RHEUMATOID ARTHRITIS

SHINE TREHAN (BPT) LPU

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Rheumatoid arthritis (RA) is an autoimmune disease that causes chronic inflammation of the joints. Rheumatoid arthritis can also cause inflammation of the tissue around the joints, as well as in other organs in the body. Autoimmune diseases are illnesses that occur when the body's tissues are mistakenly attacked by their own immune system. Rheumatoid arthritis is a common rheumatic disease, affecting approximately 1.3 million people in the United States.

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Chronic inflammation leads to the destruction of the cartilage, bone, and ligaments, causing deformity of the joints. Damage to the joints can occur early in the disease and be progressive. The disease is three times more common in women as in men. It afflicts people of all races equally. The disease can begin at any age and even affects children (juvenile rheumatoid arthritis), but it most often starts after 40 years of age and before 60 years of age.

Rheumatoid arthritis is most likely triggered by a combination of factors, including an abnormal autoimmune response, genetic susceptibility, and some environmental or biologic trigger, such as a viral infection or hormonal changes. : It may play some role in RA either in terms of increasing susceptibility to developing the condition or by worsening the disease process. A number of HLA genetic forms called HLA-DRB1 and HLA-DR4 are referred to as the RA-shared epitope because of their association with rheumatoid arthritis.

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Agents such as Mycoplasma, parvovirus B19, retroviruses, mycobacteria, and clostridium might trigger the activation of the immune system in susceptible individuals. This misdirected immune system then attacks the body's own tissues. This leads to inflammation in the joints and sometimes in various organs of the body, such as the lungs or eyes.

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The rheumatoid arthritis symptoms can grow slowly and vary from one person to another, which are normally in their most severe form. Listed below are the rheumatoid arthritis symptoms seen in adults. Stiffness in joints, especially noticed in the morning Lasting stiffness for hours since morning Swelling, redness, over the part of the involved joints. Too much pain, lack of response, and swelling in the joints of wrists, hands, shoulders, elbows, ankles, feet, knees, neck, and jaw

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Loss in weight Extreme fatigue Fever Skin rashes Less appetite More joints getting affected over time Tiny lumps named rheumatoid nodules seen on the areas such as elbows, knuckles, and heels

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Unusual changes in heart or lungs Combination of pain such as in hands and feet Symmetrical pain pattern - elbows of both the left and right hands get affected Difficulty in daily tasks such as opening the door Rheumatoid arthritis can even affect the joint that is responsible for the tightening of our vocal cords to change the tone of our voice, the cricoarytenoid joint.

The lining tissue of the joint (synovium) becomes inflamed, resulting in the production of excessive joint fluid (synovial fluid).

As the inflammation persist, the synovium become hypertrophied and surrounds the periphery of articular cartilage to form pannus.

The articlar cartilage loses its smooth shiny appearance. The pannus extends over cartilage from periphery and extends to bone and bone surface become raw. The joint get deformed, initially because of muscle spasm associated with pain and later due to fibrosis of capsule.

COMMON JOINTS: MP joints of hands, PIP joints of fingers, wrist, knees, elbow, ankle. LESS COMMON JOINTS: Hip joint and Temporomandibular joint. UNCOMMON JOINTs: Atlantoaxial joints and facet joint of cervical spine.

Deformities in Hand: Ulnar drift deformity: in which the swelling of the metacarpophalange al joints causes the fingers to become displaced, tending towards the little finger. Its name comes from the displacement toward the ulna

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Swan neck deformity Swan Neck deformity is common in RA as joint inflammation stretches the soft ligaments and capsules that keep the joints and tendons in proper alignment. The PIP joint (the joint in the middle of the finger) stretches into hyperextension and the resulting imbalance causes the DIP to bend down into flexion.

Boutonniere deformity : is a deformed position of the fingers or toes in which there is (PIP flexion with DIP hyperextension). It is commonly caused by an inflammatory condition like rheumatoid arthritis.

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Z thumb deformity: It is seen at the thumb and consists of hyperextension of the interphalangeal joint, and fixed flexion and subluxation of the metacarpophalangeal joint.

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Flexion deformity: Diffuse involvement of joint with extensive erosion in olecranon articulation and joint space narrowing with Joint effusion and olecranon bursitis may also occur.

Early there occur: flexion deformity of knee.

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Late: Triple sublxation In this there is flexed position of the knee, the tibia subluxates posteriorly & laterally & also rotates laterally over the femoral condyle. Gradually leg also goes in valgus. It is also called erosive arthropathy.

Equinus deformity of ankle: ankle equinus deformity is basically one in which the achilles tendon is shorter than needed to allow adequate dorsiflexion d uring the gait cycle.

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Hallux valgus: A bunion (hallux valgus deformity) is a bony bump on the outside and top of the great toe, where it connects to the foot.

