Rheumatoid Arthritis: Difference between revisions

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'''Original Editors '''- [[User:Florence Brachotte|Florence Brachotte]] [[Amanda Fetz & Katie Robertson from Bellarmine University's Pathophysiology of Complex Patient Problems project]]
'''Original Editors '''- [[User:Florence Brachotte|Florence Brachotte]] [[User:Amanda Fetz|Amanda Fetz]] & [[User:Katie Robertson|Katie Robertson]] from [[Pathophysiology of Complex Patient Problems|Bellarmine University's Pathophysiology of Complex Patient Problems project]]


'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} &nbsp; [[Amanda Fetz]][[ Riley Sturzebecher]][[Elaine Lonnemann]][[ Kim Jackson]] [[Rachael Lowe]]
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} &nbsp; [[User:Amanda Fetz|Amanda Fetz]],[[User:Riley Sturzebecher|Riley Sturzebecher]],[[User:Elaine Lonnemann|Elaine Lonnemann]],[[User:Rachael Lowe|Rachael Lowe]]
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== Definition/Description ==
== Introduction ==
 
[[File:Osteoarthritis and rheumatoid arthritis - Normal joint Osteoarthr -- Smart-Servier.jpg|right|frameless|532x532px|alt=]]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.
Rheumatoid arthritis (RA) is a systematic autoimmune inflammatory disease that results in persistent inflammation of synovial tissue especially of the wrists, hands and feet. RA is a long-term disease that leads to inflammation of the joints and surrounding tissues and can also affect other surrounding structures like the tendon sheath, the bursa and tendons. This pathology causes pain, stiffness in the morning and after periods of inactivity, joint swelling, weakness, fatigue and restricted joint mobility leading to reduced function. Without treatment, RA can possibly lead to joint deformities in the later stages of the disease which then function of the joints could be lost permanently. Thus, RA causes dramatic interference with quality of life if early diagnosis and appropriate treatment are not obtained.<ref name="KNGF">KNGF-richtlijn. Reumatoïde artritis. 2008</ref><ref name="Maura et al">Maura D. Iversen et. Al, Predictors of the use of physical therapy services among patients with rheumatoid  arthritis © 2011 American Physical Therapy Association, Issue 91, pages 65-67 (Level 2B )</ref> Individuals with RA are 8 times more likely to have the functional disability compared with adults in the general population from the same community.


The disease course typically follows three possible paths:<ref>National Center for Biotechnology Information, U.S. National Library of Medicine. Disease fact sheet:[https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001467/ http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001467/] (accessed 1 March 2013)</ref><ref name=":5">Arthritis Foundation. Disease fact sheet: http://www.arthritis.org/conditions-treatments/disease-center/rheumatoid-arthritis/ (accessed 25 February 2013)</ref> 
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<ref name=":6">Krati Chauhan; Jagmohan S. Jandu; Mohammed A. Al-Dhahir. Oct 2019 [https://www.ncbi.nlm.nih.gov/books/NBK441999/ RA] Available from:https://www.ncbi.nlm.nih.gov/books/NBK441999/ (last accessed 23.2.2020)</ref>
# '''''Monocyclic'':''' Having one episode that does not reoccur. This usually ends within 2-5 years of initial diagnosis.
# '''''Polycyclic'':''' The disease severity varies over the course of the progression of the condition. 
# '''''Progressive'':''' Condition continues to become more severe and non-remitting.


== Clinically Relevant Anatomy  ==
== Etiology and Pathology ==
Etiology is unknown (probably multifactorial).


[[Image:Rheumatoid arthritis joint.gif|thumb|right|350px|Diagram showing how Rheumatoid Arthritis affects a joint in the hand]] Characterizing in rheumatoid arthritis is the inflammation of the synovium&nbsp;also characterized is the destructive erosion of bone and loss of joint integrity what frequently leads to disability. <ref name="Maura et al" />&nbsp;The synovium is a thin layer of tissue which lines the joint space where there is no cartilage. It can also be found in tendon sheaths and bursae. Under normal circumstances, the synovium consists of 2 - 3 layers of cells. In patients with rheumatoid arthritis, the synovium is strongly thickened and inflamed. Due to the inflammation production of enzymes occurs, which breaks down the cartilage.&nbsp;This can cause local damage to the bone-tissue and cartilage. The cause of this inflammation in rheumatoid arthritis is unknown.<ref name="KNGF" />
* It is generally considered that a [[Genetic Conditions and Inheritance|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|Epstein-Barr virus]] postulated as a possible antigen, but not proven) lead to an [[Autoimmune Disorders|autoimmune]] response that is directed against [[Synovial Fluid Analysis|synovial structures]] and other organs.


== Epidemiology  ==
[[Image:Rheumatoid arthritis joint.gif|right|559x559px|Diagram showing how Rheumatoid Arthritis affects a joint in the hand|frameless]]
The prevalence of Rheumatoid Arthritis is estimated between 1.5- 2.1 million US adults or 10 cases per every 1000 people. There are nearly three times as many women then men with the disease. RA is found all around the world, but does tend to be more prevalent in the Native American and white population.
Activation and accumulation of CD4 T cells in the synovium start a cascade of [[Inflammation Acute and Chronic|inflammatory responses]] which result in:


The risk of RA increases with age. RA most commonly begins in women between the ages of 30 and 60. It often occurs later in life for men, but can happen at any age. When RA affects the pediatric population, it is called [https://www.physio-pedia.com/Juvenile_Rheumatoid_Arthritis Juvenile Idiopathic Arthritis (JIA)] and usually begins before the age of 16. <ref name=":5" /><ref>CDC. Rheumatoid Arthritis.http://www.cdc.gov/arthritis/basics/rheumatoid.htm (accessed 13 February 2013)</ref>
* 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 [[Immunoglobulins (Ig)|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


== Etiology  ==
The inflammatory response leads to Pannus formation.


The cause of Rheumatoid Arthritis remains unknown and can therefore not be prevented. A simple disorganisation of the immune system can be at the origin of the body attacking its own tissue. The evolution of the disease varies from person to person; sometimes the inflammation can become systemic, what means that it will expand and also affect multiple organs, systems or tissues. <ref name="KNGF" /> 
Pannus:


Systemic inflammation and autoimmunity in RA begin long before the onset of detectable joint inflammation<ref name=":1">Demoruelle MK, Deane KD, Holers VM. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4033623/ When and where does inflammation begin in rheumatoid arthritis?.] Current opinion in rheumatology. 2014 Jan;26(1):64.</ref>. Emerging data suggest that RA-related autoimmunity may be initiated at a mucosal site years before the onset of joint symptoms. The candidate sites of origin include the oral, lung and gastrointestinal mucosa, as data consistent with this hypothesis have been generated for each location. Individual patients may undergo initiation events at unique sites but still converge on similar joint findings as the disease process evolves. RA is typically divided into two subtypes designated “seropositive” and “seronegative” disease, with seropositivity being defined as the presence of serum elevations of the autoantibodies rheumatoid factor (RF) and the more recently described antibodies to citrullinated protein/peptide antigens (ACPAs).
* 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<ref name=":1">Radiopedia [https://radiopaedia.org/articles/rheumatoid-arthritis RA] Available from: https://radiopaedia.org/articles/rheumatoid-arthritis<nowiki/>(accessed 7.6.2021)</ref>


Multiple genetic and environmental factors<ref name=":0">Deane KD, Demoruelle MK, Kelmenson LB, Kuhn KA, Norris JM, Holers VM. [https://www.bprclinrheum.com/article/S1521-6942(17)30013-X/fulltext Genetic and environmental risk factors for rheumatoid arthritis]. Best Practice & Research Clinical Rheumatology. 2017 Sep 18.</ref> have been associated with an increased risk for rheumatoid arthritis (RA).  
== Epidemiology ==
 
The overall prevalence is 0.5-1% and the disease is 2-3 times more common in women.
=== Genetic and familial risk factors for RA ===
There is a generally increased prevalence of RA within families, leading to estimations of familial risk contribution of ∼40–50% of seropositive RA, with strongest risks seen in first-degree relatives (FDRs). In addition, genetic factors in RA are suggested by an increased prevalence of disease within certain racial groups such as North American natives, who exhibit prevalence rates of RA of 5–7%. Although there may be non-genetic familial or cohort factors that play a role in the family or racial/ethnic group risk, multiple specific genetic loci have been identified that are associated with increased risk for RA and in some cases decreased risk.
 
The strongest of the genetic risk factors is a set of alleles within the major histocompatibility complex (MHC) that encode amino acid sequences that predict structural similarities in the human leukocyte antigen (HLA) peptide-binding groove and are termed in the aggregate “shared epitope,”(SE). SE alleles are believed to contribute up to ∼40% of the genetic risk for RA, although other studies suggest less contribution<ref name=":0" />.  
 
=== Environmental factors ===
Multiple environmental, dietary, and lifestyle factors have been associated with RA<ref name=":0" />.
# Smoking/Tobacco Exposure: Many studies have found that exposure to smoking accounts for ∼20–30% of the environmental risk for RA. Primarily, smoking is most strongly associated with antibodies to citrullinated protein/peptide antigens (ACPA) - positive RA. It has been proposed that smoking may lead to increased citrullination and in presence of the right genetic background, it may lead to the presentation of citrullinated proteins and the generation of ACPA, along with other local and systemic effects of smoking tobacco influencing the immunity. Smoking has long been associated with the presence of RF even in the absence of RA. This suggests that there may be biologic interactions between these factors that drive the development of RA or at the very least RA-related autoimmunity.  Thus, a major unanswered question regarding the role of smoking in RA is where it acts in the natural history of RA. Specifically, does exposure to tobacco smoke act to trigger the initial autoimmunity or does it drive the propagation of autoimmunity to the point of classifiable disease?  These issues need to be investigated thoroughly, especially given the potential for smoking to be a modifiable risk factor and therefore a potential preventive intervention in RA development.   
# Dietary factors: Lower intake of vitamin D and antioxidants and higher intake of sugar, sodium, red meats, protein, iron and certain medications are associated with increased risk of RA.   
{| class="wikitable"
!Environmental and other factors associated with rheumatoid arthritis risk<ref name=":0" />.
|-
|'''Increased risk'''
|-
|Female sex
|-
|Exposure to tobacco smoke
|-
|Occupational dust (silica)
|-
|Air pollution
|-
|High sodium, red meat, and iron consumption
|-
|Obesity
|-
|Low vitamin D intake and levels
|-
|'''Decreased risk'''
|-
|Fish and omega-3 fatty acid consumption
|-
|Moderate alcohol intake
|-
|Healthy diet
|-
|Statin use
|-
|Oral contraceptive use/hormone replacement
|} 
 
=== Microbes and mucosal processes influencing RA development ===
Data suggest<ref name=":1" /> that the initial inflammation and autoimmunity in RA begins outside of the joints. Several lines of evidence support that RA-related autoimmunity may originate at a mucosal site. The general model<ref name=":0" /> underlying a hypothesis that mucosal surfaces (and potentially microbes) play a role in the pathogenesis of RA is as follows. At some point in preclinical RA, at a mucosal surface (e.g., the oral cavity, lung, gut) interactions between microbes potentially other environmental factors (e.g., tobacco smoke) and host factors lead to mucosal inflammation and initial breaks in RA-related immune tolerance.
 
