RHEUMATOID ARTHRITIS

 RHEUMATOID ARTHRITIS

Rheumatoid Arthritis is a systemic disease which results in chronic inflammation and destruction of synovial joints.It is an autoimmune disease that involves systems/organs other than the bones and joints alone.

Aetiology

The aetiology is unclear.  various factors like climate, race, diet, psychosomatic disorders trauma ,endocrine dysfunction, biochemical disorders,  hereditary influences, disturbances in the autoimmunity and infection.

Non articular Features of Rheumatoid Arthritis

1. Systemic illness:  Malaise, weakness, loss of weight, fever 
2. Blood disorders:  Anaemia, increase or decrease in white blood cell count 

3.Vascular:  Involvement of small arteries, arterioles, veins, mono-or polyneuritis 

4.Cardiac:  Myocarditis, pericarditis, valve lesions 
5.Respiratory:  Pharyngitis, laryngitis, pleuritis, diffuse pulmonary fibrosis 

6.Reticuloendothelial:  Lymph node enlargement, splenomegaly, hepatomegaly.
7.Skin:  Ulcerative lesions, purpura, erythema.
8.Eyes:  Conjunctivitis, keratitis, keratopathy, uveitis 
9.Serological:  raised ESR and C-reactive protein
10.Renal : hepatic and gastrointestinal lesions occur frequently and often silently.

Diagnosis

The diagnosis of RA is based more on clinical criteria than on laboratory tests alone.
The criteria for diagnosis is :--

1. Morning stiffness (>6 weeks) 
2. Pain on motion or tenderness in at least one joint (>6 weeks)
3. Swelling of one joint either due to soft tissues or effusion or both 
4. Swelling of at least one other joint with an interval free of symptoms no longer than 3 months 
5. Symmetrical joint swelling (same joint)
6. Positive test for rheumatoid factor (Rh factor) in serum 
7. rheumatoid nodules.

Laboratory tests:

• Rheumatoid factor and anti-CCP (anti-cyclic citrullinated peptide) tests .
• Abnormalities occur in the serum proteins: The erythrocyte sedimentation rate (ESR) is raised. There is an increase in the serum fibrinogen,  increase in the immunoglobulins.
• The CRP (C-reactive protein) is also elevated.
• Examination of the synovial fluid: The clarity, colour and viscosity.

Treatment

Conservative treatment

• Anti-inflammatory and immunosuppressive drugs
• Appropriate static splints
• Intralesional injections of corticosteroids
• Physiotherapy

Surgical treatment

Common procedures

• Synovectomy: Excision of the inflamed synovium
• Osteotomy: To correct varus or valgus deformity at the hip or knee
• Arthroplasty: In the advanced stage of the disease when the joint is destroyed.
• Arthrodesis: To stabilize the joint
• Reconstructive surgery of the hand, e.g., tendon transfers and soft tissue release. 

Physiotherapeutic management

Principles of physiotherapy

• Relief of pain and inflammation
• Prevention of deformity
• Correction of deformity
• Restoration and maintenance of joint motion
• Improvement of muscle strength and endurance
• Guidance and training to achieve optimum function

Objective assessment of the patient is carried out as follows:

1. Pain: Body image pain chart and VAS.
2. Swelling: Volumetric measures
3. Skin: Erythema, temperature, skin lesion, presence of nodules, texture of nails and hair
4. Deformity: Exact degree of deformity
5. Joint range: By goniometry
6. Muscle strength and endurance of the muscles of the joints involved and the related joints
7. Respiratory functions: Vital capacity (VC), forced expiratory volume (FEV1) and thoracic excursion .
8. Postural deviation
9. Hand function: Measurement of various grip strengths
10. Gait analysis

Acute phase (3–4 weeks)

During the acute or active phase of the disease:-
1. Properly supported positioning of the involved joints and correct bed posture are important.
2. Splints and sandbags may provide additional support to the limb.
3. Deep breathing exercises are important to improve the VC.
4. full ROM and PRE.
5. Functional mobility should be encouraged and maintained within the pain-free limits.
6. Postural guidance and methods of performing activities.
8. Isometrics:  repeated sessions of isometrics.
9. Speedy isometrics to the affected limb in elevation reduce swelling and effusion.
10. TENS, pulsed ultrasound, ice massage or ice packs .
11. Properly guided pool therapy for the whole body.

