The Team Approach to Patient Care and Treatment

Optimal management requires an interdisciplinary team approach involving many specialists, including a liaison nurse, rheumatologist, orthopedic surgeon, physical therapist, occupational therapist, psychologist, and social worker. The patient and family are also important members of the team. Because the disease is an ongoing and progressive process, the goal of management is to prevent deformities and maintain function for the patient over a lifetime.

Nursing Care and Patient Education

The liaison nurse functions as the coordinator of the team. The nurse provides the critical link between the inpatient medical and surgical management of the disease and the continuation of treatment in the outpatient environment.

Much of the responsibility for patient education in the daily care of the disease rests with the nurse, who explains the techniques for protecting joints; advises patients about the need to perform exercises for maintaining joint ROM and optimizing failing muscle strength; cautions patients that exercising too vigorously can damage weakened joints and ligaments; and reminds patients that because the disease tends to decrease their physical activity, they will need regular periods of rest during the day and good nutrition to maximize their general health and to prevent obesity.

Medical and Surgical Management

The rheumatologist is commonly the team leader and in charge of medical management, which is directed toward the control of synovitis, the relief of pain, and the prevention or treatment of other organ involvement by the disease. The medications used for treatment include aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, immunosuppressive drugs, and suppressive agents. A local injection of corticosteroids can be useful in controlling an acute inflammatory process in a specific joint.

The orthopedic surgeon should be involved early in the course of the patient's disease and not merely be called on when medical management fails to be effective. Knowledge of biomechanics, gait dynamics, and energy requirements can be useful in preserving function for the patient. The orthopedist can often recommend orthotic supports, walking aids, and shoe wear that minimize unwanted stress on joints and maximize strength.

In selected situations, early surgical intervention may prevent excessive deterioration of joint structure and function. Synovectomy is effective in preventing tendon rupture in the hand, whereas arthroscopic synovectomy of the knee and shoulder show promise for preventing joint destruction. Fusion of an unstable cervical spine can prevent the disastrous effect of an SCI.

Most surgical procedures are reconstructive. Because relief of pain is the most consistent result of reconstructive surgery, pain is the primary indication for surgery. Restoration of motion and function and the correction of deformity are additional indications for surgical intervention but are more difficult goals to achieve. Preoperative assessment is a painstaking process. In addition to performing a physical examination and reviewing radiographic findings, the surgeon must attempt to elicit sufficient information from the patient, family, and therapists to ascertain which deformities are causing the greatest functional losses. The patient can only tolerate a finite number of surgical procedures, and these must be carefully staged to obtain the maximal result.

Physical Therapy

The physical therapist uses modalities such as heat and ultrasound to decrease joint stiffness and relieve pain. An exercise program is essential for preserving the functional abilities of the patient. The exercise should gently put all joints through their full arc of motion to maintain this range.

Patients with joint effusions and synovitis automatically assume positions that minimize intraarticular pressure and therefore minimize pain. These positions are usually not optimal for function and can result in flexion deformities. An abnormal position may be reversible if discovered early. Daily joint ROM exercises are central to preventing unwanted contractures.

Muscles weakened by the concomitant myopathy need strengthening but are susceptible to damage from overuse or from an excessively vigorous exercise program. Orthotics may be indicated to support weakened ligaments and provide a means of joint protection and support for functional activities such as walking. Upper extremity walking aids may be useful to give the patients additional support. These aids often require modification to meet the specific needs of the individual. Forearm troughs allow the patient to use the entire arm for support when the hands and wrists are weak or deformed. They are also useful for protecting the hands from excessive stress. A rolling walker, which does not require the patient to lift the walker for advancement, may be useful in patients with limited strength.

Occupational Therapy

The occupational therapist evaluates and instructs the patient in modified techniques for performing ADLs, such as grooming, dressing, and meal preparation. Because of the weakness and deformities imposed by the arthritis, adaptive equipment and alternative methods are commonly needed. Modifications in clothing, such as larger fasteners for ease of manipulation, Velcro strips at seams or on shoes, and front openings, can all facilitate dressing. Upper extremity splints can be used to provide joint protection and stabilization and to prevent further deformity from occurring. The splints must be lightweight and easily donned by the patient.

Psychological Counseling

It is not uncommon for patients or their family members to have feelings of anxiety, denial, anger, or depression. The psychologist provides assistance in dealing with these feelings and coping with alterations in lifestyle and self-image. Comprehensive care involves an understanding of how patients respond to weakness, fatigue, altered physical appearance, progressive disability, diminished independence, and the financial burdens of chronic illness. Coping skills are needed to deal with these problems as well as with pain, which becomes an everyday occurrence and may interfere with both intellectual and emotional functioning.

