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Poliartrita reumatoid.

Mna n poliartrita reumatoid.

Danciu Ana Maria


Prigoana Iulia
Sturzu Ionela

Poliartrita reumatoid.
Mna n poliartrita reumatoid.
Poliartrita reumatoid ( PR ) reprezint o afeciune a esutului conjunctiv cu manifestri
predominante la nivelul aparatuui locomotor.
Caracateristica bolii este inflamaia cronic infiltrativ- proliferativ a sinovialei
articulare a extremitilor, n special a articulaiilor mici. Fenomenele inflamatoare sunt frecvent
simetrice, persistente, centripete i duc n timp la deviaii, deformri i anchiloze. Boala este
progresiv evolutiv, prezentnd exacerbri i remisiuni.
Din totalul afeciunilor reumatismale, poliartrita reumatoid reprezint aproximativ 10 %,
fiind mai frecvent la femei.
Cauza poliartritei reumatoide este necunoscut.
Poliartrita reumatoid este o boal frecvent, cu evolu ie prelungit, determinrile
osteoarticulare cu caracter invalidant duc la infirmizarea bolnavului, ceea ce face din poliartrita
reumatoid o boal cu caracter social.

Poliartrita reumatoid afecteaz celulele care nvelesc i lubrefiaz articulaiile ( esutul


sinovial ). Aceasta este o boal sistemic astfel c poate afecta articulaiile multiple, de obicei de
ambele pri ale organismului. esutul care nvelete articulaia devine inflamat i erodeaz
cartilajul i osul. Inflamaia se poate ntinde la ligamentele din vecintate care, fiind formate din
esut conjunctiv, menin oasele mpreun, astfel apar deformrile i instabilitatea. De asemenea,
procesul inflamator poate s afecteze i tendoanele, aprnd astfel elongarea , tensionarea i
chiar ruperea lor.
Localizrile leziunilor inflamatoare n poliartrita reumatoid sunt la nivelul esuturilor
articulare, capsule articulare, cartilajelor articulare, epifizelor osoase, acestea se mai gsesc i la
nivelul esuturilor periarticulare ( muchi, tendoane, burse sinoviale, nervi, tegumente).
Mna este afectat cu predilecie n poliartrita reumatoid, manifestndu-se prin
inflamarea sinovialei, afectarea cartilajului, leziuni osoase, leziuni ale capsulei articulare, ale
tendoanelor, muchilor i noduli reumatoizi.

n general boala se instaleaz fr simptome vizibile, articulaiile fiind treptat afectate.


Alteori, debutul bolii este brusc, cu inflamaia simultan a mai multor articulii diferite.
Din punct de vedere estetic, boala poate afecta i aspectul articulaiilor care se mresc din
cauza tumefaciei sau se deformeaz.

Se mai pot produce mici luxaii falangiene, cu devierea degetelor de la fiecare mn ctre
degetul mic. De asemenea, la nivelul articulaiilor tumefiate se pot produce compresii ale
nervilor din vecintate, cu apariia anesteziei sau paresteziei.

Semne i simptome
Rigididatea, edemul i durerea sunt simptome frecvente pentru toate formele de artrit a
minii. n cazul poliartritei reumatoide, unele articulaii pot fi mai inflamate dect altele.Adesea,
degetele capt o form fusiform.
Alte simptome ale poliartritei reumatoide sunt:
- nodulii de dimensiuni mici localizai pe faa dorsal a minii, care se mobilizeaz odat cu
tendoanele care ndreapt degetele,
- crepitaii n timpul micrii ,
- modificarea poziiei degetelor,
- inflamarea tendoanelor de la nivelul degetelor, aparnd crepitaiile i modificarea pozi iei la
flexiunea acestora, uneori cu amoreal i furnicturi locale ( sindromul de canal carpian),
- ruperea tendoanelor cu pierderea capacitii flexiunii i extensiunii degetelor,
- articulaii instabile,
- deformri, n care articulaiile mijlocii de la nivelul degetelor rmn ndoite n hiperextensiune
( deformarea n butonier),
- deformarea n gt de lebd.

