Rheumatoid Arthritis
Joints under siege -- and more
Rheumatoid arthritis (RA) is a disease of chronic inflammation that affects mainly the joints but can involve other organs as well. It usually affects joints of the hands and feet and can affect the hips, knees, elbows, and other joints.
Rheumatoid arthritis is not as common as osteoarthritis. It affects more than 1% of the population, women much more than men. Its cause is unknown, but seems to involve an autoimmune reaction where the body's defenses attack its own joints. This reaction can involve other parts of the body, including the lungs, blood vessels, and nerves.
Rheumatoid arthritis affects people quite differently. In some, the attacks come and go, while others face a steady decline. Different treatments aim to prevent deterioration and maintain a functional life for those with the disease.
Pronunciation
ROO-ma-toyd arth-RYE-tis
Synonyms
- RA
- Systemic arthritis
- Chronic inflammatory arthritis
- Proliferative arthritis
Detailed Description
Rheumatoid arthritis (RA) is a disease of chronic inflammation that affects mainly the joints but can involve other organs as well. It typically affects the hands and feet and can affect the hips, knees, elbows, and other joints. Several to many joints are involved, and can be painful, swollen, and red. Morning stiffness is common, as are bumps (nodules) below the skin.
Rheumatoid arthritis occurs in about 1% of the population. Women are up to three times more likely than men to have RA. It can occur at any age but begins most often between ages 20 to 50.
There are several patterns in which a person can develop RA:
- A sporadic pattern, in which attacks come and go
- A gradual course, where there is continual decline as well as flare-ups
- An aggressive disease, where there is no "rest" from deterioration
- An initial attack, with no return for weeks to months
When rheumatoid arthritis develops slowly, small joints of the hands and feet may be affected first. There are joint aches, either followed by or accompanied by swelling. Joint aches eventually become joint pain. In more severe or advanced cases, other areas of the body can become inflamed, including the eyes, blood vessels, lungs, heart, and nerves.
The cause of rheumatoid arthritis is unknown. It seems to involve an autoimmune reaction, where the body's own defenses attack its own joints. This attack is directed most prominently toward the lining of the joints, called the synovium. This lining thickens to become a "pannus," which leads to further inflammation. This in turn leads to an eroding of the joint's cartilage and bone.
Rheumatoid arthritis can cause marked impairment if left untreated, including deformity and loss of mobility. Those with severe forms are thought to have a shorter lifespan. Drugs, physical measures, and surgery are used to maintain function and reduce pain and inflammation.
Characteristics of Rheumatoid Arthritis
Common features of rheumatoid arthritis include the following:
- Several to many joints involved
- Joints involved on both sides
- Affected joints are painful, swollen, and red
- Joint deformity (sometimes)
- Small joints of hands and feet are especially involved
- Morning stiffness
- Nodules under the skin
- Erosions of joints that can be seen on X-ray
- Inflammation in other areas (skin, eyes, blood vessels, heart, lungs, nerves)
Prior to extreme joint pain and swelling, early features of the gradually starting type can include:
- Nonspecific aching
- Weakness
- Fatigue
- Joint aches
- Low-grade fever
How Common Is Rheumatoid Arthritis?
This disease affects 1% of the general population, or approximately 2.1 million individuals a year. It is more prevalent (3.5% to 5.3%) among Native Americans. The onset of the disease occurs sometime between ages 20 and 60. Ages 35 to 45 have the highest incidence. More women than men are infected with the disease, with a ratio of two or three women to every man. However, men are more likely to exhibit the systemic form of the disease, which affects other organs in the body.
What You Can Expect
The pattern of the disease varies greatly from person to person. A small number of people will have an initial flare-up and go a long time without further episodes. Most will have a long-term process with cycles of flares and "quiet times" between flares. Another group may have a severe form of the disease that is progressively consistent with no remission.
The view of rheumatoid arthritis has changed considerably over the past two decades. While it was previously viewed as a "benign" disease, it is now known that untreated RA can take years off a person's life. Those with the severe type of RA are at especially high risk. Treatment is especially aggressive for this group.
