Rheaumatoid arthritis

RA is a chronic and progressive disease leading to considerable physical functional loss and disability. Currently, there is no curative therapy for RA; therefore, patients are subjected to various life-long treatment modalities. Thus, an important component of successful management of the disease is educating patients and informing them about the planned treatment modalities.
There is no laboratory test that is pathognomonic for rheumatoid arthritis. The treatment of patients with rheumatoid arthritis requires both pharmacological and non-pharmacological agents. Today, the standard of care is early treatment with disease modifying anti-rheumatic drugs.

What is happening in Rheumatoid arthritis?

Etiology is unknown (probably multifactorial), It is generally considered that a genetic predisposition (e.g. HLA-DR B1 which is the most common allele of HLA-DR4 involved in rheumatoid arthritis) and an environmental trigger (e.g. Epstein-Barr virus postulated as a possible antigen, but not proven) lead to an autoimmune response that is directed against synovial structures and other organs. Activation and accumulation of CD4 T cells in the synovium start a cascade of inflammatory responses which result in:
• Activation of the macrophages and synovial cells and production of cytokines (eg L4 and TNF,) which in turn cause proliferation of the synovial cells and increase the production of destructive enzymes (eg elastase and collagenase) by macrophages
• Activating B cell lymphocytes to produce various antibodies (including rheumatoid factor) which makes immune complexes that deposit in different tissues and contribute to further injury
• Directly activate endothelial cells via increased production of VCAM1, which increases the adhesion and accumulation of inflammatory cells
• Producing RANKL which in turn activate osteoclasts causing subchondral bone destruction.
The inflammatory response leads to Pannus formation.
Pannus: Is an oedematous thickened hyperplastic synovium infiltrated by lymphocytes T and B, plasmocytes, macrophages, and osteoclasts. It will gradually erode bare areas initially, followed by the articular cartilage. Goes on to causes fibrous ankylosis which eventually ossifies.

Characteristics and Clinical Presentation

In rheumatoid arthritis, joint complaints are in the foreground. The most common clinical presentation of RA is

Polyarthritis of small joints of hands:

proximal interphalangeal (PIP), metacarpophalangeal (MCP) joints and wrist. Some patients may present with monoarticular joint involvement. Late in the course of the disease patient may present with "boutonniere (flexion at PIP and extension at DIP), swan neck (flexion at DIP and extension at PIP) deformities, subluxation of MCP joints and ulnar deviation.
Commonly joint involvement occurs insidiously over a period of months, however, in some cases, joint involvement may occur over weeks or overnight. Other commonly affected joints include wrist, elbows, shoulders, hips, knees, and ankles.
Stiffness in the joints in the morning may last up to several hours, usually greater than an hour. The patient may have a "trigger finger" due to flexor tenosynovitis.
Other features may include the presence of carpal tunnel syndrome, tenosynovitis and finger deformities.
Examine the joints on swelling, pain due to palpation, pain due to movement, decreased range of motion, deformation and instability.
Hallmark symptoms such as symmetrical joint swelling and tenderness, morning stiffness, positive rheumatoid factor (RF), elevated acute phase reactants, and radiographic evidence of erosive bone loss.
Significant predictors of functional decline among persons with RA are slow gait and a weak grip.
Rheumatoid arthritis can affect almost every organ in the body
In 80-90% of the patients with rheumatoid arthritis the cervical spine is involved, which can lead to instability, caused by the ligamentous laxity (between the first and second cervical vertebrae most commonly) This instability can lead to pain and neurological symptoms, e.g. headache and tingling in the fingers.

Role of Physiotherapy

All the currently available treatments are geared towards improving the symptoms and offering a better quality of life. Treatments that achieve pain relief and the slowdown of the activity of RA to prevent disability and increase functional capacity.
Physical therapists play an integral role in the non-pharmacologic management of RA.
Physiotherapy help clients cope with chronic pain and disability through the design of programs that address flexibility, endurance, aerobic condition, range of motion (ROM), strength, bone integrity, coordination, balance and risk of falls.

Components of Physiotherapy for Rheumatoid arthritis of hands are:

▷ Exercise therapy
▷ Joint protection advice and provision of functional splinting and assistive devices
▷ Massage therapy, and
▷ Patient education.

