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Rheumatoid Arthritis

RA

Rheumatoid arthritis is a chronic systemic inflammatory disease. It may affect many tissues and organs and any joint lined by a synovial membrane may be involved.


Presentation

The active disease presents itself as fatigue, loss of appetite, muscle and joint pain and stiffness. The muscle pain is more prominent in the mornings after a period of inactivity. Following the active disease, it goes into a period of remission. The active disease is usually called the flare up marked by red, warm, painful, tender and swollen joints as a result of inflammation of the synovium.

Complications

Rheumatoid arthritis may not limit itself only to the joints but can also affect various other parts of the body such as eyes, lungs, skin, blood vessels, heart and other major organs. Moreover most of the patients affect by rheumatoid arthritis suffer from emotional distress.

Effect of rheumatoid arthritis on the skin

Rheumatoid arthritis can produce small lumps on the skin called the rheumatoid nodules in 1/5 th of the people. They develop on the skin over the elbows, heels, fingers or forearm. Ulcers due to vasculitis can cause changes on the skin and may indicate a serious disease activity [4].

Effect of rheumatoid arthritis on the eye

Rheumatoid arthritis can cause inflammation of the episclera, a condition called scleritis. It is usually mild but in some extreme cases can become red, painful and inflamed and may even lead to vision loss.

Effect of rheumatoid arthritis on the heart and blood vessels

Rheumatoid arthritis can result in the accumulation of fluid around the heart resulting in pericarditis. Inflammation of the heart muscle itself, myocarditis can develop in some rare conditions. Vasculitis, the inflammation of the blood vessels can also occur, which can affect many organs [5].

Effects of rheumatoid arthritis on the lungs

Rheumatoid nodules can develop in the lungs resulting in collapsed lung, coughing up blood or pleural effusion [6]. Interstitial lung diseases and pulmonary hypertension may also develop as a result of rheumatoid arthritis.

Effect of Rheumatoid arthritis on blood cells

Rheumatoid arthritis can cause anemia and can result in Felty's syndrome. In this condition, the spleen is enlarged, the white blood cell count decreases and may even lead to lymphoma in rare conditions.

