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RHEUMATOID ARTHRITIS  
 
 
Version 2 Final 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Document control 
 
Version history 
Version Date 
Comments 
 
 
 
2e Draft 
28/02/08 
Customer comments incorporated  
2d Draft 
04/02/08 
Formatting 
2c Draft 
20/01/08 
Incorporation of external Q.A. comments by Dr 
Thomas 
2b Draft 
18/09/07 
Internal QA by Dr Gill Buchanan 
2a Draft 
04/09/07 
Initial Draft of triennial revision 

Final 
10/03/08 
Signed off by Medical Services Contract 
Management Team 
Changes since last version 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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1. Introduction 
Rheumatoid arthritis is a chronic autoimmune disease, producing joint 
damage mediated by cytokines, chemokines, and metalloproteases.  It is 
speculated that rheumatoid arthritis is a relatively new disease because 
there is a surprising lack of historical evidence for its existence. 
 
Description 
 
It is a common systemic disease characterised by a chronic inflammatory 
synovitis which typically affects the peripheral joints but which may affect 
any synovial joint in the body and periarticular synovial structures (bursae 
and tendon sheaths).  It can manifest as a single episode of painful, stiff 
joints lasting a few months or as an aggressive, destructive arthritis that 
progresses rapidly to severe physical disability. Most frequently the 
patient follows a relapsing and remitting course over many years. [1] 
 
Rheumatoid arthritis is typically a distal, symmetrical, small joint 
polyarthritis involving the proximal interphalangeal and metacarpo- and 
metatarsophalangeal joints of the hands and feet, knees and cervical 
spine. The shoulders, elbows and hips are less frequently involved but 
can cause considerable morbidity.  [2] 
 
The disease is regarded as an autoimmune disease and can have extra-
articular manifestations that may involve cardiovascular, respiratory, 
nervous and lymphatic/haematological systems and the skin, connective 
tissues, eyes, and mouth. 
 
Equally important to affected individuals is the potential loss of social and 
financial independence.  [3] 
 
The disease also exerts a considerable burden on society in terms of 
direct (i.e. medical care) and indirect (ability to work) costs.  [4] 
 
 
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2.  Aetiology 
Aetiology 
 
Although rheumatoid arthritis is regarded as an autoimmune disease, 
details of its pathogenesis remain unclear. It is probably a multifactorial 
disease which occurs when several risk factors occur simultaneously. 
 
There is considerable evidence for an important genetic component and 
a substantial portion of this risk seems to lie in the HLA region (HLA-
DR4). 
 
Predominant non-genetic factors include a theoretical ubiquitous infective 
cause or trigger and environmental influences. [5]   The onset of 
rheumatoid arthritis occurs more commonly in winter [2].  Cigarette 
smoking is also thought to play a role. [6] 
 
Hormonal influences may be significant because use of the oral 
contraceptive pill postpones or modifies the presentation.  Clinical signs 
and symptoms vary in intensity with the menstrual cycle, often abate 
during pregnancy and flare in the post partum period. 
 
Interestingly, in middle aged men nonarticular features (fever, weight 
loss, anaemia, pleural effusions and vasculitic lesions) may dominate the 
clinical picture. [2] 
 
The main pathology in rheumatoid arthritis is an auto-immune mediated 
thickening and inflammation of the synovial membrane, which becomes 
infiltrated with inflammatory cells. The synovial lining layer becomes 
continuous with vascular tissue, termed pannus, which grows over 
cartilage and causes erosion of articular cartilage and underlying bone 
due to its high content of macrophages and osteoclasts. 
With time this results in degeneration of the cartilage and the joint. 
 
Plasma cells in the subsynovium synthesise large quantities of 
immunoglobulin much of which is IgG and IgM rheumatoid factor (i.e. 
immunoglobulin with reactivity to self Ig-G). These autoantibodies form 
immune complexes that activate complement and this can cause or 
maintain local inflammation. 
 
Several observations suggest that the inflammation in rheumatoid arthritis 
is a T-Cell mediated phenomenon. 
 
Rheumatoid nodules develop in about 30% of patients with RA. They are 
granulomas consisting of a central necrotic area surrounded by palisaded 
histiocytic macrophages, all enveloped by lymphocytes, plasma cells, and 
fibroblasts. Nodules and vasculitis can also develop in many visceral 
organs.  [7] Other granuloma formation may be seen on the surface of 
the pleura, pericardium and endocardial valves.  
 
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Prevalence 
 
Rheumatoid arthritis affects about 1% of the American and Western 
European population with much lower rates in oriental and black 
populations. Although virtually non-existant in Nigeria, prevalence among 
US blacks is around 1%. There is a ratio of 3:1 females to males. It may 
occur at any age, onset is rare under 20 and over 80 (1) and peaks in the 
fourth and fifth decade. 
 
The sex difference is most pronounced in those with early onset disease, 
6:1 females to males, but is almost equal by age 65 years. 
 
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3.  Characteristics signs and symptoms in 
articular rheumatoid arthritis 

The common symptoms and signs are joint swelling, stiffness and 
deformity, nodules, vasculitis and malaise. 
 
