Physiotherapy Management of Rheumatoid Arthritis

Rheumatoid Arthritis An autoimmune disorder, occurs when your immune system mistakenly attacks your own body's tissues.
occurs when your immune system mistakenly attacks your own body's tissues. Physiotherapy play a critical component of the overall management for patients with RA

1. Physiotherapy Management of Rheumatoid Arthritis (RA) Dr. Nilofar Rasheed Assistant professor ITS institute of Allied and Health sciences

2. What is Rheumatoid Arthritis (RA) ? Rheumatoid Arthritis is a chronic inflammatory disorder that can affect more than just your joints. In some people, the condition can damage a wide variety of body systems, including the skin, eyes, lungs, heart and blood vessels. An autoimmune disorder, Rheumatoid A rthritis occurs when your immune system mistakenly attacks your own body's tissues. RA is associated with significant pain, functional impairments and co-morbid health conditions ( Kvien , 2004). 

3.   seropositive   seronegative RA juvenile RA   being another type that only affects children.

4. Etiology Women are affected more than men in the proportion of 3:1. The age of onset may be as young as 16 years but it is generally in the 20-50 year age group. - The cause is unknown but is related to a disturbance of the auto-immune system. - It may also be due to various factors like climate, diet, trauma, etc. - Researchers think it is caused by a combination of genetics, hormones and environmental factors.

5. Where does RA Attack? Shoulder joints Hip joints Knee joints Elbow joints Wrist joint - Distal Interphalangeal Joints (DIP) -   M etacarpophalangeal (MCP) -   P roximal I nterphalangeal (PIP)  Ankle joints - M etatarsophalangeal (MTP) - Tarsal Joints

6. Sign and Symptoms Onset of pain Early Morning stiffness (Last more than 30 minutes) Tenderness and swelling Weight loss Fever Fatigue or tiredness Weakness About 40% of people who have rheumatoid arthritis also experience signs and symptoms that don't involve the joints. Areas that may be affected include: Skin, Eyes, Lungs, Heart, Kidneys, Nerve tissue, Bone marrow and Blood vessels.

7. Common Deformities

8. Complication Fixed Deformity Muscle weakness Joints Infection Spinal cord compression Systemic Vasculitis Amyloidosis – Renal failure

9. Medical Treatment Analgesics to relieve pain, e.g. Aspirin, Paracetamol and Codeine Non-Steroidal Anti-inflammatory Drugs (NSAIDS), e.g. Indomethacin (Relieves early morning stiffness) Corticosteroids are used to reduce inflammation and pain and to limit deformity, e.g. Prednisolone Local Injections of corticosteroids are used to reduce the inflammation in knees, hips, elbows

10. PHYSIOTHERAPY MANAGEMENT ASSESMENT/EVALUATION Assessment of posture Testing muscle strength and power Measuring joint movement Gait analysis Functional test such as balance, walking, dressing, toileting Activities of Daily Living (ADL)

11. Treatment Goals To protect the joint from further damages Provide pain relief Prevent deformity Prevent disabilities Increase functional capacity Improve flexibility and strength Encourage regular exercise Improve general fitness. Improve sleep

12. Physiotherapy Management Physiotherapy represents a critical component of the overall management for patients with RA, as substantiated by a strong evidence base, and reflected in clinical practice guidelines (Bell et al., 1998; Ottawa Panel, 2004a,b; Li et al., 2006a,b; Forestier et al., 2009; Royal Australian College of General Practitioners, 2009; Hurkmans et al., 2011). This American College of Rheumatology (ACR) guideline addresses the use of exercise, rehabilitation, diet, and additional integrative interventions in conjunction with disease-modifying anti-rheumatic drugs

13. Patient Education In patients with RA, sociopsychological factors affecting the disease process such as poor social relations, disturbance of communication with the environment, and unhappiness and depression at work are commonly encountered. In this program, there is information about benefits and adverse effects of drug therapy, importance of physiotherapy, use of orthosis, psychological coping methods, self-relaxation, and various diets. In addition, patients are taught how to perform the scheduled exercises and how to protect the joints during routine daily life. Patients who have participated in this program have revealed improvement in disability associated with the disease, psychosocial interaction, and clinical prognosis. 

14. Management Cold Therapy (Acute phases) Dosage: 10 – 20 mins / 1 -2 times a day. Heat therapy (Chronic phases) Superficial heating Modality Hot pack application Paraffin wax Effective method for heating hands and wrists, can be used for feet, can be painted on rounded regions of the body as a pack Paraffin (5 lb.) melted in a double boiler, add W cup of mineral oil, allow to cool until a thin film is formed; hand dipped into paraffin several times until a thick coat is formed, then wrapped in a towel Duration-20 to 30 minutes Frequency-l or 2 times daily Contraindicated if there is an open wound. Contrast bath Dosage: 20 – 30 min/ 1-2 times a day

15. TENS Short term pain relief 6 – 18 hours Infrared Lamps: Suitable for heating single joints Used at a distance producing a comfortable warmth Duration-30 minutes Frequency-l or 2 times daily Intensity modified if there is poor circulation or anesthetic area. Hydrotherapy: Effective for heating of multiple joints of upper or lower extremities Water temperature-105’ to 110” F. Duration-30 minutes Frequency-daily water temperature lowered to 100” F. or less if circulation is impaired.

16. Massage Stroking and kneading movements applied to soft tissues adjacent to the involved joints, not to the joint Mechanical apparatus is not recommended as a substitute Ordinarily follows use of heat and precedes exercises to increase range of motion. Intensity of the massage depends on degree of inflammatory reaction in joints and tolerance of the patient May be employed at home by a member of the patient’s family who has been instructed in a few simple massage strokes. Follow-up patient’s regular re-evaluation. so that the treatment may be modified according to changes in the patient’s condition.

17. Joint protection strategies, such as rest and splinting, using compressive gloves, assistive devices, and adaptive equipment, have beneficial effects in managing RA symptoms and deformities. Rest and Splinting  Compression Gloves  Assistive Devices and Adaptive Equipment

18. Exercises for Acute Phase Finally, 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. Performed at least once a day. Gentle assisted movement through normal range (Joint Mobilization). Isometric (Static Muscle Contraction) helps to maintain muscle tone without increasing inflammation.

19. Exercises for Chronic Phase Can progress the above exercises to include use of light resistance. Postural / core stability exercises. Swimming / walking / cycling to maintain cardiovascular fitness. Gentle stretches for areas that become tight, such as knees and calves.

20. Regular Exercises Maintaining muscle strength is important for joint stability and preventing injury. Muscles can become weak following reduced activity. Pain signals from your nerves and swelling can both inhibit muscles. Muscle length can be affected by prolonged positions and immobilization and tightness can limit daily activities.

21. General Body Stretching

22. This guideline provides initial ACR recommendations on integrative interventions for the management of RA to accompany DMARD treatments. The broad range of interventions included in these recommendations illustrates the importance of an interprofessional team-based approach to RA management

23. Joint Protection Try to avoid prolonged positions. Balance activity with rest periods, rest should come before you get fatigued or sore. Look at your work home desk set up. During the acute phase activities such as stair climbing can put stress through your knees, ankles & hips try to keep the number of trips up & down to a minimum.

24. Alternative Therapists MUSICAL THERAPY TAI CHI YOGA THERAPY RELAXATION TECHNIQUES PILATES.

25. Thank you

26. References https://www.ser.es/wp-content/uploads/2020/04/Clinical-Practice-Guidelines-for-the-Management-of-Patients-with-Rheumatoid-Arthritis.pdf