Samenvatting Module onderzoek en behandeling IIIB: reumatologie
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Course
Module Onderzoek En Behandeling 3B
Institution
Vrije Universiteit Brussel (VUB)
Volledige, overzichtelijke en gestructureerde samenvatting van reumatologie (vak module onderzoek en behandeling IIIB). Alle nota's van de online videos werden hierin ook toegevoegd. Op het einde extra info over het examen en Q&A.
MODULE ONDERZOEK EN
BEHANDELING IIIB
REUMATOLOGIE
2020-2021
Prof: Anneleen Malfliet
1
,Inhoudstafel
Les 1 : Algemene inleiding (deel 1)......................................................................................................... 7
A. Wat is reumatologie ? ..................................................................................................................... 7
B. Structuur binnen dit opleidingsonderdeel ...................................................................................... 7
C. Belang van kinesitherapie ............................................................................................................... 8
D. Anamnese en klinisch onderzoek ................................................................................................... 8
E. Het gewricht .................................................................................................................................. 13
Les 2: Metabool- degeneratieve reuma (deel 2) ................................................................................. 15
1. OSTEOPOROSE .............................................................................................................................. 15
A. Definitie ......................................................................................................................................... 15
B. Risicofactoren ................................................................................................................................ 16
C. Pathogenese .................................................................................................................................. 16
D. Kinesitherapeutische aanpak ........................................................................................................ 17
E. Overige behandelingen ................................................................................................................. 19
2. OSTEOARTROSE ............................................................................................................................ 20
A. Definitie ......................................................................................................................................... 20
B. Primair vs secundair ...................................................................................................................... 21
C. Klinisch beloop en symptomen ..................................................................................................... 22
D. Diagnose........................................................................................................................................ 24
E. Radiografische kenmerken ............................................................................................................ 24
F. Prognose heup/knie-artrose.......................................................................................................... 24
G. Behandeling .................................................................................................................................. 25
Les 3: Weke delen reuma ..................................................................................................................... 29
1. FIBROMYALGIE.............................................................................................................................. 29
A. Definitie ......................................................................................................................................... 29
B. Epidemiologie ................................................................................................................................ 31
C. Diagnose ........................................................................................................................................ 31
D. Pathogenese.................................................................................................................................. 32
E. Behandeling ................................................................................................................................... 35
F. Prognose ........................................................................................................................................ 40
2
,Les 3: Musculoskeletale letsels ............................................................................................................ 41
1. SPIERLETSELS................................................................................................................................. 41
A. Verschillende gradaties van spierletsels ................................................................................... 41
B. Diagnose .................................................................................................................................... 41
C. Behandeling ............................................................................................................................... 41
D. Prognose ................................................................................................................................... 42
2. PEESLETSELS .................................................................................................................................. 43
A. Terminologie ................................................................................................................................. 43
B. Oorzaken ....................................................................................................................................... 43
C. Opbouw ......................................................................................................................................... 44
........................................................................................................................................................... 44
D. Pathogenese.................................................................................................................................. 44
E. Diagnose ........................................................................................................................................ 45
F. Locaties .......................................................................................................................................... 45
G. Behandeling .................................................................................................................................. 46
3. BURSITIS ............................................................................................................................................ 49
A. Algemeen ...................................................................................................................................... 49
B. Symptomen ................................................................................................................................... 49
C. Diagnose ........................................................................................................................................ 50
E. Behandeling ................................................................................................................................... 50
4. INKLEMMINGSNEUROPATHIE .......................................................................................................... 50
A. Definitie ......................................................................................................................................... 50
