We often saw patients with RA on stretchers in the county hospital clinic where I used to work. We rarely see that today. One of the best predictors of progressive structural damage is baseline damage, and current patients with RA have had less structural progression than patients in the past, so their risk for additional structural progression is reduced. We also see far fewer small and large joint surgeries, including total joint replacements, in current patients with RA, whereas individuals diagnosed with RA in the 1980s faced the prospect of having more than 1 joint replaced. We are now treating the disease much earlier, and, so, we are intervening when patients have much less damage and are at a much less severe disease stage. Further, we are better able to control and improve the disease with modern drug therapies to induce a disease-free state in many patients. 

The topic of structural progression in patients with RA who have good clinical control is an interesting one. Somewhere between 10 and 12 years ago, the medical community was talking a lot about the disconnect between clinical disease control and structural damage. The thinking at that time was that, despite the appearance of good clinical control or even remission, there was still the possibility of continuing radiographic progression. And the general understanding was that this scenario of occult progression occurred frequently. Since that time, we have learned that there is a strong connection between clinical control and the halting of radiographic progression. Moreover, additional structural damage occurs despite good clinical control in only in a small percentage of cases, or outliers. 

Today, we can offer patients with RA a life that is far closer to normal than we were able to previously. The need for functional aids declined significantly within the first 5 years of the introduction and widespread use of the biologics and continues to be lower than in the past. So, patients with RA generally can have much higher expectations, and many of them can experience a normal life. The question of structural damage and structural progression in the current era is an interesting one. Some colleagues may feel that it is no longer important to monitor for structural damage. Others point to the need to be more vigilant in certain cases, as some patients with RA may not be as well controlled as we would like them to be, and we would like to show them that they are going to have more damage if they are not as tightly controlled as is recommended.