Arthritis:
There are more than 100 known types of arthritis. Some such as rheumatoid arthritis, osteoarthritis, gout,pseudogout,fibromyalgia
and lupus are common while others are rare. Genetrics, hormones,and perhaps age (in some cases) -all may play a role in determining
who develops arthritis. Arthritis means inflammation in the joint. Inflammation is painful and is a very common medical problem.
Arthritis is not the same as arthralgia,aches and pains many people have upon awakening or over- exertion. If aches and pains
are like a light summer breeze,arthritis is like a storm and rheumatoid arthritis is like a hurricane for many patients.
Arthritis can be classified as either inflammatory or non-inflammatory. Inflammatory arthritis features inflammatory
white blood cells in the joint fluid. Forms of inflammatory arthritis includes RA,lupus,gout and many others. Forms
of non-inflammatory arthritis (generally) include osteoarthritis,arthritis of thyroid disease, arthritis after injury and
many others. Live long enough and people will have some form of (degenerative OA) arthritis. Osteoarthritis is a disease of
the cartilage. Some osteoarthritis patients affecting DIP,PIP and CMC joints may be associated with inflammation.
Rheumatoid Arthritis:
One important way to distinguish RA from other forms of arthritis is by the pattern of joint involvement. e.g.,RA affects
the wrist and many of the hand joints but usually not the joints that are closest to the fingernails.
Osteoarthritis (OA).in contrast,usually affects those joints closest to the fingernails more often than other areas of
the hand.
In RA,the joints tend to be involved in a symmetrical pattern. i.e.,if the knucles on the right hand are inflamed,the
knucles on the left hand are more likely to be inflamed as well.
Rheumatoid arthritis (RA) is an autoimmune disorder of unknown cause characterized by symmetric,erosive synovitis and
often mutisystem involvement. Most patients exibit a chronic changing course of disease that,if left untreated,results in
progressive joint destruction,deformity,diability and premature death.
RA is one of the most common and serious type of arthritis. It affects all ages and races. Rheumatoid arthritis
affects approximately 1% of the U.S. population. RA is a disease of the synovial membrane.
RA is a chronic progressive polyarthritis. Successful treatment to limit joint damage and functional loss requires early
diagnosis and timely initiation of disease-modifying agents.
The goal of treatment is to arrest the disease and to achieve remission. Although,complete remission is not common,patients
may still receive substanstial benefit from pharmacologic,nonpharmacologic and if necessary,surgical interventions.
Optimal longitudinal treatment requires comprehensive coordinated care and the expertise of a number of providers. Essential
components of management include
1) establishment of the diagnosis of RA (versus other forms of polyarthritis).
2) systemic and regular evaluation of disease activity.
3) patient education/rehabilitation interventions and initial treatment with NSAIDs.
4) use of DMARDs.
5) possible use of local or low-dose oral glucocorticoids.
6) minimization of the impact on the individuals's function.
7) assessment of the adequacy of the treatment program .
8) general health maintenance.
The course of rheumatoid arthritis cannot be predicted in a given patient. Several patterns have been described:
*A spontaneous remission particularily in the seronegative patient (mild RA) within the first 24 months of symptoms (less
than 10%).
*recurrent explosive attacks followed by periods of quiescence,most commonly in the early phases.
*the usual pattern of persistent and progressive disease that wanes and waxes in intensity.
* there is mild-moderate-severe RA patients.
*some patients will have extra-articular features associated with the disease that can affect the whole body. *the pattern
of disease activity,severity and disease progression will be individualized in most patients -this also applies to medication
and therapy.
Disability is higher among patients with RA with 60 % being unable to work 10 years after the onset of disease. Recent
studies have demonstrated an increased mortality in rheumatoid arthritis patients.
Median life expectancy was shortened an average of 7 years for men and 3 years for women compared to controlled
populations in more than 5000 oatients with RA from four centres. The mortality rate was two times greater than in the contol
population.
Patients at risk for shortened survival are those with with systemic extra-articular involvement,low functional capacity,los
social-economic status,low education and predisone use,according to the study.
Rheumatoid arthritis is characterized by the signs of inflammation: pain, swelling,heat and stiffness.
Pain is caused by inflamed cells and chemicals that affect the nerve endings. In RA pain is felt in the joint or
with joint movement.
Swelling is caused by thickening of the synovial membrane and sometimes by increased fluid or debris within the joint.
Increased blood flow to the inflamed joint results in heat and redness.
Stiffness commonly called "morning stiffness",occurs in almost all inflamed joints after a period of rest or disuse.
