Rheumatoid arthritis

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Introduction

Rheumatoid arthritis (RA) is a complex disease that causes pain, swelling, stiffness and loss of function in the joints. It is more common in the wrist and fingers but can affect other joints also. According to the Journal of Best Practice and Research Clinical Rheumatology, RA affects between 0.5% to 1% of the adult population. Further, it is found that each year, 20-25 new cases of RA may emerge in a population sample of 100,000. RA predominantly affects the middle-aged women across the world.

While Rheumatoid Arthritis is not a curable disease, it has been observed that sometimes the disease goes into a remission mode, only to emerge again. This remission period can range from a few weeks, months or even years. Rheumatoid arthritis is different from osteoarthritis which also impacts the joints. Rheumatoid arthritis is an autoimmune disease, where the body’s immune system mistakenly attacks joint tissues. The exact cause of rheumatoid arthritis is not yet understood.

A Rheumatoid Arthritis afflicted finger joint.

Signs and Symptoms of Rheumatoid Arthritis:

Bone joint showing Rheumatoid Arthritis symptoms

Rheumatoid arthritis varies from person to person, but usually, it starts slowly. Initially, the symptoms come and go. But if left untreated, it becomes worse than normal.

Common symptoms:

  • The pain and inflammation of the joints (fingers, wrists or toes)
  • Joint stiffness (morning stiffness lasting more than 30 minutes)
  • Tiredness (fatigue), depression, irritability
  • Anemia
  • Flu-like symptoms: such as malaise, feeling hot and sweating.
  • Rheumatoid nodules (fleshy growths below the elbows or hands and feet)

    • Commonly involved joints

    Depiction of how Rheumatoid Arthritis impacts bone joints

    Cervical spine

  • Frequently involved
  • Neck stiffness
  • Loss of movement
  • C1-C2 instability due to tenosynovitis of transverse ligament

    • Shoulder

  • Presence of swelling that often goes undetected.
  • Loss of movement is observed - frozen shoulder syndrome
  • Symptoms worse at night

    • Elbow

  • The easiest to detect
  • Flex joint deformity
  • Ulnar nerve neuropathies may develop

    • Hand / wrist / fingers

    Nearly all patients with RA have the hand, wrist, MCP (metacarpophalangeal) and PIP (proximal phalanx) participation.

  • MCP ulnar deviation
  • Radial deviation of the wrist
  • Deformities Boutonniere
  • Swan neck deformity
  • Deformity "Z" Thumb
  • Rheumatoid nodules along tendon sheaths
  • Nodular thickening over the flexor tendons in the palms
  • Tendon ruptures
  • Baker cyst
  • Bending with valgus and external rotation of the tibia, posterior subluxation of the tibia

    • Hip

  • Initial dysfunction usually difficulty putting on one’s shoes and socks

    • Foot & Ankle

    Lower limbs involvement leads to greater dysfunction and pain due to weight bearing role.

  • Widening of forefoot (Metatarsophalangeal) joints
  • Dropping of metatarsal (MT) heads
  • Distal displacement of MT fat pads
  • Lateral deviation of 1st toe
  • Claw or hammer toes
  • pronation and eversion of the foot

    • Tarsal tunnel involvement resulting in burning paresthesia

    Diagnosis

    X-ray showing severe Rheumatoid Arthritis impact
    Diagnosis is made by using a combination of clinical, laboratory and imaging characteristics. Laboratory studies potentially useful in diagnosing RA include:
  • Erythrocyte sedimentation rate
  • C-reactive protein level
  • Complete blood count
  • Rheumatoid factor analysis
  • Antinuclear antibody test
  • Anti-cyclic citrullinated peptide and anti-mutated citrullinated vimentin trials
  • Potentially useful image modalities include:
  • Radiography (first choice): hands, wrists, knees, feet, elbows, shoulders, hips, cervical spine, and other joints as shown
  • MRI: Mainly cervical spine
  • Ultrasound of the joints: joints and tendon sheaths, the changes and the degree of vascularization of the synovial membrane, and even erosions

    • Joint aspiration and synovial fluid analysis may be considered, including the following:

  • Gram stain
  • Cell count
  • Culture Evaluating the overall appearance

    • Treatment

    Treatment depends on several things, including your age, overall health, medical history and the severity of your condition. Treatments include medication, rest and exercise, and in some cases, surgery is required to correct the joint damage.

    Medicines

    Many drugs for rheumatoid arthritis may reduce joint pain, swelling and inflammation. Drugs that relieve joint pain, stiffness, and swelling include:

  • Anti-inflammatory painkillers, such as aspirin, ibuprofen, ornaproxen
  • Analgesics that is placed on the skin
  • Corticosteroids such as prednisone
  • Narcotic analgesics

    • There are also many strong medications called disease-modifying antirheumatic drugs (DMARDs), which work by interfering with or suppressing the immune system to attack the joints. They include:

  • Plaquenil (originally used to treat malaria)
  • Immunosuppressive drugs such as methotrexate, Imuran, and Cytoxan
  • Biological treatments such as Actemra, Cimzia, Kineret, Simponi, Enbrel, Humira, Remicade, Orencia and Rituxan.

    • Surgery

    Advanced Rheumatoid Arthritis can lead to joint replacement surgery

    The role of surgery mainly involves reconstruction or rehabilitation. It is performed to prevent the further worsening of the condition. The patient should be well informed about all the pros and cons of the surgery before he/she undergoes the procedure.

