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Rheumatoid Arthritis: Cause and Management

Updated: Jun 28, 2020



Rheumatoid arthritis (RA) is the most common type of inflammatory arthritis in old age. It is an autoimmune, chronic, inflammatory, systemic disease primarily of unknown cause affecting the synovial lining of joints as well as other connective

tissue. It is characterized by a fluctuating course, with periods of active disease and remission. The onset and progression

vary from mild joint symptoms with aching and stiffness to abrupt swelling, stiffness, and progressive deformity.


It most commonly affects the wrists/hands, shoulders, ankles and the smaller joints of the hand or feet and the inflammatory changes also occur in tendon sheaths (tenosynovitis); if subjected to recurring friction, the tendons may fray or rupture.


Cause


Rheumatoid arthritis is an autoimmune disease, it occurs when your immune system attacks the synovium — the lining of the membranes that surround your joints which then makes your joint inflamed.


This inflammation thickens the synovium, which can eventually destroy the cartilage and bone within the joint in time.

There is no clear explanation about the triggering factor of the inflammatory process, although a genetic component is said to be a factor. While your genes don't actually cause rheumatoid arthritis, they can make you more susceptible to environmental factors — such as infection with certain viruses and bacteria — that may trigger the disease.


Criteria for Diagnosis of Rheumatoid Arthritis (RA)


Rheumatoid arthritis can be difficult to diagnose in its early stages because the early signs and symptoms mimic those of many other diseases. Below is the Diagnostic Criteria for RA.


1. Morning stiffness in and around the joints, lasting at least 1 hour before maximal improvement


2. At least three of the following joints simultaneously have soft tissue swelling or fluid observed by a physician: right or left proximal interphalangeal (PIP); metacarpophalangeal (MCP); wrist, elbow, knee, ankle, and metatarsophalangeal (MTP) joints).


3. Swelling in the wrist, MCP, or PIP joints


4. Symmetrical joint involvement (bilateral involvement of PIP, MCP, or MTP joints may occur without absolute symmetry)


5. Rheumatoid nodules


6. Positive serum rheumatoid factor (done with blood testing)


7. Radiographic changes including erosions or or boney decalcification localized in or adjacent to the involved joints


NOTE: RA is defined by the presence of at least four of these seven criteria. Numbers 1–4 must have been present for at least 6 weeks.


Signs and Symptoms: Periods of Active Disease

- With synovial inflammation, there is effusion and swelling of the joints, which cause aching and limited motion.


- Joint stiffness is prominent in the morning.


- Usually there is pain on motion, and a slight increase in skin temperature can

be detected over the joints.


- Pain and stiffness worsen after strenuous activity.


- Onset is usually in the smaller joints of the hands and feet, most commonly in the proximal interphalangeal joints. Usually symptoms are bilateral.


- The person often experiences nonspecific symptoms such as low-grade fever, loss of appetite and weight, malaise, and fatigue.


MANAGEMENT GUIDELINES


There is no cure for rheumatoid arthritis. But clinical studies indicate that remission of symptoms is more likely when treatment begins early physical therapy rehabilitation and medications known as disease-modifying antirheumatic drugs (DMARDs).


Physiotherapy


Early treatment in physiotherapy can help to slow down the progression or even the need for surgery. Participating in treatment before surgery can also help speed up your recovery afterwards.

1. Patient Education - Because periods of active disease may last several months to more than a year, begin education in the overall treatment plan, safe activity, and joint protection as soon as possible


2. Relieve pain and muscle guarding and promote relaxation - heat therapy, like applying hot pack, can also help with alleviating pain and stiffness by applying it for 10-15 minutes. Cold therapy may be indicated for clients with a more active inflammatory arthritis. When the condition is in a flare up, cold can help to alleviate pain. There are other pain modalities that physiotherapists can use depending on the severity of the condition, such as acupuncture.


3. Minimize joint stiffness and maintain available motion - Some soft tissue techniques or joint mobilizations may be used to help improve the mobility and flexibility of the surrounding joints, soft tissue structures around the affected area.


4. Minimize muscle atrophy - performing specific exercises that are less stressful and apply less compression on the joints that are affected by RA can be prescribed. Range of motion, strengthening and endurance exercises are the types that are most helpful.


5. Prevent deformity and protect the joint structures - use of supportive and assistive equipment for all pathologically active joints, good bed positioning while resting and avoidance of activities that stress the joints.


Joint Protection and Energy Conservation


Therapeutic exercises cannot positively alter the pathological process of RA, but if administered carefully, they can help prevent, retard, or correct the mechanical limitations and deforming forces that occur and therefore, help maintain function.


If you or someone you know has RA, don’t wait until you require joint replacement surgery to start treating your condition.


Here are some tips you can use to minimize your symptoms:

  • 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

  • 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.


The pain and disability associated with rheumatoid arthritis can affect a person's work and family life. Depression and anxiety are common, as are feelings of helplessness and low self-esteem.


The degree to which rheumatoid arthritis affects your daily activities depends in part on how well you cope with the disease. Talk to your doctor or physiotherapist about strategies for coping. With time you'll learn what strategies work best for you.




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Reference:

Joint, Connective Tissue, and Bone Disorders and Management - CAROLYN KISNER, PT, MS, KAREN HOLTGREFE, PT, DHS, OCS 2012


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