What is gout?
- genetic disorder of purine metabolism
- Increase serum uric acid (hyperuricemia)
- Acid ▲ to crystals and deposits into joints
Joints most commonly affected by gout
knee
great toe
Gout Rx Meds + PT
Meds: NSAIDS, cox2-inhibitors, corticosteroids, ACTH
PT goals: injury prevention, education, fast intervention
OA risk factors
- Age
- F>M
- Obesity
- Physical inactivity
- Injury
- Joint stress (occupation)
Joints primarily affected by OA
- Spine: osteophytes in facet joints of L-spine = STENOSIS
- Hand - PIP = Bouchard node. DIP = Heberden’s node. CMC joints (esp thumb)
- Knee: most common joint affected by OA: varus, flexion contracture, crepitus
- Hip: walk with Trendelenburg, groin pain, osteophytes, flexion deformities
- Foot: 1st MT joint - osteophytes cause hallux valgus + rigidus, bunions
Uncommon sites for OA
Shoulder
Elbow
Wrist
Ankle
OA X-ray findings + grading system
1) joint space narrowing
2) osteophytosis
3) subchondral cysts
4) subchondral sclerosis
Grading: Kellgren – Lawrence System (0-4)
OA Dx history
- Pain most days of the last month?
- Pain over the last year?
- Worse with activity- stairs (doing down worse), overdoing it
- Relieved with rest - may have ‘gelling’ after inactivity period
3 tests indicative of knee OA
- Flexion contracture
- Abnormal gait
- Swipe test/patellar tap test +ve
OA pain sources
- Bone
- Soft tissue
- Inflammation
- muscle spasm
OA Rx
- Weight loss
- Exercise
- Protective aids
- medications
- Electromodalities
What is the goal for weight loss in OA
Decrease 10% body weight
What is the general exercise prescription for OA
- 30 min mod aerobic training (most days): 10 min bouts
- L/E resistance training
What types of protective aids might be useful in OA
Braces
Orthotics
Adaptive aids
What type of medication is used to treat OA
Acetaminophen - because it is not inflammatory
What EPA might be useful in OA
Tens
What are the two types of femoral acetabular impingement
- Cam
- Pincer
What is CAM impingement and who does it occur in
femoral head is not perfectly round leading to it driving into acetabulum with hip flexion
Young men
What is Pincer impingement and who does it occur in
abnormal acetabulum provides excessive cover of femoral head
• retroverted or deep acetabulum
women 30-40 years
Is rheumatoid factor present in spondyloarthritis
no
What is spondyloarthritis
Arthritis that attacks the spine
Characteristics of spondyloarthritis
- Spine inflammation: spondylitis and sacroiliitis
- Synovitis: unilateral peripheral joints
- Eye inflammation: iritis/uveitis & conjunctivitis
- NO rheumatoid factor (seronegative)
- Can be hereditary HLA-B27
What is psoriatic arthritis
a form of arthritis that affects some people who have psoriasis — a condition that features red patches of skin topped with silvery scales.
Characteristics of psoriatic arthritis
- Chronic, erosive, inflammation
- Affects digit joints + axial skeleton
Features of psoriatic arthritis
Dactylitis: sausage like fingers d/t swelling
Enthesitis: usually in heels and back
psoriatic arthritis Rx - Meds + PT Goals
Meds: acetaminophen, NSAIDs, DMARDs, corticosteroids, biological response modifiers
PT Goals
- joint protections strategies
- maintain joint mechanics
- endurance
What is Enteropathic spondylitis? What conditions is it seen in?
A spondyloarthritis (SpA) which occurs in patients with inflammatory bowel diseases (IBDs) and other gastrointestinal diseases,
Seen with:
- ulcerative colitis (affects lower half of bowels)
- Crohn’s disease (affects whole digestive system)
What triggers reactive arthritis
Infection in bowel or GI tract
What are the features of reactive arthritis
- hot swollen joints
- may go away and return
- LE
- Symmetrical
What is ankylosing spondylitis
stiffness/fusing of spine d/t inflammation
Is ankylosing spondylitis unilateral or bilateral
usually bilateral disease, but may start initially as unilateral then migrate
When is the onset of ankylosing spondylitis
Usually before 40 - delay is diagnosis of 8-9years
Ankylosing spondylitis cause
Unknown
Associated with HLA B27 marker
Clinical features of ankylosing spondylitis
- Pain: Worst after rest
- Stiffness: AM stiffness in the spine, after periods of inactivity
- Decreased ROM
- Deformity/instability
- Decreased strength - Altered posture/muscle imbalances
- Altered breathing mechanics
- Fatigue
- Deconditioning
What causes altered breathing mechanics in ankylosing spondylitis?
- Flexion posture
- Costovertebral and costochondral involvement of the chest wall limiting lateral costal breathing
What is the typical posture in ankylosing spondylitis
- FHP
- Flattening of the anterior chest wall
- Thoracic kyphosis
- Protrusion of abdomen
- Flattening of the lumbar lordosis
- Slight flexion of the hips
What causes fatigue in ankylosing spondylitis
Disease process
Cardiac involvement
Decreased vital capacity
What are the features of AS (MSK and other systems/organs involved)
- Scroiliitis
- Enthesitis
- Synovitis
- Eyes
- Bowels
- lungs: apical fibrosis, restrictive lung disease, avoid smoking
- Heart: inflammation/scarring of conduction system, aorta inflammation
What is the progression of enthesitis
- Early stage: bony loss - osteopenia
- Later stage: osteoporosis and fusion/rigidity = risk of fractures
- Fractures can impinge on spinal nerves
- Stiffness
What is the proposed sequence of structural damage in ankylosing spondylitis
Inflammation at corners and edges of vertebral bodies
Erosive damage and repairs
New bone formation - syndesmophytes
Fusion/bridging of syndesmophytes
Clinical criteria for ankylosing spondylitis
- LBP + stiffness for more than 3 months - Improves with ex, worse with rest
- AM stiffness
- Altered posture/muscle imbalances
- Decreased strength - deconditioning
- Decreased L-spine ROM in sagittal + front planes - flexion posture
- Altered breathing mechanics- decreased chest expansion compared to normal values, diaphragmatic breathing pattern, decreased vital capacity
- Fatigue d/t disease process
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ankylosing spondylitis Physical Ax
- Posture (tragus to wall)
- lateral trunk flexion
- trunk flexion (modified Schober’s)
- trunk extension (Smythe test)
- trunk rotation
- chest expansion
- cervical mobility
- muscle length and strength
- enthesitis sites
- peripheral joint scan
Ankylosing spondylitis Rx - Meds and physical management
MEDS: DMARDs, NSAIDs, corticosteroids, biologics
PHYSICAL MANAGEMENT
- control/decrease inflammation
- Pain management
- Decrease stiffness/Increase ROM (pool therapy is great)
- posture correction (ergonomics, frequent position changes)
- Increase mm strength and endurance, increase cardio
Ankylosing spondylitis outcome measures
- BASFI (impact of disease on function in last week)
- BASDAI (how disease is managed)
Inflammatory back pain vs. Mechanical back pain: Duration
> 60 min
<40 min
Inflammatory back pain vs. Mechanical back pain: Age of onset
12-40yrs
20-65years
Inflammatory back pain vs. Mechanical back pain: Max pain/stiffness
Early am
Late in day, increase with activity
Inflammatory back pain vs. Mechanical back pain: Type of condition
Chronic
Acute/chronic
Inflammatory back pain vs. Mechanical back pain: X-ray
Sacroiliitis, syndesmophytes, spinal ankylosis
Osteophytes, decreased disc space, misalignment