Rheumatoid Arthritis

Rheumatoid arthritis (Artritis rheumatoides) is currently one of the relatively spread diseases. Over the previous 50 years, the number of people suffering from this illness has significantly increased. The etiology of rheumatoid arthritis has not been discovered. The connection of the disease with inflectional provocative has not been proved yet. The paper investigates the disease development process, its symptoms, abnormal tests to confirm the diagnosis, treatment options and nursing interventions that may be applied to a patient, who suffers from rheumatoid arthritis.

With much probability, various harmful factors of the environment and their combinations cause the violation of the immune homeostasis with the following injuries of the connecting tissues and their compounds. Genetic factors are of significant importance for the development of rheumatoid arthritis.

St. Clair, Pisetsky, and Haynes state that one of the major reasons for the development of the disease is the primary immunity defect that weakens the immunity control and provokes pathological immune (autoimmune) reactions. Most often, there can be found the antibodies against c-fragment (Fc) of immunoglobulin (G).
According to St. Clair), autoantibodies and the derivate immune complexes (antigen + immunoglobulin + rheumatoid factor + complement) cause a chain of pathological reactions that may be perpetual. At the same time, there takes place the injury of the cellar lysosomes together with the production of active inflammatory substances, stimulation of phagocyte, activation of inflammatory mediators, and the adaptation of the blood coagulation system. Such interconnected reactions take place first in the synovial membrane, and then beyond the joints, especially in vessels. Thus, since the very beginning, the disease obtains a systematic nature that can not always be proved clinically. The predisposition factors include the constitutional and genetic peculiarities of one’s body system, violations in the system of adrenal glands and hypophysis, and the changes in the neurotrophic processes.

St. Clair state that at the beginning of a disease development, there may be noticed the injuries in joint tissues. With time, the inflammatory process transfers to the joint capsule and its soft tissues. Exudative changes are then replaced by proliferative with the formation of microvillus, lymphoid infiltrate, the set of vessels, and granulations. The growing granulation tissue (the so-called pannus) violates the tissues of cartilage and destroys them. After that, bones epiphyses get involved in the process. In the near-joint cells, there takes place the fibrosis together with the appearance of rheumatoid papules. The progress in fibrosis and sclerotic process causes the development of wrenches and contractures with the limitation of joints’ functioning, and ankylosis. Together with the changes in joints, the processes of disorganization of connecting tissues and the changes in vessels may be noticed in other organs.

Shlotzhauer and McGuire state that in the majority of cases, the disease has an acute form. As a rule, at the beginning, there may be noticed the symmetric destruction of proximal joints of arms and feet. Later, the bigger joints get involved in the process. In many cases, the bigger joints are destructed at the very beginning of the disease. There may be noticed a moderate increase in the size of joints, the rise of the local temperature, hyperemia, and painfulness in the process of palpation.

Passive and active motions are limited and cause pain. For this period of the disease, it is typical to feel the limitation of movement of the destructed joints after a long-time immobility, especially in the morning (the morning constraint). The clinical picture of arthritis remains stable even after active treatment. Very often, there takes place the hypertrophy of muscles adjacent to the damaged joints.

Sometimes, in the soft tissues adjacent to the destructed joints there appear rheumatoid papules. As a rule, they are located on arms, around the elbow joints, and in the zone of heel tendon. The location of rheumatoid papules is of a great significance for the diagnostics and further process of treatment.

According to Shlotzhauer and McGuire, in the process of the disease development, there may be strengthened the proliferative processes in joints and adjacent tissues, and facilitated the destruction of cartilage and the joint departments of bones that causes deformations and contractures. As a result of the arm joints defection, the deformation takes place. The defected joints are usually located at different degrees of the pathological process development. Some of the joints may have proliferative changes, some others – exudative, and the rest – ankylosing. In some cases, separate joints may be subjected to mixed types of changes.

First of all, with the help of X-rays, it is necessary to determine the osteoporosis of the joint ends of bones and the expansion of the joint slot. Later, there should be achieved the contraction of the joint slot. It is achieved as a result of cartilage and erosion of the joint surface of bones. At the same time, there appear botryoidal enlightenments in epiphyses and small osteophytes on the joint surfaces. At the next stage of the disease, the joint slot disappears, and is replaced by fibrosis and bone coalescences that turn into ankylosing.

Shlotzhauer and McGuire state that the clinical picture of rheumatoid arthritis is also distinguished by different symptoms that do not affect the joints. The defection of heart is characterized by the development of the pathological process, mainly in the myocardium, and more seldom – in the endocardium. It may appear as a moderate expansion of heart, mainly to the left side of the body. In some cases, there may appear a diffusional myocarditis or pericarditis.

Relatively seldom, there may be noticed the destruction of the respiration system organs, as well as dry or exudative Plevritis. The violation of the functioning of lung vessels may cause lung hypertension. Sometimes, there may be developed diffusional interstitial lung fibrosis.

