Rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease in which the immune system mistakenly attacks the synovial membrane lining the joints. This produces chronic inflammation that — if untreated — progressively destroys cartilage, erodes bone, stretches ligaments and tendons, and ultimately causes joint deformity and functional loss.

RA is approximately twice as common in women as in men and affects about 0.5–1% of the population worldwide. It can begin at any age but most commonly presents between 30 and 60. The exact trigger is unknown, but genetic susceptibility (particularly HLA-DR4 alleles) combined with environmental factors (smoking, infections) is implicated.

**Symptoms:** - Symmetrical joint pain, swelling, warmth, and tenderness — classically affecting the small joints of the hands (metacarpophalangeal and proximal interphalangeal) and feet - Morning stiffness lasting more than 30–60 minutes (a key distinguishing feature from osteoarthritis) - Systemic symptoms: fatigue, malaise, low-grade fever, weight loss - Progressive joint deformity: ulnar deviation of the fingers, swan-neck and boutonnière deformities - Changes in gait and movement pattern as larger joints (knees, hips, ankles) become involved - Extra-articular manifestations: rheumatoid nodules, lung disease (pleuritis, interstitial lung disease), pericarditis, vasculitis, and eye involvement (scleritis)

**Diagnosis** is based on clinical assessment, blood tests (rheumatoid factor, anti-CCP antibodies, CRP, ESR), and imaging (X-rays for erosions and joint space narrowing; MRI and ultrasound for early synovitis).

**Disease management goals:** - Protect joints from further damage - Reduce pain and inflammation - Prevent deformities and preserve range of motion - Maintain strength and overall physical fitness - Improve quality of life and daily function

**Treatment:** - *DMARDs:* Methotrexate is the anchor drug; hydroxychloroquine, sulfasalazine, and leflunomide are used in combination. Biological DMARDs (TNF inhibitors, IL-6 inhibitors, JAK inhibitors) are escalated when conventional DMARDs are insufficient - *NSAIDs and corticosteroids:* for short-term symptom control and bridging therapy - *Physiotherapy and occupational therapy:* essential throughout all stages; includes joint protection, exercise prescription, and assistive devices - *Interventional:* intra-articular steroid injections for localised flares; Botox, prolotherapy, and low-level laser therapy as adjuncts; tDCS and electrical stimulation for pain and muscle tone