Rheumatoid arthritis (RA) is a chronic symmetrical polyarthritis affecting mainly the peripheral small joints associated with some constitutional symptoms.
Age- Though it is seen in some children, it has increasing prevalence with increasing age up to the seventh decade and most often it starts between the ages of 30 & 40 years.
Sex-It is two or three times more common in women than men. In young adults with RA, females have a worse prognosis than males.
Cause-The cause of the disease remains unknown. An infectious agent, perhaps viral, is suspected to be the initiating factor. The process by which an infectious agent might cause chronic inflammatory arthritis with a characteristic distribution also remains unknown. Many immunological disturbances are noted in RA & it is considered to be an autoimmune disease.
(1) There is an increased incidence in those with a family history of the disease.
(2) A genetic predisposition may also be a factor. An association with HLA-DR4 has been noted in many populations, but not all. In some populations, HLA-DR1 is found in the majority of HLA-DR4 negative patients particularly in Indians & Israelis.
(3) Environmental factors are also supposed to play a role in the etiology of the disease.
(4) Smoking may also act as a risk factor for RA in persons expressing the susceptibility allele.
Pathology- Rheumatoid Arthritis is a disease of the synovium which passes through an inflammatory process followed by proliferation. The chronic inflammatory reaction causes infiltration of the synovium with lymphocytes, plasma cells & macrophages. The synovium then undergoes proliferation with growth over the surface of the cartilage.
Onset- Usually gradual, sometimes acute, especially in the elderly when it is sometimes called ‘explosive RA’.
(1) Joint pain-The pain is worst on waking in the morning which may improve with activity. Pain at night may cause a disturbed sleep.
(2) Morning stiffness-It often lasts for several hours & with progress of the disease becomes very prominent.
(3) Swelling – Gradually swelling of the small joints of fingers & toes, commonly the former is seen due to soft tissue swelling caused by effusion or synovial proliferation. The swelling starts with one joint, then another joint is involved and ultimately systemic swelling of joints is seen. Bigger joints like wrist, elbow & ankle are usually seen to be involved but shoulder, hip & spinal joints are rarely involved.
(4) Warmth-The joints are hot to feel.
(5) Tenderness- The joints are tender on pressure or movement.
(6) Formation of nodules- Presence of subcutaneous nodules is found almost invariably in individuals with circulating rheumatoid factor. They vary in size and consistency and are rarely symptomatic. Though they can develop anywhere, they are mostly found on periarticular structures, extensor surfaces & over areas subjected to mechanical pressure. Common sites of development are olecranon bursa, proximal ulna, Achilles tendon, and the occiput.
(7) Limitation of movement- Movement is restricted with muscle wasting around the affected joints.
(8) Deformities- Deformities may occur in the advanced stage of the disease.
(1) Rheumatoid factors- Rheumatoid factors which are autoantibodies may be found in more than two-thirds of adults with the disease. But as rheumatoid factor is also found in a small percentage of normal population, its presence is not specific for RA.
(2) Routine Blood Tests- Anaemia is a routine finding in almost all cases of rheumatoid arthritis & is usually normochromic, normocytic in nature. It is proportional to the activity of the inflammatory process. There is thrombocytosis which correlates with the disease activity. The white blood cell count is usually normal, but a mild leukocytosis may be present. The erythrocyte sedimentation rate (ESR) and C-reactive protein level are elevated and usually both the elevations correlate with disease activity and the likelihood of progressive joint damage. Serum alkaline phosphatase may also be raised in some cases of active rheumatoid arthritis.
(3) X-ray- Early in the disease, radiographic evaluations of the affected joints are usually not helpful in establishing a diagnosis. Juxtaarticular osteopenia is the first radiographic finding to be seen. Loss of joint space indicating thinning of the cartilage may be there after the disease process has reached a certain level. The characteristic lesion is that of an erosion that appears as a mouse-bite on the surface of the affected bone. The primary value of radiography is to determine the extent of cartilage destruction and bone erosion produced by the disease as well as the response of the disease to the treatment.
Differential diagnosis-Rheumatoid arthritis is to be differentiated from osteoarthritis, psoriatic arthritis, ankylosing spondylitis, septic arthritis, sarcoidosis, systemic lupus erythematosus (SLE) etc
(1) Vascular System-Rheumatoid vasculitis may be seen in patients with severe RA and high titers of circulating rheumatoid factor, usually in limited forms & especially in the whites. Widespread vasculitis is usually very rare.
(2) Respiratory System- RA especially in men may sometimes cause pleural disease, interstitial fibrosis, pleuropulmonary nodules, pneumonitis etc.
(3) Nervous System- RA usually has no direct action on the central nervous system but vasculitis in turn can cause peripheral neuropathy & mononeuritis multiplex. Moreover, nerve entrapment secondary to proliferative synovitis or joint deformities may produce neuropathies of median, ulnar, radial or anterior tibial nerves.
(4) Eye- Episcleritis & scleritis may be seen in some patients with long standing RA with nodules.
[A] Physical therapy- Physical therapy such as heat & ultrasound is used to decrease joint stiffness & relieve pain. An exercise programme should be fixed for preserving the functional abilities of the patient giving special stress to put all joints through their full arc of motion to maintain this range. Special importance should be given on aerobic exercise.
Relaxation techniques should be practised.
[B] Occupational therapy- Occupational therapy, after proper evaluation of the patient, aims in engaging the patient in modified techniques for performing activities of daily living.
[C] Homeopathic therapy- As no medicine is ideal, it is important to assess the patient’s response so that the most effective regimen is adopted. After proper evaluation, the suitable one is selected from the following homeopathic medicines-
(1) Arnica- This remedy may be used in patients of RA with chronic arthritis associated with a feeling of bruising & soreness, the pain being increased on movement.
(2) Bryonia- This remedy may be used in patients of RA for stiffness & inflammation with tearing or throbbing pain, the pain being increased on movement.
(3) Ledum palustre- This remedy may be used in patients of RA with initial involvement of lower joints which then gradually extends to upper ones
(4) Pulsatilla- This remedy may be used in patients of RA with flare-ups from one place to another.
(5) Calcarea carbonica (Calc.carb)- This remedy may be used in patients of RA with involvement mainly of the knees & hands, especially where nodes have already developed around the joints.
(6) Causticum- This remedy may be used in patients of RA with involvement mainly of the hands & fingers, especially with muscle weakness & contractures.
(7) Calcarea fluorica- This remedy may be used in patients of RA with swollen & hard joints, especially where nodes or deformities have already developed.
(8) Rhus toxicodendron (Rhus.tox)- Rhus.tox may be advised for patients of RA with pain & stiffness which is worse in the morning & improves with continued movement.
(9) Ruta graveolens (Ruta)- Ruta may be advised for patients of RA with deep affection or damage of tendons & capsules of the joints.
The medicine of choice & the potency & frequency of dosage as well as duration of treatment varies with the demand of the symptoms along with severity of the condition & the type of the individual। Lower potency is to be used at the beginning। A single dose is to be used first। If there is response, no second dose should be taken until there is cessation of further improvement। But if there is no response after the first dose a second dose should be taken after a gap of 2 or 3 days. If desired effect is still not noticed, it is better to switch over to a new medicine. Sometimes multiple dosages of the medicine of choice are to be used a day, the frequency is then gradually reduced according to the improvement of the condition, but have to be continued a few days even after the desired effect.
Besides the above mentioned medicines, Ferrum Metallicum may be used to combat the anemia that occurs in रा
(1) Intake of a low-protein, high carbohydrate diet with minimization of foods of animal origin.
(2) Elimination of milk & milk products from diet.
(3) Avoidance of polyunsaturated vegetable oils.
(4) Increased intake of omega-3 fatty acids.
(5) Reduction in intake of coffee & tobacco.
Prognosis- Despite full treatment & all the precautions to be taken, a few percentages of patients become severely disabled. The more the number of joints is involved, the poorer the prognosis is. Women & whites have a relatively poorer prognosis. Smoking has a detrimental effect on the course of the disease. Life expectancy may be decreased in some individuals due to associated heart disease, infection etc.
But in every case, a doctor should be consulted.