Rheumatoid Arthritis: Rheumatoid Arthritis October 11, 2011 Alex Farge Laura Morehouse Jessica Peterson Description of Rheumatoid Arthritis : Description of Rheumatoid Arthritis RA is a systemic, inflammatory disease which affects joints and can also affect the major organs of the body Eyes - Heart - Nervous System Skin - GI system - Blood Lungs - Kidneys - Can lead to fevers and fatigue 8 Most often involving the wrists, PIP, MCP, elbow, MTP and temporomandibular joints 2 Bilateral and symmetrical RA greatly affects the synovial joints in the body The immune system mistakenly attacks the synovial lining surrounding the joints leading to an inflammatory response. This response thickens the synovium by laying down fibroblasts and causes destruction of the cartilage and bone. The inflammation also leads to distention of the joint capsule causing a stretch to the surrounding ligaments and tendons leading to a decreased ability to support normal joint alignment. The result of this process is severe deformation. 2 Symptoms of RA: Symptoms of RA Symmetric polyarticular pain and swelling during the inflammatory stage Morning stiffness (lasting >2 hours) Malaise Fatigue Characterized by stages of exacerbation and remission 8 Incidence and Etiology: Incidence and Etiology Incidence RA affects 0.3-1% of the adult population occurring 2.5 times more in women as compared to men Average age of onset is 40-50 years old Etiology Unknown but likely multifactorial Genetics Exposure to unknown environmental factors 8 Diagnosis: Diagnosis American Rheumatism Association Diagnostic Criteria for R.A A diagnosis of RA requires 5 out of following symptoms to be present for > 6 weeks: - morning stiffness - pain on motion, or tenderness in at least one joint - swelling (soft tissue thickening or fluid, not bony overgrowth alone) in at least one joint - swelling of at least one other joint (any interval free of joint symptoms between the two joint) - poor mucin precipitate from synovial fluid - characteristic histologic changes in synovium - characteristic histologic changes in nodules 7 Prognosis: Prognosis 70% of patients participate independently in a regular life 1 Factors that indicate poor prognosis: Rheumatoid factor Number of joints affected Presence of extra-articular features Subcutaneous nodules Degree of physical disability at onset 4 Impact on Function: Impact on Function Decreased ability to complete ADLs and IADLs Especially activities requiring grip strength and finger dexterity including opening a jar, driving, buttoning a shirt, tying shoes, cutting food, etc 7 Role of Imagining in Diagnosis and Management of RA: Role of Imagining in Diagnosis and Management of RA Magnetic resonance (MR) imaging has been used by clinicians to visually detect bone erosion and active synovitis; this is seen before the changes are visible on conventional radiographs. MR imaging criterion shows excellent sensitivity and specificity in the diagnosis of early-stage RA. MR imaging should be used as a tool for evaluation in patients who are suspected of having early-stage RA. 6 Although MR is the best imaging modality for RA, it is time-consuming and expensive. “Axial and sagittal imaging should be performed on the basis of coronal images to correctly define pathologic changes. A multiplanar approach is especially useful for the distinction between erosions and pre-erosive changes and for the assessment of pannus. The protocol should include T1-weighted sequences without and with contrast material, a T2-weighted sequence, and a sequence suited for cartilage evaluation. Fat saturation techniques are useful in combination with T1-weighted contrast-enhanced and T2-weighted sequences. “ 7 T1 weight MRI : T1 weight MRI This image shows Increased enhancement bilaterally seen around the joints in the wrist, MCP joints , and PIP joints. Distention of joint capsules noted at PIPs and DIPs and soft tissue inflammation noted throughout all digits. 6 Standard Radiograph : Standard Radiograph Alignment: Erosions noted at MCPs, PIPs and DIPs causing irregularity of joint surface with subluxation of 5 th MCP. Severe ulnar drift at MCPs. Bone Density: Subchondral cysts and osteoporotic changes noted MCP involved greater than PIPs and DIPs. Reactive sclerosis of carpals . Cartilage: Decreased joint space throughout the entire hand. Soft Tissue: Joint capsule distention and soft tissue swelling throughout. 3 Biomechanical and Physical Impairments: Biomechanical and Physical Impairments As the joint surfaces are eroded and cartilage and bone is destroyed there is a change in the alignment especially at MCP joints. This change in alignment leads to muscular imbalances throughout the hand. Deficits would be noted in ROM, Strength, Endurance and Pain. 8 Questions?: Questions? How would you go about treatment of a patient with RA from the radiograph image if they are in an exacerbation stage? What would you look in the patient evaluation to determine if the exacerbation stage is over and the remission stage has started? References: References Dungee K. Rheumatoid Arthritis Prognosis: Introduction. http://rheumatoidarthritisprognosis.org . Accessed October 11, 2011. Mayo Clinic Staff. Rheumatoid Arthritis. http://www.mayoclinic.com/health/rheumatoid-arthritis/DS00020 . Accessed October 11, 2011. Mayo Clinic Staff. Rheumatoid Arthritis. http://www.visualphotos.com/image/2x4139561/arthritic_hand. Accessed October 5 , 2011. Rojkovich B, Poor G. Prognostic factors in rheumatoid arthritis. Orvosi Hetilap. 2002; 143(35):2019-26. Sommer OJ, Kladosek A, Weiler V, et al. Rheumatoid arthritis: A practical guide to state-of-the- art imaging, image interpretation and clinical implications. Radiograpics, 2005; 25:381-398 Sugimoto H, Takeda A, Hyodoh K. Early-stage rheumatoid arthritis: Prospective study of the effectiveness of MR imaging for diagnosis. Radiology, 2000; 216:569-575 Wheeless CR. American Rheumatism Association Diagnostic Criteria for R.A. http://www.wheelessonline.com/ortho/american_rheumatism_association_diagnostic_criteria_for_ra. Updated June 28 , 2011. Accessed October 11, 2011. Yasuda YL. Rheumatoid Arthritis, osteoarthritis, and fibromyalgia. In: Radomski MV, Trombley Latham CA, eds. Occupational Therapy for Physical Dysfunction. Baltimore, MD:Lippincott Williams and Wilkins; 2008: 1215-1230.