Introduction

Rheumatoid arthritis is a chronic condition that is characterized by persistent inflammation of a number of joints. Over a prolonged period of time, this inflammation results in irreversible joint damage. Although its cause is unknown, it is usually thought to be auto-immune disorder in which the immune system starts to attack the body’s own tissue. Rheumatoid Arthritis has a world-wide distribution and affects 0.5-1%, with a female preponderance, of the population( Kumar & Clarck’s, Clinical Medicine).

The disease, causes disability and mortality and can happen from childhood to late old age. The most common age onset is between 30 and 50 years.

Gender, genetics and family are the most important risk factors, others include heavy smoking, obesity and a history of blood transfusions.

Gender: This predominance of women with rheumatoid arthritis is mainly due to the fact that diminished immunity is a significant factor. There is a great risk that a woman will develop rheumatoid arthritis at the menopause because her ovaries will have to stopped producing hormones oestrogen and progesterone. Women before the menopause are affected three times more than men.

Genetics: Genes play a significant role in the development of rheumatoid arthritis, factors are estimated to account for up to 60% of disease susceptibility.

The condition is strongly related to the presence of a protein on the surface of white blood cells called HLA-DR4.

Family:

A consultant rheumatologist will be able to treat rheumatoid arthritis, they are hospital-based doctors with specialist training in arthritis and other diseases that affect the joints. They are capable to interpret tests and may suggest more, discuss treatments, prescribe drugs, or make a referral for surgery, if it is required. If the patient undergo surgery, the rheumatologist will manage the rehabilitation by referring the patient to physiotherapists a occupational therapists.

Assessment

Rheumatoid arthritis starts in different ways. Usually, it starts slowly, with intermittent pain and swelling in some joints, especially in the fingers, wrist, and feet. I almost 20 per cent of all cases, the disease start very suddenly: one day the individual is normal and the next many joints are painful, swollen, and stiff. In some people the disease starts in less typical ways. For example, it may involve only a single joint. In others, the disease comes and goes repeatedly, often over several years, before becoming persistent. Occasionally, it starts with pain stiffness around the shoulders and so mimics a condition called polymyalgia rheumatica.

There are many key symptoms that doctors look for when they are trying to identify any type of arthritis. Sometimes these symptoms are accompanied by other features, such as loss of function and a sensation of unbearable tiredness or general symptoms that affect the body as a whole.

Symptoms:

1. Pain: Pain in a joint maybe mild, moderate, or severe, and is usually chronic.
3. Inflammation: Symptom of various type of inflammatory arthritis.
5. Swelling: Either the lining of the joint swells or fluid flows into the joint. Swelling usually indicates inflammatory arthritis.
7. Stiffness: Morning stiffness that lasts for over an hour usually indicates a form of arthritis.

There are also a list of physical examinations that could be required in order to diagnose rheumatoid arthritis:

• Visual identification of the swelling, redness and structural deformity of the joints, which is a characteristic of rheumatoid arthritis.
• Palpation of the joints, which helps to distinguish which type of arthritis.
• Pain when moving the joints.

Examinations rarely helps the diagnosis, but it does help evaluate the severity and can pinpoint problems with specific joints. As the rheumatoid arthritis affects the joints causing pain, it will limit the patient’s ability to move. Household chores, writing, picking up things from the floor and personal care are examples of daily activities that may be affected by rheumatoid arthritis. In that way, people with rheumatoid arthritis need to make changes in their lifestyle, I order to protect their joints and to know how to cope with flare-ups and stress.

Investigations:

1. X-rays: They show joint damage and provide an assessment of its severity and progression. In rheumatoid arthritis, they may reveal loss of bone, which means the presence of erosions nest to the margins of joints. Also, helps the doctor decide whether joint replacement surgery is needed.
3. Imaging Techniques:
4. • Computerized tomography (CT).
   • Magnetic resonance imaging (MRI).
   • Ultrasound.
   • Isotope bone scans.
   • Dual- energy X-ray absorptiometry (DEXA).

All these imaging techniques can provide a more enhanced image of bones and joints than X-rays Some, particularly MRI and ultrasound, can show inflammation and soft-tissue swelling.

Blood test is also very important to confirm the diagnosis of rheumatoid arthritis, they can reveal specific chemicals that are markers of this disease, such as auto-antibodies that react with specific proteins in the body. Blood tests also reveal the level of haemoglobin, which may indicate anaemia or infection. Also, it measures the level of enzymes to check if the liver is working properly, kidney function can be checked as well by measuring the level of waste products. C-reactive protein (CRP) levels is checked to find out any acute inflammation. Also, erythrocyte sedimentation rate(ESR), to assess the body’s response to a damaging situation, such as inflammation or infection.

