Medical/Orthopaedic Management of Rheumatoid Arthritis By R- M . M A S O N , d .m ., f . r . c .p ., Physician, D epartm ent o f P hysical M edicine, The London H ospital. R h e u m a t o i d a rth ritis p resents a n e xtrem ely difficult nroblem o f tre a tm e n t since it is a n in fla m m a to ry p oly­ a rthritis w hich pursues a very v a ria b le c o u rse. S p o n ta n e o u s remissions a re frequent and o c c u r in u p to 5 0 % o f h o sp ital o u t - p a t i e n t s o ften leaving n o , o r on ly m in o r, re sid u a. T h e disease is associated with c o n s titu tio n a l d is tu rb a n c e — fever, loss o f w e i g h t , anaem ia, im p a irm e n t o f g ro w th in ch ild ren and w ith the presence o f n o d u les. T h e rh e u m a to id fa c to r is present in th e serum o f so m e 60 to 9 0 % o f a d u lt p a tie n ts. In p atien ts in w hich the disease p u rsu e s a p ro g ressiv e c o u rse the infla m m a to ry changes in th e jo in ts p ro d u c e erosive a nd destructive lesions— the re sulting disa b ility b e in g d u e to the two factors o f inflam m atory disease a n d d e stru ctiv e change. It is very im p o rta n t to assess the s e p a ra te c o n trib u tio n s o f I these tw o p h e n o m e n a before c o n sid erin g a p p ro p ria te tre a t­ ment. T h e inflam m atory c o m p o n e n t h as a ten d e n cy to dim inish in th e course o f tim e, w hilst th e disa b ility d u e to destructive changes tends to increase. T he three fu ndam ental a spects o f tre a tm e n t co m p rise physical th era p y , d rug th era p y a n d o rth o p a e d ic m easures. No single one o f these disciplines should be used in isolation and only a combined team can offer the p a tie n t a properly balanced and co-ordinated program m e o f trea tm e n t. PH Y SIC A L T H E R A P Y D u rin g th e inflam m atory p h a se o f th e disease physical treatm ent sh o u ld consist m ain ly o f sp lin tin g , p re v e n tio n o f deform ity a nd m uscle re-e d u c atio n w ith o u t p ro d u c in g jo in t traum a. H e a t has no m ore th a n a p a lliativ e effect a lth o u g h this may, o f course, be useful. In th e la te r stages o f the disease, how ever, physical th e ra p y will be m o re co n ce rn ed with the m aintenance o f jo in t sta b ility a n d ra n g e o f m o tio n . It is only if a p ro p e r assessm ent o f th e in fla m m a to ry a n d structural changes has been m a d e t h a t p h y sic al th e ra p y can be ratio n alise d . Rest as a basic fo rm o f tre a tm e n t should never b e overlooked a n d w h ilst th is m ay n o t influence disease activity, functional c ap a city c a n o ften b e im p ro v e d by prolonged, properly co n tro lled , rest. C o m p le te sp linting o f jo in ts in a p la ste r cast can be c arried o u t w ith o u t a n y risk o f loss o f ra n g e for perio d s o f u p to a t least a m o n th . DRUG T H E R A P Y T hree gro u p s o f drugs a re a v a ila b le : (i) Symptomatic. A spirin B utazolidin T an d e ril (ii) “ Anti-Rheum atic.” G old A nti-m alarials (iii) Suppressive. C orticosteroids C o rtic o tro p h in Symptomatic D rugs: A spirin is p ro b a b ly the safest a n d m o st v a lu a b le d ru g o f all, b u t it p ro d u ces a mild d egree o f g astric b lee d in g in a lm o st all subjects, usually a m ounting to 5m l. b lo o d loss p e r day. B utazolidin a n d Tanderil d o n o t p ro d u c e re g u la r g a s tro ­ intestinal bleeding b ut toxicity is m o re fre q u e n t affecting some 2 5 % o f patients. Toxic sy m p to m s d e velop e arly ra th e r th an late so th a t prolonged a d m in is tra tio n is p ossible in subjects w ho sh o w no evidence o f a n y idiosyncrasy. B lood dyscrasias m ay occur b ut if th e d o se is re stric te d to 300 to 400 mg. daily these are sufficiently ra re as n o t to fo rm a contra -in d ic atio n to the use o f th ese drugs. “ A nti-rhuem atic” Drugs: M ulti-centre double-blind ciinical trials h a v e show n the value o f gold therapy in rh e u m a to id a rth ritis . T h e th e ra ­ peutic effect is m anifest a fte r 300 to 400 m g. o f g old h ave September, 1963 been a d m in iste re d a n d o n c e this h a s been achieved th e d o se c a n b e re d u ce d o r s p re a d o u t so t h a t p ro lo n g e d a d m in is ­ tra tio n c a n b e m a in ta in e d . A n ti-m a la ria ls such as th e c h lo ro q u in e g ro u p o f d ru g s h ave a ls o been sh o w n in sim ila r , tria ls to h a v e a d istin c t a n ti-rh e u m a tic effect. T h e o nly se rio u s toxic effect re p o rte d h a s been r e tin o p a th y w hich m ay c au se a p e rm a n e n t visual d e fec t. B u t th e risk o f th is c o m p lic a tio n is slight p ro v id ed th e to ta l d u ra tio n o f a d m