medical

1. RCS 6080
Medical and Psychosocial Aspects
of Rehabilitation Counseling
Rheumatic
Diseases

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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.

10. 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.

11. Treatment
 Surgery: video
 Removal of
inflamed synovium
 Arthroplasty
 Physical therapy

12. 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

13. 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

14. 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.

15. 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.

16. 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.

17. 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.

18. 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.

19. 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

20. 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

21. 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)

22. 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

23. 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

24. 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

25. 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.

26. 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

27. Reiter's Syndrome
 For different parts of the body,
different treatments are used:
 Medications: NSAIDs, antibiotics, topical skin
medications
 Eye drops
 Joint protection
 Various symptoms are treated by
healthcare specialists

28. 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.

29. 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)

30. 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.

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. Functional Limitations and
Degenerative Joint Disease
 Limited use of the involved joint
 Walking and transfer activities may
be impaired
 Generally, ADLs will not be
significantly impaired

40. 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

41. 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

42. 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)