Arthritis literally means “inflammation of a joint”. Since there are any number of factors that can cause inflammation of a joint, there are many types of arthritis.
Some examples of arthritis include Ankylosing Spondylitis, Fibromyalgia, Osteoarthritis, Sjogren’s Syndrome, Rheumatoid Arthritis and Gout. Each of these may affect the patient differently and may have significantly different complications. It is, therefore, very important to know the exact type or form of arthritis that you may be treating.
Rheumatoid Arthritis (RA) is a chronic, systemic, inflammatory disease that chiefly affects the synovial membranes of multiple joints in the body. As a consequence of the disease being systemic, there are many extra-articular features of the disease as well.
In most cases of RA, the patient has remissions and exacerbations of the symptoms. This means that there are periods of time when it “feels good” and times when it “feels worse”. There will likely be times when RA “feels cured”. It is important to understand that there are very few people that have complete remission of the disease. It is essential that the RA patient does not stop the treatment program established by knowledgeable health care practitioners. Rarely does the disease “go away”, although at times the symptoms might temporarily remit.
The disease is considered an autoimmune disease that is acquired and in which genetic factors appear to play a role.
The prevalence of the disease is 1-2% of the general population and is found world-wide. Females with RA outnumber males by a 3:1 margin. The onset of the disease in adults is usually between the ages of 40-60 years, although it can occur at any age. The cause of RA is presently unknown.
Effects of the Disease
Rheumatoid Arthritis can attack any synovial joint in the body. Excepting the distal interphalangeal joints, it has the greatest affinity for the small joints of the hand, wrist, and foot. In many cases, the joint involvement in the limbs becomes relatively symmetrical. Further, the cervical spine, usually the superior aspect, becomes affected and patients must be watched carefully for disruption of the atlantoaxial joint. In advanced cases of the disease, subluxation at the atlantoaxial joint can occur.
Early in the course of the disease, several changes on joint structures occur. Joint effusion and inflammation of the synovium occur, producing a soft tissue swelling that is easily detected during evaluation of the patient. Additionally, changes (osteoporosis) in the ends of the bones forming the joint may be present early in the disease process.
The attack on a joint by the disease usually begins with the synovium. Early in the disease, edema begins to be seen in cells in the synovium and multiplication of synovial lining cells occurs. As the disease progresses, the synovium may grow considerably larger, eventually forming tissue called pannus. Pannus can be considered the most destructive element affecting joints in the patient with rheumatoid arthritis. Pannus can attack articular cartilage and destroy it. Further, pannus can destroy the soft subchondral bone once the protective articular cartilage is gone. The synovial fluid secreted by the synovium is thought to serve two main purposes, lubrication of the joint and provision of nutrients to the avascular articular cartilage. In this disease process, interaction between antibodies and antigens occurs, causing alterations in the composition of the synovial fluid. Ultimately, digestants are formed in the fluid, which attack the surrounding tissue. Once the composition of this fluid is altered, it is less able to perform the normal functions noted above, and more likely to become destructive.
The changes in the synovium and synovial fluid briefly described above are responsible for a large amount of joint and soft tissue destruction. The destruction of bone eventually leads to laxity in tendons and ligaments. Under the strain of daily activities and other forces, these alterations in bone and joint structure result in the deformities frequently seen with rheumatoid arthritis. Considerable destruction of the joint can occur with pannus invading the subchondral bone.
Bone destruction occurs at areas where the hyaline cartilage and the synovial lining do not adequately cover the bone. If the disease progresses to a more advanced stage, the articular cartilage may lose its structure and density, resulting in an inability to withstand the normal forces placed on the joint. In these advanced cases, muscle activity causes the involved ends of the bones to be compressed together causing further bone destruction. Further, the disease can irreversibly change the structure and function of a joint to the degree that other degenerative changes may occur, especially in the weight-bearing joints of the body. Joint destruction can progress to the degree that joint motion is significantly limited and joints can become markedly unstable.
Prevention of Disability and Preservation of Function
Another major element in the treatment of patients with Rheumatoid Arthritis is to prevent disability and preserve bodily function. One way to achieve this goal is to develop an exercise routine, based on specific needs, that preserves motion, strength, functional activities and lifestyle.
Positioning is also valuable in preserving motion and enhancing function. Patients should be encouraged to frequently change body position at work, home and during leisure activities.
Preservation of muscle strength and endurance is also very important in individuals with RA. Muscle atrophy can quickly occur because of disuse, splinting or the inflammatory process. Loss of muscle bulk is correlated with loss of functional ability. Thus, the health care practitioner must develop an exercise program that maintains or increases the strength of the patient with RA.
Maintenance of Lifestyle
The significance of a systemic disease like Rheumatoid Arthritis (RA) is that it is pervasive, leaving no part of the patient’s life untouched. Perhaps the best way for the health care practitioner to understand what it is like to live with a systemic disease is to imagine every activity that takes place during a “normal” day and how those activities might be affected by a disease like RA.
Examples of possible situations and questions that may need to be answered are:
- The first hurdle to overcome for many of these patients is fighting the morning stiffness that frequently accompanies RA in order to get out of bed. Will the patient need assistance getting out of bed and if so, what modification may be necessary?
- Depending on the degree of joint involvement, patients may have considerable difficulty performing self care activities like brushing teeth, combing hair, putting on shoes, and buttoning or zipping garments. What devices or strategies may help the patient successfully complete these activities?
- Preparing meals can offer challenges like opening boxes and cans, and attempting to pour from heavy objects like coffee pots or full containers of milk or orange juice. What strategies can the patient use to minimize the stresses placed on the wrist, hand, and finger joints when preparing meals or participating in other activities?
- Are there steps that need to be negotiated either within the house or to move in or out of the house? Will modifications need to be made?
- Does the patient need to drive? If so, what recommendation do you need to make regarding choice of vehicle?
- Is the patient employed? Are there reasonable accommodations that need to be made to keep the patient a productive employee?
- Is there family support for the patient? Are external services necessary for the patient?
The point is that health care practitioners need to carefully evaluate every element of the patient’s day, including work and social events in order to develop the strategies, assistive devices and new skills necessary for the patient to function with the illness. A major goal of health care practitioners should be to assist patients with planning and living the lifestyle of their choice.
Source: This information was made available through the Arthritis Society.