Arthritis and other Connective Tissue Problems

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  1. Rheumatology
    Connective tissue disease (CTD) is a major focus of rheumatology.Rheumatic disease is any disease or condition involving the musculoskeletal system.most connective tissues are autoimmune diseases where autobodies attack the normal cells=progressive joint deterioration and chronic pain.
  2. Define Arthritis
    Inflammation of one or more joints.
  3. What Osteoarthritis is not
    Noninflammaotry, not systemic, not autoimmune
  4. Inflammatory arthritis
    • Rheumatoid arthritis
    • Systemic lupus erythematosus
    • Autoimmune disease
    • Connective tissue disease that is inflammatory
  5. Osteoarthritis
    • Most common type of arthritis (hip, knees, hands)
    • Joint pain and loss of function characterized by progressive deterioration and loss of cartilage in the joints
  6. Synovitis
    synovial inflammation
  7. Subluxation
    partial joint dislocations, joint deformities
  8. Osteophytes
    bone spurs
  9. Hx of OA
    • pain, swelling in joint (commonly in hands)
    • ADLs affected by time of diagnosis: walking, hand issues ect.
    • aging
    • genetic
    • obesity-hip knees (weight bearing joint problem already have an increased risk)
    • smoking
    • trauma
  10. Physical assessment and clinical manifestations:
    • Joint involvement: joint pain
    • Heberden's nodes: in proximal interphalangeil joint
    • Bouchard’s nodes: middle interfalangel joint
    • Joint effusions – excess joint fluid-easily observed on the knee, you can tape the knee cap and feel it floating
    • Atrophy of skeletal muscle (aka muscle wasting)
    • Ballottement – excess joint fluid
  11. Assessment of OA
    • Laboratory assessment of erythrocyte sedimentation rate and C-reactive protein (may be slightly elevated)
    • Radiographic assessment-x-ray
    • Other diagnostic assessments-MRI imaging, CT studies
  12. Chronic Pain: Nonsurgical Management
    • Analgesics-reduce pain and joint inflammation
    • tylenol - risk for liver damage at high doses
    • Rest-splinting/bracing to rest the joint
    • Positioning-keep joint in as normal position as possible
    • Thermal modalities-heat and cold applications
    • Weight control-nutrition therapy, losing weight helps reduce pain/takes pressure off
    • Integrative therapies-CAM
  13. Chronic Pain: Surgical Management
    • Total joint arthroplasty (TJA)/Total joint replacement (TJR)
    • Arthroscopy-smooth surface
    • Osteotomy-smooth away bone in more open procedure
  14. Post-op care for THA
    • Assessment of bleeding
    • Management of anemia
    • Hip Abductor pillow-To prevent hip dislocation
    • Hip Flexion After Total Hip Replacement-knees below hip after surgery, no more then 90 degree bend, don’t cross legs= dislocation
    • assistive advices- initially (shoes and socks)
  15. Prevention of Complications with THA
    • Assessment for neurovascular compromise
    • Management of pain
    • Progression of activity
    • Promotion of self care
  16. Post-op care for TKA
    • Continuous passive motion machine
    • Hot/ice device
    • Pain management
    • Neurovascular assessment
  17. Rheumatoid Arthritis
    • One of the most common connective tissue diseases and the most destructive to the joints
    • Chronic, progressive, systemic inflammatory autoimmune disease affecting primarily the synovial joints-characterized by remissions and exacerbations
    • Autoantibodies (rheumatoid factors) formed that attack healthy tissue, especially synovium, causing inflammation
    • Affects synovial tissue of any organ or body system
  18. RA Pathology
    • synovium thickens
    • fluid arrives
    • panis developed in the joint
    • erosion of cartilage
    • eventual break down of bone
    • unclear cause - combo of environment and genetic; women more than men; may be hormone related; may be an infection; may be stress
  19. Assessment of RA
    • join mobility
    • pain
    • annorexia/weight loss- early
    • persistent low grade fever --- differentiates Osteo from RA
    • bilateral and symmetrical --- osteo only affects one hand
  20. Early and Late manifestations of RA
    • Assessment
    • join mobility
    • pain
    • annorexia/weight loss- early
    • persistent low grade fever --- differentiates Osteo from RA
    • bilateral and symmetrical --- osteo only affects one hand
  21. RA Systemic Complications
    • Weight loss, fever, and extreme fatigue
    • Exacerbations
    • Subcutaneous nodules- ulnar surface arm, fingers, achilles tendons (appear and disappear)
    • Pulmonary complications-
    • Vasculitis- arterial problems, lung nodules, anoxia issues
    • Periungual lesions
    • Paresthesias- burning an dtingling
    • Cardiac complications
    • pulmonary HTN
  22. A—Associated Syndromes
    • Sjögren’s syndrome: dry eyes, dry mouth (teeth start breaking down, and can’t swallow), dry vagina. MOST COMMON! mild or extreme.
    • Felty’s syndrome: hepatospleenomegla
    • Caplan’s syndrome: nodules in lungs
  23. Assessment tests for RA
    • Laboratory assessment—rheumatoid factor, antinuclear antibody titer, erythrocyte sedimentation rate (elevated), serum complement, serum protein electrophoresis, serum immunoglobulins
    • Other diagnostic assessments—x-ray, CT, arthrocentesis, bone scan
  24. RA—Drug Therapy
    • Disease-modifying antirheumatic drugs
    • NSAIDs
    • Biologic response modifiers
    • Glucocorticoids
    • Immunosuppressive agents
    • Gold therapy
    • Analgesic drugs
  25. RA—Nonpharmacologic Interventions
    • Adequate rest
    • Proper positioning
    • Ice and heat applications
    • Plasmapheresis- take plasma off and try to remove autobodies, give back blood cells (get rid of antibodies because those may cause the breakdown of the joint)
    • Gene therapy
    • Complementary and alternative therapies
    • Promotion of self-care- alternatvie methods, assistive devies, use lg muscle not sm
    • Management of fatigue- energy conservation (like w/ lung disease: do one ADL and rest then repeat)
    • Enhancement of body image- example regular clothing, beauty parlor get your hair done
  26. Lupus Erythematosus (rheumatic disease)
    • Chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. (most people have systemic)-small % have discoid that only affects skin
    • Characterized by spontaneous remissions and exacerbations.
