Rheumatology - Exam 1

osteoporosis definition

• disease causing architectural deterioration of bone tissue leading to increased bone fragility

• affects cancellous bone most

primary osteoporosis

due to aging

secondary osteoporosis

side effect of medication

osteoporosis clinical manifestations

• loss of height

  • affects curvature of spine

• postural changes

• back pain

• fractures

osteoporosis risk factors

• age >50

• low estrogen levels

• low testosterone levels

• genetics/family history

• long periods of immobilization

• sedentary lifestyle

• malabsorption disorders

• eating disorders

• poor nutrition

• excess alcohol, tobacco, caffeine, consumption

• hyperthyroidism

• diabetes mellitus

• medications

  • chemotherapy

  • heparin

  • glucosteroids

how estrogen affects bone growth

estrogen facilitates osteoblasts and inhibits osteoclasts

osteoporosis PT intervention

WB exercise & ROM

change diet

increase balance - decrease risk of falls

osteoporosis medical management

• bisphosphonates

  • inhibit osteoclasts, facilitate osteoblasts

• estrogen replacement therapy

• selective estrogen receptor modulators (SERMs)

• calcium supplementation

categories of arthritis

• infectious

  • septic arthritis

• degenerative

  • osteoarthritis

• inflammatory

  • rheumatoid arthritis

  • ankylosing spondylitis

  • juvenile idiopathic arthritis

  • polymyalgia rheumatica

• metabolic

  • gout

osteoarthritis

degenerative pathology within synovium, articular cartilage, and underlying subchondral bone

• progressive damage/loss of cartilage

  • due to abnormal mechanical loading

osteoarthritis risk factors

• obesity

• prolonged stresses on joints

• previous injuries/surgeries

• hypermobility

• infection

• other diseases

  • gout

  • diabetes mellitus

primary osteoarthritis

idiopathic

• potentially due to genetics and/or increased age

secondary osteoarthritis

due to pre-existing joint abnormalities

• trauma, injury, disease

osteoarthritis signs and symptoms

• unilateral involvement

• pain

• swelling without warmth/redness

• crepitus

• loss of ROM

• locking

• short-term stiffness

• worsening with inactivity or overactivity

• Heberden’s and Bouchard’s nodules

• affects distal and proximal IP joint, spares carpometacarpal joint

osteoarthritis diagnostic criteria

• pain with radiologic findings

• >50 years of age

• morning stiffness >30 minutes

• crepitus with motion

• blood tests rule out rheumatologic diseases

osteoarthritis radiograph findings

• joint space narrowing

• subchondral sclerosis

• subchondral cyst formation

• osteophyte formation

• loose bodies

osteoarthritis treatment

• medications

  • acetaminophen

  • NSAIDs

• supplements

  • glucosamine

  • chondroitin

• injections

  • corticosteroids

  • hyaluronic acid

• PT/OT

• surgery

  • arthroplasty

  • partial replacement

  • microfracture

  • fusion (arthrodesis)

rheumatoid arthritis

• chronic, systemic autoimmune disease characterized by both articular and extra-articular findings

rheumatoid arthritis effects

synovial hypertrophy

• increased macrophages and fibroblasts

• inflammatory cell infiltration

• angiogenesis

• pannus formation

rheumatoid arthritis joint clinical manifestations

• insidious onset

• joints

  • bilateral

  • edematous and warm

  • prolonged stiffness

  • irreversible deformities

    • ulnar deviation

    • boutonniere deformity

    • swan-neck deformity

• spine

  • cervical spine

  • atlantoaxial subluxation

rheumatoid arthritis constitutional symptoms

• fatigue

• weight loss

• generalized, diffuse pain

• weakness

• depression

rheumatoid arthritis integumentary clinical manifestations

• palmar erythema

• petechia and purpura

• rheumatoid nodules

rheumatoid arthritis neurologic clinical manifestations

• peripheral neuropathies

• compressive cervical myelopathy

• stocking glove myelopathy

rheumatoid arthritis cardiopulmonary clinical manifestations

• myocardial infarction

• congestive heart failure

• airway inflammation

rheumatoid arthritis medications

• analgesics

• NSAIDs

• corticosteroids

• disease modifying anti-rheumatic drugs (DMARDs)

• cytokine inhibitors

gout

characterized by deposition of urate crystals in joints

• urate crystals are a byproduct of nucleotide breakdown

• urate crystal deposits (tophi) disrupt osteoclast/osteoblast homeostasis and trigger cell damage and inflammation

gout risk factors

• diet

  • high in alcohol

  • high in red meat

  • high in seafood

• genetics

• AMAB

• increasing age

• comorbidities affecting heart and metabolic system

gout clinical manifestations

• severe pain, swelling, and inflammation of LE joints

  • 1st MTP frequently affected

• flare ups at night or early morning

• fever

• tachycardia

gout medical management

• diet and lifestyle modifications

• corticosteroids

• NSAIDs

juvenile idiopathic arthritis

A type of arthritis that occurs in children <16 y.o.a (1-4 & 9-14) and is characterized by persistent joint inflammation, pain, and swelling. It can affect growth and development and may have various subtypes.

