Rehabilitation Medicine | Dr.

Abiog | [F4] RHEUMATIC DISORDERS AND THE REHABILITATION MEDICINE IMPLICATIONS 04/28/2016

RHEUMATIC DISORDERS AND THE REHABILITATION MEDICINE o Palindromic arthritis, explosive acute
IMPLICATIONS polyarticular onset taking place over several
(pp 193-213) days.
Chapter on rayuma incorporated in this handout except ARA o Initial presentation of often lacks symmetry.
nomenclature on page 193-194 • Rheumatoid arthritis usually affects joints symmetrically
RHEUMATOID ARTHRITIS (on both sides equally), may initially begin in a couple
• Systemic autoimmune disorder of unknown etiology of joints only, and most frequently attacks the wrist,
• Major distinctive features: hands, elbows, shoulders, knees and ankles
o Chronic, symmetric, and erosive synovitis of • Structural damage begins between 1st and 2nd years,
peripheral joints although the synovitis follows a sine wave pattern of
o Majority with elevated serum Rheumatoid activity, structural damage progresses as a linear
Factor function of the amount of prior synovitis.
• Most common outcome of disease o Synovitis is potentially reversible condition and
o Progressive development of various degrees of is dealt with pharmacologically and
joint destruction, deformity, and disability nonsurgical means.
 Severity may fluctuate over time  Synovitis is the hallmark of arthritis
• Associated non-articular manifestations: o Structural damage, an irreversible process, is
o Subcutaneous nodules the end result of the inflammatory process.
o Vasculitis • Joint deformities occur from several mechanisms related
o Pericarditis to synovitis and pannus formation, the resulting cartilage
o Pulmonary nodules or interstitial fibrosis destruction, and the patient’s attempt to avoid pain by
o Mononeuritis multiplex posturing the joint in the least painful position.
o Episcleritis o Joint immobilization
o Scleritis (less common) o Muscle spasm and shortening
o Sjogren’s and Felty’s syndromes o Bone and cartilage destruction
o Ligamentous laxity
Prevalence o Altered tendon function
• Increases with age for both sexes
• Female Anti – CCP Blood Test
• Male = 2.5:1 • Anticyclic Citrunillated Peptide (ACCP)
• Oral contraceptives decrease risk o More specific serum test and becomes positive
• Nulliparity is a risk factor earlier in the course of RA than Rheumatoid
• Pregnancy leads remissions; exacerbations common in Factor (RF)
postpartum o Specimen required: Blood
• Symptoms – onset at menopause uncommon o Normal (reference) range: <20 units
• Genetic factors operative, disease penetrance low, o Overall sensitivity
environmental factors determine 60-70% of risk  75 – 80% vs 70% for RF
• Rheumatoid factor is positive in 85% of cases o Specificity
o Its clinical value tends to correlate with severe  91% with other rheumatic diseases
and unremitting disease, nodules, and  98% with infectious diseases
extraarticular lesions of RA.  99% in otherwise healthy patients vs
o But in RA cases, disease severity loses 80-85% for RF
correlates with level of the RF titer. Rheumatoid Factor
• Erythrocyte Sedimentation Rate (ESR) measures the • (+) in 85%
rheumatic activity which varies according to the degree • Clinically correlates with severe and unremitting disease,
of inflammation. nodules, and extra-articular lesions
• C-reactive protein is one of the acute phase reactants
which may monitor the level of inflammation. • Diseases associated with elevated serum RF
o Chronic bacterial infections
DISEASES ASSOCIATED WITH ELEVATED SERUM RF o Viral diseases
1. Chronic bacterial infections o Parasitic diseases
a. Subacute bacterial endocarditis o Chronic inflammatory disease of unknown
b. Leprosy
c. Tuberculosis
etiology
d. Syphilis o Mixed cryoglobulinemic purpura
e. Lyme disease
2. Viral Diseases ESR
a. Rubella • Measures rheumatic activity
b. Cytomegalovirus • Varies according to degree of inflammation
c. Infectious mononucleosis • Female – 10-20 mm
d. Influenza
3. Parasitic diseases
• Male – 0-10 mm in 1 hr
4. Chronic inflammatory disease of unknown etiology
a. Sarcoidosis C-reactive Protein
b. Periodontal disease • Acute phase reactants (monitor inflammation)
c. Pulmonary interstitial disease
d. Liver disease Clinical Features
5. Mixed cryoglobulinemia • Morning stiffness
6. Hypergammaglobulinemia purpura
o Common in all systemic inflammatory
• Most common mode of onset is insidious development rheumatic disorders, is an almost universal
of symptoms over several weeks. feature of active RA lasting in excess of an
hour, and depends on the prolonged

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Rehabilitation Medicine | Dr. Abiog | [F4] RHEUMATIC DISORDERS AND THE REHABILITATION MEDICINE IMPLICATIONS 04/28/2016

immobilization of sleep and level of • Inflammatory nodular lesions may develop involving
inflammation, both myocardium and the valves resulting to valvular
• Observation of Active Synovitis dysfunction, embolic phenomenon, conduction defects
o Warm, swollen, tender and pain on ROM and myocardiomyopathy.
• Laboratory evidence of anemia and ESR, and most • Aortitis with aortic insufficiency related to dilation of
important is the progressive joint destruction on serial aortic root and aneurysmal rupture have been
photographs described.
• Rarely remits spontaneously after the first year.
• Bon-on-bone crepitus consist of high-pitched G. Renal Manifestations
screeching crepitus that occurs when denuded articular • Glomerural disease is absent or rare.
surfaces rub together. • Proteinuria is related to drug toxicity (gold or
penicillamine) or amyloidosis.
A. Manifestations in Specific Joints • Interstitial renal disease may occur in Sjogren’s but more
• Tenosynovitis of transvers ligament of C1 often to NSAIDs or acetaminophen use resulting to
o May produce C1 – C2 instability papillary necrosis.
• Frozen shoulder
• Ulnar deviation at MCP with radial deviation at wrist H. Gastrointestinal Manifestations
• Swan-neck and boutonniere deformities • No specific GI abnormalities but xerostomia is noted with
• Posterior herniation of capsule: Baker’s Cyst Sjogren’s.
• Gastritis or peptic ulcers seen are related to NSAID
B. Extraarticular Manifestations gastropathy.
• Compressive neuropathies
o Ulnar at the median cubital tunnel or Guyon’s I. Neurologic manifestations
canal • Myelopathies related to cervical spine instability
o Carpal tunnel syndrome o Commonly at C1-C2, with a failure to stabilize
o Tarsal tunnel syndrome – medial malleolar the odontoid due to the destruction of the
area, tibial nerve compressed transverse ligament or erosion of the odontoid
• Tenosynovitis with rheumatoid nodule process
o Give obstructive symptoms of “locking and o Step-off sublaxation-related apophyseal
catching” destruction at C4-C5 or C5-C6
o Extensor pollicis longus - Most common o Lhermitte’s sign may occur as such
• Attrition rupture in extensor digitorum of 3rd, 4th and 5th o Present as sensory paresthesias of hands and
digits motor weakness
• Entrapment neuropathies
C. Skin manifestations o Posterior interosseous nerve in antecubital
• Subcutaneous nodule region
o (+) in 25-50% o Femoral nerve
o Pressure points (olecranon, extensor forearm, o Peroneal nerve near fibular head
Achilles tendon, ischial area) o Interdigital nerve at MTP joint
• Vasculitic lesions • Ischemic neuropathies related to vasculitis
o Venulitis - Earliest abnormality in formation of o Mononeuritis multiplex marked by abrupt onset
rheumatoid nodule of persistent neuropathy unaltered by change
o Small nail-fold infarcts in posture or reduction in synovial inflammation
o Palpable purpura
o Ischemic ulcers (evidence arteritis) J. Hematological Manifestations
• Drug-induced lesions • Hypochromic-microcytic anemia with a low iron and low
o Ecchymoses from NSAIDS/steroids normal iron0binding capacity is an almost universal
o Petechiae from thrombocytopenia (gold, accompaniment of active RA which poorly responds to
penicillamine, sulfasalazine) iron therapy.
o Chrysiasis, Cyanotic hue on forehead (gold) • Felty’s Syndrome
o Combination of RA, splenomegaly,
D. Ocular Manifestations leukopenia, and leg ulcers with associated
• Keratoconjunctivitis sicca (KCS) as part of Sjogren’s lymphadenopathy, thrombocytopenia, and
syndrome – Schirmer’s test HLA-DR4 haplotype.
• Episodes of episcleritis with a more benign self-limited o “Large granular lymphocyte” syndrome – its
course are more common than scleritis hematologic features are not exclusively RA
• Scleromalacia perforans – inflammation that may erode but may represent a process that permits RA to
through the sclera into the choroid leading to damage develop rather than resulting from the disease
and visual loss itself.

