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					           RCS 6080
Medical and Psychosocial Aspects
 of Rehabilitation Counseling

         Rheumatic
          Diseases
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
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
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
    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
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
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
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
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.
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.
Treatment
    Surgery: video
      Removal  of
       inflamed synovium
      Arthroplasty



    Physical therapy
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
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
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.
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.
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.
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.
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.
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
    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
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)
    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
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
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
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.
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
Reiter's Syndrome
 For different parts of the body,
 different treatments are used:
     Medications: NSAIDs, antibiotics, topical skin
      medications
     Eye drops
     Joint protection


 Varioussymptoms are treated by
 healthcare specialists
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.
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)
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.
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
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
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
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
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 10-15 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
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
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
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
Functional Limitations and
Degenerative Joint Disease
 Limited   use of the involved joint

 Walkingand transfer activities may
 be impaired

 Generally, ADLs will not be
 significantly impaired
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
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
Additional 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/juvenilerhe
    umatoidarthritis.html)
   Spondylitis Association of America
    (www.spondylitis.org)
   Arthritis.com: Latest Arthritis Information &
    Community (www.arthritis.com)

				
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