PHYSİOPATHOLOGY AND REHABİLİTATİON OF NONARTİCULAR RHEUMATİSM

1. PHYSİOPATHOLOGY AND REHABİLİTATİON OF NONARTİCULAR RHEUMATİSM Dr. Pembe Hare Yiğitoğlu Near East UniversityFaculty of Medicine Department of PhysicalMedicineandRehabilitation 2012

2. Fibromyalgia • MyofascialPainSyndrome • Bursitis • ImpingementSyndrome • CalcificTendinitis • BicipitalTendinitis • De Quervain’sTenosynovitis • PatellarTendinitis • AdhesiveCapsulitis • LateralEpicondylitis • MedialEpicondylitis • Plantarfasciitis

3. FIBROMYALGIA • Fibromyalgia is a disordercharacterized by • chronic widespread musculoskeletalpain, • stiffness, • paresthesia, • disturbed sleep, • easy fatigability, • multiple painful tender points,which are widely and symmetrically distributed.

4. Fibromyalgia affects predominantly women in a ratio of 9:1 compared to men. • The prevalence of fibromyalgia in the United States was reported to be 3.4%in women and 0.5% in men.

5. PATHOGENESİS • Disturbed sleep has been implicated as a factor in thepathogenesis. • Nonrestorativesleeporawakeningunrefreshedhas been observed in most patients withfibromyalgia. • Sleepelectroencephalographicstudiesin patients with fibromyalgia have shown disruption of normalstage 4 sleep [non–rapid eye movement (NREM)sleep] by many repeated α-wave intrusions.

6. Serotonin is a neurotransmitterthat regulates pain and NREM sleep. • Deficiency of serotonin might also beinvolved in the pathogenesis of fibromyalgia. • Low levels of serotonin metabolites have been reported in the cerebrospinalfluid (CSF) of patients with fibromyalgia.

7. Growth hormone is secreted normally during stage 4sleep, which is disturbed in patients with fibromyalgia.Thismay explain theextended periods of muscle pain following exertion. • The level of the neurotransmitter substanceP has been reported to be increased in the CSF offibromyalgia patients and may play a role in spreadingmusclepain.

8. Patients with fibromyalgia have a decreasedcortisolresponsetostress. • Autonomic dysfunction has also been suggestedto play a role in the pathogenesis of fibromyalgia. • Thismay account for the dry eyes andmouth and the cold sensitivity and Raynaud’s-like symptomsseen in patients with fibromyalgia.

9. Reduced blood flow to the areas in thebrain involved in the signaling, integration, and modulationof pain is demonstrated. (the thalamus, caudatenucleus, and pontine tectum)

10. Approximately 30% of patients fit a psychiatric diagnosis,the most common being • depression, • anxiety, • somatization,and • hypochondriasis.

11. CLINICAL MANIFESTATIONS • Symptoms are generalized musculoskeletal aching, stiffnessandfatigue. • Patientscomplain of musclepain after even mild exertion, and some degree of pain isalways present. • The pain has been described as a burningor gnawing pain or as stiffness. • Patients may complain of joint pain and perceivepalpation of the tender points.

12. Fibromyalgia may be triggered by emotional stress,infections and other medical illness, surgery, hypothyroidism,and trauma. • It has appeared in some patients withhepatitis C infection, HIV infection, parvovirus B19 infection, or Lyme disease.

13. FMS DİAGNOSİS • The Symptom Severity(SS) scale and theWidespread Pain Index (WPI)are combined to recommend a new case definition of fibromyalgia: • (WPI >7 AND SS >5) OR (WPI 3–6 AND SS >9). • This allows people with fewer painful areas but more severe symptoms to be diagnosed.

14. Treatment • Antidepressants • Tricyclic antidepressants • Selective serotonin reuptake inhibitors (SSRI’s) • Duloxetine (Cymbalta), • Pregabalin (Lyrica), • Aerobic exercise programs • NSAIDs have not been proved to be effective in the treatment of fibromyalgia. • Avoid corticosteroids and narcotics.

15. MYOFASCIAL PAIN SYNDROME • Myofascial pain syndrome is characterized by localizedmusculoskeletal pain and tenderness in association with trigger points.

