Rheumatoid arthritis
Rheumatoid arthritis: Excerpt from Professional Guide to Diseases (Eighth Edition)
A chronic, systemic, inflammatory disease, rheumatoid arthritis (RA) primarily attacks peripheral joints and surrounding muscles, tendons, ligaments, and blood vessels. Spontaneous remissions and unpredictable exacerbations mark the course of this potentially crippling disease. RA usually requires lifelong treatment and, sometimes, surgery. In most patients, the disease follows an intermittent course and allows normal activity, although 10% suffer total disability from severe articular deformity, associated extra-articular symptoms, or both. The prognosis worsens with the development of nodules, vasculitis, and high titers of rheumatoid factor (RF).
Causes and incidence
RA occurs worldwide, striking three times more females than males. Although it can occur at any age, it begins most often between ages 25 and 55. This disease affects more than 7 million people in the United States alone.
What causes the chronic inflammation characteristic of RA isn’t known, but various theories point to infectious, genetic, and endocrine factors. Currently, it’s believed that a genetically susceptible individual develops abnormal or altered immunoglobulin (Ig) G antibodies when exposed to an antigen. This altered IgG antibody isn’t recognized as “self,” and the individual forms an antibody against it — an antibody known as RF. By aggregating into complexes, RF generates inflammation. Eventually, cartilage damage by inflammation triggers additional immune responses, including activation of complement. This in turn attracts polymorphonuclear leukocytes and stimulates release of inflammatory mediators, which enhance joint destruction.
Much more is known about the pathogenesis of RA than about its causes. If unarrested, the inflammatory process within the joints occurs in four stages. First, synovitis develops from congestion and edema of the synovial membrane and joint capsule. Formation of pannus — thickened layers of granulation tissue — marks the second stage’s onset. Pannus covers and invades cartilage and eventually destroys the joint capsule and bone. Progression to the third stage is characterized by fibrous ankylosis — fibrous invasion of the pannus and scar formation that occludes the joint space. Bone atrophy and malalignment cause visible deformities and disrupt the articulation of opposing bones, causing muscle atrophy and imbalance and, possibly, partial dislocations or subluxations. In the fourth stage, fibrous tissue calcifies, resulting in bony ankylosis and total immobility.
Signs and symptoms
RA usually develops insidiously and initially produces nonspecific signs and symptoms, such as fatigue, malaise, anorexia, persistent low-grade fever, weight loss, lymphadenopathy, and vague articular symptoms. Later, more specific localized articular symptoms develop, commonly in the fingers at the proximal interphalangeal, metacarpophalangeal, and metatarsophalangeal joints. These symptoms usually occur bilaterally and symmetrically and may extend to the wrists, knees, elbows, and ankles. The affected joints stiffen after inactivity, especially upon rising in the morning. The fingers may assume a spindle shape from marked edema and joint congestion. The joints become tender and painful, at first only when the patient moves them, but eventually even at rest. They commonly feel hot to the touch. Ultimately, joint function is diminished.
Deformities are common if active disease continues. (See Joint deformities.) Proximal interphalangeal joints may develop flexion deformities or become hyperextended. Metacarpophalangeal joints may swell dorsally, and volar subluxation and stretching of tendons may pull the fingers to the ulnar side (“ulnar drift”). The fingers may become fixed in a characteristic “swan’s neck” appearance, or “boutonničre” deformity. The hands appear foreshortened, the wrists boggy; carpal tunnel syndrome from synovial pressure on the median nerve causes tingling paresthesia in the fingers.
The most common extra-articular finding is the gradual appearance of rheumatoid nodules — subcutaneous, round or oval, nontender masses — usually on pressure areas such as the elbows. Vasculitis can lead to skin lesions, leg ulcers, and multiple systemic complications. Peripheral neuropathy may produce numbness or tingling in the feet or weakness and loss of sensation in the fingers. Stiff, weak, or painful muscles are common. Other common extra-articular effects include pericarditis, pulmonary nodules or fibrosis, pleuritis, scleritis, and episcleritis.
Another complication is destruction of the odontoid process, part of the second cervical vertebra. Rarely, cord compression may occur, particularly in patients with long-standing deforming disease. Upper motor neuron signs and symptoms, such as a positive Babinski’s sign and muscle weakness, may also develop.
RA can also cause temporomandibular joint disease, which impairs chewing and causes earaches. Other extra-articular findings may include infection, osteoporosis, myositis, cardiopulmonary lesions, lymphadenopathy, and peripheral neuritis.
Diagnosis
Typical clinical features suggest this disorder, but a definitive diagnosis is based on laboratory and other test results:
❑ X-rays — in early stages, show bone demineralization and soft-tissue swelling; later, loss of cartilage and narrowing of joint spaces; finally, cartilage and bone destruction and erosion, subluxations, and deformities
❑ rheumatoid factor test — positive in 75% to 80% of patients as indicated by a titer of 1:160 or higher
❑ synovial fluid analysis — reveals increased volume and turbidity but decreased viscosity and complement (C3 and C4) levels; white blood cell count usually exceeds 10,000/µl
❑ erythrocyte sedimentation rate — elevated in 85% to 90% of patients (may be useful to monitor response to therapy because elevation commonly parallels disease activity)
❑ complete blood count — usually reveals moderate anemia and slight leukocytosis.
A C-reactive protein test can help monitor response to therapy.