E. Respiratory Manifestations Course and Prognosis

• Inflammation of the cricoarytenoid joint • Prognosis is uncertain
o Common, episodic laryngeal pain, dysphonia • Factors predicting more severe and persistent course:
and dysphagia o (+) RF
• Interstitial fibrosis, bronchiolitis obliterans, nodule and o Nodules
pleurisy with characteristic low glucose level of the o HLA-DR4 haplotype
pleural effusion are also observed.
Conventional Methods of treatment
F. Cardiac Manifestations • Nonsteroidal Anti Inflammatory Drugs (NSAIDS)
• Inflammatory pericarditis in 50% of autopsied patients o Aspirin, ibuprofen, COX-2 inhibitor
with RA o Corticosteroids – cortisone

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 Rehabilitation Medicine | Dr. Abiog | [F4] RHEUMATIC DISORDERS AND THE REHABILITATION MEDICINE IMPLICATIONS 04/28/2016

o Disease modifying antirheumatic drugs OSTEOARTHRITIS

(DMARDS) – Methotrexate, injectable gold, • Most common joint disease
hydroxychloroquine • Characterized by:
o Biologic response modifiers – Enbrel,
o Progressive loss of articular cartilage
Remicade, Humira
o Appositional new bone formation in
Treatment subchondral trabeculae
• Symptomatic medical therapy o Formation of new cartilage and new bone at
o NSAIDS and glucocorticoids the joint margins (osteophytes)
 Decrease swelling but do not prevent o Evidence of cartilage repair is evident until
cartilage destruction or bone erosion disease becomes far advanced
• NSAIDS
o Low grade synovitis is often seen and
o Inhibitors of cyclooxygenase, which catalyzes
considered to be secondary to changes in the
the conversion of arachidonic acid to
hard tissues within the joint
prostaglandins, prostacyclin and
thromboxanes
Degenerative Joint Disease Affectations
o Aspirin is the initial drug of choice
• Joints affected in order of decreasing frequency
 3,900-6,500 mg daily in 3-4 divided
(Memorize)
doses
o Knee> 1st MTP > DIP > CMC > hip > cervical
• Desired serum level = 20-30
spine > lumbar spine
mg/dl
o Usually spares the elbow and shoulders except
 Most common side effects
in cases of injury or occupation related task
• Tinnitus • Most likely affected joint to lead to disability
• Gastropathy - gastritis, o Hip and Knee joints
gastric ulceration, and o CMC joint
bleeding
− Misoprostol to CLINICAL FEATURES OF OSTEOARTHRITIS
• Signs and symptoms are usually local, but if they are
decrease gastropathy
more generalized, a systemic form of connective tissue
incidence
disease is suggested
 Irreversibly acetylates platelets,
o Symptoms show positive correlation with
interfering with platelet aggregation
radiologic abnormalities. Absence of
and prolonging bleeding time
correlation with pathologic findings, however,
o There is no good evidence to suggest that the
may be striking.
combination of two NSAIDs is preferable to a
o Pain arises from other intraarticular and
single drug, and combinations may increase
periarticular structures (cartilage has no nerve
the potential for adverse effects
supply)
 Early in the disease, it occurs after
• Corticosteroids
joint use and is relieved by rest
o Both anti-inflammatory and
 Late in the disease, it occurs with
immunosuppressive effects but have not been
minimal motion or even at rest; night
shown to have disease modification potential
pain is common.
o Not advised for routine treatment of RA
o Acute inflammatory flares are precipitated by
because of its long-term adverse effects but is
trauma or by crystal-induced synovitis.
indicated in life threatening complication of
 Local tenderness elicited when
RA such as vasculitis
synovitis is present
o Joint stiffness is relatively short lived and
• SAARDS (Slow Acting Anti-Rheumatic Drugs)
o A.k.a DMARDS(Disease modifying anti localized
rheumatic drugs) o Pain on passive motion and crepitus (feeling of
o For patients who do not respond adequately crackling as the join is moved) are prominent.
to symptomatic therapy, or have aggressive o Joint enlargement results from synovitis,
disease increased amount of synovial fluid, or
o Individualize choice of drug
proliferative changes in cartilage and bone.
o Use less toxic drugs initially unless with fulminant
progressive disease or life-threatening
complications (vasculitis) Hand Osteoarthritis
• Biologic response modifiers – Enbrel, Remicade, Humira • Heberden’s nodes
o Spurs formed at dorsolateral and medial
Classification of DMARDS by Toxicity aspects of DIP joints
SAFER MORE TOXIC VERY TOXIC o Develop slowly over months or years in most
Auranofin Azathioprine Chlorambucil patients
Hydroxychloroquine Cyclosporine Cyclophosphamide o In others, onset is rapid and is associated with
Sulfasalazine Gold salts
moderately severe inflammatory changes
Methotrexate
o Gelatinous cysts resembling ganglia may
Penicillamine
precede the appearance of the node itself

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 Rehabilitation Medicine | Dr. Abiog | [F4] RHEUMATIC DISORDERS AND THE REHABILITATION MEDICINE IMPLICATIONS
o Flexor and lateral deviations of distal phalanx
are common
o 1st CMC joint (trapeziometacarpal)
involvement lead to tenderness at base of 1st
metacarpal bone and square appearance of
hand (rhizarthrosis)
• Only proximal joint of the hand which may be involved
in primary OA is the 1st metacarpotrapezial joint.
o Initial finding is a tensed, swollen joint which is
painful to palpation and painful when pressure
is applied on the 1st metacarpal in the so called
grind test.
o Due to the pull of abductor pollicis longus
tendon and laxity of the joint capsule, the 1st
metacarpal or even dislocate at this joint
producing the “Z-collapse” deformity of the
thumb with hyperextension of the MCP and
flexion of the JP
• Trapezioscaphoid joint is commonly involved
• Flexor and lateral deviations of distal phalanx
• Bouchard’s nodes
Knee Osteoarthritis
• Characterized by local tenderness over various
components of the joint and pain on passive or active
motion
• Crepitus often detected
• Muscle atrophy seen is secondary to disease (disuse)
• Disproportionate losses of cartilage localized to medial
or lateral compartments of the knee lead to genu varus
or valgus
• Chondromalacia patellae seen most often among
young adults
o Associated with softening and erosion of
patellar articular cartilage
o Pain, localized around the patella, is
aggravated by activity (walking hills or stairs)
o Represent a common pathway of conditions
affecting the knee:
 meniscal tears, hypermobility, or
abnormal patellar positions
 lead to altered joint biomechanics,
and eventual degenerative change
Hip Osteoarthritis
• Lead to an insidious onset of pain, followed by a limp
• Pain is localized to the groin or along the inner aspect of
the thigh
o Patients may also complain of referred pain on
buttocks, sciatic region, knee
o PE reveals loss of hip motion, initially most
marked on internal rotation or extension
Foot Osteoarthritis
• OA of 1st metatarsophalangeal joint is aggravated by
tight shoes
• Tenderness is common, particularly when the overlying
bursa at the medial aspect of the joint is secondarily
inflamed
Spine Osteoarthritis
• Results from the involvement of intervertebral discs,
vertebral bodies, or posterior apophyseal articulations
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04/28/2016
• L3-L4 area most commonly involved
o Associated symptoms: local pain and stiffness
o Cauda equina syndrome with sphincter
dysfunction may result
• Large anterior osteophytes in the cervical spine may
give rise to dysphagia or respiratory tract symptoms
• Compression of the nerve roots of the cord itself lead to
variable neurologic deficits
• Spinal stenosis (in lumbar spine commonly) results from
o Degenerative spurs
o Disc herniation
o Ligamentous hypertrophy
o Spondylolisthesis
• Pain in the legs may be constant or intermittent,
simulating intermittent claudication.
Other joints
• OA may occur in joints generally considered protected
from development of OA, including:
o Elbows
o Shoulders
o Interphalangeal joints of toes
o Occupational factors or metabolic diseases
must be considered when unusual joints are
involved
VARIANT FORMS OF OSTEOARTHRITIS
1. Primary Generalized OA
o Involvement of the DIP and PIP joints of the
hands, 1st CMC joint, knee , hips and
metatarsophalangeal joints
o Radiologic changes often exceed clinical
findings
2. Erosive Inflammatory OA
o Primarily involves DIP or PIP joints of the hands
o Painful inflammatory episodes are associated
with the development of joint deformity and
ankylosis
o Joints become asymptomatic after a variable
period of years of intermittent acute flares
o Bony erosions prominent on x-rays
o May be associated with Sjogren’s syndrome
o Diffuse idiopathic skeletal hyperostosis seen
 Flowing ossification along the
anterolateral aspect of the vertebral
bodies
3. Secondary OA
o Similar to primary form
Treatment
• Approaches
o Low dose steroids
 Inhibit proteoglycan destruction by
proteases
o Glycosaminoglycan-peptide complex
 Effects related to growth-stimulating
peptides or inhibition of cytokines
o Polysulfated glycosaminoglycan
 Inhibits proteolytic enzyme
 Rehabilitation Medicine | Dr. Abiog | [F4] RHEUMATIC DISORDERS AND THE REHABILITATION MEDICINE IMPLICATIONS 04/28/2016

