• Rheumatoid arthritis is an autoimmune chronic inflammatory disorder
• The immune system attack’s its own body tissues, in this case, the joints, starting with the small joints in the hands and feet
• With progression, RA eventually results in joint deformity and bone erosion

• Of the joints:
• Tenderness
• Swelling
• Lasting stiffness
• Rheumatoid nodules = firm bumps of tissue under the skin of the arms
• Occurs in the more aggressively diseased patients
• Other:
• Fatigue, fever, weight loss
• Symptoms come and go and can vary in severity
• Increased activity period = flare
• Decreased activity period = relative remission
Rheumatoid nodule

• The immune system attacks the synovium
• Synovium = the lining of the membranes surrounding the joints
• Inflammation thickens the synovium
• The thickening will eventually invade and destroy the cartilage and bone in a joint
• The joint is held together with tendons and ligaments which lose elasticity (become weaker and stretch) with the progression of the disease
• With time, the joint loses shape and alignment, causing the characteristic image of rheumatoid arthritis

• In the beginning symptoms occur in:
• Smaller joints attaching fingers to hands and toes to feet
• With progression symptoms spread to:
• Knees
• Ankles
• Elbows
• Hips
• Shoulders

• Hard to detect in early stages
• Signs and symptoms of early stages are similar to other diseases
• During physical exam, joints will be checked for swelling, redness, and warmth
• Reflexes and muscle strength are also checked
• Blood tests
• Look for elevated erythrocyte sedimentation rate (ESR)  shows presence of inflammatory processes in body
• Also looks for rheumatoid factor and anti-cyclic citrullinated peptide
(anti-CCP) antibodies
• X-rays
• Used to track the progression of the arthritis

• As of now, there is no cure
• Various drugs can be used to reduce inflammation, relieve pain, and prevent/slow the joint damage
• Some have potentially serious side effects, so the ones with fewest side effects are prescribed first
• Physical therapy can teach the patient how to protect the joints
• If the damage is already severe, surgery may be necessary

• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Relieves pain and reduces inflammation
• Over the counter = Advil, Motrin, Aleve, etc.
• Stronger NSAIDs must be prescribed
• Side effects: stomach irritation, heart problems, liver/kidney damage, ringing in the ears
• Steroids
• Corticosteroids = reduce inflammation and pain as well as slow the damage in the joints (ex. Prednisone)
• Side effects: bone thinning, cataracts, weight gain, diabetes
• These are very strong and prescribed to relieve acute symptoms; the goal is to eventually taper off the medication

• Disease modifying antirheumatic drugs (DMARDs)
• Slow the progression of RA and can save the joints and other tissues from permanent damage
• Examples: methotrexate, ieflunomide, hydroxychloroquine, sulfasalazine, minocycline, etc.
• Side effects: liver damage, bone marrow suppression, severe lung infections
• Immunosuppressants
• Tames the immunes system because it is the immune system that is out of control in RA
• Examples: azathioprine, cyclosporine, cyclophosphamide
• Side effects: increase the patient’s susceptibility to infections

• Tumor necrosis factor (TNF)-alpha inhibitors
• TNF-alpha is an inflammatory substance naturally produced by the body
• Inhibitors reduces pain, stiffness, tenderness, and swelling
• Examples: etanercept, infliximab, adalimumab, golimumab, certolizumab
• Side effects: increased risk of serious infections, congestive heart failure, certain cancers are more potentially possible
• Other drugs
• Target a variety of processes involved with inflammation
• Examples: anakinra, abatacept, rituximab, tocilizumab
• Side effects: itching, severe abdominal pain, headache, runny nose, sore throat

• Procedures
• Total joint replacement = removing the damaged parts of the joint and inserting a metal or plastic prosthesis
• Tendon repair = tendons can loosen and rupture so the surgeon may be able to repair them
• Joint fusion = a joint can be surgically fused to stabilize or realign a joint; also for pain relief if replacement is not an option
• Surgery is a last option when medications have failed to prevent or slow the progression of joint damage

• Research has demonstrated that writing about emotionally traumatic experiences has beneficial effects in healthy individuals
• Objective of experiment: To determine if writing about stressful life experiences affects disease status in patients with asthma or rheumatoid arthritis
• After 4 months of treatment, RA patients showed improvements in overall disease activity
• Addressing patients' psychological needs produces both psychological and physical health benefits
• http://jama.jamanetwork.com/article.aspx?ar
ticleid=189437

