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 .