(Kiosk 4) Untreated Rheumatoid Arthritis in a Motor Complete Tetraplegia Undergoing Inpatient Rehabilitation

Case Diagnosis: Traumatic Motor Complete Tetraplegia

Case Description or Program Description: 31 year old female with C6-C7 fracture-dislocation after a motor vehicle accident was admitted to inpatient rehabilitation with C4 AIS A, traumatic spinal cord injury (SCI). The patient was found to have untreated rheumatoid arthritis (RA) during her inpatient rehabilitation stay. She was previously taking Methotrexate; however, she was lost to follow-up and did not take her medication for several years. Her physical exam showed ulnar deviation with worsening neuropathic pain in bilateral hands. Her limited use of her hands hindered her rehabilitation progress.

Setting: University Hospital, Inpatient Rehabilitation Unit.

Assessment/Results: Multiple X-Rays were ordered, showing multifocal erosive arthropathic changes, most severe at each radiocarpal joint and the left distal radioulnar joint. Rheumatology was consulted thereafter, and rheumatoid markers were ordered. The patient was started on Methotrexate, two 2.5 mg tablets (5 mg) twice a week on Tuesday and Friday, with a daily folic acid supplement of 1 mg. After initiating treatment, the patient significantly improved symptomatology and neuropathic hand pain, which allowed her to advance in her rehabilitation program.

Discussion (relevance): Given the enormous impact on disability, it is crucial to understand the implication of untreated RA in SCI. It is estimated that RA alone has at least a 23.6% higher relative prevalence of functional disability than age-matched controls without the condition. Thus, a previous diagnosis of RA will likely be associated with a greater functional burden in SCI during acute rehabilitation, especially in patients not undergoing treatment.

Conclusions: Physiatrists need to recognize the effects of RA on SCI. Early intervention with treatment for joint inflammation is imperative to prevent the worsening of disability, quality of life, and pain in RA patients with newly diagnosed SCI. More research is needed to determine how RA impacts function in the SCI population.