RHEUMATOID ARTHRITIS
AND REHABILITATION
Prof. Dr. Ülkü Akarırmak
Rheumatic Diseases
• Rheumatoid arthritis
• Ankylosing spondylitis and other
spondyloarthropathies
• Osteoarthritis
What is Rheumatoid Arthritis?
RA is a chronic inflammatory condition which:
•
•
•
•
Affects 1-2% of the adult population
Is more common among women than in men
Usually appears between ages 25 and 40 years
Causes pain, disability and loss of function
Rheumatoid Arthritis Background
RA is a chronic autoimmune disorder.
The disease results from the interplay between an
individual's genetic background and unknown
environmental triggers.
Human leukocyte antigens (HLAs) account for
~30% of the heritable risk. Most of the genetic
components are largely unknown.
2010 ACR/EULAR
Classification Criteria for RA
JOINT DISTRIBUTION (0-5)
1 large joint
0
2-10 large joints
1
1-3 small joints (large joints not counted)
2
4-10 small joints (large joints not counted)
3
>10 joints (at least one small joint)
5
SEROLOGY (0-3)
≥6 = definite RA
What if the score is <6?
Patient might fulfill the criteria…
Negative RF AND negative ACPA
0
Low positive RF OR low positive ACPA
2
High positive RF OR high positive ACPA
3
 Prospectively over time
(cumulatively)
SYMPTOM DURATION (0-1)
<6 weeks
0
≥6 weeks
1
ACUTE PHASE REACTANTS (0-1)
Normal CRP AND normal ESR
0
Abnormal CRP OR abnormal ESR
1
 Retrospectively if data on all
four domains have been
adequately recorded in the past
The Consequences of RA
• Decline in functional status
• Work disability
• Co-morbidity
• Increased mortality
Rationale for Early Intervention
• Some patients have early progressive
disease
• Joint damage begins within 6 months - 1
years of onset
• Disease modification thought to correlate
with control of inflammation
RHEUMATOID ARTHRITIS
MEDICATIONS
• Medications are the cornerstone of treatment for active RA
• The goals of treatment with RA medications are to achieve
remission and prevent further damage of the joints and loss of
function, without causing permanent or unacceptable side effects.
• The type and intensity of RA treatment depends upon individual
factors and potential drug side effects.
• The challenge of using medications is to balance the side effects
against the need to control inflammation. All patients with RA
who use medications need regular medical care and blood tests to
monitor for complications. If side effects occur, they can often be
minimized or eliminated by reducing the dose or switching to a
different drug.
Several classes of drugs for
treatment of RA
• NSAIDs
• DMARDs (which includes both traditional
DMARDs and biologic agents),
glucocorticoids, and,
• If needed, pain medications.
Disease-modifying antirheumatic drugs
DMARDs
• DMARDs can substantially reduce the inflammation of RA, reduce or
prevent joint damage, preserve joint structure and function, and enable
a person to continue his or her daily activities. Although some
DMARDs act slowly, they may allow to take a lower dose of
glucocorticoids to control pain and inflammation.
• Drugs in this class include methotrexate,
hydroxychloroquine, sulfasalazine, and
leflunomide.
• An improvement in symptoms may require four to six weeks of
treatment with methotrexate, one to two months of treatment with
sulfasalazine, and two to three months of treatment with
hydroxychloroquine. Even longer durations of treatment may be
needed to derive the full benefits of these drugs.
Biologic Agents
• Biologics, are DMARDs that were designed to reduce the
inflammation that damages joints. Biologics target molecules on
cells of the immune system, joints, and the products that are
secreted in the joint. There are several types of biologics, each of
which targets a specific type of molecule involved in this process.
• Biologics are often reserved for people who have not completely
responded to DMARDs .
• Biologics that bind tumor necrosis factor (TNF) include
• etanercept,
• adalimumab,
• infliximab,
• certolizumab pegol, and golimumab. These are called anti-TNF
agents or TNF inhibitors.
Biologic Agents
There are additional biologics that target other molecules
instead of TNF. These are for people with arthritis that is
not well controlled with methotrexate and one of the antiTNF agents.
