Rheumatoid Arthritis: Pathophysiology, Clinical Manifestation, Diagnosis, and Treatment

Pathophysiology

Overview
Shirley is a 27-year-old single mother to a 7-year-old boy named Adam. She resides with her sister Wendy and Wendy's husband Tom. Adams' father is not in the picture and provides no support. Shortly after Adams birth, Shirley received assistance from social services and was given the opportunity to enrol in a specialized landscaping program. After training, she went on to work landscaping for 4 years, before having to quit, due to increased pain in her hands and wrists. She was considered to be an excellent employee with many talents, especially in being able to visualize new designs. The job required a lot of manual labour, which she could no longer keep up with. As she still needs to work, for the past 2 years she has been working as a waitress, but only doing so when the pain in her hands is not severe. Living with her sister, the relationship has become strained, Wendy wants Shirley to move out and be more self-sufficient. As much as she’d like to be independent and support her son, Shirley worries about her physical abilities limiting her from having consistent work. While having rheumatoid arthritis (RA) preventing her from work, she is also concerned with her limited education as she went straight to work after high school. Her hand remains swollen with persistent pain and she has started to tire easily, and over the last six months has lost about 20 pounds. Performing daily activities to the same
capacity she used to, has been difficult. On occasion being unable to comb her hair, brush her teeth or even feed herself, and have difficulty getting dressed. Being that she is so young, her family does not believe there is a physical reason she cannot work full-time, during periods where she is unable to work her family supports her financially, and Wendy remains unaware of her physical struggles. Shirley has been taking aspirin for pain, which has only brought her short term relief. Over the past four years, she's been stiff in the mornings and when the weather is
cold and humid, she experiences more discomfort and greater stiffness in her hands and wrists.

 

Pathophysiology
Typically the onset of rheumatoid arthritis is between the ages of 36 and 50. It affects around 0.8% of adults worldwide, with females being three times more susceptible than males (Braun & Anderson, 2017) . The exact cause of rheumatoid arthritis is unknown. Physicians don't know what starts or triggers the process of RA, although a genetic component appears likely (Grassi et al., 1998). While your genes don't cause rheumatoid arthritis, they can make you more susceptible to environmental factors, such as infection with certain viruses and bacteria, that may trigger the disease. The etiology is likely a combination of genetic susceptibility, and immune triggering event or subsequent development of autoimmunity against synovial cells . Rheumatoid arthritis occurs when your immune system attacks the synovium which is the lining of the membranes that surround the joints (Braun & Anderson, 2017). Chronic inflammation and hyperplasia of the synovial membranes which for reference are connective tissues that line the joints, alongside increased synovial exudate, will lead to swelling and thickening of the synovial membrane, causing joint erosion and pain (Braun & Anderson, 2017). Despite the lack of identifiable triggers, autoimmunity plays a key role in Rheumatoid arthritis. As stated by Braun & Anderson (2017) helper T cells CD4+ have been implicated as activating the inflammatory response along with the release of cytokines. Lymphocytes and plasma cells then form antibodies in the synovial membrane . Being that this is an autoimmune disease the antibodies see other antibodies within the body as foreign and harmful. The antigens and antibodies then form complexes, called immune complexes. These immune complexes are found in the synovium of most individuals diagnosed with RA. These antigen-antibody complexes trigger an exaggerated inflammatory response. This then results in the individual's immune system attacking the tissues of the joints, causing pain and inflammation and permanent damage especially in the early years of the disease(Grassi et al., 1998).

Clinical manifestation

Clinical manifestation
Rheumatoid Arthritis can be presented through many signs and symptoms. Joints may feel stiffened, specifically more in the morning or after inactivity, and when the weather is colder or more humid. Additionally, individuals may feel their joints to be more tender, warm, and inflamed (Mayo Foundation for Medical Education and Research, 2019). Inflammation is marked by excess production and release of inflammatory mediators. These inflammatory mediators act on the vasculature of the joints to cause increased dilation of blood vessels and capillary permeability. The most common mobile targets for inflammation are in the knees, wrists and hands, and fingers (Braun & Anderson, 2017). As the disease progresses, symptoms often spread to the wrists, knees, ankles, elbows, hips and shoulders. In most cases, symptoms occur in the same joints on both sides of your body. Aside from pain and discomfort in the joints, there may be fatigue, general weakness, fever, dry mouth and loss of appetite. With early rheumatoid arthritis, it tends to affect your smaller joints first, particularly the joints that attach your fingers to your hands and your toes to your feet. 

 

Diagnostic criteria
There is currently no definitive test to diagnose RA, a diagnosis is based on a history of joint pain and stiffness and a physical examination, a doctor will check the joints for swelling, redness and warmth they may also check reflexes and muscle strength (Heidari, 2011) . Rheumatoid arthritis is a diagnostic challenge due to many auto-antibodies being reported to be involved with this disease. As mentioned by Heidari (2011) many tests indicate the presence of an inflammatory or autoimmune process but do not directly point to RA as the cause as the tests are not specific to RA. Several diagnostic tests may be involved in order to confirm RA. Blood test includes checking for elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP), which may indicate the presence of an inflammatory process in the body (Braun & Anderson, 2017). Other common blood tests look for rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP) antibodies. Furthermore, imaging tests may be recommended like X-rays, MRIs and ultrasounds. X-rays will help to identify and track the progression of rheumatoid arthritis in joints over time. The MRIs and ultrasound tests can help your doctor judge the severity of the disease in the body. The problem with so many tests is that the diagnosis may not be definitive as some tests also have a risk of false-positive or false-negative results ( Mayo Clinic, 2019). The diagnostic challenge can lead to frustration for the patient and health care professional and may lead to a delay in treatment.

Treatment
There is no cure for RA, but through the balance of pharmacological and nonpharmacological reatment, it can induce remission of symptoms, more so when treatment begins earlier on. With medications like disease-modifying antirheumatic drugs (DMARDs) which can slow the progression of rheumatoid arthritis and save the joints and other tissues from permanent damage (Heidari, 2011) . Other drugs that may serve as beneficial include steroids, anti-inflammatory, and immunosuppressive drugs (Braun & Anderson, 2017).
Regarding non-pharmacological strategies, a physician may recommend going to a physical or occupational therapist who can show the individual exercise to keep joints flexible and promote mobility. Additionally, a therapist may suggest new ways to complete daily tasks making it easier on the joints, for instance using your forearms to pick up an object rather than your hands or fingers. OTs and PTs may also introduce new devices that may help ease pain and mobility for the individual. If medications and therapies seem to be ineffective, one or more surgeries may be an option to consider to repair damaged joints, as it could restore the ability and use of the joint and reduce pain (Mayo Clinic, 2020) .

Questions:
1. Rheumatoid arthritis has been associated with multiple comorbidities and tends to increase a person's need for health care. Based on what you know about Shirley how likely is she to develop another disease ? Given her current situation what other diseases is she likely to develop (consider her mental well-being) ? What can be done to prevent or decrease the likelihood of her being diagnosed with another chronic disease?

2. What treatments plan or medications would you recommend for Shirley, given her condition? What things do you believe she should avoid, or try in order to improve the mobility in her hands? Do you believe there is a possibility to reverse some symptoms or alleviate the pain in the future?

3. As Shirley’s has limited options in regards to her work, what would you recommend she do so she can provide for herself and her son? Are there any alternatives in her landscaping specialization that require less manual labour ?

4. Given the strained relationship with her sister and doubt from her parents regarding the arthritis due to her age, what coping mechanisms can be recommended to Shirley and her family, so mend the relationship?