Onset may be acute with simultaneous inflammation in multiple joints but 
is more often insidious with progressive joint involvement. Affected joints 
are tender, swollen and warm and both active and passive movements 
are limited. This is due to joint effusion and florid synovitis. 
 
Tenderness of affected joints is a very sensitive sign and synovial 
thickening, eventually of all affected joints, is a most specific sign. 
Symmetrical involvement of hands (PIP and MCP), feet (MTP), wrists, 
elbows and ankles is typical but any joint may be affected 
 
Generally patients complain of feeling unwell in themselves and present 
with loss of function and pronounced stiffness more than pain. Morning 
stiffness of more than 60 minutes is almost pathognomonic of active 
rheumatoid arthritis. Stiffness of more than 60 minutes duration may also 
occur after prolonged inactivity and at night. [7] 
 
Inflammatory tenosynovitis can erode through tendons causing rupture 
and compression of nerves by synovitis and this can commonly lead to in 
carpal tunnel syndrome. [8]  
 
Individual joints may be affected as follows: 
Cervical spine 
Frequently involved. Atlanto-axial subluxation gives rise to neck pain, 
neck stiffness, paraesthesiae and sensory changes. Abnormal gait and 
urinary retention or incontinence occurs if there is spinal cord 
involvement. 
A "Cock robin" posture is due to erosion of vertebral body(ies) in cervical 
and upper thoracic areas.  
  Hands and wrists 
 
Fixed deformities, particularly flexion contractures, may develop rapidly; 
ulnar deviation of the fingers with an ulnar slippage of the extensor 
tendons off the metacarpophalangeal joints is typical, as are swan-neck 
and boutonnière deformities. Over time the metacarpophalangeal joints 
sublux. Range of movement and strength may be dramatically reduced. 
 
 
 
 
 
 
 
 
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Carpal tunnel syndrome can result from wrist synovitis pressing on the 
median nerve. 
 
                                                                                                                                           
 
                                                             
 
         Ulnar deviation                                                                        Boutonniere deformity                    
  Feet and ankles 
In decreasing frequency there can be involvement of metatarsal 
phalangeal joints, talonavicular, subtalar, and ankle joints. Lateral 
deviation of the toes causes hallux valgus. Dorsal subluxation of the 
metatarsophalangeal joints uncovers the heads of the metatarsals and 
may cause metatarsalgia, a painful sensation of “walking on marbles”. 
Both medial and lateral arches may collapse, resulting in pes planus and 
heel valgus, accelerated by rupture of the tendon of tibialis posterior, a 
frequent association. Metatarsophalangeal joint” [2] involvement can also 
cause hammer toes. 
 
 
 
 
Shoulders 
Effusions with inflamed rotator cuff tendons give rise to painful abduction 
arcs and loss of shoulder movements.  Rupture of the rotator cuff can 
occur. 
 
Elbows 
 

75% of patients with rheumatoid arthritis complain of elbow pain, 20% 
severely. Joint effusions, progressing to bony destruction may occur. 
Range of movement and strength decreases, especially in pronation and 
supination.  
   Hips 
Subtle reduction of internal rotation. 
 
In established rheumatoid arthritis, secondary degenerative changes can 
result in rest pain.  
 
After a variable period of time, rheumatoid arthritis may become inactive 
and may then be described as " burnt out".  At this stage there may be no 
swelling or redness, but deformed joints, surgical scars and muscle 
wasting may all be evident.  
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The degree of nonarticular involvement varies and may precede articular 
disease. 
 
Appendix 1 outlines the common extra articular manifestations. 
 
 
Revised criteria for classification of rheumatoid arthritis (1987): 
 
Any four criteria must be present to diagnose rheumatoid arthritis. Criteria 
1- 4 must have been present for at least six weeks. 
 
1. 
morning stiffness for an hour or more 
2. 
arthritis of three or more joint areas 
3. 
arthritis of hand joints (wrist, metacarpophalangeal or proximal 
interphalangeal) 
4. symmetrical 
arthritis 
5. rheumatoid 
nodules 
6. 
serum rheumatoid factor by a method positive in less than 5% of 
normal control subjects 
7. 
radiographic changes (hand x-ray changes typical of rheumatoid 
arthritis that must include erosions or unequivocal bony 
decalcification). [9] 
 
Patterns of Onset  
 
There are several distinct patterns of onset. 
Insidious onset 
In 70% of cases, increasing joint involvement develops over weeks or 
months. This has a relatively poor prognosis. Usually peripheral small 
joint involvement is followed by proximal joint (knees and hips) 
involvement. 
Palindromic 
In about 20% of patients, persistent joint disease is preceded by self 
limiting attacks of a few days of synovitis in various joints. About 50% of 
patient who have these self limiting attacks eventually develop chronic 
rheumatoid arthritis. 
Explosive onset 
10% of cases show precipitate onset with severe symmetrical 
polyarticular involvement occurring over 24 to 48 hours. Paradoxically 
they seem to do better in the longer term.  [10], [11] 
Systemic onset 
Fever, myalgia, weight loss, anaemia, pleural effusions and vasculitic 
lesions may be severe sometimes in the absence of marked joint 
pathology. It is particularly common in middle aged men. 
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Mono and Pauci articular onset 
Patients with limited joint involvement, usually young women, who are 
persistently seronegative for rheumatoid factor; usually pursues a benign 
course.  [2] 
Polymyalgic onset 
Limb girdle muscle symptoms may precede overt arthropathy particularly 
in the elderly. It may be difficult to differentiate from polymyalgia 
rheumatica initially. There is an impressive response to steroids initially 
but less so with progression of synovitis. 
Examination 
  
Soft boggy swelling of synovitis and knee effusions are common. 
Crepitus is found in early disease of degenerative joints. 
 
