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Signs and symptoms of Scleroderma
Calcinosis
Raynaud’s Phenomenon
Esophageal dysfunction
Sclerodactyly
Telangiectasis
Calcinosis
Calcium deposits in the skin
Raynaud’s Phenomenon
Spasms of blood vessels in response to cold or stress; sudden blanching, cyanosis, and erythema of the fingers and toes as the walls of blood vessels supplying the hands and feet become narrowed
Esophageal dysfunctions
Acid reflux and decrease in motility of esophagus
Sclerodactyly
Thickening and tightening of the skin on the fingers and hands
Telangiectasis
Dilations of capillaries causing red marks on surface of skin
Pathogenesis of Scleroderma
Excessive collagen deposits within blood vessels, pericapillary space and within the skin, causing scarring and fibrosis
Tied to the skin and vasoconstriction, so it distinguishes from other autoimmune disorders
How is the skin affected by Scleroderma?
Skin becomes tight, smooth, and waxy or shiny and seems bound down to underlying structures
What are the neuromusculoskeletal manifestations of scleroderma?
Disuse atrophy of muscle because of limited joint motion secondary to skin, joint, or tendon involvement
Arthralgia affects the wrist, hands, ankles, and knees
How is the viscera affected by scleroderma?
GI motility dysfunction affects the esophagus and anorectal regions, causing reflex, heartburn, dysphagia, and bloating after meals
Cardiac involvement can be manifested as myocardial or pericardial disease, conduction system disease, or arrhythmias
Pulmonary involvement is characterized by pulmonary arterial hypertension and pulmonary vascular disease
Implications for functional performance and rehabilitation professionals’ role in Scleroderma
Mitigate risks to mobility through exercise and joint protection techniques
Skin protection
Stress management
Monitor vitals signs with activity
Osteoarthritis
Slowly evolving articular disease that appears to originate in the cartilage and affects the underlying bone, soft tissues, and synovial fluid. Leads to loss of mobility, chronic pain, deformity, and loss of function
Pathogenesis for Osteoarthritis
Loss of hyaline cartilage, hypertrophic changes in neighboring bone and joint capsule, synovial inflammation, and focal calcifications of the cartilage
Progressive loss of cartilage, inflammation develops, with resulting bony overgrowth, ligament laxity, and progressive muscle weakness and atrophy accompanied by joint pain
Joint space narrows
Etiological factors for Osteoarthritis
Multifactorial, including biomechanics injury, biochemistry, previous injury, inherited predisposition. Injuries to joint ligaments and meniscus, joint malalignments, and subsequent decreases in muscle length
Clinical manifestations of Osteoarthritis
Begins in joints on ONE side of the body
Primarily the hips, knees, spine, hands, feet
Inflammation, redness, warmth, swelling
Brief morning stiffness
No system symptoms
Incidence for Osteoarthritis
40 year old and older; affects most adults over the age of 65
Onset for osteoarthritis
Gradual onset
Implications for functional performance/rehabilitation professionals’ roles for Osteoarthritis
Poor correlation between the extent of radiographic degenerative changes the presence of symptoms
Joint protection
Pt’s must minimize the mechanical stress on the involved joint(s). can do this by using postural supports, knee braces, and orthoses during an exercise program to vary the stresses
Proper posture
Evaluating the need for assistive ambulatory device, a shock-absorbent shoe insert, or heel wedge, etc
Exercise
Attempts to alleviate pain through pharmacologic or physical modalities may not improve symptoms unless accompanied by some form of physical conditioning
Educate pt to use ice prior to exercise and to incorporate a program of submaximal exercise to warm up before beginning exercise program.
Rheumatoid arthritis is what kind of disease?
Chronic systemic inflammatory disease
What are the etiological factors of Rheumatoid Arthritis?
Unknown, combination of genetic and environmental factors
For Rheumatoid Arthritis, _______ are 3x more likely get this disease than _______.
Women; men
Pathogenesis of Rheumatoid Arthritis
Joint inflammation because of massive infiltration of immune cells, especially T lymphocytes, into the synovial fluid
Clinical manifestations of Rheumatoid Arthritis
Symmetrical joint distribution
Can affect any joint but tends to be in upper extremities
Inflammation
Prolonged morning stiffness
System presentation: fatigue, weight loss, fever
Onset for Rheumatoid Arthritis
May be sudden or progress over weeks to months; exacerbation/remission cycle
Rheumatoid Arthritis is more debilitating for who?
