RHEUMATOID ARTHRITIS

RHEUMATOID ARTHRITIS
 Chronic inflammatory disease of the synovium with
the course characterized by exacerbation & remission.
 Autoimmune disease that results in a chronic,
systemic inflammatory disorder that may affect many
tissues and organs, but principally attacks synovial
joints.
 CONTD…….

 The characteristic feature of RA is persistent

inflammatory synovitis, usually involving
peripheral joints in a symmetric distribution,
with systemic manifestations.
 The synovial inflammation cause cartilage
damage and bone erosions and subsequent
changes in joint integrity & it is the hallmark of
the disease.
 EPIDEMIOLOGY

 The prevalence of RA is approximately 0.8% of

the population.
 The prevalence increase with age,
approximately 2% in men and 5% in women,
 Sex differences diminish in the older age group

 The onset is most frequent during the fourth

and fifth decades of life, with 80% of all
patients developing the disease between the
ages of 35 and 50.
 RISK FACTORS
 Genetic: family history is an important risk
factor.
 Non-genetic: smoking; more common in
smokers than non-smokers, particularly in men
 Vit- D deficiency is common in those with RA
and may be associated with it.
 AETIOLOGY
 The cause of rheumatoid arthritis is not known
 It is believed that an antigen/s enters the body
& forms antibody.
 This leads to formation of immune complex
which causes inflammation to the synovium.
PATHOPHYSIOLOGY
 CLINICAL MANIFESTATIONS