Joint counts - tenderness and swelling are measured separately. Swollen 
joint count is a better measure of inflammation than tender joint count 
because tenderness may be due to other causes whereas swelling is 
usually not. 
 
Investigations: A detailed table of investigations and prognostic factors 
generally undertaken in Rheumatoid Arthritis is given in Appendix 2.  
Differential Diagnosis 
Most exclusions are relative since two diseases causing arthritis can 
coexist. 
Polymyalgia rheumatica  
In the elderly, onset of proximal manifestations may be confused with 
polymyalgia rheumatica 
Osteoarthritis 
Typically, the OA patient stiffens whilst sitting down to lunch whereas a 
rheumatoid arthritis patient is usually enjoying the best part of their day.  
Crystal Arthropathies (gout, pseudogout) 
Crystal deposition in joints may mimic the swelling and redness of 
rheumatoid arthritis. 
SLE 
Rheumatoid arthritis shares many features with other collagen vascular 
diseases, particularly SLE. [7] 
Acute rheumatic fever 
Here there is a typical migratory joint involvement pattern. 
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Sarcoidosis 
Granulomatous reticulosis affecting almost any organ, including the small 
bones of the hands and feet. 
Amyloidosis 
Amyloid accumulation can be found in various organs. 
Whipples disease  
Malabsorption syndrome of which arthritis can be one of the 
manifestations. 
 
Inflammatory bowel disease 
Crohn’s disease and ulcerative colitis are both frequently associated with 
inflammatory joint manifestations. 
 
 
Investigations 
 

Until recently, Rheumatoid Factor (RF) was the test of choice. Recently, 
an assay of anti-CCP (antibody to cyclic citrullinated peptide) has 
become available and is showing promise of increased sensitivity and 
specificity (67% and 95% respectively, versus 69 and 85% for RF). Its 
exact role is yet unclear. [12] 
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4. Treatment 
 
The goals of treatment are to control synovitis, relieve pain, maintain 
function, improve quality of life and minimise drug side effects while being 
cost effective. [13] 
 
Deterioration in joint function and x-ray changes occur most rapidly early 
in the disease because cartilage had limited capacity for regeneration. 
Therefore all patients with rheumatoid arthritis should be referred early for 
specialist opinion. 
 
Management by a multidisciplinary team via hospital is considered best 
practice today.  [14]  Treatment plans have to take account of co-
morbidities, age, expectations and lifestyle. [8] 
 
Evidence is now accumulating that early, more aggressive intervention 
can improve longer term disease outcome.  [15] 
 
 
Drugs 
Two main drug classes are considered in the treatment of rheumatoid 
arthritis. 
 
Non-steroidal anti-inflammatory drugs (NSAIDS) and Disease modifying 
antirheumatic drugs  (DMARDS). 
 
NSAIDs – reduce joint pain and swelling but may take up to two weeks to 
start having an effect. There may be gastrointestinal and renal side 
effects and they are more toxic than previously appreciated. They do not 
reduce disability over the long term. 
(They are fully discussed in the sections on osteo-arthritis) 
 
DMARDS – are used to relieve pain and swelling, and to improve 
function. In addition, it is considered that they may reduce disease 
progression.  
 
The use of these drugs is indicated in all patients who continue to 
have active disease (stiffness, joint pains and elevated ESR) after 
three months of NSAID treatment. 
 
A major review of clinical trials of their use was undertaken by Clinical 
Evidence (June 2005) [13] who reported on their effectiveness 
(beneficial, likely to be beneficial and inconclusive) in conjunction with 
first or second line treatment options. 
 
The DMARD methotrexate is widely used as first-line treatment in people 
with rheumatoid arthritis because of consensus about its effectiveness in 
practice.  
 
 
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Sulfasalazine and combined treatment with methotrexate and 
sulfasalazine are as effective as methotrexate in improving pain, joint 
swelling, and function in people with early rheumatoid arthritis who have 
not previously received DMARDs.  
 
Antimalarials may improve symptoms and function in DMARD-naïve 
people, and are reasonably well tolerated, but radiological evidence of 
erosion is more marked with antimalarials than with sulfasalazine.  
 
There is a variety of DMARDs available for second-line treatment of 
rheumatoid arthritis. However there is no clear evidence that any one is 
superior to another.  
Methotrexate , sulfasalazine , penicillamine , and leflunomide cause 
similar improvements in symptoms and function when given to people as 
second-line DMARD treatment, although methotrexate causes fewer 
adverse effects. 
 