Systemic Lupus Erythematosus  +/- LE cells, diminished complement

• A prototypic autoimmune disease characterized by the
production of antibodies to the components of the cells
nucleus in association with a diverse array of clinical
manifestations
Clinical features:
A. constitutional complaints
• common and non-specific
• may include overwhelming fatigue, fever, wt loss
• may represent the development of infection of
fibromyalgia
B. Skin manifestation:
• “butterfly rash”
o commonly precipitated by exposure to
sunlight
o histological finding
 immune deposits at dermal-
epidermal junction
immunofluorescence)
 nonspecific inflammation
• generalized erythema
o May o may not be photosensitive
• bullous lesions
• The majority of patients demonstrate photosensitivity.
They may develop exacerbation of their systemic
disease with the sun exposure
• subacute cutaneous lupus erythematosus (SCLE)
o nonfixed, nonscarring, exacerbating, and
remitting, distinct lesion
o commonly occur in sun-exposed areas, may
be generalized
o variants:
 Papulosquamous variant- w/c mimic
psoriasis or lichen planus
 Polycyclic or annular lesion- mimic
erythema erythema annulare
centrifugum
 (+) antibody to Ro (SSA)
• discoid lesions- chronic cutaneous lesions
o begin as erythematous papules or plaques,
with scaling that may become thick and
adherent with a hypopigmented central area
o may produce scarring with central atrophy
• Alopecia is common. It may be diffuse or patchy
• mucous membrane lesion: mouth ulcers, vaginal ulcers,
and nasal septal erosions
• panniculitis, urticarial lesions
• vasculitic lesions
o Palpable purpura. Nail-fold infarcts or digital
ulceration, splinter hemorrhages
o pulp-space and palmar vasculitic lesions
(simulate Osler’s nodes & Janeway spots in SBE)
o Urticaria & livedo reticularis
• Subcutaneous nodules similar to those seen in RA are
occasionally seen
C. Musculoskeletal manifestations
• Commonly arthralgias and arthritis
• Arthritis
o May involve any joint, typically small joints of
the hands, wrists, knees
o May be migratory or persistent & chronic
o Mostly symmetric, but asymmetric polyarthritis
can also be seen
o Swelling is due to soft tissue thickening and
small effusions
o Synovial fluid
 Mild Inflammatory fluid (leukocytes
and PMNs)
levels
o Arthritis typically is not erosive or destructive of
bone, but joint deformities can occur
 Jaccoud’s arthritis may occur.
Components, which are initially
reversible and can be fixed, include:
• Ulnar deviation of the
fingers
• Swan neck deformities
• Subluxations
• Occasionally: hook-like
processes of the
metacarpal heads seen
late in the disease
o tenosynovitis & tendon ruptures may also occur
• acute synovitis
o diagnosis confused with the presence of
complications of SLE or its treatment (septic
(by arthritis and osteonecrosis)
• septic arthritis
o uncommon but suspected when 1 joint is
inflamed or out of proportion to all others
• patient also complain of muscle pain & weakness
• Myositis can be seen, but histologic features are not as
striking as those in idiopathic polymyositis /
dermatomyositis
• Patients may develop drug-related myopathy
(corticosteroids or antimalarias)
• Secondary fibromyalgia as differential diagnosis must be
considered in musculoskeletal complaints
D. Renal Manifestations
• Not felt until there is advanced nephrotic syndrome or
renal failure
• Evidence of for clinical renal disease include:
o Proteinuria > 500mg / 24 hr ( or > 3+ on dipstick
o (+) cast rbc, hgb, granular, tubular, or mixed
o Hematuria (> rbc/ HPF)
o Pyuria (>5 wbc / HPF) in the absence of
infection
o Elevated serum creatinine
• Renal biopsy
o Morphologic changes suggestive of chronic
lesions are associated with lower survival, both
for the patient and the kidney
E. Neuropsychiatric Manifestations
• Common, can be a part of SLE or as isolated event
• Neurologic manifestations
o Intractable headache unresponsive to
narcotic analgesics, can be migraine-like
o Generalized or focal seizures
o Anticardiolipin syndrome
 Chorea which resemble Sydenham’s
chorea – association with
anticardiolipin antibody has recently
been suggested
o CVA and subarachnoid hemorrhage
o Cranial neuropathies, may present as:
 Visual defects, blindness
 Papilledema
 Nystagmus or proptosis
 Tinnitus and vertigo
 Facial Palsy
o Retinopathy – correlates with CNS involvement
o Peripheral neuropathies can be motor, sensory
(stocking glove distribution), mixed motor and
sensory polyneuropathies, mononeuritis
multiplex

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Rehabilitation Medicine | Dr. Abiog | [F4] RHEUMATIC DISORDERS AND THE REHABILITATION MEDICINE IMPLICATIONS
 Acute ascending motor paralysis –
indistinguishable from Guillian – Barre
 Transverse myelitis – presents with
lower extremity paralysis, sensory
deficits, loss of sphincter control
• Psychiatric Manifestations
o Psychosis
 Association bn SLE psychosis and anti-
ribosomal P protein antibodies has
been documented
 Use of corticosteroid implicated in
causing psychosis in some patients
o Organic Brain Syndrome (OBS)
 State of distributed mental function
with delirium, emotional inadequacy,
impaired memory or concentration in
the absence of drugs, infection, or a
metabolic cause
 Significant cognitive impairment seen
in more than 80% of the patients with
neuropsychiatric involvement & 42%
of patients with no neuropsychiatric
involvement
• Wide spectrum of clinical findings can be explained by
a variety of mechanism, the most common of which are
pathologic finding of:
o Multiple microinfarcts (usually during autopsy)
o Non-inflammatory thickening of small vessels
by intimal proliferation
o Occlusion of major vessels
o Intracranial hemorrhage or embolism
o (+) autoantibodies vs neuronal membrane
antigens and lymphocytotoxic antibodies in
serum and CSF
• Diagnosis of neuropsychiatric SLE is primarily clinical.
Exclusion of possible etiologies like sepsis, uremia, and
severe HPN is mandatory
o non specific CSF abnormalities present in 1/3 of
patients (Elevated cell count, elevated
protein, reduced glucose)
o low levels of C4 and other complement
components reported
o IgG, IgA and/or IgM elevations noted
o EEG abnormalities common
o PET shows areas of low attenuation
representing areas of distributed circulation
and metabolism
o CT scan
 May reveal recent cerebral infarction
and hemorrhage
 Cortical atrophy present but not
reflective if CNS disease
o MRI shows small focal areas of increased signal
densities (areas of edema and inflammation)
which disappear after therapy
corticosteroid
o P nuclear magnetic resonance spectroscopy
provide better demonstration of brain lesions
F. Serositis
• Common and may present as pleurisy, pericarditis and
peritonitis
• Pleural rubs less frequent than clinical pleurisy or
radiographic abnormalities
• Pleural effusions
o Small (occasionally massive), frequently
bilateral and seen in older patients and in drug-
induced SLE
o Effusion is an exudate, with normal glucose
level (low in RA)
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04/28/2016
o (+) LE cells, ANAs, immune complexes, low
complement levels
• Pericarditis
o Most common presentation of heart
involvement (but less frequent than pleurisy)
o Seen in 20-30% clinically, and over 60% at
autopsies
o Usually present as precordial chest pain and
pericardial rub, but can ne painless and
clinically silent
o Posterior pericardial effusions may be seen,
fluids may have:
 Leukocytosis (neutrophils)
 Glucose level lower than in the serum
 Low complement activity
 High ANA Levels
 (+) LE cells
o constrictive pericarditis may occur but is
uncommon
G. Gastrointestinal Manifestations
• Common, manifested as diffuse abdominal pain,
anorexia, nausea, vomiting (occasionally)
• Possible etiologies
o Diffuse peritonitis - may be associated with
ascites
o Bowel vasculitis (mesenteric)
 Present with lower abdominal pain
that may be insidious and intermittent
 Can lead to intestinal perforations
 Diagnostic studies include
arteriography and colonoscopy
(rectal bleeding, ulcerations)
o Pancreatitis
 nonspecifically present with
abdominal pain, nausea, vomiting,
and elevated serum amylase
o inflammatory bowel disease
o hepatomegaly is common
 elevated liver enzymes associated
with active SLE and use of NSAIDs
(esp Salicylates)
• elevation resolved upon
control of disease and
cessation of NSAID use
H. Pulmonary manifestations
• Lupus pneumonitis
o due to immune complex deposition in blood
vessels and alveolar walls with or w/o
associated vasculitis
o acute illness simulates infectious pneumonia
o chronic form presents as diffuse interstitial lung
disease
of • pulmonary hemorrhage
o Uncommon, but is a serious feature
o Presents as cough and hemoptysis or as a
pulmonary infiltrate
o Presumed to be due to pulmonary vasculitis.
Viral pneumonia must be considered as a ddx
• Pulmonary HTN
o similar to idiopathic pulmonary HTN
o patients present with dyspnea and clear chest
radiograph, are mildly hypoxic and have a
restrictive pattern in pulmonary function testing
o Raynaud’s phenomenon is frequent
o DDX include:
 Secondary pulmonary HPN due to
DVT (deep vein thrombosis) &
Multiple pulmonary emboli
 Rehabilitation Medicine | Dr. Abiog | [F4] RHEUMATIC DISORDERS AND THE REHABILITATION MEDICINE IMPLICATIONS 04/28/2016

