Arthritis

Question 1

Define arthritis

Answer 1

A chronic joint disorder characterised by degeneration of joint cartilage and adjacent bone that can cause joint pain and stiffness

Question 2

The most common form of arthritis is …

Answer 2

Osteoarthritis

Question 3

Prevalence of osteoarthritis … with age

Answer 3

Increases

Question 4

Which joints does osteoarthritis commonly affect?

Answer 4

Knees
Hips
Hands

Question 5

Describe process of osteoarthritis

Answer 5

1. Collagen/proteoglycan producing cells become abnormal
2. An increase in cartilage growth initially and bone density (osteosclerosis) reducing joint space
3. Cartilage thins and cracks, roughening causes pain during movement
4. Bone erosion with bone on bone movement
5. Compensation occurs with development of bone spurs leading to deformation and pain
6. Inflammation thickens synovium
7. Increase in synovial fluid –> joint swells –> overstretching of muscles causes weakness

Question 6

Clinical features of osteoarthritis

Answer 6

Bone hypertrophy
Bone spurring
Fusiform swelling of joints (Bouchard’s nodes)
Heberdens nodes

Question 7

Rheumatoid arthritis is an … disease affecting the … …

Answer 7

Autoimmune

Whole body

Question 8

Rheumatoid arthritis affects … of the population

Answer 8

1%

Question 9

RhA is … times more common in …

Answer 9

3

Women

Question 10

Process of RhA

Answer 10

1. T-cells in synovial fluid become unable to distinguish between foreign and normal body cells
2. Excessive production of immunoglobulins and inflammatory cytokines (TnF alpha)
3. Excessive Ig causes abnormal division and growth of synovial cells
4. Leukocytes migrate to joints, release enzymes causing synovitis –> increases swelling, stretching of ligaments, enzyme release attacks hyaline cartilage

Question 11

4 stages of RhA

Answer 11

1. Synovitis (synovial membrane inflammation)
2. Pan us (extensive cartilage loss, exposed and pitted bones)
3. Fibrous ankylosis (invasion of joint with fibrous connective tissue)
4. Bony ankylosis (fusion of bones)

Question 12

What may blood tests reveal in RhA? Why does this happen?

Answer 12

Presence of rheumatoid factor (RF) antibody (80% sensitivity)

RF is produced to try and lower levels of other antibodies

(However some people with RF don’t have RhA and vice versa)

Question 13

RhA usually affects joints …

Answer 13

Symmetrically

Question 14

Joints commonly affected in RhA

Answer 14

Wrists
Hands
Knees
Elbows
Shoulders
Ankles

Question 15

Major aetiology of RhA

Answer 15

60% genetic plus environmental involvement

Question 16

Non-genetic factors causing RhA

Answer 16

Age
Hormonal factors
Infection 
Smoking
Obesity

Question 17

What does ankylosing spondylitis cause?

Answer 17

Acute spinal pain and stiffness without significant decrease in mobility

Question 18

Why is osteoarthritis joint specific but RhA whole body?

Answer 18

RhA is an autoimmune disease so affects multiple organs

Question 19

Why do ligaments become lax in later stage arthritis?

Answer 19

Chronic inflammation causes over-stretching

Question 20

What is TNF-alpha?

Answer 20

An inflammatory cytokines produced my macrophages

Question 21

Name some extra-articular manifestations of RhA

Answer 21

TNF-alpha causes weakness, fatigue, loss of appetite, muscle pain, weight loss

Myocardial damage and pericarditis

Pleural fluid accumulation in lungs

In 1 out of 6 people can shorten life

Question 22

Why is there increased prevalence of arthritis in older people?

Answer 22

Natural decline in glucosamine and chondroitin sulphate production (so less durable cartilage is produced)

Question 23

Men have more … OA

Answer 23

Hip

Question 24

Women have more …/… OA

Answer 24

Hand/knee

Question 25

In general ... develop RhA more frequently than ...

Answer 25

Women | Men

Question 26

What hormone is protective of OA?

Answer 26

Oestrogen - increased OA prevalence post menopause

Question 27

Weakness of which muscle is a risk factor for OA?

Answer 27

Quadriceps (from inactivity)

Question 28

Top ... for BM increases risk of hip and knee OA by ... times

Answer 28

20% | 7-10

Question 29

Modest weight loss ... OA

Answer 29

Reduces

Question 30

History of joint damage ... to OA

Answer 30

Predisposes

Question 31

True or false, there is conclusive evidence that overuse increases risk of OA

Answer 31

False - inconclusive data on athletes

Question 32

Moderate levels of physical activity ... increase risk of OA

Answer 32

Doesn't

Question 33

True or false, infection can predispose to arthritis

Answer 33

True - both OA and RhA

Question 34

There is a ...-...% influence of genetics on development of arthritis

Answer 34

30-60%

Question 35

Arthritis symptoms (general)

