Patient Management Strategies in Arthritis

Patient Management Strategies in Arthritis
Presented by: Anna Mae Smith, MPAS, PA-C
Lock Haven University of PA


Physician Assistant Program
DJD/Osteoarthritis

* Obesity
o increase in body mass
o altered biodynamics of gait
o genetic predisposition (genetically obese mice are susceptible to osteoarthritis)
o altered metabolism (e.g., estrogens)
Risk Factors

* Occupational
Treatment

* Physical measures may be subdivided into..
o Exercise
o Supportive devices
o Alterations in activities of daily living
o Thermal modalities
Exercise

* Associated with reduced pain & improved function.
o Passive range of motion
o Rest periods
o Active: range of motion, isometric, isotonic, isokinetic
* Improved muscle tone reduces muscle spasm and prevents contractures. It is theorized that improved muscle support of the joint will retard the progression of osteoarthritis.

Which Exercises
* Swimming
* Biking (Stationary)
* Walking

Support Devices & Orhotics

* Devices such as canes, forearm crutches, crutches, and walkers can improve balance and decrease pain.
* The total length of a properly measured cane should be equal to the distance between the upper border of the greater trochanter of the femur and the bottom of the heel of the shoe. This should result in elbow flexion of about 20°.
* The cane should be held in the hand contralateral to and moved together with the affected limb. The healthier limb should precede the affected limb when climbing up stairs; when climbing down stairs, the cane and the affected limb should be advanced first. The cane can unload the affected hip by 60%.

Modified activities of daily living
* Proper positioning and support when sitting, sleeping or driving a car
* Adjusting ways of performing such activities as getting dressed, etc.
* Adjusting furnishings around the house or at work (e.g., raising the level of a chair or toilet seat)

Thermal modalities
* Superficial heat (e.g., hot packs, paraffin baths)
* Deep heat (e.g., ultrasound)
* Cold applications (e.g., cold packs, vapocoolant sprays)

HEAT

* The therapeutic value of applying heat includes decreasing joint stiffness, alleviating pain, relieving muscle spasm, and preventing contractures.
* The use of heat is contraindicated over tissues with inadequate vascular supply, bleeding, or cancer. Heat should also be avoided in areas close to the testicles or near developing fetuses.

Miscellaneous

* Pulsed electromagnetic fields
* TENS
* Acupuncture
* Chiropractic
* Spa, massage, and yoga therapy


Short acting drugs
Long Acting Agents
Hyaluronic Acid Derivatives
DIET

* Avoid coffee, artificial additives, red meats & processed foods
* Limit tomatoes,potatoes,eggplants, peppers, & simple carbohydrates(white flour & refined sugar).
* Fresh fruits & veges, complex carbs, wheat germ & oily fish
* Vit. A 10,000iu/day
* Vit. C 2grams/day
* Vit. E 600iu/day
* Vit. B6 50 mg/day

First-line therapy

* Anti-inflammatories
* Aspirin
* Nonsteroidal anti-inflammatory
Second Line Therapies

* Antimalarials (chloroquine, hydroxychloroquine)
* Sulfasalazine
* Methotrexate
* Gold salts
* Auranofin
* Parenteral gold
* D-penicillamine
* Azathioprine
* Cyclosporin A
* Combination therapies
* Corticosteroids
* Systemic steroids
* Low-dose oral
* Parenteral pulse steroids
* Intra-articular

Investigational

* EPA (eicosapentaenoic) - anti-inflammatory effect of fish oil fatty acid
* Plant seed oils particularly those extracted from evening primrose oil and borage seed oil that contain large amounts of gamma linolenic acid.
Light Therapy

* Extracorporeal photochemotherapy and extracorporeal protein A immunoadsorption
Vitamins

* Vit. C 2grams/day
* Vit. E 600iu/day
* B complex vitamin
* Calcium 1200-1500/day
* Selenium 100mg/day
* Zinc 30mg/day

Hydrotherapy

* Cold compresses when acutely inflamed followed by alternating hot & cold
* Massage - lavender, tiger balm & chamomile oils

Herbs

* Black cohosh
* Wild yam
* Willow bark
* Licorice

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Patient Management Strategies in Fibromyalgia

Patient Management Strategies in Fibromyalgia
Presentation by: Anna Mae Smith,MPAS, PA-C
Lock Haven University of PA

Education

* Not a ‘psychiatric’ illness
* Usually chronic but controllable
* Not deforming or Life-threatening
* Medications that improve sleep appear to be the best treatment!

