Rheumatic

Diseases

Rheumatoid Arthritis

The prevalence of rheumatoid arthritis in most

Caucasian populations approaches 1% among
adults 18 and over and increases with age,
approaching 2% and 5% in men and women,
respectively, by age 65

The incidence also increases with age, peaking

between the 4th and 6th decades

The annual incidence for all adults has been

estimated at 67 per 100,000

Rheumatoid Arthritis

Both prevalence and incidence are 2-3 times

greater in women than in men

African Americans and native Japanese and

Chinese have a lower prevalence than Caucasians

Several North American Native tribes have a high

prevalence

Genetic factors have an important role in the

susceptibility to rheumatoid arthritis

Rheumatoid Arthritis

Rheumatoid arthritis is an autoimmune disease in

which the normal immune response is directed
against an individual's own tissue, including the
joints, tendons, and bones, resulting in
inflammation and destruction of these tissues

The cause of rheumatoid arthritis is not known

Investigating possibilities of a foreign antigen, such as a virus

Rheumatoid Arthritis

Description

Morning stiffness
Arthritis of 3 or more joints
Arthritis of hand joints
Symmetric arthritis
Rheumatoid nodules
Serum rheumatoid factor
Radiographic changes

A person shall be said to

have rheumatoid
arthritis if he or she has
satisfied 4 of 7 criteria,
with criteria 1-4 present
for at least 6 weeks

Rheumatoid Arthritis

Rheumatoid arthritis usually has a slow, insidious

onset over weeks to months

About 15-20% of individuals have a more rapid

onset that develops over days to weeks

About 8-15% actually have acute onset of

symptoms that develop over days

Functional Presentation and

Disability of RA

In the initial stages of each joint

involvement, there is warmth, pain, and
redness, with corresponding decrease of
range of motion of the affected joint

Progression of the disease results in

reducible and later fixed deformities

Muscle weakness and atrophy develop early

in the course of the disease in many people

Complications of Rheumatoid
Arthritis
Complications
Carpal

include:

tunnel syndrome, Bakers cyst, vasculitis,

subcutaneous nodules, Sjgrens syndrome,
peripheral neuropathy, cardiac and pulmonary
involvement, Feltys syndrome, and anemia

Treatment and Prognosis

Medications

NSAIDS - Usually, only one such NSAID should be given at a

time. Can be titrated every two weeks until max dosage or
response is obtained. Should try for at least 2 to 3 wk before
assuming inefficacy.
Slow acting - Generally, if pain and swelling persist after 2 to 4
mo of disease despite treatment with aspirin or other NSAIDs,
can add a slow-acting or potentially disease-modifying drug
(eg, gold, hydroxychloroquine, sulfasalazine, penicillamine)
Methotrexate, an immunosuppressive drug is now increasingly
also used very early as one of the second-line potentially
disease-modifying drugs.

Medications

Corticosteroids offer the most effective short-term relief as

an anti-inflammatory drugs. Long-term though improvement
diminishes. Corticosteroids do not predictably prevent the
progression of joint destruction, although a recent report
suggested that they may slow erosions. Severe rebound
follows the withdrawal of corticosteroids in active disease.

Immunosuppressive drugs These drugs (eg, methotrexate,

azathioprine, cyclosporine) are increasingly used in
management of severe, active RA. They can suppress
inflammation and may allow reduction of corticosteroid
doses. Major side effects can occur, including liver disease,
pneumonitis, bone marrow suppression, and, after long-term
use of azathioprine, malignancy.

Treatment
Surgery:

video

Removal

of inflamed
synovium
Arthroplasty
Physical

therapy

Vocational Implications of
Rheumatoid Arthritis

Need to make frequent assessments of the persons

functional ability as the disease progresses in order to
provide realistic goals and support

Motor coordination, finger and hand dexterity, and eye-handfoot coordination are adversely affected

Vocational goals dependent on fine, dexterous, or

coordinated movement of the hand are not ideal

Vocational Implications of
Rheumatoid Arthritis

Most jobs requiring medium to heavy lifting are

not desirable

Activities such as climbing, balancing, stooping,

kneeling, standing, or walking are hampered

Extremes of weather or abrupt changes in

temperature should be avoided indoor controlled
climate better

Lupus

Systemic lupus erythematosus

(also called SLE, or lupus) is an
autoimmune disease of the
body's connective tissues.
Autoimmune means that the
immune system attacks the
tissues of the body. In SLE, the
immune system primarily
attacks parts of the cell
nucleus.