 Antiphospholipid antibody Skeletal Extraskeletal

syndrome With intrapulmonary
clotting
• pulmonary embolism
• shrinking lung syndrome
I. Cardiac manifestation
• Pericarditis
• Myocarditis
o suspected in patients with arrhythmias or
conduction defects, unexplained
cardiomegaly (w or wo CHF), un explained
tachycardia
o CHF is less common and usually due to
combination of factors w/c include
myocarditis
o Myocardial ischemia and scarring may be
present
o Endomyocardial biopsy may confirm the
diagnosis
• Endocarditis
o Diagnosed on the basis if a murmur plus
abnormal echocardiographic studies
o Nonbacterial verrucous vegetations are less
common
o Acute and subacute bacterial endocarditis
may occur on previously involved valves
• Coronary Artery Disease
o vasculitis is uncommon, and is usually
associated with active disease (atherosclerotic
CAD associated with inactive SLE)
J. Reticuloendothelial System Involvement
• Splenomegaly is common
• Splenic atrophy (due to infarction) and splenic
lymphoma also recognized
• Lymphadenopathy is a nonspecific feature of SLE
o Nodes are soft, non-tender, and variable in size
o Pathologically, lymph nodes demonstrate
reactive hyperplasia
ANKYLOSING SPONDYLITIS
• Chronic systemic inflammatory rheumatic disorder
primarily affecting the axial skeleton
• Hallmark: sacroiliac joint involvement (sacroiliitis)
• Involvement if the limb joints other than hips and
shoulder is uncommon
• The name is derived from the Greek root ankylos
meaning, “bent” (although now it has come to imply
fusion or adhesions) and spondylos meaning spinal
vertebra
• It is strongly associated with the HLA-B27 and may show
familial aggregation
• Inflammatory process involves the synovial and
cartilaginous joints, as well as the osseous attachments
of tendons and ligaments, frequently resulting in fibrous
and bony ankyloses
• May occur in association with the reactive arthritis
(reiter’s syndrome), psoriasis, or chronic inflammatory
bowel disease (secondary AS), but most patients have
no evidence of these associated disease
Clinical manifestations
• Usually begin in late adolescence or early adulthood.
Onset after 40 is uncommon
• Has skeletal and extraskeletal manifestations and is 3
times more common in men than in women
Axial arthritis, such as sacroilitis Eyes (acute iritis)
and spondylitis
Heart and ascending aorta
Arthritis of hip and shoulder
joints Lung (apical fibrosis)
Peripheral arthritis Cauda equina syndrome
Others: enthesopathy,
osteoporosis, spinal fracture,
spondylodiscitis,
pseudoarthrosis
A. Skeletal manifestations
• Chronic LBP of insidious onset
o Most common and characteristic early
complaint
o Usually in late adolescence or early adulthood
o Pain is dull, difficult to localize, felt deep in the
gluteal or sacroiliac region
o Initially unilateral and intermittent
 Pain in the lumbar area (rather than
buttock ache) may be an initial
symptom
 becomes persistent and bilateral in
few months; lumbar area becomes
stiff and painful
 pain can be quite sever; aggravated
by maneuvers that cause a sudden
twist of the back
• back stiffness
o worse in the morning, eased by mild physical
activity or a hot shower
o prolonged periods of inactivity worsen back
pain and stiffness
o patient has considerable difficulty in getting
out of bed in the morning and may have to roll
out sideways, trying not to flex or rotate the
spine in order to minimize pain
o pain may awaken the patient from sleep
o some have difficulty sleeping well or find it
necessary to wake up at night to move about
or exercise for a few minutes before returning
to bed
o back symptoms may be absent or very mild;
some may complain only of back stiffness,
fleeting muscle aches or musculotendinous
tender spots
 these symptoms may worsen on
exposure to cold or dampness, thus
may lead to a misdiagnosis of fibrositis
• extraarticular or juxtaarticular bony tenderness
o due to enthesitis (inflammatory lesions of
entheses) that result in tenderness of
costosternal junctions, spinous processes,
scapulae, iliac crest, greater trochanters,
ischial tuberosities, tibial tubercles or heels
o involvement of thoracic spine, including the
costovertebral and costo transverse joints, and
occurrence of enthesis at costosternal areas
and manubriosternal joints may cause:
 chest pain (accentuated by
coughing or sneezing)
 inability to expand the chest fully on
inspiration
• stiffness and pain in cervical spine and tenderness of
spinous process
• hip joint involvement seen in 17% to 36%
o more common disease begins in childhood or
adolescence

