rheumatoid arthritis 4/10

rheumatoid arthritis

chronic systemic inflammatory disease

major subclassification within the category of diffuse CT diseases

affects 1-2% of US population (1.3 mil ppl)

considered an autoimmune disease (80% are RF+)

primary risk factors of RA

30-60 year old peak onset

females

initial RA joint changes

inflamed synovium

end stage RA joint changes

pannus, loss of cartilage, pannus-filled erosion

RA vs OA

initial onset can be younger or older (25-50 y/o), sudden, intermittent exacerbation & remission

affects 1% of US adults (and 30-50k children)

women affected 3x as men, more disabling and severe in men

multifactorial etiology

different clinical manifestations

has associated symptoms

synovial fluid has high WBC, low viscosity

rheumatoid factor present usually

C-reactive protein is a true indicator

age of onset

men: older than 45

women: 20-45

clinical manifestations

diffuse msk pain

fatigue, malaise, weight loss, fever

weakness

swelling/erythema

multiple joints with symmetric BIL presentation

prolonged morning stiffness lasting >1 hr

gradual loss of motion affecting gripping/holding objects

where does RA manifest?

any joint, but commonly small joints of hands and feet and C spine

inflammation is almost always present with redness, warmth, swelling

ulnar drift

RA is most common cause

leads to significant hand functional limitations

swan-neck deformity

boutonnière deformity

what systems are also affected?

heart, arteries

lungs

stomach

liver, gallbladder

goals of management

prevent/control joint damage

prevent function loss

decrease pain

decrease extra-articular manifestations of disease

poor prognosis is suggested by…

earlier age at disease onset

high titer of RF

elevated ESR

swelling of >20 joints

extra-articular manifestations (cardiopulmonary)

PREVENTATIVE medical management

new, more effective combination of drugs

behavioral interventions

education: healthy lifestyle, appropriate BW, no smoking, exercise

how WAS RA medically managed?

drug therapy—aspirin, aspirin +steroids (NSAIDs), aspirin + steroids + DMARD over 4 years

how IS RA medically managed?

aspirin/NSAIDs + steroids +DMARD 1 +DMARD 2? + DMARD 3? immediately

gradual withdrawal after remission

parameters for types & amount of intervention

determined by degree of synovitis, amount of joint destruction/deformity, pain tolerance, lifestyle

stage 1

early stage

notable by presence of synovial inflammation→joint swelling, pain w/ motion

immune cells→inflammation site→high cell counts in fluid

^ however—x-rays typically negative aside from possible presence of osteoporosis & soft tissue swelling

stage 1 treatment

focus on joint protection & inflammation control

stage 2

T and B cell proliferation and angiogenesis in synovium

synovial tissue grows into joint cavity across cartilage→destroys cartilage

typically no deformities, but mobility may become limited w/ muscle atrophy

mild malaise, presence of nodules

picture: solid arrows=swelling, open arrow=bone changes

stage 2 treatment

focus on joint protection & inflammation control

stage 3

accumulation of synovial fluid polymorphonuclear leukocytes (SFPMNs) as well as synovial cell proliferation

loss of cartilage→exposes bone

joint pain, swelling, limited ROM, morning stiffness, weakness, malaise, extensive atrophy, nodules, deformity

soft tissue swelling & cartilage loss shown on x-ray

picture: solid arrows=swelling, open arrow=erosion of MC

stage 3 treatment

pain relief & prevention of disability

stage 4

cessation of inflammatory process

formation of fibrous tissue and/or bone ankylosing (fusion)→cease joint function

MRI shows proliferative pannus (membrane of granular tissue)

joint pain, swelling, atrophy, nodules, deformity, limited ROM, morning stiffness (or general stiffness), weakness, malaise

picture: note osseous erosion

stage 4 treatment

reduce pain, stop additional joint damage

may undergo joint replacement surgery

classification of global functional status in RA

class 1-4

1=most independent, 4=least

class I

completely able to perform usual ADLs (self-care, vocational, avocational)

class II

able to perform usual self-care and vocational activities

limited in avocational activities

class III

able to perform saul self-care activities

limited in vocational and avocational activities

class IV

limited in ability to perform usual self-care, vocational, avocational activities

intervention during active stage

rest joints with splints/orthoses to maintain joint alignment and decrease pain/inflammation

APPROPRIATE rest to reduce inflammation

minimize trauma, reduce mechanical stress, large joints vs. small joints

use energy conservation principles

ring splints

decrease hypermobility of PIPs

ulnar drift splints

prolonged inactivity

loss of excs tolerance

incr weakness of muscles/ligaments

degeneration of joint cartilage

development of osteoporosis

inadequate loading of joint→reduce blood flow to synovium/cartilage

energy conservation principles

adequate nighttime rest: 8-10 hours

frequent rest periods & position changes

1 hour of rest during day to offset fatigue

goal of exercise

maximize joint motion, reduce soft tissue constriction

type of exercise

ROM exercises are safe & efficient in maintains joint motion without increasing damage/swelling

gentle ROM: AAROM or AROM without holding end position, 2-3 reps/day once a day

avoid PROM until after inflammation subsides

modalities?

goals for subacute disease

prevent deconditioning, maximize function

subacute interventions

modalities: heat prior to stretching

exercise: ROM, isometric, dynamic excs, progressive resistive training, aquatics, dance

