Rheumatoid Arthritis

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

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Definition/Description[edit | edit source]

Rheumatoid arthritis (RA) is an autoimmune disease and a form of inflammatory arthritis that affects five or more joints. Autoimmune conditions occur when the body fights its own immune system. Instead of the immune system protecting the body, it attacks itself. In RA, the immune system attacks the lining of the joints, called the synovium. RA is a long-term disease that leads to inflammation of the joints and surrounding tissues and can also affect other organs. These tissues include tendon sheaths, bursa, and tendons. Symptoms may present as inflammation of joints, pain and fatigue, morning stiffness, and hot and warm joints that may be red. Furthermore, if not treated, RA can possibly lead to joint deformities in the later stages of the disease which then function of the joints could be lost permanently.

The disease course typically follows three possible paths:
a. Monocyclic: Having one episode that does not reoccur. This usually ends within 2-5 years of initial diagnosis.
b. Polycyclic: The disease severity varies over the course of the progression of the condition.
c. Progressive: Condition continues to become more severe and non-remitting.

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Prevalence[edit | edit source]

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.

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 Juvenile Idiopathic Arthritis (JIA) and usually begins before the age of 16.
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Characteristics/Clinical Presentation[edit | edit source]

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

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**American Collage of Rheumatology Revised Criteria for Classification of Functional Status in Rheumatoid Arthritis**
Class 1	Completely able to perform usual activities of daily living (Self care, vocational and avocational)
Class 2	Able to perform usual self care and vocational activates by limited in avocational
Class 3	Able to perform usual self care activities but limited in vocational and avocational activities
Class 4	Limited ability to perform usual self care, vocational, and avocational activities

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Associated Co-morbidities[edit | edit source]

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.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title This is significant because of the comorbidities effects on quality of life, functional status, prognosis and outcome.

Associated Co-morbidities:
a) Myocardial Infarction and Cardiovascular disease
b) Stroke
c) Peripheral Vascular Disease
d) Cancer (All)
e) Infection
f) Osteoporosis
g) GI disease
h) Psoriasis and other skin conditions
i) Cataract
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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.
a) Damage to the lung tissue (rheumatoid lung)
b) Increased risk of hardening of the arteries
c) Spinal injury when the neck bones become damaged
d) Inflammation of the blood vessels (rheumatoid vasculitis), which can lead to skin, nerve, heart, and brain problems
e) Swelling and inflammation of the outer lining of the heart (pericarditis) and of the heart muscle (myocarditis), which can lead to congestive heart failure
f) Side effects from treatment and medication.
g) General deconditioning
h) Rheumatoid nodules
i) Vascular complications
j) Neurological complications
k) Cardiopulmonary complications
l) Ocular complications

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Medications
[edit | edit source]

**Common Medications for RA**
Medication	Uses/ Effects	Side Effects
NSAIDs	Pain reliever	Stomach irritation Kidney function. Gastrointestinal problems
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 Tendency to bruise easily
Corticosteriods	Decrease inflammation, swelling, redness, itching, and allergic reactions	Increased appetite Indigestion, Nervousness Restlessness
Methylprednisolone Prednisone	Used for severe flare ups	Mood changes Easy bruising Increase risks of infections
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 Fatigue Abdominal issues
Cyclosporine	Used for patients who have not responded to other Medications	Increase Blood Pressure Kidney Problems Shaking/Trembling of hands
Leflunomide	Reduces signs and symptoms Slows down the process of degeneration of the joints.	Abdominal pain, nausea, vomiting, loss of appetite, Sneezing Sore Throat
Methotrexate	Inhibits the metabolism of folic acid	Low white blood cell counts, abdominal pain, fever, infection
Sulfasalazine	Immunosuppressant	Abdominal pain, diarrhea, loss of appetite, nausea/vomiting Headache, sensitivity to light Aching joints
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

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Diagnostic Tests/Lab Tests/Lab Values[edit | edit source]

Diagnostic Criteria

http://commons.wikimedia.org/wiki/File:Postarthritische_Ankylosen_-_Roe_HG_links.jpg

Four out of the Following Seven Must be Present

Morning Stiffness for an hour or greater
Arthritis of 3 or more of the following joints: right or left PIP, MCP, Wrist, Elbow, Knee, Ankle, and MTP Joint.
Arthritis of wrist, MCP, PIP
Symmetric involvement of a Joint
Rheumatoid nodules over bony prominences or extensor surfaces or in juxaarticular regions
Positive serum rheumatoid factor
Radiographic changes including erosion or bony decalcifications localized in or adjacent to joints.

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**Diagnostic Tests**
Test	Description	Purpose
C-reactive protein (CRP) (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" (Lab Test)	Blood Test	People with severe RA will generally have a higher ESR than one with less severe RA
Rheumatoid factor (RF) 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) 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.
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

There is no test that can determine for sure whether someone has RA. Most patients with RA will have some abnormal test results, although for some patients, all tests will be normal.