16. Myofascial pain may follow trauma, overuse, or prolonged static contractionof a muscle, which may occurwhen reading or writing at a desk or working at a computer. • In addition, this syndrome may be associated withunderlying osteoarthritis of the neck or low back.

17. Triggerpoints are a diagnostic feature of this syndrome. • Painis referred from trigger points to areas distantfrom the original tender points. • Palpation of the triggerpoint reproduces or accentuates the pain. The triggerpoints are usually located in the center of a muscle belly.

18. Trigger point sites palpation may cause the muscle to twitch. • Myofascial pain most often involves theposterior neck, low back, shoulders, and chest.

19. Treatment • Stretching: Intermittent cold and stretch • Thermotherapy: Hot pack, ultrasound • Electrotherapy: Interferential current, transcutaneous nervestimulation • Coldlasertherapy • Acupuncture • Dryneedling • Myofascialtriggerpointinjection

20. Medication • Exercise therapy • Stretching and postural exercises • Strengthening • Conditioning - swimming

21. BURSITIS • Bursa is a thinwalledsac lined with synovial tissue. • The function of thebursa is to facilitate movement of tendons and musclesover bony prominences. • Bursitis is inflammation of a bursa. • Excessive frictional forces fromoveruse, trauma, systemicdisease (e.g., rheumatoidarthritis, gout), orinfectionmaycausebursitis.

22. Subacromialbursitis(subdeltoid bursitis) is the most common form ofbursitis. • The subacromial bursa, which is contiguouswith the subdeltoid bursa, is located between the undersurfaceof the acromion and the humeral head and iscovered by the deltoid muscle. • Bursitis is caused byrepetitive overhead motion and often accompanies rotatorcufftendinitis.

23. Anotherfrequentlyencountered form is trochanteric bursitis, which involves the bursa aroundthe insertion of the gluteus medius onto the greatertrochanter of the femur. • Patients experience pain overthe lateral aspect of the hip and upper thigh andhave tenderness over the posterior aspect of the greatertrochanter. • External rotation and resisted abductionof the hip elicit pain.

24. Treatment of bursitis consists of • prevention of the aggravating situation, • rest of the involved part, • nonsteroidal anti-inflammatory drug (NSAID), • local glucocorticoid injection.

25. ROTATOR CUFF TENDINITIS ANDIMPINGEMENT SYNDROME • Tendinitis of the rotator cuff is the major cause of apainful shoulder and is currently thought to be causedby inflammation of the tendon(s). • The rotator cuff consistsof the tendons of the • supraspinatus, • infraspinatus, • subscapularis and • teres minor muscles.

26. Of the tendons forming therotator cuff, the supraspinatus tendonis the most oftenaffected. • This is probably because of • its repeated impingementbetween the humeral head andthe undersurface of the anterior third of the acromionand coracoacromial ligament above, • the reductionin its blood supply that occurs with abduction of thearm.

27. The process begins with edema andhemorrhage of the rotator cuff, which evolves to fibroticthickening and eventually to rotator cuff degenerationwith tendon tears and bone spurs. • Subacromial bursitis also accompanies this syndrome.

28. Severe pain is experienced when thearm is actively abducted into an overhead position. • Thearc between 60° and 120° is especially painful. • Tendernessis present over the lateral aspect of the humeralhead just below the acromion.

29. CALCIFIC TENDINITIS • This condition is characterized by deposition of calciumsalts, primarily hydroxyapatite, withintendon. • The supraspinatus tendon is most often affected becauseit is frequently impinged on and has a reduced bloodsupply when the arm is abducted.

30. BICIPITAL TENDINITIS • Bicipital tendinitis, or tenosynovitis, is produced by frictionon the tendon of the long head of the biceps as itpasses through the bicipital groove.

31. Whentheinflammationis acute, patients experience anterior shoulder painthat radiates down the biceps into the forearm. • Abductionand external rotation of the arm are painful and limited. • The bicipital groove is very tender to palpation. • Painmay be elicited along the course of the tendon by resistingsupination of the forearm with the elbow at90°(Yergason’ssupinationsign).

32. TREATMENT OF TENDİNİTİS • NSAIDs, • Local glucocorticoid injection, • Physical therapy relieve symptoms. • Surgical decompression of the subacromial spacemay be necessary in patients refractory to conservative treatment.

