Rheumatoid arthritis
A chronic, systemic inflammatory disease, rheumatoid arthritis (RA) primarily attacks peripheral joints and surrounding muscles, tendons, ligaments, and blood vessels. Partial remissions and unpredictable exacerbations mark the course of this potentially crippling disease.
RA occurs worldwide, striking nearly three times more women than men. It can occur at any age, but peak incidence is between ages 25 and 55. RA affects 1% to 2% of the total population.
This disease usually requires lifelong treatment and, sometimes, surgery. In most patients, it 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
What causes the chronic inflammation characteristic of RA isn’t known. One theory states that abnormal immune activation (occurring in a genetically susceptible individual) leads to inflammation, complement activation, and cell proliferation within joints and tendon sheaths. Although no single environmental factor has been found to be a consistent and reproducible cause of this response, infection (viral or bacterial), hormonal factors, and lifestyle factors may all influence disease onset.
Some RA patients develop an immunoglobulin (Ig) M antibody against their body’s own IgG, which is called RF. Increased production of this antibody may also play a role in genetic inflammation.
Pathogenesis
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.
In the first stage, synovitis develops from congestion and edema of the synovial membrane and joint capsule. Infiltration by lymphocytes, macro-phages, and neutrophils perpetuates the local inflammatory response. These cells, as well as fibroblast-like synovial cells, produce enzymes that help to degrade bone and cartilage.
Formation of pannus — thickened layers of granulation tissue — marks the onset of the second stage. 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. These include fatigue, malaise, anorexia, persistent low-grade fever, weight loss, lymphadenopathy, and vague articular symptoms.
Specific symptoms
As the disease progresses, more specific localized articular symptoms develop, commonly in the fingers at the proximal interphalangeal (PIP), metacarpophalangeal (MCP), 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 on rising in the morning. The fingers may assume a spindle shape from marked edema and congestion in the joints. The joints become tender and painful, at first only when the patient moves them, but eventually even at rest. They often feel hot to the touch. Ultimately, joint function is diminished. Deformities are common if active disease continues.
PIP joints may develop flexion deformities or become hyperextended. MCP 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-neck or boutonničre deformity. The hands appear foreshortened and, the wrists boggy; carpal tunnel syndrome from synovial pressure on the median nerve causes paresthesia in the fingers.
CLINICAL TIP: Early intervention, under the guidance of an occupational therapist, with splinting and joint protection devices can effectively delay the progression of joint deformities.
Extra-articular signs
The most common extra-articular finding is the gradual appearance of rheumatoid nodules — subcutaneous, round or oval, nontender masses. These are seen in 20% of RA patients who are RF-positive. They usually appear on pressure areas, such as the elbows, hands, and Achilles tendon.
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.
Other complications
Another complication is destruction of the odontoid process, which is part of the second cervical vertebra. With C1 or C2 instability and subluxation, spinal cord compression may occur, particularly in patients with long-standing deforming RA. 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 include infection, osteoporosis, myositis, cardiopulmonary lesions, lymphadenopathy, and peripheral neuritis.
Diagnosis
Typical signs and symptoms suggest RA, with a firm diagnosis supported by laboratory and other test results:
❑ X-raysin early stages show bone demineralization and soft-tissue swelling; later, loss of cartilage and narrowing of joint spaces; and finally, cartilage and bone destruction and erosion, subluxations, and deformities.
❑ RF is positive in 75% to 80% of patients, as indicated by a titer of 1:160 or higher.
❑ Synovial fluid analysisshows increased volume and turbidity but decreased viscosity and elevated white blood cell counts (often greater than 10,000/µl).
❑ Serum protein electrophoresis may show elevated serum globulin levels.
❑ Erythrocyte sedimentation rate and C-reactive protein are elevated in 85% to 90% of patients (may be useful to monitor response to therapy because elevation typically parallels disease activity).
❑ Complete blood count usually shows moderate anemia, slight leukocytosis, and thrombocytosis.