in is­ tra tio n d oes n o t exceed tw o years. Suppressive D rugs: T h e d e cision to use stero id s in rh e u m a to id a rth ritis is a m a jo r o n e a n d sh o u ld n o t be u n d e rta k e n lightly. T h ese d ru g s a re n o m o re th a n su p p re ssiv e a n d th e re is n o p lac e fo r s h o rt co u rses o f tre a tm e n t. U n less th e p h ysician is p re p a re d to c o n tin u e a d m in is tra tio n indefinitely these d rugs sh o u ld n o t be a d m in istere d . T h e d o se m u st be lim ited to o n e w hich c an be c o n tin u e d w ith o u t p ro d u c in g u n a c c e p ta b le side effects, i.e. 10 mg. d aily o f p re d n is o n e o r its e q u iv a le n t in a m ale a n d 7 -5 m g. daily in a p o st-m e n o p a u sa l fem ale. T h e p h y sic ia n m u st b e p re p a re d to a ccep t a m o d ic u m o f c o n tro l in o rd e r to achieve p ro lo n g e d a d m in istra tio n . T h e m o st im p o rta n t side-effect is th e d e v e lo p m e n t o f a rte ritis a n d p e rip h e ra l n e u ro p a th y w hich reflect a w ide­ sp re ad inv o lv e m en t o f th e a rte rio le s th ro u g h o u t th e b o d y a n d o ften h e ra ld a fa ta l o u tco m e . T h e fo u r c o m m o n serious m ista k e s in th e a d m in istra tio n o f ste ro id s a re as fo llo w s:— (i) In c o m p le te diagnosis. (ii) P re m a tu re a d m in istra tio n . (iii) S te ro id h o n e y m o o n . (iv) M e d d leso m e d o se m a n ip u la tio n . T h e fo u r fa ta l m ista k e s a re as fo llo w s:— (i) Ineffective in d o c trin a tio n o f th e p a tie n t (including th e issue o f a ste rio d c ard .) (ii) E xcessive c o n tin u e d dosage. (iii) A b r u p t w ith d raw al o f the d ru g . (iv) I n a d e q u a te “ stre ss” cover. O R T H O P A E D IC T R E A T M E N T O rth o p a e d ic tre a tm e n t can o n ly be view ed a g ain st th e b a c k g ro u n d o f th e m edical m a n a g e m e n t o f th e disease. T h e m a jo r p ro b lem is th e b e h a v io u r o f the synovial p a n n u s w hich in v ad e s a n d d e stro y s th e j o in t a ctin g a lm o st as a locally m a lig n a n t lesion. In th e sm a ll jo in ts o f th e h a n d s e arly ra d io lo g ic a l c h an g e in d ic a te s severe d e stru c tio n o f th e jo in t. E a rly sy n o v e c to m y m ay well be a re w a rd in g p r o ­ c e d u re in c e rta in c irc u m stan c es in this s itu a tio n . Surgical in te rfere n c e o f th e h a n d sh o u ld n o rm ally b e c arried o u t e ith e r very e a rly to p re v en t d e stru c tiv e c hanges, o r very late as a salvage p ro c e d u re , b u t it sh o u ld n o t be c arried o u t as a ru le d u rin g th e m id d le p h a se s o f th e disease w hen a d a p ta tio n is g ra d u a lly ta k in g place. T h e m o re d ra m a tic a ttr itio n ru p tu re s o f th e e x te n so r, o r occa sio n ally o f th e flexor te n d o n s sh o u ld n o t go un re co g n ise d a n d e a rly re p a ir c a n b e very sa tisfac to ry . Surgery to th e w rist how ever c a n be c a rrie d o u t a t a ny stage. F u s io n o f th e ra d io -c a rp a l j o in t to g e th e r w ith excision o f th e lo w e r e n d o f th e u ln a is an o p e ra tio n a lm o s t w ith o u t pe n alty a n d re sto res to th e p a tie n t a sta b le , painless w rist w ith g o o d p r o n a tio n a n d su p in a tio n . Surgical p ro c e d u re s to th e feet su c h as excision o f th e m e ta ta rsa l h e a d s a n d o p e ra tio n s o n the toes sh o u ld be c a rrie d o u t e arly ra th e r th a n late. T h is p a rtic u la rly applies if ste ro id s a re t o be a d m in iste re d a n d m ay, in d ee d , re n d e r th em u n n e ce ssa ry . In th e k n e e sy novectom y a n d pate lle cto m y is o fte n a very re w a rd in g p ro c e d u re , a lth o u g h these o p e ra ­ tio n s d o n o t solve th e p ro b le m o f th e u n s ta b le k n e e jo in t. F in a lly , th e p ro b lem o f th e h ip j o in t re m a in s u nsolved. In v o lv e m e n t o f this j o in t is th e m o st disa b lin g in rh e u m a to id a rth ritis a n d u su a lly h e ra ld s severe loss o f fu n c tio n a l capacity. E v en in th e h ip jo in t, h ow ever, s p o n ta n e o u s h e alin g m a y ta k e place. C O N C L U S IO N T h e P h y s io th e ra p ist, th e P h y sic ian a n d th e O rth o p a e d ic S u rg e o n sh o u ld all m eet a t th e b e d sid e o f th e p a tie n t w ith c h ro n ic rh e u m a to id a rth ritis a n d w o rk o u t in c o lla b o ra tio n a p r o p e r p ro g ra m m e o f tre a tm e n t. O nly in th is w ay c a n th e p a tie n t w ith progressive rh e u m a to id a rth ritis receive a d e q u a te tre a tm e n t. Page 3P H Y S I O T H E R A P Y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )