Rheumatoid Arthritis: Symptoms & Pathological Changes

• Arthritis encompasses over 100 diseases marked by joint inflammation or inflammation in other body areas.

Key Terminology in Rheumatology

• Bouchard Nodes: Bony outgrowths on the PIP joints, found in osteoarthritis (OA).
• Boutonnière Deformity: Joint deformity with PIP joint flexion and DIP joint hyperextension.
• Cachexia: Muscle mass loss due to inflammation, affecting metabolism in rheumatoid arthritis (RA).
• Chondropenia: Cartilage loss occurring faster than its repair in the osteoarthritic joint.
• Crepitus: Crunching, creaking, or grating sensation from the articular surface during motion.
• DMARDs: Medications altering the immune response or suppressing the disease process.
• Fibrillation: Early degenerative changes in OA, with articular cartilage softening and vertical clefts.
• Heberden Nodes: Bony outgrowths at the DIP joints, associated with OA.
• Joint Protection Techniques: Ergonomic principles applied to reduce joint stress.
• Mallet Finger Deformity: Deformity from damage to the extensor tendon at the DIP joint.
• Swan-Neck Deformity: Hyperextension of the PIP joint and flexion at the DIP joint.
• Synovitis: Inflammation of the synovial membrane, which produces joint-lubricating synovial fluid.
• Volumetry: Hand volume measurement using water displacement.
• Z Deformity of OA Thumb: CMC joint adduction, MCP joint hyperextension, and IP joint flexion.
• Z Deformity of RA Thumb: Excessive hyperextension of the IP joint and flexion of the MCP joint.

Arthritis Overview

• Arthritis is often overlooked as a serious chronic condition.
• It significantly impacts lives by affecting relationships, dreams, and livelihoods.
• Inflammation leads to pain, stiffness, redness, and swelling and can cause damage.
• Common types of arthritis include osteoarthritis, rheumatoid arthritis, gout, scleroderma, lupus, and polymyalgia rheumatica (PMR).
• Arthritis can affect various body parts, including weight-bearing and non-weight-bearing joints.
• Arthritis is a chronic condition, lasting months, years, or a lifetime.

Joint Anatomy

• The joint's purpose is for motion, force distribution, and low-friction load bearing.
• Diarthroses: Joints with synovial membrane and fluid, commonly known as synovial joints.
• Key components of articular joint tissues are articular cartilage, joint capsule, synovial fluid/tissue, and subchondral bone.

Inflammatory Process

• Inflammation arises from local tissue reaction to injury, either micro or macro trauma.
• Accumulated micro trauma can trigger cytokine cascades.
• Cytokines facilitate intercellular communication between white blood cells and induce responses.
• Inflammatory reactions manifest as heat, redness, swelling, pain, and loss of function.
• Acute inflammation is short-term (hours to days), chronic inflammation lasts longer (days to years).
• Flares are acute exacerbations of inflammation.

Prevalence of Arthritis

• About 6 million Canadians over 15 have arthritis,.
• Arthritis affects about 1 in 5 Canadians.
• It's projected to affect 9 million Canadians by 2040.
• Osteoarthritis impacts over 4 million individuals or 1 in 7 people.
• Rheumatoid arthritis affects over 272,000 people, or 0.9% of the Canadian adult population.
• Rheumatoid arthritis cases are predicted to rise to 1.3% in the next 30 years.
• 1 in 8 workers has OA (11.93% of the Canadian workforce).
• 1 in 136 workers has RA.
• Osteoarthritis affects 3.9 million Canadians over 20.
• Rheumatoid arthritis is the most common inflammatory type diagnosed.

Osteoarthritis (OA)

• It occurs when clinically evident, characterized by joint pain, tenderness, limited movement, crepitus, occasional effusion, but without systemic effects.
• Osteoarthritis is frequently localized at the joint or in clusters of joints.
• ECM of cartilage is affected from traumas and the result from this can also be bony spurs, which then affects articulation.
• OA results from metabolic processes involving joint tissues.
• It mainly affects cartilage in hands (CMC, PIP, and DIP joints) and weight-bearing joints like the cervical and lumbar spine, hips, and knees.
• Onset can be gradual, and progression varies based on injury.
• Knee OA usually leads to knee replacement, hip OA leads to hip replacement after 1-5 years.

