Rheumatoid arthritis: early diagnosis and management

Rheumatoid arthritis: early diagnosis and management

ABSTRACT. Chiropractors are confronted daily with patients complaining of painful or stiff joints. This may be an early clue to a more severe disorder. Rheumatoid arthritis (RA) is easily recognized in its late stages by classic findings such as swan-neck and boutonniere deformities or by joint destruction visualized by radiographic examination. However, in its early stage, rheumatoid arthritis is often difficult to diagnose and may be confused with other types of arthritides, viral infections, or musculoskeletal problems. Because rheumatoid arthritis is a systemic disease, the patient may initially complain of symptoms such as fatigue, anorexia, or weight loss accompanied by generalized aching or stiffness. The diagnosis of rheumatoid arthritis is dependent on a pattern of clinical symptoms and signs that must be present for at least 6 weeks. Early diagnosis is crucial to the effective management of a patient with rheumatoid arthritis, and the extent of the joint damage directly affects the application of chiropractic manipulation. The Mercy Center Consensus Conference document has assigned cervical manipulation as an absolute contraindication in a patient with rheumatoid arthritis. This paper utilizes the guidelines of the Mercy document in the overall management of the patient with rheumatoid arthritis.

KEY WORDS: (MeSH) Rheumatoid arthritis -- Manipulation -- Diagnosis -- (Non MeSH) -- Contraindications -- Mercy Center Consensus Conference.

A DOCTOR OF CHIROPRACTIC IS OFTEN CONfronted with a patient who complains of joint stiffness, joint pain, fatigue, or weight loss. These possibly could be early clues to a more severe disorder such as rheumatoid arthritis. Rheumatoid arthritis (RA) is a systemic disease that commonly affects females two times more than males. The etiology of RA remains unknown; however, recent studies have cited genetic, hormonal, reproductive, and environmental factors as possible predisposing factors. Also, recent data suggests a decline in the incidence rates of RA in females from 3.2 to 2.6 per 1000 persons [ 1].

Early rheumatoid arthritis can be confusing to the clinician due to the resemblance to other rheumatic disorders such as systemic lupus erythematosus, polymyalgia rheumatica, and fibrositis, and also to vital infections and common musculoskeletal problems. Because of the similarity between these conditions, the clinical picture may be confusing and makes early diagnosis of rheumatoid arthritis difficult. This article will review the pathogenesis, historical and examination findings of early RA, including laboratory and X-ray findings, and the collaborative management of a patient both with chiropractic and allopathic care.

PATHOGENESIS

It is not known what precipitates rheumatoid arthritis; however, there seems to be a role for triggering agents such as viruses, mycoplasmas, and bacterial debris. In the early stages of the disease, there appears to be microvascular injury, edema of subsynovial tissues, and mild synovial lining cell proliferation. Electron microscopic examination shows some damage to the endothelial cells and also displays phagocytosis of large mononuclear cells within the synovium and the synovial cells. These early changes suggest that the responsible etiologic factor is transported to the joint by the circulation [ 2]. Chronic RA is characterized by destruction of articular cartilage, ligaments, tendons, and bone. The damage results from a dual attack from within by digestants in the synovial fluid and from outside the joint by granulation tissue. The most important destructive element is the rheumatoid pannus, a vascular granulation tissue composed of fibroblasts, small blood vessels, and inflammatory cells. This pannus penetrates the cartilage and causes destruction. The end result and the degree of pathological changes is unpredictable. In chronic long-standing disease the granulation tissue forms adhesions. Opposing articular cartilage surfaces become adherent and organize, causing fibrous ankylosis. Capsular scarring and shrinkage impair joint mobility. Adhesions between periarticular structures and weakening of the capsular and supporting ligaments alter joint structure and function [ 3].

DIAGNOSIS

Symptoms

Rheumatoid arthritis is easily diagnosed late in the course of the disease by the joint deformities and erosions[ 4]. However, early in the course of the disease, diagnosis can be difficult because the stiffness is diffuse and the swelling is minimal. The primary focus of this article is on the early changes detected in the history and physical examination. RA usually begins gradually over weeks to months and has a variable clinical course ranging from few joints affected for a brief duration to a progressive, highly destructive disease associated with systemic involvement.

