Rheumatoid Arthritis

An autoimmune, chronic, inflammatory, systemic disease primarily 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.

Background and Characteristics

  • Source of pain is inflammation of the synovium
  • Typically presents bilaterally, with >=3 joints involved, redness and increased skin temperature
  • Higher incidence in women and can be diagnosed in childhood (Juvenile Rheumatoid Arthritis (JRA))
  • Autoimmune response is thought to be triggered by some bacterial or viral exposure
  • Some association with family history and presence of rheumatoid factor (RF) in the blood
  • Morning stiffness in affected joints can last an hour or more
  • May also lead to osteopenia (bone thinning) in wrist and hands

Pharmacology Management

Prednisone and other steroid-based medications are used to treat RA. There are numerous drug side effects, including an increased tendon rupture and muscle weakness, particularly proximal muscles, which can increase pain, limitation and disability.

Principles of Management of Rheumatoid Arthritis

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Acute Inflammatory Period

  • Joint protection
    • especially the smaller joints in the hands and feet
    • splinting to protect from subluxation due to hypermobility from synovial degeneration
    • includes patient instruction in correct exercise technique to prevent further joint stresses during activity
  • Energy conservation
  • Joint mobility
    • stretching is NOT performed when joints are swollen (increased risk for subluxation)

  href="https://commons.wikimedia.org/wiki/File:Rheumatoid-Arthritis.png" title="National Library Of Medicine US / Public domain">Rheumatoid-ArthritisNational Library Of Medicine US / Public domain

Consider the image above: think about how muscle and ligaments involved at the knee might be affected by this type of inflammation.

  • Exercise
    • PROM, AAROM, AROM depending on pain and swelling in affected joints
  • Functional training
    • similar to OA; instruction in methods to incorporate joint protection in everyday activities

Subacute and Chronic Stages

alternative accessible content Rheumatoid arthritis -- Smart-Servier (cropped)

href="https://commons.wikimedia.org/wiki/File:Rheumatoid_arthritis_--_Smart-Servier_(cropped).jpg" title="via Wikimedia Commons">Laboratoires Servier / CC BY-SA

Common deformities at the wrist and hand in RA include

  • Boutonniere deformity of thumb
  • Ulnar deviation of metacarpophalangeal joints
  • Swan-neck deformity of fingers

Exercise considerations

  • To improve function, exercise should be aimed at
    • improving flexibility, muscle performance, and cardiopulmonary endurance
    • Nonimpact or low-impact conditioning exercises such as swimming and bicycling
    • Group activities such as water aerobics

Juvenile RA

  • classified as inflammatory, autoimmune arthritis lasting at least 6 weeks in a child younger than sixteen
  • three major subcategories:
    • systemic onset - includes spiking fevers and a short-duration rash in the trunk and extremities
    • polyarticular - five or more joints; often affects the same joint bilaterally
    • pauciarticlar - typically affects just one joint but as many as four; most common in the knee
  • benefits from PT/home exercise program in
    • avoiding high-impact activities
    • splinting to rest joints
    • engaging in fun, low impact endurance activities
    • daily prone positioning to stretch hip and knee flexors
    • exercise to encourage neutral and upright posture
    • monitoring and correcting leg length discrepancies