Diagnosis

The diagnosis of rheumatoid arthritis can be very difficult, especially in the earlier stages when the symptoms are morning stiffness or achy joints. There is no one test that is used to diagnose RA, it is a combination of things. The diagnosis comes usually after a history and physical, in addition to some lab tests and studies. Following are the clinical features that are present for a RA diagnosis:

1. Inflammatory arthritis involving three or more joints
2. Positive rheumatoid factor and/or anti-citrullinated peptide/protein antibody
3. Elevated levels of C-reactive protein (CRP) or the erythrocyte sedimentation rate (ESR)
4. Diseases with similar clinical features have been excluded, particularly psoriatic arthritis, acute viral polyarthritis, polyarticular gout or calcium pyrophosphate deposition disease, and systemic lupus erythematous.
5. The duration of symptoms of more than six weeks

The classification of RA was updated in 2010, which includes scoring on multiple domains. You can see the full explanation at this link: http://www.rheumatology.org/practice/clinical/classification/ra/ra_2010.asp

The differential diagnosis includes a variety of diseases, including:

•    Viral polyarthritis
•      Systemic rheumatic disease such as lupus
•      Palindromic rheumatism
•      Hypermobility syndrome and fibromyalgia
•      Reactive arthritis and arthritis of IBD
•      Lyme arthritis
•      Psoriatic arthritis
•       Polymyalgia rheumatica
•      Osteoarthritis

The recommendation is to suspect in RA in an adult who presents with inflammatory polyarthritis, the evaluation should include a detailed history and physical, along with the labs that help confirm the diagnosis.

As you can see from the list of differential diagnoses above, it is difficult and certainly very hard to live with the possibility of any of these diseases. Receiving a diagnosis can be helpful to focus attention on treatment, but RA is not a disease that can be cured. It is a difficult chronic disease to have that will have many uncertainty and unknowns. Healthcare providers are available to help with any step of the process, but utilizing your support system during difficult times can be very important.

Resources: 

1. http://www.rheumatology.org/practice/clinical/classification/ra/ra_2010.asp

2. http://www-uptodate-com.offcampus.lib.washington.edu/contents/diagnosis-and-differential-diagnosis-of-rheumatoid-arthritis?source=search_result&search=rheumatoid+arthritis&selectedTitle=1~150

Pathophysiology of Rheumatoid Arthritis... or my best try at it

The pathophysiology of rheumatoid arthritis is complicated so I will make this as simple and clear as possible.

The cause of rheumatoid arthritis is still unknown, but there are a few things that we do know. There are both genetic and environmental components. A widely accepted theory says that it begins with a reaction to an antigen, which is known as a trigger. What the antigen is remains unknown, and the best we have in terms of research is identifying some risk factors for RA. Here are a few of the research findings:

• Women who take oral contraceptives have a lower risk of RA compared to those who never took them or those who previously took them
• Viral infections are a potential trigger (Epstein-Barr, parvovirus)
• Bacterial infections (Proteus and Mycoplasma)
• Heat-shock

The immune response causes formation of an antibody called IgG. The body responds with autoantibodies against IgG, and these are called rheumatoid factor (RF). Then, RF plus IgG form complexes, and these deposit in the body. One place they deposit is in synovial membranes, leading to an inflammatory response. Lots goes on during an inflammatory response (refer to VIDEO), and portions of it are very harmful. The disease passes through 4 stages, listed in the table below.

Lewis, Heitkemper. Medical-Surgical Nursing, 8th Edition. 

Additionally, here are some pictures of damage to joints from RA.

Lewis, Heitkemper. Medical-Surgical Nursing, 8th Edition. 

The beginning of the disease process is not very obvious. Arthritic complaints will come after symptoms like fatigue, anorexia, weight loss and generalized stiffness. Joint manifestations include pain, stiffness, limitation of movement, and signs of inflammation. What is special to RA compared to osteoarthritis is that the joint problems will occur bilaterally, or on both sides of the body, and start with small joints in the hands and feet (though other larger joints may also be involved). Joints become more and more painful, tender, especially with movement. Eventually there will be deformity of joints, leading to disability.

 Resources:

1. Lewis, Heitkemper. Medical-Surgical Nursing, 8th Edition. 

2. Overview of Epidemiology, Pathophysiology, and Diagnosis of Rheumatoid Arthritis - See more at: http://www.ajmc.com/publications/supplement/2012/ace006_12dec_ra/ace006_12dec_gibofsky_s295to302/1#sthash.SeynEPpq.dpuf

Epidemiology of RA

I have many times mixed up different types of arthritis, rheumatoid arthritis, osteoarthritis, and regular arthritis. Generally I think of arthritis as effecting older adults, and thus think of it as a disease of aging. After so many years of using our bodies and especially our joints, they start to have problems, and that problem is arthritis. This, I found, is not true. 