This is particularily true in RA.
Morning stiffness can last from a few hours to all day long. To regain normal mobility inflamed joints must be loosened
up by applying heat or doing exercise.. Pain is one symptom virtually everyone will have regardless of which form of arthritis
they have.
Although we do not know the cause of rheumatoid arthritis, joint damage is caused by inflammation
in the synovial membrane. This normally thin membrane becomes inflamed and filled with cells called fibroblasts,lymphocytes.macrophages
and polymorphs.
This now,thick,inflamed synovial membrane is called the pannus. The cells within the pannus becomes activated and releases
enzymes and chemicals that both permanetly damage the cartilage and the bone and also attract more cells into the inflamed
tissue.
In RA,this inflammatory process is like a one way highway,the inflammation can continue indefinetly causing more and
more damage,possibly leading to joint destruction and deformity if left untreated.
This inflammatory process is part of the body's immune system. The immune system is a natural
defense against invaders such as bacteria,viruses and even cancer. The cells of the immune system normally recognize and respond
to invaders either by making antibodies to combat invaders or by attacking invaders directly.
Although the immune system is normally activated by a foreign agent,it can be activated to
attack normal cells. In RA,for unknown reasons,the immune system becomes activated and causes marked inflammation in the synovial
membrane. Many of the drugs used to fight RA have antibacterial and/or anti-immune system activity.
- The damage to the joints caused by RA is thought to be caused by the interaction of many inflammatory
cells and chemicals. Cytokines like tumour necrosis factor (TNF), interleukins,are secreated by synovial fibroblasts and other
cells resulting in pain and inflammation.
TNF may also be respnsible for influencing other inflammatory compounds including interleukins,collagenase and prostaglandins.
Complete remission is defined as the absence of
- 1) symtoms of active inflammatory joint pain (in contrast to mechanical joint pain).
- 2) moring stiffness.
- 3) fatigue.
- 4) synovitis on joint examination.
- 5) progression of radiographic damage on sequential radiographs.
- 6) elevated erthrocyte sedimentation rate or (ESR) or C-reactive protein (CRP) level.
If complete remission is not achieved, the management goals are to control disease activity,alleviate pain,maintain function
for essential activities of daily living and work,maximize quality of life and slow the rate of joint damage.
Typical symptoms:
*Pain,swelling,limited motion,warmth and tightness around involved joints,most commonly including the hands and wrists,feet
and ankles, elbows,shoulders,neck,knees and hips,usually in a symmetric pattern,over time, joints may form deformities.
*Generalized fatigue,soreness,stiffness and aching,particularily in the early morning and afternoon (described as
morning stiffness and afternoon fatigue).
*Lumps or rheumatoid nodules may appear below the skin.
*Weight loss.
- *Low grade fever and sweats.
- *Sleep difficulties.
- *Weakness and loss of mobility.
- *Depression (may worsen existing disease or provoke it as a new problem).
- Formal diagnosis criteria that RA patients have at least 5 of the 7 following:
- 1) morning stiffness lasting at least one hour. Even stiffness for more than 30 minutes,strongly suggest inflammatory
disease. Alliviations of morning stiffness with activity is a hallmark of rheumatoid arthritis. Later in the day,continued
activity will aggravate the problem and exacerbate the pain factor.
2) Simultaneous swelling in three or more joints.
3) Swelling in the hand joints (PIP,MCP or wrist).
4) Symmetric arthritis,initially joints on one side of the body may be involved but the arthritis leads to spreading to
the other side of he body.
5) Deformity or erosions on x-ray of the hand.
6) Subcutaneous rheumatoid nodules.
7) A positive rheumatoid factor assay.
They are guidlines only,set up for research purposes,and not all RA patients will fulfill the full criteria.
Some RA patients may have a negative RF factor..
In some patients,the full symptoms may not appear until later on in the course of the disease.
- The inflammation associated with RA also may occur outside the joints. These inflammatory
changes are called extra-articular features (EAF's). Extra-articular features are found more common in patients with moderate
or severe types of RA but they can occur in all types.
-
- Since RA can cause EAF's it can be viewed as a disease that affects the whole body (in some patients) not just the joints.
EAF's can affect how one functions,feel and the quality of his/her life.
Rheumatoid arthritis does not affect everyone in the same way.. Some patients will have the mild form
and others will have the moderate or severe form. Treatment and duration is also variable according to individual patient.