• Biologics tend to work rapidly, within two weeks and four
to six weeks. Biologics may be used alone or in
combination with other DMARDs (eg, methotrexate),
NSAIDs, and/or glucocorticoids (steroids).
• All biologic agents must be injected. Some can be
injected under the skin by the patient, a family member, or
nurse; there are others that must be injected into a vein,
which is typically done in a doctor's office or clinic; this
takes between one and three hours to complete.
Nonsteroidal antiinflammatory drugs
(NSAIDs)
• NSAIDs are recommended to relieve pain and reduce minor
inflammation. However, NSAIDs do not reduce the long-term
damaging effects of rheumatoid arthritis on the joints.
• NSAIDs must be taken continuously and at a specific dose to have an
antiinflammatory effect. Even at the correct doses, NSAIDs must
usually be taken for several weeks before their effectiveness is known.
If the initial dose of NSAIDs does not improve symptoms, a clinician
may recommend increasing the dose gradually or switching to another
NSAID.
• Many NSAIDS have significant side effects, including gastrointestinal
bleeding, fluid retention, and an increased risk of heart disease. The
risks need to weighed carefully against the benefit when taking these
drugs.
Therapeutic Goals
• Control of pain
• Suppression of inflammation of the CRP and the
absence of swollen joints
• Control of joint damage
• Maintenance of normal daily activities
• Maximization of quality of life
Optimal Management Strategies
• Early diagnosis
• Rapid assessment of likely prognosis and initiation of
appropriate therapy
• Early use of effective second-line agents, including,
when required, the use of agents that act at different
levels
• Rest when joints are actively inflamed
• Physiotherapy when inflammation is suppressed
(multidisciplinary approach)
Multidisciplinary Approach
• Bed rest during active disease
• Splinting of actively inflamed joints
• Behavioral approach for inadequate pain
control
• Bone-sparing agents (for osteoporosis)
when inflammation is uncontrollable
Flare-up Periods
• Resting
• Splints
• Positioning
• Bed rest
Deformities in RA
Joint
Deformity
Position of Splinting
Head and neck .Flexion, rotation .
Full extension, cervical spine,
chin forward
Palmar flexion
Wrist
30 degreees dorsiflexion
Thumb
Flexion
Finger
. Flexion, ulnar deviation Extension, apposition
Extension, no lateral deviation
Hips
. Flexion,adduction,
.
external rotation . Extension,in the line with
body;foot pointing upward
Knee
Flexion
Extension
Splinting
• Relieve pain
• Relieve muscle spasm
• Prevent deformity
X-Ray of RA Hand
Nonpharmacologic Therapy
• Education program
• Physiotherapy
• Occupational therapy
• Support from social workers
Physiotherapy
•
•
•
•
•
Effective in maintaining the range of motion
Strengthening of muscles
Prevent contractures
Prevent deformities
Maintain activities of daily living
Physiotherapy
Methods
I - Exercises
II- Cold treatment: During stages of acute
inflammation
III- Heating modalities: During subacute and
chronic stages of the disease
IV- TENS: Pain control
V- Hydrotherapy
Exercises
Acute stage
I.
- Preservation of ROM
- ROM and izometric exercises
Subacute stage
III. Chronic stage
II.
- Increasing strength and endurance
- Strengthening and endurance exercises,
ROM exercises, stretching
Occupational Therapy
• Education of patients in the use of daily
living activities
• Prevention of joint contractures and
deformities
Management of Ankylosing
Spondylitis
• Rehabilitation
• Exercises
• Hydrotherapy
Exercises in the Management of
Ankylosing Spondylitis
- Posture exercises
- Range of motion exercises
(Flexibility exercises&stretching)
ı. Hip
ıı. Knee
ııı. Spine (cervical-dorsal-lumbar)
- Respitatory exercises
- Strengthening exercises: Core muscles
Education
•
•
•
•
•
•
•
•
Life style modification
Exercises on a regular basis
Posture awareness
Swimming
Spa
Quit smoking
Patient schools
Secondary osteoporosis evaluation
Strengthening of Back
Srengthening of Gluteal Muscles
Hydrotherapy + Group Therapy
Questions
• Comments?