1. Rheumatoid Arthritis
(RA)
• A chronic, systemic disease
characterized by inflammation of
connective tissue in the synovial
joints
• Typically have periods of remission
and exacerbation
2. Rheumatoid Arthritis
(RA)
• Affects all ethnic groups
• Can occur at any time of life
• Incidence ↑ with age
• Women are affected 2-3 times more
frequently then men
• Smoking appears to be a link
3. Etiology and
Pathophysiology
• Cause of RA is unknown
• No infectious agent has been
cultured from blood and synovial
tissue or fluid
• Autoimmune etiology is currently the
most widely accepted
4. Etiology and
Pathophysiology
• Autoimmunity
– Changes begin when a susceptible host
experiences an initial immune response
to an antigen
– Antigen triggers the formation of an
abnormal immunoglobulin G (IgG)
5. Etiology and
Pathophysiology
• Autoimmunity
– RA is characterized by the presence of
autoantibodies (rheumatoid factor [RF])
– RF and IgG form immune complexes that
initially deposit on synovial membranes
or superficial articular cartilage in the
joints
– An inflammatory response results
6. Etiology and
Pathophysiology
• Autoimmunity
– Joint changes from chronic inflammation
begin when the hypertrophied synovial
membrane invades the surrounding
• Cartilage
• Ligaments
• Tendons
• Joint capsule
7. Etiology and
Pathophysiology
• Autoimmunity
– Pannus (a proliferation of synovial tissue)
forms within the joint
– Eventually covers and erodes the entire
surface of the articular cartilage
– Pannus scars and shortens supporting
structures
• Tendons
• Ligaments
– Causing joint laxity, subluxation, and
contracture
8. A. Synovial swelling & fluid accululation
B. Pannus, eroded articular cartilage &
joint space narrowing
10. Etiology and
Pathophysiology
• Genetic factors
– Genetic predisposition appears to be
important in the development of RA
– Strongest evidence for a familial
influence is the ↑ occurrence of certain
human leukocyte antigens (HLA)
11. Clinical Manifestations
Joints
• Onset of RA is typically insidious
• Nonspecific manifestations may
precede the onset of arthritic
complaints
– Fatigue
– Anorexia
– Weight loss
– Generalized stiffness
12. Clinical Manifestations
Joints
• Stiffness becomes more localized in
the following weeks to months
• Some patients report a history of
precipitating stressful events
– Research has been unable to correlate
such events directly with the onset of
RA
13. Clinical Manifestations
Joints
• Specific joint involvement
– Pain
– Stiffness
– Limitation of motion
– Signs of inflammation
• Heat
• Swelling
• Tenderness
14. Clinical Manifestations
Joints
• Joint symptoms occur symmetrically
and frequently
– Small joints of the hands and feet
– Larger peripheral joints
• Wrists, elbows, shoulders, knees, hips,
ankles, and jaw
– Cervical spine
15. Clinical Manifestations
Joints
• Often experience joint stiffness
after periods of inactivity
• Morning stiffness may last from 60
minutes to several hours or more
• Joints become tender, painful, and
warm to the touch
16. Clinical Manifestations
Joints
• Joint pain
– ↑ with motion
– Varies in intensity
– May not be proportional to the degree
of inflammation
– Tenosynovitis
• Difficult for patients to grasp objects
17. Clinical Manifestations
Joints
• Inflammation and fibrosis of the
joint capsule and supporting
structures may lead to deformity and
disability
• Subluxation
– Atrophy of muscles and destruction of
tendons around the joint cause one
articular surface to slip past the other
23. Rheumatoid Nodules
• Develop in 25% of all patients with
RA
• Usually have high titers of RF
• Appear as firm, nontender,
granuloma-type masses
• Usually over the extensor surfaces
of joints such as fingers and elbows
24. Rheumatoid Nodules
• Nodules at the base of the spine and
back of the head are common in older
adults
• Develop insidiously
• Can persist or regress spontaneously
• Usually not removed
28. Complications
• Flexion contractures and hand
deformities
– Cause diminished grasp strength
– Affect the patient’s ability to perform
self-care tasks
29. Complications
• Cataract development and loss of
vision possible from scleral nodules
• Rheumatoid nodules can ulcerate,
similar to pressure ulcers
• Hoarseness from nodules on the vocal
cords
30. Complications
• Bone destruction from nodules in the
vertebral bodies
• Cardiopulmonary effects later in the
disease
– Pleurisy, pleural effusion, pericarditis,
pericardial effusion, cardiomyopathy
• Carpal tunnel syndrome