ROM excs in subacute phase

AROM and PROm can be performed, end range position can be held

8-10 reps/day, frequency can increase, can be combined with flexibility

isom excs in subacute phase

increase reps and sets as tolerated

dynamic exercise with light resistance in subacute phase

more effective in incr strength than isom

monitor complications (ex. subluxations)

endorphin levels rise with increased intensity & freq of excs

freq & duration needed to produce change in muscle strength varies w/ severity & duration of disease

progressive resistive training for subacute phase

significantly increased lean body mass & fat-free mass w/o altering BW

overall QoL not affected, but less difficulty with advanced ADLs

no flare-ups or injuries occurred

intense training should be used to stimulate muscle growth in those w/ severe muscle wasting, pts with low-moderate disease activity would benefit more from low-impact moderate-intensity activity

aquatic excs for subacute phase

outcomes: incr aerobic capacity, CV endurance, better mood

buoyancy of water can resist or facilitate movement

waist-level water: BW=50%

neck-level: BW=10%

water temp: 82-86 F; relaxes muscle spasms and reduces pain

dance therapy

enhances functional outcomes & improves adherence to exercise

inactive disease/remission intervention

strengthening & aerobic conditioning

aerobic capacity, muscle strength, joint mobility, functional ability, mood have been shown to improve by 57% w/o apparent incr in joint symptoms/disease activity

strength from endurance training→stability to affected joints, improved shock absorption

encourage good joint protection techniques during excs sessions to use proper biomechanics

education on self-management allows pt to set realistic excs goals, monitor response, adapt to changing symptoms

implications for practice

improved outcomes in muscle strength, physical function, aerobic capacity w/ dynamic excs—more benefit w/ high intensity, best benefits w/ combined programs (strength & aerobics)

caution w/ using high impact excs to pts with high levels of baseline joint damage

no studies have addressed the effect of dynamic excs on CV outcomes in RA pts with CAD or its major risk factors—CAD = high risk for mortality in RA

don’t ignore benefits of excs with RA pts

if there is a benefit to excs, there will be a side effect (don’t encourage excs that cause more damage)

use caution in prescribing excs with pts who have significant joint damage (encourage more unloading activities, general physical activity is still beneficial for CV prevention)

juvenile idiopathic arthritis

similar to adult RA< but actually comprises a heterogeneous group of arthritides of unknown cause

children→18 y/o, occurs for at least 6 weeks

each classification (pauciarticular, polyarticular [RF+/RF-], systemic) has different presentations, genetic backgrounds, prognoses and is based on # of involved joints and presence of certain signs and symptoms

types of JIA in the population

50% pauciarticular

40% polyarticular

10% SOJIA

pauciarticular or oligoarticular JIA

affects four or fewer joints during first 6 mo of disease

usually in asymmetric pattern

most commonly involves knees, elbows, wrists, ankles

girls affected more than boys

usually btwn age 1-5

relatively mild, few extra articular features

parents may notice swollen joint, limp, abnormal gait, usually early after child wakes up in morning

leg-length discrepancy is common

pain is not a central feature at first, disease rarely manifests any constitutional symptoms

MOST COMMON

subtypes: antinuclear antibodies & high risk of uveitis; involved spine (in adolescence, HLA-B27 marker); joint involvement is extent of disease—no systemic signs

polyarticular JIA

affects five+ joints

most commonly includes large and small joints of wrists, C spine, TMJ, small joints of hands and feet, knees, ankles, hips

involvement usually symmetric, most like that of adult RA with potential for severe, destructive arthropathy

affects girls more than boys

subtypes: RF+ and RF-

RF+ polyarticular JIA

presence of rheumatoid factor (autoantibody found in blood of RA adults) and DR4 genetic type, also common in RA

subcutaneous nodules, C spine fusion, chronic uveitis (eye inflammation→irreversible damage and blindness), destructive hip disease can occur in this type

RF- polyarticular JIA

characterized only by joint involvement, usually less severe

negative rheumatoid factor

morning stiffness, fatigue, possible low grade fever

systemic onset JIA

affects boys and girls equally

with involvement of any # of joints

most severe extra articular manifestations, affects many body systems

begins w/ high fever (>102), chills that appear intermittently for weeks and may be accompanied by rash on thighs and chest that often goes away w/in a few hours

inflammatory arthritis typically develops at some point

95% of children have jiont symptoms w/in 1 year of initial symptoms

approx ½ of children w/ this type recover almost entirely

1/3 of affected children remain ill with persistent inflammation

JIA diagnosis

PMHx, physical exam, lab tests

serum evaluation: measure inflammation, detect antinuclear antibodies, RF, sometimes HLA-B27

signs of arthritis must be seen in 1+ joint for >6 wks in children under 16

pain often dull, aching, less severe; but presents in morning rather than more common presentation of nighttime growing pains

systemic features in systemic onset JIA are more readily diagnosed

JIA medical management

early use of DMARDS (MTX)

TNF inhibitors

IL-1 blockade for pts with macrophage activation syndrome

corticosteroids, anti-inflammatory for severe anemia, unrelenting fever, vasculitis

administered to control systemic and articular symptoms, and sometimes stop disease progression

bone marrow transplantation in cases where standard management isn’t effective

anti-TNF agents adverse effects

neuro disorders

weight gain

severe infection

hemorrhagic diarrhea

approximately 50% respond, but response is unsustained in many children

pt and family education for JIA

difficulty in getting appointments

long waiting lists

difficulty understanding/following therapist instructions

vocational, psychological counseling

exercise with JIA

improves functional ability, QoL, aerobic capacity

all outcome measures reported no worsening with excs therapy in short term

may safely participate in physical activities/sports w/o risking disease exacerbation

mod-sever impairment→tailor activities to lie w/in own pain limits

may benefit from combination of moderate aerobic, anaerobic, flexibility, strength training

appreciate differences between JIA subtypes

contraindications for exercise for JIA

should not participate in physical activity while febrile or any that temporarily increase joint pain/swelling

those w/ severe osteoporosis should avoid contact sports