Theoretical Causes
The cause of rheumatoid arthritis has not been established. The body's immune system seems to be stimulated in a way that leads to eroding of the joints. What triggers this reaction is not known. Suspects include the following:
- Bacteria
- Viruses
- Fungi
- Heredity
- Environmental factors
Risk Factors
The major risk factors for rheumatoid arthritis are as follows:
- Family history of RA
- Native American ancestry
- Autoimmune disorders
- Female between the ages of 20 and 50
- Having an HLA-DR4 cell surface marker (people with this marker appear to have a higher incidence of RA)
Risk factors are traits or behaviors that may make you statistically more likely than others in the general population to have a certain condition. They are not necessarily "causes" of the condition.
Symptoms
The symptoms of this disease may occur suddenly or slowly and may come and go as the disease becomes active and then inactive. Signs include the following:
- Pain, warmth, redness, and soreness in the joints
- Commonly involved joints include those of the hands, feet, wrists, knees, elbows, shoulders, and ankles.
- Joints usually affected on both sides
- Swelling of joints, leading to deformation
- Stiffness in joints in the morning and after long periods of inactivity
- Loss of joint function
- Fatigue
- Malaise
- Low-grade fever
- Lymph nodes affected
- Loss of appetite
- Weight loss
- Inflammation of eyes and mouth
- Chest pain
- Anemia
Conditions That May Be Mistaken for Rheumatoid Arthritis
The following exhibit similar symptoms to rheumatoid arthritis:
- Sjgren's syndrome
- Sarcoidosis
- Polymyosistis
- Osteoarthritis
- Seronegative spondyloarthropathy
- Vasculitis
- Gout
- Pseudogout
- Inflammatory bowel disease
- Hypersensitivity reactions
- Reiter's syndrome
- Bechet's syndrome
- Psoriatic arthritis
- Systemic lupus erythematosus
- Lyme disease
- Scleroderma
- Chronic infection
- Ankylosing spondylitis
- Whipple's disease
- Mixed connective tissue disease
- Infective arthritis
- Polymyalgia rheumatica
- Thyroid disease
- Amyloidosis
How Rheumatoid Arthritis Is Diagnosed
The history and physical examination are most important in determining the pattern. Laboratory tests, imaging studies, and biopsy may be helpful. The presence of the following symptoms is usually considered when making the diagnosis of rheumatoid arthritis:
- Morning stiffness greater than one hour in length
- Arthritis of at least three joint groups with swelling or fluid
- Symmetrical joint swelling
- Nodules (lumps) under the skin
- Positive rheumatoid factor test
- Radiographic (X-ray) changes consistent with RA
Your Medical History
Other conditions with joint inflammation may resemble stages of rheumatoid arthritis. Clues to other conditions might include the following:
- Back and sacroiliac pain (ankylosing spondylitis)
- Urinary symptoms and genital lesions (Reiter's syndrome)
- Eye and mouth dryness (Sjgren's syndrome)
Laboratory Work
There is no single laboratory test that can definitively diagnose RA. Tests that can help in making the diagnosis include the following:
- Sedimentation rate (ESR)
- Rheumatoid factor
- ANA-antinuclear antibody
- Synovial fluid analysis
- Hylauric acid
- Extractable nuclear antigens (RNP, SM)
- HLA-B27
- Antistreptolysin-O titer
- Electrolytes, creatinine, liver function, urinalysis to assess the states of the body's organs
- Hematocrit
Specific Tests
When the diagnosis is unclear, especially when primarily one joint is affected, a biopsy of joint (synovial) tissue may be performed by needle or arthroscopy.
Imaging
Several imaging techniques are utilized, including the following:
- X-rays
- Arthrography
- Bone scan
- CT (computed tomography)
- MRI (magnetic resonance imaging)
Goals of Treatment
There is no cure. But some people with RA have been known to have complete or sporadic remission of the disease. For most individuals, effective treatments ease the pain and other symptoms associated with RA. In some cases treatment can also halt the progression of the condition.
Goals of treatment include:
- Relieving pain and reducing inflammation
- Preventing joint deformity
- Avoiding side effects of the disease and some treatment drugs
- Maintaining and improving function of the whole person as well as the function of the joints
Treatment Overview
Basic elements of treatment for rheumatoid arthritis include medication, physical and occupational therapy, and surgery. Milder treatments are, of course, used as much as possible.
