CASE SCENARIO OF RHEUMATOID ARTHRITIS PATIENT Demographic data Name- Sarika Pande Age- 43 Gender- Female Occupation- housewife Dominance- right side Address- Aurangabad Chief complaint Pain and swelling in multiple joints including wrist, MCP, PIP, ankles. Restricted range of motion of the affected joints since 10 years. Associated complaint Difficulty in performing the daily activities due to increased fatigue since 6 years. History of present illness A decade ago, the patient initially experienced pain and morning stiffness in her hands, which approximately lasted for 30 min. She embarked on a medical journey that included treatment with both allopathic and homeopathic medications. While these interventions provided temporary relief from her symptoms, they did not yield lasting relief from her condition. Approximately 2 years ago, she transitioned to Ayurvedic treatment, hoping for effective management strategy. The patient was advised to undergo all the necessary investigations to further understand the progression of rheumatoid arthritis and she was prescribed physiotherapy aiming for alleviation of symptoms, enhancing mobility and improving her quality of life. Pain Assessment Site- dorsal side of MCP, PIP and wrist joints. Side- bilaterally Intensity- 6/ 10 NPRS (Activity) and 4/10 NPRS (rest) Quality- Dull ache Nature- continuous Duration- chronic Aggravating factors- Gripping activities Relieving factors- rest and medications Temporal variations- morning stiffness and night pain Past medical history No relevant history of DM/HTN/THYROID Family history No family history Gynaecological history Has regular periods (28 days cycle) Age of menarche- 12 years of her age Personal history Lives in joint family of 8 members. She is vegetarian Does not have any addiction Environmental history Has to climb 10 steps daily Has cold temperature in the house Roads near her house are uneven to walk 5 rooms in the house which makes her activities difficult General physical examination Height: 149 cm Weight: 51 kg BMI: 23 kg/m2 Blood Pressure: 126/84mmHg Posture Anterior view – 1. Foot arches Symmetrically normal 2. The position and shape of the toes Hammer toes observed bilaterally. Hallux valgus of both big toes. 3. Position of the foot The foot is externally rotated (hip External rotation) 4. Shape and position of the Left knee is lower than right; both knees are knee joints / Patella demonstrating valgus. 5. Anterior superior iliac spine Right is slightly higher. 6. Position of the shoulder girdle Right shoulder is higher. Lateral view – 1. Position of the knee joints 2. Position of the pelvis Position Both knees are extended with left more than the right. Ante version 3. Curvature of the Spine Hyper Kyphosis from C4 till TH2 4. Position of the elbow 5. Position of the shoulder girdle Both elbows are flexed with the right more Protracted shoulders 6. Position of the head Protracted head. 7. Position of the trunk Protracted / ante flexed Posterior view The base support Shape and contours of the heels Wide base of support Symmetrically rounded heels Knee Joints Valgus Position of the Posterior Superior Iliac crest The right is higher than the left Position of the scapula Right scapula is abducting outwards and the inferior angle is prominent. Right shoulder is higher than left. Position of the shoulder girdle Gait Affected Local examination On inspection Attitude of limb – patient was examined in long sitting position. Hip flexed, knee fully extended and foot