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RHEUMATOID ARTHRITIS

NIZAR ABDUL MPT Phd()

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Rheumatoid Arthritis• Rheumatoid arthritis (RA) is a chronic autoimmune

disease that causes inflammation and deformity of the joints along with extra-articular manifestations.

• The prevalence of rheumatoid arthritis approaches 1% among adults 18 and over; and increases with age, approaching 2% and 5% in men and women respectively by age of 65.

• The incidence also increases with age, peaking between the 4th and 6th decades.

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Rheumatoid Arthritis• Both prevalence and incidence are 3-4 times greater

in women than in men.

• African Americans and native Japanese and Chinese have a lower prevalence.

• Several North American Native tribes have a high prevalence.

• Genetic factors play an important role in the susceptibility to rheumatoid arthritis.

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Rheumatoid Arthritis

• Rheumatoid arthritis is an autoimmune disease in which the normal immune response is directed against an individual's own tissue, including the joints, tendons, and bones, resulting in inflammation and destruction of these tissues

• The cause of rheumatoid arthritis is not known.– Investigating possibilities of a foreign antigen,

such as a virus

Rheumatoid Arthritis• Description

– Morning stiffness– Arthritis of 3 or more joints– Arthritis of hand joints– Symmetric arthritis– Rheumatoid nodules– Serum rheumatoid factor– Radiographic changes

• A person shall be said to have rheumatoid arthritis if he or she has satisfied 4 of 7 criteria, with criteria 1-4 present for at least 6 weeks

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Rheumatoid Arthritis

• Rheumatoid arthritis usually has a slow, insidious onset over weeks to months.

• About 15-20% of individuals have a more rapid onset that develops over days to weeks.

• About 8-15% actually have acute onset of symptoms that develop over days.

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Functional Presentation and Disability of RA

• In the initial stages of each joint involvement, there is warmth, pain, and redness, with corresponding decrease of range of motion of the affected joint.

• Progression of the disease results in deformities which later become fixed .

• Muscle weakness and atrophy develop early in the course of the disease in many people.

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Complications of Rheumatoid Arthritis

Complications include:– Carpal tunnel syndrome, Baker’s cyst, vasculitis,

subcutaneous nodules, peripheral neuropathy, cardiac and pulmonary involvement, Felty’s syndrome, and anemia.

– Felty's syndrome is defined by the presence of three conditions: rheumatoid arthritis, an enlarged spleen (splenomegaly), and an abnormally low white blood cell count.

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Rheumatoid arthritis is a disease that causes destruction of joints in the body. The disease can occur in any synovial joint in the body and is most commonly symptomatic in the small joints in the hands and feet.

When rheumatoid arthritis affects the joints in the spine, it is far more common for the neck (cervical spine) to be affected than for the lower back.

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FUNCTIONAL CRITERIA IN RA

• GRADE I: Capable of doing all activities.• GRADE II: Moderate restriction• GRADE III: Marked restriction• GRADE IV: Bed/chair bound

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Rheumatoid Arthritis Symptoms in the Spine

Cervical spine involvement in patients with rheumatoid arthritis (RA) is recognized as a significant source of neck pain, with its effects ranging from minor restriction of range of motion and pain to major neurological impairment and even death.

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The joints of the cervical spine, like other joints affected by RA, encounter synovitis; erosions; and weakening and destruction of bone, cartilage, and ligamentous structures.

Various researchers have reported that up to 25% of patients with RA have subluxation at the atlantoaxial articulations, and about 50% of patients with RA have subaxial subluxation at two or more vertebral levels.

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These findings have several clinical implications for physical therapists who treat patients with RA: 1) asymptomatic patients may show radiographic evidence of cervical subluxation at some level2) patients with symptomatic complaints may not have cervical subluxation 3) patients' complaints of pain in the cervical spine may occur in various patterns4) patients may have variable neurological symptoms5) physical therapists should apply cervical spine therapeutic techniques cautiously because of the fragile nature of the tissues affected by RA.

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The end-stage results of the inflammatory process

combined with the mechanical forces on the cervical

spine can injure the neck structures and cause

atlanto-axial subluxation, atlantoaxial impaction, and

subaxial subluxation. Atlanto-axial(AA) subluxation

and dislocation at the C4-5 and C5-6 levels are among

the most common and serious complications of RA.

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RA

Confirmation of joint and vertebral subluxation can only be made radiographically or with CT.