    The following surgical procedures are used in the management of rheumatoid arthritis:
  • Synovectomy: To remove the main focus of the disease and slow down its progress.
  • Capsulotomy, tenotomy: To correct deformities due to contractures.
  • Osteotomy: It is useful in correcting the gross fixed deformity in the hip joint.
  • Arthrodesis: To relieve pain in a joint and promote painless fusion.
  • Arthroplasty: It is a minimally invasive technique, performed to restore the mobility in joints and to reduce the stiffness. Arthroplasty is done in two ways:
    • Excision arthroplasty: By excision of the articular ends of bones and shaping them to leave a gap. Replacement arthroplasty: By replacement of articular ends by prosthetic implants.

    Physiotherapy Management

    Various physiotherapy exercises for Rheumatoid Arthritis

    There are various types of physiotherapy techniques that can help relieve the symptoms of rheumatoid arthritis. The passive treatments provide muscle relaxation, pain relief, muscle and joint strength. They include massage, heat and cold therapy, hydrotherapy, TENS (transcutaneous electrical nerve stimulation), and ultrasound.

    The physiotherapy program usually begins with passive treatments. When you feel ready, you should start the active treatments which strengthen the body and prevent further pain in RA. Exercise also plays a vital role in the treatment. The physiotherapist will work with you according to the proper treatment plan.


    Passive Treatments

    Cryotherapy or (Cold Therapy):

    Cold therapy (also called cryotherapy) relieves painful outbreaks in RA. Cold therapy slows the circulation and helps reduce the swelling. Your physiotherapist can put a cold compress on the target area, to massage with ice, or even use a spray known as fluoromethane to cool the inflamed tissues.

    Heat Therapy:

    Heat causes a natural healing process of the body by relaxing the joints and tired muscles, enhancing the flow of blood to the painful area. An improved blood circulation supplies extra oxygen and nutrients.

    Heat cannot completely eliminate the source of your pain of RA but can help in temporarily reducing pain. Heat therapy is used in a couple of ways: through dry heat (heating pad or hot, dry towel) or heat (steam heat or a hot damp cloth) wet.

    When heat therapy is used on its own, take caution against overheating the painful areas. If you are using a heating pad, set to low or medium. When using a hot towel, touch it first to make sure it is not too hot.

    Hydrotherapy:

    As the name suggests, hydrotherapy involves water treatment and is an ideal rheumatoid arthritis passive relief option. As a passive treatment, hydrotherapy can involve simply sitting in a hot tub to relieve pain, relax muscles and condition your body without adding unnecessary stress to tired joints.

    Massage:

    Therapeutic deep tissue massage can help relax joints and muscles. Your therapist may use heat and cold massage therapies for the same. Always remember that you should never have the therapy directly into or near the arthritic areaf because it can cause an increase in pain.

    TENS (Transcutaneous Electrical Nerve Stimulation):

    TENS therapy sounds intense but really is not painful. The electrodes attached to the skin send a small electrical current to key points on the nerve pathway. TENS is generally believed to trigger the release of endorphins, which are natural painkillers in the body.

    Ultrasound:

    This therapy uses sound waves to create a gentle heat that increases circulation of blood to the deeper tissues. Ultrasound helps reduce swelling, stiffness and pain. This passive therapy also improves your range of motion, which is likely to be limited due to the pain of rheumatoid arthritis.

    Active Treatments

    Exercise is the cornerstone of any program of physiotherapy. Once you complete your course of passive treatments, your physiotherapist will develop a program specifically for you. Active treatments that include regular exercise helps address flexibility, strength, and joint motion. This will not only curb the recurrent pain but also improve your overall health and help you lose weight, if necessary. Your physiotherapist will work with you to develop a system based on specific symptoms and health history program.

    Active treatments include:

    Flexibility and muscle strengthening:

    Your range of motion is likely to be restricted if you have rheumatoid arthritis. By using customized stretching and strengthening exercises, your physical therapist will help stretch and strengthen muscles and improve joint movement.

    Aerobic exercise:

    Aerobic exercises like walking and biking are ideal for sufferers of RA, as they reinforce the joints without putting unnecessary strain. Aerobic exercise will also help you lose weight, so you can have reduced stress on your tired joints.

    Your physiotherapist will teach principles to understand how to treat best your pain of rheumatoid arthritis. The ultimate goal is for you to develop the knowledge to help control your symptoms yourself, without the direct supervision of a physiotherapist. It is essential that you learn the exercises and continue them after the end of formal therapy. If you continue your fitness program, you have a much better chance to enjoy the long term benefits of physiotherapy.

    Five habits that help

    The treatment of rheumatoid arthritis has improved nowadays. Many experts believe that most of the people who suffer from RA in present times are less likely to have joint damage than before.

    Follow these steps to improve your chances of that.

    1. Receive early treatment. Much of the damage that eventually becomes serious starts shortly after RA is discovered. The sooner treatment begins, the less chance of damage.
    2. Visit your doctor regularly. People who see their rheumatologist regularly (several times a year) have less damage than those who do not.
    3. Exercise! It makes your joints stronger. Your doctor or physiotherapist will help you make a plan that is safe, effective, and tailored to your fitness level.
    4. Rest when you need. You need to balance between rest and exercise to not overdo it.
    5. Use a cane in the hand opposite a painful hip or knee. This reduces wear and tear in the affected joint.

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