Splenomegaly
  • It is extremely rare for RA to present as FS or develop after initially presenting as neutropaenia and splenomegaly.[ncbi.nlm.nih.gov]
  • Other: thyroid disorders, osteoporosis, depression, splenomegaly.[patient.info]
  • […] infectious diseases anti-cyclic citrullinated peptide (anti-CCP)/anti-citruillated plasma antibody (ACPA): it is more than 80% sensitive and more than 95% specific elevated ESR or C-reactive protein Associations Felty syndrome : rheumatoid arthritis, splenomegaly[radiopaedia.org]
  • This is characterized by splenomegaly, and leukopenia – predominantly granulocytopenia. Recurrent bacterial infections and chronic refractory leg ulcers are the major complications.[hopkinsarthritis.org]
Easy Bruising
  • Steroids do have side effects, such as easy bruising, bone thinning, cataracts, and diabetes. Anti-rheumatic medicines can help treat RA. If you start taking these drugs early enough, they can slow the damage to your joints.[familydoctor.org]
  • Corticosteroids are normally only used in this way because long-term use of corticosteroids can have serious side effects, such as weight gain, osteoporosis (thinning of the bones), easy bruising, muscle weakness and thinning of the skin.[nhsinform.scot]
  • These side effects include weight gain , facial puffiness, thinning of the skin and bone, easy bruising , cataracts , risk of infection, muscle wasting, and destruction of large joints, such as the hips.[medicinenet.com]
  • These side effects are serious and can include easy bruising, thinning of the bones (osteoporosis), cataracts, weight gain, a round face, susceptibility to infections, diabetes and high blood pressure.[orthop.washington.edu]
Pain
  • Pain was reported using a VAS 100 mm for both trials, with Swinson 1988 specifically measuring night pain and Emery 1986 measuring pain in general.[doi.org]
  • Pain in rheumatoid arthritis is common, is often multi-factorial and many different pharmacotherapeutic agents are routinely used for pain management.[ncbi.nlm.nih.gov]
Fatigue
  • To evaluate the effect of biologic interventions on fatigue in rheumatoid arthritis.[ncbi.nlm.nih.gov]
  • SMD ‐0.36 (‐0.62 to ‐0.10) Relative percent change ‐13.7% (‐23.6 to ‐3.8) NNTB 7 (4 to 26) fatigue (psychosocial interventions) Various fatigue scales The mean fatigue in the control groups was 6.3 VAS (score: 0‐10) The mean fatigue (psychosocial interventions[doi.org]
Fever
  • Abstract Familial Mediterranean fever (FMF) is the most common hereditary auto-inflammatory (periodic fever) syndrome, and usually successfully treated with colchicine.[ncbi.nlm.nih.gov]
Weakness
  • It can cause arthralgias and weakness in intrinsic muscles of the hand.[ncbi.nlm.nih.gov]
  • Fatigue, muscle weakness, and weight loss are common symptoms. Often, before prominent signs appear, the affected person may complain of coldness of hands and feet, numbness, and tingling, all of which suggest compression of the vasomotor nerve.[britannica.com]
Anemia
  • This anemia is also known as 'anemia of chronic disease' ( Agarwal 2009 ; Cartwright 1966 ; Means 1995 ; Theurl 2009 ; Masson 2011 ). The term 'anemia of inflammation' reflects its pathophysiology ( Ganz 2009 ).[doi.org]
  • Erythropoiesis-stimulating agents have been used to treat anemia, one of the extra-articular manifestations of RA.[ncbi.nlm.nih.gov]
  • Anemia : Many people with RA also have anemia. Anemia happens when there are too few red blood cells in the blood. Red blood cells carry oxygen to the tissues and organs of the body.[medicalnewstoday.com]
Pleural Effusion
  • CT showed a massive right pleural effusion and a sclerotic lesion in the right ninth rib. Histopathological examination of the rib revealed IgA lambda-type plasmacytoma. Serum vascular endothelial growth factor was extremely high at 5530 pg/mL.[ncbi.nlm.nih.gov]
  • Pathogenesis A variety of mechanisms have been postulated for pleural effusions occurring in rheumatoid arthritis patients.[err.ersjournals.com]
  • Effects of rheumatoid arthritis on the lungs Rheumatoid nodules can develop in the lungs resulting in collapsed lung, coughing up blood or pleural effusion.[symptoma.com]
  • Pleurisy, pleural effusions , pulmonary fibrosis . Pericarditis , pericardial effusions , myocardial infarction , myocardial dysfunction, myocarditis . Lymphadenopathy . Dry eye syndrome (keratoconjunctivitis sicca). Neuropathy.[patient.info]
Loss of Appetite
  • Read More Rheumatoid Arthritis Symptoms Along with joint inflammation and pain, many people experience fatigue, loss of appetite and a low-grade fever. Because RA is a systemic disease, it may also affect organs and body systems.[arthritis.org]
  • These include feeling sick, loss of appetite, a sore mouth, diarrhoea, headaches and hair loss.[express.co.uk]
Xerostomia
  • Sjogren’s syndrome is an autoimmune condition that affects exocrine gland function, leading to a reduction in tear production (keratoconjunctivitis sicca), oral dryness (xerostomia) with decreased saliva of poor quality, and reduced vaginal secretions[hopkinsarthritis.org]
  • When using the criteria for Sjögren’s syndrome used in this and other studies, 36, 37 the frequency of the diagnosis depends heavily on the availability of specific tests for the evaluation of possible xerostomia and keratoconjunctivitis sicca.[doi.org]
Tachycardia
  • One week after admission, she developed fever, dyspnea, hypoxemia, tachycardia, and increased serum C-reactive protein level.[ncbi.nlm.nih.gov]
  • After weaning from mechanical ventilation, she experienced tachycardia and hypertension. Since seizures were suspected, MRI and electroencephalography were performed and which were normal.[pedinfect.com]
  • She suffers continual uncontrolled neuro/muscular contractions (jerking) and postural orthostatic tachycardia syndrome (POTS) and many other symptoms of systemic autoimmune dysregulation.[collective-evolution.com]