Morning stiffness in and around the joints that lasts more than an hour is characteristic of RA [ 2, 3, 5-8]. The stiffness is brought on by inactivity such as sleep or prolonged sitting and may limit the ability to walk, climb stairs, or open containers. The patient may also have systemic complaints such as fatigue and weight loss accompanied with generalized musculoskeletal pain. Accompanying the stiffness may be complaints of pain, limitation of motion, and swelling.

Physical Examination Findings

Bilateral involvement in rheumatoid arthritis is the rule, but the joints from side to side may flare disconcordantly with each other [ 2]. In a study by Fleming et al. [ 9], symmetrical joint involvement at onset was seen in 70% of the patients studied and this figure rose to 85% within 1 year. In a continuation of the same study, it was found that the pattern of joint involvement commonly involved the metacarpophalangeal (MCP) joints, the proximal interphalangeal (PIP) joints, and the wrists. Joint examination early in the disease reveals minimal swelling that is fusiform or spindle shaped at the PIP or MCP. Because swelling is minimal, it is important to palpate for tenderness. RA cannot be diagnosed early unless there is definite soft-tissue tenderness and swelling of one or more joints [ 6].

Tenosynovitis, particularly of the extensor carpi ulnaris, may be one of the earliest and most important signs of RA because swelling of the PIP and MCP is found in other arthritides [ 2, 7]. Signs of inflammation (tenderness, swelling, heat) are also detected along with loss of range of motion. Rheumatoid arthritis is not limited to the peripheral joints. Of particular importance to the chiropractor is cervical spine involvement. Atlantoaxial subluxation may occur as a result of synovial proliferation and transverse ligament laxity [ 5]. In early RA the patient may complain of intermittent neck pain, stiffness, and headache or may not have any symptoms. Cervical spine examination discloses localized tenderness, muscle spasm, and limitation of rotary motion [ 3]. Although not widely used, the Sharp Purser [ 10] test can be used to determine whether the atlas is translating forward on the axis. The palm of one hand is placed on the forehead and the thumb of the other hand is placed on the spinous process of the axis. The head is then brought through passive motion into extension. The doctor can palpate the translation forward. A full neurologic examination is required to determine the extent of involvement.

X-Ray and Laboratory Examination

X-ray and laboratory procedures play a secondary role in the diagnosis of rheumatoid arthritis. The role is one of confirmation and to monitor the progression of the disease and the effects of therapy [ 2, 3, 5, 7, 11-13]. It is not prudent to order X-rays for an "arthritis screen" (includes cervical spine, shoulders, hands, pelvis, hips, knees, and feet) in the early stage of rheumatoid arthritis because joint erosions are not yet evident and it would expose the patient to unnecessary radiation. A possible alternative is radionuclide bone scan, which is much more sensitive than roentgenography in early disease but is not specific [ 13, 14]. Magnetic resonance imaging may provide useful information in regard to cartilage anatomy and in determining extensive disease [ 14]. Roentgenograms can help confirm the diagnosis of RA or establish a baseline to monitor progression of the disease or can be Used to determine the effectiveness of drug interventions [ 2, 12]. A posteroanterior view of the hands is sufficient for this purpose. However, X-rays are indicated at other localized sites of complaint [ 12].

The role of laboratory examination is of confirmation. No single set of hematologic, chemical, or serologic laboratory abnormalities are pathognomonic of RA [ 7]. Rheumatoid factor (RF) should not be ordered as a screening test due to other forms of diseases that have a positive RF test. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels are commonly elevated in patients with active RA. ESR and CRP can be useful in monitoring the patient [ 7, 15].

Differential Diagnosis

Rheumatoid arthritis can present in a variety of ways that can make diagnosis difficult. RA must be differentiated from systemic lupus erythematosus, polymyalgia rheumatica, and fibrositis (see Table 1). The differentiating features are location of the pain, joint stiffness, and the amount of joint swelling. The pain and stiffness in RA is usually the PIP, MCP, or wrists and is bilateral, worst in the morning. However, SLE, polymyalgia rheumatica, and fibrositis have an increase in pain with use. The joint swelling is palpated as warm and tender in RA at all involved joints compared with SLE, polymyalgia rheumatica, and fibrositis, where these findings are usually rare or mild.