Evaluarea clinica si factori care influenteaza decizia terapeutica

Pentru diagnosticul poliartritei reumatoide se folosesc criteriile ACR:


1. redoare matinal: la nivelul i n jurul articulaiilor, cu durat de minim o or nainte de
momentul ameliorrii maxime;
2. artrit n cel puin 3 zone articulare: minim 3 zone articulare prezentnd simultan
tumefacie de esuturi moi sau acumulare de lichid sinovial observat de medic (hipertrofi ile
osoase izolate nu satisfac acest criteriu). Cele 14 zone articulare posibil afectate sunt: articulaiile
interfalangiene proximale (IFP), metacarpofalangiene (MCF), radiocubito carpiene (RCC), coate,
genunchi, tibiotarsiene (TT), me tatarsofalangiene (MTF), dreapta sau stnga;
3. artrit a articulaiilor minilor: cel puin o zon articular tumefi at (conform defi niiei de
la criteriul 2), la nivelul RCC, MCF, IFP;
4. artrite simetrice: afectarea simultan bilateral a acelorai arii articulare (definite ca la
criteriul 2). Afectarea bilateral a IFP, MCF, MTF este acceptabil fr simetrie absolut;
5. noduli reumatoizi: subcutanai, dispui deasupra proeminenelor osoase, suprafeelor de
extensie sau regiunilor juxtaarticulare, observai de un medic;
6. factor reumatoid (FR) seric: evidenierea unei cantiti anormale de FR seric, prin orice
metod care d rezultate pozitive la mai puin de 5% dintr-o populaie martor de subieci
sntoi;
7. modificri radiologice: leziuni tipice pentru PR evideniate pe radiografi a posteroanterioar
de mini cu RCC, respectiv: eroziuni sau osteoporoz clar localizat la sau mai evident n jurul
articulaiilor afectate (modifi crile izolate artrozice nu satisfac acest criteriu).
Criteriile 1-4 trebuie s fie prezentate pe o perioad de minim 6 sptmni. Pentru diagnosticul
PR este necesar prezena a minim 4 din cele 7 criterii.

Cum se poate reduce durerea


Diagnosticarea timpurie, urmarea unui tratament adecvat, recomandat de medicul reumatolog,
precum i realizarea unui plan de management al bolii pot ncetini procesul de evoluie a
acesteia. Mai mult, dieta i activitile fizice sunt deosebit de importante n meninerea unei viei
normale.
Pstrarea greutii corporale i urmarea unei diete echilibrate reduc durerile i pot preveni o
parte din dizabilitile pe care le provoac poliartrita reumatoid. Astfel, este recomandat
consumul de pete de ap rece (somon, ton, hering, macrou, halibut) pentru coninutul de acizi
grai Omega 3 i al produselor bogate n vitamina D (crevei, semine de floarea soarelui, ou,
lapte i iaurt mbogite cu viatmina D). Legumele i fructele organice i uleiul de msline
extravirgin sunt, de asemenea, recomandate. Mai mult, trebuie reduse din alimentaie sarea,
produsele lactate precum brnzeturile grase, fina alb, carnea (mai ales cea bogat n grsime) i
grsimea saturat (inclusiv uleiurile hidrogenate).

Planul de management al bolii include i un program de activiti fizice i exerciii


benefice pentru poliartrita reumatoid. Activitatea fizic este deosebit de important, fiind
demonstrat faptul c astfel sunt reduse durerile i strile de oboseal i, de asemenea, crete
flexibilitatea i puterea muchilor. Programul de activiti fizice trebuie realizat in funcie de
recomandrile medicului reumatolog, mpreun cu un specialist (kinetoterapeut).
Trei tipuri de exerciii sunt recomadate pentru poliartrita reumatoid: exerciiile care pun n
micare minile i picioarele, exerciiile de ntrire a muchilor (not, aqua gym) i exerciiile de
rezisten (cardio, aerobic, bicicleta medicinal).