Chronic phase (4-5 WEEKS)

• Deep heat (if acceptable), ultrasonics, TENS and other adjuncts may be used to relieve pain.
• It is a phase of vigorous activity to train the patient to use the involved joints.
• By 4–5 weeks of the onset, independent sitting by the use of hands can be started.
• Before allowing weight bearing, it is absolutely essential to provide the necessary orthotic support or walking aid .
• Sustained or intermittent stretching procedures may be necessary for the joints that have developed tightness.
• Efforts should be made to improve the strength and endurance .

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PERIARTHRITIS

Adhesive capsulitis
Or
Periarthritis
Or
Frozen shoulder

Periarthritis is a clinical syndrome with painful restriction of both active and passive shoulder movements.

The condition is aggravated by systemic problems like diabetes mellitus, cardiovascular disease and reflex sympathetic dystrophy.

Neviaser (1987) have classified this condition into four stages:
(1) preadhesive stage,
(2) acute adhesive stage,
(3) stage of maturation and
(4) chronic stage.

Diagnostic tests

1. Active test of range of motion (ROM)
2. Active resisted test of ROM
3. Passive test of ROM

Treatment

It is treated mainly by analgesics and physiotherapy with shoulder mobilization exercises.
 a periarticular injection of hydrocortisone is given to reduce pain and inflammation.
 These days, arthroscopic capsular release is done which improves the range of movements.

Physiotherapeutic management

Physiotherapy plays an important role in the prevention as well as resolution of this condition.

Preventive programme

1. Prevention of primary capsulitis:the regular practice of movement could be usefull in prevention.
2. Prevention of secondary capsulitis: Careful early mobilization to the extreme ROM
3. Prevention of further damage:
 (i) Suddenly applied jerky stretching and
 (ii) crude self-styled manipulations by a quack.

Restorative programme

The basic aim of the restorative programme is

1. To reduce pain,
2. To increase extensibility of the thickened and contracted capsule of the joint .
3. To improve mobility of the shoulder and
4. To improve strength of the muscles

Mobilization is attained through three basic approaches:

1. Relaxation
2. Specific exercise to offer graduated stretching
3. Passive mobilization technique

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Spina Bifida

Spina bifida

Spina bifida, a neural tube defect, is the result of the defective fusion of one or more posterior vertebral arches with results in protrusion of the contents of the spinal canal.

Classification

1. Spina bifida occulta

2. Spina bifida cystica
(a) Meningocoele
(b) Myelomeningocoele

1. spina bifida occulta
 The presence of an overlying midline skin defect, such as haemangioma, lipoma or a tuft of hair, points to an underlying spina bifida occulta.
It is rarely associated with neurological deficit.


2. spina bifida cystica
 there is a developmental deficiency of laminae, spinous processes and the overlying muscles and skin.

(a) Meningocoele: In this variety, usually the spinal cord and its nerve roots are intact, only the covering membrane (meninges) projects as a dural sac.

(b) Myelomeningocoele: the spinal cord is exposed to the surface as a plaque or nervous tissue.
 It is associated with muscle paralysis, sensory loss and paralytic deformities of the lower limbs.

Physiotherapeutic management 

Physiotherapeutic management includes the following:

1. Prevention and management of deformities
2. Management of muscle paralysis
3. Care of skin and joints
4. Management of bladder and bowel incontinence
5. Education in ambulation, and self-care

1. Prevention and management of deformities:
passive stretching and the use of night splints.
2. Management of muscle paralysis:

(a) Arm and shoulder girdle muscles. These should be developed for crutch walking and transfers.

(b) Functionally important weight-bearing muscles such as hip abductors and extensors

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ACL INJURY MANAGEMENT

                                   ACL KNEE INJURY

Conservative Management

Goals

Decrease inflammation , swelling and pain.
Restore normal ROM (especially knee extension).
Restore voluntary muscle activation.
Provide patient education for post-op rehabilitation.

TO DECREASE PAIN SWELLING AND INFLAMMATION-

Cryotherapy +elevation with the knee in full extension.
TENS/IFT .
Elastic crepe or knee sleeve.
Brace while walking.

