Rheumatoid arthritis

Question 1

what is rheumatoid arthritis?

Answer 1

it is autoimmune condition that causes a chronic inflammation of the synovial lining of joints,tendon sheath and bursa.
and it is systematic inflammatory joints

Question 2

what is synovitis?

Answer 2

the inflammation of synovial

Question 3

does rheumatoid arthritis tend to be symmetrical and not?

Answer 3

The rheumatoid arthritis are tend to be symmetrical & affect multiple joints

Question 4

which gender are more effected?

Answer 4

three time are more common in women than male

Question 5

age?

Answer 5

middle age

but can affect at any age

Question 6

What are the genetic associations?

Answer 6

HLA DR4

HLA DR1

Question 7

what gene often present in RF positive patients?

Answer 7

HLA DR4

Question 8

what gene occasionally present in RA patients?

Answer 8

HLA DR1

Question 9

which antibody found in ra?

Answer 9

rheumatoid factor (70%)
cyclic citrullinated peptide antibodies

Question 10

Presentation?

Answer 10

• symmetrical distal polyarthropathy
• stiffness
• pain
• swelling
• pt. usually complain pain in the small joints of the hands and feet, typically the wrist, ankle ,mcp and pip joints in the hand.
• they can also affected larger joints such as the knees, shoulder and elbows.
• the onset can be very rapis (i.e overnight) or over months to years.

other associates symptoms: 
fever
weight loss
flu like illness
muscle aches and weakness

Question 11

difference between RA & OA?

Answer 11

In RA pain get worse at rest & improve with movement

In OA pain get worse with activity and improve with rest

Question 12

what is palindromic rheumatism?

Answer 12

this involves slef limiting short periods of inflammatory arthritis with joint pain, stiffness and swelling typically affecting only a few joints.this episode only last 1-2 days and then completely resolve.

Question 13

does palindromic rheumatism has RF antibodies and Anti ccp antibodies?

Answer 13

yes & may indicate it will progress to full rheumatoid arthritis

Question 14

what joints are more commonly affected?

Answer 14

Proximal interphalangeal joints
metacarpophalangeal joints
wrist and ankle
metatarsophalangeal joints
cervical spine
large joints can also be affected such as the knee hips and shoulders

Question 15

which part of joint never affected in ra?

Answer 15

distal interpahalngeal joints

if affected that’s mean they have likely to be heberden nodes due to osteoarthritis

Question 16

How ppl with get ra without any family history?

Answer 16

becoz of low immunity

Question 17

Why it is affect small joints?

Answer 17

unknown reason

Question 18

clinical features

Answer 18

affects synovial lining of joints and tendon sheath

affect ligament joint

compress nerve

deformity no fix pattern ( we can’t stop but we can progress slowly deformity)

bisymmetrical involvement (first dominant affected then non dominant (which is gradually progress after 1 year but it is bound to happen)

intrinsic weakness and tightness,contracture

mcp and wrist affected early

later ip involvement

Question 19

why mcp joints affect earlier?

Answer 19

there is no exact causes unknown but we can say becoz of synovial joint (it has classical synovial joint of the hand)

Question 20

how many tendon are there in carpal tunnel?

Answer 20

9 tendon

Question 21

what is difference between oa and ra?

Answer 21

OA is degenerative disease
RA is inflammatory disease

In OA cartilage destruction
& both rub each other

In RA the cartilage is intact
the bone are not coming each other
but it showing erosion

Question 22

early Ra

Answer 22

swelling

redness

Question 23

why ulnar shift in deviation towards ulnar?

Answer 23

our fingers deviate radial to ulnar
in any kind of activities

that’s why they are more prone to deviate in ulnar shift.!

Avoiding ulnar deviation in RA

Question 24

pt education

Answer 24

Avoid ulnar deviate

changes equipment

Question 25

deformities

Answer 25

boutonnière deformity 
swan neck deformity 
mallet finger
button hole deformity of the thumb
swan neck deformity of thumb 
adducted retropositioned thumb
palmar subluxation of distal radio ulnar joint
ulnar dift at mcp
dorsal wrist involvement 
carpal tunnel syndrome, De Quervains is common 
hourglass swelling due to constriction of middle part by doral carpal ligament 
subluxation of distal ulna
ulnar shifting of carpals
volar subluxation of wrist

Question 26

what is trigger finger?

Answer 26

pain while extension

Question 27

what is de quervains?

