RHEUMATOID ARTHRITIS AND REHABILITATION

1. RHEUMATOID ARTHRITIS AND REHABILITATION Prof.Dr. Ülkü Akarırmak

2. Rheumatic Diseases • Rheumatoid arthritis • Ankylosing spondylitis and other spondyloarthropathies • Osteoarthritis

3. 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

4. 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.

6. 2010 ACR/EULARClassification Criteria for RA ≥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

7. The Consequences of RA • Decline in functional status • Work disability • Co-morbidity • Increased mortality

9. Rationale for Early Intervention • Some patients have early progressive disease • Joint damage begins within 6 months - 1years of onset • Disease modification thought to correlate with control of inflammation

10. 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.

11. Several classes of drugs for treatment of RA • NSAIDs • DMARDs (which includes both traditional DMARDs and biologic agents), glucocorticoids, and, • If needed, pain medications.

12. 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.

13. 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.

14. 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.

15. 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.

16. 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 oflife

17. 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)

18. 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

20. Flare-up Periods • Resting • Splints • Positioning • Bed rest

22. Joint Head and neck . Wrist Thumb Finger . Hips . . Knee Deformity Flexion, rotation . Palmar flexion Flexion Flexion, ulnar deviation Flexion,adduction, external rotation . Flexion Deformities in RA 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

24. Splinting • Relieve pain • Relieve muscle spasm • Prevent deformity

25. X-Ray of RA Hand

28. NonpharmacologicTherapy • Education program • Physiotherapy • Occupational therapy • Support from social workers

29. Physiotherapy • Effective in maintaining the range of motion • Strengthening of muscles • Prevent contractures • Prevent deformities • Maintain activities of daily living

30. 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

31. 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

36. Occupational Therapy • Education of patients in the use of daily living activities • Prevention of joint contractures and deformities

42. Management of Ankylosing Spondylitis • Rehabilitation • Exercises • Hydrotherapy

43. 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

44. Education • Life style modification • Exercises on a regular basis • Posture awareness • Swimming • Spa • Quit smoking • Patient schools • Secondary osteoporosis evaluation