Men
What condition affects multiple joints and deformities in the fingers are common (like ulnar deviation, swan neck and boutonniere)?
Rheumatoid Arthritis
Implications for functional performance/rehabilitation professionals’ roles for Rheumatoid Arthritis?
Exercise prescription
Moderate-level exercise for 30 minutes per 4 or 5 days to increase physical fitness
Lack of exercise → increased joint stiffness, muscle weakness, muscle atrophy, increased risk of fracture and deformity
Strength and aerobic training
Dynamic strengthening (gradually increasing resistance) through the full available ROM improves muscle strength, joint stabilization, and physical function
Low load resistive muscle training
Aerobic and aquatic exercise
Modalities
Preparatory for exercise/activity participation
Cold is more suitable but heat is typically preferred
Superficial heat (e.g, paraffin baths, moist hot packs, hydrotherapy, aquatic therapy) is recommended for acute flare-ups
Electrotherapeutic modalities and thermotherapy physical agents are used to obtain pain relief, control inflammation, and reduce joint stiffness
Etiological factors of Rhabdomyolysis
Prolonged immobilization in older adults after a fall
Pathogenesis of Rhabdomyolysis
Rapid breakdown of skeletal muscle tissue because of a mechanical, physical, or chemical traumatic injury
Large release of the creatine phosphokinase enzymes, myoglobin, and other cell byproducts into the blood system
Acute renal failure
Clinical manifestations of Rhabdomyolysis
Excessive fatigue and inability to recover from a strenuous event
Muscle pain (myalgia) and weakness ranging from mild to severe
Change in the color of urine
Implications for functional performance/Rehabilitation professionals’ roles for Rhabdomyolysis
Pt with a history of exertional rhabdomyolysis: should be cautioned regarding participation in extreme exertional activities and event
Recovery from statin-induced rhabdomyolysis should prompt the therapist to assess the individual for impaired muscle performance, especially proximal muscle weakness including the inspiratory muscles
Fall-related rhabdomyolysis:
Why did they fall?
How long did they stay on the ground?
Polymyalgia Rheumatic
Diffuse pain and stiffness in multiple muscle groups that primarily affect the shoulder and pelvic girdle musculature
Risk factors/incidence for Polymyalgia Rheumatic
Female, age, and race
Women are affected twice as often, the disease is rare before 50 years old; most cases occur after 70 years old
White women
Etiological factors of Polymyalgia Rheumatic
Unknown cause, genetic factors, infection, or an autoimmune malfunction may play a role
Pathogenesis of Polymyalgia Rheumatic
Despite complains of pain and stiffness in muscles, this disease is NOT associated with any histologic abnormalities
Arching and stiffness typical of this condition are caused by joint inflammation
What medication do patients with polymyalgia rheumatic respond to rapidly?
Prednisone
The diagnosis of what condition is based on the presence of a constellation of finding and the pt’s response to a trial of prednisone?
Polymyalgia Rheumatic
Clinical manifestations of Polymyalgia Rheumatic
May begin gradually, taking days or weeks for symptoms to become fully evident, but more often it develops suddenly and the person wakes up one morning feeling stiff and sore for no apparent reason
Symptoms are often bilateral and symmetrical, affecting the neck, sternoclavicular joints, shoulders, hips, low back, buttocks
Painful stiffness lasts more than 1 hours in the morning on arising and is a hallmark feature of this disorder
Muscle weakness is not the problem. Pain and stiffness are the primary issues.