Osteoarthritis Presentation

• In Hand OA, the first CMC joint, DIP, and PIP joints are affected.
• Small joints of the hand, particularly the thumb, are commonly affected.
• In Knee OA, the medial compartment is affected in 75% of cases, the lateral compartment in 26% of cases, and the patellofemoral compartment in 48% of cases and misalignment.
• Knee replacement is necessary, often due to walking patterns affecting the medial aspect of the knee.
• Hip OA: Superior migration is greater than medial migration, which alters joint biomechanics.
• Foot OA commonly affects the first TMT, talonavicular, and first MTP joints.
• Bone grinding on bone can be involved in patellofemoral OA due to cartilage destruction.

Pain in Osteoarthritis

• Pain, stiffness, and functional impact are primary symptoms which increase with activity and are improved by rest.
• Stiffness lasts less than 30 minutes.
• Pain occurs when active, then feels better.
• Stiffness occurs post sleep or due to prolonged inactivity.
• Joint guarding and unwillingness to move contribute to muscle weakness, limit ROM.
• Crepitus occurs in advanced cases during ROM.
• Hip osteoarthritis presents as groin pain, is persistent, and it can disrupt sleep.
• Caused by nociceptor stretching in joint capsule from synovitis, vascular pressure, or muscle spasm

Pathology of Osteoarthritis

• It involves gradual articular cartilage loss, subchondral bone thickening, and osteophytes at joint margins and there is mild, chronic, non-specific synovial inflammation.
• Any synovial joint can develop OA.
• Risk factors for cartilage damage include genetics, being female, age, higher body weight, joint injury, occupational or leisure use, and joint laxity.
• Pathophysiology includes fibrillation, cartilage loss, bone remodeling, osteophyte formation, and synovial membrane inflammation.
• OA may start as a repair process, initially symptom-free, but progresses to symptomatic OA.

Cartilage

• Normal cartilage consists of an extracellular matrix, collagens, and proteoglycans to retain water.
• The matrix is responsible for tensile strength.
• Type II collagen matrix.
• Structural and biochemical changes occur in aging cartilage
• Structural and biochemical changes, reduced capacity for retaining water, loss of tensile strength, altered biomechanical properties, fissures.

OA Joints

• OA has multiple ways to classify.
• Considering functional problems can be better than the stage.
• Characterized by abnormal cartilage, bone, synovium, and capsular lesions.
• Phase I (edema): Surface largely intact, some abrasions, pressure can lead to fibrillations.
• Phase II (fissuring and pitting): There is cell death and fissures down the middle.
• Phase III: Cartilage detaches, uncovers subchondral bone, and osteophytes form.
• Cartilage floats in the capsule

OA Hand

• The repair process can lead to osteophyte formation at joint margins and focal synovitis in affected joints.
• It commonly affects the DIP and CMC.
• Should be spaces between joints.
• You may see cartilage loss with narrowing of interphalangeal joints.
• Bouchard nodes (osteophytes PIP joints give a peanut butter feeling.
• Heberden nodes are osteophytes, in DIP joints.
• Mallet is a finger deformity at the DIP joint.
• Classic thumb deformity involves squaring at the CMC joint, with Z deformity.
• Muscle wasting is noted in the thenar eminence with reduced hand movements.

OA Treatment Recommendations

• Non-pharmacologic treatments include weight reduction and footwear while pharmacologic ones include acetaminophen and opioid analgesics.
• Surgical options involve joint replacements like hip and knee arthroplasty.
• The CMC joint arthroplasty gets ligament reconstruction with tendon interposition (LRTI).
• Arthrodesis (joint fusion) is reserved for the most painful joints only.
• Rheumatologist and orthopedic surgeon are required to consult.
• Combined finger and CMC OA leads to the worst impairments where people may have difficulties with ADL, eventually retire early.

Research

• Improving the use of joint protection for people with hand osteoarthritis can be found in Ontario.
• Development of a set of biomarkers to predict clinically relevant knee osteoarthritis progression can be found at Duke University

Rheumatoid Arthritis (RA)

• A chronic, systemic inflammatory, autoimmune disease.
• Key features: symmetric polyarticular pain, swelling, morning stiffness, malaise, and fatigue.
• Progressive joint damage and disability if untreated.
• The cause is unknown where there is genetic and environmental factors.
• Joints can be damaged within months of symptom onset.
• Smoking increases developing RA, disease activity, and mortality.

