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/EULARClassification 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)Negative RF AND negative ACPA 0

Low positive RF OR low positive ACPA 2

High positive RF OR high positive ACPA 3

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

≥6 = definite RA

What if the score is <6?

Patient might fulfill the criteria…

Prospectively over time (cumulatively)

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 anti-TNF 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

Head and neck .

Wrist

Thumb

Finger .

Hips . .

Knee

DeformityFlexion, rotation .

Palmar flexion

Flexion

Flexion, ulnar deviation

Flexion,adduction, external rotation .

Flexion

Position of Splinting

Full extension, cervical spine, chin forward

30 degreees dorsiflexion

Extension, apposition

Extension, no lateral deviation

Extension,in the line with body;foot pointing upward

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

I. Acute stage - Preservation of ROM - ROM and izometric exercises

II. Subacute stage

III. Chronic stage - 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 BackSrengthening of Gluteal Muscles

Hydrotherapy + Group Therapy

Questions

• Comments?