12 Inflammatory Arthritides

Question 1

What are the four stages of rheumatoid arthritis?

Answer 1

1. Synovitis: There is inflammation of the synovial membrane and joint effusion.
2. Pannus formation: An abnormal form of granulation tissue. An extensive network of new blood vessels forms in the synovium. This contributes to the inflammation. Pannus formation extends to the joint margins. Enzymes are released that destroy articular cartilage and bone.
3. Fibrosis: intra-articular adhesions form as a result of the inflammation. This will lead to decreased ROM of associated joints.
4. Bony ankylosis: calcification of the panni and fibrous tissue. This leads to joint fusion (ankylosis), which leads to deformity and disuse atrophy.

Question 2

Flareups and the remissions are common in RA. What are the clinical manifestations during flareups?

Answer 2

• Generalized arthralgia
• Fatigue
• Anorexia and associated weight loss
• Presentation is usually bilateral and symmetrical, involving more than one joint
• Patients often feel stiffness in the morning that lasts for an hour or more
• Progressive joint destruction may lead to instability and possible subluxation
  
  • Rheumatoid nodules may appear, as well as fibrosis of muscles with associated muscle weakness and atrophy
  • Asymmetry in muscle strength and alterations in the line of pull of muscles and tendons add to deforming forces
• The most commonly affected joints are in the hands, feet and knees

Question 3

What’s the difference between swan neck and boutonniere/zigzag deformity?

Answer 3

Question 4

During RA flare-ups, RMT’s job is to:

Answer 4

• treat inflammation (Cryotherapy, LD)
• Normalize sympathetic firing

Question 5

Between RA flare-ups, maintaining ROM is important. We do this by:

Answer 5

• Treating TrPs, spasm, unnecessary muscle tension
• Be careful with joint play – the joint capsule will be fragile
• Lengthening and strengthening should be considered (self-care)
• Postural education and consultation on sleeping position may be necessary
• NB: If C1-C1 is involved, overpressure, tractioning of the upper quadrant is CI’d. High MRT in the suboccipital’s will stabilize the region, so tone should not be reduced by very much. Keep the head in a neutral position while treating.