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Hammer toe: It primarily comprises flexion deformity of the proximal interphalangeal (PIP) joint of the toe, with hyperextension of the metatarsophalangeal (MTP) and distal interphalangeal (DIP) joints.

MILD: patient with mild form of RA will have following signs and symptoms: Joint pain Inflammation of at least three joints No inflammation in tissues other than the joints Usually, a negative result on a rheumatoid factor test An elevated ESR or CRP level No evidence of bone or cartilage damage on xrays

Between 6 and 20 inflamed joints Usually no inflammation in tissues other than the joints An elevated ESR or CRP levels A positive rheumatoid factor test or anti-cyclic citrullinated peptide (anti-CCP) antibodies Evidence of inflammation but no evidence of bone damage on x-rays

More than 20 persistently inflamed joints or a rapid loss of functional abilities Elevated ESR or CRP levels Anemia related to chronic illness Low blood albumin level A positive rheumatoid factor test, often with a high level Evidence of bone and cartilage damage on x-ray Inflammation in tissues other than joints

X RAY OF HAND SHOWING BONE EROSION AND JOINT DISPLACEMENT

DIAGNOSTIC CRITERIA FOR RA:

Morning stiffness Arthritis of 3 or more joints Arthritis of hand joints Symmetric arthritis Rheumatoid nodules Serum rheumatoid factor Radiographic changes

A person shall be said to have rheumatoid arthritis if he or she has satisfied 4 of 7 criteria, with criteria 1-4 present for at least 6 weeks

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Involvement of 1 large joint gives 0 points Involvement of 2-10 large joints gives 1 point Involvement of 1-3 small joints (with or without involvement of large joints) gives 2 points Involvement of4-10 small joints (with or without involvement of large joints) gives 3 points Involvement of more than 10 joints (with involvement of at least 1 small joint) gives 5 points

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serological parameters including the rheumatoid factor as well as ACPA "ACPA" stands for "anticitrullinated protein antibody": Negative RF and negative ACPA gives 0 points Low-positive RF or low-positive ACPA gives 2 points High-positive RF or high-positive ACPA gives 3 points

Blood Tests Various blood tests may be used to help diagnose RA, determine its severity, and detect complications of the disease. Rheumatoid Factor. Erythrocyte Sedimentation Rate Test C-Reactive Protein: indicators of active inflammation Anti-CCP Antibody Test Tests for Anemia.

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Possible RA Markers in Synovial Fluid Imaging Techniques: X-Rays Dexa Scans: dual energy x-ray absorptiometry. Useful in detecting early bone loss in rheumatoid arthritis. ). Evidence of damage on x-rays along with elevated rheumatoid factor is a significant predictor for progressive joint destruction. Ultrasound: inflammatory activity in the joint. Magnetic Resonance Imaging

Rheumatoid arthritis is a systemic disease, its inflammation can affect organs and areas of the body other than the joints. Inflammation of the glands of the eyes and mouth can cause dryness of these areas and is referred to as Sjogren's syndrome. Inflammation of the white parts of the eyes (the sclerae) is referred to as scleritis and can be very dangerous to the eye. Rheumatoid inflammation of the lung lining (pleuritis) causes chest pain with deep breathing, shortness of breath, or coughing. The lung tissue itself can also become inflamed, scarred, and sometimes nodules of inflammation (rheumatoid nodules) develop within the lungs.

Inflammation of the tissue (pericardium) surrounding the heart, called pericarditis. The rheumatoid disease can reduce the number of red blood cells (anemia) and white blood cells. Decreased white cells can be associated with anenlarged spleen (referred to as Felty's syndrome) and can increase the risk of infections. long-standing rheumatoid disease, is blood vessel inflammation (vasculitis). Vasculitis can impair blood supply to tissues and lead to tissue death (necrosis).

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GOUT Osteoarthritis Systemic lupus erythematosus (SLE) psoriatic arthritis Lyme disease Reactive arthritis Ankylosing spondylitis Acute rheumatic fever Gonococcal arthritis

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Physical assessment should include these components: Functional assessment (ie, transfer status, analysis of gait, activities of daily living); Range of joint motion (ROM) (for all joints); Muscle strength test (manual or by isokinetic equipment); Postural assessment; and Evaluation of respiratory function

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GOALS FOR MEDICAL MANAGEMENT: Reduce joint inflammation Relieve or reduce pain. delay significant joint damage Improve quality of life. PLAN: Medicines called disease-modifying antirheumatic drugs (DMARDs) that can slow or sometimes prevent joint destruction are now recommended early in the course of the disease.

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Commonly used DMARDs: Methotrexate such as Rheumatrex Sulfasalazine such as Azulfidine Medications to relieve symptoms, such as pain, stiffness, and swelling, may also be used include: Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, Corticosteroids such as prednisone or Medrol. Analgesics (pain relievers).

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GOALS: Initially (Acute stage) we have to concentrate on: joint pain Decrease inflammation Increase range of movement The maintaining of muscle strength.

