Rheumatoid arthritis and physiotherapy

2.  Rheumatoid arthritis is a chronic progressive
polyarthritis affecting the connecting tissues.
 Incidence:usually 3rd and 4th decades
 Females more affected
 20 to 40 years
 3:1 Ratio

3. 1.Early Morning Stiffness
2.Arthritis of 3 or more joint area Three or more soft tissue swelling
Possible area:MCP,RT OR LEFT
PIP,ELBOW,ANKLE AND MTP JOINTS
3.Arthritis of hand joints
4.Symmetric arthritis Simultaneous involvement of same
joints
5.Rhemuatoid nodules Subcutaneous nodules, over bony
prominences
6.Serum rheumatoid factor Serum rheumatoid factor positive in
less than normal control subjects 50%
normal control subjects
7.Radiorgraphic changes In mostly they can find in post ant hand
and wrist radiograph
Criteria:

4.  Rheumatoid Arthritis Criteria (1987 revision, American Rheumatism
Association)

 Morning stiffness
 Morning stiffness in and around the joints, lasting at least 1 hour before
maximal improvement. Symptoms present for a minimum of 6 weeks. (1
point)
 Arthritis of 3 or more joint areas
 At least 3 joint areas simultaneously have had soft tissue swelling or
fluid (not bony overgrowth alone) observed by aphysician; the 14
possible joint areas are right or left proximal interphalangeal (PIP) joints,
metacarpophalangeal (MCP)joints, wrist, elbow, knee, ankle, and
metatarsophalangeal (MPT) joints. Findings present for a minimum of 6
weeks. (1 point)
 Arthritis of hand joints
 At least one area swollen (as defined above) in a wrist, MCP or PIP joint.
Findings present for a minimum of 6 weeks. (1 point)

5.  Symmetric arthritis
 Simultaneous involvement of the same joint areas (see 2 above) on both
sides of the body (bilateral involvement of PIPs, MCPs, or MTPs is
acceptable without absolute symmetry). Findings present for a minimum
of 6 weeks. (1 point)
 Rheumatoid nodules
 Subcutaneous nodules, over bony prominences, or extensor surfaces, or
in juxta-articular regions, observed by a physician. (1 point)
 Serum rheumatoid factor
 Demonstration of abnormal amounts of serum rheumatoid factor by any
method for which the result has been positive in <5% of normal control
subjects. (1 point)
 Radiographic changes
 Radiographic changes typical of RA on posteroanterior hand and wrist
radiographs, which must include erosions or unequivocal bony
decalcification localized to or most marked adjacent to the involved
joints (osteoarthritis changes alone do not qualify). (1 point)


6.  As per American
 10 per 1000 people
 Affects womens more than male
 Year of onset 20-60

7.  Aberrant(diverging from normal type)
functioning of cell- mediated immunity and
defective T lymphocytes may trigger the
autoimmune response.
 -EBV also to initiate the ability and alter the
regulation of the immune system
 -Streptococcus ,clostridia,diptheroid and
mycoplasma
 -HLA-A,HLA-B,HLA-C
 -HLA-DRW 3 &4 60%

8.  Sign and symptoms:
 Pain
 Swelling
 Stiffness
 H/0 of wt loss
 Lethargy and depression
 Systemic manifestation:
 Morning stiffness more than a minute.

9.  Bilateral and symmetrical pattern of joint
involvement
 Crepitus present
 Cervical spine:
 Atlanto axial joint and mid cervical region
most common sites.
 Temporo mandibular joint:
 Inability to open the mouth fully

10.  Shoulder:
 Sterno-clavicular
 Acromio clavicular joint

 Elbow:
 Inflammation
 Capsular and ligamentous distension
 Joint surface erosion may lead to elbow instability
 Irregular and catchy movement
 Flexion contracture

11.  Wrist:
 Early synovitis
 Volar subluxation
 Stenosing tenosynovitis(De-querains disease)
 Ulnar drift

12.  Hand joints:
 MCP-soft tissue swelling
 Ulnar drift
 Zig Zag effect: radial deviation of carpal
bones will enhance MCP ulnar drift then the
phalanges will compensate for the loss of
normal ulnar deviation at the wrist

13.  Swan neck deformity:
 PIP hyper extension and DIP flexion
 Causes: chronic synovites of MCP lead to
reflex muscle spasm of intrinsics.
 ↓
 Tension of FDP by PIP by then PIP flexes the
DIP, leads
 = rupture of flexor digitorium sublimus

