Original Article
The Pattern of Joints Involvement in Patients with
Rheumatoid Arthritis in Rheumatology Clinic Dr. Hasan
Sadikin General Hospital Bandung
Muhammad Kevin Pratama1, Nur Atik2, Laniyati Hamijoyo3
1
Faculty of Abstract
Medicine, University Background: Rheumatoid arthritis (RA) is a chronic
of Padjajaran,
Bandung, Indonesia; inflammatory disease with primary manifestation in
2
Department of the joints. Early management of RA will prevent further
Anatomy, Physiology, joint damage. The joint damages, result of uncontrolled
and Cellular Biology,
disease activity, will decrease patient’s quality of life.
Faculty of Medicine,
University of Padjajara, RA should be diagnosed earlier and followed by early
Bandung, Indonesia; treatment initiation, in order to prevent further damages.
3
Department of This study aimed to determine the pattern of joint
Internal Medicine,
Faculty of Medicine, involvement in RA in order to made earlier diagnosis and
University of treatment initiation.
Padjajaran / Dr. Hasan Method: This research was conducted using descriptive
Sadikin General
Hospital, Bandung, study design. Data were obtained using interview of
Indonesia RA patients who coming to Rheumatology Clinic of Dr.
Hasan Sadikin General Hospital from August 2016 to
Correspondence:
October 2016. Collected data included number of joints
Muhammad Kevin
Pratama, MD involvement, duration of therapy, and duration of illness
Bandung-Sumedang after diagnosed according to the criteria of ACR / EULAR
KM.21, Jatinangor, 2010.
Sumedang
Email: prtmkvn@ Result: Ninety-seven RA patients were involved in
gmail.com this study. Subjects were dominantly women (87%),
the highest age group was 45-49 years old (17.53%),
duration of the disease <5 years (90.72%), and duration
of therapy > 3 months (86%). Joint that frequently
involved at the time when the diagnosis made was
first proximal interphalangeal (49.50%), overall findings
during the course of RA was the wrist joint (90.72%).
There were different tendency of joint involvement
between the gender, knee joints occured in 53,84% male
subjects, while PIP joints were accounted for 52,38% in
female subjects.
Conclusion: The first PIP was the most common joint
involved in RA patients when the diagnosis made. The
wrist joint involvement was dominantly found in overall
course of RA. Knee joint involvement was majorly found
in male RA patients, whereas female RA patients would
suffer mostly from PIP joint involvement.
Keywords: involvement pattern, joints, rheumatoid
arthritis
Introduction
Rheumatoid arthritis (RA) is a chronic inflammatory
condition of unknown etiology and characterized
4 Indonesian Journal of Rheumatology 2017; Vol 9 No.2
by symmetric peripheral polyarthritis. RA is the
most common form of chronic inflammation
involving the joints and often ended in joint damage
and physical disability.1 It is one of the chronic
inflammatory disease with the highest prevalence
of 0.5 - 0.8% among adult population in the world.2
Although there has been evidence that overall
RA incidence has been reduced over the past
few decades, but its prevalence is not changed.3
According to the data from Indonesia Basic Health
Research (Riskesdas) 2007 and from National
Socioeconomic Survey (2007), the prevalence of
RA in Indonesia was around 0.1% .11
Diagnosis of RA is made based on the signs
and symptoms of chronic inflammation, with the
laboratorium and radiologic results.4 In 2010,
a collaborative effort conducted between the
American College of Rheumatology (ACR) and the
European League Against Rheumatism (EULAR)
revised the 1987 classification criteria for RA.5 It
was done in attempt to make a faster diagnosis of
RA so patients will get earlier treatment.6,7 Joint
damages as the result of uncontrolled RA may
decrease the patient’s quality of life.
RA should be diagnosed as soon as possible,
followed by early treatment initiation. Early
detection of RA will provide a better disease
management. Besides, it also could prevent many
RA complications, of which the most frequent is
joints damage.7 This study aimed to provide a better
management of RA by determining the pattern of
joint involvement in RA in order to made earlier
diagnosis, so that further complication can be
prevented.
Methods
The study was conducted from August to October
2016 at Dr. Hasan Sadikin General Hospital using
a descriptive design study. The subjects were all
patients who came to Rheumatology Clinic Dr.
Hasan Sadikin General Hospital. The inclusion
criteria was all patients who has been diagnosed
as RA based on ACR / EULAR 2010 criteria. The
exclusion criteria were patients with incomplete or
 According to the previous studies, RA is one of the autoimmune diseases
strongly associated with gender, race, and ethnic origin as internal risk factors and env
exposures as external risk factors.4 The distribution of patients based on characterist
Original Article
occupation and ethnic origin, are presented on Figure 1.