This mucosal inflammation may then facilitate local, and then systemic, propagation of autoimmunity through mechanisms that may include molecular mimicry or facilitation of development of direct autoimmunity to self-antigens.
 
Few epidemiologic and other observational studies have linked inflammation in the oral cavity and specifically <u>periodontitis</u> to the preclinical period of RA. In addition, studies of RA-related autoantibody-positive individuals without IA have demonstrated the <u>presence of airways inflammation and/or lung parenchymal abnormalities</u> by imaging with a number of subjects later progressing to clinically apparent RA<ref name=":0" />.


Certain studies have shown alteration of the oral or gut microbiota may affect mucosal immunity, inducing aberrant immune responses that affect joints in patients with RA<ref>Pianta A, Arvikar SL, Strle K, Drouin EE, Wang Q, Costello CE, Steere AC. [https://www.jci.org/articles/view/93450 Two rheumatoid arthritis–specific autoantigens correlate microbial immunity with autoimmune responses in joints.] The Journal of clinical investigation. 2017 Aug 1;127(8):2946-56.</ref>
Onset is generally in adulthood, peaking in the 4th and 5th decades. The paediatric condition, [https://www.physio-pedia.com/Juvenile_Rheumatoid_Arthritis Juvenile Idiopathic Arthritis (JIA)], is discussed separately, see link.<ref name=":1" />


Scher J U et al identified the presence of Prevotella copri<ref>Scher JU, Sczesnak A, Longman RS, Segata N, Ubeda C, Bielski C, Rostron T, Cerundolo V, Pamer EG, Abramson SB, Huttenhower C. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3816614/ Expansion of intestinal Prevotella copri correlates with enhanced susceptibility to arthritis.] elife. 2013 Nov 5;2:e01202.</ref> as strongly correlated with disease in new-onset untreated rheumatoid arthritis patients. Increases in Prevotella abundance correlated with a reduction in Bacteroides and a loss of reportedly beneficial microbes in new-onset untreated rheumatoid arthritis subjects.
== Risk Factors ==
Include:  


=== Gender and rheumatoid arthritis ===
* Increased prevalence of RA within families resulting from the interaction between patients genotype and environment.
A large number of epidemiologic studies point to sex-related factors in RA risk, it has long been considered that there are female-specific factors that influence risk for RA. However, many controversies still exist<ref>Alpízar-Rodríguez D, Pluchino N, Canny G, Gabay C, Finckh A. [https://www.ncbi.nlm.nih.gov/pubmed/27686101?dopt=Abstract The role of female hormonal factors in the development of rheumatoid arthritis.] Rheumatology. 2016 Sep 29;56(8):1254-63.</ref>. The post-menopause stage, an early age at menopause, the post-partum period and the use of anti-oestrogen agents are associated with RA onset. All these phenomena have in common an acute decline in ovarian function and/or in oestrogen bioavailability. However, there are controversies regarding other female hormonal factors. The influence of systemic hormonal treatments, including contraceptive and HRT, on RA onset, remains unclear. The effect of other factors related to diverse hormonal changes (such as parity, breastfeeding or PCO) is also controversial. 
* Increases risk: Female sex; occupational dust (silica); air pollution; high sodium red and iron consumption; low vitamin D intake and levels; [[Smoking and Exercise|Smoking]] (seropositive RA); [[Obesity]]; Low socioeconomic status <ref name=":1" />
 
* Deceased risk: fish and omega 3 fatty acid consumption; moderate alcohol intake; healthy diet; oral contraceptive/HRT; statin use.<ref name=":0">Deane KD, Demoruelle MK, Kelmenson LB, Kuhn KA, Norris JM, Holers VM. [https://www.sciencedirect.com/science/article/pii/S152169421730013X Genetic and environmental risk factors for rheumatoid arthritis.] Best practice & research Clinical rheumatology. 2017 Feb 1;31(1):3-18.</ref>
The timing of oestrogen exposure also plays a role in RA onset, with female hormonal factors having varying effects during premenopause and post-menopause. Overall, the effect of sex hormones on the immune system and their interaction with environmental and genetic factors could explain the higher prevalence of RA in women. As some female hormonal factors are potentially modifiable, understanding their precise role is key for future preventive interventions focusing on women at high risk<ref name=":0" />.
[[File:RA Hand 1.png|thumb]]


== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==
A major advance in understanding how these factors impact the development of RA has been the emergence of a model of RA development, and in particular seropositive RA development. There is typically a period of circulating autoantibody elevations that may last several years prior to the first appearance of inflammatory arthritis. This period can be termed “'''Preclinical RA,'''” and its presence has raised the issue that a subset of the genetic and environmental factors that drive RA , are likely acting years prior to the first appearance of arthritis. This process of disease progression is not universal, although some studies have identified a small percentage of patients where inflammatory arthritis presents prior to the appearance of circulating autoantibodies<ref name=":0" />.
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. [[File:RA Hand 1.png|right|frameless|400x400px]]
* 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.
[[File:Rheumatoid-arthritis-hands-3.jpeg|right|frameless|399x399px]]
Image 4: 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.<ref name="SARAH et al">Adams J, Bridle C, Dosanjh S, Heine P, Lamb SE, Lord J, McConkey C, Nichols V, Toye F, Underwood MR, Williams MA. [https://link.springer.com/article/10.1186/1471-2474-13-230 Strengthening and stretching for rheumatoid arthritis of the hand (SARAH): design of a randomised controlled trial of a hand and upper limb exercise intervention-ISRCTN89936343]. BMC musculoskeletal disorders. 2012 Dec;13(1):1-0.</ref>
* 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.&nbsp;
* 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. <ref name="KNGF">KNGF-richtlijn. Reumatoïde artritis. 2008</ref><ref name="Geri et al">Neuberger GB, Aaronson LS, Gajewski B, Embretson SE, Cagle PE, Loudon JK, Miller PA. [https://onlinelibrary.wiley.com/doi/abs/10.1002/art.22903 Predictors of exercise and effects of exercise on symptoms, function, aerobic fitness, and disease outcomes of rheumatoid arthritis.] Arthritis Care & Research. 2007 Aug 15;57(6):943-52.</ref>
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. <ref name="KNGF" />
* Individuals with RA are 8 times more likely to have functional disability compared with adults in the general population from the same community.


In rheumatoid arthritis, joint complaints are in the foreground.  
== Staging ==
[[File:RA stages.png|right|frameless|359x359px]]'''Disease progression:'''


Typically in a first stage, there is:
Stages
* a chronic, symmetrical inflammation of the joints of the hands and the feet, especially the metatarsophalangeal joints (MTP), the wrists, the metacarpophalangeal joints (MCP) and the proximal interphalangeal joints (PIP).


* Softening of the ligaments can lead to deformation of the fingers, like subluxations of the metacarpophalangeal joints.
# No destructive changes on x-rays
Rheumatoid arthritis causes deformity, pain, weakness and restricted mobility and will result in loss of function.<ref name="SARAH et al">SARAH Trial Team et al., [https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/1471-2474-13-230 Strengthening and stretching for rheumatoid arthritis of the hand (SARAH): design of a randomised controlled trial of a hand and upper limb exercise intervention - ISRCTN89936343,] Trial Team et al. BMC Musculoskeletal Disorders 2012, 13:230 (Level 1A)</ref>
# 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.
The three most important complaints are the pain, morning stiffness and fatigue.
# Presence of bony or fibrous ankylosis along with stage 3 features.<ref name=":6" />
 
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. Usually, the instability occurs between the first and second cervical vertebrae. This instability can lead to pain and neurological symptoms, like a headache and tingling in the fingers. <ref name="KNGF" /><br>
 
RA is a highly disabling disease associated with high morbidity. Consequently, RA results in considerable direct costs, such as health care expenses, and indirect costs, such as loss of productivity due to morbidity and decreased life expectancy.<ref name="Ottawa">Ottawa Methods Group, Ottawa Panel Evidence-Based Clinical Practice Guidelines for Therapeutic Exercises in the Management of Rheumatoid Arthritis in Adults, Phys Ther. 2004;84:934–972 (Level 1A).</ref> The increased mortality in RA patients is mostly associated with cardiovascular disease. Accelerated atherosclerosis is of growing concern in these patients. There is increasing evidence that atherosclerotic disease is driven by inflammatory mechanisms similar to those in RA. Cardiovascular morbidity correlates with inflammatory activity in RA.
 
'''Signs and Symptoms of RA:'''
 
'''http://trcs.wikispaces.com/Rheumatism'''
* Joint Pain: warmth, redness, tenderness, swelling
* Joint Stiffness: increased in the mornings
* Fatigue throughout the body
* Fever
* Weight Loss
* Rheumatoid Nodules: small lumps of tissue felt under the skin
* Symmetrical Patterns of affected joints
* Most common joints: wrist, hand, fingers, cervical spine, shoulder, elbow, knee, hip, foot, and ankle
* Prolong symptoms
* Anemia
* Neck Pain
* Dry Eyes
* Dry Mouth
 
== Classification Of Progression of Rheumatoid Arthritis ==
{| class="wikitable"
|Stage
|Description
|-
|Stage I
Mild
|No destructive changes on radiographic examination
Radiographic evidence of osteoporosis may be present
|-
|Stage II
Moderate
|Radiographic evidence of osteoporosis, with or without slight subchondral bone destruction; slight cartilage destruction may be present
No joint deformities, although limitation of joint mobility may be present
 
Adjacent muscle atrophy
 
Extra-articular soft tissue lesions, such as nodules and tenosynovitis may be present
|-
|Stage III
Severe
|Radiographic evidence of cartilage and bone destruction in addition to osteoporosis
Joint deformity, such as subluxation, ulnar deviation, or hyperextension, without fibrous or bony ankylosis
Extensive muscle atrophy
Extra-articular soft tissue lesions, such as nodules and tenosynovitis may be present
|-
|Stage IV
Terminal
|Fibrous or bony ankylosis
Stage III criteria
|}
[[File:RA stages.png|thumb]]


== Differential Diagnosis  ==
== Differential Diagnosis  ==
* [[Systemic Lupus Erythematosus|Lupus]]
* Chronic [[Lyme Disease|Lyme disease]]
* [[Osteoarthritis|Osteoarthri]]<nowiki/>[[Osteoarthritis|tis]]
* Septic [[arthritis]]
* Psoriatic arthritis
* [[Sjogren's Syndrome|Sjogren]] syndrome
* Sarcoidosis<ref name=":6" />


There is no unique test or feature that is pathognomonic for RA. The diagnosis is made by recognizing a pattern of signs and symptoms. The classification criteria are helpful in classifying patients for the purpose of clinical research studies, but they might not clearly establish the diagnosis in an individual patient. <br>A thorough history and examination are necessary for the differential diagnosis in the individual patient. There are lots of disorders that mimic RA. Rheumatoid arthritis can resemble any disorder causing acute or chronic polyarthritis.
== Complications ==
 
