RHEUMATOID ARTHRITIS
Definition:
A chronic polyarthritis usually involving symmetrical presentation in the peripheral joints that can lead to
destruction of the bone and cartilage resulting in characteristic deformities.
Etiology:
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systemic manifestations can occur
the disease can appear in many forms:
a. from a mild short-lasting oligoarthritic illness that causes little damage to a severe progressive
polyarthropathy that leads to marked joint destruction
b. most patients present with an intermediate course of the disease
etiology is idiopathic
occurs in about 1% of the population, with women presenting 3x more often than men
usually comes on between the ages of 35-50
has a genetic association
correlated with a class II major histocompatibility gene complex antigen (HLA-DRA), esp. in Caucasians and
Japanese with the classic or definite expression of RA
it has been suggested that RA in females may be related to low estrogens or in both sexes a liver "filtering"
dysfunction
juvenile onset RA (Still's disease):
a. most common cause of chronic synovitis in children
b. similar to the adult disease
Three subtypes:
polyarticular:
a. mostly seen in females and accounts for 40-50% of all JRA
b. no eye involvement
c. usually the patient presents with multiple symmetrical joint involvement
d. 10% have a (+) RF and a (+) ANA, have a disease onset late in childhood and are usually
affected quite severely with a mild anemia and a slight leukocytosis
e. 30% have a (-) RF and a (-) ANA, and experience a milder form with a mild anemia and a slight
leukocytosis
pauciarticular:
a. responsible for another 30-40% of JRA
b. if affects only a few asymmetrical joints
c. present in 2 ways:
A. early onset before the age of 5, 30% of cases, patients often develop iritis, (-) RF and
(+) ASA
B. late onset mainly seen in boys, with frequent hip an dsacroiliac problems but no iritis
and (-) RF and (-) ANA, high association with HLA-B27
systemic-onset:
a. responsible for 20% of JRA
b. found in any age
c. affects boys slightly more than girls
d. symptoms:
A. fever, chills
B. macular rash
C. splenomegaly
D. pleuritis and/or pericarditis
E. abdominal pain
F. severe anemia
G. marked leukocytosis, followed by the appearance of a polyarthritis
e. (-) RF and (-) ANA
Signs and Symptoms:
1. onset may be sudden
a. abrupt inflammation of many joints
b. fever
c. lymphadenopathy and splenomegaly
2. insidious onset in 75-80% of patients, with systemic complaints including:
a. anorexia
b. fatigue, generalized weakness
c. vague musculoskeletal symptoms
d. the initial symptoms may exist for months, resisting clear diagnosis
e. when specific symptoms begin, the joints usually involved are the proximal interphalangeal and
metacarpophalangeal joints, feet, wrists, elbows and ankles, however, any joint may be inflamed
A. most commonly the joints are symmetrically affected
Diagnostic criteria for RA as defined by the Arthritis Foundation and JAMA (Vol.224, p.799, April 30, 1973):
RHEUMATOID ARTHRITIS
classic RA: diagnosis needs 7 or the following criteria, with the symptoms of the first 5 lasting over 6 weeks
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morning stiffness > 1 hour
pain on motion in at least 1 joint
swelling (soft tissue; not just bony growth) in at least 1 joint
swelling of at least 1 other joint
symmetrical joint swelling not including terminal phalangeal joint involvement
subcutaneous nodules usually distal to the elbow
x-ray changes typical of RA
(+) agglutination test: (+) RF
poor mucin precpitate from synovial fluid or inflammatory synovial effusion with over 2000 WBC/mm3 and
no crystals
10. at least 3 characteristic histologic changes in synovial membrane
11. characteristic changes in nodules
definitive RA: diagnosis requires 5 of the above criteria; in the first 5 the joint signs/symptoms must be continuous for at
least 6 weeks
probable RA: diagnosis requires 3 of the above criteria; of the first 5 criteria, only 1 must be continuous for 6 weeks
