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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

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Table 34-1. Criteria for the Classification of Rheumatoid Arthritis

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