Rheumatoid arthritis is a chronic systemic autoimmune disease characterized by synovitis of the joints. The persistent and recurrent attacks of synovitis can lead to destruction of cartilage and bone in the joints, joint dysfunction, and even disability. Vasculitis lesions involve all organs of the body, so the disease is also known as rheumatoid disease.
Etiology
The cause of the disease is not fully understood. Rheumatoid arthritis is a disease that is closely related to environmental, cellular, viral, genetic, sex hormone and neuropsychiatric factors.
(i) Bacterial factors
Experimental studies have shown that group A streptococci and peptidoglycan (peptidoglycan) may be a persistent stimulant for the development of RA, and the long-term presence of group A streptococci in the body becomes a persistent antigen that stimulates the body to produce antibodies and cause immunopathological damage. The animal model of arthritis created by Mycoplasma resembles human RA but does not produce rheumatoid factor (RF) held by human RA. Bacterial or bacteriophage antigenic material has never been found in the joint fluid and synovial tissue of RA patients, suggesting that bacteria may be involved in the initiation of RA, but direct evidence is lacking.
(ii) Viral factors
The relationship between RA and viruses, especially EBV, is one of the issues that scholars at home and abroad have paid attention to. Studies have shown that arthritis due to EBV infection differs from RA in that RA patients are more reactive to EBV than normal subjects. A consistently high level of anti-EB virus a cytosolic antigen antibodies appear in the serum and synovial fluid of RA patients, but so far no antibodies to EBV nuclear or shell antigens have been found in the serum of RA patients.
(iii) Genetic factors
The disease has a high incidence in certain families, and in a population survey, human leukocyte antigen (HLA)-DR4 was found to be associated with RF-positive patients. HLA studies have found that DW4 is associated with the development of RA, and 70% of patients are HLA-DW4 positive, and patients have a susceptibility gene for this point, so genetics may play an important role in the development.
(iv) Sex hormones
Studies have shown a male-to-female ratio of 1;2-4 for RA incidence, with reduced disease during pregnancy and reduced incidence in women taking birth control pills. Animal models have shown increased susceptibility to arthritis in LEW/n female rats and lower incidence in males, and the incidence of arthritis in males after castration or treatment with β-estradiol is the same as that in females, suggesting that sex hormones play a role in the development of RA.
Cold, humidity, fatigue, malnutrition, trauma, and psychological factors are often predisposing factors for the disease, but most often have no obvious predisposing factors to be identified before the disease.
Symptoms
(1) Joint pain and pressure pain
The vast majority of patients begin with joint swelling. Swelling is caused by increased exudate in the joint cavity and inflammatory changes in the soft tissues surrounding the joint, and is manifested by uniform swelling around the joint. The severity of joint pain usually parallels the degree of swelling, and the more pronounced the swelling of the joint, the more severe the pain, even severe pain.
(2) Swollen joints
Swelling can occur in all affected joints, and joint swelling indicates a high degree of inflammation. Typical manifestations are uniform swelling around the joint, such as pyknotic swelling of the proximal interphalangeal joint. Joint swelling is most easily detected in the small joints of the extremities, while swelling in large joints such as the second shoulder and hip is not easily detected.
(3) Morning stiffness
More than 95% of patients have morning stiffness of the joints. Morning stiffness refers to a longer period of stiffness and limited movement of the affected joint in the morning after the diseased joint has been stationary at night. Morning stiffness is often the first symptom of joint involvement, mostly preceded by joint pain, and in severe cases, stiffness can occur in all joints. Morning stiffness can be reduced or disappeared after getting up and moving or warming up. Morning stiffness is often accompanied by coldness and numbness in the extremities or fingers (toes).
(4) Joint friction sound
During the inflammatory phase of rheumatoid arthritis, the examiner’s hand can often feel a small twanging sound or a feeling of snow grip when moving the joints, typical of the elbow and knee joints, which indicates the presence of joint inflammation. After the inflammation of some joints has subsided, a rattling sound can be heard or touched when moving the joints, which is most obvious in the finger and knee joints and hip joints, and may be caused by rheumatoid with osteophytes.