possible RA: diagnosis requires 2 of the following criteria and the duration of the joint symptoms must be at least 3
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morning stiffness
pain or tenderness on motion for at least 3 weeks
history or present joint swelling
subcutaneous nodules
elevated ESR or C-reactive protein
iritis: only useful for diagnosis of JRA
As the disease progresses:
1. characteristic joint deformities may occur:
a. ulnar deviation of the finger at the metacarpophalangeal joint
b. swan-neck deformity (hyperextension of the proximal interphalangeal joint, with distal
interphalangeal joint in flexion)
c. Boutonniere deformity (opposite of swan-neck changes)
2. extra-articular complaints:
a. rheumatoid nodules
b. rheumatoid vasculitis
c. pleuropulmonary problems
d. neurologic symptoms
e. Felty's syndrome (consisting of RA, neutropenia, osteoporosis, splenomegaly and occasionally
anemia and thrombocytopenia)
Lab Findings:
1. mild or moderate anemia with hemoglobin rarely < 10g/dl, usually hypochromic
2. leukocytosis seen in only 25% of patients and then rarely > 15,000/mm3
3. active RA: elevated ESR and C-reactive protein values usually seen (test is not specific for RA)
4. (+) ANA
5. increased:
a. creatinine
b. ASO titer
c. copper in serum
d. ceruloplasmin causes false (+) for Bence-Jones proteing
e. platelets
6. x-ray (+) for RA
Course/Prognosis:
1. the course and prognosis varies from patient to patient and is hard to specify
2. conventional treatment can improve as many as 75% during the first year of their disease; however, despite full
treatment, 5-10% of patients eventually become disabled
3. 5 years after the onset of the disease, only 1/3 of patients may have evidence of RA, though most patients
experience persistent but cyclical illness activity
4. remissions usually occur in the 1st year; sustained RA activity greater the 1 year indicates a serious problem
5. the greatest joint damage takes place during the 1st 6 years of the disease and then progresses at a substantially
slower rate
6. the median life span of the RA patient is lowered by 3-7 years
RHEUMATOID ARTHRITIS
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an increased mortality rate can be seen in patients with severe disease and is usually due to infections, GI bleeding
and drug therapy
JRA: prognosis is more favorable than that of adult RA, as about 75% of patients enjoy complete remissions
Differential Diagnosis:
1. other collagen-vascular disorders:
a. SLE
b. polyarteritis
c. progressive systemic sclerosis
d. dermato(poly)myositis
2. sarcoidosis
3. amyloidosis
4. Whipple's disease
5. acute rheumatic fever
6. gonocaccal arthritis
7. Reiter's syndrome
8. psoriatic arthritis
9. ankylosing spondylitis
10. gout
11. Kellegren's syndrome/erosive osteoarthritis
Nutrition:
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low sugar
low fat diet of unsaturated fats
short fasts (5-7 days) are recommended with 2 week intervals between them
vegetarian cleansing diet
hypoallergenic/rotation diet
increase omega-3 and -6 FAs
sesame seeds, kale, artichokes, green beans, millet, celery, barley, okra, almonds, collards, turnip greens, raw goat's
milk, goat whey, black mission figs, gelatin, burdock root, cherries, pineapple, quince, watercress, blackberries, black
currants mustard greens, limes, lettuce, olive oil
Remedies:
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500g of red cherries in 1 liter rice wine for 10 days, drink 30-60 ml of wine BID
Avoid:
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animal products (promotion of PGE-2 pro-inflammatory mediators)
food intolerances
dairy products (promotion of PGE-2 pro-inflammatory mediators)
spinach, aspragus, rhubarb, nightshade family (tomatoes, green peppers, potatoes), pimentos, eggplant
tobacco
coffee, caffeine
sugar, refined foods
fried foods
NSAIDs
Supplements:
1. vitamin B-5 (500mg QID)
2. vitamin C
3. vitamin E (1000 IU QD)