Treatment
Salicylates, particularly aspirin, are the mainstay of RA therapy, because they decrease inflammation and relieve joint pain. Other useful medications include nonsteroidal anti-inflammatories (such as indomethacin, fenoprofen, and ibuprofen), antimalarials (hydroxychloroquine), sulfasalazine, gold salts, and corticosteroids (prednisone). (See Drug therapy for arthritis.)
Immunosuppressants — such as methotrexate, cyclosporine, and azathioprine — are also therapeutic. They’re being used more commonly early in the disease process. Cox-2 inhibitors, such as rofecoxib and celecoxib, significantly reduce the risk of GI bleeding. Cyclophosphamide, which suppresses the immune system and is associated with toxic adverse effects, may be used in patients who have been unsuccessful with other therapies.
UNDER STUDY: A number of new drugs are becoming popular for RA therapy:
❑ Etanercept, an injectable, and infliximab, given I.V. every 2 months, inhibit the inflammatory protein tumor necrosis factor.
❑ Leflunomide blocks the growth of new cells.
❑ Anakinra, an injectable, blocks another inflammatory protein, interleukin-1.
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 loss of joint function.
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.
Treatment in advanced disease
Advanced disease may require synovectomy, joint reconstruction, or total joint arthroplasty. (See When arthritis requires surgery, page 743.)
Useful surgical procedures in RA include metatarsal head and distal ulnar resectional arthroplasty, insertion of a Silastic prosthesis between MCP and PIP joints, and arthrodesis (joint fusion). Arthrodesis sacrifices joint mobility for stability and relief of pain.
Synovectomy (removal of destructive, proliferating synovium, usually in the wrists, knees, and fingers) may halt or delay the course of the 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. Apheresis may slow down RA or stop it from wor-sening.
Special considerations
❑ If the patient requires knee or hip arthroplasty, provide appropriate teaching and postoperative care.
❑ Carefully assess all joints. Look for deformities, contractures, immobility, and inability to perform everyday activities.
❑ Monitor vital signs, and note weight changes, sensory disturbances, and level of pain. Administer an analgesic, and watch for any adverse reactions.
❑ Give meticulous skin care. Check for rheumatoid nodules, as well as pressure ulcers and breakdowns from 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 a firm diagnosis and accurate monitoring of therapy.
❑ Monitor the duration, not the intensity, of morning stiffness, because duration more accurately reflects the severity of the disease. 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. If the patient is in traction or wearing splints, monitor him for pressure ulcers.
❑ Explain the nature of RA. Make sure the patient and his family understand that RA is a chronic disease that requires major lifestyle changes. 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, such as dressing and feeding himself. (Supply easy-to-open cartons, lightweight cups, and unpackaged silverware.) 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 RA patient to discuss his fears about 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 his prescribed medication and how to recognize its 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 the legs of a favorite chair. Suggest an elevated toilet seat.
❑ 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 is important, and so is correct sleeping posture. 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.
❑ Suggest dressing aids — long-handled shoehorn, reacher, elastic shoelaces, zipper-pull, and buttonhook — and helpful household items, such as easy-to-open drawers, a handheld shower nozzle, handrails, and grab bars.
❑ If the patient has trouble maneuvering fingers into gloves, suggest that he wear mittens. Tell him to dress while in a sitting position, if possible.
❑ Refer the patient to the Arthritis Foundation for more information on coping with RA.
Pictures
Book Source Details
- Book Title: Handbook of Diseases
- Author(s): Springhouse
- Year of Publication: 2003
- Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.
Other Book Chapters Related to Arthritis-like symptoms
Read excerpts from these other book chapters related to Arthritis-like symptoms:
Copyright Details: Handbook of Diseases, Copyright © 2008 Williams & Wilkins.
More About Causes of Arthritis-like symptoms
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More About This Book:
Title: Handbook of Diseases
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2003
ISBN: 1-58255-266-5
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» Next page: Septic arthritis (Handbook of Diseases)
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