Rheumatoid Arthritis is the most common form of inflammatory arthritis which was described in detail for the first time at the end of the 18th century. This systemic disease affects all ethnic groups with the peak incidence in the fifth and sixth decades of life. It is characterized by proliferating and destructive changes in the synovial membrane, periarticular structures, skeletal muscles and perineural sheaths of the host. Eventually, the affected joints become fibrosed or ankylosed because of destructive changes in the joint structure [1].
Epidemiology
The prevalence of the RA is approximately 1% in the general population in the United States. Prevalence is similar worldwide. It affects all ethnic groups with the peak incidence in women between the ages of 30 and 50. Disorder occurs three times more frequently in women than in men). Considering the significance and impact of RA is vitally important, because it is a progressive destructive disease which leads to bone deformity, joint destruction and permanent disability of the affected joints [2, 3].
Pathophysiology
Even though the exact cause is still unknown, researchers have found the disease is caused by auto-antibodies which affect synovial tissue. Most of the cases (70% to 90%) are caused by the Rheumatoid Factor (an autoantibody) coupling with IgG, itself an antibody. Most of the remainder is caused by the rheumatoid factors attaching to IgM, IgA or IgE. This immune complexes, which is a measure of these rheumatoid factors, are engulfed by WBCs and elaborate destructive lysozymes within the lysosomes.
Procollagenase, an enzyme released by neutrophils, is converted into active collagenase by the synovial fluid. Collagenase then splits the collagen of the articular surface cartilage and leads to primary synovitis. This primary synovitis gives rise to a pannus which in turn forms villi. These villi migrate toward the joint causing its destruction and ankylosis [1, 4]. In addition, some researchers say the disease is influenced by genetic, environmental, infectious factors, and autoimmunity [3].
Diagnosis
The correct diagnosis is the key to the planning of treatment at any stage of a disease. Diagnosis of RA is suspected mainly by observing, morning joint stiffness, redness and swelling of the joints of more than 6 weeks duration affecting the small joints of the hands and feet symmetrically, synovial swelling and hypertrophy with an infiltrate of various inflammatory cells including lymphocytes and macrophages. Presence of serum rheumatoid factor, radiological features of RA and periarticular osteoporosis are the characteristic features of the disease, apart from other features such as fever, fatigue, weight loss, vasculitis and rheumatoid nodules. keratoconjunctivitis, dry eyes, and dry mouth, are extra articular and systemic features of RA. Confirmation of the diagnosis is done by blood tests, joint aspiration and radiologic imaging [1, 2].
Orthopedic deformities of Rheumatoid Arthritis
Rheumatoid Arthritis can affect any joint in the body. But it involves the peripheral joints more often and very rarely affects the larger joints.
Deformities in the hand
Symmetrical peripheral swelling of phalangeal and interphalangeal joints.
Ulnar deviation of the hand is due to rupture of the collateral ligaments at the metacarpophalangeal joints. This leads to slipping of the extensor tendons from their grooves towards the ulnar side.
Boutonniere’s (button hole) deformity is due to the rupture of central expansion of the fingers resulting in flexion at the proximal interphalangeal joints.
Swan neck deformity is due to the rupture or stretching of the volar plate of the proximal interphalangeal joints which enables the tendons to slip towards the dorsal side. Here there is hyperextension of the PIP joint and flexion of the distal interphalangeal joints.
Trigger fingers and the trigger thumb are the nodules over the tendons.
Deformities in the foot
RA affects the whole foot which consists of forefoot mid foot and hind foot. If it is in the fore foot patients may develop, hallux valgus deformity of the great toe, claw toes, callosity over the dorsum of the foot and the sole, widening of the fore foot and the heel may show valgus deformity.
Deformities of the other joints
In the knee, patient may develop fibrous ankylosis or bony ankylosis due to widespread destruction of the articular cartilage by the pannus tissue. And also causes the followings such as flexion and valgus deformity of the knee.
