Presentation on theme: "RCS 6080 Medical and Psychosocial Aspects of Rehabilitation Counseling"— Presentation transcript:
1RCS 6080 Medical and Psychosocial Aspects of Rehabilitation Counseling Rheumatic Diseases
2Rheumatoid ArthritisThe 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 65The incidence also increases with age, peaking between the 4th and 6th decadesThe annual incidence for all adults has been estimated at 67 per 100,000
3Rheumatoid ArthritisBoth prevalence and incidence are 2-3 times greater in women than in menAfrican Americans and native Japanese and Chinese have a lower prevalence than CaucasiansSeveral North American Native tribes have a high prevalenceGenetic factors have an important role in the susceptibility to rheumatoid arthritis
4Rheumatoid ArthritisRheumatoid 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 tissuesThe cause of rheumatoid arthritis is not knownInvestigating possibilities of a foreign antigen, such as a virus
5Rheumatoid Arthritis Description Morning stiffnessArthritis of 3 or more jointsArthritis of hand jointsSymmetric arthritisRheumatoid nodulesSerum rheumatoid factorRadiographic changesA 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
6Rheumatoid ArthritisRheumatoid arthritis usually has a slow, insidious onset over weeks to monthsAbout 15-20% of individuals have a more rapid onset that develops over days to weeksAbout 8-15% actually have acute onset of symptoms that develop over days
7Functional 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 jointProgression of the disease results in reducible and later fixed deformitiesMuscle weakness and atrophy develop early in the course of the disease in many people
8Complications 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 anemiaSjögren's ("SHOW-grins") syndrome is a chronic disease in which white blood cells attack the moisture-producing glands. The hallmark symptoms are dry eyes and dry mouth, but it is a systemic disease, affecting many organs and may cause fatigue. It is one of the most prevalent autoimmune disorders, striking as many as four million Americans.
9Treatment and Prognosis MedicationsNSAIDS - 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.As many as 75% of patients improve symptomatically with conservative treatment during the first year of disease. However, >= 10% are eventually severely disabled despite full treatment. The disease greatly affects the lives of most RA patients.Complete bed rest is occasionally indicated for a short period during the most active, painful stage of severe disease. In less severe cases, regular rest should be prescribed. Splints provide local joint rest. Joint range of motion and exercise as tolerated must be continued. An ordinary nutritious diet is generally sufficient. Rarely, patients have food-associated exacerbations. Food and diet quackery is common and should be discouraged. However, fish or plant oil supplements may partially relieve symptoms because they can decrease production of prostaglandins.Hydroxychloroquine can also control symptoms of mild or moderately active RA. Toxic effects usually are mild and include dermatitis, myopathy, and generally reversible corneal opacity. However, irreversible retinal degeneration has been reported.Sulfasalazine, long used for ulcerative colitis, is now increasingly used for RA (for which it was developed). It is usually given as enteric-coated tablets, starting with 500 mg/day and increasing 500 mg at weekly intervals to 2 to 3 g/day. Benefit should occur within 3 mo.Oral penicillamine may have a benefit similar to gold and may be used in some cases if gold fails or produces toxicity in patients with active RA
10MedicationsCorticosteroids – 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.
11Treatment Surgery: video Physical therapy Removal of inflamed synovium ArthroplastyPhysical therapyFlexion contractures can be prevented and muscle strength restored most successfully after inflammation begins to subside. Joint splinting reduces local inflammation and may relieve severe local symptoms. Before acute inflammation is controlled, passive exercise to prevent contracture is given carefully and within the limits of pain. Active exercise (including walking and specific exercises for involved joints) to restore muscle mass and preserve the normal range of joint motion is important as inflammation subsides but should not be fatiguing. Established flexion contractures may require intensive exercise, serial splinting, or orthopedic measures. Orthopedic or athletic shoes with good heel and arch support can be modified using inserts to fit individual needs and are frequently helpful; metatarsal bars placed posteriorly to painful metatarsophalangeal joints decrease the pain of weight bearing.Although synovectomy only temporarily relieves inflammation, arthroscopic or surgical synovectomy may help preserve joint function if drugs have been unsuccessful. Arthroplasty with prosthetic replacement of joint parts is indicated if joint damage severely limits function: Total hip and knee replacements are the most consistently successful. Prosthetic hips and knees cannot be expected to tolerate resumption of vigorous activities (eg, competitive athletics). Excision of subluxated painful metatarsophalangeal joints may greatly aid walking. Thumb fusions may provide stability for pinch. Neck fusion may be needed for C1-2 subluxation with cord compression or severe pain. Surgical procedures must always be considered in terms of the total disease. Deformed hands and arms limit crutch use during rehabilitation; seriously affected knees and feet prevent full benefit from hip surgery. Reasonable objectives for each patient must be determined, and function must be considered before appearance. Surgery may be performed while the disease is active. Self-help devices enable many patients with severe debilitating RA to perform activities of daily living.
12Vocational 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 supportMotor coordination, finger and hand dexterity, and eye-hand-foot coordination are adversely affectedVocational goals dependent on fine, dexterous, or coordinated movement of the hand are not ideal
13Vocational Implications of Rheumatoid Arthritis Most jobs requiring medium to heavy lifting are not desirableActivities such as climbing, balancing, stooping, kneeling, standing, or walking are hamperedExtremes of weather or abrupt changes in temperature should be avoided – indoor controlled climate better
14LupusSystemic 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.
15Lupus - AnatomySLE 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.
16Lupus 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.
17Lupus 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.
18Lupus AnatomyLupus 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.