juvenile idiopathic arthritis clinical manifestations

• pathological changes similar to RA

  • increased synovial fluid viscosity

  • pannus formation

• asymmetric joint involvement

• pain

• edema

• erythema/warmth

• rash

• conjuctivitis

• fever

• fatigue

• weight loss

juvenile idiopathic arthritis treatment

• NSAIDs

• corticosteroids

• DMARDs

• biologic immunomodulators

• surgery

  • joint replacement

  • synovectomy

juvenile idiopathic arthritis prognosis

• ~70% experience full remission with treatment

• lack of treatment = permanent joint damage, osteoporosis, joint contractures

septic arthritis

joint inflammation triggered by bacteria, viruses, or fungi

septic arthritis risk factors

• recent surgery

• RA

• shared needles

• unprotected sex

• immunocompromise

septic arthritis clinical manifestations

• severe 10/10 pain

• edema

• erythema

• fever

lack of treatment of septic arthritis can lead to

• permanent joint damage and disability

• death

polymyalgia rheumatica

a condition characterized by widespread muscle pain and stiffness, especially in the shoulders and hips

polymyalgia rheumatica clinical manifestations

• pain, aching, stiffness in bilateral axial joints

• prolonged morning/inactivity stiffness

• weakness

• fatigue

• low-grade fevers

• weight loss and anorexia

polymyalgia rheumatica risk factors

• AFAB

• age >50

• genetics

• smoking

polymyalgia rheumatica treatment

corticosteroids

DMARDs

ankylosing spondylitis

chronic inflammatory arthritis of axial joints involving inflammation, fibrosis, and calcification of attachment points for skeletal muscle, ligaments, synovium, and cartilage

ankylosing spondylitis risk factors

AMAB

genetics

smoking

30-50 years of onset

ankylosing spondylitis clinical manifestations

• back pain, stiffness, reduced mobility

• SIJ and hip pain

• relief of pain and stiffness with movement

• postural abnormalities

• chest pain and shortness of breath

• uveitis

• inflammatory bowel disease

ankylosing spondylitis treatment

NSAIDs

DMARDs

corticosteroids

spinal osteotomy

diffuse idiopathic skeletal hyperostosis (DISH)

ossification of ligaments, typically in cervical spine among 4 consecutive segments

diffuse idiopathic skeletal hyperostosis (DISH) medical management

no cure

surgery is rare

medications

• acetaminophen

• opioids

Therapeutic exercise utilized to slow progression and reduce symptoms

degenerative disc disease

degeneration of intervertebral disc due to the loss of proteoglycans

disc becomes more fibrotic

thinning disc leads to increased loading of articular facets

osteophyte formation and narrowing of intervertebral foramen

degenerative disc disease clinical manifestations

In a dermatomal pattern

• weakness

• pain

• numbness

• paresthesias

degenerative disc disease treatment

pain management - NSAIDs, acetaminophen, corticosteroids

muscle relaxants

laminectomy

spinal fusion

heterotopic ossification

abnormal formation of bone within soft tissues occuring 3 weeks to 3 months post initial injury

heterotopic ossification risk factors

trauma

surgery

spinal cord injury

genetics

heterotopic ossification clinical manifestations

loss of ROM

pain

swelling

tenderness

warmth

heterotopic ossification treatment

NSAIDs and bisphosphonates prevent formation

AROM/PROM

surgical resection

osteomalacia (rickets)

softening of bones caused by a lack of calcium phosphate in the bone matrix due to a prolonged deficiency of Vitamin D

How is vitamin D linked to calcium

Vitamin D facilitates absorption of calcium

osteomalacia clinical manifestations

• bone pain felt over a large area

• myalgias and muscle spasms

• weakness

• waddling gait

• bowing of long bones

• fractures

osteogenesis imperfecta

fragile bones that break easily due to genetic mutation in type 1 collagen gene resulting in a lack of flexibility that collagen normally provides

osteogenesis imperfecta clinical manifestations

• frequent manifestations

• blue sclera

• recurrent nosebleeds

• weakness

• hypermobility

• hearling loss

• cardiovascular complications

osteogenesis imperfecta treatments

bisphosphonates

Vitamin D and calcium supplements

intramedullary rod placement surgery

bracing and assistive devices

water based exercise

paget’s disease

skeletal remodeling disorder that causes bones to become bigger

increased osteoclasts/osteoblast activity

paget’s disease clinical manifestations

bone pain

enlarged bones

abnormal curvatures in bones

hearing loss

abnormal pain and constipation due to increased calcium levels

paget’s disease treatments

bisphophonates

ORIF and/or joint replacements

avoidance of intense physical activity