     

COLD THERAPY HEAT THERAPY TENS ULTRASOUND HYDROTHERAPY Applications are recommended for 1020 minutes once or twice a day.

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REST AND SPLINTING COMPRESSION GLOVES MASSAGE THERAPY THERAPEUTIC EXERCISES PATIENT EDUCATION

The surgical treatments for RA of the hand and wrist include Synovectomy: emove partial or all the synovial membrane of a joint. Tenosynovectomy:excision or resection of a tendon sheath. tendon realignment reconstructive surgery or arthroplasty, and arthrodesis:dysfunctional joint surface is replaced with something better or by remodeling or realigning the joint by osteotomy

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COLD THERAPY eases painful RA flare-ups Cold therapy slows circulation, which reduces swelling. place a cold compress on the target area an ice massage use a spray known as fluoromethane to cool inflamed tissues Treatment time :15 to 20 mintes

HEAT THERAPY: Relaxes your tired joints and muscles and speeding up blood flow to the painful area. Extra blood delivers extra oxygen and nutrients. Effectively reduce your chronic pain Thermotherapy may be applied as a superficial hot-pack, infrared radiation, paraffin, hydrotherapy. IRR: acute stage: non luminous generators are more effective (WL: 15000nm to 750 nm) Treatment time: 5 to 10 minutes

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Mircowave diathermy: more deeper than IRR, depth of penetration is 3 cm. Freqency 433.93 MHz and Wavelength : 69 cm. Treatment time : 15 to 20 minutes Paraffin wax: temperature= 40 to 44 degree c Treatment time: 20 minutes As it most suitable methoed for applying heat over extremities.

TENS (transcutaneous electrical nerve stimulation): Trigger the release of endorphins, which are your body's natural pain killers. The highest frequency TENS was the most beneficial, with an analgesia Daily application of 15 minutes of TENS for 3 weeks TENS is generally a short-acting therapy (624 hours), and the most beneficial frequency is 70 Hz. Interferential current can also be used for analgesia. Studies have shown its efficacy on pain relief, swelling, and improvement in ROM.

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Hydrotherapy: its objectives are to: Increase ROM To strengthen muscles To relieve painful muscle spasms To improve the patient's well-being It has sedating effect by increasing acetylcholine release from the central nervous system through activation of parasympathetic nervous system.

Ultrasound: uses sound waves to create a gentle heat that increases blood circulation to your deep tissues. Ultrasound helps reduce inflammation, stiffness, and pain. improves your range of motion, which will likely be limited due to your rheumatoid arthritis pain. DOSAGE: In Acute conditions: 0.8 watt\cm For 4 to 5 minutes In chronic conditions:initially low dose of 0.8 watt\cm to check that there is no adverse affect. A dose of 2 watt\cm for 8 minutes is considered to be maximum permitted.
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REST AND SPLINTS:  The joints should be put into rest during the acute stage of the disease.  Bed rest relieves the pain in cases of extensive joint involvement.  Flexible wrist orthosis increases hand grip strength by 20% to 25%.  Philadelphia corset may be recommended if atlantoaxial involvement is present.
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Orthosis and splinting are used for the following objectives:  To diminish pain and inflammation,  To prevent development of deformities  To prevent joint stress  To support joints, and  To decrease joint stiffness.
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Reduced joint swelling and increased well-being.

Inactivity decreases joint motion and flexibility. Inactivity also can lead to weak muscles and deformed joints. Regular exercise helps reverse joint stiffness, builds muscle, and boosts overall fitness.

These exercises build endurance and strong bones and also strengthen leg muscles. Start by exercising a few minutes each day, adding more time as you can. Aim to exercise at a moderate pace,

include resistance exercises two to three times a week to improve muscle strength and mobility and decrease joint pain. Use elastic bands, free weights, or machines for resistance or manual resistance

The isometric chest press can be done anywhere and needs no equipment.

Swimming is a great way to increase conditioning for all your joints, as well as strengthen your back, without putting excess stress on your joints.

Finger extensions help keep your hand and fingers flexible.

Stretching improves range of motion and decreases pain.

Get more rest when your RA is active and more exercise when it is not active.

There must be organized multidisciplinary education with the participation of rheumatologists, orthopedicians, physiotherapists, psychologists, and social workers for patients with arthritis. Patients are taught how to perform the scheduled exercises How to protect the joints during routine daily life.

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The course of the disease varies greatly. Around 20%30% will have subcutaneous nodules (known as rheumatoid nodules); this is associated with a poor prognosis. With early, aggressive treatment, the outlook for those affected by rheumatoid arthritis can be very good. Patients have a less favorable outlook when they have deformity, ongoing uncontrolled joint inflammation, and rheumatoid disease affecting other organs of the body. Overall, rheumatoid arthritis tends to be potentially more damaging when rheumatoid factor is demonstrating in blood testing.