What can you do with a patient who has had a stroke, and has long-term RA? Unfortunately, there is nothing in the literature for RA, stroke, and PT. However there are two relevant articles for RA, as well as a chapter from a textbook (this post is not intended to be a thorough/critical review).
A brief review of RA
RA is a systemic autoimmune disease affecting the joints; mainly peripheral synovial joints are affected (fingers, wrists), but also knees and more proximal joints; women affected 2-3x more than men, with age of onset 35-45. The joints become swollen, warm, painful, and red, resulting from inflamed synovium and soft-tissue swelling. The cartilage is destroyed and replaced by a pannus, and the edges of the bone are worn, resulting in joint deformity (the classic ulnar drift, as well as the navicular dropping), an increase in swelling from the inflamation, and the synovium and joint capsule become thickened. It is progressive, and can lead to secondary osteoarthritic changes (such as in the weight-bearing joints, such as the knee), and to disuse atrophy.
It can also affect the skin (rheumatoid nodules, over extensor of forearm and bony prominences; vasculitis), the eyes (destroying the lacrimal and mucous glads, leading to dry eyes, with can result in inflammation of the cornea; degeneration of collagenous tissue), the lungs (interstitial pneumonitis, fibrosing alveolitis), the blood (anemia). (the above information from Pathology by A Stevens and J Lowe, 2nd ed, 2000).
1. Oldfield V, Felson DT. Exercise therapy and orthotic devices in rheumatoid arthritis: evidence-based review. Current Opin Rheumatol 2008; 20:353-359.
Exercise therapy (aerobic, strengthening) improves symptoms of pain and fatigue, and QoL, but does not change disease activity for the better.
2. Christie A, Jamtvedt G, Dahm KT, Moe RH, Haavardsholm EA, Haven KB. Effectiveness of nonpharmacological and nonsurgical interventions for patients with rheumatoid arthritis: an overview of systematic reviews. Phys Ther 2007; 87:1697-1715.
Highest quality of evidence is for teaching joint protection. There is evidence for exercise but the quality is low (reduces pain, improves function); the same for US, but for low level laser the quality is moderate. There is a disagreement noted between the American College of Rheumatology with recommends education, joint protection, conservation of energy, and a HEP for ROM and strengthening, and the authors of this paper which found evidence lacking for exercise at this time.
3. Kisner and Colby. Therapeutic Exercise, 5th edition, 2007.
During active phase of RA: educate the patient about rest, joint protection, energy conservation, ROM exercises; use massage, modalities, splints, and relaxation techniques to relieve pain, muscle guarding. Use PROM/ AAROM, grade I or II mobilization to miminmize joint stiffness and mainain ROM; gentle isometrics progressing to ROM when tolerated. Precautions: If pt has fatigue or increased pain, stop; don’t overstress lax ligaments or bones with osteoporosis. Contraindications: don’t stretch swollen joints or apply heavy resistance.
Trying to balance the comorbidities of RA and stroke may be a challenge, but it seems the activity and symptoms of the RA will dictate how you would treat the impairments from a stroke.