The defection of kidneys develops as a local (more seldom diffused) glomerulonephritis or amyloidosis. The development of kidney amyloidosis as one of the symptoms of general amyloidosis is most likely to be caused by the autoimmune processes and may take place under the influence of immune depressive therapy. As a rule, amyloidosis takes a long time to be developed. There may be noticed an increasing proteinuria with the development of the clinical picture of nephrotic syndrome in ten or more years after the development of the disease. Only in active cases of rheumatoid arthritis, amyloidosis may appear at the second or third year of the disease development. The appearance of nephrotic syndrome is a symptom of the patient’s health worsening.

According to Shlotzhauer and McGuire, the blood system is also subjected to a number of changes. During the period of aggravation, there takes place a moderate leukocytosis. After a long period of treatment, there may appear leucopenia, moderate anemia, and in more severe cases – thrombocytopenia. Thrombocytopenia together with the increase of spleen and lymphatic nodes is more typical for Felly’ syndrome that is a special form of rheumatoid arthritis.

Dysproteinemia is typical for rheumatoid arthritis. As a rule, the level of immunoglobulin is increased. In the majority of cases, the blood contains the rheumatoid factor. The location of the factor is determined with the help of Waaler-Rose test. It consists in the agglutination of erythrocytes of a ship after adding the serum of a person, who suffers from rheumatoid arthritis. A latex-text is a simpler method of investigation. Among the other defections of the immune system, there is the dysfunction of T- and B-lymphocytes, as well as the creation of pathological immune complexes and antibodies.

According to Shlotzhauer and McGuire, rheumatoid arthritis causes a chain of defections of vegetative and central nervous system. Sometimes, there may take place polyneuropathy (the feeling of heat in the limbs, the changes in the sensibility of fingers, muscle pain, evident changes of tendon reflexes, sweating, and the increase of the local temperature). In more severe cases, there takes place polyneuritis that is suggested to be caused by rheumatoid vasculitis.

A wide diversion of symptoms allowed the investigators to separate its forms depending on the involvement of the systems in the pathological process and also on the type of joint defection. The septic form is characterized by fever, intoxication and the symptoms of the destruction of many organs at the beginning of the disease development.Heart and kidneys are subjected to the impact of the disease in the first place.

Sometimes, there takes place a so-called benign form when no more than four joints are damaged. The majority of changes take place in the adjacent tissues without bone erosions and visible deformations. The defection of the internal organs is not typical for this form of the disease. The results of laboratory tests in the majority of cases are not modified, and the outcomes of the rheumatoid factor are not high. Sometimes the rheumatoid factor may be found only in the synovial fluid. During the X-ray investigation of the defected joints, there may be discovered a moderate osteoporosis.

Seronegative forms, as a rule, are less severe than seropositive as the rheumatoid factor may be found at all stages of the disease. Exudative changes and erosive processes predominate in the defected joints. The violation of internal organs’ functioning does not take place.

Cush and Kavanaugh state that the diagnosis of rheumatoid arthritis is based on typical clinical data: the symmetric progressive defection of joints; rarely hands and feet with the feeling of constraint in the morning; muscle hypertrophy; the changes in synovial fluid; the changes in the laboratory blood tests; X-ray symptoms and the destruction of the internal organs. The biopsy of the synovial membrane is of great importance for the diagnostics of the disease. It allows investigating the following pathologies in terms of morphological changes: cytoproliferation, the cytolysis of the fibroblastic elements, fibrinous sediment, the signs of disorganization of the connective tissue, vasculitis, etc. The set of the symptoms is typical for the clinical picture of rheumatoid arthritis and is less expressed if a person suffers from mono or oligoarthritis.

The therapeutic aspects of rheumatoid arthritis are extremely diverse and embrace anti-inflammatory and immunosuppressive treatment and immune stimulation. It is also possible to implement surgical and rehabilitation methods. According to the pathogenesis of the disease, it becomes obvious that there exist two levels of efficient treatment of rheumatoid arthritis. The first level oppresses the excessive activity of the immune system. The second level blocks the mediators of the inflammation, which first of all include prostaglandins.

According to Cush and Kavanaugh, the activation of the immune system is followed not only by inflammation but also by a chain of other pathological processes. Thus, the influence on the first level is deeper and more efficient than on the second one. The medical immunosuppression is basic for the treatment of the disease. To the immunosuppressive medicine that is implemented for the treatment of the disease belong the basic anti-inflammatory drugs, biological drugs, and glucocorticosteroids. On the second level, there are implemented nonsteroidal anti-inflammatory drugs. In general, the immunosuppressive therapy is followed by a slow development of the disease. It is also characterized by lowering the speed of destructive processes in tissues.

The anti-inflammatory therapy itself may have a rapid clinical effect on the patient. However, it is impossible to block the symptoms of the disease if it belongs to the active type. This treatment does not influence the development of destructive processes in tissues.

Glucocorticosteroids have both immunosuppressive and direct anti-inflammatory effect. Due to this factor, the improvement of the patient`s condition may take place within several hours. The erosive process in joints may be suppressed by the injection of low doses of glucocorticosteroids. They also have a positive influence on the patient’s functioning. At the same time, the usage of glucocorticosteroids without using other immunosuppressive means does not provide an opportunity to efficiently control the disease development process.

