21.08.2014

Rheumatoid arthritis pain treatment options

Today I finished a Pain Scale, a request from RA Warrior “What would be your model pain scale?
Most people with RAD (Rheumatoid Autoimmune Disease aka Rheumatoid Arthritis) live with chronic pain daily.
I attempted to create a chart that describes some of the types of pain that someone with Rheumatoid Arthritis would recognize easily.
Rheumatoid ArthritisBASIC INFORMATIONDEFINITIONRheumatoid arthritis (RA) is a systemic disorder characterized by chronic joint inflammation that most commonly affects peripheral joints. DIAGNOSISAlready in the early course of the disease radiologic changes may be detected in the hands and feet. IM: 10 mg followed by 25 mg 1 wk later, then 25-50 mg wkly until there is toxicity, major clinical improvement, or cumulative dose = 1 g. Pruritus, dermatitis, stomatitis, nephrotoxicity, blood dyscrasias, a€?nitritoida€? reaction: flushing, weakness, nausea, dizziness 30 min after injection. Ophthalmologic examination every 3 months (visual acuity, slitlamp, funduscopic, visual field tests), neuromuscular examination.
Oral: 125-250 mg qd, then increasing atmonthly intervals doses to max 750-1000 mg by 125-250 mg.
Leukopenia, thrombocytopenia, hematuria, GI, alopecia, rash, bladder cancer, non-Hodgkina€™s lymphoma, infection. LFTs every month, drug levels afterdiscontinuation (after 1 monththerapy, remains in blood for 2 yearswithout use of cholestyramine).
ABSTRACT: Quantitative assessment of joint swelling and tenderness, essential for rheumatoid arthritis (RA) clinical research, also improves outcomes in routine clinical patient care. Quantitative assessment of joint swelling and tenderness is essential for rheumatoid arthritis (RA) clinical research. Obesity- Obese patients often suffer with osteoarthritis of weight bearing joint such as knee and hip joint.
Joint Infection- Joint infection causes destruction of cartilages and synovial membrane resulting in triggering of osteoarthritis development. Pain Intensity- Mild to moderate at rest and severe to extremely severe with joint movement. Range of movement is restricted in the joint of the hand, which is affected by osteoarthritis. Range of movement is restricted because of pain in inter-phalangeal joint or metacarpo-phalangeal joint.
Joint swelling is observed secondary to osteophytes and hypertrophy of the bones forming the joint.
Patient is often unable to grip or pinch the object with the finger affected by Heberden's node. Restricted joint movement is observed in joint of the hand and fingers as the disease progresses. Joints in palm and finger are small joint and swelling is caused by edematous inflammatory soft tissue.
Swelling may be secondary to joint deformity and osteophyte of the bones forming the joint. Test is positive in inflammatory joint diseases like Psoriatic hip joint disease, Ankylosing Spondylitis and Reiter's Syndrome. Septic Arthritis- Bacterial cells, red blood cells and pus cells are observed in septic arthritis. Inflammation is treated with short-term restriction of joint movement and anti-inflammatory medications. Yoga therapy and stretching exercises under supervision are beneficial to prevent muscle weakness and atrophy. Moist heat (heated wet towel) or hot water bag treatment is beneficial to reduce pain and improve joint movements. Direct application of ice covered with plastic or cloth over shoulder for 20 to 30 minutes two or three times a day. Anti-Epileptic Analgesics- Most common antiepileptic prescribed as analgesics is Neurontin and Lyrica. Anti-Depressant Analgesics- Most common antidepressant prescribed as analgesics is Cymbalta and Elavil. Procedure provides excellent pain relief, good range of motion, and restores function to the thumb. Dactylitis is a condition in which the fingers or toes develops inflammation looking like a sausage. The major cause for getting dactylitis is sickle cell anemia, sickle cell disease and psoriasis.
For some people, the underlying health problems like psoriatic arthritis, leprosy, gonococcal arthritis, juvenile chronic arthritis and sarcoiditis can cause swelling on the toes and fingers which may lead to dactylitis. In case of severe pain you need to consult your doctor who may put you on intravenous fluids for keeping you hydrated. But since I am just one patient, it would need more input on how they might describe the pain.
Pain is just one symptom of RAD learn more about Rheumatoid Autoimmune Disease (also called Rheumatoid Arthritis or RA).
Found out on July 19, 2013 that I really was profoundly low on Vitamin B7 because of a rare disease called Biotinidase Deficiency. This process results in the development of pannus, a destructive tissue that damages cartilage. There is increasing evidence that the inflammation and destruction of bone and cartilage that occurs in many rheumatic diseases are the result of the activation by some unknown mechanism of proinflammatory cells that infiltrate the synovium.
In the early stage changes include periarticular soft tissue swelling and demineralization of the periarticular bones.