Onset
 Characteristically,
RA is a chronic polyarthritis.
 In approximately two-thirds of patients, it begins
insidiously
 Fatigue, anorexia, generalized weakness, and
vague musculoskeletal symptoms are the initial
symptoms until synovitis becomes apparent.
 In approximately one-third of patients,
symptoms may initially be confined to one or a
few joints.
 SIGNS AND SYMPTOMS
 Pain, swelling, and tenderness may initially be poorly
localized to the joints.
 Pain in affected joints, aggravated by movement, is the
most common manifestation of established RA.
 Stiffness is frequent and is usually greatest after periods
of inactivity. Morning stiffness of greater than 1-h
duration is an almost invariable feature of inflammatory
arthritis
 The majority of patients will experience symptoms such
as weakness, easy fatigability, anorexia and weight loss.
 Although fever to 40°C occurs on occasion, temperature
elevation in excess of 38°C is unusual.
 Clinically, synovial inflammation causes swelling,
tenderness and limitation of motion.
CONTD…..
 RA most often causes symmetric arthritis with characteristic
involvement of certain specific joints such as the PIP and MCP joints.
 The DIP joints are rarely involved.
 Synovitis of the wrist joints is a nearly uniform feature of RA and may
lead to limitation of motion, deformity, and median nerve entrapment.
 Synovitis of the elbow joint often leads to flexion contractures that
may develop early in the disease.
 The knee joint is commonly involved with synovial hypertrophy, chronic
effusion and frequently ligamentous laxity.
 Pain and swelling behind the knee may be caused by extension of
inflamed synovium into the popliteal space (Baker’s cyst).
 Arthritis in the forefoot, ankles, and subtalar joints can produce severe
pain with ambulation as well as a number of deformities.
 Axial involvement is usually limited to the upper cervical spine
(atlantoaxial subluxation)
 EXTRAARTICULAR MANIFESTATIONS
 Rheumatoid nodules : develop in 20 to 30% of persons
with RA, usually found on periarticular structures,
extensor surfaces, or other areas subjected to
mechanical pressure
 Musculoskeletal Manifestations:
 Weakness and atrophy of skeletal muscle are
common.
 Osteoporosis is common and may be aggravated by
glucocorticoid therapy
 Rheumatoid vasculitis which can affect nearly any organ,
is seen in patients with severe RA
 Pulmonary manifestations, which are more commonly
observed in men, include pleural disease, interstitial
fibrosis, Pleuropulmonary nodules, pneumonitis and
arteritis.
CONTD…….
 Cardiac Manifestations: evidence of asymptomatic
pericarditis is found at autopsy in 50% of cases
 Ophthalmic Manifestations: involves the eye in
fewer than 1% of patients (keratoconjunctivitis)
 Felty’s syndrome : consists of chronic RA,
splenomegaly, neutropenia and occasionally
anemia and thrombocytopenia. Most common in
individuals with long-standing disease
 RA is associated with an increased incidence of
lymphoma,
 RA tends to spare the central nervous system
directly, although vasculitis can cause peripheral
neuropathy. Neurologic manifestations may also
result from atlantoaxial subluxation.
 LABORATORY FINDINGS
 No tests are specific for diagnosing RA
 RA factors (autoantibodies) are found in more than two-thirds of
adults with the disease. The presence of rheumatoid factor is not
specific for RA. Rheumatoid factor is found in 5% of healthy
persons. The presence of rheumatoid factor can be of prognostic
significance because patients with high titers tend to have more
severe and progressive disease with extraarticular manifestations.
 A number of additional autoantibodies may be found in patients
with RA, including antibodies to filaggrin, citrullinated proteins,
calpastatin etc.
 Normochromic, normocytic anemia is frequently present in active
RA.
 The ESR is increased in nearly all patients with active RA
 Synovial fluid analysis confirms the presence of inflammatory
arthritis,
 DIAGNOSTIC CRITERIA - ACR, 1987
1. Morning stiffness>=1hr
2. Arthritis of 3 or more of the following joints: PIP,
MCP, Wrist, elbow, knee, ankle & MTP joints.
3. Arthritis of hand joints: wrist, MCP or PIP joint
4. Symmetrical joint involvement on opposite side
5. Subcutaneous Rheumatoid nodules over bony
prominences or on the extensor surfaces.
6. Positive serum RA factor
7. X-ray typical of RA: bony erosions, decalcification
localized in or adjacent to the involved area,
juxtaarticular osteopenia.
 4 of the above criteria must be present with 1-4
must have been present for minimum of last 6wks.
 CONTD…
 Definite RA: 5 of the above criteria. 1-5 must be
present for 6 wks
 Probable RA: 3 of the above criteria. Any one of 1-5
must be for 6 wks
 Possible RA: Diagnosis needs two of the following
criteria & total duration of joint symptoms must be
for 3wks:
 Morning stiffness
 Tenderness or pain on motion with H/O of recurrence /
persistance for 3wks
 H/O joint swelling
 Subcutaneous nodules
 Increased ESR.
REVISED CRITERIA FOR THE CLASSIFICATION OF
RA
These criteria demonstrate a sensitivity of 91 to 94% and a specificity of 89%
1. Guidelines for classification:
a. Four out of seven criteria are required to classify a patient as having rheumatoid arthritis
(RA).
b. Patients with two or more clinical diagnoses are not excluded.
2. Criteria
a. Morning stiffness: Stiffness in and around the joints lasting 1 h before maximal improvement.
b. Arthritis of three or more joint areas: At least three joint areas, observed by a physician
simultaneously, have soft tissue swelling or joint effusions, not just bony overgrowth. The
14 possible joint areas involved are right or left PIP, MCP, wrist, elbow, knee, ankle, and
MTP joints.
c. Arthritis of hand joints: Arthritis of wrist, MCP joint or PIP joint.
d. Symmetric arthritis: Simultaneous involvement of the same joint on both sides of the body.
e. Rheumatoid nodules: Subcutaneous nodules over bony prominences, extensor surfaces, or
juxtaarticular regions observed by a physician.
f. Serum rheumatoid factor: Demonstration of abnormal amounts of serum rheumatoid factor by
any method for which the result has been positive in less than 5% of normal control
subjects.
g. Radiographic changes: Typical changes of RA on posteroanterior hand and wrist radiographs
that must include erosions or unequivocal bony decalcification localized in or most marked
adjacent to the involved joints.
 Criteria a–d must be present for at least 6 weeks. Criteria b–e must be observed by a physician.
 CLINICAL DIAGNOSIS
 The previous criteria are not intended for the
diagnosis for routine clinical care; they were
primarily intended to categorize research
(classification criteria).
 In clinical practice, the following criteria apply:
 two or more swollen joints
 morning stiffness lasting more than one hour for at
least six weeks
 the detection of RA factors or auto antibodies against
ACP. A negative autoantibody result does not exclude
a diagnosis of RA.
 ACR CLASSIFICATION CRITERIA OF FUNCTIONAL
STATUS IN RHEUMATOID ARTHRITIS

Ø Class I: Completely able to perform usual activities

of daily living (self-care, vocational, and avocational
[recreational and/or leisure])
Ø Class II: Able to perform usual self-care and
vocational activities, but limited in avocational
activities
Ø Class III: Able to perform usual self-care activities,
but limited in vocational and avocational activities
Ø Class IV: Limited ability to perform usual self-care,
vocational and avocational activities
 DEFORMITIES
Common Hand Deformities:
 Ulnar drift

