Caravaggio, Michelangelo da Merisi

Spanish Empire 1571 - 1610 Spanish Empire (d.39)


Caravaggio immortalized common people with their imperfections intact often as the protagonists in holy drama. This shift from the accepted standard practice and the Classical Idealism (the idealist creation where gods walk with men) was very controversial at the time. His influence became part of the tradition of Revolutionary Realism, dramatized by inner emotions with the use of light which gave way to arcane interpretations as illustrated in the above painting, ‘Martha and Mary Magdalene' also known as The Conversion of the Magdalen’  (alternate title) ca. 1598 which is held in the Detroit Institute of Arts.

The intensity of the conversation between the two sisters is illuminated in Mary’s expression as she twirls the blossom of orange between her fingers. The models featured, Anna Bianchini (Martha) and Fillide Melandroni (Mary), were two well-known courtesans who frequented the palazzi of Del Monte and other wealthy, powerful art patrons.

 Rheumatoid Arthritis (RA)

  • autoimmune, inflammatory, systemic disease
  • RA usually effects the small joints of hands, feet, and wrists
  • pain most severe in the morning = stiffness
  • effects females more than males, and seen in children
  • RA is characterised by hyperplasia and inflammation of the synovial membrane, inflammation within the synovial fluid, and progressive destruction of the surrounding bone and cartilage
  • The cause of RA remains unknown but there is human leukocyte antigen (HLA) involvement
  • RA is believed to be initiated and driven through a T-cell mediated, antigen- specific process
  • an unidentified antigen in a susceptible host is thought to initiate a T-cell response that leads to the production of T-cell cytokines
  • other inflammatory cells, including neutrophils, macrophages, and B-cells may be involved
  • RA causes loss of joint function and deformity
  • in later stages -lung (1),

Rheumatoid Factor (RF) Test:

  • the test identifies the antibody RF
  • Rheumatoid Factor antibody is found in 80% of people diagnosed with RA
  • RF is associated with RA but not the cause of RA
  • Anti-CCP (cyclic citrullinated peptide) has a higher specificity for RA than RF?
  • Rheumatoid factor is an "anti-antibody”
  • Rheumatoid factor can be of the IgM, IgA, or IgG class
  • RF is anti-IgG, binds to IgG and forms immune complexes
  • Rheumatoid factor is the immunoglobulin that reacts with the Fc region of IgG molecule
  • increases enzymatic destruction and destruction of bone and cartilage

Geographical location of any type of rheumatoid arthritis and inflammatory polyarthropathies

Polyarthritis is any type of arthritis that involves 5 or more joints simultaneously.

Symptoms of Rheumatoid Arthritis

  • varies in severity and degrees of joint deformity; can have soft tissue and organ involvement
  • impaired posture, gait, joint mobility, motor function, muscle performance
  • history of bone nonunion  Nonsurgical Treatment
Joint appearance in RA
  • swollen with joint effusion: spindle fiber or fusiform shaped fiber, soft tissue edema, acutely painful, hot to touch, skin with erythema, loss of function
Early staged RA affects these joints most
  • Proximal Interphalangeal joints (PIPs), Metacarpophalangeal joints (MCP) in hands
  • Wrists
  • PIPs and Metatarsophalangeal joints (MTPs) of feet

Later staged RA affects these joints and tissues

  • Hips
  • Knees
  • Shoulders
  • Elbows
  • Cervical Spine
  • Temporomandibular joint (TMJ)
  • pleuropulmonary manifestations of rheumatoid arthritis - 30%


Articular Pathological Changes from RA

  • synovitis with deposition of immune complexes leading to hypertrophy and thickening one synovium, excessive production of synovial fluid, villii, pannus
  • pannus - developing in synovial membrane from chronic inflammation, villi (fingerlike projections) form on this
Muscle Atrophy in RA
  • extensive
  • may result from disuse from stiffness, pain, or damage to the tendons, ligaments, or joint
  • Fascia degraded


The course of the disease varies greatly. Some people have mild short-term symptoms, but in most the disease is progressive for life. Around 25% will have subcutaneous nodules (known as rheumatoid nodules); this is associated with a poor prognosis.(5)

Prognostic factors - Poor prognostic factors include:

  • Persistent synovitis
  • Early erosive disease
  • Extra-articular findings (including subcutaneous rheumatoid nodules)
  • Positive serum RF findings
  • Positive serum anti-CCP autoantibodies
  • Carriership of HLA-DR4 "Shared Epitope" alleles
  • Family history of RA
  • Poor functional status
  • Socioeconomic factors
  • Elevated acute phase response (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP])
  • Increased clinical severity.


