RCS 6080 Medical and Psychosocial Aspects of Rehabilitation Counseling

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RCS 6080 Medical and Psychosocial Aspects of
Rehabilitation Counseling

• Rheumatic Diseases

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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

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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

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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

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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

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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

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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

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Complications of Rheumatoid Arthritis

• Complications include
• Carpal tunnel syndrome, Bakers cyst, vasculitis,
  subcutaneous nodules, Sjögrens syndrome,
  peripheral neuropathy, cardiac and pulmonary
  involvement, Feltys syndrome, and anemia

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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.

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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.

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Treatment

• Surgery video
• Removal of inflamed synovium
• Arthroplasty
• Physical therapy

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Vocational Implications of Rheumatoid Arthritis

• Need to make frequent assessments of the persons
  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

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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

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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.

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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 its across the
  entire surface of both kidneys suggesting a
  chronic condition.

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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.

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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.

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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.

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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

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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
• Reiters syndrome may follow a wide range of GI
  infections
• Bowel inflammation has been implicated in the
  pathogenesis of endemic Reiters syndrome,
  psoriatic arthritis, and ankylosing spondylitis

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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)

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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

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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

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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

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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.

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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

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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

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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.

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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)

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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.

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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

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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

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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

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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

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Vocational Implications of the Spondylarthropathie
s

• The person should be considered for vocational or
  professional education as resources and interests
  dictate
• A stiff back will limit the persons 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

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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 ones 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

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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

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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

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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

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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

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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

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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/medlin
  eplus/juvenilerheumatoidarthritis.html)
• Spondylitis Association of America
  (www.spondylitis.org)
• Arthritis.com Latest Arthritis Information
  Community (www.arthritis.com)