For PTs requiring to examine and evaluate a patient with rheumatism and arthritis

1. Alexis B. Temblique SPT

2. Rheumatism
• Term used for conditions that causes
chronic pain & inflammation of joint and
other connective tissue
-Author/s (Year)
2

3. Types
1. Degenerative
2. Inflammatory
3. Connective Tissue Disease
4. Crystal Associated
5. Systemic or Extra articular Rheumatism
6. Infectious Arthropathies
7. Post Infection Arthropathies
-Author/s (Year)
3

4. 1. Degenerative
• Osteoarthritis
• Tendonitis
• Bursitis
-Author/s (Year)
4

5. OA
• “Primarily confined to one or more synovial to joints
and its surroundings soft tissues” (O’Sullivan, 2014)
• “OA is classified by its failure of the structure and
function of synovial joints. It is characterized by its
degradation of articular cartilage, subchondral bone
alteration, meniscal degeneration, synovial
inflammatory response, and overgrowth of bone and
cartilage” (Braddom, 2011)
-Author/s (Year)
5

6. Epidemiology
• Osteoarthritis is the most common form of arthritis and
extremely prevalent among individuals over 40 years of
age.
• Based on data from several large population based
studies, it is estimated that approximately 12% of the
U.S. population or 27 million adults age 25 and older
have clinical OA of some joint.32
• It is widespread in adults older than 65
• affects men more than women before age 50, but
reverses after age 50.
(O’ Sullivan, 2014)
6

7. • Due to repetitive loading/stress without
ample recovery time
• Resorption > Depostion
• Can affect both Non weight bearing and
Weight bearing
-Author/s (Year)
7

8. • Hallmark: Joint space narrowing with
Articular cartilage degeneration
• (+) Osteophytes
• (+) Heberdens and Bouchard
-Author/s (Year)
8

9. • Morning stiffness <1hr
• Asymmetrical/ Unilateral pain increases
that increases with activity
• Relieved by rest
-Author/s (Year)
9

10. Risk Factors
• Advanced Age > 45 yr old (Strongest Risk
Factor)
• Obesity and Overweight
• Women
• Low Estrogen level
• Vitamin D Deficiency
• Previous jt. injury
-Author/s (Year)
10

11. (O’Sullivan, 2014)
11

12. • Genetic factors:
– Knee – 39%
– Hand – 59%
– Hip - 60%
-Author/s (Year)
12

13. -Author/s (Year)
13

14. Grading
-Author/s (Year)
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15. -Author/s (Year)
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16. Medications
• Acetaminophen
• Celecoxib
• Corticosteroid injection
• Viscosupplementation
-Author/s (Year)
16

17. 2. Inflammatory
• Rheumatoid Arthritis
• Spondyloarthropathies
-Author/s (Year)
17

18. Rheumatoid arthritis
• “Primarily a disease of the synovium” (O’Sullivan, 2014)
• “A chronic, systemic inflammatory disease of unknown
etiology that primarily involves the joints. It also often
involves soft tissues, such as tendon sheaths and bursae”
(Braddom,2011)
(O’ Sullivan, 2014)
18

19. • “An autoimmune disease in which the joint lining and
occasionally other tissues become inflamed as a result of over
activity of the body’s immune system” (Braddom, 2011)
• “An autoimmune, chronic, inflammatory, systemic disease
primarily of unknown etiology affecting the synovial lining of
joints as well as other connective tissues” (Kisner & Colby,
2013)
-Author/s (Year)
19

20. Epidemiology
• The estimated prevalence of RA among adults in the
United States is approximately 1.3 million,4 and
prevalence increases with age. Women are effected two
to four times more often than men.
• African Americans < whites
• There also is a lower prevalence of RA in native
Japanese and native Chinese peoples compared to
whites.
(O’ Sullivan, 2014)
20

21. • Unknown
• Autoimmune
• F>M 3:1
-Author/s (Year)
21

22. • Signs and Symptoms:
• Symmetrical / Bilateral Pain and Swelling
• Morning Stiffness > 1hr
• Upto 1/3rd of pt with Polyarthritis presents c:
– Fatigue
– Myalgia
– Depression
– Low Grade Fever
– Weight Loss
-Author/s (Year)
22

23. • MC in :
• MCP
• Wrist
• PIP
• Knee
• Shoulder
• Ankle
• Cervical
• Hip
• Elbow
• TMJ
• Rare in DIP
-Author/s (Year)
23

