Osteoarthritis (F>M 50+)

Degeneration of joint cartilage and underlying bone

• Stiff, tender, and swollen joints
• Morning stiffness lasting up to 30 minutes
• Aches and pains in muscles
• Decreased joint range of motion
• Fatigue feeling or tiredness
• Can cause physical deformity

Caused by

• Increased weight (obesity)
• Females > Males
• Increased age
• Joint injuries
• History of fractures
• Repeated stress on joints (repetitive activities)
• Genetics
• Bone deformities
• Metabolic disorders

Diagnosed via: X – rays, observation for physical deformity

Treatment:

Condition can not be reversed. Treatment is aimed at reducing symptoms and increasing range of motion

• Manual therapy to help with surrounding soft tissue structures
• Exercise to help strengthen muscles and joints
• Medications to help reduce inflammation
• Cortisone injections into joint
• Surgery for joint replacements

Rheumatoid arthritis

Definition: an autoimmune disease, where the body mistakes its own cells as foreign invaders.

This causes an attack of the body’s joint synovium by inflammatory chemicals. Flare ups may

last from months to a lifetime with symptoms being episodic in nature.

Symptoms: (mimics many other arthritic conditions in early stages)

• Insidious onset of pain and stiffness, swelling and warmth that begins with thesmall joints of the hands and/or feet.
• Commonly affects people aged 25-45 years old.
• More than 1 joint is affected, usually bilateral involvement
• Symmetrical involvement of the metacarpophalangeal or metatarsophalangeal joints
• Symptoms may come and go
• Morning stiffness which can last hours
• Fatigue, low-grade fever, weakness
• Soft tissue swelling
• Joint effusion and synovial swelling
• Tenderness on palpation or movement of joint
• Joint Deformities (Boutonniere, Swan Neck, Z deformity of wrist, Ulnar deviation)

Caused by:

• Genetics: gene HLA-DR1
• May be associated with poor diet (high in red meats, processed meats, refined grains, fried foods, high fat dairy and sugar can increase chances of developing RA

Examination:

• Physical examination of joints observing for swelling, warmth, redness, tenderness, decreased range of motion, palpation of joint line irregularities, and joint deformity.
• Morning stiffness lasting more than 30 minutes
• Blood tests will be looking to diagnose:
  1. Rheumatoid factor
  2. Erythrocyte sedimentation rate (ESR)
  3. Full blood count (CBC)
  4. CCP antibodies
  5. Antinuclear antibody (ANA)
  6. C – reactive protein (CRP)

Treatment:

• Disease Modifying Anti -Rheumatic Drugs (DMARDs)
• Analgesics and NSAIDs
• Education on exercises
• Hydrotherapy
• Diet – introducing omega3 and fish oils
• Acute flare ups require rest
• Rheumatologist management

Prognosis:

• Fair to poor. Depending on number of symptoms. Can last for months to a lifetime depending on flare ups and management.

Psoriatic arthritis (M=F 30-55) 

Definition: chronic, autoimmune form of arthritis that causes joint inflammation and occurs with the skin condition psoriasis. Immune system attacks healthy cells in the body by mistake causing symptoms

Symptoms:

• Red patches of skin topped with silvery scales
• Multiple joint pain, stiffness, and swelling
• Swollen fingers and toes
• Nails may form pits, crumble, or separate from the nail beds.
• May present similarly as Ankylosing spondylitis

Caused by:

• Genetic predisposition (HLA-B27 gene)
• May be triggered by a viral or bacterial infection when genetically predisposed
• Physical trauma to joints may predispose to Psoriatic arthritis
• Psoriasis skin condition often predisposes Psoriatic arthritis

Examination:

• Observe for signs of swelling and tenderness around joint
• Pitted fingernails
• May present unilaterally or bilaterally
• PsA should be suspected in any patient who has psoriasis and arthritis, however it may be present in both
• Blood tests provide negative Rheumatoid factor
• Joint fluid test. Small fluid is aspirated from affected joint and examined for uric crystals which will indicate gout rather than PsA )
• X- ray to examine for joint destruction

Treatment

• DMARDS
• NSAIDS
• Management through Rheumatologist
• UV Light therapy for skin issues
• Steroid injections
• Joint replacement surgery
• Manual therapy to help increase joint ROM and reduce muscle HT

Prognosis:

Fair to poor. Although a chronic condition with no cure, condition can be managed conservatively with Rheumatologist, medications, and manual therapy