Features of Rheumatoid Arthritis

• Painful with difficult to diagnose when it starts.
• Fatigue affects 40-80% of patients from anemia, inflammatory cytokines, sleep disturbance, and depression.
• Disrupted sleep leads to depression, feeling tired mentally or physically.
• Morning stiffness lasts >30 minutes.
• Pain and stiffness improve with activity, is opposite in OA.
• The female-to-male ratio is 3:1, onset between 35 and 50.
• Most have insidious onset over weeks to months.
• Extra-articular symptoms: pericarditis, rheumatoid nodules, anemia, osteoporosis
• Diagnostic tests needed to support

Pathological Changes of RA

• Synovitis = Thickening of the synovial membrane with increased synovial fluid and edema.
• Pannus= Degrading enzymes from inflammatory cells lead to thickening membrane.
• Cachexia = Loss of muscle mass, impacts metabolism.
• Joint Instability= Joint swelling weakens joint ligaments and joint deformity from abnormal joint movement.
• Fatigue = Inflammatory proteins lead to weariness

Course and Prognosis of RA

• Periods often consist of exacerbations and remissions.
• There are three courses of RA: monocyclic, polycyclic, and progressive.

Classification Criteria of Rheumatoid Arthritis

• To test for patients that have at least 1 joint with definite clinical synovitis.
• If it's symmetrical, think RA.
• Classification criteria for rheumatoid arthritis is a score-based algorithm of joint involvement and serology.
• The rheumatoid factor indicates what the CRP/ESR's duration of symptoms are

Joints Affected and Type of Joint Damage

• Wrists and Hands affected (MCP, not DIP)
• Wrists and Hands 90-100%; Wrist/Hands, MCP,PIP jt space loss erosions, intercarpal, radiocarpal joint space loss with intercarpal fusion and ulnar styloid impacted early on
• Knee 60-80%
• Feet 50-60%
• Shoulder 50-60%
• Ankle 50-80%
• Neck 40-50%; Assess ECU
• Hip 40-50%; Feet- MTP jts and
• Elbow 40-50%; especially 5th similar to above.
• Ankylosis: restriction of movement at articular surface

Signs and Symptoms of Rheumatoid Arthritis (RA)

• Symmetrical pain, edema, early morning stiffness, malaise, and fatigue.
• The four stages are acute, subacute, chronic active and inactive.
• RA can affect eyes, skin, lungs, heart, kidneys, nervous system, and blood.
• Gradual onset, symptoms appearing first in hands and feet
• No cure exists, but early diagnosis can slow disease progression.

Hands in RA

• Average losses of 20° wrist extension, 30° wrist flexion, 15° MCP flexion, and 60% normal power; 1/3 develop deformities.
• Deformities due to persistent synovitis altering joint mechanics
• Power grip strains ligament and ulnar.

Wrist Joint Changes in RA

• The ulnar site of the wrist is an early site of inflammation.
• Triangular fibrocartilage disrupted, proximal carpal row rotates ulnarward.
• Distal row compensates by sliding radially, resulting in a gradually radially deviating wrist.
• Radioulnar ligament laxity facilitates radius and ulna rotation, with the ulnar styloid becoming more prominent.
• Radial deviation disrupts the biomechanics of the extensor and flexor tendons.

MCP Joint Changes in RA

• Persistent synovitis weakens collateral ligaments, volar plates, and dorsal hoods, leading to joint instability.
• The finger extensors slip ulnarly, increasingly act as weak flexors.
• Normal MCP joint features contribute to ulnar deviation including positioning of the flexor tendons and the ulnar interossei.

Interphalangeal (IP) Joint Changes in RA

• Persistent synovitis disrupts positions of extensor tendon/lateral bands at PIP joints, allowing Boutonnière deformity to develop.

Signs of Inflammation in RA

• Inflammation leads to increased blood flow, heat, and redness.
• The synovium produces extra fluid leading to swelling in articular or periarticular areas.
• There is pain due to swelling or cartilage damage and stiffness is a loss of function.

Deformity in RA

• Swelling stretches supporting ligament, causing joint laxity and instability

Joint Problems in RA

• Once pannus occurs it becomes irreversible
• Arthritis alters the joint's movement, causing stiffness and instability

Muscle Weakness in RA

• RA is secondary to joint inflammation and pain.
• Muscle weakness happens slowly and is reversible.
• Flared-ups can occur; it depends on the individual's approach to activity management and other psychosocial factors like stress and attempt to avoid flare-ups.