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 Rehabilitation Medicine | Dr. Abiog | [F4] RHEUMATIC DISORDERS AND THE REHABILITATION MEDICINE IMPLICATIONS
o usually bilateral, insidious in onset, potentially
more crippling than other joint involvement
o flexion contractures can give rise to a
characteristic rigid gait with some flexion of the
knees to maintain erect posture
• involvement of peripheral joints other than hips and
shoulders is infrequent in primary AS
o rarely persistent or erosive; tends to resolve with
no residual joint deformity
o e.g.
 intermittent knee effusions-
occasionally seen in juvenile onset AS
 TMJ involvement worth local pain
and tenderness seen in 10% of
patients
• mild constitutional symptoms (anorexia, malaise, mild
fever) relatively more often among patients with juvenile
onset
PE findings
• Physical sign quite minimal during early stage
• Limitation of motion of lumbar spine, especially on
hyperextension, lateral flexion or rotation
• Spasm and soreness of paraspinal muscles
• Limitation of forward flexion of the lumbar spine
o Evaluated by the Wright-Schober Test
o Cannot be solely relied on patient’s ability to
touch the floor with his fingertips (keeping the
knees fully extended), since a good ROM of
the hip joints can compensate for
considerable loss of mobility of the lumbar
spine
• direct tenderness over inflamed sacroiliac joints
• sacroiliac pain
o elicited by:
 pressure over the anterior iliac crests,
with the following positions:
• lying supine
• maximal flexion of 1 hip &
hyperextension of the other
• maximal flexion, abduction
& external rotation of hip
joints
 compression of pelvis with patients
lying over his side
 direct pressure over sacrum with
patient lying prone
o may be negative in some because:
 sacroiliac joints are surrounded by
strong ligaments that may allow only
minimal motion
 in late stages when inflammation is
replaced by fibrosis and bony
ankyloses
o costovertebral and costotransverse joint
involvement
 cause restriction in chest expansion
and diaphragmatic breathing 
chest becomes flattened and
abdomen becomes protuberant
 ventilator lung function seldom
markedly impaired
o entire spine becomes increasingly stiff, with
continued flattening of lumbar spine and
gentle thoracic kyphosis
o involvement if cervical spine results in
progressive limitation of neck motion & forward
cervical stoop
 assessed by measuring the distance
from occiput to wall with the patient
standing with back against the wall
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COURSE OF THE DISEASE
• Back pain and stiffness diminish over the years but some
degree of inflammation usually persists
• Spinal ankylosis develops at a variable rate and pattern;
sometimes confined to one part of spine
• Typical deformities tend to evolve after 10 or more years
• In extreme cases, the entire spine may be fused in a
flexed position, limiting the field of vision and making it
difficult for some patients to look ahead as they walk
B. Extraskeletal manifestations
• Acute anterior uveitis (acute iritis)
o Most common, occurs in 25 to 30%
o Unilateral and acute
o Symptoms: pain, increased lacrimation,
photophobia, and blurred vision
o PE findings:
 Circumcorneal congestion
 Iris edematous and appears
discolored
 Small pupil, may become irregular,
especially on mydriasis, if posterior
synechiae (adhesions) are formed
 Slit lamp examination: copious
exudate in anterior chamber and
small keratitic precipitates
o Episode subsides in 4-8 weeks, may recur in the
same or contralateral eye
o AS or related spondyloarthropathies must be
considered when patient presents with acute
nongranulomatous anterior uveitis
C. Cardiovascular involvement
• Rare
• Includes:
o Ascending aortitis
o Aortic valve incompetence – 3.5 % of patients
who had AS for 15 years and 10% after 30 years
o Conduction abnormalities – 2.7% of patients
who had AS for 15 years and 8.5 % after 30
years
 Complete heart block causing Stoke-
Adam’s attacks may supervene
o Risk increases with age, duration of AS,
Presence of arthritis of peripheral joints
D. Lung parenchymal involvement
• Rare and late
• Characterized by slowly progressive fibrosis of the upper
lobes of the lungs that averagely appears 2 decades
after onset of the AS
• Usually bilateral
• Appears as linear or patchy opacities at CXR, eventually
becoming cystic
• Cavities may subsequently be colonized by Aspergillus
with the formation of mycetoma
• Patient may complain of cough, increasing dyspnea,
and occasionally hemoptysis
E. Neurologic involvement
• Spinal fracture/ dislocation
o Fracture usually occurs in the cervical spine
o Resultant quadriplegia is the most dreaded
complication, with a high mortality
• Atlantoaxial subluxations (2% of patients)
o Well-recognized complication of AS
o Presents as occipital pain with or without signs
of spinal cord compression
o Observed in later stages, more commonly in
those with peripheral joint involvement
 Rehabilitation Medicine | Dr. Abiog | [F4] RHEUMATIC DISORDERS AND THE REHABILITATION MEDICINE IMPLICATIONS
• Cauda equina syndrome
o Rare
o Underdiagnosed complication of long
standing AS
o Manifestation
 Gradual onset of urinary and fecal
incontinence
 Pain and sensory loss in the sacral
distribution (“saddle anesthesia”)
 Loss of ankle jerks
F. Skeletal involvement
• There is lack of clinical evidence
• Marked muscle wasting seen in some results from disuse
atrophy
o But some ultrastructures changes and raised
levels of serum creatine phosphokinase have
been observed
• Amyloidosis is a rare complication
o Presence of renal involvement suspected
when there is proteinuria and progressive
azotemia
o IgA nephropathy can cause hematuria
Radiologic findings
• Sacroiliitis is the earliest and most consistent finding
o Progression to subchondral bone erosion can
lead to pseudo-widening of the sacroiliac
space followed by narrowing due to
interosseous bridging and ossification and later
complete bony ankyloses
• Squaring of the vertebral bodies and gradual ossification
od the superficial layers of the annulus fibrosus, w/c form
the intervertebral bony “bridging”, is called
Syndesmophytes
• “whiskering” (bony erosions and osteitis at site of osseous
attachments of tendons and ligaments, e.g. at ischial
tuberosities, iliac crest, spinous process of the vertebra)
• Bamboo spine – ankyloses of the apophyseal joint and
ossification of the spinal ligaments, resulting in a
complete fusion of the vertebral column
Differential Diagnosis
• Ankylosing hyperostosis (Forestier’s disease or Diffuse
Idiopathic Skeletal Hyperostosis [DISH])
o 1st seen at older age, characterized by thick,
layered hyperostosis affecting anterior
longitudinal ligament and bony attachments
of tendons and ligaments
o Predominant symptoms are stiffness, back
pain, and decreased ROM of the vertebra
o Most common site of x-ray abnormality is T7-T12
o C4-C7 is the commonly involved ligament in
the neck
 Thick, flowing anterior osteophytes
are present, resembling a candle
wax dripping along the anterior
cervical spine
Reiter’s Syndrome
• Develops in a genetically susceptible host following an
infection by bacteria (Chlamydia trachomatis,
Salmonella, Shigella, Yersinia, Campylobacter).
• Considered to be the only clinical manifestation of
reactive arthritis
• May occasionally be accompanied by extraarticular
symptoms of uveitis, bowel inflammation and carditis
• Alternative diagnosis:
o Sexually acquired reactive arthritis (SARA)
o BASE syndrome (B27, arthritis, sacroiliitis, and
extraarticular manifestations)
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Clinical Feature
A. Musculoskeletal
• Arthritis
o Appears within 1 to 3 weeks of inciting
urethritis or diarrhea
o Few joints involved in asymmetric pattern,
most commonly the knees, ankle, feet
and wrists
o Distinctively includes a local enthesopathy
 Inflammation is located primarily
at tendinous insertion into bone
rather than or in addition to the
synovium
 Seen as sausage digit in the
fingers and toes (suggestive of
Reiter’s syndrome or psoriatic
arthritis)
 Causes hindfoot swelling and
pain in the ankle
o Joint stiffness, myalgia, and LBP are
prominent early symptoms
 Back discomfort radiates into
buttocks or thighs and is made
worse by bed-rest and inactivity
o Spine prominently affected in severe,
chronic, recurrent cases
o Axial disease indistinguishable from
ankylosing spondylitis may be developed
by patients with chronic disease
o Childhood Reiter’s syndrome typically
presents as severe heel pain and plantar
fasciitis
o Reiter’s syndrome always suspected in a
young man with subacute arthritis of the
knee, chronic hindfoot pain,
metatarsalgia, and tenderness in the low
back over the sacroiliac joints
B. Urogenital tract
• Follows non-gonococcal urethritis in 3%
• Men experience increase frequency o and burning
during urination
• PE of penis: meatal erythema and edema, clear
mucoid discharge
• Pyuria best detected in 1st void urine
• Prostitis seen in 80% of patients
• Hemorrhagic cystitis ma develop and may clear
spontaneously
• In women:
o Silent cystitis or cervicitis may be the only
manifestation
o Salpingitis and vulvovaginitis also reported
• Sterile urethritis may be seen in Postdysenteric
Reiter’s syndrome within1 to 2 weeks of the initial
bout of diarrhea
C. Mucous membrane and skin
• 2 characteristic sites of lesion: skin and penis
• Balanitis circinata
o Small shallow painless ulcers of glans penis
and urethral meatus
o Seen in 25% of post-chlamydia and post
shigella reiter’s syndrome
o In uncircumcised: lesion are moist and
asymptomatic unless secondarily infected
o In circumcised: lesions harden into a crust
that may cause scar and cause pain
• Keratoderma blenorrhagica
o Hyperkeratotic skin lesion in 12% to 14% of
patients
 Rehabilitation Medicine | Dr. Abiog | [F4] RHEUMATIC DISORDERS AND THE REHABILITATION MEDICINE IMPLICATIONS
o Begins as clear vesicles on erythematous
bases and progresses to macules,
papules, and then to small keratotic
nodules
o Frequently on the soles of the foot, may
involve toes, scrotum, arms, penis, trunk
and scalp
• Superficial ulcers
o Early and transient feature of the disease
o Begin as vesicles and progress to small,
shallow, sometimes confluent ulcers
o Painless and often unnoticed
D. Eye
• Uveitis
o Acute and unilateral but subsequent
attacks may affect the other eye
o Inflammation is anterior (iritis) and tends to
spare the choroid and retina
• Unilateral or bilateral apparently noninfectious
conjunctivitis in 40% of patients
• Hypopyon, keratitis, corneal ulceration, posterior
uveitis, optic neuritis, and intraocular hemorrhage
are rare complications
E. Gastrointestinal tract
• Precipitating diarrhea mild and transient, but
occasionally bloody and prolonged
• Enteric infections by Shigella dysenteriae or flexneri,
Salmonella entereditis or typhimurium, Yersinia
enterocolitica or pseudotuberculosis, and
Campylobacter jejuni may give rise to Reiter’s
syndrome
• Arthritis usually appears 1 to 3 weeks following the
onset of infectious symptoms
F. Heart and others
• Aortic regurgitation in 10% of patients with severe
and longstanding disease
o Develop as a result of inflammation and
scarring o the aortic wall and valvular
cusps
• Conduction defects sometimes occur early:
o Prolonged P-R interval – most common
o 2nd and 3rd degree atrioventricular blocks
• Unusual complications:
o IgA glomerulonephritis
o Renal amyloidosis
o Cranial and peripheral neuropathies
o Thrombophlebitis
o Purpura
o Livedo reticularis
Reiter’s Syndrome and HIV
• 1st rheumatic disease to be recognized in assoc with HIV
• Symptoms of arthritis may precede any overt signs of HIV
infection
• Tx with methotrexate and azathioprine may further
suppress the immune response and provoke a full
expression of AIDS
Psoriatic Arthritis
Clinical Features
A. Joint Disease
• 95% of psoriatic patients have peripheral joint
involvement
o Majority have >5 involved joints
o Others have pauciarticular asymmetric
arthritis or exclusive DIP involvement
o Another 5% exclusive spinal form
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o 20-40% spinal with one of the forms of
peripheral joint disease
o Rare patients may have bamboo spine
typical of ankylosing spondylitis
• Inflammation involves not only joints and spine but
also at the periosteum, insertion sites of tendons into
bone (enthesopathy) which leads into the
development of sausage digits, typical finding in
reiter’s syndrome
B. Dermatologic and other features
• Definite diagnosis of psoriatic arthritis cannot be
made without evidence of skin or nail changes
typical of psoriasis
• Skin lesions are macular or popular with
characteristic scales usually at the extensor surfaces
• Auspitz sign – bleeding occurs at sites of scale
removal
• Nail changes include pitting,, transverse, or
longitudinal ridging
o Oil droplet discoloration, subungual
hyperkeratosism and onycholysis strongly
suggest its psoriasis
o 80% with psoriasis who have arthritis, but
only 20% without joint disease, express nail
abnormalities
• Eye inflammation occurs in 30%, which includes the
following:
o Conjunctivitis
o Iritis
o Episcleritis
o Keratoconjunctivits Sicca
• Usual age of onset is 30-50 years, with skin disease
usually preceding joint disease by months or even
years and without sex predisposition
C. Radiologic Features
• DIP erosion with terminal whittling of the proximal
bone at the IP joints and pencil-in-cup appearance
• Spinal involvement includes sacroiliitis,
syndesmophytes, atlantoaxial, lateral and subaxial
sublaxation of the cervical spine
• Enthesopathy may lead to x-ray evidence of
periostitis
Treatment
• Basic management includes NSAIDS, physical therapy
including complete JROM exercises but not to overuse
and abuse inflamed joints, and education
• With polyarticular progressive disease, 2nd line therapy
should be considered, i.e., gold therapy, MTX, or
hydroxychloroquine
o Sulfasalazine reported to be efficacious
• Methoxypsoralen and long wave ultraviolet A light
(PUVA) helpful for peripheral, but not for axial psoriatic
arthritis
Juvenile Rheumatoid Arthritis
Subtypes
1. Systemic Onset
• 10% of JRA cases with this onset, ratio of boys to girls
equal and begins at any age during childhood
• Spiking quotidian or diquotidian fevers, often
associated with an evanescent, salmon-pink
centripetal rash, usually in the late afternoon or
early evening
• Diffuse LAD, hepatosplenomegaly, and pericardial
or pleural effusions are common
• Early musculoskeletal findings include recurrent
arthralgias, myalgias, or transient arthritis, which are
maximal with fever spikes
 Rehabilitation Medicine | Dr. Abiog | [F4] RHEUMATIC DISORDERS AND THE REHABILITATION MEDICINE IMPLICATIONS 04/28/2016