Implications for functional performance/Rehabilitation professionals’ roles for Polymyalgia Rheumatic
Therapist must be aware of the potential risk of giant cell or temporal arteritis
An adult older than 65 with sudden onset of temporal headaches, exquisite tenderness over the temporal artery, scalp sensitivity, or visual complaints should be seen by a physician immediately as this vasculitis is associated with stroke and blindness
Medical adherence
Ensure that patient is taking prednisone as directed
As the disease progresses, ADLS become difficult. Bed mobility and sit-to-stand transfers are affected
Inflammatory response involving bursitis and tenosynovitis therefore use ultrasound as a deep heating agent in the presence of inflammation
Connective tissue disease
May present as a single entity or may have features of multiple autoimmune diseases
Etiological factors and pathogenesis of Connective tissue disease
Unknown but possibly self-antigens and infectious agents in the pathogenesis have been suggested
Most found in women younger than 50 years old
Implications for functional performance/Rehabilitation professionals’ roles for Connective tissue disease
The younger onset of age means people with it will likely be working, might be parents
Work modification/energy conservation
Psychological/emotional support
Pts should be encouraged to develop regular exercise habits and participate in an active lifestyle
Clinical manifestations of Connective tissue disease
Combines features of
Lupus (rash, Raynaud phenomenon, arthritis, arthralgia)
Scleroderma (swollen hands, esophageal hypomotility, pulmonary interstitial disease)
Polymyositis (inflammatory myositis)
Polyarthralgia
Pulmonary, cardiac, and renal involvement
Trigeminal sensory neuropathy appears to occur much more frequently than in other rheumatic diseases
Gout
Elevated level of serum uric acid and the deposition of urate crystals in the joint, soft tissues, and kidneys
Etiological factors of Gout
Unexplained impairment in uric acid excretion by the kidneys
Family history and age increases risk
Heavy alcohol consumption, obesity, renal insufficiency
Pathogenesis of Gout
In healthy people, uric acid dissolves in the blood, passes through the kidneys and then is excreted through the urine
If the body produces more uric acid than the kidneys can process or if the kidneys are unable to handle normal levels of uric acid, the acid level in the blood rises
High levels of uric acid in the blood may precipitate out and accumulate in body tissues, forming supersaturated body fluids, including the joints and kidneys
Crystal aggregates triggers an inflammatory response, resulting in local tissue necrosis and a proliferation of fibrous tissue
Uric Acid
Substance that normally forms when the body breaks down cellular waste produced called purines
Asymptomatic Hyperuricemia
Serum urate of more than 7 mg/dL
Acute Gouty Arthritis
Acute, monoarticular, inflammatory arthritis manifested by exquisite joint pain occurring suddenly at night
Erythema, warmth, extreme tenderness, and hypersensitivity are typically present
First metatarsophalangeal joint (i.e., big toe) is a common site of pain, ankle, instep, knee, wrist, elbow, and finger all can be the site of the initial attack
What is the common site of pain for acute gouty arthritis?
Big toe
Intercritical Gout
Asymptomatic phase, can last months or years
Chronic Gout
Can enter the chronic phase up to a decade after the initial attack, characterized by joint damage, functional loss, and disability
Implications for functional performance/rehabilitation professionals’ roles for Gout
Education on the causes/risk factors
Reduce obesity
Onset of severe joint pain with a swollen, hot joint must always be a concern to therapist
Could be gout or septic joint
Septic Joint: orthopedic emergency, so when a red, hot painful joint is observed without prior medical diagnoses, immediate medical evaluation is necessary
Myopathy
Nonspecific muscle weakness secondary to an identifiable disease or condition
Critical Illness Myopathy
Associated with prolonged stays in intensive care units
Etiological factors and pathogenesis of Myopathy
Idiopathic inflammatory myopathies are thought to be immune-mediated processes that are triggered by environmental factors
Expression of proinflammatory cytokines and expression of MHC class I antigens on muscle fibers are associated with muscle weakness in individuals with active and chronic disease
Diabetes is associated with myopathy of three origins: vascular, neurogenic, and metabolic
Acquired myopathy can occur as post of a paraneoplastic syndrome
Tumors may produce muscle weakness with/without inflammation
Medications
Cholesterol-lowering statins are associated with tendinitis and muscle abnormalities
Clinical Manifestations of Myopathy
Progressive proximal muscle weakness with varying degrees of pain and tenderness
Muscles may be acutely inflamed and painful to move and touch
Muscle weakness and easy fatigability eventually compromise aerobic capacity and affect the person’s endurance and ability to work, social, and complete ADLs
Implications for functional performance/Rehabilitation professionals’ roles for Myopathy
Acute care
The effects of ICU-acquired myopathy are even more pronounced in persons who are both on bed rest and critically ill
Psychologic and emotional support of the patient and the family
Exercise
Early rehabilitation with careful application of rest and exercise
Begins in the acute phase with stretching and PROM
Upper extremity splinting and lower extremity bracing may be necessary to prevent contractures, prolong mobility, and enhance functional skills
Client education with energy conservation and joint protection.