and deposition of <a urate in the ts.
II. Epidemiolo!y"
occurs after a!e *$
?$; of patients are male
rare in (lac5s
affects sin!le t.
affects primarily the 6i! toe%podagra
III. Etiolo!y"
may(e due to"
a. alcohol inta5e
(. dietary e.cess of purine
c. trauma
d. dru!s
e. radiation therapy
IV. Pathophysiolo!y"
pro(a(le causes"
a. sustained hypererucemia leads to de7elopment of microphi 'tophi
are patho!nomonic features of !out- into syno7ial linin! cells.
(. Accumulation of monosodium urate in the cartila!e in
proteo!lycans that has hi!her affinity.
c. Episodic release of urate crystals in the syno7ial fluid due to
se7eral mechanisms in7ol7in! disruption of mircrotophi turn o7er
of cartila!e proteo!lycans.
d. =o)er temp. in t, space on an une3ual distri(ution of )ater and
urate in the syno7ial fluid may accelerate precipitation.
V. 8linical 1anifestastions"
recurrent acute monoarticular pain 'early sta!e-
inflammation
attac5s precipitated (y e.cessi7e protein inta5e, dru!s, fastin!,
alcohol a(use, and trauma.
Rapid onset
S. free (et)een attac5s
,2
1ost in7ol7ed t. is foot'2
st
1TP-, hand, )rist, 5nee, and el(o)
'J- tophi
VI. Dia!nosis"
A. H%ray
early sta!e" no t. chan!es
later sta!e" typical small punch%out areas containin! uratic deposits
at the ends of the ts.
6. =a(oratory findin!s"
ele7ated (lood uric acidO
VII. 1edicalISur!ical 1ana!ement"
colchicines
phenyl(uta>one
indomethacin
i(uprofen
other <SAIDS
Bpre7ention of tophaceous deposits"
.anthine o.idase inhi(itor
allopurinol
uricosuric a!ent
increase fluid inta5e
al5alini>ation of urine
PT EVA=4ATIO< E 1A<A9E1E<T /OR SEROPOSITIVE I SERO<E9ATIVE
ARTHROPATHIES E 8R@STA=%I<D48ED ARTHROPATHIES
PT e7aluation E assessment"
2. H..
#. RO1
*. palpation
,. 11T
+. t. sta(ility
&. Endurance
:. functional assessment%AD=NS
A. 9ait assessment%in =E affectation
?. psycholo!ical status
PT 19T.
2. Pro(lems
a. pain
(. t, stiffness E =O1
c. ms atrophy
d. deformities
#. 9oals E Plan of 8are
9oal Plan of 8are
a. pain relief %heatF cold therapyF splints for immo(ility
(. maintain t. mo(. %PRO1 E ARO1, stretchin! e..
c. ms inte!rity %ms stren!thenin! e..
d. pre7ent deformities %pt. educationF (racin!F assisti7e de7ice
*.Rationale Of T.
a. decrease pain
(. inc. or maintain stren!th
c. inc. functional endurance
d. maintain RO1
e. promote indep
f. inc. t. sta(ility
!. impro7e !ait patterns
,#
DE9E<ERATIVE ARTHROPATHIES
OSTEOARTHRITIS
Ostoearthrosis, De!enerati7e Koint Disease 'DKD-, Hypertrophic Arthritis, De!enerati7e Disc Disease
' DDD, in the Spine-, 9enerali>ed Osteoarthritis ' Melle!renNs Syndrome-
I. Definition"
A slo)ly pro!ressi7e musculos5eletal disorder
Affects the oints of the hands ' those in7ol7ed )ith a pinch !rip-, spine and
)ei!ht (earin! ts ' hip, 5nee- of =E
The most common articular disorder
II. Epidemiolo!y"
Associated )ith increased a!e
1ore common in )omen than men
Radio!raphic e7idence in L +$%A$; of those &+ yIo.
Estimated #%* ; of the audit population has symptomatic OA.
III. Ris5 /actors for OA"
O(esity
Heredity ' esp. OA of the DIP ts-
A!e
Pre7ious Koint Trauma
A(normal Koint 1echanics ' E.cessi7e 5nee 7arus or 7al!us -
Smo5in! ' may contri(ute to de de!enerati7e oint dse-
IV. Patholo!ic /eatures of OA
A. EAR=@"
S)ellin!
=oosenin! of colla!en frame)or5 structure restraint
8hondrocytes increase proteo!lycan synthesis (ut also realease more
de!radati7e en>ymes.
Increase 8artila!e Gater 8ontent
6. =ATER
De!redati7e En>ymes (rea5 do)n protoo!lycans faster than it can (e
produced (y chondrocytes, resultin! in diminished proteo!lycan content in
the cartila!e.