Methotrexate leads to improvement within six to eight weeks. Other 
DMARDs take three to six months to produce a beneficial effect. Relapse 
occurs if the drug is discontinued (11). Some are less toxic than 
previously thought and are more effective analgesics than NSAIDs over 
long periods. 
 
A recent introduction has been the class of drug known both as tumour 
necrosis factor antagonists (TNFAs) and cytokine inhibitors.  
Etanercept and Infliximab are the two examples currently in use and it is 
considered that in second line therapy adding either to methotrexate is 
more effective than using methotrexate alone.[16] 
 
Infliximab allows rapid disease control and reduces rheumatoid arthritis 
disease activity. It appears to have an acceptable safety profile in trials to 
date. 
 
Etanercept appears to reduce radiological progression. 
 
Currently both etanercept and infliximab have to be administered by 
injection. For maintenance, etanercept 25mg. twice weekly and infliximab 
200mg (3mg./Kg.) eight weekly.  However etanercept appears to be 
associated with fewer side effects. 
 
Oral gold was less effective than both methotrexate and sulfasalazine in 
improving measures of disease activity in people with rheumatoid 
arthritis, although it had less toxicity. Reviews found that oral gold and 
antimalarial drugs caused comparable improvements in measures of 
disease activity, but that oral gold was less effective than penicillamine. 
 
Parenteral gold caused similar improvements in measures of disease 
activity compared with methotrexate, but caused more adverse effects. 
Parenteral gold is associated with higher levels of toxicity than most of 
the other commonly used disease-modifying antirheumatic drugs. It also 
had higher total drop out rates than the other drugs. 
 
Corticosteroid use is controversial. Although corticosteroids reduce the 
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rate of progression of the disease they are generally avoided because of 
long term effects. They are indicated for life threatening complications of 
RA such as vasculitis or pericarditis. Intra-articular steroid injections are 
used for one or two affected joints. Their current effectiveness as either 
first or second line therapy is classed as “unknown”. 
Occupational Therapy 
 
In everyday practice, the substantial impact of skilled occupational 
therapy (OT) intervention on quality of life for patients with RA is clear.  
The OT approach is multifaceted and includes: 
 
Activities of daily living, particularly washing, toileting, dressing, cooking, 
eating and working.  Sometimes the provision of equipment and 
adaptations is fundamental to the management of RA.  [17] 
 
Joint protection including adapting movement patterns, assistive devices, 
rest regimens, energy conservation techniques, exercise and splinting.  
Studies in patients with longer disease duration have shown encouraging 
results.  [18] 
Physiotherapy 
 
Thorough physical therapy evaluation should be performed initially, 
including functional assessment (transfer status, gait analysis, activities 
of daily living etc.), range of movement of all joints, strength, posture and 
respiratory status. This gives a baseline for future reference and an 
accurate and objective basis for treatment goals.  [19] 
 
Exercise and physiotherapy are used to maintain or to improve muscle 
tone in order to prevent or correct deformities and to maintain or increase 
joint mobility and function. 
 
The aim is to achieve the right balance between exercise and rest. Strong 
muscles protect joints, but inflamed joints should be rested initially and 
then gradually worked through a full range of non weight-bearing 
exercises. 
 
A variety of treatment modalities including heat therapies, cold therapies, 
electrotherapy (e.g.TENS), mobilisation and massage are used in 
physical therapy. 
 
 
 
 
 
 
 
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Splinting 
 
Is used: 
 
 
To rest actively inflamed joints at night and during flare ups. 
 
For stabilisation in optimum position for use 
 
To prevent deformity and contractures 
 
Support splints may preserve adequate function 
and improve pain but may restrict dexterity. 
 
One study showed splinting produced no change 
in grip strength and there was no difference in 
grip strength between various pain levels.  [20] 
Surgery 
 
Pain is the primary indication for surgery. The most common procedures 
involve hip, knee, shoulder, elbow and hand joint replacements. Other 
procedures include synovectomies, wrist stabilisation, forefopot 
arthroplasties and excision of the head of the radius. 
 
Strong willed, strong boned, strong 
muscled and well informed patients 
are the best candidates for surgery 
but post operative restoration of 
function is difficult to predict and a 
multidisciplinary approach is 
needed. Unfortunately most 
patients do not fit this profile, and a 
frailer patient with osteoporosis, either due to the disease mechanism, 
disuse osteopenia or therapeutic steroid use, is the norm, making surgery 
technically more difficult and complications more common. 
 
Different types of surgical intervention are appropriate to different stages 
of the disease process: 
 
Early synovitis : non-operative/splinting 
 
Persistent synovitis : synovectomy of joints, which continue to have active 
synovitis despite local steroid injections, may prevent erosions 
 
Specific deformation : reconstructive 
 
Severe crippling : salvage 
 
The most successful procedures for rheumatoid arthritis are carpal tunnel 
release, resection of metatarsal heads, total knee arthroplasty (after 
which synovitis disappears) and total hip arthroplasty. 
 
