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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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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