Rheumatoid Arthritis PDF

Rheumatoid Arthritis By Dina Othman Shokri  Learning Objectives At the end of this lecture the student should be able to: * Identify definition, genetic predisposition of RA. * Discuss pathophysiology, clinical features of RA. * Identify Diagnostic Criteria, Laboratory...

Rheumatoid Arthritis By Dina Othman Shokri  Learning Objectives At the end of this lecture the student should be able to: * Identify definition, genetic predisposition of RA. * Discuss pathophysiology, clinical features of RA. * Identify Diagnostic Criteria, Laboratory Features *Identify different treatment for RA *Discuss different physical therapy modality in management of RA Rheumatoid arthritis (RA) is a chronic systematic autoimmune inflammatory disease and results in persistent inflammation of synovial tissue especially of the wrists, hands and feet. It can affect more than just your joints. In some people, the condition also can damage a wide variety of body systems, including the skin, eyes, lungs, heart and blood vessels. Human leukocyte antigens (HLAs) account for ~30% of the heritable risk. Most of the genetic components are largely unknown. Genetic predisposition-- HLA DR4 and “Shared” epitope located on HLA DRB1. Rheumatoid arthritis affects 2 - 3 times more women then men. RA affects 0.5 to 1 % of the population world wide, It can begin at any age with peak prevalence between 30 to 50 years old  Etiology and Pathogenesis Rheumatoid arthritis occurs when the immune system attacks the synovium. We don't know what starts this process, although a genetic component appears likely. While your genes don't actually cause rheumatoid arthritis, they can make you more susceptible to environmental factors — such as infection with certain viruses and bacteria — that may trigger the disease. The cause remains unknown and can therefore not be prevented. The resulting inflammation thickens the synovium, producing a tumour- like mass called ‘pannus’ which can eventually destroys the articular cartilage and subchondral bone, producing bony erosions and juxta –articular osteopenia (This localized osteopenia occurs early in the course of the disease, often in the first 6-12 months). The tendons and ligaments that hold the joint together weaken and stretch. Gradually, the joint loses its shape and alignment. Over time, rheumatoid arthritis can cause joints to deform and shift out of place. Environmental and other factors associated with rheumatoid arthritis risk. Increased risk *Female sex *Exposure to tobacco smoke *Occupational dust (silica) *Air pollution *High sodium, red meat, and iron consumption *Obesity *Low vitamin D intake and levels  Clinical Manifestations Joint Pain such as in the joints of the feet, hands, and knees, swollen joints, fatigue fever, limping, polyarthritis, loss of range of motion, tender joints, loss of joint function, stiff joints, anemia, joint warmth and later joint deformities are common symptoms. The symptoms of RA would diminish the patients’ capabilities to perform daily activities such as grooming, brushing teeth, opening a door, turning a key or holding a cup. However, the impacts of RA on each patient is variable. In some patients, symptoms of RA will appear and last for a few days and then withdraw, but in some cases the symptoms are active most of the time, last for many years and lead to serious joint damage and disability. Rheumatoid arthritis signs and symptoms may vary in severity and may even come and go. Periods of increased disease activity, called flares, alternate with periods of relative remission — when the swelling and pain fade or disappear. 1. Morning joints stiffness for at least one hour. Or after inactivity 2. Swelling around three or more joints simultaneously. 3. At least one swollen area in the wrist, hand, or finger joints. Rheumatoid arthritis: PIP swelling 4. Arthritis involving the same joint on both sides of the body (symmetric arthritis). Symmetrical and polyarticular (>3 joints).Typically involves wrists, MCP, and PIP joints. 5. Rheumatoid nodules, May have nodules: subcutaneous or periosteal at pressure points which are firm lumps in the skin of people with rheumatoid arthritis. These nodules are usually in pressure points of the body, most commonly the elbows. 6-In 80-90% of the patients with rheumatoid arthritis the cervical spine is involved, which can lead to instability, caused by the ligamentous laxity. Usually the instability occurs between the first and second cervical vertebrae. This instability can lead to pain and neurological symptoms, like headache and tingling in the fingers. 