Articular 8artila!e thins and softens ' t%space narro)in! )ill (e seen
e7entually-
/issurin! and crac5in! of cartila!e. Repair attempted (ut inade3uate
4nderlyin! (one is e.posed, allo)in! syno7ial fluid to (e forced (y the
presence of )t into the (one. This sho)s up as cyst or !eodes on
radio!rahs
Remodellin! and hypertrophy of the su(chondral sclerosis and osteophytes
'PspursQ- formation
V. 8=ASSI/I8ATIO< O/ OSTEOARTHRITIS"
A. PRI1AR@ OR I<DIOPATHI8 OA"
2. =O8A=IRED"
Hands ' He(erdenNs and 6ouchardNs, /irst 818-
Hands ' Erosi7e, Inflammatory-
/eet ' first 1TP-
Hip
Mnee
Spine
#. 9E<ERA=IRED ' ME==E9RE<NS S@<DRO1E-
6. SE8O<DDAR@ OA"
2. Pain in in7ol7ed oints
#. Pain )orse acti7ity, (etter )ith rest
*. 1ornin! stiffness ' if present- 0 *$ mins
,*
,. Stiffness after a period of immo(ility ' !ellin!-
+. Koint enlar!ement
&. Koint Insta(ility
:. =imitation of oint mo(ility
A. Perlarticular 1m atrophy
?. 8repitus
VI. KOI<TS T@PI8A==@ I<VO=VED I< PRI1AR@ ' IDIOPATHI8- OA"
2. DIP ts of hands
#. Pip ts hands
*. /irst 818 ts of thum(
,. Acromiocla7icular t
+. Hip
&. Mnee
:. /irst <TP ts of the feet
VII. RADIO9RAPHI8 /EAT4RES"
A% <o an5ylosis
Ali!nment may (e a(normal
6% 6one 1inerali>ation
6ony Su(chondral sclerosis
6ony Spurs ' Osteophytes -
8% <o 8alcification in cartila!e
8artila!e space narro)in! )hich is non%uniform 'occurs in area of ma.imal
stress in )t (earin! ts.-
D% Deformities of He(erdenNs 6ouchardNs <odes
E% <o erasions
P9ull )in!Q Si!n in Erosi7e Arthritis
S% Slo)ly pro!ression o7er years
<o specific nail in de!enerati7e Disc Disease ' a collection of nitro!en in a
de!erated disc space-
VIII. =a(oratory /indin!s"
ESR normal
R/ <e!ati7e
A<A not present
Syno7ial /luid
Hi!h Viscosity )ith !ood strin! si!n
8olor is yello) and clear
G68 counts typically 0 2$$$%#$$$I mm*
<o crystals and ne!ati7e cultures
IH.Differential D. of OA and RA
OA RA
2. non systemic systemic
#. non%inflammatory assoc. )ith cutaneous and
inflammatory chan!es
*. affects )t. (earin! ts small ts.
,. '%- R/ 'J- R/ (ut not all
+. '%- su(cutaneous 'J- su(cutaneous nodes
&. <ormal ESR and Serolo!ic test inc. ESRF =eu5ocytosis )ith
eosinophilia
:. clear syno7ial fluidF hi!h 7iscosity syno7ial fluid is tur(idF lo) 7iscosity
and fe) cells )ith many
polymorphonuclear cells
A. 'J- osteophytes '%- osteophytes
?. DIP affectation terminal ts not usually affected
' e.. DIP-
2$. in7ol7e fe)er ts in7ol7es many ts at particular time
OA is sometimes difficult to differentiate )ith RA (ecause sometimes the t)o
,,
may co e.ist.
OA may(e stipulated (y !outy, neuropathic or tu(erculous t dse.
CLASS:
a.Primary OA
% affects DIP, PIP, 2
st
818, hip, 5nee, 1TP, cer7ical and lum(ar t.
(.Secondary OA
% See ETIO=O9@
H.1EDI8A= 1A<A9E1E<T
9eneral 1easures"
a. reassurance
(. restI modification of acti7ity
DR49S"
a. Aspirin%dru! of choice
(. <SAIDS
c. 8orticosteroid
=O8A= TREAT1E<T"
a. SplintsI (races
(. 1assa!e
c. E.ercise
HI.S4R9ER@ % last resort
Indications"
a. Se7ere pain
(. =oss of function
c. Pro!ression of deformity
SO/T TISS4E PRO8ED4RES
a. Syno7ectomy
(. Soft tissue release
c. Tendon transfer
6O<E A<D KOI<T PRO8ED4RES
a. Arthrodesis
% to relie7e pain, result to a 7ery sta(le oint (ut sacrifices freedom of
motion
(. Osteotomy
% impro7e t ali!nment
c. Arthoplasty
% t replacement to relie7e pain and restore f.n
CERVICAL S$OND.LOSIS
I.DE/I<ITIO<"
Spondylosis is descri(ed as the de!enerati7e chan!es )hich occur to the
inter7erte(ral disc and 7erte(ral (odies.
