rheumatoid arthritis

Rheumatoid Arthritis

Patients are referred by family physicians and specialists for the following conditions to rheumatology: ankylosing spondylitis, back pain, fibromyalgia, gout, myositis, osteoarthritis, osteoporosis, psoriatic arthritis, reactive arthritis, rheumatoid arthritis, scleroderma, sjogren’s syndrome, systemic lupus erythematosus and vasculitis. Furthermore, these clinics offer access to numerous autoimmune specialty clinics which provide excellence in patient care for the most serious, potentially life-threatening forms of rheumatic diseases. Rheumatology clinics also serve as a major educational resource centre for post-graduate education in rheumatology, as well as for numerous medical students and residents.

The most prominent population of these clinics are patients with rheumatoid arthritis (RA). Rheumatoid arthritis is a chronic, progressive, inflammatory disease, which affects the lining of joints, the synovium. These patients develop severe, debilitating pain, swelling and stiffness of their peripheral small joints, in a symmetrically distribution. Rheumatoid arthritis is associated with prominent fatigue, disability, physical impairment, depression, anxiety and increased comorbidity1. Moreover, rheumatoid arthritis patients have a shorter than normal life-expectancy (2,3). These patients are prone to numerous extra-articular features (EAFs), which depend on the underlying process of the disease, whether it is either a vasculitis or a lymphocytic infiltrate. Some of these features include Sjogren’s syndrome, Felty’s syndrome, and peripheral neuropathies, as well as numerous rare, but fatal complications, such as pulmonary fibrosis and pericarditis. Co-morbitidites that are related to RA include cardiovascular and gastrointestinal disease, malignancy, osteoporosis and infection.

The prevalence of rheumatoid arthritis is approximately one percent of the adult population in the US, with similar values in Canada (2,4). Rheumatoid arthritis is often a ‘dramatic, unforeseen and unasked-for life event which presents both physical and psychological problems (5). ' Even though the manifestations of rheumatoid arthritis are physical, it has a global impact and burden on well-being6. Patients with such diseases like rheumatoid arthritis comprise more than 75 % of follow-up referrals in outpatient clinics, making clinics like the Rheumatology Clinics the major setting where care management occurs, in addition to active disease diagnosis and treatment (7). Individual, as well as to society, economic costs of rheumatoid arthritis are substantial (2,8).

As there is no cure for rheumatoid arthritis, earlier and longer-term therapy is essential to halt the progression of the disease or to impend its course. This is the mainstay of treatment and usually occurs with the use of combinations of highly toxic drugs, mainly immunosuppressants, such as methotrexate, sulfasazaline and biologics, which all have numerous prominent side-effects which can significantly affect the health and quality of life of patients. Improving patients’ health-related quality of life (HRQoL) is therefore of prime importance, and is usually the main goal of therapy at the times (2,9).

The majority of resources of the clinic are directed at patients with active disease. These patients receive numerous appointments and access to healthcare professionals, as the use of slow acting anti-rheumatic and cytotoxic medications require regular monitoring. Patients with stable or less active disease, who are not receiving highly toxic medications, may only be seen on a six or twelve month basis. It is therefore essential that their clinic appointments address all issues, including issues relevant to their needs, in addition to any physical manifestations of rheumatoid arthritis. The clinic allocates each new patient one hour, and each follow-up 15-30 minute appointments. This enables functional, social, emotional and physical needs to be assessed and discussed. The physicians of the clinic spend a substantial time consulting patients about their care and disease. This enables patients to understand the process of their illness, and although the patients may not be able to control the process of their illness, they are able to control the event intellectually and reduce its threatening properties (1).

Patients with chronic illnesses such as RA have a multitude of physical, social, psychological, as well as spiritual needs that require a multidisciplinary approach to care management (1,10). The World Health Organization (WHO) defines health as a state of complete physical, social, and mental well-being (11). One of the goals of the clinic is to provide referrals to other specialists, such as physiotherapists (PT), occupational therapists (OT), and social workers (SW) to enable patients to develop effective coping and control strategies. These include development of social skills (eg when there is a need to take time off work for rest), psychomotor skills (eg, using joints effectively when carrying out activities to prevent pain and further damage), and self-regulatory skills (eg, to recognize frustration as a normal response and the need for pacing activities) (1,2).

Numerous challenges are faced by rheumatoid arthritis patients. The main challenges include: education - understanding their complex disease, its manifestations and its treatments, thereby enabling patients to make informed decisions about their care; adherence to medicine regimes; preserving joint mobility and function through joint protection; exercise regimes to maintain muscle strength; maintaining a positive self-esteem and comfort; development of appropriate coping mechanisms; involvement of family and friends, and prevention of social isolation (12).

Rheumatoid arthritis is associated with joint deterioration, considerable pain, and the gradual loss of mobility and an inability to care for oneself (13). A common social and health feature of rheumatoid arthritis patients is loss of functionality, including both daily activity and work impairments (14,15). Numerous research studies have described that functional limitation is even more significant and troublesome for rheumatoid arthritis patients than pain (15). Rheumatoid arthritis patients with severe functional impairments are more likely to not work, engage in leisure activities, or perform the activities of daily living (15). Severely disabled patients account for 6-12% of the population, with the average having a moderate level of disability (16,17). Moreover, some studies have shown that more than half of previously employed patients (60%) have reduced work capacity (13,18).

Such disabilities, presenting for the first time in active and healthy individuals, can lead to substantial psychological and social impairments. Patients begin to suffer from anxiety, depression, fatigue, and dissatisfaction with life. Depressive symptoms have been shown to occur on a yearly basis in approximately 15-17% of rheumatoid arthritis patients (19). Patients with depressive symptoms have significantly poorer function and have more hospitalizations and physician visits. Therefore, as mentioned above, there is an essential need to address depression as part of the patient’s overall treatment plan.

Rheumatoid arthritis patients also suffer severely from fatigue. Rheumatoid arthritis patients have been shown to be significantly more likely to suffer from fatigue than age and gender matched osteoarthritis patients (19,20). In addition to having functional difficulties from physical changes due to their condition, rheumatoid arthritis patients have superimposed fatigue, which creates further difficulties with activities of daily living, including employment, rehabilitation, and social relationships. These patients are more likely to report an inability to work, perceive their health as fair or poor, and have a greater disease severity as evidence by visual analogue pain scale scores and Health Assessment Questionnaires (2,20). Moreover, these patients develop a sense of helplessness when dealing with the daily challenges of their disease. Some rheumatoid arthritis patients feel a lack of control, and their helplessness has been shown to be a predictor of early mortality (21).

Rheumatoid arthritis poses a challenge to physicians and the health care system as their management and health status are multidimensional in nature. Treatments and measurements should take into account not only how an individual functions physically, mentally and socially, but also incorporates the patient’s perceived well-being in the physical, emotional and social aspects of daily life (2).

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