Tratament

Tratamentul optim al bolii necesit un diagnostic precoce, precum i utilizarea la timp a agenilor
care reduc probabilitatea leziunilor articulare ireversibile. Este necesar precizarea corect a
diagnosticului de PR (uneori difi cil n stadiile incipiente), urmat de evaluarea periodic a
activitii bolii, a efi cienei programului terapeutic i a toxicitii medicamentoase, cu revizuirea
schemei de tratament n funcie de rezultatul acestor evaluri.
Este demonstrat c pacienii cu PR activ, poliarticular i seropozitiv, au o probabilitate de
peste 70% de a dezvolta eroziuni sau leziuni articulare n primii doi ani de la debutul bolii. Este
de asemenea demonstrat c aplicarea timpurie a unui tratament agresiv poate s amelioreze
evoluia n timp a bolii, motiv pentru care majoritatea centrelor reumatologice opiniaz n
prezent pentru o schem terapeutic precoce i agresiv
Dei scopul final al tratamentului PR este inducerea unei remisiuni complete, aceasta nu este
dect rareori posibil. Remisiunea se definete ca fiind absena:
durerii de tip inflamator i a simptomelor de inflamaie sinovial
redorii matinale;
asteniei;
modificrii reactanilor de faz acut (VSH i PCR);
progresiei leziunilor radiologice pe radiografii seriate.
n cazul n care tratamentul nu poate determina remisiunea complet, scopul tratamentului este
acela de a:
controla activitatea bolii;
reduce durerea i simptomele inflamaiei sinoviale;
menine capacitatea funcional de gestic uzual i munc;
menine calitatea vieii;

ncetini evoluia leziunilor articulare

Tratamentul este realizat pentru ameliorarea durerii i restabilirea funciei.


Medicamentele care pot scdea inflamaia, ameliora durerile i ncetini progesia bolii sunt
antiinflamatoarele nesteroidiene, steroizii administrai oral i/sau injeciile de cortizon.
Kinetoterapia intr n aciune concomitent cu celelalte mijloace recuperatorii, n cadrul
planului terapeutic general, iar scopul mijloacelor kinetoterapeutice este ca prin aplicarea lor
pacienii s se reintegreze n viaa socio- profesional de la care au fost oarecum privai.
Procesul inflamator ca i durerea articular sunt cauze directe care limiteaz micrile
nc din primele faze ale bolii. Tratamentul kinetoterapeutic se aplic n func ie de cele patru
stadii ale bolii ( stadiul prodromal, stadiul de debut, stadiul clinic manifest, stadiul avansat) i de
starea clinic n care se afl pacientul.
Depirea redorilor articulare matinale se poate face prin exerciii de gimnastic, micri
active. Important este ca micrile s se execute pe toat amplitudinea de micare i pe toate
direciile de micare n ritm lent. Pentru meninerea sau creterea for ei musculare sunt
recomandate exerciiile n regim de izometrie care nu implic n niciun fel articula ia. Exerci iile
iometrice executate cu regularitate vor ameliora nu numai fora muscular ci i rezisten a
muchiului. Exerciiile fizice de intensitate mare sunt interzise.
Tratamentul prin masaj are de asemeni un rol important n tratamentul bolnavului cu
poliartrit reumatoid, efectele benefice ale acestuia fiind resimite la nivelul tegumentelor, al
circulaiei periferice de retur i asupra strii psihice a bolnavului inducndu- i o stare de bine i
confort emotional.
Terapia ocupaional joac un rol important n recuperare, aceasta urmrind refacerea
mobilitii articulare sub toate componentele ei: amplitudine articular, for i rezisten
muscular i abilitatea micrilor n scopul ctigrii unei maxime independene la domiciliu ct
i la locul de munc. Recuperarea funcional prin terapia ocupaional se poate face fie ntr-o
instituie specializat, fie la domiciliul pacientului, caz n care acesta trebuie instruit cu
mijloacele necesare mbuntirii strii lui de sntate.
Activitile recomandate pacientului cu poliartrit reumatoid sunt: lucrul la maina de
cusut cu pedal, roata olarului, mers pe biciclet, cusut de gherghef, croetat, mpletit, desenat
etc. Activitile ocupaionale nu trebuie s produc durere i oboseal musculo-articular.
Cauzele acestie boli rmn necunoscute, prevenirea ei nu este nc posibil, ns
diagnosticul precoce i nceperea unui tratament corect att medicamentos, ct si kinetoterapeutic
pot ncetini evoluia i pot preveni incapacitatea fizic.

Articole

Pentru a studia caracteristicile clinice,demografice si de tratament ale pacientilor cu


debutul poliartritei reumatoide la o varsta mai inaintata si pentru a le compara pe acestea cu cele
ale pacientilor tineri s-a efectuat un studiu ce include 62 de pacienti varstnici si 111 pacienti
tineri ce sufera de poliartrita reumatoida.
S-a constatat ca pacientii varstnici au o prevalenta mai mare de gen masculin si
depreciere mai putin functionala decat pacientii tineri.

