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An Introduction to Rheumatoid Arthritis for Therapists

Intro

This blog marks the beginning of a concept for me as I look to expand on previous bits of work I have completed. For example I wrote an article for PhysioFirst which you can read in full here. It has topped 9000 downloads at the time of writing this blog and I am immensely proud of it as a piece of work, it was however hamstrung by a word limit and primarily about the joint dysfunction component of RA. This forced me to leave important components out of the document, you can understand them not wanting me to submit a book length article to them but for me it left a lot of things unsaid that I feel would be helpful to Physios. As a result I will look at expanding on these concepts and adding fresh ones.

As usual feedback is gratefully received as are any materials I might be interested in!

PLEASE REMEMBER – THIS BLOG IS NOT A REPLACEMENT FOR CLINICAL REASONING, IF YOU ARE UNSURE GET ADVICE

Overview and Characteristics of Rheumatoid Arthritis

“Rheumatoid arthritis (RA) is a chronic inflammatory disease characterised by joint swelling, joint tenderness, and destruction of synovial joints, leading to severe disability and premature mortality” (Alehata et al 2010). It is of interest to Physiotherapists as guidance recommends therapies which offer areas of expertise in exercise and education regarding the condition and general health (Luqmani et al 2006, Luqmani et al 2009). The persistent synovitis of the joints presents as swelling, heat, stiffness and pain that is usually worse in the early part of the day. The presence of inflammatory infiltrate, if left untreated by medication, eventually causes irreparable erosion to the joint structure which can be extremely disabling. While the Metacarpophalangeal Joints (MCPJs) are the most commonly affected, any synovial joint can be affected and large joint replacements occur at a younger age in RA sufferers (Lee & Choi 2012).

Thanks to ARUK (now versus arthritis) for their kind permission to use these images

Traditionally sufferers of RA have required large amounts of input from different specialisms such as Rheumatologists, Orthopaedic Surgeons and Therapists however improvements in early detection and management from a medical point of view has significantly improved patient outcomes and prolonged function (Stoffer et al 2016). This improvement in medical management has led to the requirement to change Physiotherapy approach, no longer is it consistent of splinting, wax bath treatment and hydrotherapy but more exercise and education on self-management of the condition to return/maintain high level function.

Rheumatoid Arthritis is an extremely variable condition in almost all its characteristics. Symptom severity, number of joints affected, associated symptoms such as fatigue or malaise and age of onset are all individual in their presentation. In addition to the variability of the condition the person themselves brings with them their own beliefs, tolerances, requirements and functional challenges.

In addition to the obvious impact on joints, RA has multisystem affects causing heightened risk of Cardiovascular Disease, Osteoporotic fractures, incidence of infection and development of some malignancies (Giles 2015).

Check out some more of my Rheumatoid Arthritis work http://chewshealth.co.uk/download/suspect-rheum/ and https://rheumatology.physio/2018/12/17/pregnancy-and-rheumatoid-arthritis/

There is also a lecture from me on Trust Me Ed, sign up, it is super worth it!

Sign up for the rheumatology.physio newsletter HERE

References

Alehata D, Neogi T, Sliman A, Funovits J, Felson D, Bingham C, Birnbaum N, Burmester G, Bykerk V, Cohen M, Combe B, Costenbader K, Dougados M, Emery P, Ferraccioli G, Hazes J, Hobbs K, Huizainga T, Kavanaugh A, Kay J, Kvien T, Laing T, Mease P, Menard H, Moreland L, Naden R, Pincus T, Smolen J, Stanislawska-Biernat E, Symmons D, Tak P, Upchurch K, Vencovsky J, Wolfe F, Hawker G. 2010 Rheumatoid Arthritis Classification Criteria. Arthritis and Rheumatism 2010:62(9):2569-2581

Giles J. Cardiovascular Disease In Rheumatoid Arthritis: Current Perspectives on Assessing and Mitigating Risk in Clinical Practice. Best Practice & Research Clinical Rheumatology 2015:1-15

