How to manage rheumatoid arthritis
Author
HealthCert Education
According to WHO, 18 million people are affected with rheumatoid arthritis worldwide. Rheumatoid arthritis (RA) is a progressive autoimmune disease that symmetrically causes synovitis in multiple joints. It is a polyarthritis initially manifesting as monoarthritis.
Let's look at its management in primary care.
Clinical assessment of rheumatoid arthritis
During the initial assessment, before lab results the constitutional symptoms are key factors in investigating the possibility of pathology.
- Patients present with morning stiffness that continues for more than 1 hour
- Shoulder and hip pain, shoulder bursitis
- Z pattern deformity along with joint inflammation
- Effusion on the anterior aspect of wrist flexor tendon
- The patient may have spiniform joints of fingers which indicate early RA
The diagnostic signs of rheumatoid arthritis
Rheumatoid arthritis attacks small and large joints symmetrically in the upper and lower limbs. The patient presents with tenderness and stiffness in the affected joint bilaterally. The patient also complains of episodes of flare-up and remission along with fever, malaise, fatigue and appetite loss during the flare-up phase.
RA causes rapid proliferation of synovial tissues resulting in increased threshold of pain on slight flexion and extension. Classical RA is distinguished based on the presence of seropositive Igm RA factor, ACPA and inflammatory levels by CSR and ESR.
Differential diagnosis
The symptoms of RA vary from patient to patient. The differential diagnosis of RA is often confused with polymyalgia rheumatic, Felty Syndrome, fibromyalgia, osteoarthritis, and systemic lupus erythematosus. Rheumatoid arthritis can also be caused by the bacterium Subdoligranulum didolesgii and Epstein-Barr virus.
Types of rheumatoid arthritis
- Inflammatory rheumatoid arthritis
- Septic rheumatoid arthritis
- Psoriatic rheumatoid arthritis
- Juvenile idiopathic rheumatoid arthritis
- Reactive arthritis
Musculoskeletal observations of patients with rheumatoid arthritis
On observation, patients affected with RA have antalgic gait patterns due to hind foot pain and deformity. They have decreased velocity, cadence, stride length and single-limb support on the affected side. The kinetic EMG results show that there is an increase in the activation of the tibialis anterior muscle which increases subtalar eversion and decreases plantar flexion during the terminal stance phase. This results in delayed heel rise, increase in knee flexion and dorsiflexion during the stance phase on the affected side.
Rheumatoid arthritis complications
RA also possesses a pathological effect on extra-articular organs systemically including dry eyes, inflamed blood vessels in the lungs airway and pericardial sac of the heart. The scarring in lung tissue causes multi-organ disorder, the most common complication is interstitial pneumonia.
The extra-articular features involve the formation of firm non tender subcutaneous nodules on the extensor surface of the forearm. It may develop olecranon bursitis. These nodules are present at the site of pressure and friction e.g. sacrum and other areas such as lungs.
The patient with flare-up inflammatory arthritis presents with episcleritis (inflammation of loose connective tissue in the eye). They have dry eyes that cause conjunctivitis (keratoconjunctivitis) and blepharitis (inflammation of eyelids).
Rheumatoid arthritis treatment options
The patient initially presents with undiagnosed RA with visible signs and symptoms. The patient is put on DMARDS-TNF inhibitors (biological/nonbiological/combination therapy), and NSAIDs for pain relief and immunosuppressive effects.
Rheumatoid arthritis causes disuse atrophy of the muscles of the affected joint due to painful muscle guarding. The patient is referred to physical therapy and occupational therapy to increase joint mobility, and ROM, relieve pain, increase strength/endurance and prevent joint deformity. The goal is to enable patients to perform their ADLs with minimum assistance.
Rheumatoid arthritis is a progressive disorder. The patients present with a rapid flare of disease followed by oedema, inflammation, and stiffness. They are susceptible to infections by the use of immunosuppressive drugs. Physical therapy and occupational therapy are adjunctively guided with drugs to minimise the disease symptoms by therapeutic exercises and orthosis. Living with RA requires the patient to make lifestyle modifications and actively engage in exercises that can sufficiently reduce the aggravating symptoms of the disease.
Dr Humda, Physiotherapist
References
- https://www.who.int/news-room/fact-sheets/detail/rheumatoid-arthritis#:~:text=Rheumatoid%20arthritis%20(RA)%20is%20a,lung%20or%20nervous%20system%20problems.
- Acharya S, Musa R. Polymyalgia Rheumatica. [Updated 2022 Jun 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537274/
- Bullock J, Rizvi SAA, Saleh AM, Ahmed SS, Do DP, Ansari RA, Ahmed J. Rheumatoid Arthritis: A Brief Overview of the Treatment. Med Princ Pract. 2018;27(6):501-507. doi: 10.1159/000493390. Epub 2018 Sep 2. PMID: 30173215; PMCID: PMC6422329.
- Tanaka, Y. Rheumatoid arthritis. Inflamm Regener 40, 20 (2020). https://doi.org/10.1186/s41232-020-00133-8