missing data and the presence of other autoimmune rheumatic Figure 1. Occupation
Figure 1. Occupation Characteristics
Characteristics of Male Subjects
of Male Subjects
diseases or other joint problems. Minimum samples required
in this study were 97 determined based on the categorical Men
descriptive study formula to estimate the proportion of the 7.69%
population. 15.38%
The data were taken by interviewing subjects, as the
primary data, and collecting information from their medical
records, as the secondary data. The data were analyzed 15.38% 61.53%
descriptively by counting the number and the percentage
of the joints involvement which has been examined by the
Residents of Internal Medicine Department through the Government/ private employee Entrepreneur Student Others
standardized examination. The variables in this study were 3
Figure 2. Occupation Characteristics of Female Subjects
gender, age, occupation, ethnic, duration of therapy, duration Figure 2. Occupation Characteristics of Female Subjects
of illness, number of overall findings and manifestations when
diagnosed as RA. Women
Data collection have been approved by the Ethic 7.69% 15.47%
Committee on Health Research of Faculty of Medicine
4.76%
Universitas Padjadjaran and Ethics Committee on Health
5.95%
Research of Dr Hasan Sadikin General Hospital, Bandung.
Data was processed using Microsoft Excel 2010 program.

Result
72.61%
The number of samples obtained in this study was 97. Most of Government/ private employee Entrepreuneur
them were women (87%). Table 1 shows the characteristics of Student Housewife
RA patients by their group age. The division of this age group
RA was found commonly in women (84; 87%) than in men patients. Figure 2 show
is done to see if the prevalence of RA is not influenced by RAstudy,
was found
female subjects in the mostlycommonly
worked as in women (84;
a housewife (6187%) than72.61%),
patients; in men male subje
age, according to the previous study’s results.3 Dominant age patients.
mostly workedFigure
as civil Figure
servants
2. Occupation 2/ private
showsof Female
Characteristics female
employeessubjects
Subjects in the study,
(8; 61.53%), and allmostly
subjects are mos
group diagnosed with RA is 45-49 years (17,53%). Sundanese (82; worked
84.54%).as a housewife (61 patients; 72.61%), male subjects
Women
Figures mostly
3 and 4worked show the as civil
patternservants
of joint/ involvement
private employees in patients (8; with RA
7.69%
Table 1. Age Group Characteristic in RA Patients
Rheumatology clinic
61.53%),of Dr. andHasan Sadikinare
all subjects General
mostly
15.47%
Hospital
Sundanese based(82;on joint
84.54%).involvement at t
Men Women time of diagnosis and overall
Figures 3 course
and 4 of show the disease.
the pattern The4.76%highest
of jointpercentage
involvement of joint involv
Age Total, N(%) 5.95%
(n = 13) (n=84) when RA diagnosed in patients with RA in Rheumatology clinic of Dr. Hasan patients w
in male patients was knee joint (53.84%) and in female
15 – 19 0 2 proximal
2 (2.06%) interphalangeal
