RCS 6080 Medical and Psychosocial Aspects of Rehabilitation

Counseling

Rheumatic Diseases

Rheumatoid Arthritis The prevalence of rheumatoid arthritis in most

Caucasian populations approaches 1% among adults 18 and over and increases with age, approaching 2% and 5% in men and women, respectively, by age 65

The incidence also increases with age, peaking between the 4th and 6th decades

The annual incidence for all adults has been estimated at 67 per 100,000

Rheumatoid Arthritis Both prevalence and incidence are 2-3 times

greater in women than in men

African Americans and native Japanese and Chinese have a lower prevalence than Caucasians

Several North American Native tribes have a high prevalence

Genetic factors have an important role in the susceptibility to rheumatoid arthritis

Rheumatoid Arthritis Rheumatoid arthritis is an autoimmune disease in

which the normal immune response is directed against an individual's own tissue, including the joints, tendons, and bones, resulting in inflammation and destruction of these tissues

The cause of rheumatoid arthritis is not known Investigating possibilities of a foreign antigen, such as a virus

Rheumatoid Arthritis Description

Morning stiffness Arthritis of 3 or more joints Arthritis of hand joints Symmetric arthritis Rheumatoid nodules Serum rheumatoid factor Radiographic changes

A person shall be said to have rheumatoid arthritis if he or she has satisfied 4 of 7 criteria, with criteria 1-4 present for at least 6 weeks

Rheumatoid Arthritis Rheumatoid arthritis usually has a slow, insidious

onset over weeks to months

About 15-20% of individuals have a more rapid onset that develops over days to weeks

About 8-15% actually have acute onset of symptoms that develop over days

Functional Presentation and Disability of RA In the initial stages of each joint

involvement, there is warmth, pain, and redness, with corresponding decrease of range of motion of the affected joint

Progression of the disease results in reducible and later fixed deformities

Muscle weakness and atrophy develop early in the course of the disease in many people

Complications of Rheumatoid Arthritis Complications include:

Carpal tunnel syndrome, Baker’s cyst, vasculitis, subcutaneous nodules, Sjögren’s syndrome, peripheral neuropathy, cardiac and pulmonary involvement, Felty’s syndrome, and anemia

Treatment and Prognosis Medications

NSAIDS - Usually, only one such NSAID should be given at a time. Can be titrated every two weeks until max dosage or response is obtained. Should try for at least 2 to 3 wk before assuming inefficacy.

Slow acting - Generally, if pain and swelling persist after 2 to 4 mo of disease despite treatment with aspirin or other NSAIDs, can add a slow-acting or potentially disease-modifying drug (eg, gold, hydroxychloroquine, sulfasalazine, penicillamine) Methotrexate, an immunosuppressive drug is now increasingly also used very early as one of the second-line potentially disease-modifying drugs.

Medications Corticosteroids – offer the most effective short-term relief

as an anti-inflammatory drugs. Long-term though improvement diminishes. Corticosteroids do not predictably prevent the progression of joint destruction, although a recent report suggested that they may slow erosions. Severe rebound follows the withdrawal of corticosteroids in active disease.

Immunosuppressive drugs These drugs (eg, methotrexate, azathioprine, cyclosporine) are increasingly used in management of severe, active RA. They can suppress inflammation and may allow reduction of corticosteroid doses. Major side effects can occur, including liver disease, pneumonitis, bone marrow suppression, and, after long-term use of azathioprine, malignancy.

Treatment Surgery: video

Removal of inflamed synovium

Arthroplasty

Physical therapy

Vocational Implications of Rheumatoid Arthritis Need to make frequent assessments of the person’s

functional ability as the disease progresses in order to provide realistic goals and support

Motor coordination, finger and hand dexterity, and eye-hand-foot coordination are adversely affected

Vocational goals dependent on fine, dexterous, or coordinated movement of the hand are not ideal

Vocational Implications of Rheumatoid Arthritis Most jobs requiring medium to heavy lifting are

not desirable

Activities such as climbing, balancing, stooping, kneeling, standing, or walking are hampered

Extremes of weather or abrupt changes in temperature should be avoided – indoor controlled climate better

Lupus Systemic lupus

erythematosus (also called SLE, or lupus) is an autoimmune disease of the body's connective tissues. Autoimmune means that the immune system attacks the tissues of the body. In SLE, the immune system primarily attacks parts of the cell nucleus.

SLE affects tissues throughout the body. Five times as many women as men get SLE. Most people develop the disease between the ages of 15 and 40, although it can show up at any age.

Lupus - Anatomy SLE causes tissue

inflammation and blood vessel problems pretty much anywhere in the body. SLE particularly affects the kidneys. The tissues of the kidneys, including the blood vessels and the surrounding membrane, become inflamed (swollen), and deposits of chemicals produced by the body form in the kidneys. These changes make it impossible for the kidneys to function normally.

Note the granular appearance of the cortex of these lupus affected kidneys – it’s across the entire surface of both kidneys suggesting a chronic condition.