• Chronic polyarthritis develops within weeks to Neuropathic Arthropathy

months after disease onset • Commonly called Charcot joint, is a severe destructive
arthropathy that is consequent of impaired joint
2. Polyarticular onset sensation.
• Arthritis in 5 or more joints occurs in approx. 40% JRA Conditions assoc with neuropathic arthropathy
patients, and often presents insidiously with malaise, • DM
weight loss, low-grade fever, mild organomegaly, • Tabes Dorsalis
adenopathy, anemia and growth retardation • Syringomyelia
• Girls more affected than boys (3:1) • Spinal cord or peripheral nerve injury
• Leprosy
3. Pauciarticular onset • Amyloidosis
• Occurs in 50% of JRA cases affecting 4 or fewer • Multiple sclerosis
joints within the 1st 6 months and about 50% of the • Myelomeningocele
pauciarticular JRA, is often chronic, and insidious • Congenital insensitivity to pain
with great potential for ocular damage, including • Tumor invading nerve
band keratopathy, posterior synechiae, and • Familial dysautonomia (Riley-Day syndrome)
secondary cataracts (30%); glaucoma (20%), and • Familial interstitial hypertrophic polyneuropathy
visual loss or blindness (Dejerine-Sottas disease)
• Strong male preponderance and older age at • Hereditary sensory radicular neuropathy
onset with more than ½ having HLA B27 but RF and • Peroneal muscular atrophy (Charcot-marie-tooth
ANA re (-) disease)
o Arthritis asymmetric, affects
predominantly lower extremity joints, and Clinical Manifestations
early hip involvement is common • Two forms:
o Enthesopathy is often present o Acute neuropathic arthropathy
o Attacks of acute self-limited iridocyclitis  Atrophic or resorptive form
may occur  Presently rapidly in a period of few
weeks
Prognosis and treatment  Joint is swollen, warm and
• Although often chronic, prognosis for children is good erythematous indicating hyperemia,
o At least 75% of patients enter long periods of and may be painful
quiescence or remission with little or no residual  Typically involves nonweight-bearing
disability joint and often undiagnosed or
• Immediate therapeutic goals are relief of symptoms, mistaken as severe infection or
maintenance of JROM and muscle strength early in their aggressive bone tumor
illness, and rehabilitation seen later in the disease o Chronic neuropathic arthropathy
• Aspirin remains to be the single, most effective and least  Hypertrophic form, more common
expensive anti-inflammatory medication for JRA but  Develops over a longer period of time
compromised by its assoc with the occurrence of Reye’s and involves weight bearing joints
syndrome  Initial joint involvement mimic OA, but
o Dosage is 75 to 90 mg/kg/day to a max of 100 later becomes swollen and enlarged
to 120 mg//kg/day, if good results are not with joint effusion and/or
obtained at lower dosages hypertrophic osteophytes
o Serum salicylate level should be monitored at  Neurologic changes (loss of deep
18 to 25 mg/dl pain sensation and loss of DTRS)
o Levels above 30mg/dl do not increase evident.
therapeutic benefits but do increase side • Many patients have sudden joint collapse because of
effects intraarticular or juxtaarticular fractures
• Other approves NSAIDS include ibuprofen, tolmetin, o Spontaneous fractures, dislocations, and
naproxen, and fenoprofen (<14 y/o) infection are common complications which
o For 14y/o and above: Indomethacin may be lead to further destruction
useful as a night time adjunct to reduce
morning stiffness for pericarditis, or for persistent • Three most common causes:
enthesopathy o DM
• Because exacerbation occurs after brief remissions, ASA  Diabetic neuroarthropathy occurs in
and other NSAIDS should be continued for 12 to 18 0.15% of diabetic patients
months  Forefoot and midfoot most
• If no improvement with ASA or other NSAIDS, commonly involved, followed by
intramuscular gold therapy may be added, but should ankle, knee, spine and upper
be monitored by blood counts, urinalysis, and PE extremity joints
o If not, oral weekly pulse methotrexate, o Tabes Dorsalis
10mg/M2 is now often substituted or may be  Most commonly the lower limb joints
started before gold o Syringomyelia
• Systemic corticosteroid are contraindicated in the  1/3 predominant in the UE and
treatment of JRA for patients with severe polyarthritis or cervical spine
systemic disease that have incompletely responded to
MTX or gold therapy Management
• Total joint replacement may greatly improve function in • Treat the cause if possible
long standing disease but must await full bone growth • Immobilization or reduction of weightbearing
near affected joint recommended