4. vitamin K (5-10mg TID) [to stabilize synovial lining]
5. zinc (20-50mg TID)
6. copper
7. selenium (200mcg QD)
8. manganese
9. bromelain (2250mg BID between meals)
10. catechin
11. glycosaminoglycans
12. L-histidine
13. D, L-phenylalanine
14. tryptophan
15. omega-3 FAs
16. omega-6 FAs (EPO: 1g QID; flaxseed oil: 1-3 Tbsp. QD)
Hydrotherapy:
1. hot Epsom salt bath (1lb./tub, 2x/wk)
2. hot towels with wool over them
RHEUMATOID ARTHRITIS
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charcoal poultice: over affected joints
contrast baths (50-65oF then 99-110oF)
hammock baths for advanced arthritis
castor oil pack to affected joints
Russian steam bath
Heating compress
Alternating bath
Peanut oil rubbed on affected joints followed by salt glow to joints
Chronic:
1. constitutional hydrotherapy
Manipulation:
1. check and align T10-12
2. if hand involved: cervicals and T4
NOTE: contraindicated with active inflammation
Chronic inflammation:
1. nasal turbinate adjustment
Physiotherapy:
Acute:
1. ROM exercises within limits of pain
2. stretching, ROM and gentle resistive exercises
3. water exercises
Non-acute:
1. strength training
2. swimming, bicycling (ie. low load aerobic exercises)
3. massage: affected joints, esp. after heat to joint
Sub-acute or chronic:
1. US
2. diathermy
Botanicals:
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Apium graveolens: with mental depression
Arctium lappa:
Bryonia alba (toxic): acute, muscular pain (with Cimicifuga racemosa), < with movement, joints of fingers and hands
Capsicum frutescens:
Caulophyllum thalictroides (toxic): rheumatoid pain
Cimicifuga racemosa: rheumatoid pain, with Menyanthes trifoliata
Equisetum arvense: diuretic, antidyscratic, antihumoral
Glycyrrhiza glabra: anit-inflammatory
Guaiacum officinale: anti-inflammatory; combine with Zingiber officinale, Menyanthes trifoliata, Apium graveolens
Harpagophylum procumbens: pain, decreased mobility
Iris versicolor (toxic): chronic rheumatic conditions
Menyantheas trifoliata: with Apium graveloens or Cimicifuga racemosa
Phytolacca decandra (toxic): chronic rheumatic conditions
Salix spp.: externally; pain, inflammation
Solanum dulcamara (toxic): antidyscratic
Taraxacum officinale: chronic rheumatic conditions
Urtica spp.:
Xanthoxylum americanum (bark): peripheral circulatory insufficiency
Formulas:
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for bone pain: add Phytolacca decandra (toxic) or Zingiber officinale or Echinacea spp.
Arctium lappa or Chimaphila umbellata, Populus trichocarpa, Salix spp.; equal parts of each
rheumatism: Achillea millefolium [1 Tbsp.], Caulophyllum thalictroides (toxic)[1 Tbsp.], Sassafras officinale
[1 Tbsp.], Viburnum opulus [1 Tbsp.], Xanthoxylum americanum [1 Tbsp.], to use powder: boil designated
amounts in 1 quart water for 30 min., strain; SIG: 2 Tbsp. AC; tincture: 1/4 tsp. QID
Homeopathy:
1. Arsenicum album: like Rhus tox. except wandering pains, < after midnight; anxiety, need company
2. Aurum metallicum: < sunset to sunrise; deep wandering pains which wake patient up; < cold, uncovering; >
motion, warmth; depression
RHEUMATOID ARTHRITIS
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Bryonia: slow developing, gradually moves from one joint to another; < after eating, motion, damp; stitching
pains;> pressure
4. Calcarea carbonica: follows Rhus tox.; excessive worry; < overtired
5. Causticum: very stiff, > raining; lot of joint deformity; < rising from a seat
6. Kali bichromicum: shifting pain, disappears and appear, < motion, much > heat; alteration of arthritis with GI
symptoms (diarrhea) and pulmonary symptoms
7. Kali carbonicum: R side, very stiff, sensitive to cold; stitching pain < 3am, > moving
8. Pulsatilla: < as day goes on, stiff and sore in evening after sitting; wandering pains
9. Rhododendron: #1 < before storm, cold, damp, windy; severe arthritis; > walking
10. Rhus tox.: main remedy; < cold, damp and heat; stiffness < first motion and > continual motion, restlessness