Joint replacement surgery has revolutionised the outlook for RA patients 
because it relieves pain and improves function. 
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Cemented hip implants have 90% success rate. There is a higher failure 
rate in rheumatoid arthritis than in osteoarthritis and revision outcome is 
much poorer. Excision arthroplasty (Girdlestone) as a salvage procedure 
is still performed in failed primary and revision arthroplasty. 
 
Tendon transfers across the wrist may redirect line of muscle action 
where a joint deformity is exacerbated by the “bowstringing” effect of 
tendons crossing that joint, which have come to lie eccentrically due to 
the initial deformity. 
 
Podiatry and Dietetics 
 
Appropriate footwear and orthoses are effective with regards to comfort 
level, and stride speed and length. [21] 
 
Both weight management particularly when weight bearing joints are 
involved, and interventions to address cachexia where patients do less 
well and have poorer functional status can be effective.  [22] 
 
Analysis of clinical trials of fish oil supplementation in RA concluded that 
while there was reduction in the number of tender joints and in duration of 
morning stiffness, no effect was seen on disease activity or progression 
of RA.  [23] 
 
 
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5. Prognosis 
 
All studies of RA over ten years or more show severe morbidity [24] and 
patients with rheumatoid factor appear to have a more severe course.  
Spontaneous remission in RA usually occurs within the first two years.  
However 50 - 90% of those affected have progressive disease [24] and 
even after five years of antirheumatic drug therapy, complete remission is 
rare.  [25] 
 
Almost 50% of patients show joint space narrowing and/or erosion in the 
first two years, therefore permanent articular damage is often present 
which is progressive in almost all patients.  
 
About 50% of maximum scores for joints space narrowing and 
radiographic erosion is seen by five years of disease. 
 
Decline in functional status is seen in most patients with RA over periods 
longer than a decade. Many patients, however, show an improvement in 
morning stiffness over this time suggesting “burn out” but this still leaves 
significant losses in functional capacity.  
 
Clinical markers derived from joint counts, and functional status 
measures including patient self-report questionnaires, demographic 
measures and co-morbidity studies appear to be the most effective 
currently available data to predict mortality in rheumatoid arthritis. 
 
Formal education level is highly predictive of morbidity and mortality in 
RA, a more formal education correlating with less morbidity and mortality. 
A hypothesis has been proposed that low formal education is a variable 
that identifies behavioural risk factors predisposing to the aetiology and 
poor outcomes of most chronic diseases and is probably related to 
efficiency in using medical services, problem solving capacity, sense of 
personal responsibility, capacity to cope with stress, life stress, social 
isolation, health focus of control and learned helplessness [24]. 
 
Many patients with mild disease are not referred and do well. Functional 
outcome of RA after about six years of disease is fairly good and while 
functional impairment of different joints had progressed, most patients 
were still classed as mildly disabled. [26] 
 
In a ten-year follow up study of hospital admissions: 
 
 
25% were considered fit for most activities 
 
40% had moderate functional impairment 
 
25% were severely disabled 
 
10% were wheelchair bound [2] 
 
In the United States, among men 18 – 65 years with arthritis only 56% 
were working compared with 89% of men with no arthritis. Amongst 
women with arthritis 31% were working compared with 62% of women 
with no arthritis [24]. 
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Work disability is seen within ten years of disease onset in at least 50% 
of patients younger than 65 years who were working at the time of 
disease onset. 
 
Work disability has been primarily studied for patients under care referral 
centres and may not represent all patients with rheumatoid arthritis [24]. 
 
Poor outcomes in terms of functional disability correlates with female sex 
and seropositivity. 
Life Expectancy 
 
Rheumatoid arthritis significantly shortens life expectancy. Higher 
mortality rates are found among patients with persistent joint 
inflammation, seropositivity, functional loss, and lower levels of 
education. Overall the disease decreases life expectancy by three to ten 
years in both men and women. They die of expected causes, e.g. 
cardiovascular, cerebrovascular or malignant disease, but at a younger 
age [8]. 
 
The most important determinants of prognosis are the severity and 
persistence of disease activity. 
 
Disease that remains confined to the hands and feet has a good 
prognosis. 
 
Some features have shown association with a poor outcome and are 
given in Appendix 3. 
 
Measures indicating functional disability, as well as age and co-
morbidities, predict five-year mortality more effectively than laboratory 
data. Measures of inflammatory activity may underestimate long tem 
outcomes in rheumatoid arthritis. 
 
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6. Main Disabling Effects 
 
An important feature of the musculoskeletal system is that any 
impairment alters the biomechanics of contralateral joint structures or 
those continuous in the kinetic chain. This usually also increases baseline 
energy expenditure for activity.  
 
Pain, deformity, muscle wasting and flexion contracture may all contribute 
towards functional impairment. 
 
Extra-articular manifestations may further contribute towards the overall 
level of functional impairment. 
 
Common measurements of overall severity of disease include grip 
strength, global severity, joint count, morning stiffness, HAQ-DI scale 
[Appendix 4], ESR and haemoglobin level. 
 