SLE affects tissues throughout

the body. Five times as many
women as men get SLE. Most
people develop the disease
between the ages of 15 and 40,
although it can show up at any
age.

Lupus - Anatomy
SLE causes tissue inflammation
and blood vessel problems
pretty much anywhere in the
body. SLE particularly affects
the kidneys. The tissues of the
kidneys, including the blood
vessels and the surrounding
membrane, become inflamed
(swollen), and deposits of
chemicals produced by the body
form in the kidneys. These
changes make it impossible for
the kidneys to function
normally.
Note the granular appearance of
the cortex of these lupus
affected kidneys its across the
entire surface of both kidneys
suggesting a chronic condition.

Lupus Anatomy (cont).

The inflammation of SLE can be seen in the
lining, covering, and muscles of the heart. The
heart can be affected even if you are not feeling
any heart symptoms. The most common
problem is bumps and swelling of the
endocardium, which is the lining membrane of
the heart chambers and valves.
SLE also causes inflammation and breakdown in
the skin. Rashes can appear anywhere, but the
most common spot is across the cheeks and
nose.
People with SLE are very sensitive to sunlight.
Being in the sun for even a short time can
cause a painful rash. Some people with SLE can
even get a rash from fluorescent lights.
Rashes caused by SLE are red, itchy, and
painful. The most typical SLE rash is called the
butterfly rash, which appears on the face
particularly the cheeks and across the nose.
SLE can also causes hair loss. The hair usually
grows back once the disease is under control.

Lupus Anatomy (joints)

Almost everyone with SLE has

joint pain or inflammation. Any
joint can be affected, but the
most common spots are the
hands, wrists, and knees.
Usually the same joints on both
sides of the body are affected.
The pain can come and go, or
it can be long lasting. The soft
tissues around the joints are
often swollen, but there is
usually no excess fluid in the
joint. Many SLE patients
describe muscle pain and
weakness, and the muscle
tissue can swell.

Lupus Anatomy
Lupus can also affect the nervous system
causing headaches, seizures, and organic
brain syndrome.
It can cause anemia due to blood loss or
from the kidney disease (it does not directly
effect the red blood cells).
Pregnancy: the chances of miscarriage,
premature birth, and death of the baby in
the uterus are high.

Seronegative
Spondyloarthropathy

Consist of a group of related disorders

that include Reiter's syndrome,
ankylosing spondylitis, psoriatic
arthritis, and arthritis in association
with inflammatory bowel disease
Occurs more age at diagnosis in the
third decade and a peak commonly
among young men, with a mean
incidence between ages 25 and 34
The prevalence appears to be about
1%
The male-to-female ratio approaches
4 to 1 among adult Caucasians
Genetic factors play an important role
in the susceptibility to each disease

Seronegative
Spondyloarthropathy

The cause is unclear, but there is strong

evidence that the initial event involved
interaction between genetic factors and
environment factors, particularly bacterial
infections

Reiters syndrome may follow a wide range

of GI infections

Bowel inflammation has been implicated in

the pathogenesis of endemic Reiters
syndrome, psoriatic arthritis, and ankylosing
spondylitis

Seronegative
Spondyloarthropathy

The spondyloarthropathies share certain common features,

including the absence of serum rheumatoid factor, an
oligoarthritis commonly involving large joints in the lower
extremities, frequent involvement of the axial skeleton,
familial clustering, and linkage to HLA-B27

These disorders are characterized by inflammation at sites of

attachment of ligament, tendon, fascia, or joint capsule to
bone (enthesopathy)

Sacroiliitis

Sacroiliitis is an
inflammation of the
sacroiliac joint.

