RHEUMATOID ARTHRITIS

Overview

Rheumatoid Arthritis (RA) is a chronic, inflammatory, autoimmune disease that affects the smaller joints in the initial phase, progressing to the larger joints of the body.

Often, the bone and cartilage of joints are destroyed, and tendons and ligaments get weaken. All this damage to the joints causes deformities and bone erosion, which are usually very painful for a patient. 

Also, patients suffering from  RA tend to die younger than their peers as a result of the effects of chronic inflammation on a number of organ systems like the Heart, Kidney & Lungs.

Common Extra Articular Feature of Rheumatoid Arthritis

Systemic Nodules
Anaemia
Lymphadenopathy
Amyloidosis
Vasculitis
Neurology Peripheral Nerve Entrapment
Peripheral Neuropathy
Cervical Spine Instability
Cervical Cord Compression
Nerve root compression
Cardiovascular Pericarditis
Myocarditis
Pericardial Effusion
Conduction Defect
Therosclerosis
Pulmonary Pneumonia
Pleuritis
Pleural Effusion
Conduction Defect
Atherosclerosis
Bone Osteoporosis Ocular Keratoconjunctivitis
Scleritis
Episcleritis

EPIDEMIOLOGY:

  • Affects 1 – 3% of the population worldwide
  • With a peak prevalence between the ages of 30 and 50years
  • Women are affected 3 or 4 times more commonly than men 

 

PATHOPHYSIOLOGY:

Stage 1

Early-stage

– There is inflammation inside the joint. 

– The tissue in the joint swells up. 

– There is no damage to the bones, but the joint lining, called the synovium, is inflamed.

Raised ESR, C-reactive protein (CRP), and RF may be detectable years before the first diagnosis.

Stage 2

– Moderate-stage

– The synovium’s inflammation causes damage to the joint cartilage.

– When cartilage is damaged, people may experience pain and loss of mobility. The range of motion in the joints may become limited.

Stage 3

– Stage of Destruction

– Persistent inflammation causes joint and tendon destruction.

– At the margins of the joint, bone is also eroded by granulation tissue invasion and osteoclastic resorption.

– Similar changes occur in tendon sheaths, causing tenosynovitis.

– Partial or complete rupture of tendons.

– Swelling of the joints, tendons and bursae.

Stage 4

– Stage of Deformity or End Stage

-Combination of articular destruction, capsular stretching and tendon rupture leads to progressive instability and deformity of the joint

– The inflammatory process usually continues but the mechanical and functional effects of joint and tendon disruption now become vital

Risk Factors

Age

  • Likelihood increases with age
  • Highest among adults in their sixties


Gender

Women are affected 3 or 4 times more commonly than men

 

Genetics

  • People born with specific genes are more likely to develop RA. 
  • HLA (human leukocyte antigen) class II genotypes, can also make your arthritis worse.

 

Smoking

Increases a person’s risk of developing Rheumatoid Arthritis

 

Obesity

The role of obesity also found that the more overweight a person was, the higher his or her risk of developing RA became.

 

SYMTOMS

Stage of Synovitis (Stage 1 & 2)

  • Most commonly affected are Fingers (Meta Carpo Phalangeal Joint and Proximal Interphalangeal joint), Wrist, Tendon sheaths around the joints (wrist – feet – knee –shoulder)
  • Bilateral symmetrical polysynovitis
  • Pain, fusiform swelling, stiffness, loss of mobility
  • Constitutional symptom:
  1. Malaise
  2. Low-grade fever
  3. Tenosynovitis

 

Stage of Destruction (Stage 3)

  • Spread to other joint – wrist, ankle, knee, shoulder (in order of frequency)
  • Morning stiffness (more than 30 min) – improve with activity
  • The activity of daily living will be affected – the quality of life affected

 

Stage of Deformity (Stage 4)

  • Pain, deformity, instability, decreased ROM
  • Joint deformity – movement restricted and painful
  1. Thumb – Z-deformity
  2. Fingers –Swan neck deformity/ Boutonniere’s deformities, ulnar deviation
  3. Wrist – radial and volar displacement
  4. Elbow – limited extension
  5. Shoulder – limited abduction
  6. Knees – swollen, flexion a vulgus
  7. Toes – clawed

 

When to see a doctor:

  • Swollen Joints
  • Fever, Malaise
  • Morning Stiffness
  • Rheumatoid Nodules
  • Loss of Appetite

 

DIAGNOSIS

Rheumatoid arthritis can be difficult to diagnose in its early stages because the early signs and symptoms mimic those of many other diseases. 

Physical examination plays a significant role in diagnosing the disease

 

Physical Examination

a. Vital Signs

Low Garde Fever


b. Skin Examination

  • Rheumatoid nodule found over bony prominences
  • Erythema nodosum
  • Atrophy of digital skin
  • Palmar erythema
  • Diffuse thinning (rice paper skin), and of
  • Beading on the nails

 

c. Examination of the Eyes

  • Dry Eyes
  • Scleritis
  • Scleromalacia

 

d. Pulmonary Examination

  • Decreased breath sounds on both sides
  • Crackles may be present 

 

e. Abdomen

  • Hepatomegaly
  • Splenomegaly

 

f. Extremities

  • Redness & Swelling of the affected joints
  • Tenderness
  • Painful Movement
  • Decreased range of movement
  • Morning Stiffness

 

INVESTIGATIONS:

a. Hematological

  • CBC- normocytic hypochromic anemia (due to abnormal erythropoiesis from chronic inflammation), WBC
  • Inflammatory markers- ESR, CRP elevated (its use as an indication of disease progression monitoring, treatment response)
  • Rheumatoid factor(RF)- anti-IgG auto Ab 80% will have it
  • Anti- cyclic citrullinated peptide(CCP)Ab

b. Joint aspiration

c. Imaging

 

TREATMENT

  • There is no cure for rheumatoid arthritis
  • Aim to delay the progression of the disease, alleviate symptoms, reduce functional limitation
  • Supportive and palliative
  • Medication

 

MEDICATION

The types of medications recommended by your doctor will depend on the severity of your symptoms and how long you’ve had rheumatoid arthritis.

a. Disease-modifying antirheumatic drugs (DMARDs) 

  • To slow down the progression of rheumatoid arthritis
  • To save the joints and other tissues from permanent damage
  • Common DMARDs include methotrexate (Trexall, Otrexup, others), leflunomide (Arava), hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine)

Side effects vary but may include liver damage, bone marrow suppression and severe lung infections.

 

b. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) 

  • To relieve pain and reduce inflammation
  • Common NSAIDs include ibuprofen (Advil, Motrin IB) and naproxen sodium (Aleve).
  • Side effects may include stomach irritation, heart problems and kidney damage.


c. Steroids

  • To reduce inflammation, pain & slow joint damage
  • Common Corticosteroid medications include prednisone
  • Side effects may include thinning of bones, weight gain and diabetes

 

SURGERY

  • Synovectomy: Surgery to remove the inflamed lining of the joint (synovium) can be performed on knees, elbows, wrists, fingers and hips.
  • Tendon repair: Inflammation and joint damage may cause tendons around your joint to loosen or rupture. Your surgeon may be able to repair the tendons around your joint.
  • Joint fusion: Surgically fusing a joint may be recommended to stabilize or realign a joint and for pain relief when a joint replacement isn’t an option.
  • Total joint replacement: During joint replacement surgery, your surgeon removes the damaged parts of your joint and inserts a prosthesis made of metal and plastic

Therapeutic Management

  1. Hydrotherapy

Helps in reducing RA related pain & other symptoms

 

2. Massage 

It can help reduce muscle tension & promote good circulation

 

3. Transcutaneous Electrical Nerve Stimulation (TENS)

It works by blocking pain signals & helps in decreasing muscle spams

 

4. Ultrasound

It creates warmth using sound waves to enhance circulation and reduce joint pain, inflammation & stiffness

 

5. Strengthening Exercises

To improve range of motion & helps in building muscle strength

 

6. Aerobic Exercises

It helps in managing rheumatoid arthritis symptoms