Management of Rheumatic Diseases

Rheumatic Disease

umbrella term for over 200 conditions that affect joints, muscles, bones, tendons, ligaments, and sometimes internal organs

Common Clinical Features of Rheumatic Disease

joint pain

morning stiffness

fatigue

systemic or multi organ effects

inflammatory markers and specific antibodies in autoimmune subtypes

Example of Degenerative Joint Disease

OA

Examples of Inflammatory Joint Disease

RA

Juvenile Idiopathic Arthritis

Examples of Connective Tissue Disease

Systemic Lupus Erythematosus (SLE)

Systemic Sclerosis

Examples of Soft Tissue/Regional Pain Syndromes

polymyalgia rheumatica

fibromyalgia

5 Principles of Patient Management for Rheumatic Diseases

1. maintain or increase ROM and strength in affected joints WITHIN LIMITS OF DISEASE and pt tolerance

2. provide functional training as needed (i.e. stairs)

3. encourage/promote joint protection

4. teach principles of rest vs. exercise

5. provide patient education and promote self-management

RA: Age of Onset

commonly age 25-50

JIA: Age of Onset

under age 16

RA: Progression

sudden over weeks to months

RA: Manifestation

inflammatory synovitis and tenosynovitis --> erosion of cartilage, bones, ligaments

RA: Joint Involvement

>1-2 joints affected

usually symmetrical

What joints are commonly affected by RA?

MCP, PIP, wrists, elbows, shoulders, c spine, MTP, talonavicular and ankle

RA: Joint Signs and Symptoms

redness

warmth

swelling

prolonged morning stiffness >1hr

increased pain w/ activity

RA: Systemic Signs

fatigue - early sx

weight loss

fever

rheumatoid nodules

ocular

hematologic

respiratory and cardiac sxs

ACSM Disease Specific Exercise Training Considerations for RA

initiate in smaller bouts

avoid strenuous ex during acute flares

small discomfort following ex is common

provide alt exercises to work mm. groups in instances where pain is reproduced w/ certain ex

Evidence for Best Form of Exercise for RA

high intensity is safe - mod evidence that it DOES NOT inc disease activity and may reduce p! and improve func when compared to controls

Specific RA Precautions

1. associated w/ 2x inc CV disease

2. high intensity load not advised on acutely inflamed or unstable joints but ROM should cont

3. long term corticosteroid use and disease related bone loss inc osteoporosis and fx risk

What factors should we consider when tailoring function to be patient-specific?

pt goals

prognosis

home environment

hand function

safety

balance

Common deformities in RA

rheumatoid nodule at elbow

swan neck deformity

boutonniere's deformity

ulnar drift

Always apply universal joint protection principles. What are they?

1. determine min ROM to safely and correctly perform activity

2. if jt unstable perform mvmts in single plane when possible

3. change directions of mvmt in controlled manner

4. reduce compression, rotary and shearing forces

5. avoid high load activities for some pts - running, jumping

6. consider orthoses or splints

7. avoid prolonged static positioning

8. vigorous stretching or jt manipulation is contraindicated

What are some things used to promote joint protection?

AD

modified door handles

modified household appliances

modified self care items

General considerations for rest in RA

acute rest beneficial for flares and p! management

prolonged or excessive rest can be harmful

rest DOES NOT mean immobilization

should be scheduled proactively

respect p! as guiding principle

pacing integrates rest into daily function

balance rest w/ activity req ongoing adjustment

What are joint-specific considerations for rest?

its is accomplished w/ ADs or spints

Patient education for RA

recognize RA is chronic

self-management of condition

make sure education is evidence based

connect to national and local support groups

What is the goal of any self-management program?

behavior change

How can PTs facilitate behavior change?

multicomponent instruction - i.e group instruction, individual instruction w/ follow up