TREATMENT AND MANAGEMENT OPTIONS FOR RHEUMATOID ARTHRITIS

What is Rheumatoid Arthritis?

It is a disorder of the body system involving inflammation and degenerative changes principally in the small and large synovial joints. This is often associated with a lot of systemic disturbance and extra-articular disease. It usually pursues a chronic course that is life-long, with intermittent exacerbations and remissions with highly variable severity of symptoms and signs.

What is the cause?

The cause of the disease is unknown but autoimmunity plays a major role in its chronicity and manifestations and it is often considered to be a systemic autoimmune disease.

What are the signs and symptoms for diagnosis?

Most patients experience at least four or more of the following symptoms and signs of the disease by the time they present themselves for treatment at the clinic:-

•  Morning stiffness (> 1 hour)
•  Arthritis of hand joints
•  Symmetrical Arthritis
•  Arthritis of three or more joint areas
•  Rheumatoid nodules
•  Rheumatoid factor
•  Radiological changes seen on X-ray of joints
•  Problem has been on for more than 6 weeks

Most commonly patients present with a gradual onset of arthralgia (often symmetrical) and synovitis of the small joints of the hands, wrist and feet. In some, onset may be paindromic, with recurrent acute episodes of joint pain and swelling which may last from a few hours to days. Whatever pattern of presentation, most sufferers have evidence of morning and inactivity stiffness and stress pain.

It is to be noted that RA is a systemic disease and other extra-articular areas of the body may be affected. These include:-

• The Muscles and Tendons
• The blood vessels and Lymphatic’s including Lymph nodes
• The Lungs
• The heart
• The Nerves and nervous system
• Amyloidosis

Treatment Options and Management:

In the U.S.A. about 1.3 million people are affected by the disease, being three times more prevalent in women especially during the post-partum and breastfeeding periods. Age of onset is usually between 40 to 50 years but it can occur in any age group.

For the majority of patients, the aims of management are:-

1. To educate the patient
2. Control pain
3. Optimize bodily functions, especially that of the joints
4. Modify the disease process in such a way that will most benefit the patient

Since there is a wide variety of treatment modules, the expertise of a number of health professionals working synergistically together may be required for most patients. The patients’ symptoms and signs change with time and will usually require adjustments of the treatment modules. There is no cure for RA. Medications help to reduce joint inflammation, pain, and slow down joint damage, while occupational and physical therapy teach on how to protect the joints and how to make use of adaptive utensils where there is joint deformity causing limitations of movement. Severely damaged joints by RA may require surgery to regain some appreciable functionality back.

Type of Medications in Use:

The following are the various drugs used to treat RA. Most patients require a combination of drugs to get the most beneficial effect:-

•  Steroids:- These help reduce the inflammatory process and slow down the damage to joints. It cannot be used for long term treatment because of its undesirable side effects. Most of the time it is prescribed to relieve the acute symptoms of the disease. Those usually prescribed include Prednisone and methylprednisolone (Medrol).
•  Disease Modifying Antirheumatic Drugs (DMARDs):-These are drugs that act to slow down the auto-immune destructive processes of RA, thus saving the joints and other tissues from permanent damage. Among the common one’s often prescribed are: Minocycline (Minocin), Methotrexate (Trexall), Hydroxychloroquine (Plaquenil)
•  TNF-alpha Inhibitors:-These inhibit a destructive substance, Tumor necrosis factor alpha, produced in the body causing severe inflammatory activity in various body tissues. Use of these drugs help to reduce morning stiffness, and painful swelling of the joints. They include; Infliximab (Remicade) and Adalimumab (Humira).
•  NSAIDs:-These are Non Steroidal Anti Inflammatory Drugs and are used to relieve pain and reduce inflammation. They include Ibuprofen (Advil), and Naproxen sodium (Aleve), which are off the counter drugs (OTC). Stronger ones in this group are prescription only drugs
• Immunosuppressants:- These are drugs that try to correct the abnormal behavior of the immune body system in RA. Examples include Cyclophosphamide (Cytoxan), Azathioprine (Imuran) and Cyclosporine (Neoral)

Other Medications:-

There are some other inflammatory substances produced by the body in RA. These act as targets for some other drugs used in the treatment of RA. They include Abatacept (Orencia), Rituximab (Rituxan) and Anakinra (Kineret).