Amitriptyline & Cyclobenzaprine

* They tend to increase NREM Stage IV sleep
* the availability of brain serotonin
* decrease muscle spasm
* Decreases patients' reports of pain intensity
* Sleep quality
* Improvements in pain threshold or tender point counts
* Loses effect after 6 months

Alprazolam and ibuprofen
Other Treatments

* Aerobic Exercise
* Cognitive Behavior Therapy
* Biofeedback
* Hypnotherapy
* Acupuncture
* Inject trigger points with steroids
* Treat underlying depression if needed

Diet
* avoid the following:
* refined sugar
* alcohol
* caffeine
* foods high in saturated fats
* high-calorie, high-fat, low-food-value junk food
* A moderate diet containing the following ratio (based on percentages of calories, not grams):
40% carbohydrate/ 30% protein/ 30% fat for each meal and snack
* Water…8/8oz

Herbs

* Ginseng and gotu kola, have both been found to improve energy and mental alertness.
* Ginseng is known to contain a steroid
* Valerian Root
* St John’s Wort
* Gingko Biloba
* Grape See Extract
* Devils Claw Root

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Rheumatoid Arthritis

Rheumatoid Arthritis
Presentation by: Anand Lal, M.D.


Rheumatoid Arthritis

* Chronic systemic inflammatory disease of unknown etiology
* Affects the Synovial Membranes of multiple joints
* Prevalence 1-2%
* Female : Male ratio 3:1
* Usual age of onset 20-40 years though individuals of any age group may be affected
* Pathologic finding: chronic synovitis with pannus formation. The pannus erodes cartilage, bone, ligament and tendons. In the acute phase effusion and other manifestations of inflammation are evident; in the later stages ankylosis of the joint may set in. In both the acute and chronic phase, there may be widespread inflammation of the tissues around the joint that can lead to significant joint destruction.

* Clinical presentation
o usually presents insidiously;
o prodromal syndrome of malaise, weight loss and vague periarticular pain and stiffness may be seen
o less commonly, the onset is acute, triggered by a stressful situation such as infection, trauma, emotional strain or in the postpartum period.
o the joint involvement is characteristically symmetric with associated stiffness, warmth tenderness and pain
* Clinical Features
o the stiffness is characteristically worse in the morning and improves during the day; its duration is a useful indicator of the activity of the disease. The stiffness may recur especially after strenuous activity.
o the usual joints affected by rheumatoid arthritis are the metacarpophalangeal jts, the PIP jts, the wrists, knees, ankles and toes.
o Entrapment syndromes may occur especially carpal tunnel syndrome

* Labs
o Rheumatoid factor, an IgM antibody is seen in the sera of 75% of patients with rheumatoid arthritis. High titers of rheumatoid factor are associated with severe disease.
o Rheumatoid factor is also found in other diseases like syphilis, sarcoidosis, infective endocarditis, TB, leprosy, parasitic infections; in advanced age and in asymptomatic relatives of patients with rheumatoid disease.
o Antinuclear antibody are seen in 20% of patients with rheumatoid arthritis, though their titer is lower than in SLE

* Labs
o The ESR is elevated both in the acute and chronic phases of the disease
o a moderate anemia is often present which is usually hypochromic normocytic
o the white count is normal or slightly increased but leukopenia may occur, often in presence of splenomegaly (e.g., Felty’s syndrome)
o the platelet count is often elevated in proportion to the degree of joint inflammation
o joint fluid examination is valuable. The fluid is translucent to opaque and has between 3000 and 50,000 WBCs /microL. There are 50% or more polymorphonuclear leukocytes. The culture is negative.

* X-ray
o of all the laboratory tests, x-ray changes are most specific for rheumatoid arthritis. However, they are not sensitive and usually are negative during the first 6 months of the disease

* X-rays
o the earliest changes occur in the wrist or feet and consist of soft tissue swelling and juxta-articular demineralization. Later, diagnostic changes consisting of joint space narrowing and erosions develop. The erosions are first seen at the ulnar styloid and at the juxta-articular margin, where the bony surface is not protected by cartilage. Diagnostic changes also occur in the cervical spine with C1-2 subluxation, but this can take several years to develop.

* Differential Diagnosis
o Rheumatic fever: migratory arthritis, elevated ASO and dramatic response to Aspirin
o Systemic Lupus Erythematosus: Butterfly rash, discoid lupus erythematous, photosensitivity, alopecia, high titers of Anti Ds-DNA, renal and CNS disease
o Osteoarthritis: no constitutional manifestations and no evidence of joint inflammation
o Gouty Arthritis: usually monoarticular initially but can become polyarticular in the later years
o Pyogenic arthritis: usually monoarticular, fever and chills, abnormal joint fluid
o Chronic Lyme disease: commonly monoarticular and associated with positive titers
o Human Parvovirus infection: arthralgia more common than arthritis, rash may be present, serologic evidence of parvovirus B19 infection
o Polymyalgia rheumatica is associated with proximal muscle weakness and stiffness
o several cancers produce paraneoplastic syndromes including polyarthritis; e.g., hypertrophic pulmonary osteoarthropathy produced by lung and gastrointestinal cancers. Diffuse swelling of the palmar fascia has been associated with several cancers including ovarian cancer.

* Treatment
* Treatment (Disease Modifying Agents (DMARDs)
* Prognosis
Rheumatoid Arthritis.ppt

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