24. • (+) Pannus Formation
• (+) Heberdens and Bouchard
• (+) Bouttonaire’s and Swan Neck
Deformity
• (+) Ulnar Drift
• (+) Z deformity of thumb
-Author/s (Year)
24

25. • Others:
– Arthritis Mutilans
– Vaughn Jackson Syndrome
– Mannerfelt Syndrome
– Hammer Toe, Clawed toe, Hallux Valgus, Flat
Feet
-Author/s (Year)
25

26. -Author/s (Year)
26

27. • Extra articular manifestation:
• Fatigue
• Normocytic and Normochromic Anemia
• Rheumatoid Nodules
• Pericarditis
• Felty’s Syndrome – RA c Neutropenia and
Splenomegaly (SLLLAANT)
• Sjogren Syndrome
• Vasculitis (Arteritis, Phlebitis)
-Author/s (Year)
27

28. 28

29. -Author/s (Year)
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30. -Author/s (Year)
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31. -Author/s (Year)
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32. Medications
• NSAID’s
• Corticosteroids
• DMARD’s
• Methotrexate
• Hydrochloroquine
• Gold Therapy
• Cyclosporine
• Sulfasalazine
-Author/s (Year)
32

33. Spondyloarthropathies
• Seronegative Spondyloarthropathies
A. Psoriatic Arthritis
B. Ankylosing Spondylolitis
C. Reiter’s Disease
D. JRA
-DeLisa )
33

34. • (-) RF and (-) ANA hence Seronegative
• (+) HLA B27
– Gram Negative bacteria that interacts with
genes such as:
• B27 for Reiter’s and AS
• B27, B38, C6 for PSA
-Author/s (Year)
34

35. A.Psoriatic Arthritis
• Inflammatory Arthritis associated with
Psoriasis
-Author/s (Year)
35

36. -Author/s (Year)
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37. Moll and Wright patterns
1. Asymmetrical Oligoarthritis- 2nd MC 13%
2. Polyarthritis – MC 63%
3. Predmonant DIP involvement
4. Destructive Arthritis (Arthritis Mutilans)
5. Predmonant Spondyloarthritis
-Author/s (Year)
37

38. • Autoimmune
• Risk Factors:
– Infections (Strep and Staph, Flu)
– Lithium
– Beta- blockers
– Quinine
– Tetracyclines
– Antimalarials
-Author/s (Year)
38

39. Epidemiology
• M=F
• One of Seronegative arthritis (s RF)
• Prevalence:
– 1 to 2 per 1000
• Incidence:
– 6 per 100,000 per year
• 4 – 30% of pt with psoriasis have psoriatic
arthritis
-Author/s (Year)
39

40. • Sign and symptoms:
• DAKO
– Dactylitis (sausage digits)
– Auspitz Sign
– Koebner Phenomenon
– Onycholysis
• Pencil in cup deformity
-Author/s (Year)
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41. -Author/s (Year)
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42. • Tenosynovitis
• Enthesis
• Fluffy Periostitis
-Author/s (Year)
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43. -Author/s (Year)
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44. Medications
• NSAIDs
• DMARDs
– Methotrexate
– Sulfasalazine
• TNF inhibitor
– Ustekinumab
– Adalimumab
– Infliximab
-Author/s (Year)
44

45. B. Ankylosing Spndylitis
-Author/s (Year)
45

46. • Inflammation of Spine (Including
Sacroiliac jt)
• Seronegative
• Familial (HLA – B27)
• (+) Syndesmophyte
• (+) Bamboo spine
-Author/s (Year)
46

47. -Author/s (Year)
47

48. • Sign and Symptoms:
– Chronic Inflammation of Lower Back Pain -
(MC)
• Dull pain that is worse at night and morning
– Morning Stiffness >1hr
– Dactylitis
– Sacroiliitis
-Author/s (Year)
48

49. -Author/s (Year)
49

50. • In 35% to 50% of pt. , peripheral arthritis
also occurs
– Shoulder> Hip > Knee
• Enthesis
– MC in Achilles tendon insertion
– Plantar fascia insertion
-Author/s (Year)
50

51. • Extraarticular:
– Ant. Uveitis
– Aortic Regurgitation
– Cardiac Conduction Disturbance
– IBS
– Restrictive Lung Disease
– Apical Pulmonary fibrosis
– Renal amyloidosis
-Author/s (Year)
51

52. Epidemiology
• Prevalence:
• 0.1%- 1.4% of population
• F>M 3:2
• Peak age 20- 30 yr old
• Osteoporosis prevalence 25%
• Vertebral fracture Prevalence 10%
• SCI risk 11x higher (C>T>L)
-Author/s (Year)
52