Treatment options
At present, the treatment of rheumatoid arthritis includes medication, surgical treatment and psychological rehabilitation treatment.
1.Drug treatment
The current domestic and international application of drugs, including plant drugs can not completely control joint destruction, but only to relieve pain, reduce or delay the development of inflammation. Commonly used drugs for the treatment of rheumatoid arthritis are divided into four categories, namely non-steroidal anti-inflammatory drugs (NSAIDs), disease-modifying anti-rheumatic drugs (DMARDs), such as hydroxychloroquine, glucocorticoids and botanical drugs.
2.Surgical treatment
Patients with rheumatoid arthritis can consider surgery in order to prevent joint destruction, correct deformities and improve quality of life if the disease is still not controlled after active formal or pharmacological treatment in internal medicine. However, surgery does not cure rheumatoid arthritis, so the post-operative drug treatment is still required. Commonly used surgeries include synovectomy, arthroplasty, soft tissue release or repair, and joint fusion.
3.Psychological and rehabilitation treatment
Joint pain, fear of disability or already facing disability, inability to take care of themselves, economic loss, changes in family, friends and other relationships, and the cessation of social and recreational activities are many factors that inevitably bring mental stress to patients with rheumatoid arthritis, who are eager for treatment, but are worried about adverse drug reactions or lack of confidence in the actual effects of drugs, which in turn increases the psychological burden of patients. Depression is the most common psychiatric symptom among rheumatoid arthritis patients, and severe depression hinders the treatment of the disease. Therefore, along with active and rational drug therapy, attention should be paid to the psychological treatment of rheumatoid arthritis. In addition, the selection of the treatment plan and the evaluation of the efficacy should also take into account the changes in the patient’s psychiatric symptoms. In the acute stage, patients with severe joint pain and systemic symptoms should rest in bed, and pay attention to the resting position to avoid pressure on the joints as much as possible. Passive and active joint mobility training should be performed to prevent muscle atrophy, if the condition allows. For patients in remission, more exercise is performed to restore strength without fatiguing the patient and under the guidance of a physical rehabilitation physician.
4.Other treatment
Biological agents such as anti-tumor necrosis factor-α (TNF-α) have been used abroad for the treatment of rheumatoid arthritis. To date, there are two anti-TNF-α agents (infliximab and tanercept). infliximab is a monoclonal antibody to TNF-α, and tanercept is a recombinant human soluble TNF-α receptor fusion protein.
Autologous peripheral blood stem cell transplantation has been used in France for the treatment of refractory rheumatoid arthritis, but the exact long-term efficacy remains to be observed with the accumulation of more cases and follow-up.
Treatment strategies
In today’s world, where rheumatoid arthritis cannot be cured, it is our goal to prevent joint destruction, preserve joint function and maximize the quality of life of patients. Therefore, the timing of treatment is very important. Although NSAIDs and glucocorticoids can reduce symptoms, joint inflammation and destruction can still occur DMARDs treatment is the key to reducing disability. It is important to note that drug selection should be consistent with the principles of safety, effectiveness, economy and simplicity.
Once rheumatoid arthritis is diagnosed, DMARDs treatment is initiated, with MTX recommended as the first choice, but also with salbutamol or hydroxychloroquine. Depending on the disease, two or more DMARDs may be used alone or in combination. Patients with progressive, poor prognosis and refractory rheumatoid arthritis may be treated with a combination of DMARDs with different mechanisms.
It is important to emphasize again that no matter which treatment regimen is chosen, radiographs of both hands (including the wrist) or symmetrical radiographs of the affected joints must be taken before treatment and reviewed yearly after treatment to compare the efficacy. In order to avoid adverse drug reactions, blood and urine routine, liver and kidney function should be closely monitored and the dose should be adjusted at any time during the course of treatment. The evaluation of the response to treatment should include the evaluation of the functional status and the overall assessment of the disease activity by the physician and the patient, in addition to the joint tenderness, swelling and number of joints before and after treatment, and the radiological changes in the affected joints.
