Rheumatoid arthritis (RA) is a systemic autoimmune disease characterized by inflammatory arthritis and extra-articular involvement. RA with symptom duration of fewer than six months is defined as early, and when the symptoms have been present for more than months, it is defined as established.
There is no laboratory test that is pathognomonic for rheumatoid arthritis. The treatment of patients with rheumatoid arthritis requires both pharmacological and non-pharmacological agents. Today, the standard of care is early treatment with disease modifying anti-rheumatic drugs.
Etiology and Pathology - Etiology is unknown (probably multifactorial).
It is generally considered that a genetic predisposition (e.g. HLA-DR B1 which is the most common allele of HLA-DR4 involved in rheumatoid arthritis) and an environmental trigger (e.g. Epstein-Barr virus postulated as a possible antigen, but not proven) lead to an autoimmune response that is directed against synovial structures and other organs.
Activation and accumulation of CD4 T cells in the synovium start a cascade of inflammatory responses which result in:
activation of the macrophages and synovial cells and production of cytokines (eg L4 and TNF,) which in turn cause proliferation of the synovial cells and increase the production of destructive enzymes (eg elastase and collagenase) by macrophages
activating B cell lymphocytes to produce various antibodies (including rheumatoid factor) which makes immune complexes that deposit in different tissues and contribute to further injury
directly activate endothelial cells via increased production of VCAM1, which increases the adhesion and accumulation of inflammatory cells
producing RANKL which in turn activate osteoclasts causing subchondral bone destruction
The inflammatory response leads to Pannus formation.
Pannus:
Is an oedematous thickened hyperplastic synovium infiltrated by lymphocytes T and B, plasmocytes, macrophages, and osteoclasts.
It will gradually erode bare areas initially, followed by the articular cartilage.
Goes on to causes fibrous ankylosis which eventually ossifies
Risk Factors Include:
Increased prevalence of RA within families resulting from the interaction between patients genotype and environment.
Increases risk: Female sex; occupational dust (silica); air pollution; high sodium and iron consumption; low vitamin D intake and levels; Smoking (seropositive RA); Obesity; Low socioeconomic status
Deceased risk: fish and omega 3 fatty acid consumption; moderate alcohol intake; healthy diet; oral contraceptive/HRT; statin use.
Characteristics/Clinical Presentation
In rheumatoid arthritis, joint complaints are in the foreground. The most common clinical presentation of RA is
Polyarthritis of small joints of hands: proximal interphalangeal (PIP), metacarpophalangeal (MCP) joints and wrist. Some patients may present with monoarticular joint involvement.
Commonly joint involvement occurs insidiously over a period of months, however, in some cases, joint involvement may occur over weeks or overnight.
Other commonly affected joints include wrist, elbows, shoulders, hips, knees, ankles and metatarsophalangeal (MTP) joints.
Stiffness in the joints in the morning may last up to several hours, usually greater than an hour. The patient may have a "trigger finger" due to flexor tenosynovitis.
Advanced features of rheumatoid arthritis, with erosive subluxation most marked of the MCP joints with ulnar deviation. Prominent degenerative change is also seen at the ulnar-carpal articulation. Note also osteopenia particularly of the MCP regions. On examination,
May be swelling, stiffness, deformity, and tenderness of the PIP, MCP wrist, knee joints, referred to as synovitis, and there may be a decreased range of motion.
Deformity, pain, weakness and restricted mobility resulting in loss of function.
Rheumatoid nodules may be present in 20% of patients with rheumatoid arthritis; these occur over extensor surfaces at elbows, heels, and toes.
Late in the course of the disease patient may present with "Boutonniere (flexion at PIP and extension at DIP), swan neck (flexion at DIP and extension at PIP) deformities, subluxation of MCP joints and ulnar deviation.
Other features may include the presence of carpal tunnel syndrome, tenosynovitis and finger deformities.
Examine the joints on swelling, pain due to palpation, pain due to movement, decreased range of motion, deformation and instability.
Hallmark symptoms such as symmetrical joint swelling and tenderness, morning stiffness, positive rheumatoid factor (RF), elevated acute phase reactants, and radiographic evidence of erosive bone loss.
Significant predictors of functional decline among persons with RA are slow gait and a weak grip.
Rheumatoid arthritis can affect almost every organ in the body
The three most important complaints are pain, morning stiffness and fatigue.
Muscular strength, muscular endurance and aerobic endurance are typically reduced in patients with rheumatoid arthritis in comparison with healthy patients.
In 80-90% of the patients with rheumatoid arthritis the cervical spine is involved, which can lead to instability, caused by the ligamentous laxity (between the first and second cervical vertebrae most commonly) This instability can lead to pain and neurological symptoms, eg headache and tingling in the fingers.
Individuals with RA are 8 times more likely to have functional disability compared with adults in the general population from the same community.
Disease progression:
Stages
No destructive changes on x-rays
Presence of x-ray evidence of periarticular osteoporosis, subchondral bone destruction but no joint deformity
X-ray evidence of cartilage and bone destruction in addition to joint deformity and periarticular osteoporosis.
Presence of bony or fibrous ankylosis along with stage 3 features.
Complications
RA has many effects on individuals including mortality, hospitalization, work disability, increase in medical cost/expenses, decreases of quality of life, and chronic pain. On average, the chronic RA patient has two or more comorbid conditions. This is significant because of the comorbidities effects on quality of life, functional status, prognosis and outcome. Associated Complications include:
Infections, Chronic anaemia, Gastrointestinal cancers, Pleural effusions, Osteoporosis
Heart disease, Sicca syndrome, Felty syndrome and Lymphoma
Damage to the lung tissue (rheumatoid lung)CT demonstrates extensive pulmonary fibrosis in the mid and lower zones with co-existing severe centrilobular emphysema in the upper zones. The fibrosis is attributable to the patient's known rheumatoid arthritis, and the emphysema to a long history of smoking.
Side effects from treatment and medication.
General deconditioning
Neurological complications
Ocular complications
Diagnostic Procedures
Lab evaluation of patients with rheumatoid arthritis consists of obtaining
Rheumatoid factor (antibody against the Fc portion of IgG). About 45% to 75% of patients with RA test positive for rheumatoid factor. However, the presence of rheumatoid factor is not diagnostic of rheumatoid arthritis. It may be present in connective tissue disease, chronic infections, and healthy individuals, mostly in low titers.
Anti-citrullinated protein antibodies (ACPA) are found in about 50% of patients with early arthritis, which subsequently are diagnosed with RA.
Acute-phase reactants, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) may be elevated in the active phase of arthritis.
X-ray of both hands and feet are usually obtained for the presence of erosions, the pathognomonic feature of rheumatoid arthritis (plain radiograph does not show early changes of the disease).
Magnetic resonance imaging (MRI) and ultrasound of joints detect erosions earlier than an x-ray. MRI and US are more sensitive than clinical examination in identifying synovitis and joint effusion.
Prognosis
Rheumatoid arthritis has no cure and is a progressive disease. All individuals have multiple exacerbations and remissions. Close to 50% of patients with the disease become disabled within 10 years.
Besides the joint disease, the individuals can suffer from many extra joint-related problems which significantly alters the quality of life. The progression of disease does vary from individual to individual.
Rheumatoid arthritis is also associated with cardiovascular risk factors, infection, respiratory disease and the development of malignancies. Patients with rheumatoid arthritis have a 2-3 times higher risk of death compared to the general population.
Treatment
Treatment of rheumatoid arthritis is aimed at improving the symptoms and slowing disease progression. Because the disorder affects many other organs, it is best managed with an inter-professional team. The key is patient education by nurses, pharmacists, and primary care providers. The nurse should inform the patient about the signs and symptoms of different organ systems and when to seek medical care. A physiotherapist should implement an exercise program to recover joint function. An occupational therapy consult can help the patient manage daily living activities. The pharmacist should educate the patient on the types of drugs used to treat rheumatoid arthritis and their potential side effects.