Symptoms usually include a

fever and reduced range of
motion.

Picture on the bottom

right shows an individual
with sacroiliitis and
Ankylosing Spondylitis.
The arrows point to the
inflamed and narrowed SI
joints. They are white
due to bony sclerosis
around the joints

Ankylosing Spondylitis

Chronic disease that primarily

affects the spine and may lead
to stiffness of the back. The
joints and ligaments that
normally permit the back to
move become inflamed. The
joints and bones may grow
(fuse) together.
The effects are inflammation
and chronic pain and stiffness in
the lower back that usually
starts where the lower spine is
joined to the pelvis or hip.
Diagnosis is made through: (a)
medical history including
symptoms, (b) X-rays, and
possibly (c) blood tests for HLAB27 gene

Ankylosing Spondylitis

Treatment options:

With early diagnosis and

treatment, pain and stiffness
can be controlled and may
reduce fusing. In women, AS
is usually mild and hard to
diagnose.
Exercise
Medications: NSAIDs,
Sulfasalazine
Posture management
Self-help aids
Surgery

Reiter's Syndrome

Arthritis that produces pain, swelling, redness and

heat in the joints. It can affect the spine and
commonly involves the joints of the spine and
sacroiliac joints. It can also affect many other
parts of the body such as arms and legs. Main
characteristic features are inflammation of the
joints, urinary tract, eyes, and ulceration of skin
and mouth.

The symptoms are fever, weight loss, skin rash,

inflammation, sores, and pain.

Reiter's Syndrome

Reiter's often begins following

inflammation of the intestinal
or urinary tract. It sets off a
disease process involving the
joints, eyes, urinary tract, and
skin. Many people have
periodic attacks that last from
three to six months. Some
people have repeated attacks,
which are usually followed by
symptom-free periods.

Diagnosis is made through a

physical exam, skin lesions,
and a test for the HLA-B27
gene

Reiter's Syndrome
For

different parts of the body,

different treatments are used:

Medications:

NSAIDs, antibiotics, topical skin

medications
Eye drops
Joint protection
Various

symptoms are treated by

healthcare specialists

Psoriatic Arthritis

Causes pain and swelling in

some joints and scaly skin
patches on some areas of the
body.
The symptoms are:

About 95% of those with psoriatic

arthritis have swelling in joints outside
the spine, and more than 80% of
people with psoriatic arthritis have
nail lesions. The course of psoriatic
arthritis varies, with most doing
reasonably well.
Silver or grey scaly spots on the scalp,
elbows, knees and/or lower end of the
spine.
Pitting of fingernails/toenails
Pain and swelling in one or more
joints
Swelling of fingers/toes that gives
them a "sausage" appearance.

Psoriatic Arthritis
Diagnosis may involve X-rays, blood
tests, and joint fluid tests.
Treatment options:

Skin

care
Light treatment (UVB or PUVA)
Corrective cosmetics
Medications: glucocorticoids, NSAIDs, DMARDs
(disease-modifying anti-rheumatic drugs)
Exercise
Rest
Heat and cold
Splints
Surgery (rarely)

Inflammatory Bowel Disease

IBD consists of two

separate diseases that
cause inflammation of
the bowel and can
cause arthritis or
inflammation in joints:

Crohn's Disease involves

inflammation of the colon or
small intestines.

Ulcerative Colitis is
characterized by ulcers and
inflammation of the lining of
the colon.

Inflammatory Bowel Disease

The amount of the bowel disease usually

influences the severity of arthritis symptoms.
Other areas of the body affected by inflammatory
bowel disease include ankles, knees, bowel, liver,
digestive tract, skin, eyes, spine, and hips.
Treatment options:

Diet
Exercise
Medication: Corticosteroids, Immunosuppressants, NSAIDs,
Sulfasalazine
Surgery

