Rheumatoid Arthritis

Dr Shahzeb (PT)
Rheumatoid Arthritis (RA)
• Rheumatoid arthritis is a chronic symmetrical polyarthritis of
unknown cause and is characterized by chronic inflammatory synovitis
of mainly peripheral joints along with systemic disturbances and
extra-articular features.
• Course of disease is prolonged with exacerbations and remissions.
• Characterized by:
• Symmetrical inflammatory polyarthritis
• Extra-articular involvement e.g. in the lungs and many other organs.
• Progressive joint damage causing severe disability.
• INCIDENCE
• Prevalence 1-1.5%
• Female to male ratio 3:1
• Peak age incidence between 20-40 years.
 Etiology:
• The cause of rheumatoid arthritis (RA) is unknown. Following may be
the risk factors.
• Genetic factors: may be involved because it is usually associated with
HLA- DR4 in whites and DR1 in Indo-Pak.
• Autoimmunity:
• Female gender: a risk factor and this susceptibility is increased post-
partum and by breast feeding.
• Cigarette smoking: is also a risk facto
PATHOGENESIS
• RA is a disease of the synovium. There are two main pathological
characteristics:
• Inflammation
• Proliferation
• The synovium shows signs of chronic inflammation. There is swelling and
congestion of the synovial membrane, and the underlying connective
tissue which become infiltrated with lymphocytes, plasma cells and
macrophages
• The synovial membrane then proliferates and grows out over the surface
of the cartilage, which causes erosion and destruction of the cartilage.
CLINICAL FEATURES
• RA usually presents with insidious onset of pain and stiffness in the
small joints of hands and feet which eventually lead to bilateral
symmetrical peripheral polyarthritis.
• In 25% cases it presents as monoarthritis such as involvement of only
knee joint.
• SYMPTOMS:
• Joint pain: The pain is worst on waking in the morning and improves
progressively with activity. There is often pain at night disturbing the
sleep.
• Morning stiffness: Often lasting for several hours and then subsides.
• General symptoms: Fatigue and malaise
• SIGNS
• Swelling:
• soft swelling caused by effusion or synovial proliferation.
• Warmth
• Tenderness on pressure or movement.
• Limitation of movement with muscle wasting around affected joints.
• Deformities occurring in the later stages of the disease.
• Subcutaneous nodules (in 20%) mostly situated over bony prominence
• Pattern of joint involvement:
• Although any joint may be affected in R.A, the proximal interphalangeal and
metacarpophalangeal joints of fingers as well as the wrist, knee ankles and toes
are most often involved.
• Distal interphalangeal joints are characteristically spared.
• D/D from osteoarthritis
• In osteoarthritis, the number of joints affected is much less than RA.
• In RA distal interphalangeal joint is spared while in osteoarthritis (OA) it is
characteristically involved.
• The joints most commonly involved in OA are weight bearing joints e.g. knee and
hip joints.
• DEFORMITIEs:
• Spindling of the fingers: In early stages, swelling of the
metacarpophalangeal joints produces spindling of the finger
• Swan neck deformity:
• Button hole deformity:
• Z deformity of the thumb:
• Cervical spine:
• Synovitis of upper cervical spines leads to bone destruction, damage of
ligaments that causes atlantoaxial subluxation which may damage the spinal
cord.
• Extraarticular feature:
• Subcutaneous modules: (in 20%)
• Bursitis:
• Muscle wasting :
• Carpal tunnel syndrome (More common nervous involvement).
• Atlanto-axial subluxation:
• Sjogren ’s Syndrome: Commonest eye problem rheumatoid arthritis
• Pleural effusion (commonest lung problem)
• Caplan’s Syndrome : occurrence of nodular pulmonary fibrosis in
patients with RA exposed to various industrial dusts.
• Pericardial rub often heard.
• Fever
• Weight loss
• INVESTIGATIONS:
• No test is specific for diagnosis of rheumatoid arthritis. Following
investigations may be helpful.
• RA FACTOR:
• Rheumatoid factor (RA factor) is autoantibody is present in about 70%
of cases .
• ANA: Antinuclear antibody is positive in 30% of cases.
• ESR and C-reactive protein (CRP) are raised
• RADIOGRAPHY:
• X-rays taken during first 6 months are read normal. Early changes
occur in the wrist or feet and consist of:
• juxtra-articular osteopenia,
• Later loss of articular cartilage and bone erosions develops after
months of sustained disease activity.
Diagnostic Criteria for RA ≥ 4 criteria present
> 6 wks
• Diagnosis of RA is based on history, examination, x-ray findings and serology (RA factor).
• CRITERIA FOR THE DIAGNOSIS OF RHEUMATOID ARTHRITIS
(American Rheumatism Association 1988 Revised criteria)
1 . Morning stiffness (> 1 hour).
2. Arthritis of 3 or more joint areas.
3. Arthritis of hand joints.
4. Symmetrical arthritis
5. Rheumatoid nodules
6. rheumatoid factor
7. Radiological changes
Treatment
• NON-PHARMACOLOGICAL TREATMENT:
• Rest: Rest ameliorates symptoms. Complete bed rest for patients with
profound systemic and articular inflammation. With mild inflammation, '2
hours of articular rest decreases joint inflammation.
• Exercise
• Exercises are designed to preserve joint motion, muscular strength and
endurance. Initially passive range of motion is best tolerated. As tolerance
for exercise increases and the activity of the disease subsides’ progressive
resistance exercises may be introduced. Patients are particularly at risk of
developing progressive joint stiffness and deformity, therefore they should
undertake simple exercise to maintain joint mobility and muscle power.
• Splints:
• Splints may provide joint rest, reduce pain and prevent contractors.
They should be applied for short period
• Weight loss:
• Weight loss is also beneficial especially to reduce symptoms of weight
bearing joints
• PHARMACOLOGICAL TREATMENT:
• Medical management of RA involves 4 general approaches.
• First line NSAID and steroid while second DMARDs.
1. Non-steroidal ant-inflammatory drugs (NSAlDs) (Diclofenac sodium Voltral,
Diclofenac potassium Caflam)
2. Low dose corticosteroids.
3. Disease Modifying Anti-Rheumatic Drugs (DMARDs). methotrexate,
hydroxychloroquine, sulfasalazine, and leflunomide
4. Immunosuppressive drugs. Azathioprine Cyclophosphamide Chlorambucil and
Cyclosporine
Surgery: soft tissue release, tendon repair, joint replacement etc
• Thanks