What is Rheumatoid Arthritis?
What are the causes of Rheumatoid Arthritis?
What are the signs and symptoms of RA?
What are the Physiotherapy Treatment Modalities?
Rheumatoid arthritis (RA) is a chronic and painful clinical condition that leads to progressive joint damage, disability and shortened life expectancy. Even a mild inflammation may result in irreversible damage and permanent disability. The clinical course according to symptoms may be either intermittent or progressive in patients with RA. In most patients, the clinical course is progressive, and structural damage develops in the first 2 years.
Causes of Rheumatoid Arthritis
The exact cause of rheumatoid arthritis is unknown.
May be due to viruses, bacteria, and fungi with out any proven cause
May be due to genetic.
May be due to certain infections or factors in the environment might trigger the immune system to attack the body’s own tissues, resulting in inflammation in various organs of the body such as the lungs or eyes. Regardless of the exact trigger, the result is an immune system that is geared up to promote inflammation in the joints and occasionally other tissues of the body. Immune cells, called lymphocytes, are activated and chemical messengers (cytokines, such as tumor necrosis factor/TNF and interleukin-1/IL-1) are expressed in the inflamed areas.
Scientists have reported recently that cigarette smoking increases the risk of developing rheumatoid arthritis.
Signs and symptoms of RA
Ø In its active stage, symptoms can include fatigue, lack of appetite, low-grade fever, muscle and joint aches, and stiffness. Muscle and joint stiffness are usually most notable in the morning and after periods of inactivity commonly complained as Morning stiffness. Also during flares, joints frequently become red, swollen, painful, and tender. This occurs because the lining tissue of the joint (synovium) becomes inflamed, resulting in the production of excessive joint fluid (synovial fluid). The synovium also thickens with inflammation (synovitis).
Ø In rheumatoid arthritis, multiple joints are usually inflamed in a symmetrical pattern (both sides of the body affected). The small joints of both the hands and wrists are often involved. Simple tasks of daily living, such as opening and closing tap can become difficult during flares.
Ø The small joints of the feet are also commonly involved.
Ø Chronic inflammation can cause damage to body tissues, cartilage and bone. This leads to a loss of cartilage and erosion and weakness of the bones as well as the muscles, resulting in joint deformity, destruction, and loss of function.
Ø Rarely, 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. When this joint is inflamed, it can cause hoarseness of voice.
Ø Inflammation of the glands of the eyes and mouth can cause dryness of these areas and is referred to as siogren’s syndrome. Rheumatoid inflammation of the lung lining (pleuritis) causes chest pain with deep breathing or coughing. The lung tissue itself can also become inflamed, and sometimes nodules of inflammation (rheumatoid nodules) develop within the lungs.
Ø Inflammation of the tissue (pericardium) surrounding the heart, called pericarditis, can cause a chest pain that typically changes in intensity when lying down or leaning forward. The rheumatoid disease can reduce the number of red blood cells (anemia) and white blood cells.
Ø Decreased white cells can be associated with an enlarged spleen (referred to as Felty’s syndrome).
Ø If blood-vessel inflammation (vasculitis). Vasculitis can impair blood supply to tissues and lead to tissue death. This is most often initially visible as tiny black areas around the nail beds or as leg ulcers.
Ø Other common symptoms of rheumatoid arthritis in the hip include:
arthritis pain felt down the leg, at the knee or in the groin area, loss of motion and lower back pain
Ø Other prevalent symptoms of rheumatoid arthritis are swelling and pain in one or more joints, lasting six weeks or more fatigue and/or weakness, stiffness following periods of immobility which gradually improves with movement, general sickness, mild fevers, anemia and weight loss, fluid accumulation, especially around the ankles
Physiotherapy Treatment Modalities
Objectives of physiotherapy and rehabilitation applications in patients with RA are to prevent disability, to increase functional capacity, to provide pain relief, and to provide patient education
Before starting therapy, the physiotherapy needs of patients are determined in accordance with their incapacity, disability, and handicaps. Physical assessment should include these components:
Functional assessment includes transfer status, analysis of gait, activities of daily living
Range of joint motion including all joints
Muscle strength test (manual or by isokinetic equipment);
Postural assessment; and
Evaluation of respiratory function
Physiotherapy modalities are commonly used in the treatment of RA. These include cold/hot applications, electrical stimulation, and hydrotherapy.
Ø Cold/hot modalities are the most commonly used physical agents in arthritis treatment. Commonly cold application is mostly used in acute stages whereas hot is used in chronic stages of RA.
Ø Of periarticular structures obtained. Heat can be used before exercise for By using heat, analgesia is accomplished, muscle spasm relieved, and elasticity maximum benefit.
Ø Thermotherapy may be applied as a superficial hot-pack, infrared radiation, paraffin, fluidotherapy or hydrotherapy. Applications are recommended for 10–20 minutes once or twice a day.
Ø Caution is necessary in patients with sensorial deficits and impaired vascular circulation in hands and feet because of burn risk.
Ø Cold application is preferred in active joints where intra-articular heat increase is undesired. Cold-pack, ice, nitrogen spray, and cryotherapy are different methods of applying cold-therapy.
Ø Electrical stimulation is used in patients with RA to relieve pain. Transcutaneous electrical nerve stimulation (TENS) therapy is the most commonly used method. Highest frequency TENS was the most beneficial, with an analgesia that persisted up to 18 hours. Various studies have reported an
Ø Increase in hand grip strength after daily application of 15 minutes of TENS and a decrease in pain after using TENS once a week for 3 weeks.