• The Prodromal Stage
• The early symptoms which indicate the start of the disease before specific symptoms occur
• Includes pain or stiffness in a single joint
• Stiffness in a joint and ambiguous aching are symptoms called
“fibrositis”
• Ganglion in the wrist
• Raynaud's phenomenon = a condition where cold temperatures or strong emotions can cause blood vessels to spasm which block blood flow to the fingers, toes, ears, and nose

• Stages of Functional Capacity
• Stage 1: Can complete normal activities without handicap
• Stage 2: Normal activities can still be completed but discomfort found at some joints and limited motion in one or more joints

• Moderate to severe symptoms appear six months to a year or more after the early symptoms appear
• The same body parts affected in the prodromal stage may not be affected in the later stages
• Severe shoulder stiffness may reappear in the wrist joint
• Symptoms may disappear but than reappear in more aggressive forms

• Stages of Functional Capacity
• Stage 3: Limited only to self-care and can complete little or none of the usual activities
• Stage 4: Little to no self-care. Bed ridden or confined to a wheel chair

• Course of disease varies greatly
• Some people have mild short-term symptoms while for others it is progressive for life
• Daily living activities are impaired in most individuals
• After 5 years of disease, approximately 33% of suffers will not be working
• After 10 years, approximately half will have substantial functional disability
• Mortality:
• RA reduces lifespan by 5-10 years

• RA can increase risk of developing:
• Osteoporosis
• RA medication can trigger significant bone loss
• Pain and loss of join function caused by RA can result in inactivity which increases osteoporosis risk
• Carpal tunnel syndrome
• If RA affects your wrists, the inflammation can compress the nerve that serves most of your hand and fingers.
• Heart problems
• RA can increase risk of hardened and blocked arteries and inflammation of the sac that encloses your heart
• Lung disease
• RA can increase inflammation and scarring of lung tissue
• These complications can lead to death in the severe cases

• Rheumatoid arthritis occurs with the same frequency in both sexes
• However remission is more common in men
• The chronic form is more common in women
• It occurs in 1-2% of males and 2-5% of females
• The joints most likely affected are metacarpophalangeals, wrists, proximal interphalangeals, knees, ankles, metatarsophalangeals, and shoulders
• It most commonly begins between the ages of 40 and 60
• Smoking increases the risk of developing the disease
• Having family members with the disease increases the risk of developing the disease
• The onset of rheumatoid primarily occurs in the winter

• Osteoarthritis is a common form of arthritis
• involves the wearing away of the cartilage that caps the bones in joints
• Rheumatoid arthritis is when the synovial membrane that protects and lubricates joints becomes inflamed, causing pain and swelling.

• Jacoby, R. K., M. I. Jayson, and J. Alan Cosh. "Onset, Early Stages, and
Prognosis of Rheumatoid Arthritis: A Clinical Study of 100 Patients with 11year Follow-up." British Medical Journal (1973): 96-100. Web.
• Smyth JM, Stone AA, Hurewitz A, Kaell A. Effects of Writing About
Stressful Experiences on Symptom Reduction in Patients With Asthma or
Rheumatoid Arthritis: A Randomized Trial. JAMA. 1999;281(14):1304-1309. doi:10.1001/jama.281.14.1304.
• Staff, Mayo Clinic. "Definition." Mayo Clinic. Mayo Foundation for Medical
Education and Research, 02 Nov. 2011. Web. 20 Nov. 2012.
<http://www.mayoclinic.com/health/rheumatoid-arthritis/DS00020>.
• "Raynaud's Phenomenon." PubMed Health. U.S. National Library of
Medicine, 28 June 2011. Web. 20 Nov. 2012.
<http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001449/>.
• "Rheumatoid Arthritis Prognosis." Rheumatoid Arthritis Prognosis. N.p., n.d. Web. 20 Nov. 2012. <http://www.newsmedical.net/health/Rheumatoid-Arthritis-Prognosis.aspx>.
• "WebMD Rheumatoid Arthritis Guide - Better Information for Better
Health." WebMD. WebMD, n.d. Web. 20 Nov. 2012.
<http://www.webmd.com/rheumatoid-arthritis/guide/default.htm>.