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• Orthosis to prevent normal stress that can aggravate
joint destruction
• Arthrodesis has a high failure rate due to non-union, pin
fracture or infection
o Knee arthrodesis usually requires adequate
bone dissection, debridement, and firm
internal fixation
• Total joint replacement is generally contra-indicated
due to rapid loosening and sublaxation of the prosthesis
• Amputation should be considered in an advanced
destructive case or when complicated with infection
Gout
• Disease in which tissue deposition of monosodium urate
crystals occurs from supersaturated extracellular fluid
and results in one or more clinical manifestations,
namely:
1) Recurrent attacks or severe acute or chronic
articular and periaarticular inflammation known as
gouty arthritis
2) Accumulation of articular, osseous, soft tissue, and
cartilaginous crystalline deposits called tophi
3) Renal impairment, also referred to gouty
nephropathy
4) Uric acid calculi in the urinary tract
• Hyperuricemia, serum urate concentration more than
2SD above the mean, generally above 7 mg/dL in males
or above 6mg/dL in females, reflects metabolic
derangements in ECF that predisposes to clinical events
Prevalence: predominantly an adult male disease with peak
incidence in the 5th decade
o Gout is the most common cause of
inflammatory arthritis in men over age 30 and
inflammatory arthritis in US
o Rarely occurs in men before adolescence or in
women before menopause
Pathogenesis
• Uric acid is the normal end product of urate catabolism
• Gout in human arises from the species-wide lack of the
enzyme uricase which oxidizes uric acid and is only
sparingly soluble in body acids
Stages of Gouty Arthritis
1. Asymptomatic hyperuricemia
• Not strictly gout as by no means all patients with
hyperuricemia will develop gout
2. Acute Gouty arthritis
• The acute arthritis of gout is the most common early
manifestation
• The 1st MTP is the most commonly involved in 75% of
cases, The ankle, tarsal area, and the knee are also
commonly involved
o Podagra - a painful condition of the big
toe caused by gout
• Frequently begins abruptly in a single joint at night
so patient awakes with dramatic unexplained joint
pain and swelling which are usually warm, red and
tender
• Desquamation may occur when the inflammation
subsides
• Acute attacks may be triggered by specific events
like trauma, alcohol, drugs, surgical stress or acute
medical illness
• Swings in the level of uric acid may precede
episodes of gouty arthritis
3. Intercritical Gout
• Stage interval between attacks, which at the start is
usually without symptoms or abnormal PE findings
4. Chronic Tophaceous Gout
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• Tophi appear on the average of ten years after the
1st gouty arthritis attack
• Tophi occur most often in the synovium,
subchondral bone, olecranon bursa, infrapatellar
and Achilles tendons, subcutaneous tissue on the
extensor forearm, overlying joints and less often on
the helix of the ear
• Deforming arthritis can develop due to erosion of
cartilage and subchondral bone caused by crystal
deposition and chronic inflammatory reaction
Complications
1. Renal disease
• Urolithiasis
o Parallels increase in serum urate, acidify of
urine and urinary uric acid concentration
o Uric acid stones are usually radiolucent,
small and round
2. DM, cardiac and cerebral atherosclerosis and
hypertriglyceridemia occur more frequently with gouty
patients
Laboratory
• Demonstration of monosodium uric crystals is
mandatory for establishing the diagnosis of gout, as
serum urate levels can be misleading
• Polarizing microscope shows birefringent and bright
yellow crystals
• 20,000-100,000 cells/mm3 synovial fluid leucocytes
Treatment: Acute Gout
• Colchicine administered as 0.5mg tablet taken hourly
until 1 of the 3 endpoints is reached:
 1) Significant improvement in pain
and inflammation
 2) Gastrointestinal toxicity
 3) Maximum total dose of 8mg
o Prompt response of arthritis to colchicine is
diagnostic of gout, with more than 90% of
acute attacks improved when colchicine is
given within the first few hours of symptoms
o However, other crystal-induced arthropathies
also response to colchicine
o Gastrointestinal toxicity, in 80% of cases,
include nausea, vomiting, diarrhea and
abdominal cramps
• NSAIDS given in their recommended maximal doses at
the 1st sign of attack
o Caution in patients with renal insufficiency as it
may induce hyporeninemic
hypoaldosteronism through their inhibition of
renal prostaglandin formation
o May worsen hypertension, induce Na
retention, and cause edema
o Many physicians prefer indomethacin for
acute gout
• Corticosteroids and ACTH have been used when
colchicine and NSAIDS were contraindicated or
ineffective
• In acute gout, 20 to 40 mg of prednisone given for 3 to 4
days and gradually tapered over 1 to 2 weeks
 Rehabilitation Medicine | Dr. Abiog | [F4] RHEUMATIC DISORDERS AND THE REHABILITATION MEDICINE IMPLICATIONS
• Aspiration and intraarticular depot injection with 10 to
40mg of triamcinolone and 2 to 3mg of dexamethasone
is a useful alternative in patients with gout of 1 or 2 large
joints
Hyperuricemia and Urate Lowering agents
• Hyperuricemia alone is not a disease state and is seldom
a reason for treatment
o 1) However, moderate hyperuricemia over a
period of years may lead to gouty arthritis,
tophus formation and less commonly,
nephrolithiasis
o 2) Treatment of hyperuricemia in patients with
recurrent or chronic gout implies a long term
commitment to daily therapy and behavioral
change
 Foods with high purine content
(visceral meats, sardines, shellfish,
turkey, salmon, trout, beans, peas,
asparagus, and spinach) should be
restricted
 When possible, hyperuricemic drugs
like PZA, ethambutol, thiazides or loop
diuretics should be avoided
• Goal of treatment is consistent maintenance of serum
urate <6mg/dL at 37C
• Uricosuric drugs (xanthine oxidase inhibitor) are selected
according to patient need. The 3 most commonly used
are:
o 1) Probenecid – uricosuric used more often
 Therapy started during stable attack-
free period, as initiation during an
acute flare can lead to prolongation
of the flare
 hyperuricemia
o 2) Sulfinpyrazole
 Has mild antiplatelet effect, and
inhibited by aspirin
o 3) Allopurinol
 Reserved for patients in whom there is
urate overproduction, nephrolithiasis,
or other contraindication to uricosuric
therapy
 It is the preferred drug in renal
insufficiency
o 4) Febuxostat (Fuboxostat sa slide ni doc)
 Latest in the market
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Idiopathic Inflammatory Myopathies (IIM)
• Polymyositis and dermatomyositis are IIM
o More common in women than in men in all age
groups
o Symmetric proximal muscle weakness is the
dominant feature
 Patients most often first complain of
hip girdle symptoms, later arms and
weakness of the anterior neck flexors
o In dermatomyositis, pathognomonic skin
findings are Gottron’s papules which occur in
1/3 of cases
 Gottron’s papules are violaceous,
flat-topped papules overlying the
dorsal surface of IP joints of the hand
 Gottron’s sign or rash, a more
common finding, consists of
erythematous, smooth, or scaly
patches with or without assoc edema
over the dorsal IP or MCP joints,
elbows, knees or medial malleoli
 V-sign – a photosensitive dusky
eruption of the face especially in the
malar and periorbital areas, on the V
area of the neck
• Shawl sign – over the
shoulders and upper back
 Poikiloderma – a characteristic
speckled thinning with areas of
hyperpigmentation
 Heliotrope rash – dusky, purple, and
occurs over the often-edematous
upper eyelid especially along the
edges
 Mechanic’s hand – hyperemia and
scaling, roughened skin may be
present at the sides and tips of the
fingers
o Malignancy is found in higher than expected
proportion of patients with polymyositis and
dermatomyositis
Systemic Sclerosis
• A connective tissue disease of unknown etiology
characterized by fibrosis of the skin and visceral organ
and accompanied by relatively specific ANA and
microvascular disturbances
• Female: male ratio of 15:1 during child-bearing years
Clinical Features
• First symptoms: Raynaud’s, swelling or puffiness of the
fingers and hand, or polyarthralgias, or polyarthritis
involving the small joints of the hand
• Cutaneous sclerosis of both the digits and proximal areas
such as dorsum of the hands, face and trunk is nearly
pathognomonic
• Myopathy is characterized by mild proximal weakness,
minimal elevation of serum creatine kinase and non-
inflammatory replacement myofibrils
• Distal esophageal motor dysfunction is the most
common manifestation of internal involvement
• Bibasilar, linear or nodular interstitial fibrosis is seen on
CXR
• In the heart, subtle evidence of left ventricular
dysfunction is evident
• Renal involvement includes reduced creatinine
clearance, hypertension, azotemia, and microscopic
• Hematuria or proteinuria
 Rehabilitation Medicine | Dr. Abiog | [F4] RHEUMATIC DISORDERS AND THE REHABILITATION MEDICINE IMPLICATIONS
Rheumatic Fever
• An acute inflammatory condition that follows group A
beta hemolytic streptococcal infection and involves
joint, heart, skin, CNS and subcutaneous tissue
• Peak incidence: 5 to 20 y/o
Major manifestations
1. Acute polyarthritis
• Most frequent initial symptom, occurring in 85 to 95
% of cases
• Usually migratory, with prominent periarticular
inflammation
• Lasts 2 to 4 weeks and is very responsive to
salicylates
2. Cardiac involvement
• The most ominous clinical manifestation
• Occur in 30 to 90% of cases
• Virtually always associated with murmur that leads
to valvular damage
• Also includes tachycardia disproportionate with the
degree of fever and persistent during sleep,
cardiomegaly, heart failure and pericarditis
• Mitral insufficiency is the most common acute
manifestation followed by middiastolic mitral flow
murmur
3. Sydenham’s Chorea
• Usually a late neurologic event, occurring in 5 to
10% of all cases
• Characterized by abrupt, short, nonrhythmical
movements and purposeless grimacing
4. Subcutaneous nodules located in the extensor surface
of the elbows and forearm in 3 to 5% of cases
• Mostly in children with carditis
5. Erythema marginatum
• Nonpruritic evanescent rash on the trunk and
extremities that spares the face
o Seen in 3 to 15% of cases
THERAPEUTIC MODALITIES
HEAT AND COLD
• Superficial heat is more commonly used than deep heat
in treating rheumatic conditions.
o Felt to be more beneficial and appropriate.
 HMP, hot showers, paraffin bath and
the like lead to diminution of pain and
increased ability to move and
exercise inflamed joints,
 Deep heat increases activity of
synovial collagenase but no scientific
evidence that heat increases joint
erosions or damages it.
 But recent studies by Weinberger
using diathermy at 9.15 Hz for 1 hour
decreased chronic knee effusions of
RA patients and advocated its use as
“thermal synovectomy”.
• Many patients with RA prefer cold to heat giving better
ROM.
• Trial and patient preferences should direct the
prescription of heat or cold for rheumatic disease.
OTHER MODALITIES
• Nylon spandex compression gloves, claimed by the
patients, made them feel better with little measurable
evidence except for reduced finger circumference.
• Improved wrist and hand function with TENS was
reported in RA cases but its application to hand and
wrist would be awkward, limit its use and interfere with
compliance.
• Contractures, usually at the knee, improve with cast and
splints.
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04/28/2016
o Modalities include wedge casting, casts plus
traction, serial casting, traction, weights and
exercise and manipulation under anesthesia,
splints for knees and wrists, casts, exercise, and
traction, plaster casts and splints, plaster splints
and cuffs, plaster casts, posterior splints, and
knee-straightening device.
o Relief of contractures through constant passive
motion (CPM) has been reported anecdotally.
APPROACHES TO SPECIFIC RHEUMATIC DISEASES
RHEUMATOID ARTHRITIS
• Rehabilitation goals include:
o Relief of pain
o Increased ROM
o Increased strength and endurance
o Prevention and correction of deformities
o Provision of counseling and education
Relief of pain
• Moist heat
o Hot packs provide heat to a depth of 1 to
1.5cm
o Not only a pain reliever but it helps reduce
stiffness, and serves as preparation to an
exercise program.
o Use splints
Prevention and Correction of Deformities
• ROM active stretching exercises
• Protective splints
• Joint mobilization as described by Maigne – gentle
manipulation of joints past normal range reached by
active ROM exercises – probably will not benefit RA
patients.
• “Joint preservation” and “work simplification”
techniques help prevent deformities.
Increased Strength and Endurance
• Isometric exercise did not increase the number of
synovial fluid white cells or volume of fluid, whereas
passive ROM exercises did (Merritt and Hunder).
• Isometrics increased strength, type II muscle fibers
increase in size, ADL performed with less effort and VO2
(Nordimar).
• But it would seem prudent to suppress the inflammation
thoroughly before prescribing any exercise program.
OSTEOARTHRITIS
• Intraarticular steroid injection
• Isometric exercise for strengthening
• Total hip arthroplasty for intractable hip pain
• Use cane or crutches relieves weight-bearing stress in the
knee.
o Cane should be held in the patient’s hand of
choice. As there is no clear evidence that a
cane in the contralateral hand gives consistent
relief of pain for OA of the knee more
frequently than one held in the ipsilateral hand.
o Multiple-angle isometric exercises at the knee
increase muscle strength, improve ability to do
ADL and decrease the use of analgesics.
o Thumb spica for thumb
o Epidural injections and brace to hold the spine
in slight lumbosacral flexion can provide
temporarily in spinal stenosis with
polyradiculopathy and myelopathy.
o Deep-toe box and shoe with molded insole
accommodate dropped metatarsal heads is
helpful with hallux valgus and cock-up
deformity of digits 2 to 5, the most common
deformities of OA in the feet.
 Rehabilitation Medicine | Dr. Abiog | [F4] RHEUMATIC DISORDERS AND THE REHABILITATION MEDICINE IMPLICATIONS 04/28/2016