[[File:Rheumatoid lung.jpeg|right|frameless]]
Common disorders to consider as differential diagnoses with RA are:
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.<ref>Pubmed. Comorbidities in rheumatoid arthritis. [https://www.ncbi.nlm.nih.gov/pubmed/17870034 http://www.ncbi.nlm.nih.gov/pubmed/17870034] (accessed 12 February 2013).</ref> This is significant because of the comorbidities effects on quality of life, functional status, prognosis and outcome. Associated Complications include:<ref>Gabriel SE. [https://www.sciencedirect.com/science/article/pii/S0002934308005901 Cardiovascular morbidity and mortality in rheumatoid arthritis]. The American journal of medicine. 2008 Oct 1;121(10):S9-14.</ref>
* '''Osteoarthritis:''' best differentiated from RA by a careful history and examination. Two factors to distinguish the two disorders: the absence of systemic inflammatory signs and symptoms, onset in later life, and the pattern of joint involvement.
* Infections
 
* Chronic anaemia
*'''Infectious arthropathies:''' the important consideration in the setting of fever and polyarthritis. If bacterial arthritis is suspected, joint aspiration and synovial fluid cultures and blood cultures are often helpful in establishing the diagnosis.
* Gastrointestinal cancers
*'''Lyme disease:''' also associated with negative synovial fluid cultures. When a patient has been in an endemic region where tick exposure was likely, it should be considered.
* Pleural effusions
*'''Seronegative spondyloarthropathies''' (reactive arthritis, ankylosing spondylitis, inflammatory bowel disease–associated arthropathy): muscle weakness and antibodies associated with these disorders most often readily distinguish these disorders from RA.
* [[Osteoporosis]]
*'''Fibromyalgia (FMS):''' diffuse symmetrical arthralgias and stiffness at rest, but an absence of synovitis, the lack of pain on motion, and normal laboratory and imaging studies. <ref name="Williams">WilliamS. Wilke, Rheumatoid Arthritis</ref>
* [[Cardiovascular Disease|Heart disease]]
 
* Sicca syndrome
<u>Other pathologies to consider:</u>
* Felty syndrome
* Myelodysplastic syndrome
* Lymphoma<ref name=":6" />
* Osteoarthritis Paraneoplastic syndrome
* Damage to the lung tissue (rheumatoid lung) See '''image 6''': 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.
* Polychondritis
* Polymyalgia
* Rheumatica Psoriatic Arthritis
* Sarcoidosis Sjogren Syndrome
* Systemic Lupus
* Erythematous
* Reiter Syndrome
* Gout
 
== Associated co-morbidites ==
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.<ref>Pubmed. Comorbidities in rheumatoid arthritis. [https://www.ncbi.nlm.nih.gov/pubmed/17870034 http://www.ncbi.nlm.nih.gov/pubmed/17870034] (accessed 12 February 2013).</ref> This is significant because of the comorbidities effects on quality of life, functional status, prognosis and outcome. Associated co-morbidities include:<ref>Gabriel SE. Cardiovascular morbidity and mortality in rheumatoid arthritis. Am J Med. 2008 Oct;121(10 Suppl 1):S9-14.</ref>
* Myocardial Infarction and Cardiovascular disease;
* Stroke;
* Peripheral Vascular Disease;
* Cancer (All);
* Infection;
* Osteoporosis;
* Gastro-intestinal (GI) disease;
* Psoriasis and other skin conditions; 
* Cataract.
== Complications of RA ==
Rheumatoid arthritis can affect nearly every part of the body. Even though the joints are most commonly affected, RA can also have effects on organs.
* Damage to the lung tissue (rheumatoid lung)
* Increased risk of hardening of the arteries
* Spinal injury when the neck bones become damaged
* Inflammation of the blood vessels (rheumatoid vasculitis), which can lead to skin, nerve, heart, and brain problems
* Swelling and inflammation of the outer lining of the heart (pericarditis) and of the heart muscle (myocarditis), which can lead to congestive heart failure
* Side effects from treatment and medication. 
* Side effects from treatment and medication. 
* General deconditioning
* General deconditioning
* Rheumatoid nodules
* Vascular complications
* Neurological complications
* Neurological complications
* Cardiopulmonary complications
* Ocular complications
* Ocular complications


== Systemic Involvement<ref>Goodman C, Fuller K. Pathology: Implications for the Physical Therapist. 3rd ed. . St. Louis, MO: Saunders, an imprint of Elsevier Inc, 2009.</ref>  ==
== 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, [[Laboratory Tests|erythrocyte sedimentation rate]] (ESR) and C-reactive protein (CRP) may be elevated in the active phase of arthritis.
2. [[X-Rays|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).  


{| width="600" border="1" cellspacing="1" cellpadding="1"
3. Magnetic resonance imaging ([[MRI Scans|MRI]]) and [[Ultrasound Scans|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.<ref name=":6" />
|-
| <span style="line-height: 19px;">Malignant</span>
| <span style="line-height: 19px;">Hypertonic Osteoarthropathy, lymphoma, Leukemia, Carcinoma Polyarthritis&nbsp;</span><br>
|-
| <span style="line-height: 19px;">Hematologic</span>
| <span style="line-height: 19px;">Sickle cell anemia, Thalassemia, Multiple Myeloma, Amyloidosis</span><br>
|-
| <span style="line-height: 19px;">Gastrointestinal</span>  
| <span style="line-height: 19px;">Whipple disease, primary biliary cirrhosis, Spondyloarthropathies, hemochromatosis</span><br>
|-
| <span style="line-height: 19px;">Endocrinopathies</span>
| <span style="line-height: 19px;">DM, hypothyroidism, hyperthyroidism, hyperparathyroidism, acromegaly</span><br>
|-
| <span style="line-height: 19px;">Extra-articular Manifestations&nbsp;</span>
| <span style="line-height: 19px;">Many of the extra-articular manifestations of RA are associated with increased disease activity and with markers of inflammation, such as high levels of rheumatoid factor (RF) and C-reactive protein (CRP).</span><br>
|}


===  Diagnostic Procedures ===
== Prognosis ==
The American College of Rheumatology has defined 7 criteria, where a patient has to correspond with '''at least 4 of these 7 criteria''' for the diagnosis of rheumatoid arthritis.The first 4 of these criteria are only valid if they persist for at least 6 weeks. These 7 criteria are:<br>
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.  
# Morning stiffness
# Arthritis in 3 or more joints
# Arthritis in the joints of the hands (wrist, MCP, PIP)
# Symmetrical arthritis
# Rheumatoid nodules over bony prominences or extensor surfaces
# Positive serum rheumatoid factor
# Radiographic changes including erosion or bony decalcifications localized in or adjacent to joints.
<br>
{| width="800" border="1" cellspacing="1" cellpadding="1"
|+ <u>'''Diagnostic Tests'''</u>
|-
| Test
| Description
| Purpose
|-
| C-reactive protein (CRP)<br>(Lab Test)
| Blood Test
| Indicates inflammation. As the level of inflammation rises, so does the level of CRP. High levels of CRP over a long period of time may indicate more severe joint damage.
|-
| Erythrocyte sedimentation rate, also referred to as ESR or "sed rate"<br>(Lab Test)
| Blood Test
| People with severe RA will generally have a higher ESR than one with less severe RA
|-
| Rheumatoid factor (RF) <br>Lab Test
| Blood Test
| Indicates the presence of RA. When the immune system attacks itself, the body produces RF. 75% of people with RA are RF positive.
|-
| Cyclic citrullinated peptide (CCP)<br>Lab Test
| Blood Test
| This test is usually given to people who are experiencing new symptoms of RA, in order to rule out other autoimmune diseases.<br>
|-
| Bone Scans
| Imaging
| Detects inflammation
|-
| X-Ray
| Imaging
| Detects swelling of soft tissues and loss of bone density
|-
| Magnetic Resonance Imaging (MRI)
| Imaging
| Detects inflammation
|-
| Ultrasound
| Imaging
| Detects inflammation
|}
 
== Examination  ==
 
Symptoms of rheumatoid arthritis can progressively increase but can also fluctuate in time, therefore it is important that we search for any active symptoms during the physical examination. We need to examine the joints on swelling, pain due to palpation, pain due to movement, decreased range of motion, deformation and instability.&nbsp;Other symptoms of RA are fatigue, depression and 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. <ref name="KNGF" /><ref name="Geri et al">Geri B. Neuberger et al., Predictors of exercise and effects of exercise on symptoms, function, aerobic fitness, and disease outcomes of rheumatoid arthritis. 2007, 943-952</ref>


=== '''Prognosis''' ===
* Besides the joint disease, the individuals can suffer from many extra joint-related problems which significantly alters the [[Quality of Life|quality of life]]. The progression of disease does vary from individual to individual.
The prognosis of RA depends on the severity of symptoms and early intervention. People with rheumatoid factor, the anti-CCP antibody, or subcutaneous nodules have a more severe form of the disease. People who develop RA at younger ages also tend to progress quicker.<ref>Medicine Plus: Rheumatoid Arthritis. [https://www.nlm.nih.gov/medlineplus/ency/article/000431.htm http://www.nlm.nih.gov/medlineplus/ency/article/000431.htm](accessed 1 March 2013)</ref>
* 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.<ref name=":6" />
* 50% Disabled at work within 10 years
* 66% Significant trouble with ADL’s after 15 years
* Patients with severe RA may die 10-15 years earlier


== Medical Management  ==
== Treatment ==
Treatment of rheumatoid arthritis is aimed at improving the symptoms and slowing disease progression.


Biological DMARDs (drug treatment), optimal outcome of treatment in rheumatoid arthritis (RA) is early clinical remission to delay joint damage. Therefore, severe RA patients with inadequate response to conventional disease modifying anti-rheumatic drugs (cDMARDs) need high-potency drug as biological DMARDs (bDMARDs).&nbsp;<ref>Wacharapornin P, Suwannalai P, Predictors for low disease activity and remission in rheumatoid arthritis patients treated with biological DMARDs, J Med Assoc Thai. 2014 Nov;97(11):1157-63,</ref>
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.


