RHEUMATOID ARTHRITIS Chronic inflammatory disease of the synovium with the course characterized by exacerbation & remission. Autoimmune disease that results in a chronic, systemic inflammatory disorder that may affect many tissues and organs, but principally attacks synovial joints. CONTD…….
The characteristic feature of RA is persistent
inflammatory synovitis, usually involving peripheral joints in a symmetric distribution, with systemic manifestations. The synovial inflammation cause cartilage damage and bone erosions and subsequent changes in joint integrity & it is the hallmark of the disease. EPIDEMIOLOGY
The prevalence of RA is approximately 0.8% of
the population. The prevalence increase with age, approximately 2% in men and 5% in women, Sex differences diminish in the older age group
The onset is most frequent during the fourth
and fifth decades of life, with 80% of all patients developing the disease between the ages of 35 and 50. RISK FACTORS Genetic: family history is an important risk factor. Non-genetic: smoking; more common in smokers than non-smokers, particularly in men Vit- D deficiency is common in those with RA and may be associated with it. AETIOLOGY The cause of rheumatoid arthritis is not known It is believed that an antigen/s enters the body & forms antibody. This leads to formation of immune complex which causes inflammation to the synovium. PATHOPHYSIOLOGY CLINICAL MANIFESTATIONS
Onset Characteristically, RA is a chronic polyarthritis. In approximately two-thirds of patients, it begins insidiously Fatigue, anorexia, generalized weakness, and vague musculoskeletal symptoms are the initial symptoms until synovitis becomes apparent. In approximately one-third of patients, symptoms may initially be confined to one or a few joints. SIGNS AND SYMPTOMS Pain, swelling, and tenderness may initially be poorly localized to the joints. Pain in affected joints, aggravated by movement, is the most common manifestation of established RA. Stiffness is frequent and is usually greatest after periods of inactivity. Morning stiffness of greater than 1-h duration is an almost invariable feature of inflammatory arthritis The majority of patients will experience symptoms such as weakness, easy fatigability, anorexia and weight loss. Although fever to 40°C occurs on occasion, temperature elevation in excess of 38°C is unusual. Clinically, synovial inflammation causes swelling, tenderness and limitation of motion. CONTD….. RA most often causes symmetric arthritis with characteristic involvement of certain specific joints such as the PIP and MCP joints. The DIP joints are rarely involved. Synovitis of the wrist joints is a nearly uniform feature of RA and may lead to limitation of motion, deformity, and median nerve entrapment. Synovitis of the elbow joint often leads to flexion contractures that may develop early in the disease. The knee joint is commonly involved with synovial hypertrophy, chronic effusion and frequently ligamentous laxity. Pain and swelling behind the knee may be caused by extension of inflamed synovium into the popliteal space (Baker’s cyst). Arthritis in the forefoot, ankles, and subtalar joints can produce severe pain with ambulation as well as a number of deformities. Axial involvement is usually limited to the upper cervical spine (atlantoaxial subluxation) EXTRAARTICULAR MANIFESTATIONS Rheumatoid nodules : develop in 20 to 30% of persons with RA, usually found on periarticular structures, extensor surfaces, or other areas subjected to mechanical pressure Musculoskeletal Manifestations: Weakness and atrophy of skeletal muscle are common. Osteoporosis is common and may be aggravated by glucocorticoid therapy Rheumatoid vasculitis which can affect nearly any organ, is seen in patients with severe RA Pulmonary manifestations, which are more commonly observed in men, include pleural disease, interstitial fibrosis, Pleuropulmonary nodules, pneumonitis and arteritis. CONTD……. Cardiac Manifestations: evidence of asymptomatic pericarditis is found at autopsy in 50% of cases Ophthalmic Manifestations: involves the eye in fewer than 1% of patients (keratoconjunctivitis) Felty’s syndrome : consists of chronic RA, splenomegaly, neutropenia and occasionally anemia and thrombocytopenia. Most common in individuals with long-standing disease RA is associated with an increased incidence of lymphoma, RA tends to spare the central nervous system directly, although vasculitis can cause peripheral neuropathy. Neurologic manifestations may also result from atlantoaxial subluxation. LABORATORY FINDINGS No tests are specific for diagnosing RA RA factors (autoantibodies) are found in more than two-thirds of adults with the disease. The presence of rheumatoid factor is not specific for RA. Rheumatoid factor is found in 5% of healthy persons. The presence of rheumatoid factor can be of prognostic significance because patients with high titers tend to have more severe and progressive disease with extraarticular manifestations. A number of additional autoantibodies may be found in patients with RA, including antibodies to filaggrin, citrullinated proteins, calpastatin etc. Normochromic, normocytic anemia is frequently present in active RA. The ESR is increased in nearly all patients with active RA Synovial fluid analysis confirms the presence of inflammatory arthritis, DIAGNOSTIC CRITERIA - ACR, 1987 1. Morning stiffness>=1hr 2. Arthritis of 3 or more of the following joints: PIP, MCP, Wrist, elbow, knee, ankle & MTP joints. 3. Arthritis of hand joints: wrist, MCP or PIP joint 4. Symmetrical joint involvement on opposite side 5. Subcutaneous Rheumatoid nodules over bony prominences or on the extensor surfaces. 6. Positive serum RA factor 7. X-ray typical of RA: bony erosions, decalcification localized in or adjacent to the involved area, juxtaarticular osteopenia. 4 of the above criteria must be present with 1-4 must have been present for minimum of last 6wks. CONTD… Definite RA: 5 of the above criteria. 1-5 must be present for 6 wks Probable RA: 3 of the above criteria. Any one of 1-5 must be for 6 wks Possible RA: Diagnosis needs two of the following criteria & total duration of joint symptoms must be for 3wks: Morning stiffness Tenderness or pain on motion with H/O of recurrence / persistance for 3wks H/O joint swelling Subcutaneous nodules Increased ESR. REVISED CRITERIA FOR THE CLASSIFICATION OF RA These criteria demonstrate a sensitivity of 91 to 94% and a specificity of 89% 1. Guidelines for classification: a. Four out of seven criteria are required to classify a patient as having rheumatoid arthritis (RA). b. Patients with two or more clinical diagnoses are not excluded. 2. Criteria a. Morning stiffness: Stiffness in and around the joints lasting 1 h before maximal improvement. b. Arthritis of three or more joint areas: At least three joint areas, observed by a physician simultaneously, have soft tissue swelling or joint effusions, not just bony overgrowth. The 14 possible joint areas involved are right or left PIP, MCP, wrist, elbow, knee, ankle, and MTP joints. c. Arthritis of hand joints: Arthritis of wrist, MCP joint or PIP joint. d. Symmetric arthritis: Simultaneous involvement of the same joint on both sides of the body. e. Rheumatoid nodules: Subcutaneous nodules over bony prominences, extensor surfaces, or juxtaarticular regions observed by a physician. f. Serum rheumatoid factor: Demonstration of abnormal amounts of serum rheumatoid factor by any method for which the result has been positive in less than 5% of normal control subjects. g. Radiographic changes: Typical changes of RA on posteroanterior hand and wrist radiographs that must include erosions or unequivocal bony decalcification localized in or most marked adjacent to the involved joints. Criteria a–d must be present for at least 6 weeks. Criteria b–e must be observed by a physician. CLINICAL DIAGNOSIS The previous criteria are not intended for the diagnosis for routine clinical care; they were primarily intended to categorize research (classification criteria). In clinical practice, the following criteria apply: two or more swollen joints morning stiffness lasting more than one hour for at least six weeks the detection of RA factors or auto antibodies against ACP. A negative autoantibody result does not exclude a diagnosis of RA. ACR CLASSIFICATION CRITERIA OF FUNCTIONAL STATUS IN RHEUMATOID ARTHRITIS
Ø Class I: Completely able to perform usual activities
of daily living (self-care, vocational, and avocational [recreational and/or leisure]) Ø Class II: Able to perform usual self-care and vocational activities, but limited in avocational activities Ø Class III: Able to perform usual self-care activities, but limited in vocational and avocational activities Ø Class IV: Limited ability to perform usual self-care, vocational and avocational activities DEFORMITIES Common Hand Deformities: Ulnar drift
Swan neck deformity
Boutonniere deformity
Mallet finger deformity
Z- deformity ULNAR DRIFT The inflammatory process (infiltration) damages & weakens the capsule & supporting ligaments Chronic intra-articular swelling due to synovial effusion & hypertrophy stretches the supporting joint structure reducing their restraining power against the ulnar force. SWAN NECK DEFORMITY PIP hyperextension & DIP flexion Chronic synovitis of PIP can cause stretching of the volar capsule + dorsal migration of lateral bands of fingers. Hyperextension of the PIP causes tension to the FDP tendon It may also lead to rupture of FDS insertion which predisposes the PIP with this deformity. BOUTONNIERE /BUTTON HOLE DEFORMITY PIP flexion with DIP hyperextension The inflammatory process damages the extensor structure at the PIP & weakens their attachment Synovial hypertrophy distends the dorsal capsule, thereby mechanically stretching or displacing the extensor structures. Rupture of the central sling of EDC limits the effectiveness as extensor of the proximal phalanx. MALLET FINGER DEFORMITY Flexion of DIP The inflammatory process causes lengthening or rupture of the distal attachment of the extensor mechanism which removes the extension force at the DIP This causes /allows the profundus(FDP) insertion to pull in flexion. Z- DEFORMITY IP flexion & MCP hyperextension of thumb or IP hyperextension & MCP flexion. COMPLICATIONS OF RA § Carpal tunnel syndrome, § Baker’s cyst, § Vasculitis, § Subcutaneous nodules, § Sjögren’s syndrome, § Peripheral neuropathy, § Cardiac and pulmonary involvement, § Felty’s syndrome, and § Anemia MANAGEMENT Careful assessment § History § Musculoskelatal examination – erythema, warmth, tenderness, swelling, synovial thickening, ROM, Crepitus, Deformity, Muscle weakness, Skin condition § Pain assessment – intensity, duration § Respiratory function § Posture in standing & sitting § Gait assessment § Functional assessment GENERAL PRINCIPLES OF TREATMENT The goals of therapy of RA are (1) Relief of pain, (2) Reduction of inflammation, (3) Protection of articular structures, (4) Maintenance of function, and (5) Control of systemic involvement. None of the therapeutic interventions are curative, and therefore all must be viewed as palliative, Therapeutic interventions are aimed at relieving the signs and symptoms of the disease. PRINCIPLES OF PT MGT
Reliefof pain & spasm
Prevention of deformity
Correction of deformity
Maintenance of JROM
Restoration of lost ROM
Maintenance & improvement of strength
Maintenance of optimum function
RELIEF OF PAIN & SPASM Spasm is mainly protective in nature. So, PT is aimed at reducing protective spasm. Methods: IRR Hot Packs Wax Bath Pulsed SWD IFT/TENS for analgesic effect for large joints Isometric exercises for muscles surrounding the affected joints PREVENTION/ CORRECTION OF DEFORMITY In the early stage of the disease pain, swelling & spasm encourages a patient to assume postures that anticipate deformities. Later on there will be change of muscle fiber length, periarticular structures, inequality of strength & changes in bone. Methods: Postural awareness Proper positioning Passive stretching Splinting Serial casting/plastering for correction of deformity MAINTENANCE/RESTORATION OF JROM
For maintenance: Full ROM active/ac-assisted exercise for all involved joints For restoration of ROM:
PNF stretching
Passive stretching in Hydrotherapy etc
MAINTENANCE & IMPROVEMENT OF STRENGTH
To avoid weakness or wasting regular
exercises are required. These ex should not increase pain.
Progression of exercises should be slow.
Postural correction ex & trunk muscle ex
should be taught. Pool ex (Hydrotherapy). MAINTENANCE OF OPTIMUM FUNCTION
Use adaptive/assistive device/ADL device for
UE For LE use walking aids SURGICAL MANAGEMENT
Indications: Reliefof incapacitating pain Restoration of joint stability Maintain/Regain functional independence. Prevention of harmful stresses on other joints.
Common Surgeries: Synovectomy Arthroplasty: Excision arthroplasty Interposition arthroplasty Partial joint replacement Total joint replacement. THANK YOU