Spondylosis

Spondylosis is another word for osteoarthritis of the spine, a condition that usually develops with age, and is the result of normal “wear and tear” on both the soft structures and bones that make up the spine.
Although any part of the spine may be affected, spondylosis is more frequently seen in the spine’s highest and lowest sections – the cervical (neck) and lumbar (low back) areas, respectively. The condition is less commonly found in the thoracic spine (middle portion), possibly because the rib cage serves to stabilize this area and make it less subject to the effects of wear and tear over time.
It encompasses numerous associated pathologies including spinal stenosis, degenerative spondylolisthesis, osteoarthritis, aging, trauma, and the daily use of the intervertebral discs, vertebrae, and associated joints.

What is happening in Spondylotic spine?

The primary risk factor and contributor to the incidence of spondylosis is age-related degeneration of the intervertebral disc and spinal elements.
The primary risk factor and contributor to the incidence of spondylosis is age-related degeneration of the intervertebral disc and spinal elements. Degenerative changes in surrounding structures, including the vertebral joints, facet joints, posterior longitudinal ligament, and ligamentum flavum all combine to cause narrowing of the spinal canal and intervertebral foramina. Consequently, the spinal cord, spinal vasculature, and nerve roots can be compressed, resulting in the three clinical syndromes in which spondylosis presents: axial pain, myelopathy, and radiculopathy.
Factors that can contribute to an accelerated disease process and early-onset spondylosis include exposure to significant spinal trauma, a congenitally narrow vertebral canal, dystonic cerebral palsy affecting cervical musculature.

Is spondylosis serious?

Because spondylosis can affect people in many different ways, there is no single answer to this question. Many cases of spondylosis are effectively treated with physical therapy and pain relief measures. However, orthopedists advise seeking more immediate care if the following symptoms, which are associated with pressure on the nerves, are present:
• Weakness, including foot drop (difficulty lifting the toes and forefoot off the floor)
• Bladder or bowel dysfunction, especially incontinence
• Changes in balance that cannot be attributed to other factors
• Numbness either in a stripe-like pattern or involving the fingers
• Severe pain, especially electrical or shock like pain
• Pain in the arms and/or legs that has not responded after attempting other nonsurgical measures like physical therapy, oral pain medications and/or spinal injections

How does physiotherapy help in treating spondylosis?

Physiotherapy is very important in the treatment of spondylosis. The symptoms of cervical spondylosis can be kept under control and can further be prevented with the help of regular physiotherapy. Moving the neck and back with spondylosis can be very painful and the person will feel reduced mobility within the joints and the spinal cord area. But a certified physiotherapist will help overcome the issues with mobility and help lead a pain-free life. Physiotherapist helps their patients by
• Getting relieved from the pain in the neck quickly.
• Helping them in maintaining and increasing neck mobility.
• They help in enhancing the flexibility of the joints.
• Through physiotherapy exercises, they help to strengthen the neck and the spine muscles, so that they support the spine better.
• They prevent further degeneration of the disc and the bones.
• Relieve nerve compression by stretching the muscles.

Inter Vertebral Disc Prolapse (Herniated disk)

A prolapsed (herniated) disc occurs when the outer fibres of the intervertebral disc are injured, and the soft material known as the nucleus pulposus, ruptures out of its enclosed space.
The prolapsed disc or ruptured disc material can enter the spinal canal, squashing the spinal cord, but more frequently the spinal nerves.
Herniated discs rarely occur in children, and are most common in young and middle-aged adults. A herniation may develop suddenly, or gradually over weeks or months.

How does it happens?

Intervertebral discs can prolapse suddenly because of excessive pressure. Examples include:
Falling from a significant height and landing on your buttocks.
Bending forwards places substantial stress on the intervertebral discs

Where do disc prolapses occur?

Intervertebral disc prolapses most commonly occur in the lumbar spine (lower back) and cervical spine (neck). Less commonly, they occur in the thoracic spine (mid-back region).

What is happening at Herniated Disc?

A prolapsed disc can cause problems in two ways:
Direct pressure: The disc material that has ruptured into the spinal canal or intervertebral foramen can put pressure on the nerves (or spinal cord).
Chemical irritation: Once ruptured, the core material of the disc can cause a chemical irritation of the nerve roots and result in inflammation of the nerves. Both the pressure on the nerve root and the chemical irritation can lead to problems with how the nerve root works.

