RHEUMATOID ARTHRITIS

(RA)
 INTRODUCTION & EITOLOGY
 Rheumatoid Arthritis : Chronic, non-suppurative,
systemic, inflammatory disorder, of unknown cause.
 Characterized by symmetrical polyarthritis.
 Affects peripheral joints and extra-articular
structures.
 Commonly seen in the age group of 20-60 years.
 Ratio females: males = 3:1
 Affects approximately 1% of the adult population.
 Component found in blood : HLA- DR4/ HLA-drw4.
 THEORIES FOR RA
1. INITIATING FACTOR THEORY
2. INFECTION THEORY
3. GENETIC PREDISPOSITION
 ARTICULAR
PATHOGENESIS OF RA
CHANGES
NON-
ARTICULAR

Stage 1: Potentially reversible soft tissue proliferations

Stage 2: Controllable, but irreversible soft tissue
destruction + early cartilage erosion
Stage 3: Irreversible soft tissue and bony changes
ARTICULAR CHANGES
 Inflammation of the synovium with fluid containing granulation
tissue + increased synovial fluid
↓
Proliferation of synovium
↓
Formation of villi
↓
Synovium thickening along joint margins → pannus
↓
Erosion of joint cartilage at margins (1st at NWB areas of joint)
↓
Spreads to remaining cartilage and reaches surface of bone
↓
Erosion of subchondral bone
↓
Joint subluxation and deformities
↓
Synovial fluid consolidation → Fibrous ankylosis → Bony ankylosis
 NON-ARTICULAR CHANGES
 Nodule formation - seen in areas of pressure,
lie subcutaneously (commonest site-
olecranon , in lungs- honeycomb appearance)
 Vascular changes - Vasculitis (digital arteritis
→ necrotizing arteritis of major vessels)
 Skin - lesions, rashes, chronic leg ulcers,
gangrene
 Eyes- Scleritis, Conjunctivitis, Keratopathy
 Lungs - Pleurisy, diffuse pulmonary fibrosis
 Heart - Pericarditis, valvular lesions → aortic
regurgitation
 Nervous system - Peripheral neuritis → CTS
 RE system - Splenomegaly, increased liability to
infections.
 Serological - Dysproteinemia
 Systemic - Fever, Malaise, Loss of weight, Weakness
 Others- Anaemia (ACD), Amyloidosis
DIAGNOSTIC CRITERIA (7 SIGNS OF RA)
FUNCTIONAL GRADING OF RA
 CLINICAL FEATURES
 Hallmark symptoms : symmetrical joint swelling and
tenderness, morning stiffness
 Fever, weight loss, depression
 Deformities of extremities → weakness and restricted ROM →
loss of function (advanced)
 Other presentations:
1. Palindromic
2. Polymyalgic
3. Explosive
4. Monoarthritic
5. Systemic
 INVESTIGATIONS
 Radiological investigations : For disease staging
Stage 1: No destructive changes on x-rays
Stage 2 : Peri-articular osteoporosis + subchondral
bone destruction
Stage 3: Stage 2 features + joint deformity
Stage 4: Stage 3 features + fibrous/bony ankylosis
Features - Reduced joint space, erosion of articular
margins, subchondral cysts, juxta- articular rarefaction,
soft tissue shadow, joint deformities
 Blood analysis : Elevated ESR levels, low Hb value
 RF (may / may not be +ve)- detected by following
tests:
1. LATEX FIXATION TEST
2. ROSE - WAALER TEST
 Examination of synovium (biopsy) and synovial
fluid (joint aspiration)
 DIFFERENTIAL DIAGNOSIS
 Osteoarthritis
 Psoriatic Arthritis
 Septic Arthritis
 SLE
 Still’s Disease
 Neoplasia
ORTHOPAEDIC DEFORMITIES IN RA
 Head- Atlanto-axial subluxation
 Shoulder complex- Pain, Reduced ROM, Joint instability,
Long term- bursitis, tendinitis
 Elbow- Flexion contracture, Reduced ROM, Joint instability
 Wrist- Flexion contracture, Ulnar drift, Long term- volar
subluxation
 Hand- Z-deformity, Swan neck deformity, Boutonnaire’s
deformity, Mallet finger (Rheumatoid Hand)
 Knee- Flexion contracture, monoarthritis
 Ankle and foot- Hindfoot pronation, Hallux valgus,
Hammer toe, Splay foot, Metatarsalgia (Rheumatoid Foot)
 Medical
MANAGEMENT
Methods Non-operative
 Principles : 1) Induction of remission & its maintainence

Orthopedic 2) Preservation of joint function

3) Prevention of deformities
4) Repair of already existing joint damage

Physiotherapy

Occupational
Therapy

Operative
 GENERAL GUIDELINES
 Rest in bed.
 Good diet, rich in proteins and minerals.

 Transfusion and hematinics to correct the anemia.

 Removal of infective foci.

 Splinting in the functional position

1) Rest splint 2) Functional splint 3) Corrective splint

 MEDICAL MANAGEMENT
 Non-steroidal anti-inflammatory drugs (NSAID’s)
 Disease modifying anti-rheumatic drugs (DMARD’s)
 Biologic response modifiers
 Steroids
 SURGICAL MANAGEMENT
 Pre-operative considerations :
1) Related conditions such as diabetes, hypertension and
anemia should be adequately treated
2) Steroid dosage should be reduced
3) There should be no active infection
4) A radiograph of the cervical spine should be obtained to
exclude instability
PHYSIOTHERAPY MANAGEMENT
Chronic Phase / Inactive Period:

 To improve function, exercise should be aimed at improving flexibility,

muscle performance, and cardiopulmonary endurance
 Nonimpact or low-impact conditioning exercises such as swimming and

bicycling, performed within the tolerance of the individual with RA

 Improve aerobic capacity and physical activity and decrease depression

& anxiety.
 Group activities such as water aerobics also provide social support.

PRECAUTIONS: The joint capsule, ligaments, and tendons may be

structurally weakened by the rheumatic process (also as a result of using
steroids) - dosage of stretching and joint mobilization techniques used to
counter any contractures or adhesions must be carefully graded.
CONTRAINDICATIONS: Vigorous stretching or manipulative techniques.
PRECAUTIONS FOR JOINT PROTECTION
 Monitor activities and stop when discomfort or fatigue begins to develop.
 Use frequent but short episodes of exercise (three to five sessions per day) rather
than one long session.
 Alternate activities to avoid fatigue.
 Decrease level of activities or omit provoking activities if joint pain develops and
persists for more than 1 hour after activity.
 Maintain a functional level of joint ROM and muscular strength and endurance.
 Balance work and rest to avoid muscular and total body fatigue.
 Increase rest during flares of the disease.
 Avoid deforming positions.
 Avoid prolonged static positioning; change positions during the day every 20 to 30
minutes.
 Use stronger and larger muscles and joints during activities whenever possible.
 Use appropriate adaptive equipment e.g splints, braces
THANK
YOU