Luqmani R, Hennell S, Estrach C, Birrall F, Bosworth A, Davenport G, Fokke C, Goodson N, Jeffreson P, Lamb E, Mohammed R, Oliver S, Stableford Z, Walsh D, Wasbrook C, Webb F. British Society for Rheumatology and British Health Professionals in Rheumatology Guideline for the management of Rheumatoid Arthritis (The first 2 years). Rheumatology 2006:45(9):1167-9

Luqmani R, Hennell S, Estrach C, Basher D, Birrell F, Bosworth A, Burke F, Callaghan C, Candal-Couto J, Fokke C, Goodson N, Homer D, Jackman J, Jeffreson P, Oliver S, Reed M, Sanz L, Stableford Z, Taylor P, Todd N, Warburton L, Washbrook C, Wilkonson M. British Society for Rheumatology and British Health Professionals in Rheumatology Guideline for the management of Rheumatoid Arthritis (after the first 2 years). Rheumatology 2009:48(4):436-9

Lee J, Choi C. Total Knee Arthroplasty in Rheumatoid Arthritis. Knee Surgery and Related Research 2012:24(1):1-6

Stoffer M, Schoels M, Smolen J, Aletaha D, Breedveld F, Burmester G, Bykerk V, Dougados M, Emery P, Haraoui B, Gomez-Reino J, Kvien T, Nash P, Navarro-Compan V, Scholte-Voshaar M, Vollenhoven R, van der Heijde D, Stamm T. Evidence for Treating Rheumatoid Arthritis to Target: Results of a Systematic Literature Search Update. Annals of the Rheumatic Diseases 2016;75:16–22.

 

Pregnancy and Rheumatoid Arthritis

Intro

Pregnancy is branching away from my usual topics of blogs and reading but here is something else I get asked about with reasonable regularity. Remember that the inflammatory arthropathies commonly onset in the younger years of adult life, when people are working and wish to start having families.

Previously when asked about this my stock answer is “Rheumatoid Arthritis tends to get better during pregnancy and often flares after”. After some more in-depth research this still holds up as a statement but I am going to add a little more depth below (this is as much for my benefit as yours!).

I will look to follow up this blog with one looking at Spondyloarthropathy. Happy reading and I am especially keen to hear from anyone who finds this particular blog useful with it being outside of my usual wheelhouse!

Screen-Shot-2017-09-22-at-17.04.29More info on RA and Physio management here

PLEASE REMEMBER – THIS BLOG IS NOT A REPLACEMENT FOR CLINICAL REASONING, IF YOU ARE UNSURE GET ADVICE

Fertility and Conception

These are fundamentally linked in the “getting pregnant” part of pregnancy, I hope I don’t have to go too much further into this and we all know where its going…

This portion of the process is made complicated by a few factors in women with RA. Diagnosis is linked with longer “Time To Pregnancy” with a higher proportion of women taking longer than 12 months to conceive than matched controls. This is significantly worse with higher levels of disease activity compared to remission. Higher disease activity signifies higher levels of pain and worse function, it is also medicated more aggressively and many medications used to treat RA have a direct effect on fertility. This as a combination is not a surprising revelation that women with RA take longer to get pregnant.

Disease activity during pregnancy

Rheumatoid Arthritis symptoms tend to improve during pregnancy with 54-95% of women reporting decreased symptoms.

Disease activity post partum

Frustratingly just as there becomes a requirement to carry around and look after a new born, 62-90% of women will experience a flare in symptoms from their RA.

Pregnancy Complications

From reading the literature this is exceedingly difficult to calculate due to confounding factors and there is likely to be a difference between planned and unplanned pregnancies due to medication use during conception. My summation is that women with RA are somewhat more likely to have pre-term births and/or caesarean section than controls. There is a slightly higher risk of pre-eclampsia but miscarriage rate is likely to be comparable (again possibly this is an underestimation in unplanned pregnancy).

Women with RA tend to have slightly smaller or lower birthweight children but this has not been shown to have a long term effect on the individuals.

