Lyme arthritis Lyme disease.
psoriatic arthritis that associated with severe psoriasis. classically affecting the terminal interphalangeal joints.
rheumatoid arthritis a chronic systemic disease characterized by inflammatory changes occurring throughout the body's connective tissues. As such, it is classified as a collagen disease. This form of arthritis strikes during the most productive years of adulthood, with onset in the majority of cases between the ages of 20 and 40. No age is spared, however, and the disease may affect infants as well as the very old. The disease affects men and women about equally in number, but three times as many women as men develop symptoms severe enough to require medical attention.
Etiology. The cause of rheumatoid arthritis is unknown and it is doubtful that there is one specific cause. It is regarded by some researchers as an autoimmune disease. in which the body produces abnormal antibodies against its own cells and tissues. Evidence to support this theory is found in the fact that there is an abnormally high level of certain types of immunoglobulins in the blood of patients suffering from rheumatoid arthritis. Other researchers contend that the disease may be due to infection, perhaps from an undefined virus or some other microorganism (e.g. Mycoplasma ). There also is the possibility that rheumatoid arthritis is a genetic disorder in which one inherits a predisposition to the disease. Physical and emotional stress also play some part in the onset of acute attacks; however, psychological stress is implicated as a causative factor in the onset of many illnesses.
Symptoms and Pathology. In about 75 per cent of patients the onset of rheumatoid arthritis is gradual, with only mild symptoms at the beginning. Early symptoms include malaise, fever, weight loss, and morning stiffness of the joints. One or more joints may become swollen, painful, and inflamed. Some patients may experience only mild episodes of acute symptoms with lengthy remissions. The more typical patient, however, experiences increasingly severe and frequent attacks with subsequent joint damage and deformity. The pattern of remissions and exacerbations continues throughout the course of the disease.
If untreated, and sometimes in spite of treatment, the joint pathology goes through four stages: (1) proliferative inflammation of the synovium with increased exudate, which eventually leads to thickening of the synovium; (2) formation of a layer of granulation tissue (pannus ) that erodes and destroys the cartilage and eventually spreads to contiguous areas, causing destruction of the bone capsule and parts of the muscles that control the joint; (3) fibrous ankylosis resulting from invasion of the pannus by tough fibrous tissue; and (4) bony ankylosis as the fibrous tissue becomes calcified.
In addition to the joint changes there is atrophy of muscles, bones, and skin adjacent to the affected joint. The most characteristic lesions of rheumatoid arthritis are subcutaneous nodules, which may be present for weeks or months and are most commonly found over bony prominences, especially near the elbow.
Because rheumatoid arthritis is a systemic disease, there is involvement of connective tissues other than those in the musculoskeletal system. Degenerative lesions may be found in the collagen in the lungs, heart, blood vessels, and pleura.
Patients with rheumatoid arthritis appear undernourished and chronically ill. Most are anemic because of the effect of the disease on blood-forming organs. The erythrocyte sedimentation rate is elevated and the WBC may be slightly elevated.
Treatment and Patient Care. Management of rheumatoid arthritis is aimed at providing rest and freedom from pain, minimizing emotional stress, preventing or correcting deformities, and maintaining or restoring function so that the patient can enjoy as much independence and mobility as possible. Occupational therapy is needed to teach patients effective ways to carry out such activities of daily living as grooming and self-care, preparing meals, and light housekeeping. This often involves using specially designed utensils and tools that allow deformed joints to perform these tasks.
Rest and Exercise. It is recommended that the patient with rheumatoid arthritis plan for 10 to 12 hours of sleep out of each 24. The patient should be careful to maintain good posture while lying in bed and avoid pillows or other devices that support the joints in a flexed position. A firm mattress is recommended, with only one pillow under the head. During periods of severe attacks, the patient may require continuous bed rest.
The purpose of rest is to allow the body's natural defenses against inflammation to work at optimal level. It is necessary, however, even in the acute phase to balance rest with prescribed exercises which take into account the severity of the case, the joints affected, and the patient's individual needs and tolerance.
Physical Therapy. The goals of physical therapy for the patient with rheumatoid arthritis are to prevent and correct deformities, control pain, strengthen weakened muscles, and improve function.
Therapeutic exercise is of major importance in the physical therapy program established for the patient. It is necessary to enlist the patient's cooperation, and this can be done most effectively by explaining the purposes of the exercises and teaching ways to exercise that will not increase pain. In many instances proper exercise can actually diminish pain. The patient's tolerance for exercise must be carefully monitored. While it is expected that some discomfort may be present during exercise, there should not be persistent pain that continues for hours after the exercises have been done. If such pain and fatigue do occur, the exercise program should be reviewed and revised so that a good balance of rest and exercise is obtained. It should be remembered that overactivity can contribute to the inflammatory process.