II.EPIDE1IO=O9@"
8ommon in ad7ancin! a!e ' esp. in the cer7ical spine-
=ess than ,$ y.o ' asymptomatic-, #+; ha7e DKD, ,; ha7e foraminal stenosis.
1ore than :$ yo" :$; ha7e de!enerati7e spine chan!es.
III.ETIO=O9@
<o specific cause
/actors contri(utin! to de!enerati7e chan!es of the spine"
a. A!in!
(. Trauma
c. Gor5 acti7ities
d. 9enetics
IV.PATHOPH@SIO=O9@
2. IV disc loose hydration )ith a!e, leadin! to crac5s and fissures.
#. Disc su(se3uently collapses o)in! to (iomechanical incompetence causin!
annulus to (ul!e out)ards
,+
*. Surroundin! li!aments also loose their elastic properties and de7elop taction
spurs.
,. 4nco7erte(ral spurrin! occurs as a result of the de!enerati7e process in )hich
the facet ts. loose cartila!e, (ecomes sclerotic and de7elop osteophytes.
+. Stenonis due to spur formation, disc protrusion, li!amentum hypertrophy.
V.8=I<I8A= 1A<I/ESTATIO<
a. 1ornin! nec5 pain
(. Stiffness
c. <ec5 fati!ue late in the day
d. =oss of nec5 RO1
e. Pain at the e.tremes of RO1 e.tension RO1 is affected first
f. Sometimes crystalli>ation
VI.8O1P=I8ATIO<S
a. <eurolo!ical deficits
(. Verte(ral artery inury% ' due to facet osteophyte formation-
c. 1yelopathy% ' if arthritis is com(ined )ith disc de!eneration or post disc
herniation-
d. 8er7ical spinal stenosis
VII.DIA9<OSIS"
2. Plain films% later radio!raph
#. 8T scan% ' to RIO f.-
*. 1RI% 1ost sensiti7e
VIII.1EDI8A= 1A<A9E1E<T
2. =on! hot sho)er for mornin! stiffness
#. soft cer7ical collar
*. <SAIDS
,. Acetaminophen% <SAIDS posses unaccepta(le medical ris5 for complication.
$T EVALUATION AND &ANA-E&ENT O/ OSTEOARTHRITIS AND CERVICAL
S$OND.LOSIS
PT EVA=4ATIO<
A. O(ecti7es of Reha(ilitation
a. To impro7e function
(. To pre7ent Iremedy musculos5eletal impairment
6. Assesment
2. HPI
#. RO1
*. Stren!th
,. Endurance
+. Kt sta(ility
a. =i!amentous la.ity
(. =i!amentous insta(ility
&. /unctional Assesement S ATDEP
:. /unctional mo(ility and !ait analysis
PT 1A<A9E1E<T
A. -e -uide!ies0
2. Pro(lems
a. Kt stiffness
(. Pair due to stressIe.cessi7e acti7ity
c. =O1 due to pro!ression of condition
d. If present, pain at rest
e. Deformities
#. 9oals and Plans of 8are
!AL "lan of Care
a. dec. t stiffness PRO1 pro!ressin! to ARO1F t
play techni3uesF Pt education
,&
(. dec. pain from mechanical stren!thenin! e.., modification of
stresses acti7ities )ith intermittent rest pd.
Stretchin! e.ercise
c. Inc. RO1 !rade 2 E # oscillation and modalities
d. pre7ent deformities (races, pt education
Speci*ic Jt1 $ro2!ems
2. Hip pain% usually felt around !reater trochanter
% may radiate to the !roin (ut often e.perienced in =*
dermatone
1." use of assisti7e de7ices to decrease mechanical stresses in
am(ulation
#. Tredelen(ur! 9ait% due to a(ductor )ea5ness
1." Isometric e.ercise to !luteus mediusF use o assisti7e de7ices
*. =imitation of hip e.tension% leads to (ac5ache due to attempted
e.tension
1." maintenance of Hip e.t (y lyin! prone position ' 1cMen>ie
T2- for *$%,$ min. (id.
,. Inc. =e! len!th of the affected side% associated )ith unilateral hip
ossification
1." Shoe modification
+. Mnee pain% causes =O1
1." 1odalities )ith rest, elastic )rap or splintF !rade 2 oscillation.
&. Mnee t effusion inhi(its 7oluntary contraction of the s3uads
1." RO1 e.ercise
:. Restricted RO1 due to contractures of the 5nee t capsules and
hamstrin!s
1." Stretchin! e.ercise
A. 9enu Varum
1." shoe modification
?. Hallu. Val!us )ith 6unions
2$. Hallu. Ri!idus
22. A(rasions at solesI dorsum of toes
2#. 1etatarsal head calluses
1." 4se of proper foot)earI shoe modification
2*. 818 Kt pain
1.. use a functional thum( post splint to relie7e pain and allo)
functional acti7ities
2,. Inc tension in the Spine
1.. Rela.ation techni3uesF traction to inc. IV foramen diameter
,: