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Rheumatoid Arthritis

(Herein we shall be discussing only the articular features)

RA is a chronic inflammatory disease. The cells lining the synovial membrane are activated by some process not yet understood, triggers the immunological response. These cells proliferate, resulting in thickening and inflammation of the synovial membrane. These cells are invasive, fibroblast like cell mass (called PANNUS), which is capable of eroding cartilage and bone. The synovial fluid accumulates, and the joint swells, distending the capsule, pulling on its periosteal attachment and causing pain and potential rupture. The ligaments and muscles around the joint are also subjected to weakness and potential rupture.

Factors which may (suspected) evoke the immunological reactions are Climate, Race, Diet, Psychosomatic disorders, trauma, Endocrinal dysfunction, Hereditary, disturbance in autoimmune system and infections.

Diagnosis (Criteria given by American Rheumatoid Association)

Detection of abnormal protein, known as rheumatoid serum factor (Rh. Factor)

(There are also sero-negative variants of arthritis presenting similar feature)

Other abnormal findings,

Raised ESR, serum fibrinogen and immunoglobulins

Reduced albumin

Synovial Fluid examination reveals yellowish/greenish in color, cloudy in clarity, low viscosity and neutrophills (75%) predominantly.

Clinical Findings

  • Onset between 35-55 years of age
  • Male : female- 3:1
  • Severe pain
  • Swelling
  • Raised temperature
  • Morning stiffness
  • Phlebitis (extruded synovial fluid may irritate the soft tissue around)
  • Contractures, fibrous/ bony ankylosis
  • Secondary osteoarthritic changes
  • Deformities – wrist, small joints of hand, knee, elbow, shoulder, hip most commonly affected.

Common deformities

Hand – ulnar drift of the hand, Boutonniere deformity, Swan neck deformity

Foot – Hallux Valgus, Hammer Toe

ra-hand

ra-hand

Rheumatoid Arthritis also includes non articular affection (systemic illness, blood disorders, vascular, cardiac, respiratory, reticulo-endothelial, skin)

CLASSIFICATION

A] ON THE BASIS OF PROGRESSION OF RA :-

STAGE I (EARLY)

  1. No destructive changes on X- ray,
  2. X- ray evidence of osteoporosis may be present.

STAGE II (MODERATE)

  1. X-ray evidence of osteoporosis, with/without slight subchondral bone destruction; slight cartilage damage may be present,
  2. No joint deformity, although limitation of joint range of motion (ROM),
  3. Adjacent muscle atrophy,
  4. Extra-articular soft tissue lesions, such as nodules and tenosynovitis may be present.

STAGE III (SEVERE)

  1. X-ray evidence of cartilage and bone destruction in addition to osteoporosis,
  2. Joint deformity such as subluxation, ulnar deviation or hyper-extension without fibrous or bony ankylosis,
  3. Extensive muscle atrophy,
  4. Extra articular soft tissue lesions such as nodules and tenosynovitis may be present.

STAGE IV (TERMINAL)

  1. Fibrous or bony ankylosis,
  2. criteria’s of stage III.

B] ON THE BASIS OF FUNCTIONAL STATUS OF RA PATIENTS :-

CLASS I

Completely able to perform usual activities of daily living (self care, vocational and avocational)

CLASS II

Able to perform usual self care activities and vocational activities but limited in avocational activities

CLASS III

Able to perform usual self care activities, but, limited in vocational and avocational activities

CLASS IV

Limited ability to perform usual self care, vocational and avocational activities.

(Usual self care activities include dressing, bathing, grooming and toileting. Avocational includes recreational and leisure activities. Vocational includes work, school, homemaking etc age and sex specific)

CLINICAL COURSE

  1. Acute phase/ Active phase
  2. Chronic phase

– There may be exacerbations and remissions during the course of the disease.

PRINCIPLES OF PHYSIOTHERAPY MANAGEMENT

  1. Relief of pain and inflammation
  2. Restoration and maintenance of joint range of motion
  3. Improvement of muscle strength and endurance
  4. Prevention of deformity
  5. Correction of deformity
  6. Optimization of functional level
  7. Management of re-occurrence.

Joint Protection/ Patient Education to Prevent Deformity (in Acute Stage)

  1. Monitor the activities and stop when discomfort or fatigue begins to develop.
  2. Use frequent but short episodes of exercise
  3. Decrease level of activity or omit provoking activities if joint pain develops and persist for more than 1 hour.
  4. Balance work and rest to avoid muscular and total body fatigue.
  5. Increase rest during flare of the disease.
  6. Avoid deforming positions
    • properly supported positioning of the involved joints and correct bed postures are important
    • The use of firm mattress minimizes the effect of mal-positioning thereby preserves the integrity of the joints.
  7. Avoid prolong static positioning; change positions during the day every 20-30 mins.
  8. Use appropriate adaptive devices.