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Musculoskeletal Function
symptom of vasculitis. The visceral organs, such as the
heart, lungs, and gastrointestinal tract, also may be
affected.
Dryness of the eyes, mouth, and other mucous mem-
branes may occur, especially in advanced disease. Ocular
manifestations include episcleritis, scleritis, and scle-
romalacia, which is due to scleral nodules. Additional
extra-articular manifestations of RA include pulmonary
fibrosis and pericarditis. A small number of persons
have splenomegaly and lymph node enlargement.
Diagnosis.
The diagnosis of RA is based on findings
of the history, physical examination, and laboratory
tests. In 2010, the American College of Rheumatology/
European League Against Rheumatism collaborated to
develop new classification criteria for RA
39
(Chart 44-2).
The new criteria are aimed at diagnosing RA earlier in
persons who meet the 1987 classification criteria.
Because changes in joint structure usually are not vis-
ible early in the disease, diagnosis is often difficult. On
physical examination, the affected joints show signs of
inflammation, swelling, tenderness, and possibly warmth
and reduced motion. The joints have a soft, spongy feel-
ing because of the synovial thickening and inflamma-
tion. Body movements may be guarded to prevent pain.
The combined serologic presence of the RF and
ACPA are findings that are sensitive and fairly specific
for RA.
3,4,37
The presence of ACPA, which are often
detected very early in RA, appear to be a good prog-
nostic marker for the disease and discriminates between
erosive and nonerosive forms of the disease. Disease
severity and activity tend to correlate with RF levels;
patients with high RF levels tend to have a significantly
higher frequency of extra-articular involvement (e.g.,
rheumatoid nodules, vasculitis, neuropathy). Synovial
fluid analysis can be helpful in the diagnostic process.
The synovial fluid has a cloudy appearance, the white
blood cell count is elevated as a result of inflamma-
tion, and the complement components are decreased.
Radiologic findings provide the most specific evidence
of joint changes in RA, but are often normal during the
early stages of the disorder.
Treatment.
The treatment goals for a person with RA
are to reduce pain, minimize stiffness and swelling,
maintain mobility, and become an informed health care
consumer. The treatment plan includes education about
the disease and its treatment, physical rest, therapeutic
exercises, and medications. Because of the chronicity
of the disease and the need for continuous, long-term
adherence to the prescribed treatment modalities, it is
important that the treatment be integrated with the per-
son’s lifestyle.
Both physical rest and therapeutic exercises are
important aspects of care.
36
Physical rest reduces joint
stress. Rest of specific joints is recommended to relieve
pain. For example, sitting reduces the weight on an
inflamed knee, and the use of lightweight splints reduces
undue movement of the hand or wrist. Although rest
is essential, therapeutic exercises also are important
in maintaining joint motion and muscle strength.
37,38
Proper posture, positioning, body mechanics, and
the use of supportive shoes can provide further com-
fort. There often is a need for information about the
CHART 44-2
Criteria for Classification of Rheumatoid
Arthritis
Patient Characteristics*
Score (points)
Distribution of affected joints
(number and site)
2 to 10 large joints (shoulders,
elbows, hips, knees, and
ankles)
1
1 to 3 small joints
(metacarpophalangeal joints,
proximal interphalangeal
joints, 2nd through 5th
metatarsophalangeal joints,
thumb interphalangeal
joints, and wrists)
2
4 to 10 small joints
3
Greater than 10 joints
(including at least 1 small
joint)
5
Serology (RF or ACPA)
Low positive (above the upper
limit of normal, ULN)
High positive (greater than
three times the ULN)
2
3
Acute phase response (ESR or
CRP) above the ULN
1
Symptom duration at least 6 weeks
1
In addition to those that meet these criteria, which are
best suited to persons with newly presenting disease,
the following patients are classified as having RA:
■■
Persons with erosive disease typical of RA with a
history compatible with prior fulfillment of the criteria
■■
Persons with longstanding disease, including those
with inactive disease (with or without treatment)
who have previously fulfilled these criteria upon
retrospectively available data
*Classification of definite RA based upon the presence
of synovitis in at least one joint, the absence of an
alternative diagnosis that better explains the synovitis,
and the achievement of a total score of at least 6
(of a possible 10) from the individual scores in four
domains.The highest score achieved in a given domain
is used for this calculation.These domains and their
values are:
ACPA, anti-cyclic citrullinated peptide antibodies; CRP,
C-reactive protein; ESR, erythrocyte sedimentation
rate; RF, rheumatoid factor.
Adapted from: Aletaha D, NeogiT, Silman AJ, et al.
Rheumatoid arthritis classification criteria: an American
College of Rheumatology/European League Against
Rheumatism collaborative initiative. Arth Rheum.
2010;62(9):2569.