                   Signs of synovitis are most useful in the assessment of disease activity.  
                   The reduction in the range of movement is a useful indicator of current or 
                   potential functional problems.  An indication of the activities of daily living 
                   likely to be affected beyond certain reductions is given in [Appendix 5] 
 
 
Most individuals with early rheumatoid arthritis can perform tasks of daily 
living, although with discomfort or impaired efficiency. This is achieved 
because people adapt and work within their pain and limited joint 
movement. When contractures or joint deformity progresses beyond a 
certain range for a joint the impairment will result in a functional deficit.  
[27] 
 
Functional disability progresses more rapidly in the first few years than in 
the latter course of the disease and 50% of patients have considerable 
difficulty performing their pre-morbid domestic, work and social functions 
within six years of their first clinic visit.  
 
Pain, which is unpredictable and varies in intensity and duration, is a key 
feature of RA and night time pain often contributes to sleep disturbance.  
[28] 
 
Fatigue due to poor sleep and functional impairment may both adversely 
affect social activity which in turn may adversely affect mood. This may 
account for depressive symptoms occurring more commonly in those 
suffering from RA than in the general population. 
 
 
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7. References 
 
[1]  Walker, D J. Rheumatoid Arthritis. Arthritis & Rheumatism Council for Research  
      Collected reports on rheumatic diseases 1995 
 
[2]  Wordsworth, B P. Rheumatoid arthritis Section 18.4 Oxford Textbook of Medicine  
      Third Edition Oxford University Press 1996 CD-ROM 
 
[3]  Young A, Dixey J, Cox N, Davies P, Devlin J, Emery P, et al. How does functional 
      disability in early rheumatoid arthritis (RA) affect patients and their lives?  
       Results of 5 years of follow-up in 732 patients from the Early RA Study (ERAS).  
       Rheumatol 2000; 39: 603-11.   
 
[4]  Jantti J, Aho K, Kaarela K, Kautiainen H. Work disability in an inception cohort of 
      patients with seropositive rheumatoid arthritis: a 20 year study.  
      Rheumatology 1999; 38: 1138-41.  
 
[5]  Gestel van AM et al.  Evaluation of rheumatoid arthritis disease activity and          
     outcome. Ballieres Clin Rheumatol 1997; 11 (1): 27-48 
 
[6]  Silman AJ. Rheumatoid arthritis. In: Silman AJ, Hochberg MC, eds. Epidemiology  
      of the rheumatic diseases, 2nd ed. Oxford, Oxford Press, 2004: chapter 2, 31-71.  
 
[7]  Merck Manual Professional.  www.merck.com/mmpe/sec04/ch034/ch034b.html 
         (Last full review/revision November 2005  Content last modified April 2007) 
 
[8]  Ahern MJ. et al.  Rheumatoid arthritis. Med J Aust 1997; 166 (3): 156-161 
 
[9]  Arnett FC et al.  The American Rheumatism Association 1987 revised criteria for  
       the classification of rheumatoid arthritis. Arthritis Rheumatism 1988; 31: 315-324 
 
[10]  Young A. Early Rheumatoid Arthritis Study (ERAS)  Rheumatoid.org.uk       
27/05/04 
 
[11]  Rheumatoid Arthritis Essentials  Sock19.tripod.com 
 
[12] Nishimura K, et alMeta-analysis: Diagnostic Accuracy of Anti–Cyclic Citrullinated 
Peptide Antibody and Rheumatoid Factor for Rheumatoid Arthritis. Ann Intern 
Med. 
2007;146:797-808. 
 
[13]  Walker-Bone, K., Fallow, S. Rheumatoid Arthritis  
         BMJ Clinical Evidence June 2005 
 
[14]  Vliet Vlieland TP, Breedveld FC, Hazes JM. The two-year follow-up of a              
         randomized comparison of in patient multidisciplinary team care and routine  
         out-patient care for active rheumatoid arthritis. Br J Rheumatol 1997; 36: 82-5.  
 
[15]  van Jaarsveld CH, Jacobs JW, van der Veen MJ, Blaauw AA, Kruize AA,            
        Hofman DM, et al. Aggressive treatment in early rheumatoid arthritis: a               
        randomised controlled trial. On behalf of the Rheumatic Research Foundation,   
        Utrecht,  The Netherlands. Ann Rheum Dis 2000; 59: 468-77.  
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[16] Dhillon S. Lyseng-Williamson KA. Scott LJ. Etanercept: a review of its use in the 
management of rheumatoid arthritis. Drugs. 67(8):1211-41, 2007 
 
[17]  Helewa A, Goldsmith CH, Lee P, Bombardier C, Hanes B, Smythe HA et al.       
        Effects of occupational therapy home service on patients with rheumatoid           
        arthritis. Lancet 1991; 337: 1453-6.  
 
 
[18]  Hammond A, Lincoln N, Sutcliffe L. A crossover trial evaluating an educational-  
        behavioural joint protection programme for people with rheumatoid arthritis.        
        Patient Education Council 1999; 37: 19-32.  
 