- Early RA (less than 2 years) is the best time for treatment. The majority of patients have intermittent or steady progression
of the disease and require continued treatment (progressive).
When the symptoms of disease have subsided or have been successfully treated it is called remission.
When determining the type of one's arthritis the following must be considered:
*The severity: Is the arthritis mild,moderate or severe? Is it more charachterized more by "stiffening"
than by "swelling"?
* The number and severity of inflamed joints,whether the inflammation is symmetrical gives the physician a sense
of what type of arthritis is present. EAF's are more present in moderate and severe RA patients. i.e.,The
presence of features such as tendonitis,or rheumatoid nodules (small bumps under
the skin) is important and helps the physician on the type and severity of arthritis present. If deformity or damage has occurred,it
will also help in predicting the type and prognosis of the disease.
*The rheumatoid factor test: The level of RF,an antibody found in the blood stream that has known effects
on the immune system is partially related to the severity of RA. Patients with moderate or severe disease (not always) have
much higher levels of the RF than people with the mild RA.
Up to 20 % of people with RA,however,never develop a rheumatoid factor. In most patients the
severity of RA diagnosed at onset persists during the entire course of the disease.
However,in some patients the type do change. This usually occurs early in the disease process before the full features
of either moderate or severe RA have developed making them difficult to distinguish from the mild form of the disease. It
is rare for a severe type to turn mild.
Symmetric joint swelling,although not invariable is characteristic of RA. Careful palpation of the joints
can help to distinguish the swelling of joint inflammation from the bony enlargement of osteoarthritis. In contrast to gout
or septic arthritis,redness alone of affected joint is not a prominent feature of RA. Pain on passive motion is the most sensitive
test for joint inflammation
Types of RA:
Thirty percent of patients have the mild type of RA. It is charachterized
by symmetrical joint inflammation (on both right and left side of the body),pain,swelling and stiffness which usually occurs
upon awakening. Joint function is only slightly decreased. The only extra-articular feature (EAFs) is painful inflammation
of the tendons (tendonitis). The test for rheumatoid factor is usually negative or slightly positive. In most patients diagnosed
with mild RA,the arthritis remains mild throughout its course. In some patients,the disease may have a very short course but
in others,it may recur intermittenly or be constantly present for years. With the mild form of RA,damage or deformity of the
joints is uncommon. NSAIDs are usually employed. DMARD therapy,may,or not be used.
Thirty to forty percent of RA patients have the moderate type of RA. Patients
with moderate arthritis usually have much more pain,swelling,stiffness and loss of everday function then patients with the
mild disease. In moderate RA,the hands,wrists,elbows, knees and feet are usually all involved. Often moderate RA is
accompanied by early loss of movement and morning stiffness that can last for 1-3 hours or longer. EAFs are common,particularily
tendonitis. Many patients develop rheumatoid nodules (small non-tender bumps under the skin),some develop internal organ disorder.
The (RF)rheumatoid factor may increase 2 to 3 times normal but not always. If the disease is left untreated,moderate RA almost
always leads to joint damage and deformity) Disease modifying drugs (DMARDs) are used along with NSAIDs and corticosteriods
for short periods of disease activity.
Approximately 10 percent of all RA patients are diagnosed with severe RA.
Severe means severe. Severe RA is accompanied by marked joint stiffness,marked swelling and marked pain. Normal function is
seriouly affected Patients will usually have mobility and daily function problems. Deformity often occurs within the first
few months of onset. Suffer of this type feel very weak,and ill constantly. Other types of RA may turn severe over time if
the disease is not properly controlled.
Ten to fifteen percent of all RA patients have the type of arthritis characterized by stiffness.
This type of RA usually leads to abnormal tightness rather than to swelling in the small joints of the
hands,wrists,shoulders and sometimes the knee and feet. The stiffness is pronounced. The joints may look normal but the
patient may have difficulty holding a phone or raising her/his arms above the head. Normal everyday activities may
become impossible in a matter of weeks with this form of disease. With the exception of inflammation of the tendons (tendonitis),extra-articular
features are rare in this type of RA. The rheumatoid factor are usually negative. Loss of function is the major
proble caused by the stiffness. Mobility and daily function is seriously affected.
Some rheumatoid arthritis patients will develop or have other associated rheumatic disease along
with RA. These patients usually have the severe-moderate type but it is not limited to that population.
The aggressiveness and timing of the treatment program require an assessment of prognosis. Poor prognosis is suggested
by earlier age at onset,higher titer of (RF)rheumatoid factor,elevated ESR and swelling of more than 20 joint.