Functional Presentation and Disability of

the Spondylarthropathies

When the axial skeleton is

involved, the initial symptom is
morning stiffness and lower back
pain
As the disease worsens, there is
progressive diminution of motion
of the spine
Eventually, the sacroiliac joints,
lumbar, thoracic, and cervical
spine become fused
At this stage, the spine is no
longer painful, but the person has
lost all ability to flex or rotate the
spine and generally develops a
hunched-over posture with fused
flexion of the cervical spine and
flexion contracture of the hips to
compensate for the loss of the
lordosis curvature in the lumbar
spine

Functional Presentation and Disability of

the Spondylarthropathies
The joints where the ribs attach to the
vertebrae are also affected, and chest
expansion and lung volume are decreased
Frequently, peripheral joints are involved,
and the pattern is usually asymmetric
oligoarthritis involving primarily the large or
medium joints, including the hips, knees,
and ankles
Rarely are smaller joints or the joints in the
upper extremities involved
Loss of motion of the spine or pain in the
spine with motion generally affects a
person's mobility

Functional Presentation and Disability of

the Spondylarthropathies

Walking remains unimpaired unless the hips and

knees are affected

Frequent stooping and bending become

impossible

A person with ankylosing spondylitis typically is

able to continue vocational activity despite
progressive stiffness, unless it requires significant
back mobility or physical labor

Vocational Implications of the

Spondylarthropathies

The person should be considered for vocational

or professional education as resources and
interests dictate
A stiff back will limit the persons rotation and
flexion so that overall dexterity may be
affected
Tasks that require reaching or bending will be
difficult and lifting over 10-15 pounds may
cause increased back pain
Climbing and balancing skills, stooping, and
kneeling may be tolerated initially but become
difficult as the disease worsens
Need time to stretch spine frequently

Degenerative Joint Disease

(Osteoarthritis)

Most common rheumatic

disease and is characterized by
progressive loss of cartilage and
reactive changes at the margins
of the joint and in the
subchondral bone
The disease usually begins in
ones 40s
Prevalence increases with age
and the disease becomes
almost universal in individuals
aged 65 and older
Primarily affects weight-bearing
joints such as the knees, hips,
and lumbrosacral spine

Degenerative Joint Disease

Cause is unclear
Considered to be a wear and tear arthritis
and is thought to occur as a consequence of
some earlier damage or overuse of the joint
Obesity is frequently associated with it
Genetic factors play a role in the
development that is sex-influenced and
dominant in females, resulting in an
incidence 10 times greater than in men
The final outcome is full-thickness loss of
cartilage down to bone

Degenerative Joint Disease

In early disease, pain

occurs only after joint
use and is relieved by
rest

As the disease
progresses, pain
occurs with minimal
motion or even at rest

Nocturnal pain is
commonly associated
with severe disease

Functional Limitations and

Degenerative Joint Disease
Limited

use of the involved joint

Walking

and transfer activities may be

impaired

Generally,

ADLs will not be

significantly impaired

Treatment and Prognosis of

Degenerative Joint Disease
Meds
Early PT/exercises
Heat/cold therapy
Joint protection
Surgery

Osteoarthritis is a slowly progressive

disease
The eventual outcome is complete
destruction of the joint, and ultimately
surgical intervention is required

Vocational Implications and

Degenerative Joint Disease
Can continue in present job unless it
requires dexterous or heavy use of the
involved joint
Heavy lifting should be avoided
Light to medium work should be possible
Climbing, balancing skills, stooping, and
kneeling may be impaired
Returning to work after surgery requires
intensive postop rehab and continued
exercise to maintain muscle strength
Most individuals are able to sustain gainful
employment and a normal level of activity

Additional Resources and

Information from the Web
American

College of Rheumatology (
www.rheumatology.org)
National Institute of Arthritis and Musculoskeletal
and Skin Diseases (www.niams.nih.gov)
Arthritis Foundation (www.arthritis.org)
Arthritis National Research Foundation (
www.curearthritis.org)
Info on Juvenile RA (
http://www.nlm.nih.gov/medlineplus/juvenilerheum
atoidarthritis.html
)
Spondylitis Association of America (
www.spondylitis.org)
Arthritis.com: Latest Arthritis Information &
Community (www.arthritis.com)