العلاج الطبيعي للرماتيز

1. Rheumatoid Arthritis
Physiotherapy
BY DR/ KHALED ALSAYANI

2. Definition
⚫RA /rheumatic disease
⚫It’s a autoimmune disease
⚫Chronic inflammatory disease
⚫Crippling and disabling disorder which
affects connective tissues in the whole
body

3. Who is Affected?
•
•
•
•
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)

4. What are the Causes of RA?

5. • exact causes – unknown
• genetic susceptibility
• most likely triggered by a combination of
factors, including an abnormal autoimmune
response
• some environmental or biologic trigger, such
as a viral infection or hormonal changes

6. Disease Severity and Stages

7. Stage I
Early Acute Inflammatory
• Joint swelling
• Heat
• Redness
• Severe pain
• Radiological Changes: osteoporosis may be
present

8. Stage II
Moderate Subacute Proliferation
• Synovium begins to invade soft tissues,
leading to decreased mobility
• Tenosynovitis
• Less pain
• Radiological Changes: may show slight bone
and cartilage destruction

9. Stage III
Severe destructive, Chronic Active
• Joint deformity with soft tissue
involvement
• Radiological Changes: bone,
joint and cartilage destruction
with osteoporosis

10. 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.

11. Relative incidence of joint
involvement in RA
 MCP and PIP joints of hands & MTP of feet 90%
 Knees, ankles & wrists- 80%
 Shoulders- 60%
 Elbows- 50%
 TM, Acromio - clavicular & SC joints- 30%

12. ACRCriteria for Diagnosis
•
•
Four or more of the following criteria must be
present:
– 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
First four criteria must be present for 6 weeks or
more

14. Radiological Studies
•
•
Plain Films
– Bilateral hands & feet
– Less expensive
– Osteoporosis detection
– Deformities
Color Doppler U/S & MRI
– Early signs of damage i.e. Erosions
– Bone Edema - even with normal findings on radiography

17. Hand Deformities in RA

18. 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

20. 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.

23. MPJoint U
lnar Deviation
• Ulnar deviation of MP joint- most common
• If restraining system of tendons, ligaments
and bones are affected by synovitis, the hand
collapses into deformity, as the MP joint has
more degree of mobility.
• Also called as Ulnar drift.

24. Clinical manifestations
 Stiffness
 Tenderness
 Pain on motion
 Swelling
 Limitation of motion
 Extra-articular manifestations
 Rheumatoid nodules
 Crepitus

25. Conservative managment
⚫NonSteroidal Anti-Inflammatory Drugs
(NSAIDs),
⚫Disease-Modifying Antirheumatic Drugs
(DMARDs),
⚫Immunosuppressants, and
⚫Corticosteroids.

26. Surgical management
• Persistent pain (from, for example, joint damage or
other soft tissue cause).
• Worsening joint function.
• Progressive deformity.
• Persistent localised synovitis.
⚫Deformity becomes irreversible:
• Imminent or actual tendon rupture.
• Nerve entrapment (for example, carpal tunnel
syndrome).
• Any stress fracture.

27. Physical therapy Management

28. Assessment/ Evaluation
⚫Assessment of posture
⚫Testing muscle strength and power
⚫Measuring joint movement
⚫Gait analysis
⚫Functional test
such as balance, walking, dressing, toileting(ADL),
etc..

29. Treatment Goals
⚫To protect the joint from further damages
⚫Provide pain relief
⚫Prevent deformity
⚫Prevent disabilities
⚫Increase functional capacity
⚫Improve flexbility and strength
⚫Encourage regular exercise
⚫Improve general fitnes

30. 1. Protection principles:

31. 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.

32. Balance rest and activity:
1. Rest before exhaustion.
2. Take frequent short breaks
3. Avoid staying in one position for a long time.
4. Alternate heavy and light activities.

33. Exercise in pain-free range:
1. Initiate warm-water pool exercises.
2. Exercise should be specific to each deformity.

34. Avoid position of deformity:
1. Avoid bent elbows, knees, hips, and back
while sleeping.
2. Splinting

35. Use the larger joints
1. Use palms rather than fingers to lift or push.
2. Carry a backpack instead of a hand-held
purse.
3. Push swinging doors open with side of body
instead of hands.

36. Use adaptive aids
• Use jar openers, button hooks, etc., that are
specific to each patient’s needs.

37. 2. Splinting

38. Splinting for MP Ulnar Drift and
Palmar subluxation
• Resting Splint.
• Hand-based hinged MCP joint splint

39. Splinting for Swan-neck
deformity:
• Prevent PIP joint hyperextension, yet alow for
flexion
• Example:
• High-temperature plastic custom splint
• Oval 8 splint
• Silver-ring splint.

40. High-temperature plastic custom splint

41. Oval 8 splint

42. Silver-ring splint

43. Splinting for Boutonniere
deformity:
• PIP joint in extension, DIP joint extension
block.
• Many patients reject this splint during daily
activities as it limits the ability to flex the PIP
joint.
• Examples:
– Silver-ring splint (reverse).

45. Splinting the Rheumatoid
Thumb:

46. 3. Modalities

47. • Reduce pain, encourage relaxation:
– Superficial heating modalities.
• Paraffin
• Hot packs
• Hydrotherapy
• Electric mitts.
• Acute inflammation: cryotherapy

48. 4. Exercises:

49. 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.

52. General Body Stretching

53. Strengtheninig
• Strenthening should be done with caution- to
avoid aggravation of deformity

54. 5. Remedies

55. • Nutritional supplements
• Diet plan
• Topical medication
• Patient education on disease progression and
deformities.