Rheumatoid arthritis
Rheumatoid arthritis is a non supportive, idiopathic, systemic inflammatory disease characterized by symmetrical polyarthritis, proliferation and destruction of synovial memebrane, periarticular structure and skeletal muscles. Thus the joints are destroyed fibrous and ankylosed.
Etiology
- Idiopathic
- Hereditary
- Autoimmune disease due to formation of IgM antibodies
- Common in people with HLADR4 gene
- Psychological stress
- Allergens
- Epstein bar virus infection, rubella, herpes zoster
- Endocrinal and metabolic factors
Common joints involved
- MCP joint in hands
- PIP joint of finger
- Wrist
- Elbow
- Knee
- Hip
Clincial feature
- Articular features
- Common in women in middle age
- Pain, swelling, stiffness of small joints of hand and feet
- History of remission and exacerbation of symptoms
- Morning stiffness
- Flexion deformity of joints
- Symmetrical involvement
- Palindomic presentation. Here pain may last gor few days and then disapper
- Systemic presentation (common in middle age men characterized by pleurisy, pericarditis fever)
- Polymyalgia (diffused joint pain and stiffness with no synovitis seen in elderly patients)
- Mono- arthtis swelling ( pain and swelling in both knees )
2. Extra- articular features
- Subcutaneous nodule formation
- Vasculitis
- Vitamin B12, iron deficiency anemia, leucopenia
- Osteoporosis
- Eye disorder, conjunctivitis, glaucoma
- Cardiopulmonary disorder like lung infection, pleural effusion, arrhythmia, rheumatic heart disease.
- Neuromuscular involvement like carpal tunnel syndrome, mononeuritis multiplex, subluxation at C1- C2
Deformities in rheumatoid arthritis
A. In hand
• Symmetrical joint swelling at MCP, IP joints
• Flexion and ulnar deviation of MCP Joint
• Trigger finger, trigger thumb due to subcutaneous nodule formation over the flexor tendons
• Swan neck deformity
• Hyperextension of PIP joint & flexion of DIP joint.
• It result due to rupture of central slip of extensor tendons.
B. In wirst flexion
• Flexion and ulnar deviation of wrist
• Subluxataion of head of ulna
C. Foot deformities
• Hallux valgus deformity of great toe
• Claw toes
• Widening of forefoot
• Vaglus deformity of heel
• Callosity over dorsum and sole of foot
D. Knee
• Flexion deformity
• Valgus deformity
• Wind swept deformity
• Backer’s eyst
• Secondary osteoarthritis
E. Hip
• Flexion and adduction deformity
• Persistent pain
• Secondary OA
• Trochanter bursitis
Diagnosis of Rhematoid arthritis
• Synovial fluid analysis ( greensih in color and cloudy)
• Rose waaler test ( a test of historical interst when sheep red cells are coated with a concentration of antiserum to sheep red cells which is too low to cause agglutination the addition of serum from patient with rheumatoid arthritis will cause agglutination)
• Presence of Rh factor in serum
• X-ray
• Classical clinical features and history
Physiotherapy management of Rhematoid arthritis hand
1. Splitting
– Dorsal blocking splint (DBS) with wrist in 20° flexion, MCP joint in 50° flexion an DIP, PIP joint in full extension.
– Tripoint splint (anti-swan neck splint) ring splint to balance finger extension in swan neck deformity and prevent hyperextension of PIP joint
– Night splints
– Dynamic splints
– Anti -boutonniere splint
2. Gliding exercises
– Making a full first for maximum gliding of flexor digitorum profundus muscle
– Making a flat fist for maximum gliding flexor digitorum superficialis tendon
– Making hook fist for gliding of both flexor digitorum profundus and flexor digitorum superficialis tendon.
3. To improve and maintain ROM
– Passive exercises to all finger involving the PIP, DIP, and MCP joints
– Passive stretching to intrinsic muscles
– Active assisted and free exercises to fingers and wrist
– Fingers parting and closing
– Mannual joint mobilization
4. To relieve pain
– Moist heat
– Ultrasound
– Proper position
– Progressive relaxtion techniques
5. Strengthening exercises
– Mannual resisted exercises to fingers and wrist
– Ball squeezing buttoning if shirt writing
– Sponge or sorbo rubber can be used
– Putty clay activities
– Dough making
– Hand re-eductional board
– Improving grip strength and precision handling
6. Teach daily activites using hand (Key holding, pen or pencil holding, writing skills, door knob closing
– Still’s disease
– It is also called as systemic disease
– It is a type of juvenile chronic arthritis
– It affects children below 8years
Clinical features
• Spiking fever
• Enlarged lymph glands
• Hepatospleenomegaly
• Pericarditis
• Pleurisy
• Mal- development of limb, finger
• Popular pink rashes
• Patients is congestive to rhematoid factors