Fibromyalgia (F>M 30-50)

• Pain disorder characterized by widespread musculoskeletal pain with localized tenderness for at least 3 months. Chronic daily body aches. Overactive nerves causing pain despite lack of any physical injury. Does NOT cause joint damages

Symptoms:

• Widespread muscle pain and tenderness
• Points include shoulders, low / upper back, chest, elbows, knees, and temporal region of head
• Fatigue, altered sleep, mental distress
• Lack of energy
• Morning stiffness in joints
• Cognitive difficulties
• Stress can magnify symptoms

Common causes:

• Unknown
• Genetics
• May be initiated or triggered by physical or emotional event
• Chemical receptors in the brain can become sensitised and overreact to painful and non-painful stimuli
• Central sensitisation. Blunting of inhibitory pathways and changes in neurotransmitters cause aberrant neuro-chemical processing of sensory signals in the CNS. This lowers the patient’s pain threshold and amplifies the normal sensory signals causing pain.

 Diagnosed via:

• Mild to severe pain in 3 to 7 different areas of your body
• Symptoms for at least 3 months
• No other reason for your symptoms

Treatment – medicines / procedures

• Patient education on stress reduction strategies, good sleep hygiene, and assistance for anxiety or depression related symptoms
• Exercise regimen involving cardiovascular training which improves sleep and helps decrease pain levels (recommended 30 mins of aerobic exercise 3 x a week)
• Manual therapy
• Hydrotherapy
• Medications to help reduce pain levels (consult your medical doctor)

Prognosis: Fair to poor. Factors included are listed here.

• A long duration of disease
• High-stress levels
• Presence of depression or anxiety that has not been adequately treated
• Long-standing avoidance of work (unemployed)
• Alcohol or drug dependence
• Moderate to severe functional impairment

Specialist: Rheumatologist, Psychiatrist, Physical medicine and rehabilitation physician (Physiatrist)

Polymyalgia Rheumatica (F>M 70-79)

• Connective tissue inflammatory disorder characterised by bilateral pain and stiffness in the muscles

Symptoms:

• Shoulder, neck, and hip pain associated with restricted range of motion and stiffness. Pain often spreads to the arms and legs
• Pain can develop quickly or progressively over a few weeks.
• Morning stiffness that lasts more than an hour
• Commonly bilateral
• Symptoms may be worse in the morning and with inactivity.

Common causes:

• Suspected genetic and environmental factors

Diagnosed via:

• A combination of clinical symptoms and laboratory findings
• ESR and C reactive protein blood tests can be used to check the levels of inflammation in the body.

Treatment

• Corticosteroids are considered the treatment of choice because they often cause complete symptom resolution and reduction of the ESR to normal.

Prognosis 

• With early diagnosis and appropriate management, the average length of disease is 3 years. Usually lasts 1-5 years. However, exacerbations may occur if steroids are tapered too rapidly.

Deep Vein Thrombosis (DVT)

• Blood clots forming in a deep vein
• Swelling and bruising
• Painful
• Increase in temperature
• May have NO symptoms
• Caused by: sitting for long periods, pregnancy, injury to vein, obesity, post-surgery, increased age, blood disorders
• Duplex ultrasonography: an imaging test that uses sound waves to look at blood flow in the veins
• Compression stocking and anti-coagulants (blood thinners given orally or by injection, typically do not break up clots, but prevent new ones from forming)

Fracture (Radial head / Lateral humerus epicondyle)

• Immediate swelling on lateral aspect of elbow
• Dull ache, throbbing pain on outside of elbow
• Difficult to straighten elbow, painful
• Bruising
• X – ray / MRI
• Surgery or casting required

Reflex sympathetic disorder / Complex regional pain syndrome (CRPS)

• Chronic limb pain
• Pain is greater than expected than injury that may have caused it
• Continuous throbbing, burning, numbness and tingling
• Sensitive to touch (painful)
• Skin colour and temperature changes
• Not well understood
• May be post-surgery, injury, stroke, or heart attack
• May involve abnormal inflammation or nerve dysfunction

Treatment: Challenging to manage as results vary between patients. Some options may include:

• Acupuncture
• Pain relief medication, anti inflammatory medication
• Nerve block injection, morphine
• Intravenous Ketamine
• Manual / Physical / Exercise therapy
• Meditation, relaxation therapies