adducted and pronated. Elbow flexed to 90 degrees and pronated. Swelling- present on the dorsal aspect of MCP and PIP joint Deformity- boutonniere deformity, swan neck deformity, ulnar drift, z deformity Nodules- presence of subcutaneous nodules Texture of skin- shinny and bright skin due to skin Muscle wasting- presence of cachexia due to lack of physical activity On palpation Localized temperature- raised on the fingers bilaterally Swelling- present on the dorsal aspect of MCP & PIP joint Tenderness- Present on the joint line of affect joint of MCP and PIP joint (Grade 1) Sensory examination Superficial and deep sensations- Intact Joint Assessment Range of motion – Goniometric measurements Wrist Flexion Extension Radial and Ulnar Deviation Active ROM (in degrees) Left Right 0-75 0–70 0-45 0-35 Painful Painful 10-0-12 10-0-10 Painful Passive ROM (in degrees) Left Right 0-75 0-70 0-65 0-60 Painful Painful 10-0-12 10-0-10 Painful Metacarpophalangeal Joints Extension and flexion 1st 2nd 3rd 0 – 0 – 15 0 – 0 – 10 0 – 0 – 20 Painful Flexion Painful Flexion Painful Flexion 10 – 0 – 85 10 – 0 – 80 10 – 0 – 85 Painful Flexion 10 – 0 – 85 10 – 0 – 80 10 – 0 – 85 0 – 0 – 10 Painful Flexion 10 – 0 – 80 Painful Flexion 10 – 0 – 80 Painful Flexion 10 – 0 – 85 10 – 0 – 80 Painful Painful Flexion Flexion 10 – 0 – 85 10 – 0 – 80 Painful Painful Flexion Flexion 4th 10 – 0 – 85 10 – 0 – 80 5th 10 – 0 – 85 10 – 0 – 80 2nd 3rd 4th 5th 20 - 0 - 25 20 – 0 – 10 20 – 0 – 10 20 – 0 – 10 20 – 0 – 10 20 – 0 - 25 10 - 0 - 5 10 - 0 - 5 20 – 0 – 10 20 – 0 – 10 20 – 0 - 25 20 – 0 – 10 20 – 0 – 10 20 – 0 – 10 20 – 0 – 10 20 – 0 - 25 20 - 0 - 10 20 – 0 - 10 20 – 0 – 10 20 – 0 – 10 Interphalangeal Proximal joint Extension & Flexion 1st 0 – 0 – 40 0 – 0 – 40 2nd 3rd 4th 5th 85 – 0 – 0 85 – 0 – 0 85 – 0 – 0 85 – 0 – 0 0 – 0 – 20 Painful flexion 85 – 0 – 0 85 – 0 – 0 85 – 0 – 0 85 – 0 – 0 0 – 0 – 20 Painful flexion 90 – 0 – 0 90 – 0 – 0 90 – 0 – 0 90 – 0 – 0 0 – 0 – 20 0 – 0 – 20 0 – 0 – 20 0 – 0 – 20 5 – 0 – 20 Painful Till the tip of 3rd Metacarpal Painful 0 – 0 – 20 0 – 0 – 20 0 – 0 – 20 0 – 0 – 20 5 – 0 – 20 Painful Till the tip of 4th Metacarpal Painful Thumb (1st) Carpometacarpal & Metacarpophalangeal Joints Abduction & Adduction 1st 90 – 0 – 0 90 – 0 – 0 90 – 0 – 0 90 – 0 – 0 Interphalangeal Distal joint Extension & Flexion 2nd 3rd 4th 5th Carpometacarpal Extension & Flexion Thumb Opposition 0 – 0 – 20 0 – 0 – 20 0 – 0 – 20 0 – 0 – 20 Thumb 5 – 0 – 20 Painful Till the tip of 4th Metacarpal Knee Joint Extension and Flexion Ankle Joint Dorsal and Plantarflexion 0 – 0 – 20 0 – 0 – 20 0 – 0 – 20 0 – 0 – 20 5 – 0 – 20 Painful Till the tip of 3rd Metacarpal Painful Active ROM (in degrees) Left Right 0 – 0 – 110 0 – 0 – 110 Painful Passive ROM (in degrees) Left Right 0 – 0 – 110 0 – 0 – 110 Painful 15 – 0 - 40 15 – 0 – 40 15 – 0 - 40 20 – 0 – 40 Eversion and Inversion Metatarsal-phalangeal joints Extension and 1st flexion 2nd 3rd 4th 5th 15 – 0 – 35 20 – 0 – 35 Painful 15 – 0 – 35 Painful 70 – 0 - 40 75 – 0 – 45 70 – 0 – 40 75 – 0 – 50 60 – 0 - 45 65 – 0 - 40 65 – 0 - 40 65 – 0 - 40 60 – 0 – 45 60 – 0 - 40 60 – 0 - 40 60 – 0 - 40 60 – 0 – 45 65 – 0 – 45 65 – 0 – 45 65 – 0 – 45 60 – 0 – 45 60 – 0 – 40 60 – 0 – 40 60 – 0 – 40 Muscle Length Testing Grade 0 – no shortness Grade 1 – slight / moderate shortness Grade 2 – marked shortness Left Right Grade 1 Ankle plantar flexor Two joint Grade 1 (dorsiflex 10°) Grade 0 Ankle plantar flexor One joint Grade 0 (knee flexed, dorsiflex 20° and more) Grade 