Sadikin joint General (52.38%).
Hospital The joint
based involvement
on joint found in overall at
involvement course of RA
20 – 24 1 4 male
5 (5.15%) subjects was the knees joint
the time of diagnosis and (84.61%) and
overall course of the disease. Thejoint (91.67%
72.61%
in female patients was the wrist
Without gender classification, the
Government/ joint
private that
employee showedEntrepreuneur
the highest percentage at the time
25 – 29 1 4 5 (5.15%) highest percentage Student of joint involvedHousewife when RA diagnosed in
diagnosis was the proximal interphalanges (49.50%), and the findings during the whole course
30 - 34 3 7 10(10.31%) maleRApatients
was found was knee
commonly joint (84;
in women (53.84%)
87%) thanand in men inpatients.
female patients
Figure 2 shows
RA is wrist joint (90.72%).
35 - 39 0 13 13(13.40%) was subjects
female proximal interphalangeal
in the study, joint (61(52.38%).
mostly worked as a housewife patients; 72.61%),The joint
male subjects
mostly worked as civil servants / private employees (8; 61.53%), and all subjects are mostly
40 - 44 0 13 13(13.40%)
Figure 3. Pattern involvement
of Joint
Sundanese found inatoverall
(82; Involvement
84.54%). the Time course of RA in male subjects
of Diagnosis
45 - 49 2 15 17(17.53%) was Figures
the knees3 and 4joint show (84.61%)
the pattern ofandjointininvolvement
female inpatients wasRAthein
patients with
60.00% Rheumatology clinic of Dr. Hasan Sadikin General Hospital based on joint involvement at the
50 - 54 2 9 11(11.34%) wrist joint (91.67%). Without gender classification, the
time of diagnosis and overall course of the disease. The highest percentage of joint involved joint
55 - 59 1 10 11(11.34%)
50.00% that showed the highest percentage at the time of diagnosis
when RA diagnosed in male patients was knee joint (53.84%) and in female patients was
proximal interphalangeal joint (52.38%). The joint involvement found in overall course of RA in
60 - 54 1 3 4 (4.12%)
40.00% wassubjects
male the was
proximal interphalanges
the knees joint (49.50%),
(84.61%) and in female patients wasand thejoint
the wrist findings
(91.67%).
65 - 69 0 2 2 (2.06%)
30.00% during the whole course of RA is wrist joint (90.72%).
Without gender classification, the joint that showed the highest percentage at the time of
diagnosis was the proximal interphalanges (49.50%), and the findings during the whole course of
70 - 74 2 2 4 (4.12%)
20.00% RA is wrist joint (90.72%). Men
≥75 0 0 0
10.00% Figure
Figure 3. Pattern
3. Pattern of JointatInvolvement
of Joint Involvement at the
the Time of Diagnosis Time of Diagnosis Women

0.00% 60.00%
Total
According to the previous studies, RA is one of the 50.00%

autoimmune diseases which are strongly associated with 40.00%

gender, race, and ethnic origin as internal risk factors and 30.00%

20.00% Men
environmental exposures as external risk factors.4 The 10.00% Women

distribution of patients based on characteristics gender, 0.00% 4 Total

occupation and ethnic origin, are presented on Figure 1.