Applications of heat or cold may be used in the management of rheumatoid arthritis. Heat applications improve circulation, promote relaxation, and relieve pain. When used in conjunction with exercise, heat can allow more freedom of joint movement. Various forms of heat therapy may be used, including dry heat, moist heat, diathermy. and ultrasound. For dry heat a therapeutic infrared heat lamp may be most convenient during home care. Hot water bottles or electric heating pads also may
be used. For treatment of the hands, paraffin baths are effective. Wet heat can be applied by hot tub baths with the water temperature not exceeding 39°C (102°F) or by means of a towel dipped in hot water, wrung out, and applied to the joint. Whirlpool baths are effective, especially when prolonged treatment is indicated. Relief from pain and stiffness can be provided for some patients by applications of cold packs to the affected joints. This can be done by placing ice packs directly over the joint. When either heat or cold is used, care must be taken to protect the patient's skin. It should be remembered that rheumatoid arthritis affects the skin as well as other tissues.
Whenever it is necessary to handle the joints and limbs of a patient with rheumatoid arthritis, it is extremely important to move slowly and gently, avoiding sudden, jarring movements which stimulate muscle contraction and produce pain. The affected joints should be supported so that there is no excessive motion.
Medication. There is no drug that will cure arthritis. The health care provider does have a variety of medications that may be prescribed, depending on the needs and tolerance of the patient. It is important that the patient be advised of the expected results and possible undesirable side effects that may accompany ingestion of certain drugs. He or she should also be advised that therapeutic trials of several different drugs may be necessary. With this information at hand, he or she can work cooperatively with the physician in determining which drug or drugs can be most beneficial for treatment of the condition.
Aspirin was among the first drugs used to treat rheumatoid arthritis and remains a low-cost treatment option. It is a potent antiinflammatory agent when given at dosages that achieve a serum level of 20–30 mg/100 ml. For those prone to stomach upset or other gastrointestinal side effects from aspirin, enteric-coated tablets or antacid mixtures of aspirin are available.
Other nonaspirin, nonsteroidal antiinflammatory drugs (NSAIDs) include the indole derivatives indomethacin. sulindac. and tolmetin and the phenylalkanoic acid derivatives fenoprofen. ibuprofen. and naproxen. Nowadays NSAIDs are the most used group of medications for treatment of arthritis. They may provide more relief than aspirin for certain patients, but they also may have side effects related to the gastrointestinal and nervous systems. COX-2 (cyclooxygenase-2) inhibitors are the latest class of NSAIDs. They have fewer gastrointestinal side effects than other NSAIDs.
Cytotoxic agents may also be used; these drugs act as immunosuppressants and block the inflammatory process of the disease. methotrexate is the most common of these. The dosage for the management of rheumatoid arthritis is much lower than the dosages for malignancies; thus the associated side effects are fewer. gold compounds or penicillamine may be prescribed for selected patients who cannot tolerate or are not responding well to more conservative methods of treatment.
The corticosteroids may be used in treating rheumatoid arthritis, but they are not a substitute for other forms of treatment. In some cases these drugs produce side effects that are more difficult to treat than arthritis. They also may worsen certain features of the disease rather than relieve them. Drugs included in this group are cortisone. hydrocortisone. prednisone. prednisolone. and dexamethasone .
Another group of medications that reduce inflammation are the biological response modifiers. Members of this group used to treat arthritis include etanercept and infliximab .
Surgical Intervention and Orthopedic Devices. In the past, surgical intervention was reserved for patients who had already suffered severe joint deformity. There is presently a trend toward the use of surgery in the early stages of the disease so that deformities and serious mechanical abnormalities can be prevented or at least modified.
One surgical procedure employed is synovectomy (excision of the synovial membrane of a joint). The goal of this treatment is to interrupt the destructive inflammatory processes that eventually lead to ankylosis and invasion of surrounding cartilage and bone tissues.
Surgical repair of a hip joint (arthroplasty ) may be performed when there is extensive damage and ambulation is not possible. The purpose of this procedure is to restore, improve, or maintain joint function. In cases in which it is not possible to restore the damaged hip joint there is a surgical procedure in which the diseased joint is completely replaced with a total hip prosthesis. The procedure is called a total hip replacement. A similar procedure involving total replacement of the knee can be done when there is extensive damage to the knee joint.
Braces, casts, or splints are sometimes used to immobilize the affected part so that it can rest during an active stage of the disease. Devices that immobilize the affected joint also may allow for motion of adjacent muscle, thereby improving muscle strength and permitting more independence on the part of the patient. Braces also may be used to prevent deformities by maintaining good position of the joints.
Patient Education. Unfortunately, arthritis is so widespread and such a crippling disease that its victims may be easy prey for charlatans and promoters of “miraculous cures.” The nature of the disease, with its unexplained remissions and relief of symptoms, makes it easy for unscrupulous individuals to convince the arthritic patient that some bizarre treatment they have used has indeed “cured” the arthritis. It is important that members of the health team recognize the need for patient education and work diligently with the patient and family so that they can cooperatively participate in a program of care that is most effective for the individual patient.
Home care is an essential part of the management of arthritis. To help in education of the public The Arthritis Foundation provides a number of pamphlets and other educational materials, supports a broad program of research and education, and helps finance improvement of local facilities for treatment of arthritis. The address of the foundation is The Arthritis Foundation, 1330 W. Peachtree St. Atlanta, GA 30309, telephone 404-872-7100.
suppurative arthritis inflammation of a joint with a purulent effusion into the joint, due chiefly to bacterial infection.