C. Luck, C. Stanger, D. Anderson, S. Schlake Rheumatoid Arthritis ● ● ● ● ● ● Screening: ○ Are you stiff in the morning? If yes, how long does this last? ○ Does your stiffness increase after sitting? Does aspirin or ibuprofen help? ○ Where do you think the pain is coming from? If joints, which ones are involved? ○ Do you ever notice any joint swelling or other changes? ○ Does anyone else in your family have RA or other kinds of arthritis? Signs and Symptoms: ○ Abrupt onset of bilateral, symmetrical joint swelling, erythema, and pain ○ Common Sites of Involvement: hands, feet, wrists, shoulders, elbows, hips, knees, ankles. Essentially every joint can be involved. ○ After initial onset, symptoms are insidious and progress slowly. ○ Peak onset 20-50 y/o ○ Soreness, stiffness, tightness in joints ○ Severe early morning stiffness takes >30-60 minutes to subside ○ Prolonged rest and intense activity aggravate symptoms ○ Short rest and mild activity ease symptoms Red Flags: ○ Joint pain associated with malaise, low-grade fever, anorexia, weight loss, fatigue, nutritional deficiencies, weakness, anemia, enlarged spleen, lymphadenopathy ○ Unexplained joint pain for 1 month or more, especially when accompanied by systemic complaints, skin rash, or extensor nodules Clinical Guidelines: ○ Interdisciplinary approach ■ Includes: drug therapy, PT and/or OT, and recreational therapy ○ PT examination items: ■ Measurement of independence with functional activities ■ Measurement of joint inflammation and ROM ■ Determination of limiting factors such as pain, weakness, and fatigue ○ PT intervention items: ■ Energy conservation techniques ■ Therapeutic positioning to prevent development of deformities (i.e. splinting) ■ Joint protection techniques ■ Prescription of ambulatory and adaptive devices (may overlap with OT) ■ Pain relief measures: strengthening, exercises for increasing joint extensibility, ice, and heat ■ Improve general fitness and encourage regular exercise at low to moderate aerobic intensity Medical Tests for Screening and Diagnosis: Morning Stiffness Arthritis in 3 or more joints Antinuclear Antibody Titer Arthritis of Hand Joints Symmetric Arthritis Radiographic Changes Rheumatoid Nodules Serum Rheumatoid Factor Blood Tests, US, Radiography Squeeze Test Medications: ○ Indications: ■ Aspirins and NSAIDS, corticosteroids, gold, penacillamine ■ Disease Modifying Anti-Rheumatic Drugs - DMARDS (Methotrexate, Sulphasalzine & Hydroxychloroquine) ○ Contraindications: ■ DMARDS blood tests: bone marrow suppression, liver & renal dysfunction ○ Potential Adverse Effects: stomach ulcers (aspirins, NSAIDS), osteoporosis (corticosteroids), impaired renal function (gold, penicillamine), diarrhea and nausea, skin reactions, pneumonitis, immunosuppression (DMARDS) C. Luck, C. Stanger, D. Anderson, S. Schlake References: Boissonnault WG. Primary Care for the Physical Therapist: Examination and Triage. St. Louis, Missouri: Elsevier, Inc; 2005. Clinical Guideline for the Diagnosis and Management of Early Rheumatoid Arthritis. South Melbourne, Victoria, Australia: The Royal Australian College of General Practitioners; 2009. Available at: http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/cp118-early-rheum-arthritis.pdf. Accessed February 14th, 2015. Dutton M. Dutton’s Orthopaedic Examination Evaluation and Intervention, Third Edition. United States: McGrawHill Companies, Inc; 2012: 197-199, 731. Goodman CC. Pathology: Implications for the Physical Therapist, Third Edition. St. Louis, Missouri: Elsevier, Inc; 2009. Rheumatoid arthritis: The management of rheumatoid arthritis in adults. National Institute for Health and Care Excellence Web site. 2014. Available at: http://www.nice.org.uk/guidance/cg79/chapter/1-recommendations#themultidisciplinary-team. Accessed February 14, 2015. Ryan S. Rheumatoid arthritis diagnosis and management. Practice Nurse [serial online]. June 13, 2014;44(6):3640. Available at: CINAHL with Full Text, Ipswich, MA. Accessed February 16, 2015.