Lupus Anatomy (cont). The inflammation of SLE can be seen in the

lining, covering, and muscles of the heart. The heart can be affected even if you are not feeling any heart symptoms. The most common problem is bumps and swelling of the endocardium, which is the lining membrane of the heart chambers and valves.

SLE also causes inflammation and breakdown in the skin. Rashes can appear anywhere, but the most common spot is across the cheeks and nose.

People with SLE are very sensitive to sunlight. Being in the sun for even a short time can cause a painful rash. Some people with SLE can even get a rash from fluorescent lights.

Rashes caused by SLE are red, itchy, and painful. The most typical SLE rash is called the butterfly rash, which appears on the face – particularly the cheeks and across the nose. SLE can also causes hair loss. The hair usually grows back once the disease is under control.

Lupus Anatomy (joints) Almost everyone with SLE has

joint pain or inflammation. Any joint can be affected, but the most common spots are the hands, wrists, and knees. Usually the same joints on both sides of the body are affected. The pain can come and go, or it can be long lasting. The soft tissues around the joints are often swollen, but there is usually no excess fluid in the joint. Many SLE patients describe muscle pain and weakness, and the muscle tissue can swell.

Lupus Anatomy Lupus can also affect the nervous system

causing headaches, seizures, and organic brain syndrome.

It can cause anemia due to blood loss or from the kidney disease (it does not directly effect the red blood cells).

Pregnancy: the chances of miscarriage, premature birth, and death of the baby in the uterus are high.

Seronegative Spondyloarthropathy

Consist of a group of related disorders that include Reiter's syndrome, ankylosing spondylitis, psoriatic arthritis, and arthritis in association with inflammatory bowel disease

Occurs more age at diagnosis in the third decade and a peak commonly among young men, with a mean incidence between ages 25 and 34

The prevalence appears to be about 1%

The male-to-female ratio approaches 4 to 1 among adult Caucasians

Genetic factors play an important role in the susceptibility to each disease

Seronegative Spondyloarthropathy

The cause is unclear, but there is strong evidence that the initial event involved interaction between genetic factors and environment factors, particularly bacterial infections

Reiter’s syndrome may follow a wide range of GI infections

Bowel inflammation has been implicated in the pathogenesis of endemic Reiter’s syndrome, psoriatic arthritis, and ankylosing spondylitis

Seronegative Spondyloarthropathy The spondyloarthropathies share certain common features,

including the absence of serum rheumatoid factor, an oligoarthritis commonly involving large joints in the lower extremities, frequent involvement of the axial skeleton, familial clustering, and linkage to HLA-B27

These disorders are characterized by inflammation at sites of attachment of ligament, tendon, fascia, or joint capsule to bone (enthesopathy)

Sacroiliitis Sacroiliitis is an

inflammation of the sacroiliac joint. Symptoms usually include a

fever and reduced range of motion.

Picture on the bottom right shows an individual with – sacroiliitis and Ankylosing Spondylitis. The arrows point to the inflamed and narrowed SI joints. They are white due to bony sclerosis around the joints

Ankylosing Spondylitis Chronic disease that primarily

affects the spine and may lead to stiffness of the back. The joints and ligaments that normally permit the back to move become inflamed. The joints and bones may grow (fuse) together.

The effects are inflammation and chronic pain and stiffness in the lower back that usually starts where the lower spine is joined to the pelvis or hip.

Diagnosis is made through: (a) medical history including symptoms, (b) X-rays, and possibly (c) blood tests for HLA-B27 gene

Ankylosing Spondylitis Treatment options:

With early diagnosis and treatment, pain and stiffness can be controlled and may reduce fusing. In women, AS is usually mild and hard to diagnose.

Exercise Medications: NSAIDs,

Sulfasalazine Posture management Self-help aids Surgery

Reiter's Syndrome Arthritis that produces pain, swelling, redness and

heat in the joints. It can affect the spine and commonly involves the joints of the spine and sacroiliac joints. It can also affect many other parts of the body such as arms and legs. Main characteristic features are inflammation of the joints, urinary tract, eyes, and ulceration of skin and mouth.

The symptoms are fever, weight loss, skin rash, inflammation, sores, and pain.

Reiter's Syndrome Reiter's often begins following

inflammation of the intestinal or urinary tract. It sets off a disease process involving the joints, eyes, urinary tract, and skin. Many people have periodic attacks that last from three to six months. Some people have repeated attacks, which are usually followed by symptom-free periods.

Diagnosis is made through a physical exam, skin lesions, and a test for the HLA-B27 gene

Reiter's Syndrome For different parts of the body,

different treatments are used: Medications: NSAIDs, antibiotics, topical skin

medications Eye drops Joint protection

Various symptoms are treated by healthcare specialists

Psoriatic Arthritis Causes pain and swelling in

some joints and scaly skin patches on some areas of the body.

The symptoms are: About 95% of those with psoriatic

arthritis have swelling in joints outside the spine, and more than 80% of people with psoriatic arthritis have nail lesions. The course of psoriatic arthritis varies, with most doing reasonably well.

Silver or grey scaly spots on the scalp, elbows, knees and/or lower end of the spine.