Men

There is a dearth of literature on the impact of male RA on offspring. Some medications can affect fertility but there isn’t much other than expert opinion to suggest an effect on the child. Advice would be the same as for women…

Advice

Practically other than educating on the above information, my best advice is that any person with a diagnosis of RA consults their Rheumatologist prior to trying to conceive. There is a delicate balancing act and maybe some concessions to be made with regards to optimising disease activity without affecting the likelihood/outcome of pregnancy. It is my opinion that there is no place for professionals outside of the Rheumatology consultant or Rheumatology Specialist Nurse to try and provide this counselling without specific training as it is a complex minefield with the medications.

Symptom management, activity modification/maintenance however is very likely going to be required post-partum alongside any necessary management due to the effects of giving birth and here Physiotherapists can play a strong role.

As usual thanks for reading and I hope that you find this useful.

Patient facing info here from NRAS

References

Ince-Askan H, Dolhain RJEM, Pregnancy and rheumatoid arthritis, Best Practice & Research Clinical Rheumatology (2015).

De Man, Y. A., Dolhain, R. J. E. M., & Hazes, J. M. W. Disease activity or remission of rheumatoid arthritis before, during and following pregnancy. Current Opinion in Rheumatology (2014).

Brouwer J, Hazes JMW, Laven JSE, et al. Fertility in women with rheumatoid arthritis: influence of disease activity and medication Ann Rheum Dis (2014).

Mini Blog – SCREEND’EM

Ok so this one is a bit of a cheat.

If you dont follow Paul Kirwan on twitter then head over there now and do that.

Paul came up with the following memory aid to help remember the extra-articular features of Spondyloarthropathies and to be honest, it is awesome.

PLEASE REMEMBER – THIS BLOG IS NOT A REPLACEMENT FOR CLINICAL REASONING, IF YOU ARE UNSURE GET ADVICE.

This is definitely something to add to your clinical reasoning with back pain, multi joint pain or inflammatory type monoarthropathies.

Screendem

Good isn’t it! There is more info on my previous mini blog as well…

As usual thanks for reading and I hope that you find this useful.

Hypermobility Part 3 (The Syndromes)

Intro

Hypermobility is common in Physio clinics the world over, over a series of blogs I hope to convey my current understanding of the factors at play with regards to diagnosis and management of these individuals. I would like to take this opportunity to say this is MY synthesis of available evidence and experience of working with these individuals. I am perfectly happy to be challenged and corrected as I feel I have a lot to learn about this highly complex group!

This blog will outline some of the different types of hypermobility syndromes, I hope this helps you in your clinical reasoning process when faced with this client group. If you didn’t read part 1 or part 2 yet, please give them a look over first.

PLEASE REMEMBER – THIS BLOG IS NOT A REPLACEMENT FOR CLINICAL REASONING, IF YOU ARE UNSURE GET ADVICE

As outlined in part 1, joint hypermobility is not always part of a clinical disorder and it is important that this distinction is made to avoid over medicalising those who do not fulfil this criteria. According to Castori et al the word syndrome in combination with Hypermobility should be reserved for “Joint Hypermobility together with the primary involvement of at least a second tissue/structure (e.g. skin involvement in hypermobile EDS)”. This essentially means try not to label those without extra-articular features with a “syndrome”.

Below I have elaborated on some of the syndromes associated with hypermobility, the list is by no means exhaustive in both the possible conditions mentioned and their possible associated symptoms/manifestations.

Hypermobility Spectrum Disorder (HSD)

In theory the simplest of the syndromes, this covers the patients WITHOUT extra-articular symptoms (skin, autonomic dysfunction, bowel dysmotility). To satisfy the criteria for this syndrome we are looking at multi joint hypermobility with a history of dislocation (multi joint or same joint multiple times) and/or persistent multi joint pain.

I suppose technically Ehlers Danlos Syndrome would be a HSD with extra-articular manifestations, welcome to the world of grey and overlapping diagnostic boxes. I suspect these will still get mixed up from time to time mostly due to the absolute mess that was the laundry list of previous diagnoses put upon these patients historically. At least this on the face of it is much simpler.