Both old and new RA classification criteria involve careful joint assessment, and the results of several studies indicate that performing quantitative joint counts improves patient care. Continuous manual work with heavy and vibrating equipment causes wear and tear of joint cartilages in palm and fingers resulting in early development of osteoarthritis.
Sometimes, the entire feet develop inflammation and the person may suffer from fever and tenderness on the affected fingers. Leprosy, Reiter’s syndrome, tuberculosis, mycobacterium tuberculosis and sarcoidosis are some of the other factors which give rise to inflammation on the fingers and toes.
You should take more water and plenty of liquids than the normal days, in case if you are infected.
In case of blistering dactylitis, the infection is caused by streptococcus and hence your doctor may prescribe antibiotics for controlling viral infection. Inflammation happens when you are cut, you sprain something or when you are hit by a truck (tissue damage, broken bones, etc). I also made section for recommendations which I think individual patients would have to fill in.
When I found out I was very weak, hardly could get out of bed, could not turn my head without getting light headed, dragging my feet when I tried to walk, struggled to breath daily for years and was having many many other issues.
These cells, in turn, release various substances, such as cytokines and tumor necrosis factor (TNF) alpha, which subsequently cause the pathologic changes typical of this group of diseases.


In later stages they include joint space narrowing along with erosions and subluxations (Fig. We synthesized the published information and developed a video CME program to provide physicians and other health care professionals with training on performing quantitative joint examinations. Our mission is to save precious time by offering the best and latest on rheumatology in an easy-to-read format, always hyperlinked for more in-depth reading later. What's inside? For some people, it becomes very difficult to walk or eat or carry out routine activity using fingers or toes. The fleshy pad of the fingers develops swelling on children making it a symptom of underlying sickle cell anemia. If the person is infected with distal dactylitis, yoru doctor would make incision for draining out the pus. I put an example of something they may write to allow family members to see what help they may need during those levels of pain.
From the first 24 hours of taking Biotin my symptoms started to disappear and my body started getting stronger again. Women are affected about three times more often than men.Clinical FindingsSymmetric distribution of the joint disorder is characteristic.
Many of the newer therapeutic agents are directed at the suppression of these final mediators of inflammation. The RA Joint Count, which includes 6 joint areas for a total of 28 joints, involves a uniform procedure that includes specific instructions to the patient, precise identification of anatomical joint landmarks, and defined joint examination techniques. In the Tight Control for Rheumatoid Arthritis (TICORA) study, a “treat to target” strategy was used.9 The TICORA investigators compared usual care with more intensive care of patients with RA who have active disease.
News summaries based on studies published in leading medical journals and specialty medical journals, conference coverage, case-based quizzes and more. Small blisters may develop on the fingers making it very painful to move (blister dactylitis). In the early phase of the disease hand, metacarpophalangeal and interphalangeal joints (Fig.
This validated tool provides important information for assessing severity and outcomes in RA.
The usual-care group was evaluated every 3 months, and no quantitative measures of disease activity were used. We also publish case studies and practice-related articles by rheumatologists and other specialists.
Very often this symptom can be an indication of ankylosing spondylitis, sickle cell anemia and arthritis problem. Another type of dactylitis called tuberculosis dactylitis affects the bones of hands and feet and makes it difficult to treat them. If you were to get hit by a truck and survive, you would probably have months of pain, recovery and rehabilitation. In contrast, the intensive-treatment group received therapy that was adjusted using a predefined algorithm based on the DAS score.Patients who received the intensive-therapy regimen achieved a lower DAS score more rapidly and sustained the lower DAS score longer than patients with RA treated in the usual fashion. Osteoarthritis of the hand is also known as degenerative disease because of wear and tear of the cartilage and soft tissue of the joint. Apart from being fleshy, the fingers will also cause severe pain and hence the person may not be able to use them.
Some of my thoughts were about bee stings, sunburns, sprained bones, strained muscles, broken bones, torn muscles, headaches, migraines, cuts, surgery, childbirth, being ran over by a truck and even torture. Involvement of the distal interphalangeal joints is rare and points to differential diagnoses, such as psoriatic arthritis or reactive arthritis.
Rheumatoid arthritis may lead to spondylarthritis, instability, or rarely ankylosis, but also to destruction of the atlantal dentate ligaments through inflammatory pannus resulting in atlantoaxial subluxation or even compression of the spinal cord.
Osteoarthritis is more often seen in hand and weight bearing joint like hip and knee joint.
Usual symptoms of rheumatoid arthritis include joint pain and swelling, often associated with severe and long-standing morning stiffness, as well as loss of strength, particularly in the hands.