HMG-CoA reductase inhibitors (also known as statins) are widely used as lipid-lowering agents in patients with rheumatoid arthritis (RA) to reduce their cardiovascular risk. The Statin therapy also significantly reduced tender joint counts, swollen joint counts, erythrocyte sedimentation rate (ESR), compared with placebo groups.<ref>Xing B. et al., Effect of 3-hydroxy-3-methylglutaryl-coenzyme a reductase inhibitor on disease activity in patients with rheumatoid arthritis: a meta-analysis.</ref> However, statins influences immune regulation, which may potentially facilitate autoimmunity, eventually resulting in autoimmune diseases such as rheumatoid arthritis (RA)<ref>de Jong HJ, Klungel OH, Van Dijk L, Vandebriel RJ, Leufkens HG, van der Laan JW, Tervaert JC, Van Loveren H. [https://ard.bmj.com/content/71/5/648.long Use of statins is associated with an increased risk of rheumatoid arthritis.] Annals of the rheumatic diseases. 2011 Oct 1:annrheumdis-2011.</ref>. A matched cohort study<ref>de Jong HJ, Tervaert JW, Lalmohamed A, de Vries F, Vandebriel RJ, Van Loveren H, Klungel OH, van Staa TP. [https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0193297#sec011 Pattern of risks of rheumatoid arthritis among patients using statins: A cohort study with the clinical practice research datalink.] PloS one. 2018 Feb 23;13(2):e0193297.</ref> with prospectively collected data suggested the risk of RA is substantially increased in the first year after initiation of statins and then diminishes to baseline, suggesting an association between statin use and an increased risk of RA in the first year after initiating statin treatment.
== Medical Management ==
Medications used in treatment include:


Radiosynovectomy is a well-established therapy in arthritis and involves an intra-articular injection of small radioactive particles to treat a synovitis. The treatment can be repeated 3-time in an interval of 3 months if the first treatment showed an insufficient effect. Repeated treatments are more effective than single treatments with higher activity. The therapy is well-tolerated with a low rate of side effects. In respect of the specific uptake of particles in the synovia and short range of beta radiation, the radiation exposure outside the joint is very low.<ref>Knut L. Radiosynovectomy in the therapeutic management of arthritis, World J Nucl Med, 2015 Jan-Apr;14(1):10-5</ref>&nbsp;Their findings may suggest that statins can accelerate disease onset in patients susceptible to develop RA, but in other patients, statins are probably safe and well tolerated, even after prolonged use.  
* 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


Surgical treatment, operative treatment was aimed at the inflammatory focus elimination, reduction of the pain syndrome severity, the function loss, and the joint deformity correction. The most used operative interventions are tenonectomy, synovectomy, arthrodesis, total endoprosthesis.<ref>(No authors listed) Affection of radio-carpal joint in patients with rheumatoid arthritis and its surgical treatment, Klin Khir. 2014 Aug;(8):65-9.</ref>
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.<ref name=":1" />
== Medications  ==


{| width="800" border="1" cellspacing="1" cellpadding="1"
See link [[Pharmacological Management of Rheumatoid Arthritis]]
|+ <u>'''Common Medications for RA'''</u>
|-
| ''Medication''
| ''Uses/ Effects''
| ''Side Effects''
|-
| NSAIDs
| Pain reliever
| Stomach irritation <br>Kidney function. <br>Gastrointestinal problems<br>
|-
| Acetaminophen
| Pain reliever
| If taken in excessive, liver damage may occur which could potentially lead to liver failure
|-
| Aspirin Buffered Plain
| Decrease pain, swelling, inflammation
| Upset stomach<br>Tendency to bruise easily<br>
|-
| Corticosteriods
| Decrease inflammation, swelling, redness, itching, and allergic reactions<br>
| Increased appetite<br>Indigestion, <br>Nervousness <br>Restlessness<br>
|-
| Methylprednisolone<br>Prednisone
| Used for severe flare ups
| Mood changes<br>Easy bruising<br>Increase risks of infections<br>
|-
| Disease-modifying antirheumatic drugs (DMARDs)
| Relieve painful, swollen joints and slow joint damage
| May increase the risk of infection, hair loss, and kidney or liver damage
|-
| Azathioprine
| Used for patients who have not responded to other medications
| Cough or hoarseness<br>Fatigue <br>Abdominal issues <br>
|-
| Cyclosporine
| Used for patients who have not responded to other Medications
| Increase Blood Pressure <br>Kidney Problems <br>Shaking/Trembling of hands
|-
| Leflunomide
| Reduces signs and symptoms<br>Slows down the process of degeneration of the joints.<br>
| Abdominal pain, nausea, vomiting, loss of appetite, <br>Sneezing <br>Sore Throat<br>
|-
| Methotrexate
| Inhibits the metabolism of folic acid
| Low white blood cell counts, abdominal pain, fever, infection
|-
| Sulfasalazine
| Immunosuppressant&nbsp;
| Abdominal pain, diarrhea, loss of appetite, nausea/vomiting<br>Headache, sensitivity to light<br>Aching joints<br>
|-
| Biologic response modifiers
| Block the autoimmune response that is involved in the roll with inflammation
| Increase risk of infection
|-
| Tumor necrosis factor inhibitors
| Blocks the autoimmune response that is involved in the roll with prolong inflammation as seen in RA
| lymphoma, infections, congestive heart failure, and systemic side effects
|-
| Interleukin-1 inhibitor
| Decreases inflammation in moderate-severe RA
|
Abdominal Pain, Nausea, Vomiting, Headache
 
|-
| Selective costimulation modulator
| Anti-inflammatory
| Headache, dizziness, abdominal pain, dyspepsia, nausea, rash, flushing, urticaria, pruritus, and wheezing
|-
| CD20 antibody
| Depletes B Cells that are associated with autoimmune response
| Abdominal pain
|}


== Nutritional Guidelines ==
== Nutritional Guidelines ==
Dietary interventions necessitate a widespread appeal for both patients as well as clinicians due to factors including affordability, accessibility, and presence of scientific evidences that demonstrate substantial benefits in reducing disease symptoms such as pain, joint stiffness, swelling, tenderness and associated disability with disease progression. However, there is still an uncertainty among the community about the therapeutic benefits of dietary manipulations for RA<ref name=":3">Khanna S, Jaiswal KS, Gupta B. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5682732/ Managing Rheumatoid Arthritis with Dietary Interventions.] Frontiers in nutrition. 2017 Nov 8;4:52.</ref>. Dietary modification helps in staying in the remission phase of the inflammatory condition.
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)<ref name=":3">Khanna S, Jaiswal KS, Gupta B. [https://www.frontiersin.org/articles/10.3389/fnut.2017.00052/full?fbclid=IwAR0KZSCDuK9gWpMr7Ab-t8xCDUekU-tkUXufwnIf2uacv4eBJ3SFTd2Xd6w Managing rheumatoid arthritis with dietary interventions.] Frontiers in nutrition. 2017 Nov 8;4:52.</ref>. Dietary modification include:
 
* Avoiding food that causes inflammation like processed food, high salt, oils, butter, sugar, and animal products.  
Eating certain [https://www.arthritis.org/living-with-arthritis/arthritis-diet/anti-inflammatory/rheumatoid-arthritis-diet.php foods] can help you manage its symptoms. Dietary supplements<ref name=":3" /> like vitamin D, cod liver oil, and multivitamins can also help in managing RA.
* Supplements''':''' Research suggests that there are vitamins and minerals which may have an effect on RA<ref name=":3" />eg. [[Vitamin D Deficiency|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.  
 
Avoiding food which causes inflammation like processed food, high salt, oils, butter, sugar, and animal products. <br><br>
 
'''Supplements:''' Research suggests that there are vitamins and minerals which may have an effect on RA. These effects range from reducing joint inflammation to improving bone health. Some of the vitamins and minerals are listed below. It is recommended to consult your primary care physician before consuming any of the supplements listed below.
* Calcium
* Copper
* Fluoride
* Iron
* Magnesium
* Selenium
* Vitamin A
* Vitamin B-1
* Vitamin B-12
* Vitamin B-3
* Vitamin B-6
* Vitamin D
* Vitamin K
* Zinc


== Physical Therapy Management ==
== Physical Therapy Management ==
At present, there is no therapy that can completely heal RA. But there are treatments that achieve pain relief and the slowdown of the activity of RA to prevent disability and increase functional capacity. RA patients are unfortunately committed to a treatment for life.<ref name=":4">Vural Kavuncu, MD* and Deniz Evcik, MD Physiotherapy in Rheumatoid ArthritisfckLRMedGenMed. 2004; 6(2): 3.</ref> The benefits of physical therapy interventions have been well documented.&nbsp;
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.<ref name=":6" /> Treatments that achieve pain relief and the slowdown of the activity of RA to prevent disability and increase functional capacity.<ref name=":4">Kavuncu V, Evcik D. [https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1395797/ Physiotherapy in rheumatoid arthritis]. Medscape General Medicine. 2004;6(2).</ref><ref>Williams MA, Srikesavan C, Heine PJ, Bruce J, Brosseau L, Hoxey‐Thomas N, Lamb SE. Exercise for rheumatoid arthritis of the hand. Cochrane Database of Systematic Reviews. 2018(7).</ref>


Physical therapists play an integral role in the nonpharmacologic management of RA. They help patients with RA cope with chronic pain and disability through the design of programs that address flexibility, endurance, aerobic condition, a range of motion (ROM), strength, bone integrity, coordination, balance and risk of falls.&nbsp;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 three 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, exercise therapy and patient education.&nbsp;Dynamic exercise (aerobic capacity and/or muscle strength training) was effective in improving muscular endurance and strength, without detrimental effects on disease activity or pain.
See also [[Hand Rheumatoid Arthritis|Hand RA]]
 
[[File:Hydrotherapy Pool Exercises.jpg|right|frameless]]
The therapy goals in most cases are:&nbsp;<ref>Marry J. Bell et al., A Randomized control trial to evaluate the efficacy of community based physical therapy in the treatment of people with rheumatoid arthritis, 1998 Feb;25(2):231-7. (Level 1B)</ref>&nbsp;  
The benefits of physical therapy interventions have been well documented.&nbsp;
* 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.&nbsp;
* 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.  
[[File:Resting wrist hand brace.jpeg|right|frameless|333x333px]]
The four most common components of PT/OT for RA hands are  
# [[Hand Exercises|Exercise therapy]],  
# [[Joint Protection Principles|Joint protection]] advice and provision of functional splinting and [[Assistive Devices|assistive devices]]
# [[Massage]] therapy, and
# Patient education.&nbsp;
The therapy goals in most cases are:&nbsp;<ref>Bell MJ, Lineker SC, Wilkins AL, Goldsmith CH, Badley EM. [https://europepmc.org/article/med/9489812 A randomized controlled trial to evaluate the efficacy of community based physical therapy in the treatment of people with rheumatoid arthritis.] The Journal of rheumatology. 1998 Feb 1;25(2):231-7.</ref>&nbsp;  


*Improvement in disease management knowledge  
*Improvement in disease management knowledge  
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*Improve stability and coordination
*Improve stability and coordination


<br>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.&nbsp;<br>
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.&nbsp;
 
=== Physiotherapy Modalities: ===
'''•''' Cold/Hot Applications: cold = for acute phase; heat = for chronic phase and used before exercise. Dose and/or withdraw thermal energy by means of hot/cold application. <ref>Bijlsma J.W.J., Geusens P.P.M.M., Kallenberg C.G.M., P.P. Tak. Reumatologie en klinische immunologie. Houten: Bohn Stafleu van Loghum  2004. (level 5)</ref>
 
'''•''' Electrical Stimulation: Aperitif administering of electric energy by means of an alternating current. Transcutaneous electrical nerve stimulation (TENS) is used to relieve pain. <ref>Pelland L, Brosseau L, Casimiro L, Robinson VA, Tugwell P, Wells G. Electrical stimulation for the treatment of rheumatoid arthritis. The Cochrane database of Systematic Reviews. 2002;2:CD003687. (Samenbundeling van zowel RCT’s, cohortstudies als case-control studies dus level of evidence: 1, 2 en 3)</ref> 
 
