Rheumatoid Arthritis

It is a painful chronic systemic autoimmune disease characterized by inflammatory polyarthritis that affects peripheral joints mainly small joints of hands and feet (metacarpophalangeal joints, interphalangeal joints).

EPIDEMIOLOGY AND CAUSES

CLINICAL FEATURES AND PATHOPHYSIOLOGY

Joint swelling and pain

RA shows characteristic symmetrical pattern of joint involvement

The proximal interphalangeal joints and metacarpophalangeal joints are often the first to be affected, then wrists, elbows, shoulders, hips, knees, ankles, and metatarsophalangeal joints.

The axial skeleton is largely spared, except for the cervical spine in some cases.

Inability to “wring out a washcloth” or produce a strong grip

Caused by synovial inflammation, pannus, and effusion

Morning stiffness

Typically should last for at least one hour to be characterized as stiffness due to inflammatory arthritis

Stiffness after rest is often called “gelling”

Constitutional Symptoms
Fatigue
Anorexia
Mild weight loss

Deformity

Signs of late disease with irreversible damage in the hands and wrist:

“Swan-Neck Deformity”

Hyperextension of the PIP and flexion of the DIP. Progressive shortening of the tendon maintains DIP flexion and PIP extension.

“Boutonniere Deformity ”

The opposite of swan-neck (flexion of the PIP and extension of the DIP)

Subluxation at the MCP joint with ulnar deviation

Radial deviation of the wrist

Rheumatoid nodules

Occur in 20%; generally those with more severe disease and high-titer RF.

A rheumatoid nodule is a mass of inflammatory tissue with a central focus of necrosis, presumably the consequence of vascular inflammation, surrounded by chronic inflammatory cells.
Occur over extensor surfaces and joints, at sites of chronic mechanical irritation (elbow, toe, and heel), and in the subcutaneous tissues of the fingers.

PHYSICAL EXAMINATION AND DIAGNOSIS

American College of Rheumatology has defined 7 criteria, where a patient has to correspond with at least 4 of these 7 criteria for the diagnose of rheumatoid arthritis.

The first 4 of these criteria are only valid if they persist for at least 6 weeks. These 7 criteria are:

Morning stiffness

Arthritis in 3 or more joints

Arthritis in the joints of the hands (wrist, MCP, PIP)

Symmetrical arthritis

Nodules

Rheumatoid factors

Radiological deviations

Radiogaphic Findings

Soft-tissue swelling

Joint space narrowing from cartilage destruction

Erosion of periarticular cortical bone may occur early in the disease and results from excessive local bone resorption and inadequate bone formation

Subluxation

ACR/EULAR CRITERIA FOR RA

PHYSIOTHERAPY MANAGEMENT

The therapy goals in most cases are:

Improvement in disease management knowledge

Pain control

Improvement in activities of daily living

Improvement in Joint stiffness and Range of motion

Prevent or limit joint damage

Improve strength

Improve fatigue levels

Improve the quality of life 

Improve aerobic condition

Improve stability and coordination

Physiotherapy Modalities

• Cold/Hot Applications

Cold = for acute phase
Heat = for chronic phase and used before exercise.

• Electrical Stimulation

Transcutaneous electrical nerve stimulation (TENS) is used to relieve pain.

Rehabilitative Treatment

Joint Protection Strategies

Rest & Splinting

Orthosis and splinting prevent the development of deformities and support joints

Therapy Gloves

To control and manage hand pain, to maintain or restore the patient’s hand function

Compression Gloves

Used to reduce moderate joint swelling and consequently reduce the pain

Assistive Devices and Adaptive Arrangements like elevated toilet seats to facilitate activities of daily living

Soft tissue Manipulation Therapy

Manipulation and the manual therapy of an articular movement focused on the improvement of function, pain reduction, reduction of disease progression, improve flexibility etc

Therapeutic Exercise

Exercise improves general muscular endurance and strength without detrimental effects on disease activity or pain in rheumatoid arthritis. 

Before beginning an exercise program, it is important to have a global evaluation of the situation, joint inflammation local or systemic, state of the disease, age of the patient and grade of collaboration.

Exercises:

1. ROM exercises

In acute phase

isometric/static exercises -> be held for 6 seconds and repeated 5–10 times each day ; load = 40% 1RM.

In chronic phase: isotonic exercises for example: swimming, walking, cycling -> minimum 4 repetitions for each joint in 2 to 3 days These exercises increase the mobility of the joint, but the joint will not be loaded during this exercises.

2. Stretching: Has to be avoided in acute cases.

Strengthening: Moderate-intensive exercise therapy where a minimum of 8-10 exercises is necessary for the major muscle groups.

Use light weights important for stabilization of the joint and prevention of traumatic injuries.

3. Aerobic condition exercises: There are two types of exercises to improve the aerobic condition

Intensive exercises and moderate-intensive exercises.

The intensive exercise therapy has a minimum duration of 20 minutes per session and this 3 times a week with an intensity of 65 to 90 percent of the maximal heart rate.

The moderate intensive exercise therapy has a minimum duration of 30 minutes per session and this 5 times a week with an intensity of 55 to 64 percent of the maximal heart rate. The aim of this exercises is to improve the muscle endurance and aerobic capacity.

Stabilizing and coordinating exercises

The improvement of stabilization and coordination of a certain joint will be achieved by doing exercises that stimulate the sensorimotor system.

4. Routine daily activities

SARAH (Strengthening and stretching for rheumatoid arthritis of the hand) exercise program: The SARAH trial tests an intervention against the usual hand care. The main aim of the exercise program is increased hand function, which is suggested to be mediated by increases in strength, dexterity and range of motion.

A modified Borg scale is used to set the  resistance for the strength exercises based on self perception of effort. The level of resistance is determined by the patient’s s rating of perceived effort using the weaker hand for each strength exercise.

Exercise therapy in patients with RA is used to improve the daily functioning and social participation through improving muscle strength, aerobic endurance, joint mobility (range of motion, ROM) and stability and/or coordination.

5. Patient Education

Information about their condition and the different therapies disposed to improve their quality of life. In addition, patients are taught how to protect the joints during routine daily life.