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Etiology/Causes[edit | edit source]

Etiology

The cause of Rheumatoid Arthritis is unknown. RA occurs when the immune system attacks the synovium — the lining of the membranes that surround the joints. The resulting inflammation thickens the synovium, and can eventually invade and destroy the cartilage and bone within the joint. The tendons and ligaments that hold the joint together weaken and stretch, overtime. Gradually, the joint loses its shape and alignment.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

http://plastic.surgery.ucsf.edu/conditions--procedures/rheumatoid-hand-disorder-surgery.aspx

**Classification of Progression of Rheumatoid Arthritis**
Stage	Description
I: Early	1. Early destructive changes on radiographic examination 2. Radiographic evidence of osteoporosis may be present
II: Moderate	1. Radiographic evidence of osteoporosis, with or without slight subchondral bone destruction; slight cartilage destruction may be present 2.No joint deformities, although limitation of joint mobility may be present 3. Adjacent muscle atrophy 4. Extra-articular soft tissue lesions, such as nodules and tenosynovitis may be present
III. Severe	1. Radiographic evidence of cartilage and bone destruction, in addition to osteoporosis 2. Joint deformity, such as subluxation, ulnar deviation, or hyperextension, without fibrous or bony ankylosis 3. Extensive muscle atrophy 4. Extra-articular soft tissue lesions, such as nodules and tenosynovitis may be present
IV. Terminal	1. Fibrous or bony ankylosis 2. Criteria of Stage III

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Risk Factors:

Although there is no known cause for RA, it is believed that certain factors can increase an individual’s risk for developing RA due to the interaction between genetic factors and environmental exposures:
a) Smoking: A history of smoking is associated with a modest to moderate increased risk of RA onset.
b) Gender: The incidence of RA is two to three times higher in women than men.

c) Age: Rheumatoid arthritis can occur at any age, but it most commonly begins between the ages of 40 and 60.
d) Family History: Family history can indicate a higher risk for RA.
e) Reproductive and breastfeeding history
a. Live birth history: Women who have never had a live birth have a slight to moderately increased risk of RA.
b. Breastfeeding: Recent population based studies have found that RA is less common among women who breastfeed.
c. Menstrual history: Women with irregular menses or a shortened menstrual history have an increased risk of RA.
d. Oral contraceptives (OC): Women who had ever used OCs had a modest to moderate decrease in risk of RA.
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Prognosis

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.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

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
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Systemic Involvement[edit | edit source]

Malignant	Hypertonic Osteoarthropathy, lymphoma, Leukemia, Carcinoma Polyarthritis
Hematologic	Sickle cell anemia, Thalassemia, Multiple Myeloma, Amyloidosis
Gastrointestinal	Whipple disease, primary biliary cirrhosis, Spondyloarthropathies, hemochromatosis
Endocrinopathies	DM, hypothyroidism, hyperthyroidism, hyperparathyroidism, acromegaly
Extra-articular Manifestations	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).

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Medical Management (current best evidence)[edit | edit source]

The goal of medical management for RA is to prevent or control joint damage, prevent loss of function, and decrease pain.

Medications: See full list in <a href="http://www.physio-pedia.com/RA_(Rheumatoid_Arthritis)#Medications">medication section</a>

Disease-modifying antirheumatic drugs (DMARDs)- Slow the progression of rheumatoid arthritis and save the joints and other tissues from permanent damage.
Immunosuppressants- Control the immune system
TNF-alpha inhibitors- Inhibit the inflammatory substance produced by the body and help reduce pain, morning stiffness, and tender or swollen joints.
Other drugs- Target a variety of processes involved with inflammation in your body

Surgical Treatment: If medications fail to prevent joint damage, surgical intervention may be needed to repair the joints, restore ability, decrease pain, and correct deformities.

Total Joint Replacement
Tendon Repair
Joint Fusion

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

[2]

Physical Therapy Management (current best evidence)[edit | edit source]

Goals and Expected Outcomes

http://wiki.medpedia.com/Rheumatoid_Arthritis_Medicines

Decrease pain
Decrease joint swelling or inflammation
Increase or maintain strength
Improve joint integrity and stability
Improve range of motion
Improve endurance for functional activities
Independence for ADL’s
Safe and efficient gait
Improve functional mobility
Increase in quality of life
Self management

Interventions:

Range of Motion/ Flexibility: Range-of-motion exercises and exercise programs can delay the loss of joint function and help keep muscles strong.
Modalities: Heat, ice, massage, ultrasound, hydrotherapy, and electrical stimulation may be used to reduce pain and improve joint movement.
Joint protection: Assistive devices, splints or orthotic devices to support and align joints may be very helpful.
Energy Conservation: Frequent rest periods between activities, as well as 8 to 10 hours of sleep per night, are recommended.
Aerobic Endurance: aerobic capacity/endurance conditioning,
Therapeutic exercise: gait training, aquatic programs, range of motion techniques, stretching, strength, power and endurance training
Functional Training: ADLs, task adaptation, injury prevention
Manual Therapy: passive range of motion, soft tissue mobilization
Patient Education
Lifestyle changes (Physical activity, dietary, and emotional changes)

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**ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities Exercise Prescription**
Benefit	Type	Prescription
CV Health	Cycling, walking, swimming, dance	60-80% HR Max, 30-60 min/session, 3-5 days a week; Increase duration, then intensity over time
Muscle Mass and Strength	Free weights, weight machines, therabands	60-80% 1RPM, 8-10 exercises (large muscle groups), 8-12 repetitions, 2-3 sets, increase intensity over time
ROM and Flexibility	Stretching, Tai Chi, Yoga/Pilates	10-15 minutes, 2 days a week
Balance	One leg stance, stability ball, strengthening core muscles	Regular basis

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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

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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
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

[2]

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).
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.
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.
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.

[14] [15]

Differential Diagnosis[edit | edit source]

A) Fibromyalgia
B) Lyme Disease
C) Myelodysplastic syndrome
D) Osteoarthritis
E) Paraneoplastic syndrome
F) Polychondritis
G) Polymyalgia Rheumatica
H) Psoriatic arthritis
I) Sarcoidosis
J) Sjogren Syndrome
K) Systemic Lupus Erythematous

L) Reiter Syndrome
M) Gout

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