Rheumatoid Arthritis Information
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Arthritis: Inflammation of a joint, marked by pain, heat, redness, and swelling. Arthritic disorders are among the most common chronic conditions that is painful and disabling. There are different types of arthritic disorders they include: Rheumatoid arthritis, Osteoarthritis, Septic arthritis, Gout, Intermittent hydrarthrosis, Traumatic arthritis, Schonlein-Henoch purpura, and Hemophilic arthrosis.
Rheumatoid arthritis or RA: This chronic, systemic inflammatory disease mainly attacks peripheral joints and surrounding muscles, tendons, ligaments, and blood vessels. Spontaneous remissions and unpredictable exacerbation's mark the course of rheumatoid arthritis. This disorder has the potential to cripple and in some cases patient becomes totally disable from severe articular deformity or associated extra articular symptoms, or both. In most patients, the disease follows an intermittent course and allows normal activity.
Cause: Rheumatoid Arthritis is believed to have an autoimmune basis, though the exact cause remains unknown.
Early stage - may experience:
Persistent low-grade fever
May experience vague articular symptoms
Joint pain - joint symptoms occur bilaterally and symmetrically
Warmth and swelling
Paresthesias in hands and feet
Stiff , weak, and painful muscles
May develop rheumatoid nodules ( subcutaneous, round or oval, non tender masses, usually on pressure areas, such as the elbow)
Joint deformities and diminished joint function
Salicylates - such as aspirin to decrease inflammation and relieve joint pain
Nonsteroidal anti inflammatory agents - such as ibuprofen
Corticosteroids - such as prednisone
Immunosuppressives - such as cyclophosphamide and azathioprine, are also therapeutic
Supportive measures include: Adequate sleep and frequent rest period.
Physical therapy program - Range of motion exercises and carefully individualized therapeutic exercises, forestalls loss of joint function.
Application of heat relaxes muscles and relieves pain. Ice packs are effective during acute episodes.
Advanced disease may require synovectomy, joint reconstruction, or total joint arthroplasty.
Osteoarthritis: The most common form of arthritis, this chronic condition causes deterioration of the joint cartilage and formation of reactive new bone at the margins and subchondral areas of the joints. Degeneration results from a breakdown of chondrocytes, most often in the hips and knees.
Disability depends on the site and severity of involvement and can range from minor limitation to severe disability in people with hip or knee involvement. The rate of progression varies, and joints may remain stable for years in an early stage of deterioration.
Cause: The exact cause is unknown. Primary osteoarthritis, a normal part of aging, results from varies things, such as: metabolic, genetic, chemical, and mechanical factors.
Secondary osteoarthritis usually follows an identifiable predisposing event, most commonly trauma or congenital deformity which may lead to degenerative changes.
Signs and symptoms increases with poor posture, obesity, and occupational stress
Joint pain - that occurs particularly after exercise or weight bearing and that is usually relieved by rest.
Stiffness in the morning and after exercise that is usually relieved by rest
Aching during changes in weather
'Grating' of the joint during motion
Irreversible changes in the distal joints (Heberden's nodes) and proximal joints (Bouchard's nodes) occur in osteoarthritis of the interphalangeal joints.
Nodes may be painless at first but eventually become red, swollen, and tender, causing numbness and loss of dexterity.
Non narcotic analgesics
In some cases, intra articular injections of corticosteroids.
Patients who have severe osteoarthritis with disability or uncontrollable pain may undergo one or more of the following surgical procedures:
-Arthroplasty (partial or total) - replacement of a deteriorated joint or part with a prosthetic appliance.
-Arthrodesis - surgical fusion of bones; used primarily in the spine
-Osteoplasty - scraping of deteriorated bone from a joint
-Osteotomy - excision of bone to change alignment and relieve stress
Septic arthritis: is a medial emergency. Bacteria invade a joint, resulting in inflammation of the synovial lining. If the organisms enter the joint cavity, effusion and pyogenesis follow, with eventual destruction of bone and cartilage.
Septic arthritis can lead to ankylosis and even fatal septicemia. Prompt antibiotic therapy and joint aspiration or drainage cure most patients.
Causes: In most cases, bacteria spread from a primary site of infection, usually in adjacent bone or soft tissue, through the bloodstream to the joint.
Infecting organisms include four strains of gram positive cocci:Staphylococcus aureus, Streptococcus pyogenes, Streptococcus pneumoniae, and Streptococcus viridans.
Two strains of gram negative cocci: Neisseria gonorrhoeae and Hemophilus influenzae.
Several gram negative bacilli: Escherichia coli, Salmonella, and Pseudomonas to name a few.