Answer 27

it is overuse injury
& inflammation of tendon sheath
between at the snuff box resulting in pain

finklestien test

Question 28

short term gaol?

Answer 28

30 days of goal

& every day therapist has to give goal & see improvement & this will become their habit

Question 29

Deformities?

Answer 29

boutonnière deformity 
swan neck deformity 
button hole deformity 
swan neck deformity of thumb 
Z thumb (Hitchhiker’s thumb)
Rheumatoid nodules
ulnar drift

Question 30

Hitchhiker’s thumb

Answer 30

Hitchhiker’s thumb occurs when the thumb flexes at the metacarpophalangeal joint (connecting the thumb to the palm of the hand) and hyperextends at the interphalangeal joint (the one just below your thumbnail).

This is sometimes also called the Z-shaped deformity.

Question 31

Rheumatoid nodules

Answer 31

Rheumatoid nodules are hard lumps that form under the skin near the joints. These are another common symptom of RA in the hands.

They can also occur in multiple areas, most commonly near your elbows. The nodules usually aren’t painful or debilitating, but some people might not like how they look.

Less common among people with RA are Heberden nodes and Bouchard nodes. These are visible bumps at the joints that are more typical of osteoarthritis.

Question 32

Boutonniere deformity

Answer 32

• extension of DIP
• Mcp joints with flexion of PIP joints
• capsular distension of pip joints
• capsular & bony attachment of central tendon are weakened
• relatives lengthening of central tendon
• lengthening of transverse fiberes
• lateral tendon palmar subluxation
• increased extensor tendon full on distal phalanx
• hyperextension deformity of DIP
• collapse of the 3 level system
• joint disorganisation

Question 33

Swan-neck deformity

Answer 33

Swan-neck deformity, the most common change in people with RA, occurs when there’s weakness or tearing of a ligament due to inflammation.

This results in laxity of the middle joint of the finger and flexion of the distal joint.

cause - contracture of intrinsic muscle
synovitis of the flexor tendon sheath

increase flexion pull on mcp
imbalance to the extensor central slip through the long extensor tendon and intrinsic muscle

stretch of palmar plate of pip joint

hyper extension of pip joint
stretching of transverse fibers of retinacular ligament

dorsal subluxation of lateral tendon
relatives lengthening of lateral tendon

flexion of dip due to pull of fdp

joint disorganisation

Question 34

button hole deformity

Answer 34

flexion of mcp joint with extension of ip joint
synovitis of mcp joint
epl & adductor exapansion displaced ulnarly
attachment of EPB to the base of proximal phalanx is lengthened & become ineffective

extensor tendon & extensor insertion of intrinsic muscle apply force to DIP

Question 35

swan neck deformity of thumb

Answer 35

flexion of CMC & IP with extension of mcp joint

synovitis of cmc joint

contracture of adductor pollicis

Question 36

ulnar drift

Answer 36

Ulnar deviation is also known as ulnar drift. This hand condition occurs when your knuckle bones, or metacarpophalangeal (MCP) joints, become swollen and cause your fingers to bend abnormally toward your little finger.

What are the symptoms?

Swelling in your knuckles is one of the most noticeable symptoms of ulnar deviation. You may also find that your fingers, especially your middle and index fingers, bend toward your pinky finger.

As the condition progresses, you may experience:

abnormal heat around your wrist, hand, and finger joints
pain or tenderness around your wrist, hand, and finger joints, especially when you move or flex your fingers
inability to fully flex your fingers or make a fist
tightness of your hand muscles
inability to pick up objects or do certain tasks with your index finger and thumb, such as using zippers or squeezing objects
Ulnar deviation is often linked to types of arthritis, especially rheumatoid arthritis.

Other symptoms that go along with these conditions include:

abnormal weight loss
stiffness in your hand joints and similar joints, such as your toe joints
feeling of exhaustion

What causes ulnar deviation?

One of the most common causes of ulnar deviation is rheumatoid arthritis (RA). RA is an autoimmune disorder that causes your immune system to target your joint tissue.

With RA, inflammation can cause damage to both the MCP joint and the areas surrounding the joint. Over time, this can cause your joints to wear away and your bones to erode. This may eventually make your hands look distorted.

RA doesn’t have a specific known cause. It’s thought that your genes can trigger the condition when you’re exposed to certain environmental factors, such as infection.