Indonesian Journal of Rheumatology 2017; Vol 9 No.2 5

 Original Article

Figure
Figure 4. Pattern
4. Pattern of Joint of Joint Involvement
Involvement during
during Overall Course of RAOverall Course of RA (85%).11 This is not consistent with the results of this
100.00%
study, based on the data obtained, regardless the gender
90.00%
80.00%
of the patient, the joint that showed the highest percentage
70.00% of occurrence for RA is wrist joint (90.72%), while for the
60.00%
50.00% highest percentage occurrence at the time of diagnosis is the
40.00%
30.00%
Men
proximal interphalangeal joint (52.38%).
20.00% Women
10.00% Total More than 5 joints involvement were documented on
0.00%
patients with >3 months duration of therapy, this result was
differed from the results of study conducted by Nell et al
which showed a lower joint involvement after > 3 month
therapy.10 Research conducted by Demourelle et al also found
The results of the study conducted by Monti et al, suggested a correlation between the the maximum results of therapy were shown after the therapy
The
patient's results
response of the
to therapy andstudy
duration conducted bystudy,
of disease.6 In this Montithere et al,differences
were suggested in the at first 3 months of therapy and persisted throughout 3 years
number of joint manifestations of patients based on the duration of treatment and disease of each
a correlation
patient between
group. Most patient thetherapy
had received patient’s response
for > 3 months to therapy
group (55.4%); and
and had suffered of followup.8 The difference results found in this study may
duration
from RA for <5 ofyears
disease. 6
In this
group (90.72%). Of thestudy, there
88 patients were from
who suffered differences
RA <5 years, in 58 be due to the differences of patient adherence to the treatment.
patients (65.91%) had ≥ 5 joints involvement, but also had lower percentage than patients
the number of joint manifestations of patients based
suffered from RA for > 5 years (77.78%). Of 83 patients undergone therapy for > 3 months, 53on the Patients who tend to be less alert to the conditions at the onset
duration
(63.86%) of had
patients treatment and disease of each patient group. Most
≥ 5 joints involvement. of RA may have delay the diagnosis, therefore affect the
patient
Table had ofreceived
2. Duration Therapy andtherapy
Illness of Thefor >3
Subject months group (55.4%); progression of this disease, so patients will suffer the more
and
Number had sufferedDuration
of joints fromof Therapy
RA for <5 years group
Duration of Illness(90.72%). Of severe condition, as described in Nagano et al.9
involvement < 3 months > 3 months < 5 years >5 years
the 188 jointpatients who
0 (0%) suffered0 (0%) from RA
0 (0%) <5 years,
0 (0%) 58 patients RA is a progressive disease if not treated immediately.12
2 – 4 joints 6 (42.86%) 30 (36.14%) 30 (34.09%) 2 (22.22%)
(65.91%)
≥ 5 joints had8 (57.14%)
≥ 5 joints involvement,
53 (63.86%) 58 (65.91%) but7 (77.78%)
also had lower Schneider, et al. mentioned that duration of illness affects the
Total
percentage 14 (14.43%)
than patients 83 (85.57%)
suffered88 (90.72%)
from RA9 (9.28%) for > 5 years number of joints involved in the overall course of the disease.3
(77.78%). Of 83 patients undergone therapy for > 3 months,
Discussion The finding was accordance with the our data that most
53 (63.86%) patients
This study showed had ≥
that patients 5 RA
with joints involvement.
were mostly women. These results are similar patients who suffered >5 years had ≥ 5 joints involvement.
with the joint researches conducted by WHO in several countries included medium-to-low
We realized some limitations of this study. Our study
income countries group which showed the prevalence of female RA patients was five times
Table
higher than male2.patients.
Duration
3
of Therapy
It suggested and with
to be related Illness of The role
the important Subject
of estrogen in cannot determine the correlation of cause and effects in the
activating inflammatory response within the pathogenesis of RA.12
Number Duration of Therapy Duration of Illness
course of disease. The gender and occupation of RA patients
of joints might be related to their joints involvement, however further
involvement < 3 months > 3 months
5 < 5 years >5 years
investigation with proper study design is needed to proved
1 joint 0 (0%) 0 (0%) 0 (0%) 0 (0%) that.
2 – 4 joints 6 (42.86%) 30 (36.14%) 30 (34.09%) 2 (22.22%)
≥ 5 joints 8 (57.14%) 53 (63.86%) 58 (65.91%) 7 (77.78%) Conclusion
Total 14 (14.43%) 83 (85.57%) 88 (90.72%) 9 (9.28%) The involvement of joints in patients with rheumatoid arthritis
is different and depends on several aspects. Overall patients
Discussion had PIP joint involvement at the time being diagnosed and
This study showed that patients with RA were mostly women. wrist joint involvement in overall course of RA. Based on
These results are similar with the joint researches conducted the gender, most male patients had knee joint involvement
by WHO in several countries included medium-to-low income at the time being diagnosed as RA and at overall course of
countries group which showed the prevalence of female RA RA. While RA female patients mostly suffered PIP joint
patients was five times higher than male patients.3 It suggested involvement at the time being diagnosed and wrist joint
to be related with the important role of estrogen in activating involvement at overall course of RA. Most patients have ≥ 5
inflammatory response within the pathogenesis of RA.12 joints involvement even they had been treated for >3 months
Previous research showed the influence of gender on suggested the low compliance of patients. Further studies
RA.3 Our results also supported that statement. We found investigated the correlation of each study parameter is needed.
the differences in the joint involvements of each gender.
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