SYMPTOMS

The symptoms of a herniated or prolapsed disc may not include back or neck pain in some individuals, although such pain is common. The main symptoms of a prolapsed disc include:
• In severe cases, loss of control of bladder and/or bowels, numbness in the genital area, and impotence (in men)
• Numbness, pins and needles, or tingling in one or both arms or legs
• Pain behind the shoulder blade(s) or in the buttock(s)
• Pain running down one or both arms or legs
• The location of these symptoms depends upon which nerve(s) has been affected. In other words, the precise location of the
• Symptoms helps determine your diagnosis.
• Weakness involving one or both arms or legs

Importance of Physiotherapy In Treating A Disc Prolapsed

Conservative i.e. non-surgical treatments for a prolapsed disc tend to focus on painkillers, analgesics and physiotherapy. However, many patients do not embrace the exercises that are prescribed for them and there can be reluctance to complete exercises at home, since patients can feel that they are in so much pain already and they are fearful that exercising will exacerbate their condition.
This is in fact a groundless fear, because the role of the physiotherapist is to help restore the patient to health and ensure that the situation does not re-occur. In fact physiotherapists play a vital role in the treatment process in three main ways:

Reducing Inflammation and Pain	Educational Advice	Re-Training Role

Frozen shoulder

Frozen Shoulder, often referred to as Adhesive capsulitis (AC), is characterized by initially painful and later progressively restricted active and passive Glenohumeral (GH) joint range of motion with spontaneous complete or nearly-complete recovery over a varied period of time. Common names for Frozen Shoulder include:

Adhesive Capsulitis	Painful stiff shoulder	Periarthritis	Idiopathic restriction of shoulder movement

What is happening in Frozen shoulder?

The disease process affects the antero-superior joint capsule, axillary recess, and the coracohumeral ligament. Patients tend to have a small joint with loss of the axillary fold, tight anterior capsule and mild or moderate synovitis but no actual adhesions.
Contracture of the rotator cuff interval has also been seen in frozen shoulder patients, and greatly contributes to the decreased range of motion seen in this population. There is continued disagreement about whether the underlying pathology is an inflammatory condition, fibrosing condition, or an algoneurodystrophic process.
It is proposed that there is an imbalance between aggressive fibrosis and a loss of normal collagenous remodeling, which can lead to stiffening of the capsule and ligamentous structures.

Frozen shoulder progresses through three overlapping clinical phases:

Acute/freezing/painful phase: Gradual onset of shoulder pain at rest with sharp pain at extremes of motion, and pain at night with sleep interruption which may last anywhere from 2-9 months.
Adhesive/frozen/stiffening phase: Pain starts to subside, progressive loss of GH motion in capsular pattern. Pain is apparent only at extremes of movement. This phase may occur at around 4 months and last till about 12 months.
Resolution/thawing phase Spontaneous, progressive improvement in functional range of motion which can last anywhere from 5 to 24 months. Despite this, some studies suggest that it's a self-limiting condition, and may last up to three years.

Role of Physiotherapy

Initial Phase: Pain relief and the exclusion of other potential causes of your frozen shoulder is the focus during this phase.
• Gentle Shoulder mobilization
• Muscle releases,
• Dry needling and Kinesiology taping
TENS
• Hot packs & Moist heat in conjunction with stretching
• Ultrasound, massage and phonophoresis
Second Phase: Decreased Range of Movement
• Pendular exercises, Shoulder pulley and wheel exercise to assist range of motion and stretch,
• Isometric strengthening in all ranges once motion
• Theraband exercises in all planes, and
• Scapular stabilization exercises,
• Muscle release techniques,
• Mobilisation with movement (MWM)
• Scapulohumeral rhythm
Third Phase: Resolution
Physiotherapy is most effective during this thawing phase. Progressed primarily by increasing stretch frequency and duration, whilst maintaining the same intensity, as tolerated by the patient. The stretch can be held for longer periods and the sessions per day can be increased. As the patient’s irritability level reduces, more intense stretching and exercises using a device, such as a pulley, can be performed to influence tissue remodeling.