****Please see end of blog****

Ehlers Danlos Syndrome

Aka EDS, EDS type 3, hypermobile EDS, benign hypermobility syndrome… (probably some others I can’t remember)

Ehlers Danlos Syndrome is the archetypal Hypermobility Syndrome that contains non-musculoskeletal symptoms. Fortunately in recent history efforts have been made to simplify the diagnostic nomenclature of this condition. For our purposes we are now encouraged to use the term “Hypermobile EDS”. There are other types of EDS but in all honesty as long as Physio’s refer appropriately on recognition it is not particularly relevant in this context. Be aware there are potentially life limiting complications of some of the more serious forms of EDS but these are fortunately rare and SHOULD be being looked after in specialist MDT centres.

The majority of Hypermobility Syndrome diagnoses will fall into the category of the newly termed (and hopefully simplified) Hypermobile EDS. As mentioned in Part 2 of this series, we were previously reliant on the Brighton Criteria to help recognise associated extra-articular manifestations. This has now been superseded by the RCGP EDS toolkit which is definitely useful when suspicious. Importantly this now includes POTS (Postural Orthostatic Hypertension) which is worth its own line of questioning outside the scope of this particular blog.

Things to remember regarding people with Hypermobile EDS is they are prone to hyperalgesia and persistent pain at a higher rate than the average population. A combination of multiple injuries, lack of confidence in their joints and differences in the neural periphery are probably significant contributing factors. There is also a high likelihood of disturbed proprioception. Adding these factors together alone can give some idea of why these individuals have functional difficulties even before you start to map on autonomic dysfunctions.

Marfan Syndrome

A usually inherited condition which is recognised by physical characteristics, these include being very tall with long limbs, pes planus and crowded teeth (there is more info here). There is also a significant relationship with Hypermobility of the joints.

They are an important group to be aware of because they often have heart problems commonly to do with the Aorta and this can be significantly life limiting. All Marfan Syndrome patients should have been screened by Cardiology but hopefully this will have already occurred by adulthood as the signs tend to present during the teenage growth years or earlier so unless you are in a paediatric environment you shouldn’t be the one noticing it!

Please do visit the links in this blog for further information, the nomenclature should be much simpler to grapple with these days rather than the minefield of diagnoses previously concocted even though there does remain overlap.

The final blog in this series will look Physiotherapy management. Please feel free to ask questions or point me in the direction of further information!

As usual thanks for reading and I hope that you find this useful.

Great resources are the following paper and the http://hypermobility.org website.

Castori, M., Tinkle, B., Levy, H., Grahame, R., Malfait, F. and Hakim, A., 2017, March. A framework for the classification of joint hypermobility and related conditions. In American Journal of Medical Genetics Part C: Seminars in Medical Genetics(Vol. 175, No. 1, pp. 148-157).

***Please note, since writing this blog I have received information in conflict to this definition. Below you will see an image lifted from the paper on which these definitions were extracted and you will see where my line of reasoning arises. While I am aware I have simplified things for the sake of keeping the blog of readable length I know feel I need to clarify some points.

HSD (Hypermobility Spectrum Disorder) CAN be associated with extra-articular features such as POTS, bowel dismotility etc. As previously pointed out, if your patient has extra-articular symptoms they should be referred for review by an appropriate medical colleague.

This essentially leaves us in the same place as before and my advice would be to assess the same as any other condition. Assess the whole person, be vigilant and listen to the patients story. 

I promise I will return to Hypermobility Syndromes when more literature is released to clear this up, although I am extremely tempted not to****

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MINI BLOG – Spondyloarthropathy Extra-Articular Symptoms

Intro

Just as a reminder… Spondyloarthritis (SpA) is an umbrella term covering auto-immune conditions affecting the Axial skeleton (the spine and sacro-illiac joints). Conditions falling under this umbrella include, Ankylosing Spondylitis and Psoriatic Arthritis. This blog will outline some of the extra-articular features associated with these conditions, it is important to recall that these are not co-morbidities which are separate conditions which can co-exist alongside the discussed condition. These will be explored in different blogs as they have a significant impact on SpA.