 Swan neck deformity

 Boutonniere deformity

 Mallet finger deformity

 Z- deformity
ULNAR DRIFT
 The inflammatory process (infiltration) damages
& weakens the capsule & supporting ligaments
 Chronic intra-articular swelling due to synovial
effusion & hypertrophy stretches the supporting
joint structure reducing their restraining power
against the ulnar force.
SWAN NECK DEFORMITY
 PIP hyperextension & DIP flexion
 Chronic synovitis of PIP can cause stretching of
the volar capsule + dorsal migration of lateral
bands of fingers.
 Hyperextension of the PIP causes tension to
the FDP tendon
 It may also lead to rupture of FDS insertion
which predisposes the PIP with this deformity.
BOUTONNIERE /BUTTON HOLE DEFORMITY
 PIP flexion with DIP hyperextension
 The inflammatory process damages the extensor
structure at the PIP & weakens their attachment
 Synovial hypertrophy distends the dorsal capsule,
thereby mechanically stretching or displacing the
extensor structures.
 Rupture of the central sling of EDC limits the
effectiveness as extensor of the proximal phalanx.
MALLET FINGER DEFORMITY
 Flexion of DIP
 The inflammatory process causes lengthening
or rupture of the distal attachment of the
extensor mechanism which removes the
extension force at the DIP
 This causes /allows the profundus(FDP)
insertion to pull in flexion.
Z- DEFORMITY
 IP flexion & MCP hyperextension of thumb or
 IP hyperextension & MCP flexion.
COMPLICATIONS OF RA
§ Carpal tunnel syndrome,
§ Baker’s cyst,
§ Vasculitis,
§ Subcutaneous nodules,
§ Sjögren’s syndrome,
§ Peripheral neuropathy,
§ Cardiac and pulmonary involvement,
§ Felty’s syndrome, and
§ Anemia
MANAGEMENT
 Careful assessment
§ History
§ Musculoskelatal examination – erythema, warmth,
tenderness, swelling, synovial thickening, ROM,
Crepitus, Deformity, Muscle weakness, Skin
condition
§ Pain assessment – intensity, duration
§ Respiratory function
§ Posture in standing & sitting
§ Gait assessment
§ Functional assessment
 GENERAL PRINCIPLES OF TREATMENT
 The goals of therapy of RA are
(1) Relief of pain,
(2) Reduction of inflammation,
(3) Protection of articular structures,
(4) Maintenance of function, and
(5) Control of systemic involvement.
 None of the therapeutic interventions are curative, and
therefore all must be viewed as palliative,
 Therapeutic interventions are aimed at relieving the
signs and symptoms of the disease.
 PRINCIPLES OF PT MGT

 Reliefof pain & spasm

 Prevention of deformity

 Correction of deformity

 Maintenance of JROM

 Restoration of lost ROM

 Maintenance & improvement of strength

 Maintenance of optimum function

 RELIEF OF PAIN & SPASM
 Spasm is mainly protective in nature. So, PT is
aimed at reducing protective spasm.
 Methods:
IRR
Hot Packs
Wax Bath
Pulsed SWD
IFT/TENS for analgesic effect for large
joints
Isometric exercises for muscles
surrounding the affected joints
 PREVENTION/ CORRECTION OF
DEFORMITY
 In the early stage of the disease pain, swelling & spasm
encourages a patient to assume postures that
anticipate deformities.
 Later on there will be change of muscle fiber length,
periarticular structures, inequality of strength & changes
in bone.
 Methods:
Postural awareness
Proper positioning
Passive stretching
Splinting
Serial casting/plastering for correction of
deformity
 MAINTENANCE/RESTORATION OF JROM

 For maintenance:
Full ROM active/ac-assisted exercise for
all involved joints
 For restoration of ROM:

PNF stretching

Passive stretching in Hydrotherapy etc

MAINTENANCE & IMPROVEMENT OF STRENGTH

 To avoid weakness or wasting regular

exercises are required.
 These ex should not increase pain.

 Progression of exercises should be slow.

 Postural correction ex & trunk muscle ex

should be taught.
 Pool ex (Hydrotherapy).
 MAINTENANCE OF OPTIMUM FUNCTION

 Use adaptive/assistive device/ADL device for

UE
 For LE use walking aids
 SURGICAL MANAGEMENT

 Indications:
 Reliefof incapacitating pain
 Restoration of joint stability
 Maintain/Regain functional independence.
 Prevention of harmful stresses on other joints.

 Common Surgeries:
 Synovectomy
 Arthroplasty:
 Excision arthroplasty
 Interposition arthroplasty
 Partial joint replacement
 Total joint replacement.
THANK YOU