Attention and careful recording of the patient's complaints and periodic methodical re-evaluation of the patient's cervical spine will alert the therapist to contact the patient's physician when concerns arise. Cervical spine manifestations in patients with RA were first described by Garrod in 1890.

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RA may affect the cervical spine in several ways

Atlantoaxial subluxation due to erosion of the odontoid process and/or the transverse ligament of C1 can lead to posterior slippage of the odontoid process and will result in myelopathy. There may be upward impingement of the odontoid process on the foramen magnum and cord compression.

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A-A JOINT

Changes may develop in all cervical segments, but those most seriously considered are found in the atlanto-axial joints. An important stabilizer is the transverse ligament, which on its passage behind the odontoid process keeps this in close and firm contact with the anterior arch of the axis. The stability this ligament affords becomes jeopardized when erosions and destructions develop by the invasion of granulation tissue. The atlanto-axial joints may gradually dislocate. https://www.youtube.com/watch?v=YRBtisJhKlw

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Transverse Ligament: Primary stabilizer of atlanto-axial junction

If the transverse ligament that maintains the position of the odontoid process relative to C1 is torn, C1 will translate forwards on C2 in flexion. Cervical spinal cord compromise due to atlanto-axial subluxation can have serious neurological consequences, including quadriplegia and even death.

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Transverse ligament of Atlas

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ATLANTOAXIAL INSTABILITY (AAI)

The clinical presentation of atlantoaxial instability varies widely. Severe cases can present with progressive myelopathy, vertebrobasilar insufficiency, or quadriplegia. Less severe signs and symptoms include neck pain, apprehension with neck movement, headaches, intolerance to prolonged static posture, and increased muscle tone. Mild cases can present without neurological deficits and mimic the clinical presentation of mechanical neck pain or cervicogenic headaches.

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Atlantoaxial Impaction

Atlantoaxial impaction (ie, cranial settling or vertical subluxation) occurs when the skull settles downward onto the atlas and the atlas settles onto the axis. The impaction is caused by bony erosion and osteoporosis in the atlanto-occipital and atlantoaxial joints.

Atlantoaxial impaction occurs in 5% to 32% of patients with RA.

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Atlanto-axial Impaction (Basilar Invagination)

Vertical subluxation is one of the most serious complications of rheumatoid arthritis, and may affect up to 5-10% of patients have cervical spine disease.Basilar invagination may result from erosion and/or bone loss between occiput and dens or may result from erosion and settling of the C1 / C2 articulation. Lateral masses of atlas may collapse secondary to erosive changes in atlanto-occipital and atlanto-axial synovial joints; this leads to vertical subluxation of odontoid process through foramen magnum.

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Clinical Findings

Need to rule out myelopathy:Patients may note headaches Loss of pain / touch sensation over the trigeminal nerve distributionNystagmus Facial diplegiaDysphagia (due to CN IX dysfunction)

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Subaxial Subluxations

Subaxial subluxations are found at multiple vertebral levels and tend to be severe, giving a "stepladder" appearance to the cervical spine on a roentgenogram. Subaxial subluxations occur in 10% to 20% of patients with RA.

Narrowing and subluxation of C2-C3 or C3-C4 are characteristic of patients with RA, although disko-vertebral destruction does not always accompany vertebral subluxation. The lack of osteophyte formation is typical of RA. Subluxation may result from disk destruction caused by synovitis with erosion of the adjacent bone and disk or may be secondary to facet arthritis and ligamentous laxity leading to chronic disk trauma with destructive changes.

The end result of encroachment on the spinal cord may be meningitis, arachnoiditis, and SC compression.

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RA may affect the cervical spine

Clinical signs and symptoms of this complication include hyper-reflexia, weakness of the extremities, positive Babinski and Lhermitte sign, and posterior neck pain.

If the posterior cerebral circulation is affected, visual disturbances, vertigo, paresthesias, and paresis may occur.

Most patients with cervical subluxation have extensive and longstanding erosive joint disease, nodulosis, and rheumatoid factor (RF) positivity.

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CLINICAL PRESENTATIONRheumatoid arthritis of the spine can lead to neck pain, back pain, and/or pain that radiates into the legs or arms.

