Академический Документы
Профессиональный Документы
Культура Документы
Definition:
Rheumatoid arthritis a chronic systemic disease primarily of the joints, usually polyarticular, marked by inflammatory changes in the synovial membranes and articular structures and by atrophy and rarefaction of the bones. In late stages, deformity and ankylosis develop.
Rheumatoid arthritis (RA) is a chronic autoimmune disease that causes inflammation and deformity of the joints. Other problems throughout the body (systemic problems) may also develop, including inflammation of blood vessels (vasculitis), the development of bumps (called rheumatoid nodules) in various parts of the body, lung disease, blood disorders, and weakening of the bones (osteoporosis). [1]
Genetic Factors
Main genetic marker identified with rheumatoid arthritis is HLA HLA-DRB1 and HLA-DR4 alleles are referred to as the RA-shared epitope because of their association with rheumatoid arthritis These genetic factors do not cause RA, but they may make the disease more severe once it has developed.
Environmental Triggers
Traces of E. coli have appeared in the synovial fluid of people with RA. may stimulate the immune system to prolong RA once the disease has started Other potential triggers include:
Mycoplasma Parvovirus B19 Retroviruses Mycobacteria, and Epstein-Barr virus.
Who is Affected?
RA affects over 21 million people worldwide [2] There are about 3 million people living with RA in Europe [3] RA affects 3 times as many women as men [4] It can affect people of all ages but it is most common in the 30-50 age range [5]
2. United Nations World Population Database, 2004 revision. 3. Weinblatt ME. Rheumatoid arthritis: treat now, not later. Ann Intern Med 1996;124:773-774 4. Arthritis Research Campaign (http://www.arc.org.uk) 5. Arthritis Care (http://www.arthritiscare.org.uk)
Stage I
Early Acute Inflammatory
Stage II
Moderate Subacute Proliferation Synovium begins to invade soft tissues, leading to decreased mobility Tenosynovitis Less pain
Stage III
Severe destructive, Chronic Active
Joint deformity with soft tissue involvement Radiological Changes: bone, joint and cartilage destruction with osteoporosis
Stage IV
Skeletal Collapse and Deformity Joint disorganization Severe deformity Muscle contracture Radiological Changes: severe bone, joint, cartilage destruction with Joint instability, dislocation and joint fusion.
Morning stiffness > 1 hour Arthritis of > 3 joint areas Arthritis of hand joints (MCPs, PIPs, wrists) Symmetric swelling (arthritis) Serum rheumatoid factor Rheumatoid nodules Radiographic changes
Radiological Studies
Plain Films
Bilateral hands & feet Only 25% of lesions Less expensive Osteoporosis detection Deformities
Hand Deformities in RA
Swan-neck Deformity
Flexion of DIP joint, hyperextension of PIP joint Flexor tendon synovitis- leads to use of primarily the MP joint for digit flexion Intrinsic plus type position during activities
Boutonniere Deformity
PIP joint flexion and DIP joint hyperextension Synovitis causes central tendon to become weakened, lengthened, disrupted from bony capsular attachment, allowing PIP to rest in flexion.
Arthritic degeneration, leads to weakened ligamentous structures. Dorsal prominence of distal ulna, pain, crepitations with pronation and supination
Thumb deformities
Type I (Boutonniere deformity) Type II (uncommon) Type III (Swan neck) Type IV (Gamekeepers) Type V Type VI (Arthritis mutilans)
[6]
6. Nalebuff, Philips: The rheumatoid Thumb. In Hunter JM, Rehabilitation of the Hand: surgery and therapy. Ed 3, Philadelphia, 1990, Mosby.
Type
IP Joint
Hyperextended
Hyperextended Flexed Not involved
Type V
Type VI (Arthritis Mutilans)
Volar dislocation
Not involved
Bone loss at any level Bone loss at any level Bone loss at any level
Swan-neck Thumb
Gamekeepers thumb
Other Features:
Synovitis
Stage I; Redness and heat at the joints may be apparent, with swelling and tenderness at the joints Later stages: less or no synovitis, more of structural changes On Observation: location of swelling and presence of deformities, helpful to determine stage of the disease
Nodules
Rheumatoid nodules develop in 50% of RA patients. Nodules-made up of granulomatous and fibrous tissue, may or may not be painful. Should not be confused with nodes (DIP- Heberdens, PIP- Bouchards)
Crepitus
Grating/Crepitus- a crunching or popping sound on performing AROM. Can be indicative of a damaged cartilage. Grind test- compression of joint, while gently rotating Metacarpal over the Carpal. Positive sign- pain and/or crepitus
Skin Condition
Evaluate- color, temperature and noted areas of swelling Initial stage- skin is red and warm Later stages- skin may be very thin and bruise easily.
Range of Motion
Increased stiffness, often noted early in the morning. Loss of AROM can be caused by tendon rupture. EPL and ED tendons are particularly vulnerable.
Strength
Joint instability- rather than weakness, usually is more of a problem during ADL. Even with a good muscle strength, patients will be unable to maintain a grip on an object if their joints collapse into deformities.
Pain
Pain caused by acute inflammation in the early stages of the disease is usually greater than in the end stages. Rheumatoid nodules can be painful when palpated- important to evaluate and note.
May affect splint design or strap placement
Respect pain:
1. Stop activities before the point of discomfort 2. Decrease activities that cause pain that lasts for more than 2 hours. 3. Avoid activities that put strain on painful or stiff joints.
Oval 8 splint
Silver-ring splint
A.ROM
To work within the comfortable ROM. Wrist AROM Gentle digit flexion and extension Thumb opposition Shoulder and Elbow ROM in supine Pool exercises- to reduce strain on weight bearing joints and also for conditioning.
Strengtheninig
Strenthening should be done with caution- to avoid aggravation of deformity
Nutritional supplements Diet plan Topical medication Patient education on disease progression and deformities.
THANK YOU