53. Medications
• NSAIDs
• DMARDs
– Methotrexate
– Sulfasalazine
• TNF inhibitor
– Ustekinumab
– Adalimumab
– Infliximab
-Author/s (Year)
53

54. C. Reiter’s Disease
• Reactive arthritis (ReA) is a synovitis
which occurs after a gastrointestinal or
urogenital infection.
• ReA belongs to Spondyloarthritis
-Cargnelluti & Di Genario (2013)
54

55. • In Reiter's syndrome, urethritis appears
as follow-up to dysenteric infection
(gastrointestinal Reiter's syndrome or
enteric Reiter's syndrome) or as a
sexually transmitted infection
-Author/s (Year)
55

56. • Initially thought to be STD only (Cedeño
& Molina, 2009)
• Secondary syndrome to known pathogens
such as Chlamydia, Shigella, Yersinia,
Campylobacter and Salmonella
-Author/s (Year)
56

57. • Chlamydia trachomatis mRNA has been
detected in the joints of patients
(Cargnelluti & Di Genaro,2013)
-Author/s (Year)
57

58. • Sign and Symptoms
• axial joint arthritis and peripheral
oligoarthritis(less than 5 joint affected)
usually asymmetrically
• Dactylitis
• Enthesis of Plantar fascia and Achilles T.
-Author/s (Year)
58

59. • Extraarticular
– Conjunctivitis
– Urethritis and cervicitis in women
– Painless ulcers in oral mucus, tongue, palate
and genital glands
– Keratodermia blennorrhagica
– Circinata Balanitis
-Author/s (Year)
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60. -Author/s (Year)
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61. -Author/s (Year)
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62. D. JRA
• A systemic disease presenting as RA in
children
-Author/s (Year)
62

63. • 3 types:
• Pauciarticular/ Oligoarticular - <4 jts., MC
• Polyarticular- >4 jts.
• Systemic/ Still’s disease- Rarest
-Author/s (Year)
63

64. • Pauciarticular subtypes:
• (-) ANA type
– M>9 yrs old
– Associated with ankylosing spondylitis and
few peripheral jt involvement
– (+) HLA B27
-Author/s (Year)
64

65. • (+) ANA type
– F <5 yrs old
– associated with chronic iridocyclitis and
uveitis
-Author/s (Year)
65

66. • Polyarticular subtype:
– (-) RF
– (+) RF
• Older male and same as Seropositive disease
-Author/s (Year)
66

67. • Systemic or Still’s disease:
• Subtypes
– Juvenile onset
– Adult onset
-Author/s (Year)
67

68. • Initially presents with jt. Pain (MC in Hip)
• Fever, Lymphadenopathy, Serositis
• (+) Evanescent rash (salmon colored
rash)
-Author/s (Year)
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69. -Author/s (Year)
69

70. E. IBD
• Characterized by chronic inflammation of
the intestinal tract
• associated with an imbalance of the
intestinal microbiota
-de Mattos et, al. 2015
70

71. • Types
– Ulcerative collitis – Ulcers on lower part of
large intestine (sigmoid colon & rectum)
– Crohn’s Disease – Most severe, Most chronic
and affects whole GIT from mouth to rectum
-Author/s (Year)
71

72. • Signs and Symptoms
– Vomiting
– Abdominal Cramping
– Diarrhea
– Fever
– Athralgia (Knee)
-Author/s (Year)
72

73. 3.Connective Tissue Disease
A. SLE
B. PM-DM
C. Scleroderma
-Author/s (Year)
73

74. A. SLE
• Autoimmune disease that affects all the
organ characterized by antibody
production against component cell
nucleus
• (+) Antibody Nuclear Antigen (Hallmark)
-Author/s (Year)
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75. Epidemiology
• African American > Whites
• Young Women ages 15- 40 y/o
-Author/s (Year)
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76. • Sign and Symptoms
– *RA like arthritis
• Arthritis associated with SLE are non erosive
• Reversible
– Myositis, Bursitis and Tendonitis
-Author/s (Year)
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77. • Extraarticular:
• DOPAMINRASH
– Discoid Rash
– Oral Ulcer
– Photosensitivity
– Arthritis
– Malar rash
– Immunologic Disease
– Neurologic Disease
– Renal Disease (Lupus
Nephritis)
– Anti Nuclear Antibody
– Serositis (Pleuritis,
Pericarditis,
Peritonitis)
– Hematologic disease
-Author/s (Year)
77