Management
Pharmacological management
Under pharmacological management, Analgesics NSAIDs and DMARDs are the main drug categories that are prescribing for the purpose of reduce the progression of the disease and the symptoms such as inflammation, swelling and pain. Usually Azathioprine, Cyclophospamide, Ciclosporin, Hydroxychloroquine, Leflunomide, Methotrexate, Penicillamine, Sulfasalazine are the major drugs which use for the management of RA [3, 4].
Physiotherapeutic and rehabilitative management in Rheumatoid Arthritis
The main purpose of physical therapy management for RA is to achieve pain relief and prevent joint damage and the functional loss. Physiotherapeutic and rehabilitative applications have significantly augmented medical therapy by reducing the handicaps in daily living for patients with RA.
The basic PT plan of care for the patients who have RA include educate the patient, relieve pain and muscle guarding, promote relaxation, minimize joint stiffness, maintain available motion, minimize muscle atrophy, and prevent deformity by protecting joint structures.
Inform the patient on importance of rest, joint protection, energy conservation, and performance of range of motion (ROM) are the initiative steps of the patient education. Also teach home exercise program and activity modification that conserve energy and minimize stress to vulnerable joints will reduce the progression of the disease.
Application of physiotherapy modalities and interventions include cold / heat applications, electrical stimulations, gentle massage, immobilize in splint, relaxation technique and hydrotherapy are the treatment techniques which use to relieve pain, muscle guarding and to promote relaxation. Even though there are several physiotherapy agents that commonly used in daily practice, most often their use is based on the personal experiences of the physiotherapist [5].
Cold is one of the most commonly used physical agents which is using in various types of arthritic conditions especially during the acute stage. Applications of cold packs, Ice, cold air are some of the different methods of applying cold therapy.
According to the pathology of RA, the enzymes (cartilage - destroying enzymes) such as collagenase, elastaase, hyaluronidase and protease which are causing destruction of the joint structure are affecting by the temperature of local joints. The normal intra-articular temperature is 33 0C, but it may be rise up to 36 0C in patient with RA. With temperature of 30 0C or lower, effects of these enzymes are negligibly small.
Cold is affecting on the circulation of the local joints and causes vasoconstriction which reduces the blood supply to the joint. Reduced pressure inside the blood vessels results low fluid exudation which reduces swelling and pain.
Application of hot packs is effective for the chronic arthritic pain. Vasodilatation occurs with the heat and delivers extra blood in to the damaged tissues. Increased oxygen and nutrients supply to the damaged tissues facilitate tissue repairing. Heat therapy can be applied as hot packs, dry hot towels, and as well as moist heat (steam).
Transcutaneous Electrical Nerve Stimulation (TENS), form of electrical stimulation which uses to reduce the pain perception. According to the pain gate theory, the electrical impulses travel through the sensory A-delta fibers which has connections with substantia gelatinosa, elicit a negative response at T cells. Perception of pain diminishes due to closing of the pain gate by negative response of the T cells. Application of electrodes over where the pain is most intense is beneficial to reduce the pain perception.
Passive or active assistive ROM within absolute limits of pain and gradual progression as tolerated are required to minimize joint stiffness and maintain available motion. Gentle grade I and II joint distraction and oscillation techniques are used to inhibit pain and minimize fluid stasis. In fact these techniques reduce the swelling significantly.
Maintain normal muscular strength and prevent muscle atrophy are essential to become independent in Activities of Daily Living (ADL’s). Gentle isometric exercises in pain free positions and progression as tolerated minimize muscle atrophy caused due to inadequate muscle work. In the meantime, use of supportive and assistive equipment for all pathologically active joints, good bed positioning while resting, and avoidance of activities that stress the joints must be practiced to prevent progressive joint deformity.
The ultimate goal of physiotherapy plan of care for the patients with RA is to make them independent in their ADLs. However, there are some contraindications and precautions that physiotherapist should consider before administer any PT intervention to patients. Joint distraction, oscillation technique, stretching and passive ROM should be done with the extreme care of pain and tissue damage. Also application of heavy resistance over affected joints and vigorous stretching are contraindicated especially when joints are swollen.
The idea of the text was to give an overall description about RA and its management strategies related to physiotherapy. However, planning treatment sessions and determine necessary interventions are the duties of the therapist and also it depends on patients disease status. It is far beyond the scope of this text.
