Rheumatoid Arthritis, pathology ,Clinical features

It is thought to be an autoimmune disease involving the synovium, often affecting several joints at the same time. The joints are affected symmetrically and eventually there is destruction of articular cartilage, capsule, ligaments and tendons, leading to deformity. Eventually joints are destroyed, fibrosed, ankylosed. eighty percent affected are women. Male : Female ratio - 1:3.

Etiology:-

The exact cause is unknown but malfunction of the cellular and humoral arms of the immune system are cited as the probable cause.

Pathology:-

Due to synthesis of auto-antibodies, against unknown antigenic agents in the synovium, primary synovitis sets in. This primary synovitis gets rise to pannus, which in turn forms the villus. This villus migrates towards the joint causing its degeneration and ankylosis, fibrous in the early stages followed by ankylosis in the late stages. 

Clinical features:-

Pain, swelling, stiffness, of small joints of hands  and feet.

history of weight loss, lethargy and depression.

joint swelling could be symmetrical and the patient present with deformities of bones and joints in late stage, exacerbation of symptoms with seasonal changes, symptoms fluctuate from day-to-day.

Other presentations This consists of palindromic presentation involving one or two joints, systemic presentation usually seen in middle aged men presenting with pleurisy, pericarditis, etc., it may present as polymyalgia particularly in elderly patients. it may present with monoarthritic swelling. 

Extra-articular features:-Two or more features are present with75 % of cases

• Subcutaneous nodules are present in25% of cases
• Widespread vasculitis.
• Blood abnormalities 
• Osteoporosis
• Eye changes
• Lung affections
• Heart affections
• Neurological system
• Reticuloendothelial system.

Investigations:-

laboratory HB % is low and shows normochromic, hypochromic anemia. WBC are decreased or normal, there are increased lymphocytes and the ESR is raised.

Radiological features

• Soft tissue swelling 
• Juxta-articular osteoporosis.
• Erosion of joint margins.
• Joint spaces are decreased.
• Deformities.
• Atlantoaxial subluxation
• Subchondral erosions and cyst formation
• Fibrous and bony ankylosis develops in late stages.

Others common abnormalities These include increased C reactive protein, increased alkaline phosphatase, increased platelets, and decreased serum albumin.

Synovial fluid analysis it typically yellow, Watery and turbid due to high WBC and has low sugar content.

Management:-General measures:-

• Rest in bed
• Good diet, rich in proteins and minerals.
• Transfusion and haematinics to correct the anemia.
• Hormones combination of estrogen and androgen to improve the bone stock.
• Removal of infective foci.
• Splinting is the functional positions helps in the event that ankylosis ensues.

Drug therapy:-

Three classes of drugs are used regularly:

• Analgesics
• Anti-inflammatory drugs
• Disease modifying drugs

Steroids especially intra-articular injections have an important role.

Surgery:-

Synovectomy:-

• Failed chemotherapy
• Joint destruction should be minimal
• Useful in knee/ankle.

Osteotomy:-

• Less than 60 years of age.
• When joint is partially damaged.
• Commonly done at hip(Intertrochanteric osteotomy and abduction osteotomy).

Arthrodesis:-

• Long-term relief
• Reserved for peripheral joints where arthroplasty results in pain.
• Causes secondary osteoarthritis in bigger joints.

Arthroplasty:-

• Advanced stages.
• In hip and knee.

Physiotherapy Measures:-

During the acute phase

• Measures to control pain

Cryotherapy:- Cold - pack, ice, nitrogen spray, and cryotherapy are different methods of applying cold therapy

Thermotherapy:- Superficial hot-pack, infrared radiation, paraffin, fluido therapy, or hydrotherapy.10-20 min twice a day

TENS and interferential current of 90-100 Hz is recommended, tens is generally a short acting therapy and the most beneficial frequency is 70 Hz.

• Deep breathing exercises
• Isometric exercises to the shoulder, hip and knee muscles are recommended.
• Active ROM exercises to all the joints.
• Splints should be used to maintain the joints in functional position.
• Postural guidance.
• Hydrotherapy (pool therapy) helps to increase ROM, to strengthen muscles, to relieve painful muscle spasm and to improve the patients well-being.

During the chronic phase

measures to prevent contractures.

1. Proper positioning of the joints:

• Spine is prone for flexion contracture, hence prone posture is encouraged.
• Hip joints To prevent flexion contractures of hip, prone lying position, firm bed, avoiding pillow under the knee are recommended.
• Knee joints Efforts are made to avoid flexion attitude of the knee, by repeatedly stretching it, active and active assisted exercises, etc.
• Ankle and foot Active ROM exercises to the ankle and foot are recommended
• Shoulder full ROM exercises to the ankle and foot are recommended.
• Elbow is immobilized in extension to prevent the flexion contractures.
• Wrist and hand Active ROM exercises to the hand and proper splinting are recommended to prevent various deformities of the hand.

      2. Use of splints Splint plays a big role in not only preventing but also correcting various deformities of the joints due to RA 

Ten self - help techniques

1. Positive mental attitude
2. Regular medication
3. Regular exercises
4. Use of joints
5. Energy conservation
6. Assistive device
7. Adequate sleep
8. Massage
9. Relaxation techniques
10. Modification in the daily activities

• Using western toilets
• Bath aids and railings
• Long handle broomstick and mop to clean the floors
• Use of walking sticks while walking, climbing, etc., 
• High chairs
• Avoid squatting on the ground for food, etc., use of dining table and chairs are recommended.
• To avoid squeezing clothes after washing and just rinsing them dry
• To avoid walking on hard and uneven and rough surfaces.
• To sleep on a hard surfaces.