78. • Jacoud’s Arthritis - chronic, deforming,
non-erosive arthropathy occurring in a
subset of patients with systemic lupus
erythematosus (SLE).
– Initially associated with RA, but unlike in RA
its NON EROSIVE
-Author/s (Year)
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79. -Author/s (Year)
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80. -Author/s (Year)
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81. B. Inflammatory Myopathies
• Systemic Rheumatic Disease that affect
Skeletal muscle
-Author/s (Year)
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82. Epidemiology
• Combined Annual Incidence:
– 2 per 100,000
• Prevalence
– 5 – 20 per 1,000,000
-Author/s (Year)
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83. • Mean age of onset:
– PM: 50 to 60 y/o
– IBM: >50 y/o
– DM two peaks:
• 5 to 15 y/o
• 45 to 65 y/o
-Author/s (Year)
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84. • Signs and Symptoms
• Muscle weakness
– Painless
– Symmetrical
– PROX > DISTAL
– Weak Pharyngeal
-Author/s (Year)
84

85. • Types
I. Polymyositis (PM)
II. Dermatomyositis (DM)
III. PM-DM associated with malignancy
IV. PM-DM associated with vasculitis (Juvenile DM)
V. PM-DM associated with collagen vascular disease
VI. Inclusion Body Myositis (IBM)
-Author/s (Year)
85

86. • Type I PM
– Insidious onset
– Begins at Pelvic Girdle then to Shoulder Girdle
– Weak Pharnygeal & Larnygeal Muscles
– (+) Raynaud’s Phenomenon
-Author/s (Year)
86

87. • Type II DM
– Acute onset
– Prox. Muscle weakness
– (+) Heliotrophic rash on eyelids and dorsum
of hand
– (+) Gottron Papules
– (+) V sign
– (+) Shawl sign
-Author/s (Year)
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88. -Author/s (Year)
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89. -Author/s (Year)
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90. • Type III Cancer associated Myositis
– MEN > 40 with CA
– Progressive muscle weakness that is
unresponsive to steroid after 1 – 2 yrs CA
diagnosis
-Author/s (Year)
90

91. • Type IV Juvenile DM
– Rapidly Progressing muscle weakness of
children
– Severe muscle atrophy and jt. Contractures
– (+) Calcinosis Universalis
-Author/s (Year)
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92. -Author/s (Year)
92

93. • Type V Myositis associated with other
vascular disease
– Myositis with RA/SLE/PSS
-Author/s (Year)
93

94. • Type VI IBM
– Men > 40 yr old w/o CA
– Slowly progressive muscle weakness of
PROXIMAL & DISTAL
– Atrophy of QUADS, PELVIC & SH GIRDLE
– (+) Rimmed Vacuoles
• Small areas of focal destruction in muscle fibers
containing amyloid protein
-Author/s (Year)
94

95. Scleroderma
• Progressive Systemic Sclerosis (PSS)
• is a complex disease in which extensive
fibrosis, vascular alterations, and auto
antibodies against various cellular
antigens are among the principal features
Avvedimento, Gabrielli, Krieg(2009)
95

96. Epidemiology
• F>M 3:1 OR 14:1
• Incidence:
– 2.3 to 22.8 cases per 1,000,000
• Prevalence:
– 50 – 300 per 1,000,000
- Avvedimento, Gabrielli, Krieg(2009
96

97. • Two types:
• Type I Localized
• Type II Systemic
– Limited
– Diffuse
- Avvedimento, Gabrielli, Krieg(2009)
97

98. • Type I Localized:
– Morphea – Thickening of skin of trunk
– En Coup De Bande – Thickening of skin of
extremity
– En Coup De Sabre – Thickening of skin of face
-Author/s (Year)
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99. -Author/s (Year)
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100. -Author/s (Year)
100

101. • Type II Limited (CREST syndrome)
– fibrosis is mainly restricted to the hands,
arms, and face.
– Raynaud’s phenomenon is present for several
years before fibrosis appears
– Pulmonary hypertension is frequent
– (+) anticentromere antibodies occur in 50
to 90% of patients
- Avvedimento, Gabrielli, Krieg(2009
101

102. -Author/s (Year)
102

103. • Type II Diffuse
– Diffuse cutaneous scleroderma is a rapidly
progressing disorder that affects a large area
of the skin and compromises one or more
internal organs.
-Author/s (Year)
103

104. -
104

105. 4. Crystal Associated Arthropathies
A. Gout
B. Psedogout
-Author/s (Year)
105