The non-medical ways of rheumatoid arthritis treatment (physiotherapy, diet therapy, acupuncture and others) are the additional methods that may improve the physical condition and functional status of the patient. However, they are unable to block the symptoms and to influence reliably on the destruction of joints.

The orthopedic treatment that includes the surgical correction of joints and the rehabilitation methods (physical training and others) are of great importance predominantly at the late period of the disease. It allows supporting the functional ability and the patient’s quality of life.

The treatment of rheumatoid arthritis pursues three main aims: to block the symptoms of the disease and achieve a clinical remission or, at least, a low activity; to slower the progress of the structural changes in joints and corresponding functional defectiveness; to improve the patient’s quality of life and to maintain their ability to work.

It is necessary to take into consideration the fact that the aims of treatment may significantly vary depending on the length of the disease process. For example, if the disease lasts from six to twelve months, the achievement of clinical remission is a realistic task together with making slower the process of erosions in joints. With the help of modern methods of active medical treatment, it is possible to achieve a remission in almost a half of cases. The investigations prove the absence of new erosions according to the data of X-ray analysis at the length of observation from one to two years.

At a longer period of rheumatoid arthritis, particularly due to the insufficient therapy at the first years of the disease, the achievement of total remission is theoretically possible. However, this possibility is significantly lower. The same refers to the possibility of restoring the progress of the destruction of joints that have been defective for many years. That is the reason why at the later periods of rheumatoid arthritis treatment the role of rehabilitation measures and orthopedic surgery significantly increases. Moreover, the basic supportive therapy may be used for secondary prevention of the disease complications such as vasculitis and secondary amyloidosis.
Lahita states that the basic therapy of rheumatoid arthritis is the basic component of the disease treatment. If there are some contraindications, such means of treatment should be recommended to every patient with such a diagnosis. It is of a particular importance to prescribe the basic therapy at the earliest period of disease development when there is limited time for the achievement of the best long-lasting results.

The classic basic treatment is able to oppress the activity and the proliferation of immunocompetent cells and the proliferation of synoviocytes and fibroblasts followed by the lowering of laboratory activity of rheumatoid arthritis. It guarantees the stability of the clinical effect even after the cancellation of medications. It allows retaining the development if the erosive process in joints. The treatment may induce clinical remission.
The term biological drugs refers to the medications produced with the help of biotechnologies and helping to block the key moments of inflammation with the help of antibodies or soluble cytokine receptors, as well as other biologically active molecules. Due to a vast number of target molecules, the influence of which may suppress the immune inflammation, there was developed a range of medications. To the negative sides of biological therapy belong the oppression of anti-infection and anti-tumor immunity. It may also cause an increase in the risk of allergy reactions and the induction of autoimmune syndromes caused by the protein nature of biological drugs. The biological method of treatment is recommended if the classic basic treatment is inadequate due to its inefficiency or personal incompatibility.

Glucocorticosteroids have a versatile anti-inflammatory effect explained by their possibility to block the synthesis of the anti-inflammatory cytokines and prostaglandins together with inhibiting the proliferation due to the influence on the genetic apparatus of cells. Glucocorticosteroids have a strong dose-dependent effect in relation to the laboratory and clinical manifestations of the inflammation. However, the implementation of glucocorticosteroids may cause a chain of negative side effects the frequency of which increases with the amount of the medications taken. The usage of glucocorticosteroids without additional methods of treatment is unable to provide a total control of the disease development and should be prescribed together with the basic treatment.
According to Lahita, a person suffering from rheumatoid arthritis should choose an option of the basic treatment. The other types of medications should be used only as an additional means of treatment. A person should be well-informed about the following: the nature of the disease; the prognosis and the necessity of a complicated long-lasting treatment; possible negative side effects; methods of the disease control and the unfavorable combination of the prescribed drugs with other substances (in particular, with alcohol); possible activation of chronical infection; the necessity of timely cancellation of immunosuppressive drugs in case of inflectional diseases; and the necessity of contraceptive methods in the process of treatment.

St. Clair state that the monitoring of the disease activity should include the evaluation of the joint status results, pain and disease activity by a visual analog scale, the evaluation of the functional activity of the patient in everyday life. Moreover, there should also be carried out the monitoring of the therapy safety in accordance with the existing clinical recommendations. Because the erosive process may be developed even in the conditions of low inflammatory activity, it is necessary to use X-ray diagnostics to monitor the condition of joints. The progress in the destructive changes of joints may be evaluated with the help of standard X-ray diagnostics of arms and feet with the use of rheumatoid arthritis period evaluation scale, and the methods of Sharp and Larsen indexes.

Rheumatoid arthritis is one of the severest diseases with a vast number of complications. The reasons that cause the development of the disease still require to be thoroughly investigated. At the earliest period of the disease development, it is possible to achieve the best results and even a clinical remission. At the later periods it is also possible to relieve the patient`s condition, however, the treatment in this case will be more complicated and long-lasting.