TO RESTORE NORMAL ROM –

Ankle pumps.
Heel slides- knee flexion upto tolerance and knee extension to 0˚.
SLR– 3 way SLR(flexion, abduction, adduction).

RESTORE NORMAL MUSCLE STRENGTH-

Initially

Quadriceps setting.
Hamstring setting( 3 times more than quads setting).
Elecrical muscle stimulation to quadriceps during voluntary muscle stimulation.

Surgery after ACL knee injury

The aim of reconstruction is to restore stability of the knee.

Reconstruction techniques can be broadly split into two groups:
(i) Extraarticular reconstruction
(ii) Intraarticular reconstruction

REHABILITATION PROTOCOL AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

PHASE 1 : 
 Week 0-2 Goals-
• Minimise effects of immobilization. • Control inflammation.
• No CPM.
• Achieve full extention, 90 degree of knee flexion.

Brace- • Locked in extention for ambulation & sleeping

Weight bearing- • Weight bearing with 2 cruthes. • Discontinue crutches as tolerated after 7 days.

Therapeutic exercises for acl knee injury- • Quadriceps sets, hamstrings sets
 • Patellar mobilisation.
 • Non-weight bearing gastrocsoleus, hamstring streches.
Straight leg raises(SLR) all planes with braces in full extension.

Functional training-

Proprioception
• Active / passive joint positioning.
 • Balancing activities.
• Seated ball throwing and catches.

PHASE 2 :
Week 2-4

Goals-
• Restore normal gait.
 • Restore full ROM.
• Protect graft fixation.
• Improve strength, endurence and proprioception to prepare for functional activities.

Weight- bearing • Patellar tendon graft- continue ambulation with brace locked in extension. • Hamstring graft and allograft- may discontinue brace use when normal gait pattern and quadriceps control are achieved.

Therapeutic exercises acl knee injury--
  • Continue hamstings streches, progress to weight bearing gastrosoleus streches. • Continue prone leg hangs with progressively heavier ankle weights untill full extension is achieved.

Functional training-
 Aerobic conditioning-
• Continue upper extremity ergometry
 • Advance to two-leg bicycling. Plyometrics / eccentric muscle training-
• Stair walking- up/down, forward/backward.
Aquatherapy- • Pool walking. • Pool jogging (deep water running).
 Proprioception- • Balancing activities.

PHASE 3 :
Week 6- month 4

Goals- • Improve confidence in the knee. • Avoid overstreching graft fixation. • Protect the patellofemoral joint. • Progress strength, power and proprioception to prepare for functional activities.

Therapeutic exercises acl knee injury-  • Continue flexibility exercises as appropriate for patient.
• Advance closed kinetic chain strengthening (one leg squats,leg press 0-60 degrees).
• Cross country skiing machine.

Functional training- (6-12 weeks)

Aerobic Conditioning
• Continue bicycling/ upper extremity ergometry.
• Stair stepper/ elliptical stepper.
• Pool walking/ jogging. • Plyometrics
 • Stair jogging. • Box jumps 6-12inch heights.

PHASE 4 :
 Month 4

Goals- • Return to unrestricted activities.

Therapeutic exercises acl knee injury-  • Continue and progress flexibility and strengthing programs.

Functional training-

Aerobic Conditioning
• Pool walking/ jogging. • Cross country skiing machine. Running • Figure of 8 pattern. • Small circles and running. Agility • Start at slow speed, advance slowly. • Shuttle run. • Lateral slides. • Carioca cross-overs. • Cutting drills. Proprioception • Reaction drills. •Plyometrics

PHASE 5 :
 Return to Sports

Goals- • Safe returns to athletics. • Maintain strength,endurence and proprioception. •Patient education concerning any possible limitations.

Brace- • Functional brace may be  for use during support for the 1-2 year after acl knee injury for psychological confidence.

Therapeutic exercises acl knee injury-  • Gradual return to sport participation. • Maintaince program for strength and endurence. • Agility and sport specific drills progressed.


Prevention of ACL knee injury

Use proper techniques when playing sports or exercising. 

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ACL INJURY

                                     ACL Knee Injury

ACL knee injury is common in sports that involve sudden changes of direction, such as football, and soccer. Most occur during sudden twisting motion or when landing from a jump.

