Rheumatoid arthritis

• Rheumatoid arthritis (RA) is an autoimmune, chronic, inflammatory,

systemic disease primarily of unknown etiology affecting the synovial
lining of joints as well as other connective tissue.
• It is characterized by a fluctuating course, with periods of active
disease and remission.
• The onset and progression vary from mild joint symptoms with aching
and stiffness to abrupt swelling, stiffness, and progressive deformity.
Characteristics of RA
• This disease is characterized by symmetric, erosive synovitis with
periods of exacerbation (flare) and remission.
• Joints are characteristically involved with early inflammatory changes in
the synovial membrane, peripheral portions of the articular cartilage,
and subchondral marrow spaces. In response, granulation tissue
(pannus) forms, covers, and erodes the articular cartilage, bone, and
ligaments in the joint capsule.
• Adhesions may form, restricting joint mobility. With progression of the
disease, cancellous bone becomes exposed. Fibrosis, ossific ankylosis, or
subluxation may eventually cause deformity and disability.
1. Migration
of immune 2. WBC
cell in the releases 3. Cytokines attack the
Joint cytokine synovial membrane which
causes synovial cell to
release of other
destructive substances
from synovial membrane
4.Cytokines also causes
synovial membrane to
grow new blood vessel
and form thicken area
called pannus
5. Pannus
grows and
destroy
cartilage
6.Inflammation and
fluid build up
7. Narrow joint
space and
ankylosed
https://www.youtube.com/watch?v=Yc-9dfem3lM
Characteristics of RA
■ Inflammatory changes also occur in tendon sheaths (tenosynovitis); if subjected to recurring
friction, the tendons may rupture.
■ Extra-articular pathological changes sometimes occur; they include rheumatoid nodules, atrophy
and fibrosis of muscles with associated muscular weakness, fatigue, and mild cardiac changes.
■ Progressive deterioration and decline in the functional level of the individual attributed to the
muscular changes and progressive muscle weakness is often seen, leading to major economic loss
and significant impact on families.
■ The degree of involvement varies. Some individuals experience mild symptoms that require
minor lifestyle changes and mild anti-inflammatory medications. Others experience significant
pathological changes in the joints that require major adaptations in lifestyle.
Loss of joint function is irreversible, and often surgery is needed to decrease pain and improve
function. Early recognition is essential during the initial stages, with referral to a rheumatologist for
diagnosis and medical management to control the inflammation and minimize joint damage
Signs and Symptoms: Periods of Active
Disease
■ With synovial inflammation, there is effusion and swelling of the joints, which cause
aching and limited motion. Joint stiffness is prominent in the morning. Usually there is
pain on motion, and a slight increase in skin temperature can be detected over the
joints. Pain and stiffness worsen after strenuous activity.
■ Onset is usually in the smaller joints of the hands and feet, most commonly in the
proximal interphalangeal joints. Usually symptoms are bilateral.
■ With progression, the joints become deformed and may ankylose or subluxate.
■ Pain is often felt in adjoining muscles, and eventually muscle atrophy and weakness
occur. Asymmetry in muscle strength and alterations in the line of pull of muscles and
tendons add to the deforming forces.
■ The person often experiences nonspecific symptoms such as low-grade fever, loss of
appetite and weight, malaise, and fatigue.
Treatment: Acute stage:
• Protect: use resting splints, brace joint during ADLs, adaptive tools to reduce
joint strain during ADLs
• NO STRETCHING as it may stretch the synovial membrane and cause
irreversible damage
• Energy conservation – decrease exercise
• Gentle ROM- pain free
• No lifting heavy weights or doing activities that stress joints
• Ice to reduce inflammation
• Heat only applied briefly in AM to reduce morning stiffness
• Hydrotherapy
Treatment: Chronic stage
• Chronic- no disease flare up
• Capitalize on decreased pain and increased energy
• ROM- full and pain free x Increase cardiovascular activity - aquatics is a
great suggestion
• Strength and endurance activities - pain free: lighter weights, high reps
• Continue joint protection strategies
• Use splints/braces while exercising
• Ice after activity to reduce inflammation
• Heat before activity if needed for stiffness
Principles of Management: Active
Inflammatory Period of RA
■ Patient education. Because periods of active disease may last several months to more than a
year, begin education in the overall treatment plan, safe activity, and joint protection as soon as
possible. It is vital to involve the patient in the management, so he or she learns how to conserve
energy and avoid potential deforming stresses during activities and when exercising.
■ Joint protection and energy conservation. It is important that the patient learns to respect
fatigue and, when tired, rests to minimize undue stress to all the body systems. Because inflamed
joints are easily damaged and rest is encouraged to protect the joints, teach the patient how to
rest the joints in nondeforming positions and to intersperse rest with ROM.
■ Joint mobility. Use gentle grade I and II distraction and oscillation techniques to inhibit pain and
minimize fluid stasis. Stretching techniques are not performed when joints are swollen.
■ Exercise. The type and intensity of exercise vary depending on the symptoms. Encourage the
patient to do active exercises through as much ROM as possible (not stretching). If active exercises
are not tolerated due to pain and swelling, passive ROM is used. Once symptoms of pain and
signs of swelling are controlled with medication, progress exercises as if subacute.
Principles of Management: Subacute and
Chronic Stages of RA
■ Joint protection and activity modification. Continue to emphasize the importance of
protecting the joints by adapting the environment, and by modifying activity, using
orthoses, and assistive devices.
■ Flexibility and strength. To improve function, exercises should be aimed at improving
flexibility, muscle strength, and muscle endurance within the tolerance of the joints.
■ Cardiopulmonary endurance. Nonimpact or low-impact conditioning exercises—such
as aquatic exercise, cycling, aerobic dancing, and walking/running—performed within
the tolerance of the individual improve aerobic capacity and physical activity and
decrease depression and anxiety. Group activities, such as water aerobics, also provide
social support in conjunction with the activity. One randomized review suggested that
aerobic training also has a positive impact on the cardiovascular status of patients with
RA.
CONTRAINDICATIONS:
• Do not perform stretching techniques across swollen joints. When
there is effusion, limited motion is the result of excessive fluid in the
joint space. Forcing motion on the distended capsule overstretches it,
leading to subsequent hypermobility (or subluxation) when the
swelling abates. It may also increase the irritability of the joint and
prolong the joint reaction.