rheumatoid ARTHRITIS

RHEUMATOID ARTHRITIS A chronic, systemic inflammatory disorder characterised by recurrent inflammation of multiple joints and related structures. It is a disorder that principally affects synovial tissues and frequently accompanied by extraarticular manifestations. Although the cause of rheumatoid arthritis is unknown, autoimmunity is thought to play a pivotal role in its chronicity and progression. Most clients exhibit a pattern of symmetric involvement of multiple peripheral joints and periods of remission and exacerbations.

Incidence It affects three times as many women as men. The onset is mostly between the ages of 30 and 50.

The actual cause is unknown Hereditary or genetic factors Smoking Aetiology The actual cause is unknown Hereditary or genetic factors Smoking Autoimmunity Infections e.g. EBV Metabolic or biochemical abnormalities, Nutritional factors e.g. vit D deficiency,

Diagnostic investigations Rheumatoid factors FBC ESR Synovial fluid analysis X-ray of the joints

Pathophysiology RA begins when T lymphocytes infiltrate the synovial membrane, following the invasion of the body by antigens. They proliferate in the synovium and initiate an immune response. B cells are also stimulated to produce auto antibodies [rheumatoid factors] to IgG. The antigen-antibody interaction leads to the formation of immune complexes which initiates synovitis, with swelling of the synovial lining membrane and production of excess synovial fluid. Pannus [granulation inflammatory tissue] is formed at the juncture of synovium and cartilage. This extends over the surface of the articular cartilage and eventually invades joint capsule and subchondral bone.

PATHOPHYSIOLOGY Tough fibrous connective tissue replaces the pannus, occluding the joint space. Fibrous ankylosis results in decreased joint motion, mal- alignment and deformity. Finally, as the fibrous tissue calcifies, bony ankylosis may result in total joint immobilisation.

Swan neck deformity and ulnar deviation

Clinical manifestations Musculoskeletal Spine General Cervical pain Symmetric polyarticular joint swelling Neurologic manifestations Joint redness, warmth, pain, tenderness Wrists Limited range of motion Morning stiffness Deformity Limitation of motion • Carpal tunnel syndrome

Clinical manifestations cont’d Hands Ankles Ulnar deviation Limited range of motion Swan-neck deformity [DIP hyperflexion with PIP hyperextension] Pain on ambulation Feet Subluxation Boutonnière deformity [PIP flexion with DIP hyperextension] Hallux valgus [deviation of the great toe towards other digits of the foot] Knees Joint effusion Lateral toe deviation Instability Cock-up toe

Clinical manifestations cont’d Respiratory • Pleural disease • Pneumonitis Integumentary • Rheumatoid nodules Exocrine glands Sjögren’s syndrome • Dry eyes • Dry mouth Cardiovascular • Vasculitis • Pericarditis Hematologic Felty's syndrome • Splenomegaly • Neutropenia • Anemia

Clinical manifestations cont’d Metabolic Processes • Fatigue • Weakness • Anorexia • Weight loss • Low-grade fever

NSAIDs: especially Aspirin: Corticosteroids e.g. prednisolone management Pharmacologic NSAIDs: especially Aspirin: Corticosteroids e.g. prednisolone Immunosuppressive or cytotoxic drugs e.g. methotrexate, cyclophosphamide Disease modifying anti-rheumatic drugs: e.g. methotrexate, gold salts, antimalarial agents e.g. hydroxychoroquine, sulfasalazine and D-penicillamine, leflunomide

management Rest and sleep Complete bed rest is unnecessary and should be avoided to prevent stiffness and immobility Regularly scheduled rest periods alternated throughout the day help relieve pain and fatigue and minimise excessive weight bearing Encourage client to sit instead of standing Teach client good body alignment while resting Provide a firm mattress or bed board Encourage position of extension and avoid position of flexion Never place pillows under client’s knees

Joint protection Exercise: management Help client to identify ways to modify tasks Encourage periods of rest in-between activity to avoid fatigue Encourage client to use assistive devices to conserve the joints Exercise: ROM exercise, isometric exercise, Lying prone and allowing the legs to hang over the end of the mattress will help prevent flexion contractures. The client should be told to do this several times a day.

management Pain management: Psychological support: Assess the level of pain and duration of morning stiffness Encourage client to relate pain to activity level and adjust activity accordingly Application of cold or warm compress to relieve pain Serve prescribed analgesics Psychological support: Self image disturbance Body image disturbance Monitor the level of pain and duration of morning stiffness. Pain and morning stiffness are indicators of disease activity. Increased pain may necessitate changes in the therapeutic treatment plan. ■ Encourage the patient to relate pain to activity level and adjust activities accordingly. Teach the importance of joint and whole-body rest in relieving pain. Pain is an indicator of excess stress on inflamed joints. Increasing pain indicates a need to decrease activity levels.