There are many kinds of arthritis, listed below, with an image of the prevalence of some:

• Childhood arthritis (Juvenile Idiopathic Arthritis (JIA) is a kind of childhood arthritis)
• Fibromyalgia
• General
• Gout
• Osteoarthritis
• Rheumatoid arthritis (RA)
• Systemic lupus erythematosus
• Psoriatic arthritis
• Polymyalgia rheumatica

       

1. Clough JD. The Cleveland Clinic Guide to Arthritis. New York, NY: Kaplan Publishing; 2009.

3. Lawrence RC, Felson DT, Helmick CG, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II. Arthritis Rheum 2008;58:26-35.

4. Gelfand JM, Gladman DD, Mease PJ, et al. Epidemiology of psoriatic arthritis in the population of the United States. J Am Acad Dermatol 2005;53:573.

 5. Espinosa M, Gottlieb BS. Juvenile Idiopathic Arthritis. Pediatr Rev 2012;33:303-13.

6. http://rheumatoidarthritis.net/types-of-arthritis/

We can see the different kinds ranging from children to adults. Rheumatoid arthritis is seen in all ages and in both genders, and is most common in older adult women. Here is some additional epidemiological data on Rheumatoid arthritis:

• Annual incidence: 40/100,000 diagnosed each year
• Disease prevalence in Caucasians is 1%, varies in different populations between 0.1% and 5%.
• Women effected 2-3 times more often than men
• Peak onset 50-75
• Prevalence in females over the age of 65 is 5%
• Significant reductions in employment, productivity, and function with attendant negative economic impact
• Lifetime risk of RA in adults is 3.6% for women, 1.7 for men

Gender differences:

• It is perhaps in part due to the stimulatory effects of estrogen on the immune system, seen in increased risk in nulliparous women, remission of RA during the third trimester in pregnancy, and decreased testosterone levels in men with RA.
• It is unclear if in men changes in hormones are a result of chronic inflammation or if abnormal estrogen and testosterone levels are a risk factor for developing RA

You may ask how this data is gathered. You would be very smart, because I didn’t, and the answer is very interesting. The most current data on RA comes from the Rochester Epidemiological Project. They conduct population-based research in Olmsted County, Minnesota in conjunction with the Mayo Clinic (see, I’m sounding smart again!) With a high percentage of residents in the county participating, they can do statistical analysis to find the most accurate data to date on many diseases and outcomes. This is an 8 min video about the project.

Rochester Epidemiological Project:

Rheumatoid Arthritis can cause disability in those it effects, and because it is still unknown what causes it, there is no way to prevent it. Next we will look at the pathophysiology and risk factors for RA.

Sources:

1.     http://www.cdc.gov/arthritis/basics/rheumatoid.htm

2.     http://www-uptodate-com.offcampus.lib.washington.edu/contents/epidemiology-of-risk-factors-for-and-possible-causes-of-rheumatoid-arthritis?source=search_result&search=rheumatoid+arthritis+epidemiology&selectedTitle=1~150

3.     http://rochesterproject.org/

What is Rheumatoid Arthritis?

Rheumatoid Arthritis (RA) has always been a confusing disease to me. When you ask about it, people start talking about autoimmunity, inflammation, cytokines, immunoglobulin’s, and synovial joints. These are all complicated processes of our bodies, so I just accepted it as something I wouldn’t understand. Until NOW! (I hope that sounded exciting!)

I am going to learn what I can about how to nurse patients and populations with Rheumatoid arthritis, and am going to teach as much as I can to you!

Ok, so you don’t understand rheumatoid arthritis? Let’s start with this short video from the Mayo Clinic (It makes me feel smart to use the Mayo Clinic, also you can use this website to diagnose any symptom you have as cancer!)   

Rheumatoid Arthritis (RA) is a chronic inflammatory autoimmune disease that attacks the lining of synovial joints, but can affect almost every system in the body. We will get into the details later. Diagnosis is done by history and physical, as well as lab tests (such as rheumatoid factor, C-reactive protein, and other inflammatory indicators). X-rays are not diagnostic in RA, but they can show some damage later in the disease. There are many medications that can decrease pain and disability that RA can cause.

So let’s dive into a few of the ideas they talk about here.

Autoimmunity: When your body attacks itself. Think about the American military, and imagine that the strongest branch of the army (and I don’t know a lot about the military so I don’t know what branch that is) decides they don’t want to defend America’s Democratic freedom, but rather want to defend mosquitos. Yes, mosquitos, the worst little bug on earth (a personal opinion). They begin to battle against the remaining military branches for a cause that is clearly questionable.

Inflammation: This is the process by which the body’s white blood cells and the substances they produce protect us from infection. In the case of RA, it is protection the body from itself. The substances produced by white blood cells also attacks itself. So this is when they military branch gone rogue buys weapons and recruits other members.            

Chronic: chronic diseases are ones that persist for long periods of time, and the damage the disease causes also progresses over time.

Synovial joints: joints that have synovial fluid, such as the knee, fingers, elbow, wrist, shoulder, and many more. Those most effected by RA are the small joints in the hands and feet, though other larger joints can be involved.

This is a fairly long but entertaining and good review of the immune system: