Rheumatoid Arthritis (RA) is a chronic, symmetrical inflammatory arthritis that typically affects the small joints of the hands and feet, but can affect any synovial joint (Mooney & McGee, 2012). RA is an autoimmune disease; the immune system is the body’s own defense mechanism against foreign invaders and infection. In RA, the immune system starts to attack the normal, healthy lining (synovium) of joints and surrounding ligaments, muscle, tendons and blood vessels causing an inflammatory response. The inflammation causes pain, stiffness and swelling, which,
if untreated, will result in joint damage and deformity, and decreased mobility. The disease is unpredictable, characterized by periods of remission and flares (Mooney & McGee, 2012).
I have been longing to write a post on RA. I saw a patient last month and she came for physical therapy for low back pain and radiculitis. While examining her low back I accidently look at her fingers. I got curious and asked her to let me see her fingers and her knuckles. By looking I instantly realized that she has RA. I took some pictures of her hand showing her knuckles and fingers and I shall post that below.
Rheumatoid Arthritis is a multisystem disease that can affect many organs such
as the heart, lungs, nerves, skin and eyes. It is associated with an increased risk of cardiovascular disease, similar to that seen in type 2 diabetes, thought to be owing to the underlying inflammatory process (Peters et al, 2009). It affects 0.8 % of the population and it is more common in females than males (.3:1) with the incidence peaking at the age of 50-60 years (Symmons et al, 2002).
The risk factors of Rheumatoid Arthritis are not fully understood. Evidence suggests that there are likely to be a combination of factors such as genetic susceptibility, and environmental, hormonal and reproductive factors (Mooney & McGee, 2012).
Signs & Symptoms of Rheumatoid Arthritis (Mooney & McGee, 2012).
v Pain, stiffness and swelling of three or more joints
v Symmetrical joint swelling of metacarpophalangeal (MCP) and proximal interphalangeal (PIP) (small joints of the hands)
v Joint swelling of shoulders, elbows, wrists, knees and ankles
v Early morning joint stiffness lasting more than 30 minute
v Malaise and Weight loss
Extra-Articular Features of Rheumatoid Arthritis (Mooney & McGee, 2012).
v Rheumatoid nodules (lumps that develop in the soft tissues mainly around bony prominences)
v Nail fold infarcts (small red spots around the fingernail)
v Dry mouth
v Mouth ulcers
v Episcleritis/scleritis (inflammation of the white of the eye (sclera)
v Scleromalacia perforans (thinning of the solera)
v Pulmonary fibrosis (swelling and scaring of air sacs (alveoli)
v Pleural effusions (excess fluid in the lining of the lung)
v Peripheral neuropathy (damage to nerves of the peripheral nervous system)
v Pericarditis (inflammation of the lining of the heart)
v Pericardial effusion (excess fluid in the lining that surrounds the heart)
v Splenomegaly (enlarged spleen)
Differentiating Osteoarthritis and Rheumatoid Arthritis.
It is important to differentiate between osteoarthritis and RA as their treatment and management are different. Osteoarthritis (OA) is the most common form of arthritis, affecting approximately 8.5 million people in the UK (Arthritis Care, 2004). Many older people are affected by OA and
it is estimated that 12% of people over the age of 65 years will have symptomatic OA
(Walker, 2011). OA is a syndrome of joint pain with functional limitation (Conaghan et al,
2008) and reduced quality of life (NICE, 2008). It affects the synovial joints of the thumb, base of big toe, hips and knees leading to destruction of articular cartilage and overgrowth of bone (osteophytes) around the joint resulting in pain and restricted movement (NICE 2008). OA has become synonymous with the term ‘wear and tear’ but this is not an accurate reflection of the pathogenesis of OA (Birrell et al, 2011). OA is a metabolically active condition and not the simple wearing out of a joint (Birrell et al, 2011).
The following differences were noted by Mooney and Mcgee (2012).
v The pattern of joint involvement is symmetrical
(affecting the same Joints on both sides)
v Joint morning stiffness can last for more than
v Predominantly affects the smaller joints of
hands, feet and wrists
v Joint swelling appears red and hot to touch
v The distal interphalangeal joints (DIPs) are not
typically involved in RA but they are in OA
v RA the course is unpredictable with episodes of
flares and remissions
v Anemia of chronic disease is a feature of RA
but not OA
v It is usually asymmetrical affecting one or two
v Joint morning stiffness generally lasts 15-30
v Often affects the large weight-bearing joints
such as the knees and hips
v Swelling is not as evident and the joints are
cool to touch
v You may be able to see swellings of the distal
(Heberden’s nodes) or proximal interphalangeal
joints (Bouchard’s nodes).
v The course of OA is progressive
v OA is not a systemic disease, therefore it is not
necessarily associated with fever or weight loss
v The extra articular features seen in RA are not
associated with OA
v OA pain is more symptomatic after repetitive
use of joints or activity.
Pictures of Heberden’s Nodes and Bouchard’s Nodes and Early Synovitis.
Figure 2 & 3 demonstrated Heberden nodes and synovitis. The pictures were taken by me. You could see the bumps and irregularities near the end bones of the fingers and over the knuckles.
Treatment of Rheumatoid Arthritis.
Several guidelines have been produced on the management of RA which recommend early diagnosis and initiation of disease-modifying antirheumatic drugs (DMARDs) and escalation of therapy to reach therapeutic dosages in order to achieve tight control of inflammation (Luqmani et al, 2006; NICE, 2009; Smolen et al, 2010). There are several DMARDs used to treat RA; methotrexate, sulfasalazine, azathioprine, leflunomide, ciclosporin, mycophenolate mofetil, sodium aurothiomalate and hydroxychloroquine. These medications do not work immediately and can take 6-12 weeks to work. Therefore, oral steroids or intramuscular depo-medrone 120mg (a steroid) is often administered as a ‘bridging therapy’ until the DMARDs takes effect. DMARDs can be prescribed as monotherapy or as a combination of several different DMARDs.
Methotrexate is the most commonly used DMARD (given once weekly) and is the cornerstone of combination therapy. There are two schools of thought on managing RA: the step-up approach and the step-down approach.
The step-up approach begins with one DMARD and adds in others if there is an inadequate response. The step-down approach begins with several and gradually reduces them over time. Most rheumatology practitioners use the Disease Activity Score (DAS28) to monitor disease activity in RA (Fransen and van Riel, 2005).. This tool records tenderness and swelling in the shoulder, elbow, wrist, knee, metacarpophalangeal and proximal interphalangeal joints. It also includes a measure of the patient’s general health on a visual analogue scale (VAS) of 100 mm. A score is calculated, with a DAS28 score of >5.1 indicating high disease activity and a DAS28 score of <3.2 indicating low disease activity.
Although many individuals respond to therapy with DMARDs, approximately 15% will still have active disease (NICE, 2009). These people will be assessed for eligibility for starting a biologic agent as recommended by NICE (2009). These agents are to be prescribed when:
• Active RA measured by (DAS28) >5.1 is confirmed on at least two occasions 1 month apart
• The individual has tried two DMARDs, including methotrexate (unless contraindicated)
for 6 months
• DMARDs should be continued only if there is an adequate response at 6 months. This is defined as an improvement in DAS28 of 1.2 points or more.
Below is the Picture showing how to calculate the DAS score for Rheumatoid Arthritis. The figure is by Mooney & McGee (2012).
Swollen joints (0-28)
Tender joints (0-28)
Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP)
Visual analog scale (VAS) disease activity (0-lOOmm)
DAS28=(0.56*V(tender joints) + 0.28*V(swollen joints) + 0.70*Ln(ESR/CRP) + 0.014*VAS).
I hope you guys find it useful. Do let me know if you need some more information as this is not the overall RA. RA is a vast symptoms with tons of information and I just tried to describe the basic.