Rheumatoid Arthritis

Brooke Ray, Megan Ready, Elliah Redden,

McKenze Thompson
 Prevalence/Incidence/Etiology

What is RA?

● Autoimmune disease causing joint

inflammation (primarily synovial)3
● Peripheral joints → proximal joints2

Prevalence?

● 1-2% in US3
● Lifetime risk: 3.6% women, 1.7% men2
● Peak incidence: 65-80 years old1
○ Peak onset 30-60 yrs old3
Genetics & Epigenetics

Genetic: HLA-DRB1 allele

○ Helps immune system distinguish body’s own proteins from foreign
invader proteins3
○ Strongest genetic predisposition4
○ Genetic disposition: 40%2

Environmental:
○ Cigarette smoking2,3
○ Diet and nutrition: Western diet increases risk2
○ Obesity: 30% increase in risk2
Prevention
Pathology
Pathogen responsible for RA

○ Unknown
○ Bacteria triggers the infiltration of T-lymphocytes into the synovial
fluid
■ Genetic and environmental factors
● 80% of individuals with RA are rheumatoid factor positive
○ Autoantibodies react with immunoglobulin antibodies
within the blood, synovial fluid, and synovial membrane
○ Interaction between rheumatoid factor and immunoglobulin
trigger causes inflammatory response3
Pathology
Types of cells involved

○ Immune cells but specifically T-lymphocytes3

Location of tissue damage

○ Synovial lining of the joint capsule3

Cause of tissue damage

○ Multiplication of cells within synovial lining3

■ Macrophages - type of white blood cell responsible for
stimulating immune system
■ Synoviocytes - produce and exchange synovial fluid within joint
cavity
○ Influx of leukocytes3
 Pathology
Course of Disease

● RA starts by attacking the synovial lining

of the joint3
● Cells within synovial lining multiply
○ Increased influx of leukocytes
○ Synovium becomes inflamed which is
known as Pannus
○ Inflammatory cells within Pannus start
to destroy synovial lining
■ Prevents synovium from
lubricating the joint and
providing nutrients to articular
cartilage3
○ Inflammation continues…
■ Results in breakdown of collagen,
cartilage, subchondral bone, and
other tissue3
Pathology
Common sites

● Hands, knuckles of fingers/toes, wrist, and

knees8

Secondary problems following infection

● Infect lungs, heart, and eyes

● Development of heart disease and diabetes8

Treatment

● Use of medications
○ DMARDs (disease modifying
antirheumatic drug) to slow disease
and prevent joint deformity8
■ Most common: MTX (methotrexate)3
○ Corticosteroids and NSAIDs
(nonsteroidal antiinflammatory drugs)3
● Non Medicated treatment3
○ Acupuncture
○ Vitamins. Minerals, and fish/plant
oils
○ Autogenic training (meditation)
 Diagnostic Criteria: American College of
Rheumatology-European League against

Diagnosis and Treatment

Rheumatism(ACR-EULAR)5

Diagnosis

● Imaging:
○ MRI, Ultrasound, X-rays
● Elevated Lab markers:
○ C-reactive protein(CRP)
○ Erythrocyte Sedimentation Rate(ESR)
○ Other RA-specific autoantibodies (ACPA)5

Treatment

● Therapeutic drugs:
○ NSAIDs, DMARDs (disease-modifying
antirheumatic drugs)
● Physical Therapy:
○ joint mobility
● Patient Education
○ Slow disease progression5
Signs and Symptoms
Early Onset (within 6 mo.)

● Swollen, tenderness, or aching in 1 or more joints

● Morning stiffness
● Fever
● Weakness
● fatigue8

Late Onset

● Atherosclerosis
● Joint malalignment
● Bone erosion
● Cartilage destruction
● Loss of ROM
● Rheumatoid nodules5

Pattern: Symptoms typically occur on both sides of the body8

 Prognosis

Mortality
● 26.90 / 1000 persons a year will die from complications of RA
● Significant decline since 20061
Common Problems associated with RA and Long term impact
● Bilateral joint pain and stiffness
● Characterized by intermittent flare ups of symptoms
● Systemically RA can contribute to dry eye, lung inflammation, and
cardiovascular disease.
● Depression and neuropathy and other mood disorders
Treatment
● Reduce inflammation
● “Treating to target” – individualized treatment
 Prognosis

Do RA patients require Rehabilitation?

● Yes! Commonly prescribed to improve ADLs for RA patients

● RA often leads to functional limitations in the hands and
wrist that patients may seek PT for
Implications for Physical Therapists
Presentations used for Differential Diagnosis

● Visible red and swollen joints

● Increased erythrocyte sedimentation rate and c-reactive
protein (inflammation markers)7
Implications for Physical Therapists
Contraindications

● For RA patients on steroids avoid excessive loading

on joints or bones.

Precautions and implications for treatment/interventions

● Avoid anything that instigates more inflammation

○ Ex. exercises that compress or irritate the
joints

How involved is PT?

● Mobility, mobility, mobility! Do what we can to

increase movement and decrease stiffness
● Education on healthy lifestyle is also the PT’s role
as part of the healthcare team3
Clinical Pearl

If you forget everything else... Remember this.

● RA’s main presenting symptom is persistent, otherwise

unexplained, specific joint pain.
● Usually presents in small joints first
● Joint pain combined with any other body system
involvement is a 🚩
● RA will affect passive AND active ROM
What tissue type is damaged in Rheumatoid Arthritis?

a. The synovial lining of the joint

capsules
b. Soft tissue
c. Muscle
d. Epithelial cells
What is a common sign of Rheumatoid Arthritis?

a. Red and swollen joints

b. Chest pain
c. Hearing loss
d. Dyspnea
References

1. Abhishek A, Nakafero G, Kuo CF, et al. Rheumatoid arthritis and excess mortality: down but not out. A primary care cohort study using data
from Clinical Practice Research Datalink. Rheumatology (Oxford). 2018;57(6):977-981. doi:10.1093/rheumatology/key013
2. Chauhan K, Jandu JS, Goyal A, Al-Dhahir MA. Rheumatoid Arthritis. In: StatPearls. Treasure Island (FL): StatPearls Publishing; June 4, 2022.
3. Goodman CC, Fuller KS. Introduction to Pathology of the Musculoskeletal System. Goodman and Fuller’s Pathology: Implications for the
Physical Therapist Fifth Edition. Elsevier; 2021: 1275-1287.
4. HLA-DRB1 gene: Medlineplus genetics. MedlinePlus. https://medlineplus.gov/genetics/gene/hla-drb1/. Accessed September 27, 2022.
5. Lin Y-J, Anzaghe M, Schülke S. Update on the pathomechanism, diagnosis, and treatment options for rheumatoid arthritis. Cells.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7226834/. Published April 3, 2020. Accessed September 28, 2022.
6. Radu AF, Bungau SG. Management of Rheumatoid Arthritis: An Overview. Cells. 2021;10(11):2857. Published 2021 Oct 23.
7. Siemons L, Ten Klooster PM, Vonkeman HE, van Riel PL, Glas CA, van de Laar MA. How age and sex affect the erythrocyte sedimentation rate
and C-reactive protein in early rheumatoid arthritis. BMC Musculoskelet Disord. 2014;15:368. Published 2014 Nov 6.
doi:10.1186/1471-2474-15-368
8. US Department of Health and Human Services. Rheumatoid Arthritis. Centers for Disease Control and Prevention. Published July 7, 2020.
Accessed September 27, 2022. https://www.cdc.gov/arthritis/basics/rheumatoid-arthritis.html