RHEUMATOID ARTHRITIS

• Rheumatoid arthritis (RA) is a common chronic systemic inflammatory disease that clinically presents as symmetric polyarthritis affecting small and large diarthrodial joints of the extremities. It is an inflammatory autoimmune disorder characterized by joint pain, swelling, and synovial destruction
• The peak age of onset is in the fourth and fifth decade of life and women are more commonly affected. It is a heterogeneous disease with variable severity, and unpredictable course
• Most commonly the onset of symptoms of joint pains and swellings are insidious, evolving slowly in a fluctuating manner, over weeks to months

• Exact cause is not known
• Hypotheses suggest multi factorial etiology
• Genetic disposition: RA appears to be associated with specific HLA types (HLA-DR4, HLA-DR1)
• Environmental triggers (e.g. infection, tobacco)
• Hormonal factors

• Typically presents with involvement of small joints in the hands and feet with pain, swelling, and stiffness on inactivity, that improves with activity
• Prominent symmetry of involvement is Typical of RA

Articular manifestations

• Polyarthralgia :Symmetrical pain and swelling of affected joints
• Frequently affected joints : Metacarpophalangeal joints, Proximal interphalangeal joints, joints of fingers, Wrists, mid foot, Metatarsophalangeal joints, Knee joints, ankles
• Usually not involved: Distal interphalangeal joints, sacroiliac joints, thoracolumbar spine
• Morning stiffness : that usually improves with activity

Joint deformities

• Ulnar deviation : that occurs at the metacarpophalangeal joints
• Swann neck deformity : Flexion of the distal interphalangeal joints and MCP with hyperextension of PIP joint
• Boutonniere deformity: PIP flexion and DIP hyperextension
• Hitchhiker thumb deformity (Z deformity of the thumb): hyperextension of the interphalangeal joint with fixed flexion of the MCP joint
• Cock up toe deformity
• Hammer toe
• Rocker bottom deformity
• Atlanto-axial subluxation

 Extra-articular manifestations

Patients with positive rheumatoid factor (RF) are more likely to develop extra-articular manifestations of rheumatoid arthritis

• Constitutional symptoms: low-grade fever, myalgia, malaise, fatigue, weight loss, night sweats, uncommonly rheumatoid cachexia
• Rheumatoid nodules : Non-tender, firm, subcutaneous swellings ,commonly in areas exposed to higher pressure e.g., extensor side of the forearm, bony prominences
• Skin: palmar erythema, Raynaud’s phenomenon, RA vasculitis, pyoderma gangernosum
• Lungs: Pleuritis , Interstitial pneumonia ,Fibrosis
• Eye: keratoconjunctivitis sicca, scleritis, and episcleritis 
• Heart: pericarditis and myocarditis
• Haematological : Anaemia of chronic disease Splenomegaly (Felty syndrome)

 Other

• Tenosynovitis and bursitis
• Carpal tunnel syndrome (entrapment neuropathy)
• Typical nocturnal paresthesia of volar hand and fingers I–III
• Atrophy of thenar muscles

Differential diagnosis

• Osteoarthritis
• Psoriatic arthritis
• Gout
• Pseudogout

• ACR & EULAR classification criteria : score of >= 6 points confirms RA
• ESR, CRP , possibly leukocytosis, thrombocytosis
• Anti CCP – confirmatory
• Rheumatoid factor
• X ray
• MRI

• Physical and occupational therapy
• cryotherapy
• Physical activity

Internal medicines

• Rasna saptaka kashaya
• Rasna erandadi kashaya
• Saddharana choorna
• Kaisora guggulu
• Simhanadha guggulu
• Amrutarishta
• Punarnavasavam
• Chyavanaprasha
• Vardhamana pippali

Procedures

• Abhyanga – Pinda taila, Balaguduchyadi taila
• Virechana – Nimbamruta eranda
• Anuvasana – madhuyashtyadi taila
• Vasti –Ksheera vasti
• Dhara –Dhanyamla, Dashamoola ksheera dhara
• Pinda sweda