  • However, potentially more serious adverse effects can occur including confusion, anaphylaxis and tachycardia ( Evans 2008 ).[doi.org]
Hearing Impairment
  • Hyemin Jeong, Young-Soo Chang, Sun Young Baek, Seon Woo Kim, Yeong Hee Eun, In Young Kim, Jaejoon Lee, Eun-Mi Koh, Hoon-Suk Cha and Emilio Russo, Evaluation of Audiometric Test Results to Determine Hearing Impairment in Patients with Rheumatoid Arthritis[doi.org]
Arthritis
  • ., area with all ranges of rheumatoid arthritis severity. The arthritis patients' experiences were measured against other study subjects who did not have rheumatoid arthritis but who matched the arthritis patients in age and gender.[web.archive.org]
  • Interstitial lung diseases and pulmonary hypertension may also develop as a result of rheumatoid arthritis. Effect of Rheumatoid arthritis on blood cells Rheumatoid arthritis can cause anemia and can result in Felty's syndrome.[symptoma.com]
  • What causes rheumatoid arthritis? Doctors don't know the exact cause of rheumatoid arthritis. They know that with this type of arthritis, a person's immune system attacks his or her own body tissues.[niams.nih.gov]
Morning Stiffness
  • LLLT could be considered for short-term treatment for relief of pain and morning stiffness for RA patients, particularly since it has few side-effects.[ncbi.nlm.nih.gov]
  • 15 ] No difference: number of swollen joints, morning stiffness, disease activity, pain, ESR, CRP Feverfew UK 41 Difference ( ): grip strength 1.5 4 [ 16 ] No difference: early morning stiffness, inactivity stiffness, Ritchie articular index, patient[dx.doi.org]
Osteoporosis
  • Abstract Most previous research investigating osteoporosis in rheumatoid arthritis (RA) has focused on female patients and there is a lack of data regarding clinical characteristics of osteoporosis in male patients with RA.The aim of this study was to[ncbi.nlm.nih.gov]
  • C Calcium Pyrophosphate Deposition (CPPD) Carpal Tunnel Syndrome Cryopyrin-Associated Autoinflammatory Syndrome (CAPS) (Pediatric) D Dermatomyositis (Juvenile) F Familial Mediterranean Fever Fibromyalgia G Giant Cell Arteritis Glucocorticoid-induced Osteoporosis[rheumatology.org]
Joint Deformity
  • We report a case of a 57-year-old woman diagnosed with Hansen disease 10 years ago, who suffered from joints swelling, pain and joints deformities of both hands for 19 years.[ncbi.nlm.nih.gov]
  • In addition to triggering painful joint swelling and stiffness, rheumatoid arthritis can cause fever and fatigue and potentially lead to long-term joint deformities.[arthritis-health.com]
  • Some of the conditions the doctor looks for include swelling and warmth around the joint, painful motion, lumps under the skin, joint deformities, and joint contractures (inability to fully stretch or bend the joint).[orthoinfo.aaos.org]
Joint Swelling
  • We report a case of a 57-year-old woman diagnosed with Hansen disease 10 years ago, who suffered from joints swelling, pain and joints deformities of both hands for 19 years.[ncbi.nlm.nih.gov]
  • […] rheumatoid factors and improve the serological detection significantly. 5 Diagnostic Criteria The American College of Rheumatology has defined 7 criteria that confirm the diagnosis of "rheumatoid arthritis": Morning stiffness of at least 60 minutes Joint[flexikon.doccheck.com]
  • These medicines work very well to reduce joint swelling and inflammation, but they can have long-term side effects. Therefore, they should be taken only for a short time and in low doses when possible.[medlineplus.gov]
Subcutaneous Nodule
  • The most characteristic lesions of rheumatoid arthritis are subcutaneous nodules, which may be present for weeks or months and are most commonly found over bony prominences, especially near the elbow.[medical-dictionary.thefreedictionary.com]
  • Joint involvement and subcutaneous nodules can result from gout, cholesterol, and amyloidosis as well as RA; aspiration or biopsy of the nodules may occasionally be needed.[merckmanuals.com]
  • The subcutaneous nodule is the most characteristic extra-articular lesion of the disease. Nodules occur in 20 to 30% of cases, almost exclusively in seropositive patients.[hopkinsarthritis.org]
Urticaria
  • Hayfever (allergic rhinitis), eczema, asthma and urticaria all result from type I hypersensitivity. It is caused upon contact with antigen against which the host has pre-existing IgE antibody.[web.archive.org]
  • Patients with urticaria, rhinitis, or asthma caused by aspirin can have the same problems with these other NSAIDs, but celecoxib may not cause these problems.[merckmanuals.com]
  • […] side effects Interleukin-1 inhibitor Decreases inflammation in moderate-severe RA Abdominal Pain, Nausea, Vomiting, Headache Selective costimulation modulator Anti-inflammatory Headache, dizziness, abdominal pain, dyspepsia, nausea, rash, flushing, urticaria[physio-pedia.com]
  • Safety of etoricoxib, a new cyclooxygenase 2 inhibitor, in patients with nonsteroidal anti-inflammatory drug-induced urticaria and angioedema. Ann Allergy Asthma Immunol 2005 Aug; 95: 154–8 PubMed CrossRef Google Scholar 122.[doi.org]
Palmar Erythema
  • erythema, and skin fragility (often worsened by corticosteroid use).Diffuse alopecia areata (Diffuse AA) occurs more commonly in people with rheumatoid arthritis.[en.wikipedia.org]
Headache
  • A 57-year-old man presented with the subacute onset of headache, depression, and anorexia 7 months before the onset of RA. Brain magnetic resonance imaging showed symmetric parenchymal lesions involving the medial temporal lobes.[ncbi.nlm.nih.gov]
  • Figures and Tables - Analysis 2.2 Comparison 2 Cyclosporine vs placebo ‐ Toxicity, Outcome 2 Headache. Figures and Tables - Analysis 2.3 Comparison 2 Cyclosporine vs placebo ‐ Toxicity, Outcome 3 Tremor.[doi.org]
  • These include feeling sick, loss of appetite, a sore mouth, diarrhoea, headaches and hair loss.[express.co.uk]