'''•''' Hydrotherapy-Balneotherapy: allows exercise with minimal load on the joints. <br> Simply being in another environment, where the patient can relax has a positive effect on the disease's progression (physically as well as on mentally)<ref>Angela Reid1 , Audrey Brady1 , Catherine Blake2 , Anne-Barbara Mongey3 , Douglas J Veale3 , Oliver FitzGerald3 and Tara Cusack2fckLRRandomised controlled trial examining the effect of exercise in people with rheumatoid arthritis taking anti-TNFα therapy medicationfckLRBMC Musculoskeletal Disorders 2011, 12:11doi:10.1186/1471-2474-12-11 (level 1B)</ref> The evidence for Balneotherapy is positive but lacks trials undertaken with robust methodologies. <ref>Verhagen AP, Bierma-Zeinstra SM, Cardoso JR, Bie RA de, Boers M, Vet HC de. Balneotherapy for rheumatoid arthritis. The Cochrane Database of Systematic Reviews. 2003;4:CD00518. (Level 1A)</ref>
=== Rehabilitative Treatment: ===


===== Joint Protection Strategies: =====
=== Treatment techniques ===
*Rest &amp; Splinting: Orthosis and splinting prevent the development of deformities and support joints
[[Thermotherapy|Cold/Hot]] Applications: cold for acute phase; heat for chronic phase and used before exercise. <ref>Bijlsma JW, Geusens PP, Kallenberg CG, Tak PP. Reumatologie en klinische immunologie.</ref>
*Therapy Gloves: to control and manage hand pain, to maintain or restore the patient’s hand function, or to psychologically help to relax or calm the wearer. Wearing therapy gloves led to the improvement in hand grip strength. The glove can be worn during the day or at night. They are made of various materials: nylon, wool and elastane fibres.&nbsp;<ref>Nasir SH, Troynikov O, Massy-Westropp N. Therapy gloves for patients with rheumatoid arthritis: a review. Therapeutic Advances in Musculoskeletal Disease. 2014;6(6):226-237. doi:10.1177/1759720X14557474. (level 3A)</ref>
*Compression Gloves: moderate joint swelling and consequently reduce the pain


===== Assistive Devices and Adaptive Equipment: =====
[[Transcutaneous Electrical Nerve Stimulation (TENS)|Transcutaneous electrical nerve stimulation]] (TENS) is used to relieve pain. <ref>Pelland L, Brosseau L, Casimiro L, Welch V, Tugwell P, Wells GA. [https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003687/abstract Electrical stimulation for the treatment of rheumatoid arthritis]. Cochrane Database of Systematic Reviews. 2002(2).</ref>
Arrangements (like elevated toilet seats,...) to facilitate activities of daily living


===== Massage Therapy:   =====
[[Hydrotherapy]]-Balneotherapy: exercise with minimal load on the joints.<ref>Verhagen AP, Bierma‐Zeinstra SM, Boers M, Cardoso JR, Lambeck J, de Bie R, de Vet HC. [https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000518/abstract Balneotherapy for rheumatoid arthritis]. Cochrane Database of Systematic Reviews. 2004(1).</ref>  
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) <ref>Brownfield A. Aromatherapy in arthritis: a study. Nurs Stand. 1998;13;5:34-35. (Level1)</ref>


===== Therapeutic Exercise: =====
[[Joint Protection Principles|Joint Protection]] see link
Physical exercise helps to increase the physical capacity of the patient but it does not reduce the activity of the disease<ref name=":4" />. There is evidence suggesting that exercise improves general muscular endurance and strength without detrimental effects on disease activity or pain in rheumatoid arthritis. However, few studies have investigated the effect of exercises for the rheumatoid hand. Some improvement in strength, mobility and/or function with no negative effects have been reported, although the long-term effectiveness has not been established due to various weaknesses in trial design.<ref>Heine P.J. et al., Development and delivery of an exercise intervention for rheumatoid arthritis: Strengthening and stretching for rheumatoid arthritis of the hand (SARAH) trial. Physiotherapy 98 (2012) 121-130 (Level 1B)</ref> The duration and the frequency of the treatment depend on the perceived limitations in activities and participation, and the impairments in functions and structures.<ref>Minor MA, Hewett JE, Webel RR, Anderson SK, Kay DR. Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis. Arthritis Rheum. 1989;32;11:1396-1405. (Level 1B)</ref><ref>Ende CH van den, Hazes JMW, le Cessie S, Mulder WJ, Belfor DG, Breedveld FC, et al. Comparison of high and low intensity training in well controlled rheumatoid arthritis. Results of a randomized clinical trial. Ann Rheum Dis. 1996;55;11:798-805. (Level 1B)</ref>&nbsp;


Before beginning an exercise program, it is important to have a global evaluation of the situation: joint-inflammation local or systemic, state of the disease, age of the patient and grade of collaboration.<ref name=":4" /><br>Exercise therapy is used by patients with RA with the aim of improving daily functioning and the social participation by means of improvement of the strength, aerobic condition, the range of motion, stabilization and coordination.
[[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) <ref>Brownfield A. [https://search.proquest.com/openview/7a2dd05233ca4d957526193c76694cda/1?pq-origsite=gscholar&cbl=30130 Aromatherapy in arthritis: a study.] Nursing Standard (through 2013). 1998 Oct 21;13(5):34.</ref>


<br>In general, we can say that patients with RA need a high-intensive exercise program which is aimed at improving aerobic capacity, strength and endurance. This program can be completed with ROM-exercises and stabilization/coordination exercises. Sometimes the therapist chooses to start with a moderate-intensive exercise program and built this up. This is often the case in patients with joint prostheses, severe physical disabilities and/or kinesiophobia. <ref>Jong Z de, Munneke M, Zwinderman AH, Kroon HM, Jansen A, Ronday KH, et al. Is a long term high intensity exercise program effective and safe in patients with rheumatoid arthritis? Results of a randomized controlled trial. Arthritis Rheum. 2003;48;9:2415-24. (Level 1B)</ref><ref name="p6">Ende CH Van den, Vliet Vlieland TP, Munneke M, Hazes JM. Dynamic exercise therapy for rheumatoid arthritis. Cochrane Database Syst Rev 2000;(2):CD000322. (Level 1A)</ref> The duration and intensity of the exercises should be based on the individual patient and their assessment<ref name=":4" />.  
===== Therapeutic Exercise =====
* Physical exercise helps to increase the physical capacity of the patient <ref name=":4" />.
* 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.<ref name=":4" />
* 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.
Programs for Patients with RA 
* Includes; ROM-exercises; aerobic exercise: stabilisation/coordination exercises.
* Start with a moderate-intensive exercise program <ref>de Jong Z, Munneke M, Zwinderman AH, Kroon HM, Jansen A, Ronday KH, van Schaardenburg D, Dijkmans BA, Van den Ende CH, Breedveld FC, Vlieland TP. [https://onlinelibrary.wiley.com/doi/abs/10.1002/art.11216 Is a long‐term high‐intensity exercise program effective and safe in patients with rheumatoid arthritis?: results of a randomized controlled trial.] Arthritis & Rheumatism: Official Journal of the American College of Rheumatology. 2003 Sep;48(9):2415-24.</ref><ref name="p6">Van Den Ende CH, TP VV, Munneke M, Hazes JM. [https://europepmc.org/article/med/10796342 Dynamic exercise therapy for rheumatoid arthritis.] The Cochrane database of systematic reviews. 2000 Jan 1(2):CD000322-.</ref>
* Progress to a high-intensive exercise program if possible aimed at improving aerobic capacity, strength and endurance.
* The duration and intensity of the exercises should be based on the individual patient and their assessment<ref name=":4" />.  


<u>Precautions:</u><ref name=":4" />
==== Precautions<ref name=":4" /> ====
* When the patient experiences an exacerbation and the joints are acutely inflamed then isometric exercises should be done
* When the patient experiences an exacerbation and the joints are acutely inflamed then isometric exercises should be done
* Avoid stretching in acute cases.   
* Avoid stretching in acute cases.   
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* Patients with active RA in their knees should avoid climbing stairs or weight lifting as it could lead to intra-articular pressure in the knee joint
* Patients with active RA in their knees should avoid climbing stairs or weight lifting as it could lead to intra-articular pressure in the knee joint
* Avoid excessive stress over the tendons with stretches and avoid ballistic movements
* Avoid excessive stress over the tendons with stretches and avoid ballistic movements
<u>Exercises:</u>
 