Joint Deformities from RA

-Trigger Finger
-Boutonniere Deformity
-Swan-neck Deformity
-Ulnar Drift
-changes at the Radioulnar joint
-Carpal Tunnel Syndrome

-Rheumatoid Foot
-changes in Knee
-changes to Cervical Spine

Trigger Finger
  • caused by finger flexor tenosynovitis (occurs after rheumatoid nodules near tendon or flexor tendon rupture)
  • snapping type motion with attempt at flexion and extension of finger
Boutonniere Deformity
  • S&S: hyperextension of DIP, flexion of PIP, and hyperextension of MCP. Expressed in 3 stages:
  • Stage 1: mild PIP joint synovitis, normal MCP joint, and DIP may be hyperextended
  • Stage 2: PIP joint with moderate flexion of contracture (30-40 degrees), hyperextension at MCP joint with loss of finger function
  • Stage 3: destruction of PIP joint
Swan-neck Deformity
  • flexion of DIP joint and hyperextension of PIP joint
  • caused by adhesions and shortening of finger extensor tendons, and joint capsule
Ulnar Drift (Z deformity)
  • disruption of collateral ligaments of MCP joints
  • Ends in a Z-shaped hand
Radioulnar Joint
  • Synovitis that results in limited and painful motion into pronation and supination of forearm
  • wrist ligaments become damaged from constant stretching: subluxation of head of ulna
  • joint still in capsule, but more space within joint than normal (1)
Carpal Tunnel Syndrome
Median nerve compressed from:
  • Inflammation of tendons and tendon sheaths at wrist
  • swelling in carpal tunnel
  • causes: atrophy of thenar eminence muscles in hand; depending on severity the patient can have limited use of thumb

Rheumatoid Foot

  • changes occur in mid foot and forefoot
  • synovitis and tendonitis of posterior tibialis tendon
  • loss of longitudinal arch of foot occurs
  • Severe subcalcaneal pain, subluxation of metatarsals heads (cock-up toes), hallux valgus (bunion), hammer toes, mallet toes

RA joint deformity of the Knee

  • tend to experience a knee misalignment that turns  knees inwardand/or bowing at the knee

RA joint deformity of the Cervical Spine

  • most affected joint is the atlantoaxial (AA) joint
  • causes synovitis, ligamentous subluxation, vertebral body fractures, osteopenia, risk for odontoid process of axis detaching, compression of the spinal cord
  • pressure on the blood vessels causes Transient Ischemic Attacks (TIAs)
  • can lead to vertebral artery insufficiency (vertebral basilar insufficiency): ataxia, dizziness, motor and sensory changes, vertigo, and visual deficits
Physical Therapy interventions for RA
-Passive Stretching
-Active Exercise
-Electrical Modalities and Thermal Agents
-Pain Reduction
-Psychological Aspects


Natural Path Nutrition for RA treatment

  • Diet analysis
  • based on Gut microbiome analysis (1)
  • Administration of omega-3 polyunsaturated fatty acids at high doses resulted in a reduction in RA disease activity (1)
  • vitamin D: 5,000 - 10,000 UI daily (1). (2) (6 months)
  • alkaline Mineral Supplementation Decreases Pain in Rheumatoid Arthritis Patients
  • high, acidic, diets
  • Avoid:  Sugar, enriched wheat flour, palm oil, dextrose, corn starch, artificial flovour, soy lecithin, plam kernel oil, sodium bicabronate, protese, xylanase, sulphites
Hydrotherapy for RA
  • water temp kept between 90-100 degrees
  • hot show every morning to loosen tightness or before bed to relax
  • gait Reeducation, stretch, and strengthening
Passive Stretching for RA Active exercise for RA
  • Swimming, stretches fascia
  • Strengthen, cardiovascular conditioning
Electrical Modalities/Thermal Agents for RA
  • strengthening, pain relief, reduction of Edema
Psychosocial Aspects for RA treatment
  • create positive/social situations to help normalize pt's life to avoid depression

 Splinting to help RA

  • used to prevent or minimize joint deformity
  • protects involved joint
Nonarticular S&S of RA

 - scleritis
- skin nodules
- Felty's syndrome
- weight loss

-severe fatigue possibly related to anemia or anorexia,
-Sjogren's syndrome
-pleural effusion
-interstitial lung disease
-respiratory infection
-Raynaud's Phenomenon

  • inflammation of sclera

Skin Nodules

  • See link

Felty's Syndrome

  • swollen spleen, decreased WBCs, can have liver enlargement
Sjogren's Syndrome
  • dry eyes, photophobia


Surgical Intervention of RA
  • helps to reduce severe pain and improve function of joints with Total Joint Replacement
  • osteotomy - removal of bone to help improve movement
Natural Treatment of RA Pharmacology Treatment of RA

Alkaline Mineral Supplementation decreases pain in Rheumatoid Arthritis patients (1), (2), (3)

reduce pain through diet (1)

Magnesium (1), (2),

Vitamin D (1),

Controls inflammation

prevents severe complications and deformities

-drugs to control inflammation
-Salicylates (Aspirin), NSAIDS (Celebrex, Cox-2 inhibitors), DMARDS (cyclosporine, gold salts), corticosteroids (prednisone, dexamethasone), New Drugs: Enbrel, Humira, Kinceret