Rheumatoid arthritis
Diagnosis criteria – Stiff> 1 hour, 6 weeks , BL, 3=> joints, BL: tender MTP joints, boney erosions on X ray
Chronic inflammatory disease of joints, presence of autoantibody – autoimmune can affect eyes lungs heart kidneys salivary glands, bone marrow
Genetic factors
aim to induce remission/decrease disease activity, decrease joint destruction, prevent disability.
If remission cannot be attained, aim of treatment is keep disease activity as low as possible to improve the quality of life.
Assess severity—- rheumatoid arthritis disease activity index
Medications based on disease activity – mild /mod/severe
Symptom control – NSAID
Omeg3,
Induce remission or reduce disease activity – DMARD, BDMARDS , steroids , Prednisolone , combination ( before – zoster and other immunisation , FBE, LFT, RFT, Hep B and C, HIV , Chest X ray , Tuberculin Igra ) , xray USS hand feet
Rest and splinting. This is necessary where practical for any acute flare-up of arthritis,
Maintain remission – DMAREDS, BDMARDS
Reduce joint destruction – Refer Physiotherapist, exercise physiologist, occupational therapist for functions.
pool therapy, ROM, muscle strengthening ,
prevent disability – Quit smoking, diet, safe alcohol, physical activities (SNAPS C Salts)
Refer rheumatologist, Optometrist
Screen- DEXA
Immunisation
Contracptives ,
dietitian to maintain weight and adequate nutrition, podiatry , GPMP
Psychotherapy as appropriate
Sleep ,smoking ,
Weight control, patient education and self management program, psychosocial support , sleep promotion , thermotherapy
Complication management, home safety, occupation modification, Driving,
Monitor potential complications CV risk, osteoporosis, peptic ulcer, lung disease ,joint deformities , CKD risk assessment
SLE
Lupus is an autoimmune disease, and the antibodies produced by the immune system in lupus cause inflammation, tissue damage and pain.
characterized by flare-ups and periods of improvement (remissions), and can affect almost any organ or system of the body. In most people, only the skin and joints are affected. However, in some people SLE can also affect the kidneys, lungs, heart, blood vessels and/or brain.
Cause is unknown trigger factors are Hormones , Certain medications, infections, Exposure to UV light Dietary factors, Stress, Pregnancy
Aim- symptoms control ,achieve remission, maintain remission, , prevent relapse , prevent organ damage
NSAID for acute joint symptoms , Steroid for organ involvement , and hydroxychloroquine to reduce flair and maintain remission , monitor side effects
Avoid triggers – stress , infection , OCP diet factors
PO contraceptives
Immunisation
Psychotherapy
Physiotherapist- pool therapy , ROM, muscle strengthening
Quit smoking, diet, safe alcohol, physical activities ( SNAPS C Salts)
Refer rheumatologist,
Refer exercise physiologist , occupational therapist function , dietitian to maintain weight and adequate nutrition , podiatry , GPMP
Monitor potential complications renal hepatic lungs CV risk , osteoporosis, peptic ulcer
osteoarthritis
Osteoarthritis is a chronic condition characterised by the breakdown of the cartilage that overlies the ends of bones in joints. This results in the bones rubbing together, causing pain, swelling and loss of motion (Figure 1). Osteoarthritis mostly affects the hands, spine and joints such as hips, knees and ankles, and usually gets worse over time.
Provide explanation and reassurance including patient education hand-outs.
1 Absence of systemic findings
2 Minimal articular inflammation ( stiffness less than 30min and less synovial swelling )
3 Distribution of involved joints (e.g., distal and proximal interphalangeal joints)— OA
Any secondary causes – eg RA, Gout, Trauma, etc)
Any Complications – back nerve impingement
examination
Decreased range of motion of affected joints
Mechanical symptoms (clicking, locking) may be present,
Crepitation is a late sign.
Local pain and stiffness with OA of spine; radicular pain ( compression of nerve roots)
Changes in joint alignment (genu varum [bowlegs] and genu valgum [knock-knees])
1 Assess severity-
impact on day to day functioning, deformities, and complications, responding to NSAID, etc.
2 Control pain and maintain function with appropriate drugs.—– Simple analgesia, Topical NSAID /Capsaicin, NSAID ( check HTN/RFT)( ruling out triple wammy )
3 Correct modifiable risk factors: obesity, injury, overuse.—- loose weight
4 Physiotherapy. Referral should be made for specific purposes such as:
— correct posture and/or leg length disparity
— supervision of a hydrotherapy program
— heat therapy and advice on simple home heat measures
— teaching and supervision of isometric strengthening
Quadriceps-strengthening exercises relieve knee pain and disability.
Periscapular strengthening and range of motion exercises for shoulder arthritis
Abductor and core strengthening as well as gait mechanics for hip arthritis
— exercises (e.g. for the neck, back, quadriceps muscle)
Transition to non–weight-bearing exercises (i.e., elliptical, stationary bike, swimming).
5 Occupational therapy. Refer for advice on aids in the home, more efficient performance of daily
Protect joints from overuse; ambulatory aides are beneficial as is proper-fitting footwear.
Correction of predisposing factors and aids. Apart from weight reduction, the following may help walking
stick, heel raise for leg length disparity.
Bracing, joint supports, or insoles in patients with biomechanical instability
Suggest judicious activity, exercise and physical therapy. ————- to maintain joint function. Aim for a good balance of relative rest with a sensible exercise. It is necessary to stop or modify any exercise or activity that increases pain.
7 Consider factors lowering the coping threshold (e.g. stress, depression, anxiety, overactivity).
8 Refer for surgical intervention for debilitating and intractable pain or disability. Examples include OA of hip, knee, shoulder, first CMC joint of thumb, and first MTP joint, where surgery is now very successful.
Glucosamine
Allied health interventions
- Land based exercise program (B)
- Aquatic therapy (C)
- Multimodal physical therapy (C)
- Tai chi (especially if at risk/fear of fall) (C)
- Thermotherapy (C)
- TENS (C)
- Acupuncture (C)
- Patellar taping (D)
- Massage therapy (D)
- Low level laser therapy (D)
Education and Self Management Support
Review
- Medication and self care adherence
- Consider referral to pharmacist for home medication review
