Approach to a patient with
bone and joint disorders
Dr Chathurika Dandeniya
Senior Lecturer in Medicine
Consultant in Rheumatology and Rehabilitation
Department of Medicine
Faculty of Medicine- UoP
Case 1
• A 74-year-old female with long standing rheumatoid arthritis, presents
with pain in hands and bilateral knees.
• She is on a wheelchair.
• Rheumatoid arthritis for >20 years
• Poorly managed and been on long-term steroids
• Flexion contractures and osteoarthritis of both knees
• Active inflammation of all PIP and MCP joints of the hands and both knees
• Lives with her 80-year-old husband. Only son lives abroad.
• She appears depressed
Overall goal of her care
• Pain management
• Improve independent mobility
• Reduce dependency for activities of daily living
• Overall, improve her quality of life
How do we do that?
Intended learning outcomes..
• Integrate knowledge from prior basic science courses to analyze the function of various
human body systems at the cellular, tissue, organ, and systemic level.
• Describe the etiology, manifestations, risk factors, medical management and
physiotherapy clinical correlates with common diseases encountered by the
physiotherapist.
• Integrate knowledge of the diseases covered and physiotherapy primary, secondary, and
tertiary prevention.
• Apply the model of disablement to various health conditions and discuss the role of
physiotherapy examinations, prognosis, and interventions in the reduction of functional
and social limitations that result from the associated health conditions or process.
• Demonstrate professional practice behaviors including accountability, altruism,
compassion/caring, cultural competence, ethical behavior, integrity, personal /
professional development, professional duty, social responsibility and advocacy,
communication including documentation, clinical reasoning, evidence-based practice,
education and teamwork.
Rheumatoid arthritis
An inflammatory arthritis with a long history
• Initially comprehensively described in the
1700’s
• An autoimmune disease
• If untreated, deforming with devastating
consequences
• Predominantly affects middle-aged
females, but can happen at any age
• Affects synovial joints
• Upper limbs, small joints, symmetrical in
most cases
Management..
• Early diagnosis and treatment is crucial
• Now we have very effective medications
• Steroids allow rapid symptom relief but do not prevent progressive
disease or deformities
• Also high side effect burden
• Core of treatment is immunosuppression
Problems that you will encounter in this
patient
• Muscle weakness
• Bone weakness
• Knee joint contractures
• Pain
• Active inflammatory arthritis
• Hand deformities
• Poor motivation
• WHY?????????
The answers lay in
pathophysiology
Muscle weakness
• Multifactorial
• Disuse atrophy
• Steroid myopathy
• Inflammatory myositis
• Poor nutrition- feeding difficulty, loss of appetite due to
drugs/disease/depression
• Drug-induced sarcopaenia- eg leflunomide
• Negative nitrogen balance due to overwhelming chronic inflammation
Disuse atrophy
• Maintaining muscle strength is energy consuming
• If a muscle is mechanically less loaded, there is less need to maintain
a bulky muscle
• Commonly seen in bulky muscles
What are steroids?
• Naturally produced by the adrenal cortex
• ‘Philip Showalter Hench along with his Mayo Clinic co-worker Edward
Calvin Kendall and Swiss chemist Tadeus Reichstein was awarded
the Nobel Prize for Physiology or Medicine in 1950 for the discovery
of the hormone cortisone, and its application for the treatment
of rheumatoid arthritis.’
• Suppress immunity
Steroid myopathy
• At high doses of 40 to 60mg/day, steroid-
induced clinically detectable weakness can
develop within 30 days
• Increases myofibrillar degeneration
through the activation of ubiquitin-
proteasome system
• Induces myocyte apoptosis
• Reduces the potential of satellite cells to
differentiate into myocytes
• End result- skeletal muscle weakness.
Predominantly, large volume proximal
muscles
Inflammatory myositis
• Very uncommon in rheumatoid arthritis, but has been described
• Autoimmune inflammation leads to myocyte death
Problems that you will encounter in this
patient
• Muscle weakness
• Bone weakness
• Knee joint contractures
• Pain
• Active inflammatory arthritis
• Hand deformities
• Poor motivation
Bone weakness
• Multifactorial
• Inflammation
• Use of steroids
• Poor mobility
• Poor nutrition due to loss of appetite (drugs/ disease)
On cross section, two macroscopic appearances identified in health
• Trabecular vs cortical bone
Bone histology….
• Cells and matrix (proteins and minerals)
• Cells: osteocytes, osteoblasts, osteoclasts. These are basically
messengers/mediators, producers and destroyers
• Matrix- type 1 collagen and calcium hydroxyapatite
Osteocytes
• Differentiated
• Embedded within the bone
• Detects mechanical stressors
on the bone and transmits
the signals to the osteoblasts
via transverse processes
• Bone is a dynamic tissue
• Process called remodeling: formation and loss at the same time
• Which process is dominant will determine if one gains bone or
loses bone
• This helps understand the condition known as ‘osteoporosis’
Why is the presence or absence of
osteoporosis important to the
physiotherapist???
Problems that you will encounter in this
patient
• Muscle weakness
• Bone weakness
• Knee joint contractures
• Pain
• Active inflammatory arthritis
• Hand deformities
• Poor motivation
Knee joint contractures
• Damage to the joint
• Shortening of soft tissue structures due
to flexed posture caused by trying to
avoid pain
• Muscle atrophy
• Using splints/bandages to immobilize
the knees in a flexed or semi-flexed
position
Problems that you will encounter in this
patient
• Muscle weakness
• Bone weakness
• Knee joint contractures
• Pain
• Active inflammatory arthritis
• Hand deformities
• Poor motivation
Pain…
• Pain is multifactorial in such patients
• Active inflammatory arthritis
• Secondary osteoarthritis
• Muscle strains/sprains due to abnormal posturing
• Central pain sensitization
• Unless pain is controlled, patient will not engage in physiotherapy
Problems that you will encounter in this
patient
• Muscle weakness
• Bone weakness
• Knee joint contractures
• Pain
• Active inflammatory arthritis
• Hand deformities
• Poor motivation
Active inflammatory arthritis
• Reduces joint movement due to pain
• In turn leads to disuse atrophy and contractures
• But, any exercise applying stress on an inflamed joint can aggravate
the pain and the inflammation
• Isometric exercises and gentle ROM exercises should be encouraged
for inflamed joints
• Remember the physiology of nociceptive response
Problems that you will encounter in this
patient
• Muscle weakness
• Bone weakness
• Knee joint contractures
• Pain
• Active inflammatory arthritis
• Hand deformities
• Poor motivation
Problems that you will encounter in this
patient
• Muscle weakness
• Bone weakness
• Knee joint contractures
• Pain
• Active inflammatory arthritis
• Hand deformities
• Poor motivation
Intended learning outcomes..
• Integrate knowledge from prior basic science courses to analyze the function of various
human body systems at the cellular, tissue, organ, and systemic level.
• Describe the etiology, manifestations, risk factors, medical management and
physiotherapy clinical correlates with common diseases encountered by the
physiotherapist.
• Integrate knowledge of the diseases covered and physiotherapy primary, secondary, and
tertiary prevention.
• Apply the model of disablement to various health conditions and discuss the role of
physiotherapy examinations, prognosis, and interventions in the reduction of functional
and social limitations that result from the associated health conditions or process.
• Demonstrate professional practice behaviors including accountability, altruism,
compassion/caring, cultural competence, ethical behavior, integrity, personal /
professional development, professional duty, social responsibility and advocacy,
communication including documentation, clinical reasoning, evidence-based practice,
education and teamwork.
Thank you!