Laboratory examination often reveals elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), normochromic and normocytic anemia, thrombocytosis, and low serum iron. Osteoarthritis of the hand in younger patient is caused by injury and genetic bone disease. Fatigue and general malaise, and at times slightly elevated temperatures, are often the first indications of the ongoing disease process. Without effective medication, rheumatoid arthritis is characterized by functional deficit due to progressive joint destruction. DIFFERENTIAL DIAGNOSISa€? SLEa€? Seronegative spondyloarthropathiesa€? Polymyalgia rheumaticaa€? Acute rheumatic fevera€? SclerodermaAccording to the American College of Rheumatology, RA exists when four of seven criteria are present, with criteria 1 to 4 being present for at least 6 wk.1. The standardized RA Joint Count, adapted from the 1989“simplified twenty-eight–joint quantitative articular index” described by Fuchs and colleagues,14 is used in the ACR improvement criteria and in the DAS. The other inflammatory joint disease, which may affect hand joints are rheumatoid arthritis and psoriatic arthritis.
Late stages are characterized by deformities, rheumatic nodules, as well as postinflammatory changes of bones, joints, and soft tissue. The patient should be provided with the following instructions: “I am going to examine various joints for swelling and tenderness. Please say yes or no if there is tenderness when I press a specific joint.”In RA, joint swelling and tenderness are caused by inflammation of the joint synovium, increased synovial fluid production, and periarticular swelling in the joint capsule and surrounding tissues. Visual clues of joint swelling include enlargement of the joint soft tissue, skin stretching with loss of folds and furrows, and red or blue skin color changes around the joint.After inspection, each joint is examined by palpation using the thumbs and index fingers.
Commonly used agents are methotrexate, cyclosporine, hydroxychloroquine, sulfasalazine, leflunomide, and infliximab.
Joint swelling may be detected by finding tissue sponginess and ballotting the joint for increased synovial fluid. Identifying anatomical landmarks of specific joints and comparing joints on one side of the body with those on the other side are helpful in assessment of joint swelling.Note that RA joint and soft tissue structural abnormalities may cause joint malalignment, which may influence the assessment for swelling. They are also usually slow-acting drugs that require more than 8 wk to become effective (see Table 1-13)a€? Oral prednisonea€? Intrasynovial steroid injectionsa€? Etanercept (Enbrel), a tumor necrosis factor alpha blocker is indicated in moderately to severely active RA in patients who respond inadequately to DMARDs. Adipose tissue may be present near joints and is related, in part, to body size; it should not be confused with inflammation. Joints that have severe deformity or are fused should be noted and should not be included in the scoring for swelling.During joint palpation, tenderness is determined primarily by applying sufficient pressure to the joint line to cause blanching of the examiner's fingernail bed. The patient is asked, “Is that tender?”Joint tenderness also is assessed by moving joints through their respective ranges of motion. The numbers of swollen and tender joints are calculated independently and then added together to determine the total score for the RA Joint Count. The patient is instructed to make a fist and then extend the fingers to make the palm as flat as possible, which allows for inspection of joint range of motion and places the 4 PIP joints and the first IP joint in a neutral position. Thin horizontal skin folds present over the joints decrease with joint flexion.The joints are flexed to 30°.
The examiner places his or her thumbs on the medial and lateral sides of each PIP joint to examine for swelling (Figure 2). Next, he exerts pressure with one thumb and then the other to ballot for increased joint fluid.


One thumb and index finger are placed on the ventral and dorsal sides of the patient's joint and the other thumb and index finger on the sides at the joint line.
Tenderness is assessed with bilateral thumb pressure at the joint line margins.•MCP joints 1-5. The MCP joints are evaluated by inspection with the patient's fingers fully extended using a procedure similar to that used for the PIP joints.
This position reduces the transverse and longitudinal arches of the hand and the prominence of the second and third MCP joints. The furrows between the MCP joints decrease with swelling.The MCP joints are flexed to 30°. The examiner presses his thumbs inwardly in a horizontal plane on the sides at each joint line.
The patient's thumb MCP joint is palpated with the hand rotated laterally to detect sponginess of tissues resulting from inflammation.The hand is returned to the neutral position to examine MCP joints 2-5. Skin, subcutaneous fat between the metacarpals, and ligamentous structures add to the sensation of palpation and must be accounted for when judging joint swelling. Tenderness of each MCP joint along the medial and lateral joint line margin is determined by applying thumb pressure that blanches the examiner's nail.Several additional anatomical points should be considered in the MCP and PIP joint examination. Adipose tissue may be present on the dorsum of the hand; it is related, in part, to body size and should not be confused with inflammation.
RA swan neck, boutonnire, and MCP ulnar deviation deformities do not necessarily indicate swelling or tenderness.
The intrinsic muscles of the hands between the metacarpals may become atrophied in RA, increasing the furrows between the metacarpals in the dorsal hand. The furrows may be lost with MCP joint swelling.WristsThe wrist joint is divided by septae into radiocarpal and inferior radioulnar cavities.