Workup

Diagnosis is usually made by several tests such as blood tests involving the Erythrocyte Sedimentation Rate and C-reactive protein (CRP). X-rays are made to evaluate joints. Various imaging techniques such as MRI and CT scans are useful to evaluate and diagnose rheumatoid arthritis.

The laboratory studies used in the diagnosis of rheumatoid arthritis fall under three categories such as the hematological parameters, immunological parameters and markers of inflammation [7].

Hence some of such tests include, Erythrocyte Sedimentation Rate, C-reactive protein, complete blood count, Rheumatoid factor assay, anti–nuclear antibody assay, anti-cyclic citrullinated peptide and anti-mutated citrullinated vimentin assay [8].

These biomarkers can not only help in early diagnosis of the disease, but also can help in assessing the prognosis of the disease.

Pericardial Effusion
  • Pericarditis , pericardial effusions , myocardial infarction , myocardial dysfunction, myocarditis . Lymphadenopathy . Dry eye syndrome (keratoconjunctivitis sicca). Neuropathy.[patient.info]
  • Other extra-articular signs include vasculitis causing leg ulcers or mononeuritis multiplex, pleural or pericardial effusions, pulmonary infiltrates or fibrosis, pericarditis, myocarditis, lymphadenopathy, Felty syndrome, Sjögren syndrome, scleromalacia[merckmanuals.com]
  • Occasionally, a comorbid pericardial effusion may exist. Similarly, pneumothorax is possible, but rare. Pathogenesis A variety of mechanisms have been postulated for pleural effusions occurring in rheumatoid arthritis patients.[err.ersjournals.com]
Joint Space Narrowing
  • It will depict only indirect signs of cartilage loss, such as joint space narrowing and bony erosions due to previous destructive synovial inflammatory activity.[web.archive.org]
  • JSN, joint space narrowing.[doi.org]
  • space narrowing: symmetrical or concentric marginal erosions: due to erosion by pannus of the bony “ bare areas ” Hands and wrists Diagnosis and follow-up of patients with RA commonly involve imaging of the hands and wrists.[radiopaedia.org]
  • Initially, joint spaces in the small joints of the hands show widening as a result of effusion; however, with cartilage destruction, joint spaces narrow.[emedicine.medscape.com]
Nephrolithiasis
  • Kramer HJ, Choi HK, Atkinson K et al. (2003) The association between gout and nephrolithiasis in men: The Health Professionals‘ Follow-Up Study. Kidney Int 64: 1022–1026 PubMed CrossRef Google Scholar 14.[doi.org]
Thrombocytosis
  • FBC: normochromic, normocytic anaemia and reactive thrombocytosis are common in active disease. Raised ferritin but low serum iron concentration and total iron binding capacity. LFTs: mild elevation of alkaline phosphatase and gamma GT.[patient.info]
  • Similarly, the platelet count is usually normal but thrombocytosis occurs in response to inflammation.[hopkinsarthritis.org]
  • Acute-phase reactants (eg, thrombocytosis, elevated ESR, elevated CRP) reflect disease activity. A mild polyclonal hypergammaglobulinemia often occurs. ESR is elevated in 90% of patients with active disease.[merckmanuals.com]
HLA-DR4
  • It is generally considered that a genetic predisposition (HLA-DR B1 which is the most common allele of HLA-DR4 involved in RA) and an environmental trigger (Epstein-Barr virus postulated as a possible antigen, but not proven) lead to an autoimmune response[radiopaedia.org]
  • EBV infection in normal individuals triggers production of antibodies to gp110, which were demonstrated in vitro to bind to HLA-DR4 [ 9 ].[dx.doi.org]
  • HLA DR4 and DR1 are associated, especially in severe disease. There is possible infective aetiology, although no organism has been demonstrated. Onset is more common in winter.[patient.info]
HLA-DR1
  • HLA-DR1 (HLA-DR beta *0101) also carries this shared epitope and confers risk, particularly in certain southern European areas. Other HLA-DR4 molecules (eg, HLA-DR beta *0402) lack this epitope and do not confer this risk.[emedicine.medscape.com]
Pleural Effusion
  • CT showed a massive right pleural effusion and a sclerotic lesion in the right ninth rib. Histopathological examination of the rib revealed IgA lambda-type plasmacytoma. Serum vascular endothelial growth factor was extremely high at 5530 pg/mL.[ncbi.nlm.nih.gov]
  • Pathogenesis A variety of mechanisms have been postulated for pleural effusions occurring in rheumatoid arthritis patients.[err.ersjournals.com]
  • Effects of rheumatoid arthritis on the lungs Rheumatoid nodules can develop in the lungs resulting in collapsed lung, coughing up blood or pleural effusion.[symptoma.com]
  • Pleurisy, pleural effusions , pulmonary fibrosis . Pericarditis , pericardial effusions , myocardial infarction , myocardial dysfunction, myocarditis . Lymphadenopathy . Dry eye syndrome (keratoconjunctivitis sicca). Neuropathy.[patient.info]