Answer 35

``` Pain and crepitation on movement Enlarged and deformed joints Inflammation of joints Stretched ligaments - instability Decreased ROM or complete freezing of joints ```

Question 36

3 movements most affected by arthritis

Answer 36

Stooping/bending Standing Walking

Question 37

Exercise limitations in people with arthritis

Answer 37

Less muscular strength/endurance Less flexibility and ROM Lower peak VO2 (20-30%) Increase in oxygen demand of movement due to movement inefficiencies

Question 38

Why do you get exercise limitations with arthritis?

Answer 38

Inactivity causing retraining Structural changes in bone and tendons Reduced coordination and motor control

Question 39

What can imposed inactivity with arthritis cause?

Answer 39

Increased risk of CHD, diabetes, osteoporosis Increased weight exacerbating joint loading and reducing mobility further

Question 40

Aims of treatment of arthritis (ACSM 2010)

Answer 40

``` Ease pain and inflammation Improve joint function Lessen joint damage Improve functional capacity Reduce risks of comorbidities ```

Question 41

Non exercise treatment of arthritis

Answer 41

Firm beds/chairs Heat - warm baths Massage Drugs: aspirin, ibuprofen, steroids, DMARDs, COX-2 inhibitors (reducing prostaglandins --> reducing inflammation)

Question 42

Exercise does not stop ... ... of arthritis, but does not exacerbate ... or ... ...

Answer 42

Pathological process Pain Disease progression

Question 43

How can exercise help arthritis patients? | 8

Answer 43

Increase joint mobility Increase muscle strength around joint (improved stability, shock absorption, lower risk of falls) Reduces swelling at joints Reduces body weight Increased bone density Reduced pain on movement Increased peak vo2 Reduced CHD RFs

Question 44

T or F, cartilage has direct blood vessels and nerves

Answer 44

False - cartilage has no direct vessels or nerves

Question 45

How does cartilage receive nutrients?

Answer 45

Movement of the joint allows diffusion of nutrients into cartilage

Question 46

How does movement increase "feeding" of cartilage?

Answer 46

Increased proteoglycan production Increased glucosamine and chondroitin sulphate secretion from ECM (needed for cartilage production)

Question 47

Weight loss is important in reducing symptoms of OA, which is most important - body fat or body mass reduction?

Answer 47

Body fat reduction

Question 48

How does improvement in muscular strength help arthritis?

Answer 48

Quadriceps strengthening cushions force transmission through muscle rather than joint Improvement in quad:hamstring ratio helps balance load on joint

Question 49

Exercise may help reduce ... ... production

Answer 49

TNF-alpha

Question 50

Aims of exercise in arthritis patients

Answer 50

Increase or preserve ROM and flexibility Increase muscle strength and endurance Increase aerobic conditioning Ameliorate health risks of inactivity

Question 51

When should exercise be avoided in arthritis pts?

Answer 51

During 'flares' or if exercise is particularly painful

Question 52

Exercise considerations with arthritis pts

Answer 52

Decreased ROM Work within pain threshold and maximum ROM Difficulty gripping Balance problems Reduce load each joint is taking Joints stiffer when cold Stiffer in morning

Question 53

Considerations when undertaking pre-exercise testing in arthritis pts

Answer 53

Screen for CAD Joint disease may affect ability to give true maximum effort

Question 54

Which exercise testing method would you use for a patient with: mild joint impairment, mild to moderate lower extremity impairment, and severe lower extremity impairment?

Answer 54

Mild - treadmill Moderate - cycle regime try Severe - arm ergometry

Question 55

A goniometer is used to test ...

Answer 55

ROM

Question 56

How would you test balance in arthritis pt?

Answer 56

Figure right walking (mild) Berg balance scale (moderate-severe)

Question 57

Recommended stretching exercises in arthritis pts

Answer 57

All joints Static - hold 10-30s PNF if supervised - 5s stretch followed by 10-30s assisted stretch 3-4 times/session

Question 58

Recommended strength exercises in arthritis

Answer 58

Isometric: start with isometric, 40-60% MVC, 1-10s, major muscle groups Isotonic: low weight (40-60% 1RM), build up to high no. of reps, 1-3 sets 1-3 days/week, use fixed weights and bands, work all muscles

Question 59

Recommended aerobic exercises for arthritis pts

Answer 59

Low impact: 40-80% HRmax, RPE 12-14 Cycling, rowing, swimming, low impact aerobics Start 5-15 mins every other day, increase to 30-40 mins Increase in 10% intensity increments Consider interval training

Question 60

Do you think that exercise training is worthwhile for people with RA?

Answer 60

Yes - muscle strength and aerobic capacity is vastly improved with exercise in RhA patients without negative effects in disease activity which may be improved

Question 61

What mechanisms may explain why and how exercise may bring about an improvement in disease activity and does this call for a reappraisal of the 2001 statement of the American College of Geriatricians about exercise and arthritis?

Answer 61

Aerobic exercise seems to reduce joint swelling in RA, strengthening exercise reduces pain reports in RhA patients. Exercise-related changes in synovial circulation, immune response and inflammatory factors , and neuropeptide levels. General exercise research also may pertain to this population in terms of the benefits of neuromuscular learning and improved elasticity and strength of peri-articular structures