Osteoarthritis (OA) is also known to cause ulnar deviation. Unlike RA, OA isn’t caused by your immune system. It’s caused by your joint cartilage gradually wearing away due to overuse or age. When the cartilage has worn away significantly, your bones start to rub together in the joint. This damages the joints and can cause them to become distorted and bend.

Other causes of ulnar deviation include:

psoriatic arthritis, a type of chronic arthritis also caused by your immune system attacking your joints
lupus, another autoimmune condition that can cause joint damage associated with arthritis and other symptoms such as fevers and fatigue

Question 37

Joint Protection Principles

Answer 37

1. Planning

Think before starting ­can the work be more efficient?
Can things be re-organised?
Can certain jobs be delegated, or done less frequently?
Do work when you’re at your best
2. Pacing

Break down tasks to be little and often
Take regular breaks to change position
Mix heavy and light jobs
Start with the more difficult tasks first
3. Respect for Pain

Fear of pain results in inactivity and loss of motion and strength.
Disregard for pain can lead to poor movement patterns and can increase the pain.
Stop activities before reaching the point of discomfort or pain.
Limit activities which cause pain to last more than one hour after you have stopped the activity.

4. Balance Activity and Rest

Rest before becoming tired
Plan rest periods during longer or more difficult activities.
By resting 10 minutes during an activity, you will have more energy to continue.
5. Maintain muscle strength and joint range of motion

Achieve full range of each joint while performing daily activities.
Perform specific exercises and range-of-motion activities.
Loss of range of motion and strength leads to a loss of function.
6. Use larger, stronger joints for activities

Instead of using fingers, use wrist; instead of using wrist, use elbow; instead of using elbow, use shoulder.
For example: To lift a bag from a counter, bend knees, hug the bag with both arms. Bend elbows so that the bag is held tightly to chest and straighten knees. Keep hold on the bag by keeping elbows bent. If the load is too heavy, push shopping cart, or get help with groceries - use drive-up service.
7. Avoid staying in one position for extended periods of time.

Plan/set a reminder for when to change position.
Moving/ getting up from your desk when at work regularly will help prevent stiffness
Keep mobile
8. Maintain good movement patterns

If the body moves well it can minimise stress on joints
Proper body mechanics allows use of body more efficiently.
Try to avoid breath holding and jerky movements.
9. Loosing weight[11]

Additional weight leads to increased stress on weight-bearing joints
10. Wear splints/braces to offload joints

Use of a splint or brace can be used temporarily to help offload acutely painful joints.
Splints can also be used to immobilise smaller joints in order for them to rest
It is important to spend time out of a brace in order to maintain full ROM
11. Change the way you move objects

For example: slide pots and pans across stove and counter to sink. Use a kitchen cart to carry foods and dishes and a laundry cart for laundry.

1. Avoid tight grasp

Use a relaxed grip.
Enlarge handles.
Place palm of hand on jar lid, and using weight of body, turn arm at shoulder to open jar. A sponge or wet towel under the jar prevents sliding
Hold the knife or mixing spoon like a dagger, with the handle parallel to knuckles. Cutting is then changed from sawing to pulling
Don’t carry heavy handbags, pails, and bags by the handle.
Hold everything no tighter than necessary.
Release tight grasp frequently if you have to use it.
Use built-up handles on writing utensils, pot handles, tools, etc.
Use adaptive equipment such as jar openers.
2. Avoid weight bearing on the knuckles (Metacarpal-phalangeal joints)

Avoid putting weight against the backs of fingers
This occurs while pushing up from a chair using a closed fist or resting chin on the backs of fingers.
Use palms while holding fingers straight.
3. Use both hands when possible
4. Avoid repetitive activities

Take breaks
Change activity regularly, i.e. when doing DIY using screwdriver for a while, change the activity to painting or something different.
5. Avoid pressure to tip or pad of thumb

The thumb is needed for 40% of hand activities
Example: opening car doors, ringing doorbells
To protect thumb joints, open milk containers with heels of the hands rather than thumbs.
6. Avoid pressure against the radial side of each finger

Don’t rest chin on the side of fingers.
Add levers to keys, handles, and knobs.
Hold handles straight across the palm.
7.Avoid prolonged periods of hands in the same position

Re-position yourself often.
Move your hands frequently to ensure they do not get stiff

Question 38

splint

Answer 38

•swan neck deformity-oval 8 splint, silver ring splint
•boutonnière deformity- splinting the pip joint in extension with dip extension hook
•splinting for mp ulnar drift shift & palmar subluxation- resting splint
hand -based hinged mcp joint splint