Anaerobic organisms, such as gram positive cocci, usually infect adults and children over age 2. H. influenzae most often infects children under age 2.
There are various factors that can predispose a person to septic arthritis. Any concurrent bacterial infection (such as, upper respiratory tract or genitourinary), or serious chronic illness (such as renal failure, RA, diabetes, or cirrhosis) heightens susceptibility. Intravenous drug abuse ( heroin addicts, for example) can also cause septic arthritis. Other predisposing factors include recent articular trauma, joint surgery, intra articular injections, and local joint abnormalities.
Acute septic arthritis begins abruptly, causing intense pain, inflammation, and swelling of the affected joint, with low grade fever. Most often develops in the large joints but can strike any joint, including the spine and small peripheral joints. Systemic signs of inflammation may not appear in some patients. If the bacteria invade the hip, pain may occur in the groin, upper thigh, or buttock. migratory polyarthritis sometimes precedes localization of the infection.
Emergency action is needed. Seek medical attention promptly.
Antibiotic therapy (medication selection requires drug sensitivity studies of the infecting organism) Bioassays or bactericidal assays of synovial fluid and bioassays of blood may confirm clearing of the infection.
Treatment requires monitoring of progress through frequent analysis of joint fluid cultures, synovial fluid leukocyte counts, and glucose determinations.
Propoxyphene or Codeine may be given for pain - (aspirin causes a misleading reduction in swelling, hindering accurate monitoring of progress)
The affected joint can be immobilized with a splint or put into traction until movement can be tolerated.
Arthrocentesis to remove grossly purulent joint fluid should be repeated daily until fluid appears normal. Patient may require arthrotomy with lavage of the joint with resistant infection or chronic septic arthritis
Late reconstructive surgery is warranted only for severe joint damage and only after all signs of active infection have disappeared, may take up to several months. In some cases, the recommended procedure may be arthroplasty or joint fusion.
Gout: Urate (a salt of uric acid) deposits lead to painfully arthritic joints. Gout can strike any joint but favors those in the feet and legs. Gout usually occurs in men older than age 30 and in post menopausal women. Secondary gout occurs in the elderly. Gout follows an intermittent course and often leaves patients totally free of symptoms for years between attacks. Gout can lead to chronic disability or incapacitation an, rarely, severe hypertension and progressive renal disease. Prognosis is good with treatment.
Cause: Exact cause of primary gout is unknown. It may be linked to a genetic defect in purine metabolism, which causes overproduction of uric acid (hyperuricemia), retention of uric acid, or both.
Secondary gout can also follow drug therapy, especially after hydrochlorothiazide or pyrazinamide, which interferes with urate excretion. Increased concentration of uric acid leads to urate deposits, called tophi, in joints or tissues, causing local necrosis or fibrosis.
There are four different stages: Asymptomatic, acute, intercritical, and chronic.
Asymptomatic gout: serum urate levels rise but produce no symptoms. As the disease progresses, it may cause hypertension or nephrolithiasis (a condition marked by the presence of renal calculi), with severe back pain.
Acute gout: The first acute attack strikes suddenly and peaks quickly. It may involve a few joint, but usually involves only one joint, this initial attack is extremely painful. Affected joints appear hot, tender, inflamed, dusky red, or cyanotic.
The metatarsophlageal joint of the great toe usually becomes inflamed , then the instep, ankle, heel, knee, or wrist joints. May develop a low grade fever. Mild acute attacks often subside quickly but tend to recur at irregular intervals. Sever attacks may persist for days or weeks.
Intercritical : Intercritical periods are the symptom free intervals between gout attacks. Most patients usually have a second attack within 6 months to 2 years, but in some the second attack is delayed for 5 to 10 years. Delayed attacks are more common in those who are untreated and tend to be longer and severer that initial attacks. Such attacks are also polyarticular, invariably affecting joints in the feet and legs, and are sometimes accompanied by fever. A migratory attack sequentially strikes various joints and the Achilles tendon and is associated with either sub deltoid or olecranon bursitis.
Chronic: Eventually, chronic polyarticular gout sets in. This final, unremitting stage of the disease is marked by persistent painful polyarthritis, with large, subcutaneous tophi in cartilage, synovial membranes, tendons, and soft tissue.. Tophi (a deposit of urates in the tissues about the joints) form in fingers, hands, knees, feet, ulnar sides of the forearms, helix of the ear, Achilles tendons, and rarely, in internal organs, such as the kidneys and myocardium. The skin over the tophus may ulcerate and release a chalky, white exudate of pus. Chronic inflammation and tophaceous deposits precipitate secondary joint degeneration, with eventual erosions, deformity, and disability. Kidney involvement, with associated tubular damage, leads to chronic renal dysfunction. Hypertension and albuminuria occur in some patients, also urolithiasis (a formation of urinary calculi) is common.