Orthopaedic surgeons have a number of joint surgeries available as part of a treatment, they all aim to relieve pain or prolong the life of a joint. The main types of joint surgery available include washing out, synovectomy, realignment, fusion, and total replacement.

Diagnosis.

Diagnosing rheumatoid arthritis requires a team effort involving the patient and several types of health care professionals, such as general practitioner, internist and rheumatologist. The diagnose of rheumatoid arthritis in its early stages can be difficult, as there is no single test for the disease. In addition, symptoms differ from person to person and can be more severe in some people than in others. Also, symptoms can be similar

Science

Rheumatoid arthritis is an autoimmune disorder that the immune system attacks his or her own body tissue. However there is not a exact cause yet, there still research on many things that could cause rheumatoid arthritis. Such as genes, environment and hormones.

It can affect various systems in the body, such as: cardiovascular, immune, respiratory, nervous, integumentary, endocrine, skeletal and excretory. Also soft tissue surrounding joins, lungs, skin, heart, eyes, kidneys, spleen, lymph nodes, and blood.

The signs that is shown in rheumatoid arthritis are caused by inflamed synovial membrane of one or more joints, causing pain and swelling. When inflammation spreads to the synovial sheats that protects the tendons, there is progressive and usually irreversible damage to joints. Bony swellings appear and deformity develops as the damage joints begin to fail. Muscles weaken due to lack of use and from the effects of generalized inflammation

Prognosis

Research on rheumatoid arthritis has massively improved the knowledge of the immune system and genetics. Studies to understand the development of the disease may help finding new therapies that would improve the disease at early stage ( inflammatory process). Although there is an increased in knowledge about the cause of rheumatoid arthritis, the prognosis still very poor. Two factors to consider before giving the prognosis are:

How early the disease was diagnosed and how old was the patient when first diagnosed.

Research studies suggest that conditions such as heart diseases, osteoporosis, stroke, and infections may be more likely. One reason may be that people with rheumatoid arthritis are not able to exercise freely. In some cases, the drugs for rheumatoid arthritis can raise blood pressure or weaken the immune system, making infections more likely. About 10 to 20% of rheumatoid arthritis patients have sudden onset of the disease, followed by many years with no symptoms. This is considered a prolonged remission. (Carol & Richard Eustice, about.com guide).

Treatment

Current research shows that in the early days of the disease, NSAIDs (Non-steroidal Anti-inflammatory drugs) may provide some relief from the symptoms. However, they do not prevent progressive joint damage. Such damage is mainly treated with DMARDs (Disease-modifying-antirheumatic-drugs). They act slowly, taking several weeks or months to feel their effect. The rheumatologist will determine how long they should be taken as different people respond to individual DMARDs in different ways. If the disease do not respond to these, the patient may be considered for a new generation of drugs called biologic agents. They can help reduce inflammation and structural damage to the joints by blocking the action of cytokines, proteins of the body’s immune system that trigger inflammation during normal immune responses.

When the joints are damaged to the point where the pain cannot be controlled with drugs or the joint can barely move, the surgery may be the only answer. The surgeon will need to weigh up the risks and benefits before making a decision about surgery. Joint replacement, in particular, requires operating theatres equipped with ultraclean airflow systems to help maintain hygiene and reduce the risk of infection. Trained nursing staff, physiotherapists and occupational therapists are part of the multidisciplinary team working towards effective post-operative recovery and rehabilitation. There are a good number of professional involved to make any adjustment to the patient’s new lifestyle; occupational therapists can help patients to achieve personal, work, domestic, educational or leisure goals. Also, help to prevent or reduce the chance of loosing abilities in the future. A rheumatologist can refer the patient to a occupational therapist, who is specialised in solving problems with rheumatoid arthritis. Therefore, the specialist you be able to advice the patient on home adaptations.

The rheumatologist will always be involved in the patient’s care in every treatment stage, by prescribing the DMARDs, deciding about surgery, referring to a occupational therapist, physiotherapist or dietician.

Ethics

It is essential that the patient I fully aware of the treatment and if the surgery is offered as part of the treatment, the patient will have to be mentally active to understand the whole process of the joint replacement. There is no age limit as longer as the patient is understanding the procedure and the rehabilitation.

Bibliography

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