# ROM exercises: In acute phase: isometric/static exercises -&gt; be held for 6 seconds and repeated 5–10 times each day&nbsp;; load = 40% 1RM. in chronic phase: isotonic exercises (= active exercises with constantly the same tension) for example: swimming, walking, cycling -&gt; minimum 4 repetitions for each joint in 2 to 3 days These exercises increase the mobility of the joint, but the concerned joint will not be loaded during this exercises.<ref name=":2">Minor MA, Hewett JE, Webel RR, Anderson SK, Kay DR. Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis. Arthritis Rheum. 1989;32;11:1396-1405. (Level 1B)</ref> Contractures can be held for 6seconds and repeated 5-10 times daily<ref name=":4" />.  
==== Exercises examples ====
# Stretching: Has to be avoided in acute cases.     
# In acute phase: isometric/static exercises -&gt; be held for 6 seconds and repeated 5–10 times each day&nbsp;; load = 40% 1RM. Chronic phase -&gt; minimum 4 repetitions for each joint in 2 to 3 days These exercises increase the mobility of the joint, but the concerned joint will not be loaded during this exercises.<ref name=":2">Minor MA, Webel RR, Kay DR, Hewett JE, Anderson SK. [https://onlinelibrary.wiley.com/doi/abs/10.1002/anr.1780321108 Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.] Arthritis & Rheumatism: Official Journal of the American College of Rheumatology. 1989 Nov;32(11):1396-405.</ref> Contractures can be held for 6seconds and repeated 5-10 times daily<ref name=":4" />.
# Strengthening: Moderate-intensive exercise therapy where a minimum of 8-10 exercises is necessary for the major muscle groups. Each exercise has to be repeated 8-10 times and a minimal start intensity of 30-50 percent of 1 repetition maximum (RM).&nbsp;<ref name="p6" /> <ref name=":2" /> Use light weights important for stabilization of the joint and prevention of traumatic injuries.
# [[Stretching]]: Avoid in acute cases.     
# Aerobic condition exercises: There are two types of exercises to improve the aerobic condition: Intensive exercises and moderate-intensive exercises. The intensive exercise therapy has a minimum duration of 20 minutes per session and this 3 times a week with an intensity of 65 to 90 percent of the maximal heart rate. The moderate-intensive exercise therapy has a minimum duration of 30 minutes per session and this 5 times a week with an intensity of 55 to 64 percent of the maximal heart rate. The aim of this exercises is to improve the muscle endurance and aerobic capacity.  
# [[Strength Training|Strengthening]]
# Stabilizing and coordinating exercises:&nbsp;The improvement of stabilization and coordination of a certain joint will be achieved by doing exercises that stimulate the sensorimotor system. For example, standing on a balance board. Important aspects during this exercises are motion control, balance and coordination.  
# [[Aerobic Exercise|Aerobic]] condition exercises: There are two types of exercises to improve the aerobic condition: Intensive exercises and moderate-intensive exercises. The intensive exercise therapy has a minimum duration of 20 minutes per session and this 3 times a week with an intensity of 65 to 90 percent of the maximal heart rate. The moderate-intensive exercise therapy has a minimum duration of 30 minutes per session and this 5 times a week with an intensity of 55 to 64 percent of the maximal heart rate. The aim of these exercises is to improve muscle endurance and aerobic capacity. eg: swimming, walking, cycling
# Routine daily activities: SARAH (Strengthening and stretching for rheumatoid arthritis of the hand) exercise program: The SARAH trial tests an intervention against the usual hand care. The main aim of the exercise program is increased hand function, which is suggested to be mediated by increases in strength, dexterity and range-of-movement. The exercise program consists of the usual care plus a hand and wrist exercise program which includes seven mobility exercises and four strength exercises against resistance (i.e. therapy putty, theraband or hand exerciser balls).<ref name="SARAH et al" />
# Stabilizing and [[Coordination Exercises|coordinating]] exercises:&nbsp;The improvement of stabilization and coordination of a certain joint will be achieved by doing exercises that stimulate the sensorimotor system. For example, standing on a [[Balance Boards|balance board]]. Important aspects during these exercises are motion control, [[balance]] and coordination.
# Conditioning exercises in people with chronic inactive RA: swimming walking, cycling (include adequate rest periods)<ref name=":4" />.<br><br>
# Conditioning exercises in people with chronic inactive RA: swimming walking, cycling (include adequate rest periods)<ref name=":4" />.
# Routine daily activities: SARAH (Strengthening and stretching for rheumatoid arthritis of the hand) exercise program see below table: The SARAH trial tests an intervention against the usual hand care. The main aim of the exercise program is increased hand function, which is suggested to be mediated by increases in strength, dexterity and range-of-movement. The exercise program consists of the usual care plus a hand and wrist exercise program which includes seven mobility exercises and four strength exercises against resistance (i.e. therapy putty, theraband or hand exerciser balls).<ref name="SARAH et al" />
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| Step 1: 2x 10 repetitions<br>Step 2: 4-5 on Borg scale<br>Step 3: 5-6 on Borg scale <br>Step 4: 3x 10 repetitions <br>
| Step 1: 2x 10 repetitions<br>Step 2: 4-5 on Borg scale<br>Step 3: 5-6 on Borg scale <br>Step 4: 3x 10 repetitions <br>
|}
|}
* Use [[Borg Rating Of Perceived Exertion|modified Borg scale]]  to set the load (resistance) for the strength exercises based on self-perception of effort.
* The level of resistance is determined by the patients’ rating of perceived effort using the weaker hand for each strength exercise.
* Exercise therapy in patients with RA is used to improve daily functioning and social participation through improving muscle strength, aerobic endurance, joint mobility and stability and/or coordination.
* Preference is given to an active policy, especially where the physiotherapist has a supporting role.
* In individual cases, passive treatments, such as manual operations, can be part of the treatment.
5. Patient Education: information about their condition and the different therapies disposed to improve their quality of life. eg Patients are taught how to protect the joints during routine daily life; adjusting their movement-behaviour;  behavioural change by your patient (a process with 3 phases: the motivation-phase, the initial-behavioural change phase and the phase where the intended behaviour is continued).


<br>A modified Borg scale is used to set the load (resistance) for the strength exercises based on self-perception of effort. The level of resistance is determined by the patients’ rating of perceived effort using the weaker hand for each strength exercise. Exercise therapy in patients with RA is used to improve the daily functioning and social participation through improving muscle strength, aerobic endurance, joint mobility (range of motion, ROM) and stability and/or coordination. Therefore, preference is given to an active policy, especially where the physiotherapist has a supporting role. However, in individual cases, passive treatments, such as manual operations, can be part of the treatment.
• Formulate achievable goals with the patient.  
 
5. Patient Education: information about their condition and the different therapies disposed to improve their quality of life. In addition, patients are taught how to protect the joints during routine daily life. To let patients become more active, you have to adjust their movement-behaviour. Different manners to achieve a behavioural change by your patient:<br>• A behavioural change is a process with 3 phases: the motivation-phase, the initial-behavioural change phase and the phase where the intended behaviour is continued. It’s important to know in which phase your patient is located. In the 1st phase is education and motivation important. In the 2nd phase is structure and accompaniment important and in the 3rd phase is the patient capable to keep moving with the help of his natural environment.


• The therapist has to formulate achievable goals with the patient.  
• Give proper instructions and be sure that the patient understands.  


• The therapist should give proper instructions and be sure that the patient understands him.  
• Enough variation in the exercises is important to prevent boredom.


• Enough variation in the exercises is important. Otherwise, the patient can become bored which is not positive for your therapy.  
• The therapist has to involve the partner and other important people in the process because they have an important motivation-role. Also, the therapist himself has to motivate the patient.<br>• Keep in touch with the patient to be sure that the treatment was effective. <ref>Brodin N, Eurenius E, Jensen I, Nisell R, Opava CH, PARA Study Group. [https://onlinelibrary.wiley.com/doi/abs/10.1002/art.23327 Coaching patients with early rheumatoid arthritis to healthy physical activity: a multicenter, randomized, controlled study.] Arthritis Care & Research. 2008 Mar 15;59(3):325-31.</ref>


• The therapist needs to avoid that the patient gets again in his old movement-pattern. You must warn the patient for this.
<br>'''Management of flare ups'''


• The therapist has to involve the partner and other important people in the process because they have an important motivation-role. Also, the therapist himself has to motivate the patient.<br>• Keep in touch with the patient to be sure that the treatment was effective. <ref>Brodin N, Eurenius E, Jensen I, Nisell R, Opava CH, PARA study group. Coaching patients with early rheumatoid arthritis to healthy physical activity: a multicenter, randomized, controlled study. Arthritis Rheum. 2008;59;3:325-31. (Level 1B)</ref> <br>
People who are diagnosed with RA also may experience a phenomenon that is called an “flare up”. Usually happen after eg experiencing a secondary illness, being involved in a high-stress situation, overexerting oneself, What triggers flare ups is currently still unknown. Strategies that can help someone who is experiencing a flare up  
 
'''Adult Rheumatoid Arthritis Physical Therapy Practice Patterns'''
 
4A: Primary Prevention/Risk Reduction for Skeletal Demineralization (low bone density)
 
4B: Impaired Posture (cervical involvement)
 
4C: Impaired Muscle Performance
 
~4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Connective Tissue Dysfunction
 
4H: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Joint Arthroplasty
 
4I: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Bony or Soft Tissue Surgery ( tenosynovectomy, tendon reconstruction)
 
5H: Impaired Motor Function, Peripheral Nerve Integrity, and Sensory Integrity Associate with Nonprogressive Disorders of the Spinal Cord (cervical spine)
 
6B: Impaired Aerobic Capacity/Endurance Associated with Deconditioning
 
~Most Commonly used practice pattern for RA.
 
'''Management of flare ups''':
 
People who are diagnosed with RA also may experience a phenomenon that is called an “flare up” of the condition. Research suggests that these flare ups usually happen after experiencing a secondary illness, being involved in a high stress situation, overexerting oneself, . What triggers flare ups is currently still unknown. Current evidence suggests some strategies that can help someone who is experiencing a flare up by reducing pain, inflammation, and improve their quality of life:
* Balance is key, schedule plenty of down time to reduce the likelihood of affected joints from becoming flared up
* Balance is key, schedule plenty of down time to reduce the likelihood of affected joints from becoming flared up
* Educate family, staff at work, and other people who you interact with, they can help you during flare ups
* Educate family, staff at work, and other people who you interact with, they can help you during flare ups
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== Outcome Measures ==
== Outcome Measures ==
* Rheumatoid Arthritis Disease Activity Index (RADAI-5): A self-reported outcome measure that consists of 5 questions in a Likert scale format that briefly surveys the patient regarding their views of their condition (both over the past 6 months and current status).
* Simplified disease activity (SDAI) index: tender joint count, swollen joint count, patient global assessment, physician global assessment and c reactive protein in mg/dl
* Disabilities of the Arm, Shoulder and Hand (DASH): The DASH is a patient-reported outcome measure that evaluates function of the upper extremities, and can be used to examine change over time.
* Clinical disease activity index (CDAI): tender joint count, swollen joint count, patient global assessment, physician global assessment
* Short Form-36 (SF36): A patient reported outcome measure that is designed to evaluate quality of life through measures such as physical functioning, role limitations due to physical or emotional problems, and general mental health.
* DAS28-ESR (disease activity score): tender joint count, swollen joint count, patient global assessment, and erythrocyte sedimentation rate in mm
* Fatigue Severity Scale: A 9-item questionnaire that rates the patient’s fatigue and how it interferes with activities such as work or social life.
* DAS-Crp (disease activity score): tender joint count, swollen joint count, patient global assessment, and c reactive protein in mg/dl.<ref name=":6" />
* Rheumatoid Arthritis Disease Activity Index (RADAI-5): A self-reported [[Outcome Measures|outcome measure]] that consists of 5 questions in a Likert scale format that briefly surveys the patient regarding their views of their condition (both over the past 6 months and current status).
* [[DASH Outcome Measure|DASH]]
* [[36-Item Short Form Survey (SF-36)|36-Item Short Form]]
* [[Fatigue Severity Scale]]
<ref>O’Sullivan and Schmitz. Physical Rehabilitation. 5th edition. Philadelphia, PA: F.A. Davis Company. 2007.</ref>
<ref>O’Sullivan and Schmitz. Physical Rehabilitation. 5th edition. Philadelphia, PA: F.A. Davis Company. 2007.</ref>


The Multi-Dimensional Health Assessment Questionnaire (MDHAQ) is a recognized quality-of-care indicator. Assesses pain and fatigue using visual analogue scales (VASs) and includes items to assess disability in these patients. <br>The Multi-Dimensional Health Assessment Questionnaire (MDHAQ) derived from the HAQ (=a disease-specific questionnaire), which includes an index of the three RA core data set measures (physical function, pain, and global estimate), also known as a routine assessment of patient index data 3 (RAPID 3). The MDHAQ is created for the clinical standard care to save time for the rheumatologist and to improve the quality of patient visits.
== Classification of Functional Status ==
 
The difference between the HAQ and MDHAQ are:
 
#The MDHAQ has two activities more than the HAQ – “Are you able to walk 2 miles or 3 kms?” and “Are you able to participate in recreation and sports as you would like?”. These ADLs were added as scores for eight items on a modified HAQ (MHAQ) and were systematically lower than HAQ scores by 0.2 units to 0.3 units. Scores on the HAQ and MDHAQ are quite similar. Inclusion of two complex activities reflects higher expectations for patient status in rheumatology care at this time than in the 1970s when the HAQ was developed.
#All 10 activities are listed on one side of the first page, allowing the physician or other health professionals to scan the information rapidly.
#The MDHAQ does not include HAQ queries concerning aids, devices, or help from another person, which complicates scoring, may not add important information (particularly at this time), and possibly elevate scores artifactually with use of a device.
#The MDHAQ VAS for pain and patient global estimate are in a format of 21 numbered circles, rather than a 10-cm line and require no ruler to score.
#The MDHAQ includes a patient self-report RA disease activity index (RADAI) joint count.
#Boxes are available on the MDHAQ to record scores for physical function, pain, patient global estimate, and RADAI self-report joint count.
#Scoring templates are available on the MDHAQ to convert physical function scores from 0-30 to a 0-10 scale, and RADAI self-report joint counts scores from 0-48 to a 0-10 scale.
#Scoring templates are also available to record RAPID composite scores. RAPID 4 adds a RADAI self-report joint count and RAPID 5 adds a physician global estimate.
#The MDHAQ also includes three psychological items concerning sleep, anxiety, and depression (queried in the standard patient-friendly HAQ format), not scored formally, a review of systems, medical history, fatigue VAS, queries about change in status, morning stiffness and exercise, and demographic data—within two sides of one page.
 
