article “A Case of Rheumatoid Arthritis Improved from Steinbrocker
Classification Class IV to Class II after Multi-Joint surgery” (Matsuda, et
al., 2012)
 describes the case of a 61-year-old man with
uncontrolled rheumatoid arthritis (RA) who experienced significant improvement
in mobility after multiple joint surgeries. RA is a chronic autoimmune disorder
that causes inflammation of multiple synovial joints that can lead to severe
damage and deformity (Johns Hopkins Arthritis Center,
The main physiological systems involved in RA are the skeletal and immune

 The skeletal system includes bones, cartilages,
ligaments, and joints. Its major functions are making blood cells, protecting
and structurally supporting other systems, storing minerals, and creating
movement with skeletal muscles. Joints are connections
between bones that serve important functions in the skeletal system such as stabilizing
proper alignment of bones, allowing bone growth, and permitting bones to be
moved by skeletal muscles (Martini, Nath, & Bartholomew,

Synovial joints allow the most movement and are usually found
between long bones. Due to their great mobility, they are less stable than
other joints and require supportive accessory structures like menisci,
ligaments, tendons, bursae, and fat pads. Synovial joints are encased in a
joint capsule that consists of a strong fibrous capsule lined by a synovium. A
synovium is a thin membrane that produces synovial fluid, which fills the area
inside the joint capsule between bones called the joint cavity. At the
articulating ends of bones is a layer of slippery articular cartilage. It protects
the bones and improves mobility by absorbing shock and reducing friction.  When articular cartilage is damaged, the
surface of the cartilage becomes prickly instead of slippery, which increases
friction and compromises joint function. In healthy joints, a thin layer of synovial
fluid separates the opposing cartilages to prevent damage from friction and
shock. The synovial fluid also supports the health of the articular cartilage
by providing nutrient distribution and waste removal (Martini,
Nath, & Bartholomew, 2017). Since synovial
fluid serves all of these vital functions, the health of the synovium is
imperative for proper joint functioning and thus movement.

Normally, the immune system defends the body against pathogens and
toxins.  However, in RA the immune system inappropriately attacks the
synovium and causes it to inflame. The inflammation
leads to thickening of the synovium, resulting in pain, stiffness, and swelling
of the joint (National Institute of Arthritis
and Musculoskeletal and Skin Diseases, 2017). As the disease
progresses, the thickened synovium destroys the cartilage and bones it is
supposed to protect. Additionally, the fibrous capsule, ligaments, and tendons
become so weak from being overstretched by the enlarged synovium that they can
no longer maintain joint stability (Mayo Clinic, 2017). Such destruction
can cause severe pain, deformity, instability, and/or immobility of the joints.
Currently, the exact cause of RA is unknown, but experts suspect environmental
factors, infectious agents, hormones, viruses, genes, and allergies may contribute
to the immune system’s malfunctioning (Johns Hopkins Arthritis Center,

The patient in the case report exhibited
common symptoms of RA including swelling, instability, and decreased mobility. Other
classic symptoms include joint pain, low-grade fever, fatigue, depression, and
weight loss (Murphy, 2017). Like most people
who suffer from RA, the patient’s symptoms were present in the joints of his
elbow, knees, and wrists. The symmetrical symptoms in the patient’s knees and
wrists are also characteristic of RA (Johns Hopkins Arthritis Center,
Approximately 40% of RA patients have symptoms in non-joint structures such as
the lungs, kidneys, eyes, and cardiovascular system (Mayo Clinic, 2017). The patient suffered from nephrotic syndrome, which is
kidney condition commonly associated with RA (Yamada, et al., 2014).
Due to new advancements in pharmacotherapy, many RA patients do not progress to
Stage IV, Class IV like this patient (Matsuda, et al., 2012).  The patient’s
inability to get out of bed, joint and ligament destruction, and joint
deformities are all characteristic of Stage IV, Class IV RA (Johns Hopkins Arthritis
Center, 2017). The
destruction of joint structures and decreased mobility indicated skeletal
system involvement. Due the severity of destruction in the left elbow and knee joints,
surgery was the only option to restore mobility.