[19]  Ganz SB et al. General overview of rehabilitation in the rheumatoid patient         
        Rheumatic Dis. clinics of N America  
 
[20]  Anderson K et al.  Immediate effect of working splints on grip strength of arthritic 
        patients. Aust Occup Ther Journal 1987; 34(1): 26-31 
 
[21]  MacSween A, Brydson G, Hamilton J. The effect of custom moulded ethyl vinyl  
        acetate foot orthoses on the gait of patients with rheumatoid arthritis.  
        Foot 1999; 9:128-3.  
 
[22] Helliwell M, Coombes EJ, Moody BJ, Batstone GF, Robertson JC.  
       Nutritional status in patients with Rheumatoid Arthritis.  
       Ann Rheum Dis 1984; 43: 386-90.  
 
[23]  Fortin P, Lew RA, Liang MH, Wright EA, Beckett LA, Chalmers TC et al.             
        Validation of a meta-analysis: The effects of fish oil in Rheumatoid Arthritis.  
        J Clin Epidemiol 1995; 48: 1379-90. 
 
[24]  Pincus T et al. The side effects of rheumatoid arthritis: joint destruction,              
        disability and early mortality. Br J Rheumatol 1993; 32(1): 28-37 
 
[25]  Wolde S., et al.  Randomised placebo controlled study of stopping second line   
         in rheumatoid arthritis.  Lancet 1996; 347: 347 – 352 
 
[26]  Eberhardt,  K.B. Functional disability and impairment in early rheumatoid            
        arthritis – development over five years.  J Rheumatol 1994; 21(6); 1051 – 55 
 
[27]  Dalgas M. et al. Disability issues in rheumatoid arthritis. Physical Med and          
        Rehab Clinics of North America  1994; 5(4): 859 – 865 
 
[28]  Ferguson SJ. Et al.  Broken sleep, pain, social activity and depressive                
        symptoms in rheumatoid arthritis. Aust. J Psychol. 1996; 48(1): 9 – 14 
 
[29]  Kirwan JR, Reeback JS., Stanford Health Assessment Questionnaire modified   
        to assess disability in British patients with rheumatoid arthritis. 
        Br. J. Rheumatol.1986 May;25(2):206-9  
 
 
 
 
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Appendix 1 
Common extra-articular manifestations of Rheumatoid Arthritis 
 
Skin 
Subcutaneous nodules. Vasculitis. Thinning and 
ulceration. 
 
Eyes 
Episcleritis (<1%). Keratoconjunctivitis sicca (15-25%). 
 
Cardiac 
Pericarditis and pericardial effusions – 50% of 
asymptomatic patients undergoing echocardiography have 
evidence of pericarditis [12] 
Constrictive pericarditis. Aortitis 
Conduction defects 
Coronary arthritis 
Myocarditis 
 
Respiratory 
Crico-arytenoid joint inflammation. Interstitial lung disease 
(frequently found at autopsy). Visceral nodules. Pleural 
effusions. Bronchiolitis obliterans. Pulmonary arteritis. 
 
Neurological  
Atlanto-occipital subluxation and spinal cord compression. 
Carpal tunnel syndrome and entrapment neuropathy. 
Mononeuritis multiplex. Muscle wasting. Peripheral 
neuropathy. 
 
Haematological  Anaemia of chronic disease. Thrombocytosis 
 
General 
Rheumatoid nodules are characteristic and are found in 
25-50%. They form subcutaneously in bursae and along 
tendon sheaths, over pressure points e.g. olecranon, ulna 
border of forearm. Achilles tendon and ischial spines. 
Splenomegaly and lymphadenopathy. Sjögrens syndrome. 
Sicca symptoms – dry mouth. Low grade fever. 
Amyloidosis in internal organs.  
 
 
  
 
  
 
 
 
 
 
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Appendix 2 
 
Investigations and prognostic factors in Rheumatoid arthritis 
 
 
Prognostic Indicators 
Elevated ESR in 90%, plasma viscosity, C-reactive 
protein (acute phase indicators – persistently 
elevated associated with worse prognosis). C-
reactive protein is better indicator than ESR or 
viscosity [27]. 
 
FBC 
Hb 8-10 in 80% normochromic normocytic anaemia 
Thrombocytosis may be present Neutropenia and 
splenomegaly = Felty’s syndrome (2%) 
 
Rheumatoid factors  
Antibodies to altered gamma globulin are present in 
about 70%. Various tests – different sensitivity and 
specificity. High titres broadly correlate with more 
severe disease. False positive results occur more 
frequently with ages. 
 
Synovial Fluid 
Cloudy, sterile, reduced viscosity, 3000 – 50,000 
WBCs per microlitre Synovial fluid complement is 
often less than 30% serum level. 
 
Radiology 
Early disease –soft tissue swelling only later – 
periarticular osteoporosis, joint space narrowing 
(articular cartilage) and marginal erosions, then joint 
degeneration and deformity. The rate of 
deterioration clinically and radiologically is highly 
variable. X-rays are used to monitor progression. 
 