Two prerequisites are essential for success in having patients complete questionnaires:
 
#The questionnaire must be reviewed by the rheumatologist prior to seeing the patient, so the staff and patients recognize that this is an important matter and not simply an exercise to meet abstract goals or requirements for a clinical study (as is the situation in completion of questionnaires in many research studies) or requirements to administer a certain therapy.
#The staff must project an attitude of enthusiasm, reflecting the interest of the clinician. For example, <br>a comment such as “Would you mind completing a questionnaire?” is inappropriate. A better comment might be: “We need you to complete this questionnaire as part of your medical evaluation.”<br>The MDHAQ is useful in all rheumatic diseases by documenting changes in status over long periods, and by improving rheumatology care and outcomes. . <br>Goals of the MDHAQ:<br>- to be scanned (“eyeballed”) by a clinician in 5 sec to 10 sec<br>- using scoring templates on the questionnaire for individual measures in less than 10 sec or 10 sec<br>- RAPID indices based on self-report data.
All quantitative data require interpretation by a clinician, along with information from a history, physical examination, and other sources in formulating a clinical decision. Nonetheless, the availability of quantitative data can add considerably to the decision process and help focus the visit on the concerns of the patient.&nbsp;
 
=== Classification of Functional Status ===
The American College of Rheumatology classified functional status in Rheumatoid Arthritis as:
The American College of Rheumatology classified functional status in Rheumatoid Arthritis as:
* '''Class I''': Completely able to perform usual activities of daily living (self-care, vocational, and avocational)
* '''Class I''': Completely able to perform usual activities of daily living (self-care, vocational, and avocational)
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# [http://www.aidsforarthritis.com/ Self-help (Aids for Arthritis)]
# [http://www.aidsforarthritis.com/ Self-help (Aids for Arthritis)]
# [http://www.ra.com/ra-treatment.aspx RA Treatments]
# [http://www.ra.com/ra-treatment.aspx RA Treatments]
# [http://www.rheumatology.org American College of Rheumatology]
# [http://www.rheumatology.org American College of Rheumatology]<u></u>
<u></u>
== Clinical Bottom Line  ==
== Clinical Bottom Line  ==
The outcome of most patients with Rheumatoid arthritis is guarded.
* The disorder has frequent relapses and remissions, and at least 40% of patients will become disabled within ten years.
* Some patients have mild disease, others may have a severe disease that severely affects the quality of life.
* Worse outcomes are usually seen in patients with a high titer of autoantibodies, HLA-DRB1 genotypes, age younger than 30, multiple joint involvement, female gender, and extra-articular involvement.
* The drugs used to treat rheumatoid arthritis also have potent side effects which often are not well tolerated. As the disease progresses, many patients will develop adverse cardiac events leading to death.
* The overall mortality in patients with rheumatoid arthritis is three times higher than in the general population.
* Despite advances in care, mortality from infection, cancer, and ongoing vasculitis remains unchanged<ref name=":6" />


Rheumatoid arthritis (RA) is a systematic autoimmune inflammatory disease and results in persistent inflammation of synovial tissue especially of the wrists, hands and feet. There is no therapy that can completely heal RA. But there are treatments that achieve pain relief and the slowdown of the activity of RA to prevent disability and increase functional capacity. Physical therapists play an integral role in the nonpharmacologic management of RA. They help patients with RA cope with chronic pain and disability through the design of programs that address flexibility, endurance, strength, bone integrity, coordination, balance and risk of falls.
== References  ==
== References  ==


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[[Category:Vrije_Universiteit_Brussel_Project]]
[[Category:Occupational Health]]
[[Category:Occupational Health]]
[[Category:Autoimmune Disorders]]
[[Category:Course Pages]]
[[Category:Plus Content]]

Latest revision as of 11:20, 18 August 2022

Original Editors - Florence Brachotte Amanda Fetz & Katie Robertson from Bellarmine University's Pathophysiology of Complex Patient Problems project

Top Contributors - Amanda Fetz, Riley Sturzebecher, Kim Jackson, Lucinda hampton, Amanda Ager, Admin, Aminat Abolade, Elaine Lonnemann, Wendy Walker, Shaimaa Eldib, Amrita Patro, 127.0.0.1, Katie Robertson, WikiSysop and Simisola Ajeyalemi   Amanda Fetz,Riley Sturzebecher,Elaine Lonnemann,Rachael Lowe

Introduction[edit | edit source]

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[1]

Etiology and Pathology[edit | edit source]

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.
Diagram showing how Rheumatoid Arthritis affects a joint in the hand

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[2]

Epidemiology[edit | edit source]

The overall prevalence is 0.5-1% and the disease is 2-3 times more common in women.

Onset is generally in adulthood, peaking in the 4th and 5th decades. The paediatric condition, Juvenile Idiopathic Arthritis (JIA), is discussed separately, see link.[2]

Risk Factors[edit | edit source]

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 red and iron consumption; low vitamin D intake and levels; Smoking (seropositive RA); Obesity; Low socioeconomic status [2]
  • Deceased risk: fish and omega 3 fatty acid consumption; moderate alcohol intake; healthy diet; oral contraceptive/HRT; statin use.[3]

Characteristics/Clinical Presentation[edit | edit source]

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.
    RA Hand 1.png
  • 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.
Rheumatoid-arthritis-hands-3.jpeg

Image 4: 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.[4]
  • 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. [5][6]

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. [5]
  • Individuals with RA are 8 times more likely to have functional disability compared with adults in the general population from the same community.

Staging[edit | edit source]

RA stages.png

Disease progression:

Stages

  1. No destructive changes on x-rays
  2. Presence of x-ray evidence of periarticular osteoporosis, subchondral bone destruction but no joint deformity
  3. X-ray evidence of cartilage and bone destruction in addition to joint deformity and periarticular osteoporosis.
  4. Presence of bony or fibrous ankylosis along with stage 3 features.[1]

Differential Diagnosis[edit | edit source]

Complications[edit | edit source]

Rheumatoid lung.jpeg

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.[7] This is significant because of the comorbidities effects on quality of life, functional status, prognosis and outcome. Associated Complications include:[8]

  • Infections
  • Chronic anaemia
  • Gastrointestinal cancers
  • Pleural effusions
  • Osteoporosis
  • Heart disease
  • Sicca syndrome
  • Felty syndrome
  • Lymphoma[1]
  • Damage to the lung tissue (rheumatoid lung) See image 6: 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[edit | edit source]

  1. 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.

2. 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).

3. 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.[1]

Prognosis[edit | edit source]

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.[1]

Treatment[edit | edit source]

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[edit | edit source]

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.[2]

See link Pharmacological Management of Rheumatoid Arthritis

Nutritional Guidelines[edit | edit source]

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)[9]. 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 RA[9]eg. 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[edit | edit source]

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.[1] Treatments that achieve pain relief and the slowdown of the activity of RA to prevent disability and increase functional capacity.[10][11]

See also Hand RA

Hydrotherapy Pool Exercises.jpg

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.
Resting wrist hand brace.jpeg

The four most common components of PT/OT for RA hands are

  1. Exercise therapy,
  2. Joint protection advice and provision of functional splinting and assistive devices
  3. Massage therapy, and
  4. Patient education. 

The therapy goals in most cases are: [12] 

  • 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[edit | edit source]

Cold/Hot Applications: cold for acute phase; heat for chronic phase and used before exercise. [13]

Transcutaneous electrical nerve stimulation (TENS) is used to relieve pain. [14]

Hydrotherapy-Balneotherapy: exercise with minimal load on the joints.[15]

Joint Protection see link

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) [16]

Therapeutic Exercise[edit | edit source]
  • Physical exercise helps to increase the physical capacity of the patient [10].
  • 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.[10]
  • 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.

Programs for Patients with RA

  • Includes; ROM-exercises; aerobic exercise: stabilisation/coordination exercises.
  • Start with a moderate-intensive exercise program [17][18]
  • Progress to a high-intensive exercise program if possible aimed at improving aerobic capacity, strength and endurance.
  • The duration and intensity of the exercises should be based on the individual patient and their assessment[10].

Precautions[10][edit | edit source]

  • When the patient experiences an exacerbation and the joints are acutely inflamed then isometric exercises should be done
  • Avoid stretching in acute cases.
  • Revise the exercise program if pain persists 2 hours after the activity or there is an increase in joint swelling
  • Patients with active RA in their knees should avoid climbing stairs or weight lifting as it could lead to intra-articular pressure in the knee joint
  • Avoid excessive stress over the tendons with stretches and avoid ballistic movements

Exercises examples[edit | edit source]