Un alt studiu ce analizeaza indicile de predictie a riscului de 10 ani a unui fatal eveniment
de boala cardiovasculara la 100 de pacienti cu poliartrita reumatoida de sex feminin comparativ
cu 100 de pacienti ce fac parte din grupul de control arata faptul ca prevalenta comorbitatilor
analizate a fost similara la pacientii cu poliartita reumatoida comparative cu grupul de control.

Concluziile unul studiu ce analizeaza frecventa a patru biomarkeri la pacientii cu


poliartrita reumatoida si rudele acestora si de a identifica posibilele asocieri cu constatarile
clinice de boala arata faptul ca unui numar mai mare de biomarkeri a fost prezent la pacientii cu
poliartrita reumatoida unde lipsesc manifestarile extra-articulare. Constatarile acestui studiu
consolideaza legatura dintre biomarkerii distincti si mecanismele fiziopatologice la pacientii cu
poliartrita reumatoida.

1.

OBJECTIVE: To investigate the longitudinal relationship between disease activity


and self-reported physical activity (PA) in patients with early rheumatoid
arthritis during the first year of treatment with combination therapy.

METHODS: PA was measured with the Short Questionnaire to Assess Health-Enhancing


Physical Activity at baseline, 13 weeks, 26 weeks, and 52 weeks after start of
treatment in the context of the Combinatietherapie Bij Reumatode Artritis-Light

trial. The reported PA classified patients as meeting or not meeting the World
Health Organization (WHO) PA guideline (cutoff: 150 minutes of
moderate-to-intense activity per week). Other measurements included the Disease
Activity Score (DAS). Since both treatment arms showed equal treatment effect,
these were analyzed as 1 group with simple before-after analyses and generalized
estimating equations (GEE).

RESULTS: In these analyses, 140 patients (86% of the trial population, 66% women,
mean age 52 years) with complete data were included. At entry, 69% of the
patients met the WHO PA guideline, increasing to 90% at week 13, and remaining
stable at 89% after 1 year (P < 0.001). Mean DAS improved from 4.0 to 1.8 during
the first year of treatment (P < 0.001). In GEE analyses, DAS decreases were
significantly associated with PA increases (P=0.008). Patients with clinically
relevant responses (expressed as DAS remission, European League Against
Rheumatism good response or American College of Rheumatology criteria for 70%
improvement response) showed higher PA levels compared to nonresponders,
regardless of the definition of response, for both the WHO and Dutch PA
guideline.

CONCLUSION: Early rheumatoid arthritis patients using combination therapy


improved both disease activity and PA, a beneficial effect persisting for at
least 1 year.

2.
OBJECTIVES: To evaluate the frequency of four serum biomarkers in RA patients and
their relatives and identify possible associations with clinical findings of the
disease.

METHODS: This was a transversal analytical study. Anti-cyclic citrullinated


peptide (anti-CCP), anti-mutated citrullinated vimentin (anti-MCV) and
IgA-rheumatoid factor (RF) were determined by ELISA and IgM-RF by latex
agglutination in 210 RA patients, 198 relatives and 92 healthy controls from
Southern Brazil. Clinical and demographic data were obtained through charts
review and questionnaires.

RESULTS: A higher positivity for all antibodies was observed in RA patients when
compared to relatives and controls (p<0.0001). IgA-RF was more frequent in
relatives compared to controls (14.6% vs. 5.4%, p=0.03, OR=2.98; 95%CI=1.11-7.98)
whereas anti-CCP was the most common biomarker among RA patients (75.6%).
Concomitant positivity for the four biomarkers was more common in patients
(46.2%, p<0.0001). Relatives and controls were mostly positive for just one
biomarker (20.2%, p<0.0001 and 15.2%, p=0.016, respectively). No association was
observed between the number of positive biomarkers and age of disease onset,
functional class or tobacco exposure. In seronegative patients predominate
absence of extra articular manifestations (EAMs) (p=0.01; OR=3.25;
CI=1.16-10.66). Arthralgia was present in positive relatives, regardless the type
of biomarker.

CONCLUSIONS: A higher number of biomarkers was present in RA patients with EAMs.