Criteria for Diagnosis

The diagnosis of rheumatoid arthritis is a clinical one. Because there is not a specific test for RA, the descriptive criteria will remain the basis for diagnosis of the disease [ 5]. In 1987 the American College of Rheumatology (ACR) revised the criteria for the classification of RA (see Table 2) [ 15]. According to this table a patient is classified to have RA if at least four of the seven criteria are present.

MANAGEMENT

Chiropractic Management

Manipulation or Adjustment: Manipulation by definition in the Mercy Center Consensus Conference document is "passive movement of short amplitude and high-velocity which moves the joint into the paraphysiologic range..." and adjustment as "...high or low velocity; short or long lever; high or low amplitude; with or without recoil...may or may not involve the cavitation or gapping of a joint..." [ 16]. As a general rule, manipulation is avoided in joints in acute inflammation. This rule can be applied to rheumatoid arthritis in that joints that are acutely inflamed should not be manipulated. Since RA does not typically effect the sacroiliac, lumbar, or thoracic spine, manipulation can be utilized if indicated, in a nonacute stage. However, each of the apophyseal and ligamentous articulations of the cervical spine is susceptible to the same inflammatory changes as those in peripheral joints [ 17]. A patient may have damage to the cervical spine without any symptomatology. The literature states that manipulation of the cervical spine in a patient with rheumatoid arthritis is an absolute contraindication [ 18-20]. Because of the weight of evidence regarding cervical spine changes from expert consensus, case studies, and reviews, the Mercy Center Consensus Conference gave manipulation of the cervical spine a moderate to high condition rating for risk of complication. This represents an absolute contraindication to high-velocity thrust procedures in anatomical regions involved. The Mercy document is a guideline for care of a patient and as stated in its disclaimer "...is intended to be flexible and places the ultimate judgment in the hands of the individual practitioner."

The definition of an absolute contraindication from the above-mentioned document states, "Any circumstance which renders a form of treatment or clinical intervention inappropriate because it places the patient at undue risk." The risk to a patient with RA in general and especially after manipulation is subluxation of the atlas on the axis. It would seem that this absolute contraindication could move to a relative contraindication which is defined as, "Any circumstance that places the patient at undue risk unless treatment approach is modified." A treatment approach can move from an absolute to relative contraindication or decrease the complications of manipulation depending on a) practitioner's knowledge, b) practitioner's skill in diagnosis and manipulative techniques, c) practitioner's rational attitude and adequate diagnostic habits, and d) proper reevaluation and referral [ 21]. The contraindication is for high velocity manipulation of the cervical spine. It is recommended that mobilization without a thrust or impulse combined with neuromuscular therapies and stretching may improve the patients range of motion and give symptomatic relief [ 19, 22, 23].

Splints, Exercise, and Physical Modalities: It is best if management of RA is approached according to the acute, subacute, and chronic (inactive) phases. The goal is to provide analgesia, prevent and relieve joint contractures and to improve function. It is important that before any exercises are recommended that concomitant health problems and limitations due to the disease process be thoroughly investigated.

Acute Phase: Acutely inflamed rheumatoid joints need to be protected from overstretching. Inflamed joint capsules, ligaments, and tendons are vulnerable to tearing [ 24]. Protection can be accomplished by splinting the inflamed joints, which provides temporary local rest. The goals of splinting range from relief of pain and inflammation to improvement of function [ 25]. Physical modalities can be used prior to exercise or mobility to decrease pain and facilitate movement. Due to the variation of pain receptors in RA, the choice of modality should be determined by patient preference and the presence of acute or chronic inflammation [ 26]. Heat includes hydrocollator, paraffin and diathermy, and cold includes ice pack and ice massage. Cold is contraindicated when Raynaud's phenomenon is apparent. Exercise includes active and passive range of motion and strengthening. In the acute stage, range of motion should only be carried out once or twice with gentle force at end range and then the joint should be rested and maintained in anatomical position [ 27, 28].