0 Grade 1 Grade 1 Grade 1 Grade 2 Grade 2 Hip flexors One Joint Hip flexors Two joints Hip Abductor Hamstring Muscles Paravertebral Muscles Muscle Pectoralis major - Lower Sternum Muscle Pectoralis major Middle and upper sternal part Grade 0 Grade 1 Grade 1 Grade 1 Grade 2 Grade 2 Muscle Pectoralis major Clavicle part and pectorals minor Muscle Pectoralis Minor (Kendall) Cranial part of the Trapezius muscle Levator Scapula Sternocleidomastoid Grade 0 Grade 1 Grade 0 Grade 1 Grade 2 Grade 1 Grade 2 Grade 2 Grade 1 Grade 2 Grade 2 Grade 2 20 – 0 – 40 Manual muscle strength test Grade 0 - no contraction of the muscle Grade 1 – contraction of the muscle felt but no movement seen Grade 2 - position in horizontal plane with gravity Grade 3 - against gravity Grade 4 - against gravity with moderate resistance given Grade 5 - against gravity with maximum resistance given Left Grade 4 Grade 4; Painful Grade 4 Grade 3 Grade 3 Grade 3 Grade 4 Grade 4 Grade 4 Grade 4 Grade 4 Grade 4 Grade 3 Grade 3 Grade 3 Grade 3; painful Grade 3; painful Grade 2; painful Grade 3; painful Grade 2; painful Grade 3 Grade 3; painful Grade 4 2nd finger and 5th finger Grade 2 and rest Grade 3 Grade 3 Grade 3 Grade 3 Grade 3; painful Grade 2; painful Grade 3; painful Upper Extremity Serratus anterior Upper Trapezius Lower trapezius Middle trapezius Rhomboids Lateral rotators Medial rotators Pectoralis minor Pectoralis major Deltoid Triceps brachii and Anconeus Biceps brachii and brachialis Supinator Pronator Teres and quadratus Extensor Carpi Ulnaris Extensor carpi radialis longus and brevis Flexor carpi Ulnaris Flexor carpi Radialis Flexor digitorum profundus Flexor digitorum superficialis Right Grade 3 Grade 3; painful Grade 4; painful Grade 3 Grade 3 Grade 4 Grade 3 Grade 4 Grade 4 Grade 3 Grade 4 Grade 4 Grade 3; painful Grade 3 Grade 3 Grade 2; Painful Grade 3; painful Grade 2; painful Grade 2; painful Grade 1; painful Extensor Indicis, Extensor Digiti Grade 2; painful Minimi & Extensor Digitorum Palmaris Longus Lumbricales Palmar Interossei Grade 2; painful Grade 3 Grade 3 Dorsal Interossei Flexor Digiti Minimi Opponens Digiti Minimi Abductor Digiti Minimi Extensor Pollicis Brevis Extensor Pollicis Longus Grade 3 Grade 3 Grade 3 Grade 3; painful Grade 2; painful Grade 3; painful Grade 2; painful Grade 3; painful Grade 3 Grade 3; painful Grade 2; painful Grade 3 Flexor Pollicis Brevis Flexor Pollicis Longus Opponens Pollicis Abductor Pollicis longus Abductor Pollicis Brevis Adductor Pollicis Left Grade 5 Trunk Grade 4 Grade 3 Left Grade 3 Grade 3 Grade 4 Grade 3 Grade 3 Grade 3 Grade 3 Grade 3 Grade 3 Grade 3 Grade 3 Grade 4 Grade 3 Grade 3 Grade 2; painful Grade 3; painful Grade 1; painful Grade 3; painful Grade 2; painful Grade 3 Right muscles Grade 5 Upper Abdominal (Rectus Abdominis) Anterior Neck Flexors (Longus Grade 4 Capitis, Longus Colli, Rectus Capiti Anterior, Sternocleidomastoid, Anterior Scalene, Suprahyoid, Infrahyoid.) Anterolateral Neck Grade 3 Flexors (Sternocleidomastoid & Scalene) Lower extremity Right Gluteus Maximus Grade 3 Tensor Fasciae Latae Grade 2 Quadriceps Femoris Grade 4 Hip Flexor Iliopsoas Grade 3 Hip Adductors (Pectineus, Grade 3 Gracilis, Adductor Longus, Adductor Magnus & Brevis) Gluteus Medius & Minimis Lateral Rotator of Hip Joint (Quadratus Femoris, Obturator internus & externus, Gemellus Superior & Inferior, Piriformis) Lateral & Medial Hamstrings (Bicep Femoris & Semimembranosus, Semitendinosus) Tricep Surae (Ankle Plantar Flexor) Peroneus Longus & Brevis (Plantar Pronator) Tibialis Posterior (Plantar Supinator) Tibialis Anterior (Dorsal Supinator) Extensor Digitorum & Extensor Hallucis Longus & Brevis Flexor Hallucis Longus & Brevis Grade 3 Grade 3 Grade 3 Grade 3 Grade 3 Grade 3 Grade 3 Grade 2 Grade 3 Flexor Digitorum Longus Flexor Digitorum Brevis Plantar Interossei Dorsal Interossei Abductor Hallucis Grade 3 Grade 3 Grade 2 Grade 2 Grade 2 Grade 3 Grade 3 Grade 2 Grade 2 Grade 2 Investigations – 1. Blood tests – Rheumatoid factor (RF) - The normal RF range is 0–20 units per ml. Having a higher level than this might point to RA, but this alone does not confirm the presence of the condition. Several other health conditions can increase levels of RF in the body, and around 5% of people with high RF levels do not have RA. Rheumatoid factor is a type of antibody found in an estimated 80% of rheumatoid arthritis patients. It’s an antibody that attacks healthy tissue and leads to joint inflammation potentially resulting in the development of rheumatoid arthritis symptoms. Peptide (CCP) – Anti-CCP is thought to be present in anywhere between 60% and 80% of rheumatoid arthritis patients. The presence of anti-CCP and rheumatoid factor in a patient’s blood provides a strong case for making a rheumatoid arthritis diagnosis, provided the patient’s symptoms are also clearly consistent with rheumatoid arthritis. Erythrocyte Sedimentation Rate (ESR) C-Reactive Protein (CRP) Antinuclear Antibody (ANA) - ANA testing looks for the presence of ANAs and can help confirm a rheumatoid arthritis diagnosis. Cyclic Citrullinated None of these tests can singularly conclude that a patient has rheumatoid arthritis. Rather, doctors look at the combined results from all, alongside a number of other criteria including physical symptoms and genetics, in order to reach a rheumatoid arthritis diagnosis. Results Meaning positive CCP antibodies and positive RF The person likely has RA. positive CCP antibodies and negative RF The person has early stage RA or is likely to develop it. negative CCP antibodies and negative RF The person has a lower chance of developing RA. The normal range of anti-CCP is 0–20 units per milliliter (ml). If a person has more than this, they may have RA. X-ray the hands and feet in adults with suspected RA and persistent synovitis. With advanced disease, joint involvement on plain radiographs will reveal periarticular osteopenia, joint space narrowing, and bony erosions (marginal). Erosions of cartilage and bone are considered pathognomonic findings for RA, although not absolutely specific. However, these findings are consistent with advanced disease. Magnetic resonance imaging (MRI) and ultrasonography are useful in early disease before radiographic evidence of bone erosion occurs. A decreased signal from the bone marrow on T1-weighted images and gadolinium-enhanced images indicates bone marrow edema. MRI can also reveal synovial thickening, which has been shown to predict the future presence of bony erosions. The clinical utility of MRI and its incorporation into the diagnostic criteria for RA remains to be determined. Synovial fluid examination usually reveals a leukocyte count between 1500 to 25,000/cubic mm and is predominantly polymorphonuclear cells. Cell counts higher than 25000/cubic mm are rare and can be seen with very active disease; however, they warrant workup to rule out underlying infection. The synovial fluid in RA will also reveal low C3 and C4 levels despite elevated serum levels.