Positivity of biomarkers was related to arthralgia in relatives. These findings
reinforce the link between distinct biomarkers and the pathophysiologic
mechanisms of AR.

3.
INTRODUCTION: Rheumatoid arthritis is an autoimmune disease that causes systemic
involvement and is associated with increased risk of cardiovascular disease.

OBJECTIVE: To analyze the prediction index of 10-year risk of a fatal


cardiovascular disease event in female RA patients versus controls.

METHODS: Case-control study with analysis of 100 female patients matched for age
and gender versus 100 patients in the control group. For the prediction of
10-year risk of a fatal cardiovascular disease event, the SCORE and modified
SCORE (mSCORE) risk indexes were used, as suggested by EULAR, in the subgroup
with two or more of the following: duration of disease 10 years, RF and/or
anti-CCP positivity, and extra-articular manifestations.

RESULTS: The prevalence of analyzed comorbidities was similar in RA patients


compared with the control group (p>0.05). The means of the SCORE risk index in RA
patients and in the control group were 1.99 (SD: 1.89) and 1.56 (SD: 1.87)
(p=0.06), respectively. The means of mSCORE index in RA patients and in the
control group were 2.84 (SD=2.86) and 1.56 (SD=1.87) (p=0.001), respectively. By
using the SCORE risk index, 11% of RA patients were classified as of high risk,
and with the use of mSCORE risk index, 36% were at high risk (p<0.001).

CONCLUSION: The SCORE risk index is similar in both groups, but with the
application of the mSCORE index, we recognized that RA patients have a higher
10-year risk of a fatal cardiovascular disease event, and this reinforces the
importance of factors inherent to the disease not measured in the SCORE risk
index, but considered in mSCORE risk index.

4.

BACKGROUND: The age of onset of rheumatoid arthritis (RA) appears to be a

determining factor in differences in disease presentation.


OBJECTIVE: To study the clinical, demographic and treatment characteristics of
patients with elderly onset rheumatoid arthritis (Eora) and to compare them to
those with younger onset rheumatoid arthritis (Yora) patients.
METHODS: We studied 62 patients with Eora and 111 with Yora for gender, presence
of rheumatoid nodules, interstitial pneumonitis, tobacco exposure, rheumatoid
factor (RF) and antinuclear antibodies (ANA), medications, functional index
measured by Health Assessment Questionnaire (HAQ) and inflammatory activity
measured by DAS (Disease Activity Score) 28.
RESULTS: Higher prevalence of male gender (p=0.02), positive RF (p=0.007) and
lower HAQ scores (p=0.04) were found in Eora's patients. There were no
differences regarding the use of medications, presence of nodules and
interstitial pneumonitis, ANA and tobacco exposure (p=NS).
CONCLUSION: Individuals with Eora have a higher prevalence of male gender and
RFpositivity and less functional impairment than individuals with Yora.

5.
OBJECTIVES: To investigate the association of comorbidities with mobility
limitation and functional disability in patients with rheumatoid arthritis (RA)
and to identify which comorbidity indicator is the most appropriate to determine
this association.

METHODS: Sixty RA patients were enrolled in a cross-sectional study for a period


of 11 months. Comorbidities were assessed using three indicators: (i) the total
number of comorbidities (NCom); (ii) the Charlson comorbidity index (CCI); and
(iii) the functional comorbidity index (FCI). Disease activity was assessed using
the Disease Activity Score 28 (DAS-28/ESR). Functional capacity was measured
using the Health Assessment Questionnaire (HAQ), and mobility was measured using

Timed Up and Go Test (TUG) and Five Times Sit To Stand Test (FTSTS). Statistical
analysis was performed using a stepwise log-linear multiple regression with a
significance level of 5%.

RESULTS: In the final model, only comorbidity (FCI) was associated with mobility
limitation (FTSTS and TUG). The FCI score explained 19.1% of the variability of
the FTSTS (coefficient of determination [R(2)]=0.191) and 19.5% of the TUG
variability (R(2)=0.195). With regard to functional disability (HAQ), the
associated factors were comorbidity (FCI) and disease activity (DAS-28/ESR),
which together explained 32.9% of the variability of the HAQ score (adjusted
R(2)=0.329).

CONCLUSION: Comorbidities were associated with mobility limitation and functional


disability in RA patients. The FCI proved to be an appropriate comorbidity
indicator to determine this association.