3. DEFINITION
It is a chronic inflammatory systemic autoimmune disease characterized by destructive and proliferative changes in synovial membrane ,
periarticular structures , skeletal muscles , and perineural sheaths
Joints are destroyed , ankylosed & deformed
Associated with extraarticular manifestations ( involvement of other organs )
4. Joints affected
Joints most frequently affected in RA include:
Proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints of the hands
Wrist joint
Shoulder joint
Elbow joint
Knee joint
Ankle joint
Metatarsophalangeal (MTP) joints of the feet
Distal interphalangeal (DIP) joints are typically spared
5. Extra-articular manifestations
Secondary Sjögren’s syndrome
Heart
Pericarditis
Myocarditis
Endocarditis
Valvular fibrosis
Liver
Enzyme abnormalities due to drug reactions or Sjögren’s syndrome
Blood / blood vessels
Mild anemia
Vasculitis
Felty’s syndrome
7. EPIDEMIOLOGY
• Prevalence of RA is approximately 0.8 – 1.0 % in Europe and the Indian
subcontinent
• Female : Male = 3 : 1
• Prevalence is lower in South – east Asia ( 0.4 % )
• Highest prevalence in the world is in Pima Indians ( 5 % )
8. PATHOPHYSIOLOGY
• In RA , the immune system’s antibodies attack the synovium which is
the smooth lining of a joint
Pain & inflammation in joint
Synovial thickening occurs - Cartilage destruction
Tendons & Ligaments - weaken and stretch
Joint eventually loses it’s shape & configuration
9. AUTOIMMUNITY
• Defined as the failure of an organism in recognizing its own
constituent parts as
NON SELF , which allows an immune response against its own cells
and tissues
Any disease that results from such an aberrant immune response is
termed an
autoimmune disease
10.
11.
12.
13. RISK FACTORS
• AGE > 60 YRS
• FEMALE
• SPECIFIC GENETIC TRAITS
• OBESITY
• SMOKING
14. GENETICS
• PRODUCTS OF HLA REGION OR CLASS 2 GENES OF MHC CONTROL
BOTH IMMUNE RESPONSES AND SUSCEPTIBILITY TO RA
• HLA DRB4 POSITIVE PATIENTS – DEVELOP EROSIVE DISABLING
DISEASE
• ONLY 1/3 – HLA DRB4 +ve
22. Poor prognostic factors Extra-articular signs and symptoms (e.g. Cutaneous ulcers, vasculitic rash, neuropathy, scleritis,
subcutaneous nodules)
Female gender
Shared epitopes
Poor functional status
Involvement of multiple joints
Early radiographic evidence of erosive changes
Advanced age at onset of disease
High RF titer
23. Poor prognostic factors
Sustained elevation of acute-phase reactants (e.g. ESR)
Low socioeconomic status/educational level
High titre CCP antibody
Smoking
24. DIAGNOSIS
• HISTORY & PHYSICAL EXAMINATION – SWELLING, FUNCTIONAL
LIMITATIONS & DEFORMITY
• BLOOD TESTS
• ERYTHROCYTE SEDIMENTATION RATE [ESR] & CRP – to assess
inflammation level in body
• ANEMIA
• RHEUMATOID FACTOR – associated with RA
25. RHEUMATOID FACTOR
• Antibody reactive against Fc
fragment of IgG
• Not specific for RA: chronic infections, cirrhosis,
malignancies, other rheumatic diseases.
ANTI- CCP
Antibodies to Cyclic
Citrullinated Peptides
Anti-CCP has high
diagnostic specificity for
RA (98%)
26. XRAYS
• GENERALLY HAND & FOOT XRAYS ARE TAKEN
• REVEALS SOFT TISSUE SWELLING, JOINT EROSIONS, OSTEOPOROSIS
OF ADJACENT JOINTS – BONE CYST FORMATION & NARROWING OF
JOINT SPACE
27. 1987 Revised ACR Classification of RA
Criterion Definition
Morning stiffness Lasting ≥ 1 hour before maximal improvement
Arthritis ≥ 3 joints Clinical evidence of soft tissue swelling or fluid in right or left PIP, MCP, wrist, elbow, knee, ankle, and M
joints.