Exercise and Occupational Therapy:-

Occupational therapists play a very important role in the treatment and management of RA patients. They teach them basic exercise movements that will help affected joints not to become stiff. They also help them to find different methods to approach everyday tasks in ways that take stress off painful joints and also teach and encourage the use of assistive devices to make their work easier.

Surgery:-

This should be a last resort when all else has failed and there is evidence of damage to joints.

The different types of Surgery performed for RA are as follows:-

• Total joint replacement (Arthroplasty)
• Tendon repair 
• Removal of the joint lining (Synovectomy)
•  Joint fusion (Arthrodesis)

Author: Ola Suyee

                                                                                                                                                                                                                                                                                                 

CORE TRAINING ANATOMY AND EXERCISE

What is core anatomy?

Core anatomy refers to the body minus the legs and arms. The major muscles involved in these core areas include the muscles of the belly, mid and lower back (external and internal obliques, tranversus abdominus, rectus abdominis, multifidus, erector spinae (sacrospinalis), longissimus thoracis, and the diaphragm. The minor muscles are distributed peripherally and include latissimus dorsi, gluteus maximus, medius and minimus and trapezius.

What are the functions of the core?

The core has the function of stabilizing the thoracic cage and the pelvis during dynamic movements. An efficient core helps to maintain a normal length-tension relationship between the muscles of the core, maintains normal muscle force coupling and optimizes arthrokinematics. It also ensures optimal efficiency of the entire kinetic chain during movements, giving dynamic stabilization to acceleration and deceleration and proximal stability to movements of the extremities as well.

It is also involved in providing internal pressure in the expulsion of substances from the abdominal cavity (passage of feces, air, and vomiting). Women employ the core muscles for labor and delivery (especially the tranversus abdominus). A weak core musculature of the pelvic region can result in either urinary or fecal incontinence or both. In summary, the core muscles are needed for:-

•  Pushing
•  Lifting 
•   Excretion
•  Birthing

The core is involved in most full-body functional movements, especially in sporting activities and it determines to a large extent, a person’s posture. The core muscles align the pelvis, spine and ribs of an individual to resist a specific force, static or dynamic.

What are the aims of core muscle training exercise?

The aims of core muscle training should include:-

• Spinal stabilization to ensure proper coordination and control of the spine and effectively utilize or restore strength, power, neuromuscular control and endurance of the major core muscles to control and protect the spine from injury.
• Facilitate and balance muscular functioning of the entire kinetic chain.
•  Enhance neuromuscular control and increase neuromuscular efficiency throughout the entire body and provide a more efficient body positioning during sporting activities and at rest.

Guidelines for Exercise Selection

The exercises should be such that will be safe, challenging, proprioceptively rich, ensure stress in multiple planes, be activity specific, incorporate multi-sensory environment and be progressively functional and continuous (i.e. slow to fast, simple to complex, low force to high force, static to dynamic, known to unknown etc)

Exercises:-

There are various types of exercises designed to train the core muscles and guidelines for selecting some of them has been given above. These exercises may include:-

1.  The McGill stability exercises
2.  Pilates exercises
3.  Swiss ball program
4.  Balance board
5.  Shoe training program

and many more. For the abdominal muscles like rectus abdominis, internal and external obliques, they can be trained using the abdominal hollowing technique. This involves the athlete lying on his or her back in the neutral position, he/she is instructed to relax the muscles of the abdomen, bend the knees and while slowly exhaling, pull the lower abdomen inwards as if trying to push the belly button (umbilicus) towards the floor. This is a common exercise known as zipping-up maneuver. This technique can be combined with other exercises involving the lower extremities like straight leg lifts and knee to chest exercises. The athlete must always remember to begin with the abdominal hollowing technique before adding limb movements exercises.

It is to be noted that abdominal exercises are an important part of any core training program, for example, it forms a major part of coordination and control exercises that are designed to help the body proprioceptive systems coordinate muscle control to prevent injury during movements or when colliding into external forces as is the case in some sports (e.g.rughy).

Author: Ola Suyee