A systematic search of the medical literature was conducted on
December 27, 2006. The search, limited to human subjects and journals
in the English language, included the National Guideline Clearinghouse,
PubMed, and the Cochrane database.
Rheumatoid arthritis (RA) is a systemic disease with symmetric
inflammation of joints as a hallmark feature. Many other organ systems
may also be involved. Joint destruction with loss of ability to
perform daily functional activities often results if adequate treatment
is not used. Early treatment with therapies that slow disease progression
is recommended together with physical modalities to assist the patient
to maintain normal activities of daily living and prevent disability.
RA occurs in approximately 1% of the population. The
factors responsible for RA are not known.
Symptoms of RA often are insidious with nonspecific symptoms
such as fatigue, weakness, low-grade fever, and loss of appetite
in addition to joint symptoms. Stiffness and myalgia may precede the
development of synovitis. Joint stiffness tends to be more of a
problem early in the morning. Duration of morning stiffness is a
useful clinical parameter to follow as patients with more active inflammation
remain stiff for longer periods of time and successful suppression
of disease activity should reduce the duration ideally to less than
30 minutes. Fatigue onset tends to be earlier in the day for patients
with more active disease and lessens with effective treatment. Joint
involvement tends to be symmetrical although early in the disease,
it may involve a few joints and be asymmetrical in pattern.1 No
single physical finding or laboratory test can be used to make the
diagnosis. The American College of Rheumatology has developed criteria
for RA classification that can be useful in making the diagnosis
(Table 34-1). These criteria have been criticized as they are not
very useful for patients with early disease. For example, radiographic
changes and rheumatoid nodules are late-disease manifestations and
symmetric involvement may not be seen early in the disease.2
Table 34-1. Criteria for
the Classification of Rheumatoid Arthritis |Favorite Table|Download (.pdf)
Table 34-1. Criteria for
the Classification of Rheumatoid Arthritis
|1. Morning stiffness||Stiffness of joints lasting at least 1 h before improvement|
|2. Arthritis of 3 or more joints||Soft-tissue swelling or fluid in joint|
|3. Arthritis in hand joints||At least one swollen wrist, MCP, or PIP|
|4. Symmetric joint swelling||Simultaneous involvement of bilateral joint areas|
|5. Rheumatoid nodules||Subcutaneous nodules over extensor tendons, bony prominences,
or near joints|
|6. Positive rheumatoid factor||Significantly elevated rheumatoid factor concentration|
|7. Radiographic changes||Characteristic changes for rheumatoid arthritis noted on hand
radiographs including erosions and periarticular osteoporosis|
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