Pseudogout also causes abrupt joint pain and swelling but results from an accumulation of calcium pyrophosphate in periarticular joint structures. (See below)
To terminate an acute attack, reduce hyperuricemia, and prevent recurrence, complications, and calculi formation.
Acute gout: Bed rest, immobilization and protection of the inflamed, painful joints, and local application of heat or cold. Analgesics to relieve pain. Acute inflammation requires concomitant treatment with colchicine, until the pain subsides or nausea, vomiting, cramping, or diarrhea develops. Phenylbutazone or indomethacin in therapeutic doses may be prescribed. Resistant inflammation may require corticosteroids or corticotropin, or joint aspiration and an intra -articular corticosteroid injection per doctors orders.
Chronic gout: Aims to decrease serum uric acid level. The doctor may order continuing maintenance dosage of allopurinol to suppress uric acid formation or control uric acid levels.(Caution used with patients with renal failure)
Uricosuric agents - promote uric acid excretion and inhibit accumulation of uric acid. (not to be used on patients with calculi - unless your doctor says otherwise)v
Adjunctive therapy emphasizes a few dietary restrictions, - avoidance of alcohol and purine rich foods. (obesity puts additional stress on painful joints)
In some cases, surgery may be necessary to improve joint function or correct deformities. Tophi must be excised and drained if they become infected or ulcerated.
Pseudogout: Also called Calcium pyrophosphate disease: Results when calcium pyrophosphate crystals collect in periarticular joint structures. If left untreated it can lead to permanent joint damage in about half of the patients it affects, most of whom are elderly.
Paseudogout causes abrupt joint pain and swelling, most commonly affecting the knee, wrist, ankle, and other peripheral joints. These recurrent, self limiting attacks may be triggered by stress, trauma, surgery, severe dieting, thiazide therapy, and alcohol abuse.
Symptoms are similar to those of rheumatoid arthritis. (see rheumatoid arthritis)
Treatment: joint aspiration to relieve fluid pressure
Instillation of steroids
Analgesics, or non steriodial anti inflammatories.
If appropriate, treatment of the underlying endocrine or metabolic disorder.
Intermittent hydrarthrosis: a rare, benign condition characterized by regular, recurrent joint effusions. Commonly affecting the knee joint.
Cause: unknown. Onset is usually at or soon after puberty and may be linked to familial tendencies, allergies, or menstruation.
Symptoms: May be asymptomatic. The patient may have difficulty moving the affected joint.
Treatment: No effective treatment exists
Traumatic arthritis: arthritis that is caused from blunt, penetrating, or repeated trauma or from forced inappropriate motion of a joint or ligament.
Symptoms: Swelling, pain, tenderness, joint instability, and internal bleeding.
Treatment: Analgesics, anti inflammatories, application of cold followed by heat, and if needed, compression dressings, splinting, joint aspiration, casting, or possibly surgery.
Schonlein-Henoch purpura: A vasculitic syndrome, it is marked by palpable purpura, abdominal pain, and arthralgia that most commonly affects the knees and ankles, producing swollen, warm, and tender joints without joint erosion or deformity.
Symptoms: (those mention above). Most patients have microscopic hematuria and proteinuria 4 to 8 weeks after onset. Renal involvement is common. It is common in children and young adults, occurring most often in the spring after a respiratory infection.
Treatment: may include corticosteroids.
Hemophilic arthrosis: Produces transient or permanent joint changes. Usually precipitated by trauma,. This disorder usually arises between ages 1 and 5 and tends to recur until about age 10. It usually affects only one joint at a time, most commonly in the knee, elbow,, or ankle, and tends to recur in the same joint.
Symptoms: At first, the patients may feel only mild discomfort; later, he may experience warmth, swelling, tenderness, and severe pain with adjacent muscle spasm that leads to flexion of the extremity. Mild hemophilic arthrosis may cause only limited stiffness that subsides within a few days. In prolonged bleeding, however, symptoms may subside after weeks or months or not at all. Severe hemophilic arthrosis may be accompanied by fever and leukocytosis. Severe, prolonged or repeated bleeding may lead to chronic hemophilic joint disease.
Treatment: I.V. infusion of the deficient clotting factor, bed rest with the affected extremity elevated, application of ice packs, analgesics, and joint aspiration may be prescribed.
Physical therapy includes progressive range of motion and muscle strengthening exercises.
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