Before surgery, the patient had the standard blood
tests, physical exams, and x-rays to assess disease progression. The first set of
blood tests showed that white blood cells (WBC), inflammatory reactions, and
C-reactive protein (CRP) levels were elevated, and albumin (Alb) was low. Such
results are indicative of uncontrolled RA (Johns Hopkins Arthritis Center,
To better manage symptoms doctors switched the patient’s medication from
bucillamine (BUC) to salazosulfapyridine (SASP). After switching to SASP, blood
tests showed normal WBC and Alb levels as well as lower CRP levels, indicating
better control of the disease (Johns Hopkins Arthritis Center,
Rheumatoid factor, anemia, and anti-CCP blood tests could have also been used
to monitor the patient’s RA (Mayo Clinic, 2017). During physical
exams, doctors observed deformities in the wrists, left elbow, and knees,
swelling of the knees, bone damage in the right wrist, and abnormal range of
motion of the left elbow and knees. The x-rays showed dislocation and
significant destruction of the knee and elbow joints. The observations in the
physical exams and x-rays are consistent with Stage IV RA (Johns Hopkins Arthritis Center, 2017). To assess soft
tissue structures affected by RA the doctors could have utilized
ultrasonography (Grassi, De Angelis, Lamanna, & Cervini, 1998).

While no cure exists for RA,
the right medications started early can prevent debilitating joint damage and help
patients maintain close to normal functioning (Murphy, 2017). Unfortunately, the
patient’s local doctor prescribed BUC for 10 years without noting any
significant improvement in symptoms. Although switching to SASP could not fix
the joint destruction, it is likely to make the patient more comfortable and lessen
further damage. SASP and BUC are both disease modifying
anti-rheumatic drugs (DMARDs). The majority of RA patients are prescribed
DMARDs to slow disease progression and reduce inflammation (Murphy, 2017). However, DMARDs can
cause serious side effects including increased risk of infection and liver
damage (Mayo Clinic, 2017). A category of DMARDs called biologic response modifiers are used
for patients who have severe RA (Murphy, 2017). Biologic response
modifiers target certain steps in the immune response rather than the whole immune
system like traditional DMARDs. They also work more rapidly than traditional
DMARDs. With that being said, they still increase the risk of infection and are
more expensive (Kahlenberg & Fox, 2011).

Non-steroidal anti-inflammatory drugs (NSAIDs) and
corticosteroids are other drugs typically used in RA treatment. They are often
used in the beginning of DMARD treatment, because they work quickly while
DMARDs may take months to cause a significant clinical effect (Johns Hopkins
Arthritis Center, 2017). While NSAIDs effectively reduce
acute inflammation and pain, they do not prevent joint damage, so they are not typically
used alone for RA treatment. Side effects include gastrointestinal distress,
kidney and liver damage, and cardiovascular disease (Rheumatoid
Arthritis Support Network, 2017). Corticosteroids regulate
the immune system and reduce inflammation. They have several serious side
effects like weight gain, high blood pressure, diabetes, and osteoporosis.
Although they are effective, they are normally used as a temporary supplement to
DMARDs due to their side effects (Johns Hopkins Arthritis Center,

Surgery is used as last
resort treatment for RA patients to restore joint function. For this patient, joint
replacement surgery of his left elbows and knees was necessary to restore his
ability to get out of bed. In joint replacement surgery, damaged tissue is
removed, and the joint is reconstructed with artificial materials (Mayo Clinic,
With all surgeries, there is a risk for complications such as bleeding,
infection, and poor healing. RA patients have an increased risk for
complications due to poor bone quality, immunosuppressive medications, and
other afflicted joints preventing adequate rehabilitation (Lee & Choi, 2012). Generally, this type
of surgery is very safe, successful, and long lasting (Paz, 2017).  The
patient’s surgeries were so successful that he went from bedridden (Class IV) to walking independently (Class II).

Although it was not mentioned in the case
report, exercise is a powerful tool for RA management. Exercise has been shown
to reduce many RA symptoms like pain, inflammation, stiffness, and fatigue (Richardson,
2017). Strength
training can significantly improve joint stability and function by
strengthening tendons, ligaments, tendon, bones, cartilage, and supporting
muscles (Cooney, et al., 2011). Aerobic
exercise is very beneficial to RA patients since they have a high risk of developing cardiovascular disease (Crowson, et
al., 2013).
Thus, the best exercise program for RA patients would include both aerobic
and strength training exercises (Cooney, et al., 2011).

A low
percentage of RA patients exercise despite the many benefits (Sokka, et
al., 2008).
Common reasons for RA patients not exercising include not knowing how to safely
exercise, pain, and lack of enjoyment (Cooney, et al., 2011). I propose a new fitness program called RA Strong. This program would consist of
both aerobic dance and strength training exercises specifically designed to
maximize cardiovascular and joint health. To reduce the fear of harm and pain, the fitness
professional leading RA Strong would help patients adapt
moves to their own abilities and comfort. To make RA Strong more
enjoyable, it would be performed in a group setting and include dance instead
of other aerobic exercises. With these features, RA Strong would increase the number of RA patients committed to an
aerobic and strength training exercise program. Consequently, RA Strong would improve the health of
the RA population.