Social Services

A variety of modifications in lifestyle accompany chronic illness with RA. Occupational changes may be necessary, or the patient may no longer be able to work at all. Additional assistance may be needed in the home for housework and the preparation of meals. In more advanced stages, the patient may require help for personal care. Transportation needs become more complex, and the patient finds it increasingly difficult to leave the home. The social worker becomes an invaluable team member in helping families with the numerous practical arrangements required for everyday existence and for locating financial aid to help defray the mounting costs.

Beasley J: Osteoarthritis and rheumatoid arthritis: conservative therapeutic management. J Hand Ther 2012;25:163.   [PubMed: 22326361] 
Durmus B, Altay Z, Baysal O, et al: Can the patient-reported outcome instruments determine disease activity in rheumatoid arthritis? Bratisl Lek Listy 2011;112:555.  [PubMed: 21954539] 

 

 


In rheumatoid arthritis, the body's immune system attacks its own tissue, including joints. In severe cases, it attacks internal organs.

Rheumatoid arthritis (RA) is a chronic systemic disease that affects connective tissue and results in chronic inflammatory synovitis, loss of articular cartilage, and erosion of juxtarticular bone, usually with bilateral joint involvement.1Over long periods of time, the inflammation associated with rheumatoid arthritis can cause bone erosion and joint deformity.

Rheumatoid arthritis affects joint linings, causing painful swelling.
While there's no cure for rheumatoid arthritis, physiotherapy and medication can help slow the disease's progression. Most cases can be managed with a class of medications called anti-rheumatic drugs (DMARDS)
Ages affected

 

 

 

 

 

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he causes of RA remain elusive.

The genetic contribution to RA is substantial, and more than 30 loci conferring risk for RA have been identified thus far. Most genes linked to RA influence immune responses (eg, T cell activation, cytokine signaling). The strongest known association is with alleles of HLADRB1, which encodes the β chain of HLA-DR, a major histocompatiblity class II molecule directly involved in the presentation of antigen to T cells. Allelic variants of HLADRB1 associated with risk for RA encode a similar sequence (amino acids 70–74) known as the “shared epitope.”1

Studies of genetic risk reinforce the concept that clinical RA is not a single entity. Most notably, shared-epitope-encoding HLADRB1 alleles confer risk only for RA associated with antibodies to citrullinated protein epitopes (present in approximately 70% of all patients with RA). Citrullination—a post-translational modification of proteins in which arginine residues are converted to citrulline—occurs at sites of inflammation. How patients with RA lose tolerance to citrullinated protein epitopes is uncertain. Interestingly, epidemiologic data links smoking (which induces inflammation and citrullinated proteins in the lung) and periodontitis (which is associated with the citrullination of proteins in periodontal tissues) to risk of developing anti-CCP-positive RA.

 

 

 

RA affects approximately 1% of the adult population worldwide and is more common in women (female:male, 3:1)

Although RA may present at any age, the typical age of onset in women is the late childbearing years; in men, RA develops more often in the sixth to eighth decade.

 

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The natural history of the disease is one of progressive joint damage and deformity and, in a sizeable minority, the development of extra-articular manifestations. Fortunately, current therapeutic strategies, particularly if the disease is diagnosed and treated early, result in substantial clinical benefit for most patients.1

The systemic nature of RA and its variable clinical pattern make it difficult to devise a precise system for describing the overall functional ability of the patient.

The most commonly employed scale is the functional classification devised by the American Rheumatism Association

American Rheumatism Association Classification of Function in Patients with Rheumatoid Arthritis.1

Class

Description

 I

Complete function; able to perform usual duties without handicap.

 II

Adequate function for normal activities, despite handicap of pain or limited range of motion in one or more joints.

 III

Limited function; able to perform few or none of the duties of usual occupation or self-care.

 IV

Largely or wholly incapacitated; bedridden or confined to a wheelchair; able to perform little or no self-care.

 

 

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All of the following are characteristic extra-articular manifestations of rheumatoid arthritis EXCEPT:

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The correct answer is E. You answered E.

The answer is E. Anemia is common in RA and parallels the degree of inflammation as measured by C-reactive protein or erythrocyte sedimentation rate (ESR). Felty syndrome, typically occurring in late-stage poorly controlled disease, is characterized by the triad of neutropenia, splenomegaly, and rheumatoid nodules. Rheumatoid vasculitis is not common and typically occurs in long-standing disease. It is associated with hypocomplementemia. The cutaneous signs are typical of vasculitic lesions with palpable purpura, digital infarcts, livedo reticularis, and ulcers. Clinical manifestations of pericarditis occur in 10% of patients with echocardiographic or autopsy findings in about half of those cases. Secondary Sjögren syndrome manifest as keratoconjunctivitis sicca or xerostomia occurs in approximately 10% of patients with RA. RA also appears to increase the risk of developing B-cell lymphoma by two- to fourfold compared with the general population. The risk of lymphoma appears to correlate with high levels of disease activity or the presence of Felty syndrome. Platelet counts in RA are typically elevated in association with the acute-phase response of inflammation. Immune thrombocytopenia is rare.

 

 

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