Treatment
Salicylates, particularly aspirin, are the mainstay of RA therapy because they decrease inflammation and relieve joint pain. Other useful medications include nonsteroidal anti-inflammatory drugs (such as indomethacin, fenoprofen, and ibuprofen), antimalarials (hydroxychloroquine), gold salts, penicillamine, and corticosteroids (prednisone). Immunosuppressants, such as cyclophosphamide, methotrexate, and azathioprine, are also therapeutic and are being used more commonly in early disease. (See Drug therapy for arthritis.)
Supportive measures include 8 to 10 hours of sleep every night, frequent rest periods between daily activities, and splinting to rest inflamed joints. A physical therapy program including range-of-motion exercises and carefully individualized therapeutic exercises forestalls joint function loss; application of heat relaxes muscles and relieves pain. Moist heat usually works best for patients with chronic disease. Ice packs are effective during acute episodes.
Advanced disease may require synovectomy, joint reconstruction, or total joint arthroplasty.
Useful surgical procedures in RA include metatarsal head and distal ulnar resectional arthroplasty, insertion of a Silastic prosthesis between the metacarpophalangeal and proximal interphalangeal joints, and arthrodesis (joint fusion). Arthrodesis sacrifices joint mobility for stability and pain relief. Synovectomy (removal of destructive, proliferating synovium, usually in the wrists, knees, and fingers) may halt or delay the course of this disease. Osteotomy (the cutting of bone or excision of a wedge of bone) can realign joint surfaces and redistribute stresses. Tendons may rupture spontaneously, requiring surgical repair. Tendon transfers may prevent deformities or relieve contractures. (See When arthritis requires surgery.)
Special considerations
❑ Assess all joints carefully. Look for deformities, contractures, immobility, and inability to perform everyday activities.
❑ Monitor the patient’s vital signs and note weight changes, sensory disturbances, and level of pain. Administer analgesics as ordered and watch for adverse effects.
❑ Provide meticulous skin care. Check for rheumatoid nodules as well as pressure ulcers and breakdowns due to immobility, vascular impairment, corticosteroid treatment, or improper splinting. Use lotion or cleansing oil, not soap, for dry skin.
❑ Explain all diagnostic tests and procedures. Tell the patient to expect multiple blood samples to allow firm diagnosis and accurate monitoring of therapy.
❑ Monitor the duration, not the intensity, of morning stiffness because duration more accurately reflects the disease’s severity. Encourage the patient to take hot showers or baths at bedtime or in the morning to reduce the need for pain medication.
❑ Apply splints carefully and correctly. Observe for pressure ulcers if the patient is in traction or wearing splints.
❑ Explain the nature of the disease. Make sure the patient and his family understand that RA is a chronic disease that requires major changes in lifestyle. Emphasize that there are no miracle cures, despite claims to the contrary.
❑ Encourage a balanced diet, but make sure the patient understands that special diets won’t cure RA. Stress the need for weight control because obesity adds further stress to joints.
❑ Urge the patient to perform activities of daily living (ADLs), such as practicing good hygiene and dressing and feeding himself. Suggest ADL aids, such as a long-handled shoehorn; elastic shoelaces; zipper-pulls; button hooks; easy-to-handle cups, plates, and silverware; elevated toilet seats; and battery-operated toothbrushes. Household cleaning devices such as long-handled dustpans are also available. Patients who have trouble maneuvering fingers into gloves should wear mittens.
❑ ADLs that can be done in a sitting position should be encouraged. Allow the patient enough time to calmly perform these tasks.
❑ Provide emotional support. Remember that the patient with chronic illness easily becomes depressed, discouraged, and irritable. Encourage the patient to discuss his fears concerning dependency, sexuality, body image, and self-esteem. Refer him to an appropriate social service agency as needed.
❑ Discuss sexual aids: alternative positions, pain medication, and moist heat to increase mobility.
❑ Before discharge, make sure the patient knows how and when to take prescribed medication and how to recognize possible adverse effects.
❑ Teach the patient how to stand, walk, and sit correctly: upright and erect. Tell him to sit in chairs with high seats and armrests; he’ll find it easier to get up from a chair if his knees are lower than his hips. If he doesn’t own a chair with a high seat, recommend putting blocks of wood under a favorite chair’s legs. Suggest an elevated toilet seat.
❑ Mobility aids are very helpful. Many medical and commercial stores offer assistive and supportive devices that promote self-care, including an overhead grasping trapeze to get out of bed, easy-to-open drawers, handheld shower nozzles, handrails, and grab bars.
❑ Instruct the patient to pace daily activities, resting for 5 to 10 minutes out of each hour and alternating sitting and standing tasks. Adequate sleep and correct sleeping posture are important. He should sleep on his back on a firm mattress and should avoid placing a pillow under his knees, which encourages flexion deformity.
❑ Teach the patient to avoid putting undue stress on joints and to use the largest joint available for a given task, to support weak or painful joints as much as possible, to avoid positions of flexion and promote positions of extension, to hold objects parallel to the knuckles as briefly as possible, to always use his hands toward the center of his body, and to slide — not lift — objects whenever possible. Enlist the aid of the occupational therapist to teach how to simplify activities and protect arthritic joints. Stress the importance of shoes with proper support.
ELDER TIP Reinforce safety precautions for elderly patients, such as the removal of throw rugs and the use of handrails and adequate night lighting. Recommend a step stool for elderly patients who need to reach in overhead cupboards. Suggest that the patient purchase medication without safety caps, if available, because these caps can be difficult to open. Medication administration should be designed to follow a standard regimen that fits with the patient’s lifestyle.
❑ Refer the patient to the Arthritis Foundation for more information on coping with the disease.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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