14.  ↓
 Rapture of extensor digitorium
communis,resulting in DIP flexion and PIP
hyper extension.
 PIP:
 Boutonniere deformity:
 DIP extension with PIP flexion
 ↓

15.  Distal inter Phalanges
 Osteophytes found in DIP is called Heberdens
node.

 Mallet finger/trigger finger:
 DIP Flexion
 Rapture of extensor digitorium communis
will rapture
 ↓
 Pull flexor dig profundus lead to mallet finger

16.  Synovial swelling
 According to classification of Nalehuff
 Type I deformity:
 MCP flexion with IP hyper extension
 Type II:
 CMC is subluxed and IP hyper extension –more
common in RA
Type III:
 CMC is subluxed and MCP is Hyper extension

17.  Mutilans deformity: (opera-glass hand)
 Grossly unstable thumb and severely
deformed phalanges
 Transverse folds of skin of the thumb and
fingers resemble a folded telescope
 Leads to shortening of MCP,PIP,Radiocarpal
and Radioulnar joint

18.  Pain
 Trochontric bursitis
 Protrusion acetabuli : severe inflammatory
destruction of femoral head and acetabulam-
leads to push the acetabulam into pelvic
cavity called protrusio acetabuli.

19.  Knee:
 Flexion contracture
 Valgas deformity
 Wind swept deformity
 Bakers cyst
 Instability of the knee
 Secondary OA

20.  Splay foot:
 Synovities weakened the tranverse arch Leads
to metatarsal spread may develop splay foot
 Hallus valgus:
 Bunion: painful bursitis over the medial
aspect of first MTP joint.
 Metatarsalgia:Pain over the MT heads

21.  Hammer toes:
 PIP&MTP flexion
 Cock up or Claw toes:
 Volar sublux of metatarsal head &flexion of
PIP and DIP joints
 Bowstring Appearance:
 Long toe extensors bowstring over the PIP
joints

22.  Muscles involved in RA:
 Atrophy of muscle around the joint

 Tendons:
 Inflammation of tendon lead to tenosynovitis
 Lag phenomenon:
 Which refers to a substantial difference in
passive versus active ROM

23.  ESR
 CRP both elevation found
 RA factor
 Blood count: RBC ↓
 WBC normal
 Synovial analysis

24.  Rheumatoid factor (RF) is the autoantibody
(antibody directed against an organism's own
tissues) that was first found
in rheumatoid arthritis. It is defined as an
antibody against the Fc portion of IgG (an
antibody against an antibody). RF and IgG
join to form immune complexes that
contribute to the disease process.

25.  Psoratic arthritis
 Erosive OA
 Ankylosing spondylitis
 Reiters syndrome
 Chronic tophaceous gout
 Hypoparathyroidism
 Infection
 Polymyalgia

26.  Reconditioning
 :
 Loss of weight
 Rheumatoid nodules:
 25% OF Patients
 Found in subcutaneous and deeper tissues.

27.  Malnutrition
 Infection
 Congestive cardiac failure
 Gastro intestinal bleeding
 Foot drop or wrist drop
 Wide spread vasculitis
 CONT-

28.  Chronic anemia
 Iron deficiency
 Vitamin B12 and folate deficiency
 Leucocytopaenia
 Thrombocytosis
 Osteoporosis

29.  Peripheral neuropathies
 Mostly nerve compression or entrapment
 Ex:carpal tunnel or tarsal tunnel syndrome
 Subluxation of C1 and C2,muscle wasting.

30.  Peri carditis -4% of patients
 Pleuritis
 Arrhythmias
 Heart block
 Spleno megaly
 Fetty syndrome:
 RA + SPLENOMEGALY+NEURTROPAENIA
 Lymphadenopathy

31.  Sjogrens disease:
 Its inflammatory disorder of lachrymal and
salivary glands
 Scleritis
 Caplans syndrome:
 RA+PNEUMOCONIOUS OF UPPER LOBE

32.  Generalized joint pain, stiffness
 Swelling in upper extremities
 Polymyalgia rheumatic:
 Distinct disease affecting the shoulder and
pelvic girdle)

33. Polymyalgia rheumatica (which takes its name
from the word Πολυμυαλγία "polymyalgia" which
means "pain in many muscles" in medical-
scientific Greek) abbreviated as PMR, is a
syndrome with pain or stiffness, usually in the
neck, shoulders, upper arms and hips, but which
may occur all over the body. The pain can be very
sudden, or can occur gradually over a period. It
may be caused by an inflammatory condition of
blood vessels such as temporal arteritis

