About Rheumatoid Arthritis and Chiropractic care

What is it?

Rheumatoid arthritis(RA) is an autoimmune condition of an unknown cause. There are studies suggesting the cause of RA could be genetics, and/or virus infection.


It occurs in 0.3~0.8% of the population with male:female ratio of 1:3.

Most common in age 30~50, and males are more affected over 60.




Patho-mechanism

When the autoimmune system activates due to either genetic or viral reason, inflammatory cells form around the T cells. This causes inflammation of the synovial membrane, resulting in the formation of a pannus or bone destruction.


RF (Rheumatoid factor) is one of the autoantibodies, and the immune complexes produced by RF and IgG activate the neutrophils at the articulatory lesion, releasing inflammatory prostaglandin E2 or proteinase.



Symptoms

  1. The most commonly affected site is proximalinterphalangealjoint ; PIP, metacarpophalangealjoint ; MCP in the hands and the MCP in the foot.

with rheumatoid arthritis, the joints are symmetrically affected on both left and right side of the body.



2. Morning Stiffness.

There might not be any pain involved. This is usually felt in the shower in the morning and slowly disappears throughout the day as the patient keeps using the hand.


3. Tenderness and swelling


4. Deformities of joints.

There are different types of deformities associated with RA.

a) boutonniere deformity

b) swan neck deformity

c) ulnar deviation

d) hallux valgus



Symptoms in other systems


Skin

25% of patients who have RA also have subcutaneous nodules form usually at the elbow, these are not painful nor itchy.


Eyes

25% of patients who have RA also have Sjögren's syndrome. These cause eyes to be dry and itchy.




Examinations

blood tests: due to chronic inflammation, there is anaemia. white blood cell count is normal and platelets will increase.


Biomarkers:

ESR increase

Positive CRP

Positive Rheumatoid factor (80%)

serum complementary system increase


X-ray: Signs of bone weakening and decreased joint spaces.



Diagnostic criteria


Follows the announcement of American College of Rheumatology(ACR), and European League Against Rheumatism (EULAR) in 2010.


Target Population:

  1. swelling in at least 1 joint

  2. synovitis which does not have other diagnosis

Classification criteria:

  1. invaded joints

  2. 1 large joint (shoulder, elbow, hip, knee) = 0 points

  3. 2-10 large joints = 1 points

  4. 1-3 small joints (±large joints) = 2 points

  5. 4-10 small joints (±large joints) = 3 points

  6. >10 joints (includes at least 1 small joint) = 5 points

  7. serological findings (require at least 1 examination)

  8. RF(–) and ACPA*(–) = 0 points

  9. RF(+) or ACPA(+) = 2 points

  10. RF(++) or ACPA(++) = 3 points

  11. acute reactant (require at least 1 examination)

  12. CRP(normal) and ESR(normal) = 0 points

  13. CRP(abnormal) or ESR(abnormal) = 1 points

  14. symptom duration

  15. <6 weeks = 0 points

  16. >6 weeks = 1 points


* ACPA(Anti-citrullinatedproteinantibody)

- Anti-Fillagrin Ab includes AKA/APF/Anti-CCP/Anti-Sa Ab, etc.

- Clinically, it is mainly an anti-CCP indication.

- Diagnostic value is higher than RF (Sensitivity: ~75% / Specificity: >95%), and RA diagnosis prediction is higher after 1 year / 2~3 years.

- It was first recognized by this standard and recognized the same importance as RF.

- AntiCCP inspection is considered only if RF is less than 50U/mL.

- More standardization/improvement of inspections is needed in the future.


Score of 6 or more points in criteria 1~4 is considered Rheumatoid arthritis.




Indicators of RA activity

To determine the therapeutic effects of RA, the activity of RA is evaluated. Being active means less or less effective in treatment, and being less active means that enough treatment has been achieved, and that a little treatment is enough.


As an indicator of activity, the Lansbury index is used, consisting of four:

  1. duration of morning stiffness

  2. grip strength

  3. number of invaded joints

  4. ESR

Each is graded to represent activity as a quantity. The larger the Lansbury index, the more active it is.


Other useful indicators of activity are: • CRP • Platelet count.

Also, it is important that rheumatoid factors are not indicators of activity.


Treatment

The objectives of treatment are as follows.

  1. It relieves pain in the joints.

  2. It prevents rheumatoid activity and inflammation of the joints.

  3. Prevention of joint deformation and securing operational stations.

  4. Reconstruct a broken or modified joint.

Medications for RA

  1. non-biological DMARDs

  2. immunomodulatory agents- Sulfasalazine(SASP) and bucillamine

  3. Correct abnormal immune function without affecting normal immunity.

  4. side effects: kidney impairment(from bucillamine), skin rash, liver impairment, white blood cell reduction

  5. immunosuppressants - methotrexate(MTX) and leflunomide

  6. Non-specifically inhibits immune function

  7. side effects: interstitial pneumonia, bone marrow suppression

  8. biological DMARDs -infliximab, etanercept, adalimumab, tocilizumab

  9. Proteins inhibit cytokines (TNF-α, IL-6, etc.) involved in RA.

  10. side effects: Infectious disease (pneumonia, recurrence of tuberculosis), reduced effectiveness by production of neutralizing antibodies (prevented by combined MTX)

  11. NSAIDs - loxoprofensodium

  12. suppresses inflammation and pain.

  13. side effects: gastrointestinal disorders such as stomach ulcers (prevented by taking PPIs and etc. )

  14. Steroids - prednisolone

  15. strong inhibitor for inflammation and pain.

  16. side effects of long-term doses: decreased weakened system

How can chiropractic care help with the management of RA?

Chiropractic care is known to help slow the process of arthritis by improving the range of motion, strength of people with arthritis. Also there are numerous studies suggesting that exercise improves the treatment result of patients with RA. The studies does not tell which specific exercise because everyone has arthritis in different joints, this is where chiropractors or physiotherapist etc comes in to play to help patients find which exercise is good for them.

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