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Rheumatoid Arthritis
RA, Chronic Systemic Arthritis
WHAT IS IT?
Rheumatoid arthritis (RA) is a systemic inflammatory disease that primarily affects synovial tissue that lines joints and tendon sheaths. The disease is one of the autoimmune disorders in which the body seems to not recognize its own self and begins a self-destructive process. The synovial tissue becomes thickened (pannus), and grows to cover the joint surface, tendons, ligaments and joint capsule. The erosive and inflammatory process continues leading to joint destruction, tendon rupture and deformity. The disease may primarily involve the small joints in the hands and feet, or primarily the large joints, or both. The inflammation is usually symmetrical (for example, involving both hands).Other organs may be affected by the inflammation. Small lumps may develop under the skin (rheumatoid nodules), especially where there is pressure. The eyes sometimes become dry with burning and sensitivity to light (Sjogren's syndrome). Another common organ involvement is the spleen, which becomes enlarged (Felty's syndrome). The disease may involve the lung and/or heart.Rheumatoid arthritis affects women two to three times more than men, but there does not seem to be any ethnic or racial tendency. The highest incidence is during the middle years of life, but it can strike any age group. There seems to be a genetic indicator involved, as clusters of family members who develop the disease have been noted.
HOW IS IT DIAGNOSED?
History: Individuals will have morning stiffness lasting more than an hour, multiple joint swelling with symmetrical pattern and nodules under the skin. They will complain of fatigue, loss of appetite and weakness. There may be a family history of rheumatoid arthritis.
Physical exam may reveal joint swelling with warmth and decreased range-of-motion. Joints may be deformed if disease has progressed. Subcutaneous nodules, splenomegaly, pericarditis and vasculitis may be observed. Individuals may be so impaired that they have a difficult time climbing onto an exam table.
Tests Lab tests include a rheumatoid factor (positive in about 80% of cases, but if negative does not exclude the diagnosis of RA) ESR, CBC, ANA, and synovial fluid analysis. X-rays are used to evaluate joint space, erosive activity, effusion, and osteoporosis. Joint deformity will be apparent in the later stages.
HOW IS IT TREATED?
There is no cure for rheumatoid arthritis. Management of the effects of the disease is done by a team of specialists. A pyramid of treatment includes education, rest and exercise, salicylate and other nonsteroidal anti-inflammatory drugs (NSAIDs) and referral to social services. Splints may be used. Joint injections with corticosteroid may be helpful for acute flare ups. As the disease progresses, surgery may be necessary to relieve pain by attempting to restore joint function and to slow the disease by removing the synovial tissue. The drugs used in treatment may be changed to antimalarial and gold, then disease modifying agents such as methotrexate and lastly, experimental drugs such as cyclophosphamide. Corticosteroids are reserved for local injections or if the systemic disease is severe. All of the medications have potential serious side effects.
COMPLICATIONS
Drug reactions, multiple system involvement, joint destruction, tendon rupture, neuritis, changes in the blood contents, poor healing response to injury, depression, fatigue, and weight loss are possible complications of RA and its treatment. Neck involvement may lead to spinal instability, usually at C1-C2 joints.
PREDICTED OUTCOME
There is no cure for RA. The goal is management of the symptoms and slowing of the destructive process.
ALTERNATIVES
Pseudogout, systemic lupus erythematosus, scleroderma, polyarthritis, osteoarthritis, and osteoporosis must be ruled out.
WHAT TYPE OF REHABILITATION MIGHT BE APPROPRIATE FOR THIS CONDITION? AT WHAT FREQUENCY AND FOR HOW LONG?
Physical and occupational therapy (including paraffin bath, activities of daily living, range-of-motion exercises, massage), three times a week for a period of four to six weeks. Some individuals may require longer treatment, depending on functional loss.
APPROPRIATE SPECIALISTS
Rheumatologist, orthopedic surgeon, and physiatrist.
MEDICATIONS
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