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1. Rheumatoid arthritis
• Rheumatoid arthritis (RA) is an autoimmune, chronic, inflammatory,
systemic disease primarily of unknown etiology affecting the synovial
lining of joints as well as other connective tissue.
• It is characterized by a fluctuating course, with periods of active
disease and remission.
• The onset and progression vary from mild joint symptoms with aching
and stiffness to abrupt swelling, stiffness, and progressive deformity.

4. Characteristics of RA
• This disease is characterized by symmetric, erosive synovitis with
periods of exacerbation (flare) and remission.
• Joints are characteristically involved with early inflammatory changes
in the synovial membrane, peripheral portions of the articular
cartilage, and subchondral marrow spaces. In response, granulation
tissue (pannus) forms, covers, and erodes the articular cartilage,
bone, and ligaments in the joint capsule.
• Adhesions may form, restricting joint mobility. With progression of
the disease, cancellous bone becomes exposed. Fibrosis, ossific
ankylosis, or subluxation may eventually cause deformity and
disability.

6. 2. WBC
releases
cytokine
1. Migration
of immune
cell in the
Joint
3. Cytokines attack the
synovial membrane which
causes synovial cell to
release of other
destructive substances
from synovial membrane

7. 4.Cytokines also causes
synovial membrane to
grow new blood vessel
and form thicken area
called pannus

8. 5. Pannus
grows and
destroy
cartilage

9. 6.Inflammation and
fluid build up

10. 7. Narrow joint
space and
ankylosed

11. https://www.youtube.com/watch?v=Yc-9dfem3lM

14. Characteristics of RA
■ Inflammatory changes also occur in tendon sheaths (tenosynovitis); if subjected to
recurring friction, the tendons may rupture.
■ Extra-articular pathological changes sometimes occur; they include rheumatoid nodules,
atrophy and fibrosis of muscles with associated muscular weakness, fatigue, and mild
cardiac changes.
■ Progressive deterioration and decline in the functional level of the individual attributed
to the muscular changes and progressive muscle weakness is often seen, leading to major
economic loss and significant impact on families.
■ The degree of involvement varies. Some individuals experience mild symptoms that
require minor lifestyle changes and mild anti-inflammatory medications. Others experience
significant pathological changes in the joints that require major adaptations in lifestyle.
Loss of joint function is irreversible, and often surgery is needed to decrease pain and
improve function. Early recognition is essential during the initial stages, with referral to a
rheumatologist for diagnosis and medical management to control the inflammation and
minimize joint damage

15. Signs and Symptoms: Periods of Active
Disease
■ With synovial inflammation, there is effusion and swelling of the joints, which
cause aching and limited motion. Joint stiffness is prominent in the morning.
Usually there is pain on motion, and a slight increase in skin temperature can be
detected over the joints. Pain and stiffness worsen after strenuous activity.
■ Onset is usually in the smaller joints of the hands and feet, most commonly in the
proximal interphalangeal joints. Usually symptoms are bilateral.
■ With progression, the joints become deformed and may ankylose or subluxate.
■ Pain is often felt in adjoining muscles, and eventually muscle atrophy and
weakness occur. Asymmetry in muscle strength and alterations in the line of pull of
muscles and tendons add to the deforming forces.
■ The person often experiences nonspecific symptoms such as low-grade fever, loss
of appetite and weight, malaise, and fatigue.

16. Treatment: Acute stage:
• Protect: use resting splints, brace joint during ADLs, adaptive tools to
reduce joint strain during ADLs
• NO STRETCHING as it may stretch the synovial membrane and cause
irreversible damage
• Energy conservation – decrease exercise
• Gentle ROM- pain free
• No lifting heavy weights or doing activities that stress joints
• Ice to reduce inflammation
• Heat only applied briefly in AM to reduce morning stiffness
• Hydrotherapy

17. Treatment: Chronic stage
• Chronic- no disease flare up
• Capitalize on decreased pain and increased energy
• ROM- full and pain free x Increase cardiovascular activity - aquatics is a
great suggestion
• Strength and endurance activities - pain free: lighter weights, high reps
• Continue joint protection strategies
• Use splints/braces while exercising
• Ice after activity to reduce inflammation
• Heat before activity if needed for stiffness

18. Principles of Management: Active
Inflammatory Period of RA
■ Patient education. Because periods of active disease may last several months to more than a year,
begin education in the overall treatment plan, safe activity, and joint protection as soon as possible.
It is vital to involve the patient in the management, so he or she learns how to conserve energy and
avoid potential deforming stresses during activities and when exercising.
■ Joint protection and energy conservation. It is important that the patient learns to respect fatigue
and, when tired, rests to minimize undue stress to all the body systems. Because inflamed joints are
easily damaged and rest is encouraged to protect the joints, teach the patient how to rest the joints
in nondeforming positions and to intersperse rest with ROM.
■ Joint mobility. Use gentle grade I and II distraction and oscillation techniques to inhibit pain and
minimize fluid stasis. Stretching techniques are not performed when joints are swollen.
■ Exercise. The type and intensity of exercise vary depending on the symptoms. Encourage the
patient to do active exercises through as much ROM as possible (not stretching). If active exercises
are not tolerated due to pain and swelling, passive ROM is used. Once symptoms of pain and signs
of swelling are controlled with medication, progress exercises as if subacute.

19. Principles of Management: Subacute and
Chronic Stages of RA
■ Joint protection and activity modification. Continue to emphasize the
importance of protecting the joints by adapting the environment, and by
modifying activity, using orthoses, and assistive devices.
■ Flexibility and strength. To improve function, exercises should be aimed at
improving flexibility, muscle strength, and muscle endurance within the
tolerance of the joints.
■ Cardiopulmonary endurance. Nonimpact or low-impact conditioning
exercises—such as aquatic exercise, cycling, aerobic dancing, and
walking/running—performed within the tolerance of the individual improve
aerobic capacity and physical activity and decrease depression and anxiety.
Group activities, such as water aerobics, also provide social support in
conjunction with the activity. One randomized review suggested that aerobic
training also has a positive impact on the cardiovascular status of patients
with RA.

22. CONTRAINDICATIONS:
• Do not perform stretching techniques across swollen joints. When
there is effusion, limited motion is the result of excessive fluid in the
joint space. Forcing motion on the distended capsule overstretches it,
leading to subsequent hypermobility (or subluxation) when the
swelling abates. It may also increase the irritability of the joint and
prolong the joint reaction.