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Rheumatological

What meds will someone take for

low bone density?

Fosamax

Non Steroidal anti-inflammatories

Rheumatoid Arthritis

What is it? Chronic, inflammatory disorder which mainly attacks synovial

joints (but may affect many tissues a& organs)

F to M 3:1

Age Range 20-70

Typical Age 40 - 50 years

S&S morning stiffness for more than 30 min

malaise

arthritis in 3+ joints and soft tissue swelling

arthritis in hand joints rheumatoid nodules (found at elbow or wrist)

symmetrical arthritis

fever

What kind of investigations to

confirm

positive RF

Increased ESR

Increased WBC count

Increased CRP

X ray changes with erosions esp. in wrist hands and feet

Which joints does initially RA affect? 75% at the joints of the hands, wrist and feet

30% at the large joints

Red= more common

Cause / aetiology unknown, considered multi-factorial, with genetic,

environmental and hormonal factor

What is Pannus? Vascularised granulation tissue (rich in fibroblasts,lymphocytes & macrophages) derived from synovial tissue,which overgrows the surface of joint

What is the pathology of RA? Auto-immune response triggered (normal tissue targeted)

Inflammatory reaction in the synovium (& subsequent joint

damage)

Synovium then develops a PANNUS (associated with the

breakdown of the articular surface)

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Effusion distends the capsule & stretches ligaments

Laxity, joint deformity and rheumatoid nodules

Describe what happens to the joint

In brief terms what can happen to

hands with RA?

Differential Diagnosis for RA Gout, OA, SLE ,Psoriatic Arthritis ,Reactive Arthritis

Ankylosis SPondilitisWhat are the TTT goals for RA? Relieve pain

Reduce inflammation

Slow down or haltjoint damage

Improve sense of well being & ability to function

Sjogrens Syndrome

What is it? Autoimmune disease; characterised by inflammation of

exocrine glands that produce tears and saliva

What is its aetiology? Unknown, possible link with HLA DR3?

How prevalent is it in the

population?

Prevalence 1-3%

What is the male to female ratio? Female-Male ratio 9:1

What is the typical age group? 5060

What are the classifications? Primarya disease in its own right

Secondaryas a result of another disease

What other diseases may cause

secondary?

Association with RA, SLE, systemic sclerosis, chronic

acute hepatitis,

What are the symptoms? Dry Mouth - difficulty swallowing or talking for long

periods, tongue fissures, dental caries, oral candidiasis

Dry Eyes - less tears, dry, gritty, reddened

RA - episodic arthritisVaginal Dryness

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Systemic: fever, weight loss, fatigue, Raynauds

Sarcoidosis

What is sarcoidosis? An autoimmune disease in which abnormal collections of chronicinflammatory cells (granulomas) form in multiple organs.

What is its Aetiology? Unknown; environmental, genetic factors link with HLAB8 DR3

AGE 10-40years

S&S May be assymptomatic

Common symptoms are:

Fatigue unchanged by sleep

Lack of energy

Weight loss

Aches & pains

Arthritis

Dry eyes SOB

Blurry vision

Rashes and noduli

Diagnosis Chest x-ray or CT scann

Whatd a hand xray look like? Hand x-ray reveals osseous erosions bilaterally.

Swollen fingersArrows: granulomous erosion

OA

What is it? A degenerative condition of synovial joints affecting the

articular cartilage and subchondral bone.

S&S Joint pain, tenderness, stiffness, locking and effusionCauses Hereditary, mechanical, metabolic, developmental

http://en.wikipedia.org/wiki/Granulomashttp://en.wikipedia.org/wiki/Granulomashttp://en.wikipedia.org/wiki/Granulomashttp://en.wikipedia.org/wiki/Granulomas

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Progression Slow

Explain the process?

BS RED

1. Breakdown of articular surface cartilage becomes

fissured. Small particles of cartilage of break of down

2. Synovial Irritation

Friction from cartilage particles causes the release ofinflammatory mediators

3. Remodelling

Cartilage is slow to repair due to its poor bloods supply. The

increased pressure on the bone causes excessive subchondral

activity causes increase in bone cells and density giving rise

to osteophytes.

4. Eburnation of bone & cyst formation:

Eventually cartilage layer may be completely eroded. This

causes bone on bone contact pain & the exposed bonebecoming polished & eburnated. This causes changes in

structure & overloads certain parts of the joint causing micro-

fracture in the cancellous (spongy/less dense bone). Healing

via callus formation leading to increased rigidity, increased

density & reduced resilience, in turn there are more micro

fracture

5. Disorganisation

Cells grow back in a disorganised

What is the common demographic

for O/A?

The 4 Fs:

Female Fat

Forty

Fair (Caucasian)

What different physiological

stages/events may occur?

How is O/A classified? Primary O/A(no specific underlying cause)

Secondary O/A(secondary to an identifiable cause) Metabolic: calcium crystal deposition, acromegal

Inflammatory: A/S, septic arthritis

Congenital / Developmental: Perthes disease, slippedupper femoral epiphysis, CDH

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Traumatic:joint trauma, surgery, chronic injury,

neuropathic

What are the risk factors? increasing age, gender, obesity

trauma, repetitive occupational trauma

genetic factors, history of inflammatory arthritis, metabolic

disorderneuromuscular disorder, infection

Which joints are normally involved? Typically the weight bearing joints & hands

How is the patients general health? Systemically well

What is the character of their pain? Often burning or aching in character

What is their pain pattern like? Worse after activity or at the end of the day

What is causing the pain? Inflammatory mediators, intra-articular hypertension,

bursitis, enthesis pain (tendinous attachment to bone), muscle

weakness, lack of use

Relieved by? Relieved by rest

What is the joints quality of motion

like?

Joints feel stiff to move, patients occasionally mention

clicking or crepitus

Is their any weakness? Weakness is usually a secondary issue due to lack of muscle

activity

What are Herbedens Nodes? Heberdens nodes often affects the base of thumb & DIP

joints. Initially are red, swollen & tender, over time swellings

become firm & painless. Despite the nodes function is usuall

good, however the thumb may be a persistent problem.

Typical of OA

What should you observe for? Observation look for altered weight bearing, joint deformity

muscular wasting (secondary to disuse) swelling of whole

joint often with effusion

What should you palpate? Palpate for swelling often with effusion, crepitus on

movement and ROM or joint deformity

What is the aim of osteopathic OA

TTT?

Given that there is no cure for osteoarthritis

Aim of treatment: reducing pain levels

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maintain function

develop muscle strength (OA knees)

Hip OA