PLEASE REMEMBER – THIS BLOG IS NOT A REPLACEMENT FOR CLINICAL REASONING, IF YOU ARE UNSURE GET ADVICE

Just for clarity, the following percentages are the prevalence of the extra-articular feature in the lifetime of a diagnosed SpA patient.

Common extra articular features include:

Peripheral arthropathy/synovitis – 30%

Peripheral Enthesitis – 40%

Dactylitis – 7%

Psoriasis – 9% (The prevalence of Axial disease in Psoriatic Arthritis patients varies between 25%-75% depending on the definition used which I suspect artificially lowers this number)

Iritis/Uveitis – 20-26%

Crohns/Ulcerative Colitis (IBD) – 4-10%

A number of studies have shown that investigating patients with Psoriasis/Uveitis/IBD and chronic back pain could identify a significant number of undiagnosed Spondyloarthropathies and reduce delay to diagnosis by up to 7 years.

As usual thanks for reading and I hope that you find this useful.

Please get back to me with any feedback, there will be more mini blogs like this one to interlude the longer ones.

Hypermobility Part 2 (syndrome?)

Intro

Hypermobility is common in Physio clinics the world over, over a series of blogs I hope to convey my current understanding of the factors at play with regards to diagnosis and management of these individuals. I would like to take this opportunity to say this is MY synthesis of available evidence and experience of working with these individuals. I am perfectly happy to be challenged and corrected as I feel I have a lot to learn about this highly complex group!

This blog will outline when we might consider the attending individual to have systemic effects related to their hypermobility warranting referral for medical review. If you didn’t read part 1 yet, please give that a look over first.

PLEASE REMEMBER – THIS BLOG IS NOT A REPLACEMENT FOR CLINICAL REASONING, IF YOU ARE UNSURE GET ADVICE

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For a number of years there have been guides on which symptoms to look out for in individuals who may have hypermobile joints that can help us as clinicians, the “Beighton” and “Brighton” scores are the most famed of these. The Beighton score looks at 9 areas for hypermobility and the higher the score the more likely a “generalised hypermobility” would be present. The Brighton score includes the Beighton but with the addition of extra-articular features such as skin  thus giving a higher likelihood of a “Hypermobility Syndrome”.

It is important to have an understanding of these associated symptoms and signs for a number of reasons. In people presenting without a diagnosis, recognition is key, it will help to ensure appropriate management. In those presenting with a pre-existing diagnosis it will help to understand the effects/side effects of proposed therapy interventions.

Aside from the obvious joint related symptoms such as pain and laxity, there are a LOT of potentially associated symptoms. Some of these will affect therapy interventions to a greater or lesser degree but we can explore that a later date. Lets concentrate on recognition and referral for now.

The hypermobility syndromes are a spectrum, it is certainly not necessary to refer every person with excess mobility or laxity in joints for a Rheumatologist review but it is important that we understand the complex blend of relating symptoms to the syndrome or them being a separate medical issue requiring investigation. As such my general rule is that symptoms suggestive of an autonomic issue or related to the gut then I deem these outside of my “wheelhouse” and refer out to appropriate medical professionals (usually a Rheumatologist).

In the era of the internet some will attend with a preconceived idea of a referral being necessary and in some cases this will be the correct course of action and in others it will be an over medicalisation of their condition but at this time the best course of action is to take this on a case by case basis.

These symptoms indicating an outward referral can mostly be found in the Brighton criterias “Minor Criteria” notably these include, multi joint dislocations or multiple dislocations of the same joint, Marfanoid habitus and skin related issues (stretchy, easy bruising, abnormal scarring). Not included in the score are autonomic issues namely POTS (postural orthostatic tachycardia syndrome) and intestinal dysmotility.

As such my advice really is the following: an onward referral is to be considered when an individual presents with multiple hypermobile joints (beighton 4+) and at least one of the symptoms listed above. The location of the referral will depend mostly on your available referral pathways so become familiar with these.