B. Lokalisatie ...................................................................................................................................... 50
5. CRPS................................................................................................................................................... 51
A. Epidemiologie................................................................................................................................ 51
B. Terminologie ................................................................................................................................. 51
C. Kliniek ............................................................................................................................................ 51
D. Diagnose........................................................................................................................................ 52
E. Pathofysiologie .............................................................................................................................. 52
F. Behandeling ................................................................................................................................... 53
G. Prognose ....................................................................................................................................... 54
8. Preventie ....................................................................................................................................... 54
3
,Les 4: Systeemziekten of bindweefselaandoeningen.......................................................................... 55
1. LUPUS - SYSTEMATIC LUPUS ERYTHEMATOSUS (SLE) ................................................................. 55
A. Epidemiologie................................................................................................................................ 55
B. Kliniek ............................................................................................................................................ 55
C. Diagnose ........................................................................................................................................ 56
D. Belangrijkste AL ............................................................................................................................. 57
E. Pathogenese .................................................................................................................................. 57
F. Behandeling ................................................................................................................................... 57
G. Prognose ....................................................................................................................................... 58
2. INTERMEZZO CORTICOSTEROIDEN .............................................................................................. 58
3. INTERMEZZO RAYNAUD ............................................................................................................... 59
A. Kliniek ............................................................................................................................................ 59
B. Types ............................................................................................................................................. 59
C. Differentiaal diagnose ................................................................................................................... 59
D. Behandeling .................................................................................................................................. 59
4. SJOGREN SYNDROOM................................................................................................................... 60
A. Epidemiologie................................................................................................................................ 60
B. Kliniek ............................................................................................................................................ 60
C. Diagnose ........................................................................................................................................ 60
D. Behandeling .................................................................................................................................. 61
5. SCLERODERMIE ............................................................................................................................. 62
A. Epidemiologie................................................................................................................................ 62
B. Kliniek ............................................................................................................................................ 62
C. Diagnose ........................................................................................................................................ 63
D. Behandeling .................................................................................................................................. 65
E. Prognose ....................................................................................................................................... 65
6. POLYMYOSITIS & DERMATOMYOSITIS ........................................................................................ 66
A. Epidemiologie................................................................................................................................ 66
B. Kliniek ............................................................................................................................................ 66
C. Diagnose ........................................................................................................................................ 67
D. Technische onderzoeken .............................................................................................................. 67
E. Differentiaal diagnose ................................................................................................................... 67
F. Behandeling ................................................................................................................................... 68
G. Prognose ....................................................................................................................................... 68
4
,Les 5: Inflammatoire reuma ................................................................................................................. 70
1. REUMATOIDE ARTRITIS ................................................................................................................ 70
A. Epidemiologie ............................................................................................................................ 70
B. Definitie ..................................................................................................................................... 70
C. Kliniek ........................................................................................................................................ 70
D. Pathogenese.............................................................................................................................. 71
E. Diagnose .................................................................................................................................... 72
F. Behandeling ............................................................................................................................... 74
G. Prognose ................................................................................................................................... 79
Les 6 : Inflammatoire reuma ................................................................................................................ 80