    • Autoimmune complexes tend to be attracted to the glomeruli of the kidneys.
    • Many patients with SLE have some degree of kidney involvement-leading cause of death = kidney failure
  27. Clinical Manifestations of Lupus
    • Skin involvement
    • alopecia
    • Polyarthritis-arthritis in small joints and knees - not severely deforming
    • Osteonecrosis-especially with chronic steroid therapy
    • Muscle atrophy
    • Fever and fatigue- classic sign!!!!
    • Characteristic “Butterfly” Rash of Lupus
    • nephritis = leading COD
    • pneumonia
    • Pericarditis- most common carido sign, chest pain, myocardial
    • Raynaud’s phenomenon-on exposure to cold or stress,fingers/toes white or blue - very painful
    • Neurologic manifestation
    • Serositis
  28. Assessment for Lupus
    • Skin biopsy
    • Immunologic-based lab tests (same as RA)
    • CBC
    • Body system function test (Renal, cardiac, electrolyte, etc)
  29. DLE—Drug Therapy (discoid lupus)
    • Topical drugs-especially for discoid--cortisone
    • Plaquenil (chloroquine)-antimalarial
    • Tylenol or NSAIDs
    • Chronic steroid therapy
    • Immunosuppressive agents--methotrexate
    • all these drugs increase risk for infection!
  30. Scleroderma (Systemic Sclerosis)
    • Chronic, inflammatory, autoimmune connective tissue disease
    • Not always progressive
    • Hardening of the skin is one manifestation
  31. CREST Syndrome (scleroderma)
    • C—calcinosis: calcium deposits throughout body
    • R—Raynaud’s phenomenon: cold/stress - lead to diginecrosis/severe
    • pain; tips can fall off from poor circulation
    • E—esophageal dysmotility:
    • S—sclerodactyly (scleroderma of the digits): sausage like fingers
    • T—telangiectasia (spider like hemangiomas)
  32. Clinical Manifestations (other that CREST)for scleroderma
    • Arthralgia joint pain throughout body
    • GI tract dysphagia; reflux; decreased peristalsis, malabsorption syndrome
    • Cardiovascular system: raynauds, paracardial fibrosis
    • Pulmonary system pulmonary fibrosis
    • Renal system almost always have renal involvement - lead to malignant HTN and death
  33. Gout
    Also called gouty arthritis, a systemic disease in which urate crystals deposit in the joints and other body tissues, causing inflammation. most common inflammatory disease of older adults.
  34. Primary vs Secondary Gout
    • Primary gout: inborne purine malmetabolism with uric acid. usually excreted by kidneys but production exceeds the excretion and its deposited into tissues= inflammation.
    • Secondary gout—hyperuricemia (excessive uric acid in the blood)-caused by renal insufficiency; diuretic therapy; chemotherapy
  35. Tophi
    deposits of uric acid like little bubbles on ears with yellowish straw fluid.
  36. Drug therapy - specific for gout
    • colchicine - acute flairs of gout-given with NSAID to decrease inflammation
    • alopurinol - chronic-prevents production of uric acid. long term
    • probenicid - chronic - promotes excretion of uric acid. long term
  37. Nutritional therapy for Gout
    certain foods cause gout attacks: pork (purine, pyrimadine= uric acid crystal)
  38. Lyme Disease
    • bulls eye rash: is first thing you may see with tick bite in middle and rash around edges.
    • Reportable systemic infectious disease caused by the spirochete Borrelia burgdorferi, resulting from the bite of an infected deer tick.
    • If not diagnosed and treated in early stages, chronic complications such as arthralgias, fatigue, and memory and thinking problems, bells paulsy can result.
    • For some patients, the first and only sign of Lyme disease is arthritis.
    • avoid tick bites in woods or grass lands and check for ticks
  39. Stages I and II of Lyme Disease
    • 1: flu like symptoms; bulls-eye rash; for some pt’s the first and only sign is arthritis
    • 2: if not picked up early and no antibiotic tx = carditis; dysrhythmias; dyspnea; dizziness; palpitations; meningitis; facial paralysis; peripheral neuritis
  40. Fibromyalgia Syndrome
    • Chronic pain syndrome, not an inflammatory disease, looks like arthritis
    • pain and tenderness in back of neck, chest, upper truck and are called “trigger points” if they are hit they cause pain. pain in predictable and reducible patterns. “Gnawing pain” in character.
    • symptoms worsen in response to stress, increased activity and weather changes
    • treated with anti-depressives (b/c pain all the time) nsaids, muscle relaxants and physical therapy.
  41. Chronic Fatigue Syndromes
    • immune dysfunction syndrome - Chronic illness in which patients have severe fatigue for 6 months or longer, usually following flu-like symptoms.
    • Sore throat; substantial impairment in short-term memory or concentration; tender lymph nodes; muscle pain; multiple joint pain with redness or swelling; headaches of a new type, pattern, or severity; unrefreshing sleep; and postexertional malaise lasting more than 24 hours
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Arthritis and other Connective Tissue Problems
Arthritis and other Connective Tissue Problems
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