Normal Joint Movement for RA

• Maintain finger function such as fist and tip to tip.
• Maintain wrist function, tend to lose deviation,

Hand Deformities with RA

• Piano Key (bump), ulnar deviation (shifting fingers to the little finger), and then there is Boutonniere deformity.
• The boutonniere deformity involves DIP hyperextended, PIP flexed and volar plate under DIP irritated.
• There is also swan neck deformity (DIP flexed, PIP extended) as well as wasting.

RA Medical Management

• Pharmacology can reduce the inflammation to prevent or limit it and the earlier the start, the better the outcome.
• Typical surgical procedures include synovectomy, tenosynovectomy, arthrodesis (joint fusion), arthroplasty (joint replacement), and tendon repair and transfers.

RA Functional Impairments

• There is a 60% chance that those diagnosed with RA from early stages will have difficulty with hand function and there are daily challenges.
• From 20 to 70% of working adults stop working within 7-10 years of initial diagnosis.
• Physical activity = decrease pain, improve physical function, reduce 40% of health care costs; ⅓ are inactive.

RA vs OA

Rheumatoid Arthritis

• It is chronic, systemic, affects multiple organs, autoimmune or inflammatory. The treatments aim to control symptoms and diseases, the joints lining is abnormal as infection-fighting cells start to fight normal tissue,

Osteoarthritis

• It is chronic, joint-specific, degenerative, and for "wear&tear". These can be symptom treatments only. The cartilage becomes abnormal and is the body is not able to keep up with the repair when microscopic or regular trauma occur, and can cause destruction.

Symptoms

• Can be insidious.
• Fluctuating, Symmetrical which is predominantly in the small joints in hands and feet (plus or minus larger).
• Pain is worse at night and there is prolonged stiffness (>30 minutes) and after inactivity.
• The joints feel hot; malaise, fatigue, weight loss.
• What they tell you is triggers to onset (major lift stress event)

Signs

• Joint swelling, tenderness, heat, and redness as well as there can be symmetrical patterns.

• Signs are predominantly in the small joints in hands and feet plus or minus larger

• Decreased active and passive joint range, functional impairment, and deformity as well as there can be disarrangment

• CT can be used to discover a joint degeneration.

• RA is systemic, progressive, affects synovial joints and other body systems, is associated with substantial personal and societal burden.

• Effective medical treatments like early diagnosis reduce disease activity, improving long-term outcomes.

The role of the Occupational Therapist

• To identify, assess, and address concerns related to daily activities, physical, and social.
• They can help people identify and access community resources and support systems.
• The OT can help with education and also splint so you can protect damaged joints, reduce pain, limit deformity and enable function.

OT strategies

• Understanding the disease process
• Joint protection
• Posture / positioning
• Pain management
• Fatigue management / energy conservation
• Relaxation / stress management
• Footwear recommendations
• Activity adaptations and aids
• Environmental adaptations
• Fall prevention
• Problem-solving strategies
• Personal goal-setting / motivation

What is Joint Protection?

• Joint protection aims to reduce loads, reducing injury risks.
• Avoid deformity positions, flexion, deviation, and poor

Maximizing Energy

• Manage everyday tasks.
• Maintain balance between work and leisure,.

The main goals is to participate in you most important activities

Identify issues you need to eat and get a good sleep.

• STEP ONE: Identify CONTRIBUTORY FACTORS to fatigue: arthritis, med nutrition stress exercise.

The management

• Use orthoses and continue to manage energy.
• The most commonly affected joints when it comes to ergonomics are the hands. -Hand joints are the most commonly affected due to ergonomics, so that needs to be addressed.
• The correct equipment has to be used with that area that is affected.
• If pain persists with no change, a rapid decline may often persist with the HA and the OA.
• It can be that the person cannot handle simple movement, or is not be able to get better with just a little assistance.
• When there is no help with simple work, the pain may get to a point where its going so fast.

Test your knowledge about Rheumatoid Arthritis (RA). Learn about pathological changes in RA, duration of morning stiffness, and the impact of activity on pain. Explore extraarticular symptoms and factors contributing to fatigue in RA patients.