All patients should be tested for disease activity. Patients with early, acute or persistent disease activity should be followed closely until the disease is controlled. Patients in remission can be followed up every six months, while the appropriate indicators are tested regularly according to the requirements of the therapeutic drug.
It should be clear that symptomatic remission after treatment is not the same as cure of the disease, and immediate effectiveness is not the same as long-term effectiveness. DMARDs can delay the progression of the disease, but they cannot cure rheumatoid arthritis, based on this, in order to prevent relapse of the disease, in principle, the drug is not stopped, but the maintenance treatment can be gradually reduced according to the condition until it is finally discontinued.
Postural care
Abnormal posture dynamics of rheumatic patients often affect the patient’s future activity function and future life and work. The purpose of posture care is to correct the patient’s poor posture and position at all times, so as to facilitate future health recovery and normal work.
Patients with rheumatic diseases often adopt various incorrect postures and positions in an attempt to relieve pain due to numbness, pain, unfavorable flexion and extension, and stiffness of the limbs. Therefore, in the care of patients’ sitting, standing, walking, sleeping and other postures must be noted and corrected in time to prevent lifelong regrets.
Care should also pay attention to the maintenance of physiological posture. For example, in order to prevent ankylosing spondylitis patients spine, hip and knee deformities, stiffness, generally require patients to stand should try to stand up, abdomen and arms crossed waist, avoid slouching loose hunchback posture, the bed should not be too soft, to board bed is better, sleep avoid using high pillows, lying posture to take a prone posture is better, etc..
The above describes the rheumatoid arthritis posture care, you may also understand, rheumatoid arthritis posture is very important, so if there is incorrect posture, medicine timely correction.
Rehabilitation treatment exercises
(1) Neck exercises; relax the neck and move the head up and down; slowly turn to the left and right; bend the head to the sides with the ears as close to the shoulders as possible.
(2) Shoulder exercises; move the shoulder joints forward and backward, left and right, and up and down in each direction, making circular movements; hold your hands together behind your head and pull your elbows backward as much as possible.
(3) Wrist movement; wrist movement up and down, left and right.
(4) Finger movements; fingers apart, together, fingers flexed, straightened, thumb and other fingers one to another.
The above treatment exercises are simple and easy to perform, and should be done after waking up and before going to bed, at least 10 times for each movement.
How to maintain the finger attack?
1.Press and knead the twisted finger method; insist on twisting the ten finger joints alternately with both hands every day, and press and knead the joints and related acupuncture points to relieve spasm f, pain and swelling.
2, because the hands are often exposed to the outside, the most extensive contact with the outside world, the most susceptible to hand wind, cold and dampness. So patients should usually pay attention to the hand warmth, wind, moisture. Attention should also be paid to maintain the normal functional posture of the joints to avoid ankylosing deformities.
3, shaking method; every morning after waking up, insist on self-shaking wrist, finger palm, interphalangeal joints to achieve the effect of decongestion and pain, maintain and help restore the normal function of the joint.
Regular follow-up
Rheumatoid arthritis is a chronic disease, the effect of drugs is slow, and each person’s reaction to drugs is different, the doctor needs to understand the patient’s efficacy and side effects of drugs, and adjust the drugs. Some patients who have taken medication for a period of time and no longer have pain in their joints think that they are cured, so they stop taking medication and stop coming to follow-up appointments, and eventually relapse and have to start treatment again. This repeatedly stopping the medication, repeatedly relapsing, the condition is not effectively controlled, and the best time for treatment will be lost. Some patients take medication for a long time without laboratory tests, resulting in abnormal blood picture, liver function damage is not known, by the time it is found, it is too late.