Medical Management
Medications used in treatment include:
non-steroidal anti-inflammatory drugs (NSAIDs)
disease-modifying anti-rheumatic drugs (DMARDs)
conventional synthetic DMARDs (csDMARDs): e.g. methotrexate, leflunomide, prednisolone
biological DMARDs (bDMARDs): e.g. TNF-α inhibitors (e.g. infliximab), tocilizumab, abatacept, rituxumab
targeted synthetic DMARDs (tsDMARDs): e.g. tofacitinib
The disease carries a significant burden of disability. There is also a reduction in life expectancy, with excess mortality usually related to its non-articular manifestations.
Nutritional Guidelines
Dietary interventions demonstrate substantial benefits in reducing disease symptoms such as pain, joint stiffness, swelling, tenderness and associated disability with disease progression (still an uncertainty about the therapeutic benefits of dietary manipulations for RA). Dietary modification include:
Avoiding food that causes inflammation like processed food, high salt, oils, butter, sugar, and animal products.
Supplements: Research suggests that there are vitamins and minerals which may have an effect on RAeg. vitamin D, cod liver oil, and multivitamins. These may help eg reduce joint inflammation, improve bone health. It is recommended to consult your primary care physician.
Physical Therapy Management
Rheumatoid arthritis is a chronic disorder that has no cure. All the currently available treatments are geared towards improving the symptoms and offering a better quality of life.Treatments that achieve pain relief and the slowdown of the activity of RA to prevent disability and increase functional capacity.
The benefits of physical therapy interventions have been well documented.
Physical therapists play an integral role in the nonpharmacologic management of RA.
Physiotherapy help clients cope with chronic pain and disability through the design of programs that address flexibility, endurance, aerobic condition, range of motion (ROM), strength, bone integrity, coordination, balance and risk of falls.
All current UK clinical guidelines for the management of RA recommend the use of physiotherapy (PT) and occupational therapy (OT) as an adjunct to drug treatment.
The four most common components of PT/OT for RA hands are
Exercise therapy,
Joint protection advice and provision of functional splinting and assistive devices
Massage therapy, and
Patient education.
The therapy goals in most cases are:
Improvement in disease management knowledge
Pain control
Improvement in activities of daily living
Improvement in Joint stiffness (~ Range of motion)
Prevent or control joint damage
Improve strength
Improve fatigue levels
Improve the quality of life
Improve aerobic condition
Improve stability and coordination
Patient questionnaires, not joint counts, radiographic scores, or laboratory tests, provide the most significant predictors of severe 5-year outcomes in patients with RA, including functional status, work disability, costs, joint replacement surgery and premature death.
Treatment techniques
Cold/Hot Applications: cold for acute phase; heat for chronic phase and used before exercise.
Transcutaneous electrical nerve stimulation (TENS) is used to relieve pain.
Hydrotherapy-Balneotherapy: exercise with minimal load on the joints.
Joint Protection
Massage Therapy: Massage and the manual trigger of an articular movement focused on the improvement of function, pain reduction, reduction of disease activity improve flexibility and welfare (dimension of depression, anxiety, mood and pain)
Therapeutic Exercise
Physical exercise helps to increase the physical capacity of the patient.
Exercise improves general muscular endurance and strength without detrimental effects on disease activity or pain in RA
Before beginning an exercise program perform a global evaluation of the situation: joint-inflammation local or systemic, state of the disease, age of the patient and grade of collaboration.
Exercise therapy is aimed at improving daily functioning and social participation by means of improvement of the strength, aerobic condition, range of motion, stabilisation and coordination.
Dr N Hegde (Ortho-Surgeon) | Prolife Hospital | Bangalore
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