Pitting of fingernails/toenails Pain and swelling in one or more

joints Swelling of fingers/toes that gives

them a "sausage" appearance.

Psoriatic Arthritis Diagnosis may involve X-rays, blood

tests, and joint fluid tests. Treatment options:

Skin care Light treatment (UVB or PUVA) Corrective cosmetics Medications: glucocorticoids, NSAIDs, DMARDs

(disease-modifying anti-rheumatic drugs) Exercise Rest Heat and cold Splints Surgery (rarely)

Inflammatory Bowel Disease IBD consists of two

separate diseases that cause inflammation of the bowel and can cause arthritis or inflammation in joints:

Crohn's Disease involves inflammation of the colon or small intestines.

Ulcerative Colitis is characterized by ulcers and inflammation of the lining of the colon.

Inflammatory Bowel Disease The amount of the bowel disease usually

influences the severity of arthritis symptoms. Other areas of the body affected by inflammatory bowel disease include ankles, knees, bowel, liver, digestive tract, skin, eyes, spine, and hips.

Treatment options: Diet Exercise Medication: Corticosteroids, Immunosuppressants, NSAIDs,

Sulfasalazine Surgery

Functional Presentation and Disability of the Spondylarthropathies When the axial skeleton is involved,

the initial symptom is morning stiffness and lower back pain

As the disease worsens, there is progressive diminution of motion of the spine

Eventually, the sacroiliac joints, lumbar, thoracic, and cervical spine become fused

At this stage, the spine is no longer painful, but the person has lost all ability to flex or rotate the spine and generally develops a hunched-over posture with fused flexion of the cervical spine and flexion contracture of the hips to compensate for the loss of the lordosis curvature in the lumbar spine

Functional Presentation and Disability of the Spondylarthropathies The joints where the ribs attach to the

vertebrae are also affected, and chest expansion and lung volume are decreased

Frequently, peripheral joints are involved, and the pattern is usually asymmetric oligoarthritis involving primarily the large or medium joints, including the hips, knees, and ankles

Rarely are smaller joints or the joints in the upper extremities involved

Loss of motion of the spine or pain in the spine with motion generally affects a person's mobility

Functional Presentation and Disability of the Spondylarthropathies

Walking remains unimpaired unless the hips and knees are affected

Frequent stooping and bending become impossible

A person with ankylosing spondylitis typically is able to continue vocational activity despite progressive stiffness, unless it requires significant back mobility or physical labor

Vocational Implications of the Spondylarthropathies

The person should be considered for vocational or professional education as resources and interests dictate

A stiff back will limit the person’s rotation and flexion so that overall dexterity may be affected

Tasks that require reaching or bending will be difficult and lifting over 10-15 pounds may cause increased back pain

Climbing and balancing skills, stooping, and kneeling may be tolerated initially but become difficult as the disease worsens

Need time to stretch spine frequently

Degenerative Joint Disease(Osteoarthritis) Most common rheumatic

disease and is characterized by progressive loss of cartilage and reactive changes at the margins of the joint and in the subchondral bone

The disease usually begins in one’s 40s

Prevalence increases with age and the disease becomes almost universal in individuals aged 65 and older

Primarily affects weight-bearing joints such as the knees, hips, and lumbrosacral spine

Degenerative Joint Disease Cause is unclear Considered to be a “wear and tear” arthritis

and is thought to occur as a consequence of some earlier damage or overuse of the joint

Obesity is frequently associated with it Genetic factors play a role in the

development that is sex-influenced and dominant in females, resulting in an incidence 10 times greater than in men

The final outcome is full-thickness loss of cartilage down to bone

Degenerative Joint Disease In early disease, pain

occurs only after joint use and is relieved by rest

As the disease progresses, pain occurs with minimal motion or even at rest

Nocturnal pain is commonly associated with severe disease

Functional Limitations and Degenerative Joint Disease Limited use of the involved joint

Walking and transfer activities may be impaired

Generally, ADLs will not be significantly impaired

Treatment and Prognosis of Degenerative Joint Disease Meds Early PT/exercises Heat/cold therapy Joint protection Surgery

Osteoarthritis is a slowly progressive disease The eventual outcome is complete

destruction of the joint, and ultimately surgical intervention is required

Vocational Implications and Degenerative Joint Disease Can continue in present job unless it requires

dexterous or heavy use of the involved joint Heavy lifting should be avoided Light to medium work should be possible Climbing, balancing skills, stooping, and

kneeling may be impaired Returning to work after surgery requires

intensive postop rehab and continued exercise to maintain muscle strength

Most individuals are able to sustain gainful employment and a normal level of activity

Additional Resources and Information from the Web American College of Rheumatology (

www.rheumatology.org) National Institute of Arthritis and Musculoskeletal and

Skin Diseases (www.niams.nih.gov) Arthritis Foundation (www.arthritis.org) Arthritis National Research Foundation (

www.curearthritis.org) Info on Juvenile RA (

http://www.nlm.nih.gov/medlineplus/juvenilerheumatoidarthritis.html)

Spondylitis Association of America (www.spondylitis.org)

Arthritis.com: Latest Arthritis Information & Community (www.arthritis.com)