In advanced cases, the joint deterioration in the spine can lead to compression of the spinal cord and/or the spinal nerve roots. The range of symptoms is broad and can include any combination of the following: •Pain is the most common symptom, especially pain at the base of the skull as rheumatoid arthritis most commonly affects the joints connected to the upper cervical vertebrae.•Swelling and warmth in one or more joints, may even be described as burning•Tenderness, Loss of flexibility of the joints.

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• A crunching feeling when the joint is moved (called crepitus), particularly notable in the neck

• Headaches, related to cervical rheumatoid arthritis

• Pain that radiates down one or both arms, indicating that a cervical spinal nerve root is affected.

• Pain that radiates down one or both legs, indicating that a lumbar nerve root is affected.

• A change in the ability to walk can signal increasing pressure on the spinal cord.

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RA

• Sensations of tingling and/or weakness in the arms or legs, or a loss of co-ordination or ability to walk, which may be an indication that the spinal cord is affected.

• Any type of difficulty with bowel or bladder control, such as incontinence or inability to urinate, or lack of ability to control the bowels.

• Symptoms of bowel or bladder dysfunction or change in the ability to walk or move the arms are serious medical symptoms and immediate medical attention should be sought.

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Various complaints regarding patterns of pain in the neck have been reported in the literature. Generalized pain may occur in the neck and occipital area, or the pain may radiate from the occiput to behind the ears with aching and radiation into the shoulders caused by head motion.

Some patients with RA may experience pain in the neck, occipital region, or posterior scalp, or complain of headaches or a band-like constriction of pain about the forehead. Pain may be aggravated by forward flexion of the head.

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As the patient moves his head into forward flexion, a gibbus deformity of C2 may appear; as the spinous process protrudes posteriorly.

Radiating pain, numbness, and tingling in the upper extremities and neck will be aggravated in some patients by forward flexion of the head.

Patients often complain that their head feels too heavy to hold up and that their neck muscles are weak.

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• Vertebrobasilar insufficiency may contribute to blackouts, loss of equilibrium, tinnitus, vertigo, visual disturbances, and diplopia. Bulbar disturbances may appear during swallowing, phonation, and respiration. Bladder sphincter control may be lost.

• Death may result from spinal cord or medullary compression in patients with cervical RA, but such compression does not appear to be the only cause of premature death in these patients.

Medical management Medications

NSAIDs DMARDs Hydroxychloroquine,Sulfasalazine, Penicillamine Methotrexate, an immunosuppressive drug is

now increasingly used very early as one of the second-line potentially disease-modifying drugs.

Steroid therapy: Corticosteroids – offer the most effective short-term relief as an anti-inflammatory drugs.

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Treatment Surgery: Removal of inflamed

synovium Arthroplasty

Physical therapy

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Physical therapy measures

Flexion contractures can be prevented and muscle strength restored most successfully after inflammation begins to subside. Joint splinting reduces local inflammation and may relieve severe local symptoms. Before acute inflammation is controlled, passive exercise to prevent contracture is given carefully and within the limits of pain.

Active exercise (including walking and specific exercises for involved joints) to restore muscle mass and preserve the normal range of joint motion is important as inflammation subsides.

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PT

Established flexion contractures may require intensive exercise, serial splinting, or orthopedic measures.

Orthopedic or athletic shoes with good heel and arch support can be modified using inserts to fit individual needs and are frequently helpful; metatarsal bars placed posteriorly to painful metatarsophalangeal joints decrease the pain of weight bearing.

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Vocational Implications of Rheumatoid Arthritis

Need to make frequent assessments of the person’s functional ability as the disease progresses in order to provide realistic goals and support

Motor coordination, finger and hand dexterity, and eye-hand-foot coordination are adversely affected

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Vocational Implications of Rheumatoid Arthritis

Most jobs requiring medium to heavy lifting are not desirable.

Activities such as climbing, balancing, stooping, kneeling, standing, or walking are affected.

Extremes of weather or abrupt changes in temperature should be avoided – indoor controlled climate is better.

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Surgical ManagementSevere sub-axial subluxation or atlantoaxial impaction with impending neurological deficit, with or without pain, may also be an indication for surgical stabilization.

Posterior fusion of the upper cervical spine with central cord decompression is indicated in any unstable atlantoaxial joint or in the presence of significant myelopathy. Inflammation-induced acute AAI that involves stable lesions without any neurologic symptoms may be reduced. The patients may be placed in a halo brace with vest reduction and immobilization for 3 months.

