PATIENT STUDY

Patient Study

Patient Study

Introduction

Rheumatoid arthritis (RA), a chronic inflammatory joint disease with an autoimmune component, affects about 0.4% of Caucasians. Gradual destruction of the joints and surrounding tissues leads to functional impairments. Motion limitation by pain, joint destruction, and deformities lead to impairments in range of motion, muscle strength, endurance, and aerobic capacity. Disability develops within a few years, its components being loss of function, reduced quality of life and self-esteem, impaired social and family function, impaired work ability, and partial or total dependency. Joint rehabilitation is part of the treatment of RA. A combination of rest and gentle, passive, non-weight-bearing exercises was long the cornerstone of the physical management of RA. Although this approach remains useful during flares, it has proved inadequate during periods of disease stability.

Shoulder involvement with rheumatoid arthritis (RA) is underestimated, although symptoms due to erosions by the rheumatoid pannus are common. The central role of the shoulder in upper limb function and the need for treatment before the stage of irreversible functional loss mandate early detection and management. In practice, however, the shoulder often receives little attention until advanced joint destruction occurs, when analgesic therapy is the only treatment option. To increase awareness and knowledge of rheumatoid shoulder involvement, the GREP (French Shoulder Rheumatic Diseases Group, a section of the French Society for Rheumatology) convened a panel of international experts, who developed consensus statements based on current knowledge about the rheumatoid shoulder. Nevertheless, many points still lack validation by original research studies. No controlled therapeutic trials are available, and the best studies to date used a retrospective design. Thus, the level of evidence underlying the consensus statements is fairly low.

Normal Musculoskeletal Anatomy

The histological features are typical, with hypertrophic fimbriae, multiple layers of synovial cells, fibrin deposition, and increased vascularity. Although none of these abnormalities is specific when present alone, the combination has 42% sensitivity and 95% specificity for the diagnosis of RA. Histological criteria are difficult to collect and have been removed from classification criteria for RA. However, advances in histochemical techniques may provide prognostic information. For instance, disease severity was positively correlated with TNF-a and interleukin-6 expression within synovial tissue and negatively correlated with presence of CD4 + T cells. Initially, the disease targets the glenohumeral joint and often causes erosions in the greater tuberosity. Acromioclavicular involvement and subacromial bursitis may be present. When the rotator cuff is trapped between the pannus superiorly and a swollen subacromial bursa inferiorly, severe cuff thinning is extremely common. Although there are usually no tears, cuff function is severely impaired.

Epidemiological data

Among patients with RA, 65-90% report shoulder symptoms, mainly pain. Shoulder symptoms may be more common in patients who are older than 60 years at disease onset, although this remains debated; in those with joint destruction, particularly at the hands and wrists; and in those with positive rheumatoid-factor serology. A history of joint replacement at the lower limbs is associated with shoulder symptoms, perhaps in part because the use of crutches during the postoperative period imposes considerable loads ...