Introduction
Rheumatoid arthritis (RA) is a systemic disease which results in chronic inflammation and destruction of synovial joints. It is an autoimmune disease that involves systems/organs other than the bones and joints alone.
Etiology
The etiology is unclear; however, various factors like climate, race, diet, psychosomatic disorders, trauma, endocrine dysfunction, biochemical disorders, hereditary influences, disturbances in the autoimmunity and infection have been found to initiate the rheumatoid process. Environmental conditions precipitate the disease in genetically predisposed individuals. It is possible that genetic factors predispose certain individuals to tissue damage by infection; even viral infections may predispose RA.
Clinical Features
Criteria for the Diagnosis of Rheumatoid Arthritis (American Rheumatism Association):
- Morning stiffness (>6 weeks).
- Pain on motion or tenderness in at least one joint (>6 weeks) Swelling of one joint either due to soft tissues or effusion.
- Swelling of at least one other joint with an interval free of symptoms no longer than 3 months.
- Symmetrical joint swelling (same joint).
- Typical radiographic changes that must include demineralization in periarticular bone as an index of inflammation with subcutaneous nodules.
- Positive test for rheumatoid factor (Rh factor) in serum.
- Synovial fluid showing poor mucin clot formation when added to dilute acetic acid.
- Histopathology of synovium consistent with rheumatoid arthritis.
- Characteristic histopathology of rheumatoid nodules.
Investigation
- Examination of the synovial fluid: The clarity, colour and viscosity of the synovial fluid can assist in the diagnosis as well as differential diagnosis from other traumatic and degenerative conditions. Predominance of polymorphonuclear leukocytes in the synovial fluid is peculiar to RA.
- Abnormalities occur in the serum proteins: The erythrocyte sedimentation rate (ESR) is raised. There is an increase in the serum fibrinogen with reduction in albumin and marked increase in the immunoglobulins.
- Rheumatoid factor and anti-CCP (anti-cyclic citrullinated peptide) tests are positive.
- The CRP (C-reactive protein) is also elevated.
Physiotherapy Management
During the acute or active phase of the disease, the acute symptoms – pain, erythema, tenderness and swelling – are present.
- Properly supported positioning of the involved joints and correct bed posture are important. The use of firm mattress or occasional back support minimizes the effects of malpositioning and thereby preserves the integrity of the affected joints. The limb is placed in a position of minimal discomfort; however, contracture should be avoided. 2. Splints and sandbags may provide additional support to the limb. Special attention is needed for the knee and elbow joints as they are prone to develop flexion contractures. The use of casts should be kept to the minimum. Splints or casts should be checked regularly to avoid complications due to them.
- Deep breathing exercises are important to improve the VC.
- Joints and muscles free from immobilization and the active disease need to be put through the full ROM and PRE.
- Functional mobility should be encouraged and maintained within the pain-free limits.
- Postural guidance and methods of performing activities without putting extra strain on the affected joints are taught.
- In cases where weight-bearing joints are involved, the upper extremities should be prepared for future crutch walking.
- Isometrics: Isometric exercises do not involve movements of the joints and are therefore relatively painless. They should be started early. Muscles like quadriceps and deltoids are susceptible to disuse atrophy and hence need repeated sessions of isometrics. Other functional muscles concerned with weight bearing and body balance need strengthening and improved endurance and thus require repetitive isometrics.
- Speedy isometrics to the affected limb in elevation reduce swelling and effusion (especially of the knee). No heat therapy should be given to the joints that are already warm.
- TENS, pulsed ultrasound, ice massage or ice packs for longer periods offer reduction in the muscle spasm and pain. Interferential current of 90–100 Hz reduces the accommodation of nerves, whereas a frequency of 50–100 Hz improves healing, blood supply and membrane permeability by improving absorption.
- Properly guided pool therapy for the whole body provides an ideal medium for exercises.
- Chronic phase It is a phase of vigorous activity to train the patient to use the involved joints to the greatest extent for physical independence. By 4–5 weeks of the onset, independent sitting by the use of hands can be started.
- If pain permits, active and functional therapeutic programmes should be initiated. This will include standing and walking. However, weight bearing should be deferred till pain and discomfort subside. Before allowing weight bearing, it is absolutely essential to provide the necessary orthotic support or walking aid to relieve compressive forces on the affected joints.
- This should be done between the parallel bars to judge the effects of weight bearing on the diseased joints. Sustained or intermittent stretching procedures may be necessary for the joints that have developed tightness or contractures during the acute phase. Deep heat (if acceptable), ultrasonic’s, TENS and other adjuncts may be used to relieve pain.
- Efforts should be made to improve the strength and endurance of the muscles related to the affected joints. Education and assistance are provided in adopting functional positions, speed and proper gait. Job-oriented performance should be imparted in the exercise regime.
Conclusion
Rheumatoid Arthritis is a complex condition requiring a multidisciplinary approach. While there is no cure, effective management strategies, particularly those involving timely physiotherapy, slow disease progression can significantly reduce symptoms and enable individuals to lead fulfilling lives.