1. SPONDYLARTROPATHIEEN ........................................................................................................... 80
2. PSORIASIS ARTRITIS ...................................................................................................................... 80
A. Epidemiologie ............................................................................................................................ 80
B. Kliniek ........................................................................................................................................ 80
C. Pathogenese .............................................................................................................................. 81
D. Diagnose.................................................................................................................................... 81
E. Behandeling ............................................................................................................................... 82
3. ZIEKTE VAN BECHTEREW (spondylitis ankylosans) ...................................................................... 83
A. Epidemiologie ............................................................................................................................ 83
B. Kliniek ........................................................................................................................................ 83
C. Pathogenese .............................................................................................................................. 84
D. Diagnose.................................................................................................................................... 84
E. Evaluatie .................................................................................................................................... 85
F. Behandeling ............................................................................................................................... 86
G. Prognose ................................................................................................................................... 88
4. INFECTIES EN ARTRITIS (niet te kennen voor examen 2021!) ...................................................... 88
5. JUVENIELE ARTRITIS ...................................................................................................................... 91
A. Epidemiologie................................................................................................................................ 91
B. Kliniek ............................................................................................................................................ 91
C. Diagnose ........................................................................................................................................ 92
D. Behandeling .................................................................................................................................. 92
E. Prognose ........................................................................................................................................ 92
5
,Les 7: Stofwisselingsreuma................................................................................................................... 93
1. JICHT (GOUT) ................................................................................................................................. 93
A. Epidemiologie................................................................................................................................ 93
B. Pathogenese .................................................................................................................................. 93
C. Diagnose ........................................................................................................................................ 95
D. Behandeling .................................................................................................................................. 96
E. Prognose ........................................................................................................................................ 97
2. CHONDROCALCINOSIS .................................................................................................................. 98
A. Epidemiologie................................................................................................................................ 98
B. Kliniek ............................................................................................................................................ 98
C. Diagnose ........................................................................................................................................ 98
D. Behandeling .................................................................................................................................. 98
3. ZIEKTE VAN PAGET ........................................................................................................................ 99
A. Epidemiologie................................................................................................................................ 99
B. Kliniek ............................................................................................................................................ 99
C. Diagnose ........................................................................................................................................ 99
D. Behandeling ................................................................................................................................ 100
INFO OVER EXAMEN ........................................................................................................................... 101
Q&A ..................................................................................................................................................... 102
6
,Les 1 : Algemene inleiding (deel 1)
• Wat is reumatologie ?
• Structuur binnen dit opleidingsonderdeel
• Belang van kinesitherapie
• Anamnese en klinisch onderzoek
• Het gewricht
A. Wat is reumatologie ?
« Reumatologie houdt zich bezig met aandoeningen van bindweefsels, gewrichten en gerelateerde
structuren die gekarakteriseerd worden door inflammatie, degeneratie of metabole stoornissen. “
➔ Specifiek gaat het over: gewrichten/ bot/ spieren/ pezen
Reumatologie bevindt zich in de kern (overkoepelende term, maar ook onderdeel van deze 3
groepen aandoeningen)
B. Structuur binnen dit opleidingsonderdeel
Degeneratieve aandoeningen Osteoporose en osteo-artrose
Weke delen aandoeningen Carpaaltunnelsyndroom, tendinopathie, bursitis, frozen shoulder,
(> over spieren en ligamenten) epicondylitis, hernia/ ischias, fibromyalgie, Dupuytren
Inflammatoire reuma Reumatoïde artritis, reactieve artritis, juveniele artritis,
(Ontstekingsreacties) tuberculeuze artritis, septische artritis, spondylartropathie (ziekte
van Bechterew, ziekte van rohn, ziekte van Reiter, psoriasis)
Andere Ziekte van Lyme, stofwisselingsreuma (jicht, chondrocalcinosis,
hemochromatoze, osteomalaci, hyperparatyroidie, ziekte van
Paget,…)
7
,C. Belang van kinesitherapie
Op welke manier zou je invloed kunnen hebben als kinesitherapeut voor mensen met
reumatologische aandoeningen? Specifieke doelen?
• Pijndemping
• Bewegingsbereik winnen/ verbeteren en onderhouden
• Informatie en advies: hoe men kan omgaan met de klachten?
• Ondersteunen in (hername) lichamelijke activiteit en actieve levensstijl
• Acute symptomen van inflammatie onder controle te houden (aanpakken van primaire
stoornissen en beperkingen)
• Secundaire preventie van reuma samenhangende klachten (pijn, verminderde spierkracht,
verminderde aerobe capaciteit, verminderd evenwicht, afgenomen mobiliteit, valangst,
beperkingen in activiteiten en participatie etc.)