33. DE QUERVAIN’S TENOSYNOVITIS • In this condition, inflammation involves the abductorpollicislongus and the extensor pollicisbrevis as thesetendons pass through a fibrous sheath at the radial styloidprocess. • The usual cause is repetitive twisting of thewrist. • It may occur in pregnancy, and it also occurs inmothers who hold their babies with the thumb outstretched.

34. Patients experience pain on grasping withtheir thumb, such as with pinching. • Swelling and tendernessare often present over the radial styloid process.

35. The Finkelstein signis positive. • It is elicited by havingthe patient place the thumb in the palm and closethe fingers over it. • The wrist is then ulnarly deviated,resulting in pain over the involved tendon sheath in thearea of the radial styloid.

36. Treatment consists initially of splinting the wrist and an NSAID. • When severe orrefractory to conservative treatment, glucocorticoidinjections can be very effective.

37. PATELLAR TENDINITIS (JUMPER’S KNEE) • Tendinitis involves the patellar tendon at its attachmentto the lower pole of the patella. • Patients may experiencepain when jumping during basketball or volleyball,going up stairs. • Tenderness isnoted on examination over the lower pole of the patella.

38. Treatment consists of rest, icing, and NSAIDs, followedby strengthening and increasing flexibility.

39. ADHESIVE CAPSULITIS (FROZEN SHOULDER) • Adhesive capsulitis is characterized by pain and restricted movement of theshoulder, usually in the absence of intrinsic shoulder disease.

40. Adhesive capsulitis, however, • may follow bursitis or tendinitisof the shoulder • or be associated with systemicdisorders such as chronic pulmonary disease, myocardialinfarction, and diabetes mellitus. • Prolonged immobilityof the arm contributes to the development of adhesive capsulitis.

41. The capsule of the shoulder isthickened, and a mild chronic inflammatory infiltrateand fibrosis may be present.

42. The shoulder is tender to palpation, and both active and passive movement is restricted. • In most patients, the condition improves spontaneously1–3 years after onset. • While pain usuallyimproves, most patients are left with some limitation of shoulder motion.

43. Local injections of glucocorticoids, NSAIDs, and physical therapy provide relief of symptoms.

44. LATERAL EPICONDYLITIS (TENNIS ELBOW) • Lateral epicondylitis, or tennis elbow, is a painful conditioninvolving the soft tissue over the lateral aspect ofthe elbow. • The pain originates at or near the site ofattachment of the common extensors to the lateral epicondyleand may radiate into the forearm and dorsumof the wrist.

45. This painful condition iscaused by repeated resisted contractions of the extensormuscles. • The pain usually appears after work involving repeated motions of wristextension and supination against resistance. • Most patientswith this disorder injure themselves in activities like tennis, carrying suitcases, or using a screwdriver.

46. MEDIAL EPICONDYLITIS • Medial epicondylitis is an overuse syndrome resulting inpain over the medial side of the elbow with radiationinto the forearm. • The cause of this syndrome is consideredto be repetitive resisted motions of wrist flexionand pronation, which lead to microtears and granulationtissue at the origin of the pronatorteres and forearmflexors, particularly the flexor carpiradialis.

47. Itoccurs in work-related repetitive activities orwhileplaying golf or throwing a baseball. • Onphysical examination, there is tenderness just distal tothe medial epicondyle over the origin of the forearmflexors. • Pain can be reproduced by resisting wrist flexionand pronation with the elbow extended.

48. LATERAL AND MEDİAL EPICONDYLITIS TREATMENT • Discontinuationof aggravating activities, • Use of analgesic medications, • Physical modalities, • Bracing (e.g., medial/lateral counter-forcestrap and neutral wrist splint), • Corticosteroidinjections, • Operative treatment can be warranted for those who fail toimprovewithconservativemeasures.

49. PLANTAR FASCIITIS • Plantar fasciitis is a common cause of foot pain in adults. • Plantar fasciitis is thought to bethe result of repetitive microtrauma to the tissue.

50. Several factors that increase the risk ofdeveloping plantar fasciitis include • obesity, • pesplanus(excessive pronation of the foot), • pescavus (high-archedfoot), • limited dorsiflexion of the ankle, • prolonged standing, • walking on hard surfaces, • faulty shoes.