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Intravenous Steroids

Some surgeons and certain cervical spine trauma protocols recommend the administration of high-dose intravenous steroids in the initial presentation of acute cervical spine injuries. The reason is to potentially reduce cervical cord swelling and subsequent neurologic complications.

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Rheumatoid Arthritis Treatment

The goals of treatment for rheumatoid arthritis in the spine are primarily to: Reduce or eliminate the pain Maintain the ability to function in everyday life Reduce or slow the progression of the disease.

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For the vast majority of people, treatment is nonsurgical and will include one or a combination of physical therapy and exercise, medications, diet and nutrition, and possibly alternative or complementary forms of care.

Surgery for rheumatoid arthritis in the spine is rare. Physical therapy combines passive treatments with therapeutic exercise. Passive treatment modalities include heat/ice, ultrasound and electrical stimulation to alleviate muscle spasm and pain.

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Therapeutic exercises help the patient to increase flexibility and range of motion while building strength. Patients need not be fearful of physical therapy.

Even patients experiencing pain and great difficulty moving have found that isometric exercises are beneficial.

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ORTHOTIC MANAGEMENT

Cervical collars do not prevent RA progression, but they are often prescribed with the rationale that a collar prevents sudden neck flexion and extension that could result in neurological impairment or death. A soft cervical collar Philadelphia collar Four-poster brace Cervico-thoracic brace SOMI brace Halo device with a plastic body vest

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• The cervicothoracic brace was the most effective of the conventional orthoses. The cervicothoracic brace is most effective at the middle and lower vertebral levels and better at controlling motion than the other orthoses.

• The Cervical Soft Collar is a medium density soft foam collar with vinyl stabilizing panel that helps support the cervical spine in the neutral position.

• A halo device is the most rigid of all neck braces.

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A Philadelphia collar is a stiff foam collar composed of two pieces that are attached on the sides with Velcro.

The upper portion of the Philadelphia collar supports the lower jaw and the brace extends down to cover the upper thoracic

spine.

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Sternal Occipital Mandibular Immobilizer-SOMI, controls flexion, extension, lateral and rotational movements C2 -

C5

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Halo Device

Subjects wearing the halo device with the plastic body vest were assessed for flexion and extension between the occiput and first thoracic vertebrae. The halo device with the plastic body vest allow only 4% of normal flexion-extension of the whole cervical spine.

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Four-poster brace

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Cervico-thoracic brace: The cervicothoracic brace is the most effective of the conventional orthoses.

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PHYSICAL THERAPY MANAGEMENT

• Physical therapy is an important component of the total management of patients with RA.

• Treatment is directed toward 1) relieving pain and discomfort2) maintaining or restoring ROM and

muscle strength 3) helping patients adapt activities of daily

living that aggravate neck pain.

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RELIEF OF PAIN AND DISCOMFORT

• Before evaluating and treating the neck of the patient with RA, the physical therapist should realize that cervical spine RA is a potentially life-threatening condition.

• Physical therapists should make decisions about methods of pain relief for patients with RA with knowledge of the potential hazards.

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• Heat therapy has been widely advocated for patients with RA. Superficial heat is used for pain relief, for relaxation, and as a warming activity before muscle exercise.

• Deep-heating treatments (ie, microwave therapy, diathermy, or ultrasound) are generally contraindicated for direct use on inflamed, painful joints.

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Cervical traction is not recommended because of the potential of further damage to the integrity of the cervical joints.

MOBILIZATION AND MANIPULATION TECHNIQUES ARE ABSOLUTELY CONTRAINDICATED.

Transcutaneous electrical nerve stimulation has become a popular modality for pain relief in RA. The advantage of TENS is that patients can use it at home after appropriate instruction by a physical therapist.

IRR, Hydro collator packs, fluidotherapy, paraffin baths are used in pain management. Hot shower also helps before exercise session.

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MAINTAINING OR RESTORING RANGE OF MOTION AND MUSCULAR STRENGTH

A frequent complaint of patients with cervical RA is the feeling that their head is too heavy for their neck muscles to hold up.

Patients must be taught to accomplish gentle ROM exercises of the head and neck and may need to be told to avoid excessive hyperextension or any circumduction motions of the head.