• Instrueren bij gebruik van hulpmiddelen: rolstoel, kruk, …
OPM: patiënt in zijn geheel bekijken: functiestoornissen,
activiteitenniveau, participatie, … (zie ICF-model)
Prognose
Afhankelijk van:
1. Medische toestand en specifieke diagnose
2. Functionele toestand (anamnese en klinisch onderzoek)
3. Psychosociale factoren (gele vlaggen!)
➔ Een patient met een goede medische en functionele prognose kan toch slecht herstellen omwille
van psychosociale factoren die het herstel in de weg staan
D. Anamnese en klinisch onderzoek
Anamnese en klinisch onderzoek
1. Onset en verloop symptomen
2. Lokalisatie symptomen (lokaal/ veralgemeend, symmetrisch,…)
3. Familiale achtergrond
4. Beïnvloedende factoren: wat maakt de klachten erger of minder erg?
5. Impact op functie, activiteiten en participatie
6. Co-morbiditeiten: aantasting bewegingsstelsel en cardiovasculair stelsel, ontwikkeling van
neurologische problemen
7. Pijntypes: nociceptieve pijn – neuropathische pijn – centrale sensitisatie pijn
8. Andere onderzoeken
8
,Extra info over dominante pijntypes
1. Nociceptieve pijn
Onderscheid tussen 2 soorten pijn:
Inflammatoire pijn Mechanische pijn
• Dolor – rubor – calor – tumor • Pijn bij belasting
• Nachtelijke pijn (wakker worden • Geen nachtelijke pijn
door pijn) • Pijn verdwijnt in rust
• Pijn bij rust • Kortdurende ochtendstijfheid
• Aanhoudende ochtendstijfheid
(>1uur)
• Beter bij inspanning
2. Neuropathische pijn
Zowel myotomen als dermatomen testen:
- Gevoeligheid of sensorische spiertesting (hyper/hypo-esthesie, paresthesie, hyper/hypo-
algesie, allodynie)
- Spiertesting (voldoende kracht: functioneel of EMG)
- Vragenlijsten (LANSS, painDETECT)
- Testen die druk zetten op zenuw
Neuropatische pijn Niet- neuropatische sensitisatie pijn
• Bewijs schade zenuwstelsel • Geen bewijs schade zenuwstelsel
• Medische oorzaak • Geen medische oorzaak
• Neuro-anatomisch logisch • Neuro-anatomisch niet-logisch
• Brandend, stekend, prikkelend • Niet brandend, stekend en prikkelend
• Locatie sensorische dysfunctie • Verhoogde sensitiviteit in niet-
logisch segmentaal gerelateerde zones
3. Centrale sensitisatie pijn
9
, Hoe kunnen we centrale sensitisatie bepalen?
CRITERIUM 1: Disproportionele pijn?
- Gerapporteerde pijn en problemen (dysfuncties of intoleranties voor dagelijkse activiteiten)
staan niet in relatie tot wat we verwachten bij de diagnose of bij medische beeldvorming
= DISPROPORTIONEEL
- Typisch: verschil tussen wat je ziet op medische beeldvorming en wat patient zal rapporteren
(vaak zien we letsels op medische beeldvorming die niet overeenkomen met de klachten van
de patient)
- Ook bij mensen die geen klachten rapporteren kunnen we afwijkingen terugvinden op hun
beeldvorming → pas hiervoor op!
CRITERIUM 2: Diffuse pijn distributie ?
- Beschreven pijn zal groter oppervlak / ander oppervlak omvatten dan verwacht (groot
pijngebied met niet-segmentale verdeling)
- Dagelijks of wekelijks zal pijn veranderen van localisatie
- Pijn varierend naargelang (anatomische) locatie
- Allodynie buiten segmentaal gebied van primaire nociceptie
- Bilaterale pijn/ mirror pain (symmetrisch pijn patroon)
CRITERIUM 3: Hypersensitiviteit voor allerlei prikkels?
- Overgevoeligheid voor reuk, smaak, licht, geluid, tast, medicatie, koude/ warmte, etc.
- Gebruik maken van vragenlijst (totaalscore op 100): Central sensitization inventory > 40?
- Indien > 40: Centrale sensitisatie
- Indien < 40: Geen CS
OPM: heel veel overlap met depressieve klachten en angststoornissen (kunnen ook heel hoog
scoren) → nooit vragenlijst alleenstaand gebruiken om pijntypes te differentieren
10
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