106. A. Gout
• Monosodium Urate Monohydrate Crystals
accumulation
• Caused by deficiency of Hypoxanthine-
Guanine Phosphotransferase resulting to
Hyperuricemia
-Author/s (Year)
106

107. • Risk factors
– Aging
– High Temperature
– Trauma
– Excessive intake of High purine foods (Meat
and Seafood)
– High Fructose diet
– Alcohol intake (Beer)
-Author/s (Year)
107

108. • Podagra- 1st MTP MC
• Gonagra- Knee
• Chiragra- Wrist
-Author/s (Year)
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109. • Onset of symptoms is sudden reaching
maximum intensity with 8 to 12 hours
• Podagra - Red, Tender, Swollen, Hot base
of 1st MTP
• (+) Tophi formation
– Helix of ear, Fingers, Olecranon and
Prepatellar bursa
-Author/s (Year)
109

110. • Lesch- Nyhan Syndrome – aka Juvenile
Gout
– deficiency of Hypoxanthine- Guanine
Phosphotransferase leading to gout, kidney
problems and intellectual disability
-Author/s (Year)
110

111. B. Pseudo Gout
• Aka Calcium Pyrophosphate Deposition
Disease (CPPD)
• Accumulation of Calcium Pyrophosphate
Crystals
-Author/s (Year)
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112. • Symptoms is more insidious gradually
intensifying over several days
• Can lead to Chondrocalcinosis
• Chondrocalcinosis - Calcification of
hyaline and fibrocartilage, MC in knee
-Author/s (Year)
112

113. Medications
• Acute attack: NSAIDs
• Prophylaxis:
– Colchine – aborts full blown arthritis, for gout
and Pseudogout
– Allopurinol – decrease uric acid crystal stores
-Author/s (Year)
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114. 5. Extraarticular Rheumatism
• Fibromyalgia
• Non Specific neck pain
• Non Specific low back pain
-Author/s (Year)
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115. 6. Infectious Arthropathies
• Viral
• Bacteria
• Tuberculosis
• Fungi
-Author/s (Year)
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116. 7. Post Infectious Arthritis
• Post Streptococcal – Rheumatic Fever
• Post Chlamydial – Reiter’s Disease
• Post viral
-Author/s (Year)
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117. Age and Sex
OA RA PSA AS SLE
Age and Sex <50 y/o M
>50 y/o F
F>M F=M 20 – 30
y/o
F>M
15-40 y/o
F>M
-Author/s (Year)
117
PSS PM IBM DM
Age and Sex F>M 50-60 y/o >60 y/o 5-15 y/o
45-65 y/o

118. References:
• O’Sullivan, Susan B, Thomas J Schmitz, and George D Fulk.
Physical Rehabilitation. Philadelphia: F.A. Davis Co., 2014.
• Braddom, Randall L., Leighton Chan, and Mark A. Harrast,
eds. Physical Medicine and Rehabilitation: [Expert Consult,
Activate at Expertconsult.com, Searchable Full Text Online].
4. ed. Philadelphia, Pa: Saunders/Elsevier, 2011.
• Kisner, Carolyn, and Lynn Allen Colby. Therapeutic
Exercise: Foundations and Techniques. 6th ed. Philadelphia,
Pa: F.A. Davis Comp, 2012.
-Author/s (Year)
118

119. • Bassyouni, I. H., Mashahit, M. A., Bassyouni, R. H., Ibrahim, N. H., El-
Sherbiny, N. A., & El-Tahlawy, E. M. (2011). Jaccoud’s arthropathy in
patients with systemic lupus erythematosus: One centre study. Journal
of Advanced Research, 2(4), 327–332.
https://doi.org/10.1016/j.jare.2011.02.005
• Cargnelutti, E., & Di Genaro, M. S. (2013). Reactive Arthritis: From
Clinical Features to Pathogenesis. International Journal of Clinical
Medicine, 4(12), 20–30.
https://doi.org/10.4236/ijcm.2013.412A2004
-Author/s (Year)
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120. • de Mattos, B. R. R., Garcia, M. P. G., Nogueira, J. B.,
Paiatto, L. N., Albuquerque, C. G., Souza, C. L., …
Simioni, P. U. (2015). Inflammatory Bowel Disease:
An Overview of Immune Mechanisms and Biological
Treatments. Mediators of Inflammation, 2015, 1–11.
https://doi.org/10.1155/2015/493012
• Gabrielli, A., Avvedimento, E. V., & Krieg, T. (2009).
Scleroderma. New England Journal of Medicine,
360(19), 1989–2003.
https://doi.org/10.1056/NEJMra0806188
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