Treatment

Treatment of rheumatoid arthritis aims at reducing the inflammation of the joints, relieving pain, preventing joint damage and minimizing disability. Treatment is mostly symptomatic as there is no cure for the disease.

The treatment involves exercise and lifestyle modifications, medications and surgery in some extreme cases. The medications for treating rheumatoid arthritis include, NSAIDs, corticosteroids, DMARDs (Disease Modifying Anti–Rheumatic Drugs) and immunesuppressants [9].

Prognosis

Rheumatoid arthritis is a debilitating disease. Though treatment can delay and reduce the severity of the disability, there is no cure for this condition.

If the disease pattern is not altered by any medication, there is an ultimate destruction of the joints. The bone and the cartilages get eroded and the surface on which the joint moves is destroyed, resulting in rigidity and immobility of the joint, leading to a loss in the range of motion.

It may take years for the disease to progress to this stage, though the process may be hastened in some individuals. In very rare cases, when the organs such as the blood vessels are affected, life-threatening vasculitis may develop  [3].

Usually, the symptoms appear within the first two years of occurrence of the disease and manifests as pain, stiffness and immobility. As the disease progresses it results in 'burnt out' disease where there is severe immobility, deformity but very little inflammation.

Etiology

Etiology of occurrence of rheumatoid arthritis has not yet been identified and various researches are being carried out to identify the cause. It has been suggested that rheumatoid arthritis can be caused by both genetic and environmental factors. The Human Leukocyte Antigen (HLA) type is identified to be the gene linked with rheumatoid arthritis [1]. Of this, the HLA-DRB1 contains a sequence for the shared epitope and is found to be linked with the occurrence of rheumatoid arthritis.

Antibodies like RF and anti-CCP are associated with the occurrence of rheumatoid arthritis [2]. Apart from the genetic cause, it has been documented that various other causes such as smoking, bacteria, endocrinology and reproductive and psychological factors can predispose to the occurrence of rheumatoid arthritis.

Epidemiology

Woman are found to be more prone to be affected by this condition than men. It has been estimated that this disease is prevalent in 1% of women and 0.4% of men and 3.6% of women and 1.7% of men have a lifetime risk of acquiring this disease. The highest incidence is among the individuals between 40 to 75 years of age and the ratio of occurrence of this disease between women and men is 2:1. Rheumatoid arthritis is more common in the northern Europe and Northern America, but less common in Asia and Africa.

Sex distribution
Age distribution

Pathophysiology

The pathophysiology of rheumatoid arthritis is complex and is not completely understood.