Wrist inflammation may occur in the articular synovium and in the dorsal and volar synovial sheaths. These sheaths surround the tendons, which connect the forearm muscles to the fingers and extend to midway between the wrist and the MCP joints.Assessment of the wrist should be performed by observing the joint in both the neutral and flexed positions. Wrist swelling is detected with thumb palpation applied dorsally along the joint line and at the ulnar styloid. Dorsal wrist swelling and inflammation of the extensor tenosynovial sheaths may become more prominent with the patient's fingers extended and the radiocarpal joint in the neutral position. Overlying skin that is tucked in, or bunched up, under the distal tendon sheath is a positive tuck sign (Figure 3).Volar radiocarpal and extrinsic finger flexor tendon swelling on the palmar side of the joint also may be detected with palpation. Deformity of the wrist with rotatory subluxation causes prominence of the ulnar styloid region, making assessment for swelling more difficult.
Also, normally there is a fat pad adjacent to the ulnar styloid that should not be scored as swelling. Joint tenderness is elicited by palpating over the radiocarpal joint line dorsally and at the ulnar styloid.ElbowsThe elbows are inspected with the joint brought to full extension. Swelling is evident visually as a loss of the medial and lateral recesses on either side of the ulna. With the patient's elbow flexed and extended, the examiner uses his thumb and index finger to palpate the lateral recess between the lateral epicondyle of the humerus and the head of the radius and the medial recess between the medial epicondyle and the ulna.
To determine tenderness, pressure is applied to the elbow along the lateral joint line with the thumb pad.Posterior swelling in the olecranon bursa, which lies superficially over the olecranon, is not considered true elbow joint swelling. The findings are recorded on the basis of the presence of swelling in the medial and lateral recesses of the elbow and tenderness along the joint line on palpation.ShouldersEvaluation of shoulder swelling is challenging because of the musculature overlying the joint. In addition, the shoulders may not be similar in size—the shoulder of the dominant hand often is larger.The patient is assisted in abducting the arm 50° from the body laterally. Unlike in other joints, tenderness in the shoulder is not determined principally with palpation but rather with the patient's report of pain with abduction. The examiner detects synovitis and synovial effusions of the shoulder by using the thumb pads at the joint line anteriorly at the medial humeral head just lateral to and below the coracoid process (Figure 4).
The examiner ballots the shoulder joint for fluid with pressure applied posteriorly moving fluid anteriorly, makingit easier to detect.
Shoulder tenderness also may be elicited by applying thumb pressure to the shoulder joint line anteriorly.KneesThe knee, the largest joint in the body, is involved in RA frequently. Inspection starts with the patient lying flat with the hip externally rotated to 60° and the knee slightly flexed.
Then, joint range of motion with flexion and extension is assessed by comparing one knee with the other.There are recesses medial and lateral to the patella along the joint line. Each of these recesses and bursae may become swollen with synovial proliferation and increased joint fluid.In more than 90% of persons, the suprapatellar bursa communicates with the knee joint and fluid there may be moved to the joint cavity. The examiner detects swelling by placing a hand on the suprapatellar region and applying downward pressure. Palpating with the thumb and index finger medially and laterally below the patella at the joint margin detects movement of fluid.
Ballottement of the patella also may help determine the presence of fluid.Tenderness in the knee is assessed by applying thumb pressure over the medial joint line, which is proximal to the anserine bursa and is felt as a groove. Fat pads above and below the knee in the suprapatellar and infrapatellar regions may be prominent, depending, in part, on body size. Knee swelling and tenderness are recorded on the scoring sheet.SUMMARYThe RA Joint Count is a validated tool that provides important information for assessing severity and outcomes in RA. With the use of uniform procedures, precise identification of anatomical landmarks, and defined joint examination techniques, it can be performed effectively and efficiently to improve outcomes for patients with RA.References1. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States, part I.
The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis.
American College of Rheumatology: preliminary definition of improvement in rheumatoid arthritis.
Development of a disease activity score based on judgment in clinical practice by rheumatologists. Modified disease activity scores that include twenty-eight-joint counts: development and validation in a prospective longitudinal study of patients with rheumatoid arthritis. Effect of a treatment strategy of tight control for rheumatoid arthritis (the TICORA study): a single-blind randomised controlled trial. Clinical and radiographic outcomes of four different treatment strategies in patients with early rheumatoid arthritis (the BeSt study): a randomized, controlled trial.
Tight control in the treatment of rheumatoid arthritis: efficacy and feasibility [published correction appears in Ann Rheum Dis. Clinical studies with an articular index for the assessment of joint tenderness in patients with rheumatoid arthritis.



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Comments to «Rheumatoid arthritis pain treatment options»

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  2. L_500 writes:
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