Arthritis of hand joints 1 or more swollen areas in wrist, MCP, or PIP joint
Symmetric arthritis Simultaneous involvement of same joint areas on both sides of body
(bilateral involvement of PIP, MCP, or MTP joints is acceptable without
absolute symmetry)
Rheumatoid nodules Clinical evidence of subcutaneous nodules over bony prominences, extensor surfaces, or in juxta articular
regions
Serum RF Elevated rheumatoid factor measured by any method in which positive
results are found in < 5% of normal subjects
Radiographic changes Erosions or unequivocal body decalcification localized in or adjacent to
involved joints on posteroanterior hand and wrist radiographs
28. 2010 ACR/EULAR classification criteria for RA
A score of ≥6/10 is needed to classify RA
Joint involvement Score
1 large joint 0
2-10 large joints 1
1-3 small joints (with or without involvement of large joints) 2
4-10 small joints (with or without involvement of large joints) 3
>10 joints (at least 1 small joint) 5
Serology (at least 1 test result is needed) Score
Negative RF and negative ACPA 0
Low-positive RF or low-positive ACPA 2
High-positive RF or high-positive ACPA 3
29. 2010 ACR/EULAR classification criteria for RA
A score of ≥6/10 is needed to classify RA
Acute-phase reactants (at least 1 test result is needed) Score
Normal CRP and normal ESR 0
Abnormal CRP or abnormal ESR 1
Duration of symptoms Score
<6weeks 0
>6 weeks 1
30. Principles of Therapy
Early initiation of therapy
Treat to target
Combine medications to achieve remission
31. RA: Current Pharmacologic Options
Symptomatic treatment of RA[ to reduce inflammation & pain]
• NSAIDs
• COX-2 inhibitors
• Analgesics
DMARDs (Disease-modifying antirheumatic drugs) - impact the signs, symptoms, and disease
progression of RA, as well as improve the quality of life and functionality of the patient.
Corticosteroids have anti-inflammatory and immunoregulatory activity, but nominal disease-modifying
capability.
33. Methotrexate
Most effective single DMARD (used as baseline therapy in most
patients.)
Typical dose is 15 mg/week.
34. PHYSIOTHERAPICAL IMPORTANCE IN RA
• PATIENT EDUCATION
• PSYCHO-SOCIAL INTERVENTIONS
• LIFESTYLE MODIFICATIONS
• NUTRITIONAL & DIETARY INTERVENTIONS
35. PATIENT EDUCATION
• Explaining the nature of the illness & how it occurs
• Treatment options available with pros & cons of each treatment
• Importance of blood tests and why some of the blood tests need to
be done periodically during the treatment
• Importance of compliance with treatment
• Role of diet, exercise and fitness
• Education of the spouse or the care-giver is equally important
37. LIFESTYLE MODIFICATIONS
• REST
• EXERCISE –
1. include muscle strengthening exercises [like isometric , isotonic,
isokinetic] – to preserve the joint function
2. Regular aerobic exercise [walking, swimming , cycling] – improve
muscle function, joint stability, aerobic capacity
WEIGHT REDUCTION- reduces the inflammatory markers- thereby
decreasing the stress upon the joints involved- preventing joint
destruction
CARDIOVASCULAR RISK REDUCTION
38. NUTRITIONAL AND DIETARY INTERVENTIONS
• BALANCED DIET – less carbohydrates, more natural vegetables &
fruits, adequate proteins, healthy fats – recommended to RA patients
39. NUTRITIONAL AND DIETARY INTERVENTIONS
INCREASES RISK OF RA
• Red meat
• Coffee
• Low vitamin-C intake
• Obesity
DECREASES RISK OF RA
• Alcohol – may decrease
• Tea
• Vitamin –D [may or maynot]
40. गुरूनहत्वा हह महानुभावान्
श्रेयो भोक्ुुं भैक्ष्यमपीह लोके |
हत्वार्थकामाुंस््ु गुरूननहैव
भुञ्जीय भोगान् रुधिरप्रहिग्िान् || 5||
gurūnahatvā hi mahānubhāvān
śhreyo bhoktuṁ bhaikṣhyamapīha loke
hatvārtha-kāmāṁstu gurūnihaiva
bhuñjīya bhogān rudhira-pradigdhān
measning-It would be better to live in this world by begging,
than to enjoy life by killing these noble elders, who are my
teachers. If we kill them, the wealth and pleasures we enjoy
will be tainted with blood.