o A rocker-bottom sole to compensate for a
stiffened hallux rigidus makes walking difficult
and unstable,
PSORIATIC ARTHRITIS
• Characterized by tendinitis, enthesistitis, and synovitis of
both peripheral and spinal joints.
• High-toe box shoes with soft leather uppers for the
tendinitis and synovitis of the toes
• Heel lift and longitudinal arch support for associated
plantar fasciitis
• Paraffin baths to inflamed fingers for pain relief
• Splinting PIP or DIP can relieve pain but does not prevent
deformity in the long run
• Spinal extension exercises for spondylitis
• Major problem usually is inability to flex the knee
adequately.
o In some centers, if 90 degrees of flexion has not
been achieved by 3 weeks, manipulation
under anesthesia is done.
• Non-cemented knees cannot do FWB for 6 to 8 weeks
postoperatively.
• Isometric or resistive exercise probably should not be
started for 8 weeks after surgery.
Most outstanding note takers of Rehab:
Ang, Adrian
Perlas, Jim

ANKYLOSING SPONDYLITIS
• An inflammation of the enthesis (the tissue attaching
tendons and joint capsules to bone) plus synovitis.
o Synovial joints and tendons heal by ossification
• No studies have demonstrated that exercises, braces, or
medications preserve the flexibility of the spine or
prevent stiffening.
o An extension deformity of the spine is better for
most purposes than extreme flexion.
o Exercise thought to maintain the erect posture
include performing push-ups and “walking into
corners” with the hands on the occiput and the
shoulders abducted.
o Daily exercise to maintain upright posture is a
battle, and should not slip into noncompliance.
o If arthroplasty is performed, be on the lookout
for postoperative heterotopic ossification, a
very common situation is AS than OA or RA.

SYSTEMIC LUPUS ERYTHEMATOSUS

• Forms of SLE Arthritis
o Jaccoud’s arthritis – non-erosive deforming
arthritis e.g., ulnar deviation and MCP
subluxation, Swan-neck > Boutonnierre
deformities
o Avascular necrosis not only the hip but may
also involve the knees, shoulders and other
joints.
o Rupture of the patellar and Achilles tendons
with or without association with ACS
• Splint, use of walker or other assistive device to lessen
weight bearing, tenorrhaphy, diminution of the steroid
dose and exercise may help.

REHABILITATION AFTER ARTHROPLASTY

A. HIP
• Ambulation can be started as early as 1 to 2 days
postoperatively.
• Avoid hip adductions, flexion and internal rotation
following posterior approach.
• Elevated chair seats, and especially toilet seats to
prevent excessive hip flexion.
• Resistive exercises are not begun for 6 to 8 weeks
postoperatively, and a cane or walker should be used
until the hip abductor muscles are strong enough so that
the patient no longer limps during a=unassisted walking.
• Stair-climbing and other precautions are taught before
discharge.

B. KNEE
• FWB can be permitted as early as a few days
postoperatively, as pain tolerance allows.
• PWB is suggested for knee instability, revision
arthroplasty, previous infection or bone grafts.
• CPM within the 48 hours postoperatively.

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