Subacute Phase: Heat is recommended prior to exercise to warm the joint and increase the extensibility of contracted soft tissue. The preferred timing for range of motion exercise is when stiffness has subsided later in the morning [ 29]. The types of range of motion include passive, assistive, active, and mechanically assisted. These should be incorporated throughout the day with 2-10 repetitions. The strengthening exercises are important to restore and improve function or the ability for the muscles to do work, not to build muscle size [ 27, 29]. These include isometric exercises that are safe and have minimal joint movement and strain. Isotonic exercise can also be utilized provided pain and supporting structures are not a problem [ 29].

Chronic Phase (Inactive): Range of motion, isometric, and isotonic exercises can be maintained depending on the amount of joint derangement. It is crucial that during the inactive phase that aerobic conditioning be maintained or improved [ 27-29]. Heat may be utilized to warm the joints prior to exercise and ice can be used to control for postexercise inflammation.

Nutrition: The role of nutrition in rheumatoid arthritis has been a controversial one. Recently, there is renewed interest in the role of food allergy or food intolerance [ 30-32]. Elimination diets may help determine if the patient does indeed have a food allergy. Corn and wheat were found to possibly cause symptoms in patients with RA [ 31]. Also, challenge with dairy products produced marked exacerbation of arthritis, as measured by increased pain, morning stiffness, swelling, and decreased grip strength [ 32]. Nutritional supplementation has been utilized when levels have been found to be low and also for immunoenhancing effects. The suggestion has been for supplementation of vitamin C, copper, zinc, Lhistidine, and pantothenic acid [ 32, 33].

Allopathic Management

Knowledge of allopathic management of rheumatoid arthritis is a vital step in coordinating collaborative care. It is therefore important to have knowledge of the drug interventions used in the allopathic management of a patient with rheumatoid arthritis. Once RA is suspected, an immediate referral is indicated to a rheumatologist. Rheumatologists use a stepwise, pyramidal approach to drug management (see Fig. 1). In this concept other treatments higher in the pyramid are not implemented until previous treatments have been tried and failed.

A therapy's position is dependent on a) how quickly they act, b) how toxic the treatment is, and c) efficacy. The variability in the natural history is a perplexing factor in the decision of which drug to prescribe. Usually 3-4 weeks is needed before treatment effectiveness and improvement can be detected clinically [ 34]. Several months may pass before the maximal effects of nonsteroidal anti-inflammatory (NSAID) therapy are achieved. The traditional pyramid does not call for the use of disease-modifying drugs until later in the disease, which may be after the progression of joint destruction.

Recently, there have been new thoughts about the traditional use of the pyramid where the authors point out that some of the drugs higher in the pyramid can actually modify the disease and may be less toxic than NSAID [ 35-37]. They therefore call for these drugs to be used earlier in the treatment regimen.

CONCLUSION

In its early stages rheumatoid arthritis can be difficult to diagnose due to its variable presentation. Morning stiffness that lasts more than an hour is characteristic of RA. The most common joints affected are the proximal interphalangeal joint, metacarpal phalangeal joint, and the wrists. Once diagnosed, a chiropractor can collaboratively manage the patient with a rheumatologist. Chiropractic management includes manipulation exercise, splints, and physical modalities. Manipulation of the cervical spine should only be used if the patient does not have active disease and it is indicated.

The Mercy Center Consensus Conference has given cervical manipulation for a patient with RA an absolute contraindication for high velocity cervical manipulation. However, mobilization procedures can be utilized. The Mercy document is a guide for the practice of chiropractic. Ultimately, the decision for the benefit or risk of therapeutic procedures is left to the expertise of the individual practitioner.

ACKNOWLEDGMENTS

The author would like to thank the resident supervisor, Dr. Alfred Traina, for reviewing the article and guidance. Also, thanks goes to the Los Angeles College of Chiropractic library staff for their professionalism and efficiency in helping with the literature review.

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Article copyright The National College of Chiropractic.

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By Jacquline D. Bougie

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