 
 
 
 
 
 
 
 
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Appendix 3 
 
Features associated with poor outcome in RA 
 
  Persistently high acute phase response 
  High titre of rheumatoid factor 
  Erosion during the first year 
  Family history of rheumatoid arthritis 
  HLA-DR4 
  Extra-articular disease 
  Insidious onset 
  Female sex 
  Low educational attainment 
  High level of functional disability 
  Low socio-economic status 
  Early age of onset (10) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Appendix 4 
Health Assessment Questionnaire (Modified for British 
rheumatoid arthritis patients )  [29]
 
Patient Label 
Date 
 
We are interested in learning how your illness affects your ability to function in daily life. 
Please feel free to add any comments at the end of this form. 
PLEASE TICK ONE RESPONSE WHICH BEST DESCRIBES YOUR USUAL ABILITIES 
OVER THE PAST WEEK: 
 
Without ANY 
With SOME  With MUCH 
  
Unable to do 
difficulty 
difficulty 
difficulty 
 
  
Score = 0 
Score = 1 
Score = 2 
Score= 3 
1. DRESSING AND 
GROOMING 

  
  
  
  
Are you able to 
Dress yourself, including 
tying shoelaces and doing    
  
  
  
buttons? 
Shampoo your hair? 
  
  
  
  
2. RISING - Are you able    
  
  
  
to 
Stand up from an armless    
  
  
  
straight chair? 
Get in and out of bed? 
  
  
  
  
3. EATING - Are you 
  
  
  
  
able to 
Cut your meat? 
  
  
  
  
Lift a full cup or glass to 
  
  
  
  
your mouth? 
Open a new carton of milk   
  
  
  
(or soap powder)? 
4. WALKING - Are you 
  
  
  
  
able to 
Walk outdoors on flat 
  
  
  
  
ground? 
Climb up five steps? 
  
  
  
  
 
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PLEASE TICK AIDS OR DEVICES THAT YOU USUALLY USE FOR ANY OF THESE 
ACTIVITIES:
 
Walking stick 
  
Crutches 
  
Devices for dressing e.g. 
Special or built-up chair 
buttonhook, zipper pull, 
  
  
Wheelchair  
long handled shoe horn 
Walking frame 
  
Other (please specify) 
  
Built-up or special utensils    
PLEASE TICK ANY CATEGORIES FOR WHICH YOU USUALLY NEED HELP FROM 
ANOTHER PERSON:
 
Dressing and grooming 
Rising 
Eating 
Walking 
Without 
With SOME 
With MUCH 
  
ANY 
Unable to do
difficulty 
difficulty 
difficulty 
  
Score = 0 
Score = 1 
Score = 2 
Score= 3 
5. HYGIENE - Are you 
  
  
  
  
able to 
Wash and dry your entire 
  
  
  
  
body? 
Take a bath? 
  
  
  
  
Get on and off the toilet? 
  
  
  
  
6. REACH - Are you able 
  
  
  
  
to 
Reach and get down a 5lb 
object (e.g. a bag of 
  
  
  
  
potatoes) from above your 
head? 
Bend down to pick up 
  
  
  
  
clothing from the floor? 
7. GRIP - Are you able to    
  
  
  
Open car doors? 
  
  
  
  
Open jars which have been    
  
  
  
previously opened? 
Turn taps on and off? 
  
  
  
  
8. ACTIVITIES - Are you 
  
  
  
  
able to 
Run errands and shop? 
  
  
  
  
Get in and out of a car? 
  
  
  
  
Do chores such as 
vacuuming, housework or 
  
  
  
  
light gardening? 
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PLEASE TICK AIDS OR DEVICES THAT YOU USUALLY USE FOR ANY OF THESE 
ACTIVITIES:
 
Jar opener (for jars 
Long handled appliances for 
Raised toilet seat 
previously opened) 
reach 
Bath seat 
Bath rail 
Other (please specify) 
PLEASE TICK ANY CATEGORIES FOR WHICH YOU USUALLY NEED HELP FROM 
ANOTHER PERSON:
 
Errands and 
Hygiene 
Reach  Gripping and opening things 
housework 
SCORING OF HAQ 
Add the maximum score for each of the 8 sections and divide by 8 to give a score 
between 0-3. 
If aid/device or help is needed the score for that activity automatically = 2 (unless 3 has 
already been ticked
.) 
Normal function = 0 
Most affected function = 3 
 
 
 
 
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Appendix 5 
 
 
Joint 
Reduction to 
Effect on 
Temporo-mandibular 
  < 2.5 cms of opening 
Biting, eating 
Temporo-mandibular 
     Fusion 
Chewing 
Shoulder 
  < 90° Abduction 
Washing , dressing 
Elbow 
< 140° Flexion 
Dressing (top buttons) 
Elbow 
  < 80° Flexion 
Carrying a shopping bag 
Elbow 
  < 40° supination 
Use pen or pencil 
Elbow 
  < 60° pronation 
Operating yale type lock 
Hip 
< 110° flexion 
To rise unaided 
Hip 
 < 90° flexion 
To sit comfortably 
Knee 
 < 90° flexion 
To rise unaided 
Knee 
 < 45° flexion 
Walk or use stairs 
Knee 
 < Full extension 
Walking steadily 
Knee 
 > 20° fixed flexion deformity 
Fatigue on walking 
Ankle 
 < 20° plantar flexion 
Difficulty walking 
 < 10° dorsiflexion 
 
 
 
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