34.  1.NSAID:ASPRIN,CLINORIL,MECLOMEN,ANSAR
D,NALFON
 2.DMARD (DISEASE MODIFYING ANTI
RHEUMATIC DRUGS)
 RHEUMATREX
 RIDURA
 IMURAN
 CYTOXAN
 MINOCIN

35.  3.CORTICOSTERIOD:
 PREDISONE
 PREDISOLONE
 CORTISONE
 DEXA METHISONE

36. 
 FOR SOFT TISSUE :
 Synovectomy
 Soft tissue release
 Tendon transfers

37.  Bones:
 Osteotomy
 Arthroplasty
 Arthrodesis
 Total jt replacement
 Arthoplasties for
hip,knee,ankle,shoulder,elbow,wrist

38.  Problem list:
 Patient history
 Pain
 Objective assessment
 Include:
 Cardio pulmonary
 Integumentary
 Neuromuscular systems

39.  Range of motion:
 Passive ROM
 Active ROM
 Functional ROM

 Strength:
 Break test:
 Isometric holding at the end of range or
resistance throughout the ROM.

40.  JOINT STABLITY:
 Check for joint laxity
 ENDURANCE:

 FUNCTIONAL ASSESSMENT:
 AIMS2 SCALE
 ARTHRITIS IMPACT MEASUREMENT SCALE
 IT CONTAIN: PSYCHOLOGICAL
 SOCIAL DOMAIN
 PATIENT SATISFICATION
 ASSESS FOR BED MOBLITY AND BED TRANSFER:

41.  GAIT EVALUATION:
 SENSORY INTERGRITY:
 FOR PHERIPHERAL NERUOPATHY OR NERVE
INVOLVEMEN

 SENSORY INTERGRITY
 For peripheral neuropathy or nerve
involvement

42.  Psychological status:
 Patient attitude and overall psychological
status
 Environmental Barriers
 Home and environment modification

43.  To decrease pain
 To increase or maintain the ROM of all joints
 To increase or maintain strength sufficient
 To increase jt stability
 To increase endurance of all functional
activities

44.  To promote independence all ADL&bed
mobility and transfer
 To improve gait pattern
 To improve cardio vascular and muscular
skeletal fitness
 To educate the patient, family and other
personnel to promote the individual capacity.

45.  Modalities:
 Moist heat pack
 Dry heating pack
 IRR lamps
 Paraffin- gives results in superficial heat
 Hydro therapy

46.  Deep heat may effect the viscoelastic
properties of collagen
 And increase the plastic stretch of ligaments
–used in acute inflammation.
 Cryotherapy: useful around the swollen
joint/contra-indicated for Reynaud's
phenomenon.
 Tens is useful but controversial
 Splints to immobilization specific joints and
help reduce pain

47.  Joint mobility:
 Teach proper position
 Self ROM
 In acute stage: Excessive repitative motion
aggravates inflammation and delay recovery-
slow minimal exercise
 Active movt is encouraged more.
 Treatment should be given during drug
period (Analgesic period)
 Splint and casts may be used to maintain
newly gained ROM following treatment.

52.  STRENGTHENING:
 Acute: isometric exercises -To improve
muscle tonestatic endurance
 Strength and
to prepare for activity
 For 6 sec/5 to 10 per day

53.  Splints used:
 Rest splints
 Corrective splints
 Fixatation splints

54.  Instruction during isometrics exercises:
 Maintain contraction more than 6 sec
 Avoid maximal effort
 Exhale during contraction inhale during
period of relaxation
 Not contract more than two muscle group

55.  Dynamic exercise :
 Eccentric exercises
 Concentric
 Resistance given through free wts,elastic
bands or resistive exercise equipment

56.  Should be performed within pain free range
 Initiate functional movement more
 Gradual progression of resistance and
repetition recommended
 Circuit training
 8-10 repetition against gravity
 8-10 exercises
 2-3 times /week an alternate days

57.  Joint stability:
 Splints –to used to relieve pain
 Ex:metatarsal pad or pad to relieve pain
 Orthotosis plays major role
 Rocker shoe is used to facilitate push off for
limited ankle motion

58.  Endurance training:
 Cardiovascular conditioning exercise
 Bicycle ergo meter or adequate programme

 Functional training:
 Upper extremity involvement
 Platform attachment can be used to
transform the forearm into a weight bearing
surface

59.  Home and work environment modification is
done
 Increase an individuals independence
 Modification in daily activities

60.  Gait training:
 With ambulatory aids
 Every aspect gait training should be taught
 Going to shopping
 To work
 To hospital

61.  Massage:
 Relaxation techniques

 Education:
 Hydrotherapy
 Proper health guidance should be given by
Physical therapist