 ACL Injury?
An anterior cruciate ligament injury is the over-stretching or tearing of the anterior cruciate ligament (ACL) in the knee. An acl tear may be partial or complete.

Medial collateral ligament (MCL) - runs along the inner part (side) of the knee and prevents the knee from bending inward.
Lateral collateral ligament (LCL) - runs along the outer part (side) of the knee and prevents the knee from bending outward.
Anterior cruciate ligament (ACL) - lies in the middle of the knee. It prevents the tibia from sliding out in front of the femur, and provides rotational stability to the knee.
Posterior cruciate ligament (PCL) - works with the ACL. It prevents the tibia from sliding backwards under the femur.

Causes for ACL Knee Injury

Direction change while running, pivoting, landing from a jump, or overextending the knee joint (called hyperextended knee), also can cause injury to the ACL.
 Basketball, football, soccer, and skiing are common causes of ACL tears.

Symptoms of ACL tear

A "popping" sound at the time of injury
Knee swelling within 6 hours of injury
Pain when you try to put weight on the injured leg
Restricted movement

Diagnosis for ACL tear

 The pivot-shift test,
 anterior drawer test
 the Lachman test
 magnetic resonance imaging MRI

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Osteoarthritis

 OSTEOARTHRITIS

Osteoarthritis is a noninflammatory degenerative disorder of the joints characterized by progressive deterioration of the articular cartilage.

TYPES :-
(a) primary when the aetiology is natural wear and tear with aging, overuse or obesity
(b) secondary when it follows some known primary cause, e.g., trauma, infection and rheumatoid arthritis (RA)

COMMON SITES :-
◼ Weight-bearing joints: Hip, knee, ankle and spine
◼ Overused joints: wrist joints, carpometacarpal joint of thumb, distal metacarpophalangeal joints, etc.
◼ Most common site: knee joints

CLINICAL FEATURES :-

↪Pain is the main presenting symptom.
↪The joint becomes swollen due to synovitis.
↪Stiffness gradually sets in,  severe pain and capsular contractures.

On examination
There is swelling due to synovial thickening and/or effusion,
 muscle wasting
 prominence of the articular margins Movements are painful and restricted. Crepitus is felt on passive joint movement.
Radiographic examination reveals the following main features
◼ Narrowing of the joint space
◼ Osteophytes at the margins of articular cartilages
◼ Sclerosis and cysts in the subchondral bone

Principles of physiotherapeutic management (general) in osteoarthritis.

General principles of treatment

1. Prevention
2. Control of pain
3. Prevention of further damage
4. Improvement in range of motion (ROM)
5. Improvement in strength, endurance and muscle functions .
6. Improvement in the functional status

Assessment

1. Assessment of pain:  Pain is an index of the degree of joint irritability. The site of pain, its nature and duration are noted.
pain can be reliably assessed by the visual analogue scale (VAS)

2. Assessment of function:  The impact of the disease on the functional performance of the patient is examined and recorded on a functional evaluation chart.
3. Assessment of joint stiffness:  Accurate evaluation of the passive ROM with its end feel.
5. Assessment of tenderness:  The degree and the area of tenderness, effusion and crepitus.

Prevention: Physiotherapy can play a vital role in the prevention of the painful symptoms of osteoarthritis. Understanding the following factors
1. History of trauma:
2. Characteristics of joint cartilage:
3. Effects of immobilization:
4. Weight bearing:
5. Full ROM exercises:

**Treatment*

1. Pain control
(a) To control pain, suitable electrotherapeutic modality ,Ultrasound therapy, transcutaneous electrical nerve stimulation (TENS),  Short-wave diathermy (SWD) may be used in the later phase .
(b) Hydrotherapy is particularly useful when the weight-bearing joints are affected.
(c) proper position, splints or joint distraction by manual or mechanical traction, CPM or functional bracing.

2. Improvement of muscle power, endurance and tone:  Graduated exercise programme is initiated, which consists of progressive resistive exercises (PRE), strong and sustained repeated sessions of isometrics .

3. Improvement in ROM
(a) Active free relaxed rhythmic movements .
(b) Relaxed passive movements should be started first to mobilize stiff joints.

4. Improvement of functional independence:Providing assistive aids, modified supports, corrective orthoses.

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