19Seronegative Spondyloarthropathy Consist of a group of related disorders that include Reiter's syndrome, ankylosing spondylitis, psoriatic arthritis, and arthritis in association with inflammatory bowel diseaseOccurs more age at diagnosis in the third decade and a peak commonly among young men, with a mean incidence between ages 25 and 34The prevalence appears to be about 1%The male-to-female ratio approaches 4 to 1 among adult CaucasiansGenetic factors play an important role in the susceptibility to each disease
20Seronegative Spondyloarthropathy The cause is unclear, but there is strong evidence that the initial event involved interaction between genetic factors and environment factors, particularly bacterial infectionsReiter’s syndrome may follow a wide range of GI infectionsBowel inflammation has been implicated in the pathogenesis of endemic Reiter’s syndrome, psoriatic arthritis, and ankylosing spondylitis
21Seronegative 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-B27These disorders are characterized by inflammation at sites of attachment of ligament, tendon, fascia, or joint capsule to bone (enthesopathy)Oligoarthritis: Inflammation of four or fewer joints.Human leukocyte antigen B27HLA-B27 is found in 5 to 7% of Caucasian people without autoimmune disease.What abnormal results mean A positive test indicates a greater than average risk for developing:ankylosing spondylitisReiter's syndromesacroiliitis (inflammation of the sacroiliac joint)In the presence of suggestive clinical findings, a positive HLA-B27 test may confirm the diagnosis.What the risks are excessive bleedingfainting or feeling light-headedhematoma (blood accumulating under the skin)infection (a slight risk any time the skin is broken)multiple punctures to locate veins
22Sacroiliitis 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 jointsSclerosis: hardening of tissue due to chronic infection
23Ankylosing 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
24Ankylosing 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.ExerciseMedications: NSAIDs, SulfasalazinePosture managementSelf-help aidsSurgery
25Reiter's SyndromeArthritis 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.
26Reiter's SyndromeReiter'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
27Reiter's SyndromeFor different parts of the body, different treatments are used:Medications: NSAIDs, antibiotics, topical skin medicationsEye dropsJoint protectionVarious symptoms are treated by healthcare specialists
28Psoriatic ArthritisCauses 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/toenailsPain and swelling in one or more jointsSwelling of fingers/toes that gives them a "sausage" appearance.
29Psoriatic ArthritisDiagnosis may involve X-rays, blood tests, and joint fluid tests.Treatment options:Skin careLight treatment (UVB or PUVA)Corrective cosmeticsMedications: glucocorticoids, NSAIDs, DMARDs (disease-modifying anti-rheumatic drugs)ExerciseRestHeat and coldSplintsSurgery (rarely)
30Inflammatory 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.
31Inflammatory 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:DietExerciseMedication: Corticosteroids, Immunosuppressants, NSAIDs, SulfasalazineSurgery
32Functional Presentation and Disability of the Spondylarthropathies When the axial skeleton is involved, the initial symptom is morning stiffness and lower back painAs the disease worsens, there is progressive diminution of motion of the spineEventually, the sacroiliac joints, lumbar, thoracic, and cervical spine become fusedAt 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
33Functional 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 decreasedFrequently, peripheral joints are involved, and the pattern is usually asymmetric oligoarthritis involving primarily the large or medium joints, including the hips, knees, and anklesRarely are smaller joints or the joints in the upper extremities involvedLoss of motion of the spine or pain in the spine with motion generally affects a person's mobility
34Functional Presentation and Disability of the Spondylarthropathies Walking remains unimpaired unless the hips and knees are affectedFrequent stooping and bending become impossibleA person with ankylosing spondylitis typically is able to continue vocational activity despite progressive stiffness, unless it requires significant back mobility or physical labor
35Vocational Implications of the Spondylarthropathies The person should be considered for vocational or professional education as resources and interests dictateA stiff back will limit the person’s rotation and flexion so that overall dexterity may be affectedTasks that require reaching or bending will be difficult and lifting over pounds may cause increased back painClimbing and balancing skills, stooping, and kneeling may be tolerated initially but become difficult as the disease worsensNeed time to stretch spine frequently
36Degenerative 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 boneThe disease usually begins in one’s 40sPrevalence increases with age and the disease becomes almost universal in individuals aged 65 and olderPrimarily affects weight-bearing joints such as the knees, hips, and lumbrosacral spine
37Degenerative Joint Disease Cause is unclearConsidered to be a “wear and tear” arthritis and is thought to occur as a consequence of some earlier damage or overuse of the jointObesity is frequently associated with itGenetic factors play a role in the development that is sex-influenced and dominant in females, resulting in an incidence 10 times greater than in menThe final outcome is full-thickness loss of cartilage down to bone
38Degenerative Joint Disease In early disease, pain occurs only after joint use and is relieved by restAs the disease progresses, pain occurs with minimal motion or even at restNocturnal pain is commonly associated with severe disease
39Functional Limitations and Degenerative Joint Disease Limited use of the involved jointWalking and transfer activities may be impairedGenerally, ADLs will not be significantly impaired
40Treatment and Prognosis of Degenerative Joint Disease MedsEarly PT/exercisesHeat/cold therapyJoint protectionSurgeryOsteoarthritis is a slowly progressive diseaseThe eventual outcome is complete destruction of the joint, and ultimately surgical intervention is required
41Vocational Implications and Degenerative Joint Disease Can continue in present job unless it requires dexterous or heavy use of the involved jointHeavy lifting should be avoidedLight to medium work should be possibleClimbing, balancing skills, stooping, and kneeling may be impairedReturning to work after surgery requires intensive postop rehab and continued exercise to maintain muscle strengthMost individuals are able to sustain gainful employment and a normal level of activity
42Additional 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)