  1. In acute phase: isometric/static exercises -> be held for 6 seconds and repeated 5–10 times each day ; load = 40% 1RM. Chronic phase -> minimum 4 repetitions for each joint in 2 to 3 days These exercises increase the mobility of the joint, but the concerned joint will not be loaded during this exercises.[19] Contractures can be held for 6seconds and repeated 5-10 times daily[10].
  2. Stretching: Avoid in acute cases.
  3. Strengthening
  4. Aerobic condition exercises: There are two types of exercises to improve the aerobic condition: Intensive exercises and moderate-intensive exercises. The intensive exercise therapy has a minimum duration of 20 minutes per session and this 3 times a week with an intensity of 65 to 90 percent of the maximal heart rate. The moderate-intensive exercise therapy has a minimum duration of 30 minutes per session and this 5 times a week with an intensity of 55 to 64 percent of the maximal heart rate. The aim of these exercises is to improve muscle endurance and aerobic capacity. eg: swimming, walking, cycling
  5. Stabilizing and coordinating exercises: The improvement of stabilization and coordination of a certain joint will be achieved by doing exercises that stimulate the sensorimotor system. For example, standing on a balance board. Important aspects during these exercises are motion control, balance and coordination.
  6. Conditioning exercises in people with chronic inactive RA: swimming walking, cycling (include adequate rest periods)[10].
  7. Routine daily activities: SARAH (Strengthening and stretching for rheumatoid arthritis of the hand) exercise program see below table: The SARAH trial tests an intervention against the usual hand care. The main aim of the exercise program is increased hand function, which is suggested to be mediated by increases in strength, dexterity and range-of-movement. The exercise program consists of the usual care plus a hand and wrist exercise program which includes seven mobility exercises and four strength exercises against resistance (i.e. therapy putty, theraband or hand exerciser balls).[4]
Exercises Frequency Sets Repetitions Initial Hold Initial Load Progression
Mobility • MCP flexion
• Tendon gliding
• Finger radial walking
• Wrist circumduction
• Finger adduction
• Hand-behind-head
• Hand-behind-back
 Daily 1 x 5 5 seconds (where required) Step 1: increase up to 10 repetitions
Step 2: Increase up to 10 seconds hold
Strength • Eccentric wrist extension
• Gross grip Finger adduction
• Pinch grip
Daily 1 X 8 (min. 8 repetitions, max. 12 repetitions) Between 3 and 4 on modified 10 pt Borg Scale Step 1: 2x 10 repetitions
Step 2: 4-5 on Borg scale
Step 3: 5-6 on Borg scale
Step 4: 3x 10 repetitions
  • Use modified Borg scale to set the load (resistance) for the strength exercises based on self-perception of effort.
  • The level of resistance is determined by the patients’ rating of perceived effort using the weaker hand for each strength exercise.
  • Exercise therapy in patients with RA is used to improve daily functioning and social participation through improving muscle strength, aerobic endurance, joint mobility and stability and/or coordination.
  • Preference is given to an active policy, especially where the physiotherapist has a supporting role.
  • In individual cases, passive treatments, such as manual operations, can be part of the treatment.

5. Patient Education: information about their condition and the different therapies disposed to improve their quality of life. eg Patients are taught how to protect the joints during routine daily life; adjusting their movement-behaviour; behavioural change by your patient (a process with 3 phases: the motivation-phase, the initial-behavioural change phase and the phase where the intended behaviour is continued).

• Formulate achievable goals with the patient.

• Give proper instructions and be sure that the patient understands.

• Enough variation in the exercises is important to prevent boredom.

• The therapist has to involve the partner and other important people in the process because they have an important motivation-role. Also, the therapist himself has to motivate the patient.
• Keep in touch with the patient to be sure that the treatment was effective. [20]


Management of flare ups

People who are diagnosed with RA also may experience a phenomenon that is called an “flare up”. Usually happen after eg experiencing a secondary illness, being involved in a high-stress situation, overexerting oneself, What triggers flare ups is currently still unknown. Strategies that can help someone who is experiencing a flare up

  • Balance is key, schedule plenty of down time to reduce the likelihood of affected joints from becoming flared up
  • Educate family, staff at work, and other people who you interact with, they can help you during flare ups
  • Have a backup plan, be prepared in case of a flare up and become familiar with warning signs of a flare up
  • Practice relaxation and self calming strategies: Research suggests that regularly practicing these relaxation techniques can reduce stress and lead to a reduction in pain.
  • Use modalities such as a cold pack or hot pack: Both of these have various effects on tissues which research suggests can be beneficial in reducing inflammation and pain during a flare up
  • Lastly, corticosteroid injections can be used to reduce inflammation and reduce pain in a flared up joint

Outcome Measures[edit | edit source]

  • Simplified disease activity (SDAI) index: tender joint count, swollen joint count, patient global assessment, physician global assessment and c reactive protein in mg/dl
  • Clinical disease activity index (CDAI): tender joint count, swollen joint count, patient global assessment, physician global assessment
  • DAS28-ESR (disease activity score): tender joint count, swollen joint count, patient global assessment, and erythrocyte sedimentation rate in mm
  • DAS-Crp (disease activity score): tender joint count, swollen joint count, patient global assessment, and c reactive protein in mg/dl.[1]
  • Rheumatoid Arthritis Disease Activity Index (RADAI-5): A self-reported outcome measure that consists of 5 questions in a Likert scale format that briefly surveys the patient regarding their views of their condition (both over the past 6 months and current status).
  • DASH
  • 36-Item Short Form
  • Fatigue Severity Scale

[21]

Classification of Functional Status[edit | edit source]

The American College of Rheumatology classified functional status in Rheumatoid Arthritis as:

  • Class I: Completely able to perform usual activities of daily living (self-care, vocational, and avocational)
  • Class II: Able to perform usual self-care and vocational activities, but limited in avocational activities
  • Class III: Able to perform usual self-care activities, but limited in vocational and avocational activities
  • Class IV: Limited ability to perform usual self-care, vocational, and avocational activities

Resources[edit | edit source]

  1. Rheumatoid Arthritis: Help to understand Rheumatoid Arthritis
  2. Rheumatoid Arthritis: Frequently asked Questions
  3. Rheumatology Check List Visit
  4. The RA Symptom Tracker Sheet
  5. The Arthritis Organization
  6. American College of Rheumatology Patient Education
  7. Self-help (Aids for Arthritis)
  8. RA Treatments
  9. American College of Rheumatology

Clinical Bottom Line[edit | edit source]

The outcome of most patients with Rheumatoid arthritis is guarded.

  • The disorder has frequent relapses and remissions, and at least 40% of patients will become disabled within ten years.
  • Some patients have mild disease, others may have a severe disease that severely affects the quality of life.
  • Worse outcomes are usually seen in patients with a high titer of autoantibodies, HLA-DRB1 genotypes, age younger than 30, multiple joint involvement, female gender, and extra-articular involvement.
  • The drugs used to treat rheumatoid arthritis also have potent side effects which often are not well tolerated. As the disease progresses, many patients will develop adverse cardiac events leading to death.
  • The overall mortality in patients with rheumatoid arthritis is three times higher than in the general population.
  • Despite advances in care, mortality from infection, cancer, and ongoing vasculitis remains unchanged[1]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Krati Chauhan; Jagmohan S. Jandu; Mohammed A. Al-Dhahir. Oct 2019 RA Available from:https://www.ncbi.nlm.nih.gov/books/NBK441999/ (last accessed 23.2.2020)
  2. ↑ 2.0 2.1 2.2 2.3 Radiopedia RA Available from: https://radiopaedia.org/articles/rheumatoid-arthritis(accessed 7.6.2021)
  3. ↑ Deane KD, Demoruelle MK, Kelmenson LB, Kuhn KA, Norris JM, Holers VM. Genetic and environmental risk factors for rheumatoid arthritis. Best practice & research Clinical rheumatology. 2017 Feb 1;31(1):3-18.
  4. ↑ 4.0 4.1 Adams J, Bridle C, Dosanjh S, Heine P, Lamb SE, Lord J, McConkey C, Nichols V, Toye F, Underwood MR, Williams MA. Strengthening and stretching for rheumatoid arthritis of the hand (SARAH): design of a randomised controlled trial of a hand and upper limb exercise intervention-ISRCTN89936343. BMC musculoskeletal disorders. 2012 Dec;13(1):1-0.
  5. ↑ 5.0 5.1 KNGF-richtlijn. Reumatoïde artritis. 2008
  6. ↑ Neuberger GB, Aaronson LS, Gajewski B, Embretson SE, Cagle PE, Loudon JK, Miller PA. Predictors of exercise and effects of exercise on symptoms, function, aerobic fitness, and disease outcomes of rheumatoid arthritis. Arthritis Care & Research. 2007 Aug 15;57(6):943-52.
  7. ↑ Pubmed. Comorbidities in rheumatoid arthritis. http://www.ncbi.nlm.nih.gov/pubmed/17870034 (accessed 12 February 2013).
  8. ↑ Gabriel SE. Cardiovascular morbidity and mortality in rheumatoid arthritis. The American journal of medicine. 2008 Oct 1;121(10):S9-14.
  9. ↑ 9.0 9.1 Khanna S, Jaiswal KS, Gupta B. Managing rheumatoid arthritis with dietary interventions. Frontiers in nutrition. 2017 Nov 8;4:52.
  10. ↑ 10.0 10.1 10.2 10.3 10.4 10.5 10.6 Kavuncu V, Evcik D. Physiotherapy in rheumatoid arthritis. Medscape General Medicine. 2004;6(2).
  11. ↑ Williams MA, Srikesavan C, Heine PJ, Bruce J, Brosseau L, Hoxey‐Thomas N, Lamb SE. Exercise for rheumatoid arthritis of the hand. Cochrane Database of Systematic Reviews. 2018(7).
  12. ↑ Bell MJ, Lineker SC, Wilkins AL, Goldsmith CH, Badley EM. A randomized controlled trial to evaluate the efficacy of community based physical therapy in the treatment of people with rheumatoid arthritis. The Journal of rheumatology. 1998 Feb 1;25(2):231-7.
  13. ↑ Bijlsma JW, Geusens PP, Kallenberg CG, Tak PP. Reumatologie en klinische immunologie.
  14. ↑ Pelland L, Brosseau L, Casimiro L, Welch V, Tugwell P, Wells GA. Electrical stimulation for the treatment of rheumatoid arthritis. Cochrane Database of Systematic Reviews. 2002(2).
  15. ↑ Verhagen AP, Bierma‐Zeinstra SM, Boers M, Cardoso JR, Lambeck J, de Bie R, de Vet HC. Balneotherapy for rheumatoid arthritis. Cochrane Database of Systematic Reviews. 2004(1).
  16. ↑ Brownfield A. Aromatherapy in arthritis: a study. Nursing Standard (through 2013). 1998 Oct 21;13(5):34.
  17. ↑ de Jong Z, Munneke M, Zwinderman AH, Kroon HM, Jansen A, Ronday KH, van Schaardenburg D, Dijkmans BA, Van den Ende CH, Breedveld FC, Vlieland TP. Is a long‐term high‐intensity exercise program effective and safe in patients with rheumatoid arthritis?: results of a randomized controlled trial. Arthritis & Rheumatism: Official Journal of the American College of Rheumatology. 2003 Sep;48(9):2415-24.
  18. ↑ Van Den Ende CH, TP VV, Munneke M, Hazes JM. Dynamic exercise therapy for rheumatoid arthritis. The Cochrane database of systematic reviews. 2000 Jan 1(2):CD000322-.
  19. ↑ Minor MA, Webel RR, Kay DR, Hewett JE, Anderson SK. Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis. Arthritis & Rheumatism: Official Journal of the American College of Rheumatology. 1989 Nov;32(11):1396-405.
  20. ↑ Brodin N, Eurenius E, Jensen I, Nisell R, Opava CH, PARA Study Group. Coaching patients with early rheumatoid arthritis to healthy physical activity: a multicenter, randomized, controlled study. Arthritis Care & Research. 2008 Mar 15;59(3):325-31.
  21. ↑ O’Sullivan and Schmitz. Physical Rehabilitation. 5th edition. Philadelphia, PA: F.A. Davis Company. 2007.
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