Musculoskeletal exam chapters 61 to 63 ***Only content on blue print, Will discuss any changes in
class*******
RHEUMATOID ARTHRITIS/OSTEOPOROSIS/GOUT/SYSTEMIC LUPUS ERYTHEMATOSUS= 8
RHEUMATOID ARTHRITIS
WHAT IS IT?
Autoimmune disease characterized by inflammation connective tissue in the diarthrodial
(synovial) joints.
RA is typically marked by periods of remission and exacerbation.
INCIDENCE:
Increase w/ age, peaking btw 30 – 50 years
3x as many women
More common in whites
Native Americans – higher incidence of RA
Black and Hispanic women are at greater risk than white women for developing RA
Hispanic & blacks incidence of arthritis more related to limitations: scleroderma ( Chronic
hardening and tightening of the skin and connective tissues.)
Ankylosing spondylitis – more common in whites
Ankylosing spondylitis (AS) is a rare type of arthritis that causes pain and stiffness in your spine.
This lifelong condition, also known as Bechterew disease, usually starts in your lower back. It can
spread up to your neck or damage joints in other parts of your body.
DIAGNOSTIC:
Immunoglobulin G( IgG) – abnormal; autoantibodies are known as rheumatoid factor ( RF). –
Leads to an inflammatory response.
Neutrophils are attracted to the site of inflammation, where they release proteolytic enzymes
that damage articular cartilage and cause the synovial lining to thicken.
These cytokines drive the inflammatory response in RA.
Some patients report a precipitating stressful event, such as infection, work stress, physical
exertion, childbirth, surgery, or emotional upset. However, research has been unable to
directly correlate such events with RA onset.
Rheumatoid Arthritis
Parameter Osteoarthritis
Young to middle age. Usually older than 40 years.
Age at onset
, Rheumatoid Arthritis
Parameter Osteoarthritis
Female-to-male ratio is 2:1 Females 2:1 after age 60; except
Gender or 3:1. Less marked sex for traumatic arthritis, men less
difference after age 60. affected until age 70 or 80.
Lost or maintained weight. Often overweight or obese.
Weight
Systemic disease with Localized disease with variable,
Disease exacerbations and progressive course.
remissions.
Small joints typically affected Weight-bearing joints of knees
Affected joints first (PIPs, MCPs, MTPs), and hips, small joints (MCPs,
wrists, elbows, shoulders, DIPs, PIPs), cervical and
knees. Usually bilateral, lumbar spine. Often
symmetric joint asymmetric.
involvement.
Stiffness lasts 1 hr to all day Stiffness occurs on arising but
Pain and may ↓ with use. Pain is usually subsides after 30 min.
characteristics variable, may disrupt sleep. Pain gradually worsens with
joint use and disease
progression, relieved with joint
rest but may disrupt sleep.
Common. Uncommon.
Effusions
Present, especially on Heberden’s (DIPs) and
Nodules extensor surfaces. Bouchard’s (PIPs) nodes.
WBC count 5000–60,000/μL WBC count <2000/μL (mild
Synovial fluid with mostly neutrophils; ↓ leukocytosis); normal viscosity.
viscosity.
Joint space narrowing and Joint space narrowing,
X-rays erosion with bony osteophytes, subchondral
overgrowths, subluxation cysts, sclerosis.
with advanced disease.
Osteoporosis related to
decreased activity,
, Rheumatoid Arthritis
Parameter Osteoarthritis
corticosteroid use.
Rheumatoid factor positive in Rheumatoid factor negative.
Laboratory 70%–90% of patients;
findings negative titers in early
disease for about 25% of
patients.
↑ In ANA titer likely. ANA negative.
Positive anti-CCP in 60%– Anti-CCP negative.
80% of patients
↑ ESR, CRP indicative of Transient elevation in ESR
active inflammation. related to synovitis.
, Rheumatoid Athritis: Look for Ulnar Deviation “ swan – neck “ deformity
Sjögren’s syndrome can occur by itself or with other arthritic disorders, such as RA and SLE
(Systemic lupus E). The inflammation of RA can damage the tear-producing (lacrimal)
glands, making the eyes feel dry and gritty.11 Suggest the patient use OTC artificial tears
Affected patients may have photosensitivity. (Sjögren’s syndrome is discussed later in this
chapter on p. 1526.)
Felty syndrome is rare but can occur in those with long-standing RA. It is characterized by an
enlarged spleen and low white blood cell (WBC) count. Patients with Felty syndrome are at
increased risk for infection and lymphoma.
Flexion contractures and hand deformities cause decreased grasp strength and affect the
patient’s ability to perform self-care tasks. Depression may occur. However, it is unclear if the
patient becomes depressed from struggling with chronic pain and disability or if depression is
part of the autoimmune disease process. Levels of C-reactive protein (CRP), a marker of
inflammation, are higher in patients with depression compared to those with no symptoms of
depression.
Rheumatoid nodules: Access the nodules for skin breakdown or infection. The nodules can
break down or become infected. They are not surgically removed as they have a high
probability of recurrence.
Taking a warm shower or bath is recommended to relieve joint stiffness, which is worse in the
morning.
Isometric exercises would place stress on joints and would not be recommended. Stretching
and ROM should be done later in the day, when joint stiffness is decreased.
