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RCS 6080 Medical and Psychosocial Aspects of Rehabilitation Counseling

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1 RCS 6080 Medical and Psychosocial Aspects of Rehabilitation Counseling
Rheumatic Diseases

2 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

3 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

4 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

5 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

6 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

7 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

8 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 Sjögren'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.

9 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. 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

10 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.

11 Treatment Surgery: video Physical therapy Removal of inflamed synovium
Arthroplasty Physical therapy Flexion 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.

12 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

13 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

14 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.

15 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.

16 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.

17 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.

18 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.

19 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

20 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

21 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) Oligoarthritis: Inflammation of four or fewer joints. Human leukocyte antigen B27 HLA-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 spondylitis Reiter's syndrome sacroiliitis (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 bleeding fainting or feeling light-headed hematoma (blood accumulating under the skin) infection (a slight risk any time the skin is broken) multiple punctures to locate veins

22 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 Sclerosis: hardening of tissue due to chronic infection

23 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

24 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

25 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.

26 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

27 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

28 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.

29 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)

30 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.

31 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

32 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

33 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

34 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

35 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 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

36 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

37 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

38 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

39 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

40 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

41 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

42 Additional Resources and Information from the Web
American College of Rheumatology ( National Institute of Arthritis and Musculoskeletal and Skin Diseases ( Arthritis Foundation ( Arthritis National Research Foundation ( Info on Juvenile RA ( Spondylitis Association of America ( Latest Arthritis Information & Community (

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