7. Abnormal amounts of rheumatoid factor in the blood. Rheumatoid factor 45% positive in first 6 months 85% positive with established disease Not specific for RA, high titer early is a bad sign 8. X-ray changes in the hands and wrists typical of rheumatoid arthritis, with destruction of bone around the involved joints. However, these changes are typical of later-stage disease. in rheumatoid arthritis, there may be no changes in the early stages of the disease, or the x-ray may demonstrate juxta-articular osteopenia, soft tissue swelling and loss of joint space. As the disease advances, there may be bony erosions and subluxation. X-rays of other joints may be taken if symptoms of pain or swelling occur in those joints. Deformity in RA in the hands, the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and thumb interphalangeal (IP) joints are most frequently involved. The distal interphalangeal (DIP) joints are involved only in the presence of a coexisting MCP or PIP disease. Tenosynovitis of the flexor tendons causes a reduction in finger flexion and grip strength. Nodular thickening in the tendon sheath may also produce a trigger finger. The most common deformity in RA Ulnar deviation at the metacarpophalangeal joints is common but causes surprisingly little functional disability. Late in the course of the disease patient may present with "boutonniere (flexion at PIP and extension at DIP), swan neck (flexion at DIP and extension at PIP) deformities. Theses deformities markedly affect the patient's ability to grip. Boutonnière deformity Ulnar deviation at the metacarpophalangeal joints Of the 20% of patients whose initial joint involvement is in the foot, problems for 80% of these begin in the forefoot. Common deformities are hallux valgus, dropped metatarsal heads and possibly hammer and claw toes. At the knees there may be fixed flexion deformity and valgus or less commonly varus. The typical RA knee deformity has been described as one of flexion, valgus and external rotation. The valgus deformity is often combined with an eversion deformity at the subtalar joint with increased pronation of the forefoot.  Diagnosis Rheumatoid arthritis can be difficult to diagnose in its early stages because the early signs and symptoms mimic those of many other diseases. There is no one blood test or physical finding to confirm the diagnosis. Blood tests People with rheumatoid arthritis often have an elevated erythrocyte sedimentation rate (ESR, or sed rate) or C-reactive protein (CRP), which may indicate the presence of an inflammatory process in the body. Other common blood tests look for rheumatoid factor. the presence of rheumatoid factor is not diagnostic of rheumatoid arthritis. It may be present in connective tissue disease, chronic infections. Anti-cyclic citrullinated peptide (anti-CCP) antibodies. Anti-citrullinated protein antibodies (ACPA) are found in about 50% of patients with early arthritis. Imaging tests X-rays, MRI and ultrasound tests  X-Ray X-rays are an important diagnostic test for monitoring the disease progression. Patients may reveal NO changes on an X-ray in the early stages OR may demonstrate juxta-articular osteopenia. (Gulanick & Myers, 2011; Day et al., 2010)  MRI scans MRI is particularly sensitive for the early and subtle features of RA. Used for better visualization of soft tissue. Can detect changes of Rheumatoid Arthritis prior to an X-Ray (Radiopaedia, 2010; Dat et al., 2010) Differential Diagnosis  Treatment Pharmacological; There are four types of medications used to treat RA: Non-steroidal anti-inflammatory drugs (NSAIDs) Disease-modifying anti-rheumatic drugs (DMARDS). Corticosteroids Biologic Response Modifiers (“Bioligics”). Nutritional Guidelines Eating certain foods can help you manage its symptoms. Dietary supplements like vitamin D, cod liver oil, and multivitamins can also help in managing RA. Avoiding food which causes inflammation like processed food, high salt, oils, butter, sugar, and animal product. (Arthritis Foundation, 2012; Gulanick & Myers 2011)  Physical Therapy Management The therapy goals in most cases are: Improvement in disease management knowledge and patient education Pain control Improvement in activities of daily living Improvement in Joint stiffness (~ Range of motion) Prevent deformity or control joint damage Improve strength Improve fatigue levels Improve the quality of life Improve aerobic condition Improve stability and coordination Patient Education: before starting any exercises programme, we should give each patient 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. To let patients become more active, you have to adjust their movement- behaviour. Physiotherapy Modalities Modalities: Heat (During subacute and chronic stages of the disease), ice (During stages of acute inflammation), ultrasound, and electrical stimulation (TENS, Iontophoresis, Interferential current) may be used to reduce pain and improve joint movement. Normal intra-articular temperature is 33° Celsius, whereas it may rise up to 36° Celsius in patients with RA. Increasing intra-articular temperature is also related to an increase in collagenase activity and cartilage damage. N.B Cartilage-destroying enzymes are produced within the inflamed joints of patients with RA. Levels of destructive enzymes such as