Initially, the external factors such as smoking, triggers an autoimmune response in susceptible individuals. This results in the hyperplasia of the cells in the synovial joint and activation of the endothelial cells. These are early events that later progresses into bone and cartilage destruction due to uncontrolled inflammation. The mononuclear phagocytes, CD4 T-cells, osteoclasts, fibroblasts and neutrophils play a major role in the development of symptoms while, the B-cells produce autoantibodies.

Moreover there is an abnormal production of inflammatory mediators, cytokines, chemokines and growth factors that result in the further deterioration of bones and cartilages. The inflammation and the abnormal proliferation of the synovia, otherwise known as the pannus, ultimately results in the destruction of cartilage, bones, blood vessels, tendons and ligaments.

Though only the articular structures are the primary sites involved, other structures are also affected as a result of this inflammation.

Prevention

Though rheumatoid arthritis cannot be prevented, because of its genetic influence. The disease can be easily managed by appropriate exercise and avoiding triggering factors such as smoking and infection [10].

Summary

Rheumatoid arthritis is an autoimmune disorder that presents itself as a chronic inflammatory condition. An external trigger such as smoking, drinking, trauma or infection can trigger the immune system resulting in this condition. Rheumatoid arthritis is characterized by synovial hypertrophy and chronic inflammation of the joints. There may be extraarticular manifestations of this condition.

Genetic predisposition for the occurrence of this disease is still a topic of debate. Small joints of the hands and feet are the most affected in this condition and symmetric polyarthritis is its classical presentation. Early intervention of the condition is mandatory to avoid further complications.

Patient Information

Rheumatoid arthritis is a chronic inflammatory condition that affects mainly the joints, though it can also affect other organs. Though the specific cause of the disease is not known, it can triggered by various factors such as smoking.

Treatment of rheumatoid arthritis must be tailored according to individual needs and is usually a combination of drug and non-drug therapies. Early intervention can prevent progression of the disease and can prevent further deterioration of the joints and other associated complications.

References

Article

  1. Lipsky PE. Harrison's Principles of Internal Medicine. In: Isselbacher KJ, Braunwald E, Fauci AS, et al.Rheumatoid arthritis. 17th ed. New York, NY: McGraw-Hill; 1994:1648-55.
  2. Barton A, Worthington J. Genetic susceptibility to rheumatoid arthritis: an emerging picture. Arthritis Rheum. Oct 15 2009;61(10):1441-6.
  3. van Venrooij WJ, van Beers JJ, Pruijn GJ. Anti-CCP antibodies: the past, the present and the future. Nat Rev Rheumatol. Jun 7 2011;7(7):391-8
  4. van der Heijde DM. Radiographic imaging: the ‘gold standard' for assessment of disease progression in rheumatoid arthritis. Rheumatology (Oxford). Jun 2000;39 suppl 1:9-16
  5. Lindhardsen J, Ahlehoff O, Gislason GH, et al. Risk of atrial fibrillation and stroke in rheumatoid arthritis: Danish nationwide cohort study. BMJ. 2012;344:e1257.
  6. Komano Y, Harigai M, Koike R, Sugiyama H, Ogawa J, Saito K. Pneumocystis jiroveci pneumonia in patients with rheumatoid arthritis treated with infliximab: a retrospective review and case-control study of 21 patients. Arthritis Rheum. Mar 15 2009;61(3):305-12
  7. Ahlmén M, Svensson B, Albertsson K, Forslind K, Hafström I. Influence of gender on assessments of disease activity and function in early rheumatoid arthritis in relation to radiographic joint damage. Ann Rheum Dis. Jan 2010;69(1):230-3.
  8. Bang H, Egerer K, Gauliard A, et al. Mutation and citrullination modifies vimentin to a novel autoantigen for rheumatoid arthritis. Arthritis Rheum. 2007;56(8):2503–11
  9. Luqmani R, Hennell S, Estrach C, Basher D, Birrell F, Bosworth A, et al. British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of rheumatoid arthritis (after the first 2 years). Rheumatology (Oxford). Apr 2009;48(4):436-9.
  10. Macedo AM, Oakley SP, Panayi GS, Kirkham BW. Functional and work outcomes improve in patients with rheumatoid arthritis who receive targeted, comprehensive occupational therapy. Arthritis Rheum. Nov 15 2009;61(11):1522-30.

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Last updated: 2019-07-11 21:04