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RHEUMATOID ARTHRITIS OF SPINE: PHYSIOTHERAPY

Effective pain relief would reduce the need for cervical spine operations, since pain is their frequent indication. Optimal conservative treatment would also stop or retard radiological progression of the abnormalities, or even possibly reduce the instability, which would reduce the risk of complications. Thus, the treatment has to be multidisciplinary: the basis is patient education, along with collars, ergonomics, practical aids, muscular exercises, NSAIDs, analgesics, DMARDs etc.

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Hot and cold packs

•Hot and cold packs can’t treat the underlying causes of back pain and neck pain, but they can help to reduce the pain and stiffness a sufferer feels during a flare-up.•A heat pack can help to improve blood flow and reduce muscle spasms. It can also help make the pain more manageable.•A cold pack can be particularly helpful to reduce RA inflammation. Cold packs may feel uncomfortable at first, but they can help numb pain.

•Swimming, water aerobics, walking or bicycling are best exercises for RA.

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Work Your Posture •Whenever you sit or stand, make sure you exercise good posture. This not only helps to align your spine properly, but it also can alleviate joint pain.

•Furthermore, good posture can place less pressure on joints, thereby decreasing wear-and-tear. Engage core, sit up straight and roll shoulders back. You can even imagine the crown of your head being raised up towards the ceiling to naturally lift your spine.

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Stretches First, place your arms to your sides with elbows in and palms facing out. Then move the elbows gently back until you feel your shoulder blades squeezing together.

Overhead Side Reach

The overhead side reach is a good way to begin the day.

•Stand with your feet about shoulder-width apart.•Clasp your hands together above your head.•Lean to the left.•Hold 30 seconds.•Switch to the right, and repeat 3-5 times on each side.

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ROLE OF EXERCISES

•Many people with rheumatoid arthritis tend to avoid exercise because they're afraid that the activity might worsen their joint pain. But exercise is one of the key treatments to reducing the disability often associated with rheumatoid arthritis. •Regular exercise can boost strength and flexibility in people who have rheumatoid arthritis. Stronger muscles can better support your joints, while improved flexibility can aid joint function.

•Exercise can reduce fatigue and ease depression. Better overall fitness helps prevent heart disease and diabetes, two life-shortening ailments that often accompany rheumatoid arthritis.

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REST AND ACTIVITYPatients 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. 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.

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EXERCISESThere 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 without exacerbation of clinical disease activity. Isometric exercises are preferred.

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. If pain persists more than 2 hours or too much fatigue, loss of strength, or increase in joint swelling occurs after an exercise program, then it should be revised.

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Electrical Stimulation

Transcutaneous electrical nerve stimulation (TENS) therapy is the most commonly used method.

Nevertheless, 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.

Interferential current can also be used for analgesia. Studies have shown its efficacy on pain relief, swelling, and improvement in ROM. Also, no difference was found between interferential current and TENS in the magnitude of analgesia.

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Rather than do active hyperextension, the patients can perform isometric extension against a pillow on their bed against a wall; or in a high-backed, overstuffed chair.

If patients' hands are severely deformed, isometric contractions of the neck against the hand may be impossible, and they may use a beach ball placed between themselves and the wall while sitting in a chair to perform isometric neck exercises.

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RA

Physical therapists should realize that cervical exercises may aggravate rather than decrease RA pain. Patients with RA should be re-evaluated routinely to determine the extent of neck aggravation caused by the exercise program.

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HANDLING PATIENTS WITH RA

Therapists should take precautionary measures when physically handling patients with RA. Not only must therapists be judicious when the patient is unable to transfer, they must also fulfil their role as an educator of the patient, family, and staff about how patients should be transferred. When assisting the patient out of bed, for example, the care giver should not lift the patient from the back of the head, but should roll the patient onto one side and bring him to a sitting position by grasping him around the trunk under the arms.

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CAUTION

Death may result from spinal cord or medullary compression. Physical therapists treating patients with RA should use wisdom and caution when designing and implementing a treatment plan. Communication is imperative between all members of the health care team, including patients and their families.

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PROGNOSIS

About 15% of all RA patients will have symptoms for a short period of time and will ultimately get better, leaving them with no long-term problems. A number of factors are considered to suggest the likelihood of a worse prognosis. These include:• Female gender.• More than 20 joints involved.• Extremely high erythrocyte sedimentation rate.• Extremely high levels of rheumatoid factor.• Consistent, lasting inflammation.• Evidence of erosion of bone, joint, or cartilage on x rays.• Poverty.• Older age at diagnosis.• Rheumatoid nodules.• Other coexisting diseases.