collagenase, elastase, hyaluronidase, and protease are affected by the temperature of local joints. With temperatures of 30° Celsius or lower, effects of these enzymes are negligibly small. Hydrotherapy-Balneotherapy: allows exercise with minimal load on the joints. Simply being in another environment, where the patient can relax has a positive effect on the disease's progression (physically as well as on mentally). Treatment during flare-up periods Resting Splints Positioning Joint Protection Strategies Rest & positioning and Splinting: Rest position should be as follows: shoulder joint in 45° abduction, both wrist joints in 20° to 30° extension, fingers slightly in flexion, hips at 45° abduction without any flexion, knees totally extended, and feet in a neutral position. * Orthosis and splinting prevent the development of deformities and support joints. Ankle foot orthoses can also be employed to lessen joint contractures or assist any weakened muscles around the ankle. Viscoelastic soles may decrease shock loading occurring at proximal tibia during the gait, by up to 40%. Philadelphia collar may be recommended If atlantoaxial involvement is present.  Assistive Devices And Adaptive Equipment Assistive devices and adaptive equipment have beneficial effects on joint protection and energy conservation in arthritic patients. Assistive devices are used in order to reduce functional deficits, to diminish pain, and to keep patients' independence and self- efficiency. Loading over the hip joint may be reduced by 50% by holding a cane. The procedures needed to increase compliance of the patient with the environment and to increase functional independence are mainly determined by the occupational therapist. Catalogues introducing various assisting equipment models designed for every kind of requirement should be presented to patients. Elevated toilet seats, widened gripping handles, arrangements related with bathrooms, etc. might all facilitate the daily life. One treatment recommended by occupational therapist is wearing of a therapy glove/s. Wearing therapy gloves led to the improvement in hand grip strength, control and manage hand pain, to maintain or restore the patient’s hand function, or to psychologically help to relax or calm the wearer. The glove can be worn during the day or at night. They are made of various materials: nylon, wool and elastane fibers. Broadly there are different types of gloves available on the market with use for different purposes and would fall under a broad umbrella of ‘therapy gloves’. Some of them are designed to provide warmth (i.e. ‘thermal gloves’), some to provide extra support (glove splints), some to provide compression, compression gloves give moderate joint compression so reduce the swelling and pain. and some to provide both warmth and compression. Range of Motion/ Flexibility: Range-of-motion exercises and exercise programs can delay the loss of joint function. ROM exercises: passive ROM, active assisted and active free. Stretching: Has to be avoided in acute cases. Avoid excessive stress over the tendons with stretches and avoid ballistic movements. Massage and the manual trigger of an articular movement focused on the improvement of function, pain reduction, reduction of disease activity improve flexibility and welfare (dimension of depression, anxiety, mood and pain) 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. swimming, walking, cycling. These exercises increase the mobility of the joint, but the concerned joint will not be loaded during this exercises. Strengthening: In acute phase: isometric/static exercises -> be held for 6 seconds and repeated 5–10 times each day; load = 40% 1RM. According to Hettinger, daily isometric contractions of 10%-20% of maximum tension held for 10 seconds can maintain isometric strength. Moderate-intensive exercise therapy where a minimum of 8-10 exercises is necessary for the major muscle groups. Each exercise has to be repeated 8-10 times and a minimal start intensity of 30-50 percent of 1 repetition maximum (RM). Use light weights important for stabilization of the joint and prevention of traumatic injuries. Revise the exercise program if pain persists 2 hours after the activity or there is an increase in joint swelling 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. For example, standing on a balance board. Important aspects during this exercises are motion control, balance and coordination. Routine daily activities: SARAH (Strengthening and stretching for rheumatoid arthritis of the hand) exercise program: The SARAH, 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-movement. The exercise program consists of the usual care plus a hand and wrist exercise program which includes seven mobility exercises and four strength exercises against resistance (i.e. therapy putty, theraband or hand exerciser balls). Alternative therapies Thi chi Muscial therapy yoga therapy Relaxation techniques Pilates THANK YOU