Ø Postoperative pain control by TENS therapy following knee joint arthroplasty reduces need for analgesic drugs and hospital stays. TENS is generally a short-acting therapy (6–24 hours), and the most beneficial frequency is 70 Hz. It also has a high placebo effect. It cannot be used in every painful joint simultaneously, which is a disadvantage in patients with polyarticular involvement.
Ø Interferential current can also be used for analgesia. It is efficacy on pain relief, swelling, and improvement in ROM.Also, no difference was found between interferential current and TENS in the magnitude of analgesia.
Initially, the term “balneotherapy” was used to discriminate thermal and mineral water therapy from hydrotherapy, In recent years, balneotherapy has served as one of the therapeutic alternatives in other rheumatoid diseases, particularly in chronic degenerative diseases. Objectives of balneotherapy are to increase ROM, to strengthen muscles, to relieve painful muscle spasms, and to improve the patient’s well-being.
Balneotherapy leads to muscle, tendon, and ligament relaxation and a feeling of well-being. Here the action mechanism provides exponential benefits. Decreasing perception of pain by increasing the pain thresholds at free nerve endings, relieving muscle spasm by effecting gamma muscle fibers, peripheral vasodilatation, and removal of painful mediators are among these mechanisms. In addition, balneotherapy has a sedating effect by increasing acetylcholine release from the central nervous system through activation of parasympathetic nervous system. Endorphin release throughout the therapy also contributes to improved action mechanisms.
Physiotherapy treatment is important in helping patients with RA manage their disease. In conjunction with occupational therapists, physiotherapists educate patients in joint protection strategies, use of assistive devices, and performance of therapeutic exercises.
Rest and Splinting.
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. It is critical, at this stage, to put the joints into rest at a functional position.
Rest position should be as follows:
Shoulder joint in 45° abduction, both wrist joints in 20° to 30° dorsal flexion, fingers slightly in flexion, hips at 45° abduction without any flexion, knees totally extended, and feet in a neutral position.
Splints may be used to give desired position at rest and functional positioning to the involved active joints. Increased compliance can be gained by offering the patient splints made of soft materials.
Orthosis and splinting are used for the following objectives:
· To diminish pain and inflammation,
· To prevent joint stress
· To support joints, and
· To decrease joint stiffness.
Various reports have shown benefits of wrist splints in controlling pain and inflammation and preventing the development of deformities. Flexible wrist orthosis increases hand grip strength by 20% to 25%.
Philadelphia corset may be recommended if atlantoaxial involvement is present. Orthosis provides better immobilization and may be used in the presence of cervical instability.
Joint Protection Strategies
Joint protection strategies, such as rest and splinting, using compressive gloves, assistive devices, and adaptive equipment, have beneficial effects ins managing RA symptoms and deformities.
Compression Gloves. Patients using compression gloves have reported reduced joint swelling and increased well-being. However, there is no positive evidence regarding improved grip strength or hand functions from using gloves. Improvement may be provided by using compression gloves for hour intervals or only at night in patients with inflammation in their hands or fingers. Gentle compression is beneficial because of the containment of joint swelling and subsequent decrease of pain.
Assistive Devices and Adaptive Equipment. Assistive devices are used in order to reduce functional deficits, to diminish pain, and to keep patients’ independence and self-efficiency.
Elevated toilet seats, widened gripping handles, arrangements related with bathrooms, etc. might all facilitate the daily life. The procedures needed to increase compliance of the patient with the environment and to increase functional independence are mainly determined by the occupational therapist.
Massage is a commonly used treatment tool that improves flexibility, enhances a feeling of connection with other treatment modalities, improves general well being, and can help to diminish swelling of inflamed joints.
Dhondt and colleagues have reported that pain thresholds both at the massage site and at the knee and ankle have decreased after applying oscillatory manual massage to the intervertebral paraspinal region.
Massage is found to be effective on depression, anxiety, mood, and pain. This finding leads to the question of whether there are some changes in peripheral nociceptive perception and central information in RA. Also, massage decreases stress hormone levels.
Muscle weakness in patients with RA may occur because of immobilization or reduction in activities of daily living. Maintenance of normal muscle strength is important not only for physical function but also for stabilization of the joints and prevention of traumatic injuries. It may be proposed that exercise therapy has beneficial effects on increasing physical capacity rather than reducing the activity of the disease.
§ Treatment should be modify, whether the involvement of the joints is local or systemic, stage of the disease, age of the patient, and compliance of the patient with the therapy. Duration and severity of the exercise are adjusted according to the patient.
§ ROM exercises, stretching, strengthening, aerobic conditioning exercises, and routine daily activities may be used as components of exercise therapy.
§ There should be no straining exercises during the acute arthritis. However, every joint should be moved in the ROM at least once per day in order to prevent contracture.
§ In the case of acutely inflamed joints, isometric exercises provide adequate muscle tone. Moderate contractures should be held for 6 seconds and repeated 5–10 times each day.
§ If the disease activity is low, then isotonic exercises should be performed by using very low weights. Low-intensity isokinetic knee exercises (by 50% of the maximum voluntary contraction) were reported to be safe and effective in patients with RA
§ Patients with active arthritis should particularly avoid activities such as climbing stairs or weight lifting. Producing excessive stress over the tendons during the stretching exercises should be avoided. In sudden stretches, tendons or joint capsules may be damaged.
§ In chronic stage with inactive arthritis, conditioning exercises such as swimming, walking, and cycling with adequate resting periods are recommended. They increase muscle endurance and aerobic capacity and improve functions of the patient in general, and they also make the patient feel better.