The third blog in this series will look at types of Hypermobility syndrome, I hope that this will help to combine this and part 1 to help with the clinical reasoning process. Please feel free to ask questions or point me in the direction of further information!

As usual thanks for reading and I hope that you find this useful.

Great resources are the following paper and the http://hypermobility.org website.

Castori, M., Tinkle, B., Levy, H., Grahame, R., Malfait, F. and Hakim, A., 2017, March. A framework for the classification of joint hypermobility and related conditions. In American Journal of Medical Genetics Part C: Seminars in Medical Genetics(Vol. 175, No. 1, pp. 148-157).

Hypermobility Part 1

Intro

Hypermobility is common in Physio clinics the world over, over a series of blogs I hope to convey my current understanding of the factors at play with regards to diagnosis and management of these individuals. I would like to take this opportunity to say this is MY synthesis of available evidence and experience of working with these individuals. I am perfectly happy to be challenged and corrected as I feel I have a lot to learn about this highly complex group!

This blog will outline when we observe joints which have excess mobility.

PLEASE REMEMBER – THIS BLOG IS NOT A REPLACEMENT FOR CLINICAL REASONING, IF YOU ARE UNSURE GET ADVICE

Hypermobility

Hypermobility is an observation not a diagnosis, it is also not synonymous with “instability” and it is important that as physios we understand this so we are able to effectively communicate this difference to patients.

The definition of hypermobility is (note remember “normal” has a huge variance):

“Joint hypermobility (JH) is the term universally accepted to define the capability that a joint (or a group of joints) has to move, passively and/or actively, beyond normal limits along physiological axes”1

Hypermobility as an observation can be classified in 2 main ways, distribution and pathophysiology.

The easiest to define is distribution. Usually when hypermobility is observed at a single or only a few joints then it is “localised hypermobility” this includes conditions such as Genu Recurvatum and may be bilateral. When there is hypermobility observable in multiple locations (and in theory) all 4 limbs and the axial skeleton the term “generalised hypermobility” is more applicable. It is possible to have hypermobility in all 4 limbs if the hands and feet are the only areas affected “peripheral joint hypermobility” is a term that could be used in this circumstance.

The pathophysiology of an individual’s hypermobility requires a detailed history. It can of course indicate an underlying systemic pathology but it can also be acquired following, surgery, injury (trauma), joint disease or training.

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Instability

Joint instability is the increased risk of dislocation or subluxation, while this can of course be caused by hypermobility the two can exist in isolation. Other causes of joint instability include trauma, acquired or congenital joint abnormality, muscle or neurological disorders.

Remember, these are observations and/or descriptors, they are NOT a diagnosis.

Practice as a physio for any period of time and you will see circumstances of asymptomatic hypermobility and instability. These findings alone are not sufficient to cause problems (usually pain) and in some circumstances are advantageous. Just go watch the gymnasts in the Olympics…!

It quickly becomes clear that an individual presenting with joint pains or other symptoms alongside hypermobility of joints is a complex picture prior even to consideration of there being a systemic issue at play. It is also easy to see how confusing it can become for not only the individuals affected but the clinicians aiming to help them manage their symptoms. There will be overlap with many presenting to healthcare with trauma on top of pre-existing hypermobility or all manner of other presentations.

I believe we do a disservice to individuals to not consider all these factors sufficiently prior to “diagnosing” or attributing specific complaints to these observations and I suspect in most cases a multidisciplinary approach would be necessary to fully grasp the implications for the individual.

Subsequent blogs in this series will look at the systemic features of “hypermobility syndromes”, different syndromes that may present and management. Please feel free to ask questions or point me in the direction of further information!

As usual thanks for reading and I hope that you find this useful.

Great resources are the following paper and the http://hypermobility.org website.

Castori, M., Tinkle, B., Levy, H., Grahame, R., Malfait, F. and Hakim, A., 2017, March. A framework for the classification of joint hypermobility and related conditions. In American Journal of Medical Genetics Part C: Seminars in Medical Genetics(Vol. 175, No. 1, pp. 148-157).