However, treatment very much depends on the course of the disease. Recent approaches to rheumatoid arthritis focus on aggressive early treatment to stop inflammation and prevent joint damage. If NSAIDs don't produce any improvement quickly, the physician may move quickly to consider stronger drugs (disease-modifying anti-rheumatic drugs, or DMARDs), although both types of drugs have potential side effects.
Rheumatoid arthritis is usually treated with a team approach that includes several health care professionals and various measures. Team members may include several types of physicians and allied health workers.
Drug Therapy
Treatment usually begins with over-the-counter (OTC) NSAIDs to stop the inflammation. If there's no improvement soon, your doctor will quickly move to the stronger disease-modifying antirheumatic drugs (DMARDs) to prevent joint damage. The type prescribed will depend on the stage of your arthritis and on how well the drug controls the symptoms. The DMARDs are often used in combinations.
Drugs most commonly prescribed
For early stages of the disease:
- Aspirin or other OTC NSAIDs (nonsteroidal anti-inflammatory drugs) such as ibuprofen (Advil, Motrin IB, Nuprin), naproxen (Aleve), and ketoprofen (Orudis KT)
- Prescription NSAIDs such as:
- Cataflam (diclofenac potassium), Voltaren (diclofenac sodium), Arthrotec (diclofenac with misoprostol)
- COX-2 inhibitors such as Vioxx (rofecoxib) and Celebrex (celecoxib)
- Indocin (indomethacin)
- Motrin (ibuprofen)
- Naprosyn or Anaprox (naproxen)
- Orudis (ketoprofen)
- Relafen (nabumetone)
For severe disease or flares:
- Glucocorticoids such as prednisone in pills, or other steroids as injections
- Disease-modifying antirheumatic drugs (DMARDs), which include:
- Arave (leflunomide)
- Azulfidine (sulfasalazine)
- Cuprimine (penicillamine)
- Gold injections
- Imuran (azathioprine)
- Oral Gold (auranofin)
- Plaquenil (hydroxychloroquine sulfate)
- Rheumatrex (methotrexate)
- Enbrel (ethanercept), a biologic response modifier recently approved for RA.
A note about medications: Many of the powerful drugs that can slow or even stop RA progression also have powerful side effects. Be sure to discuss treatment benefits and risks with your doctor.
Exercise
Doctors used to think exercise wore joints out faster; now they know some exercise is essential to keep joints healthy. Your doctor will recommend exercises, and will probably send you to a physical or occupational therapist to teach you exercises appropriate for your case of rheumatoid arthritis, age, and overall condition.
- Warm-water exercise:
Swimming and doing other aerobic water exercises in a heated pool can help you exercise without putting pressure on your joints.
Topical painkillers
If you have only a few joints affected by RA, you might benefit from using an over-the-counter cream, gel, or lotion containing various kinds of pain killers.
Counterirritants distract the sensation of pain. Some brands include ArthriCare, Eucalyptamint, Icy Hot, and Therapeutic Mineral Ice.
Some contain salicylate, which is related to aspirin, and work the same way. Some brands are Aspercreme, Bengay, Flexall, Mobisyl, and Sportscreme (only the "extra-strength" versions seem to contain aspirin, so read the labels).
Hot pepper might cool your pain as well. A cream or gel that contains capsaicin, an ingredient in cayenne pepper, interrupts substance P, a neurotransmitter believed to carry pain messages to the brain. Brands include Zostrix, Zostrix HP, and Capzasin-P.
Physical therapy and joint protection
Strategies to protect your joints from further damage include:
- Avoiding prolonged positions and activities
- Using larger muscles and joints to do a task whenever possible
- Using splints and other joint protection devices to reduce pain and improve function
- Applying therapeutic hot and cold treatments to ease pain
- Taking paraffin baths (warm wax is poured over the sore joint, holding in heat)
- Having a massage to relieve stress and relaxed tense muscles
- Using TENS (transcutaneous electrical nerve stimulator) and other pain-relief measures
Assistive devices
Canes, splints, braces, and other assistive devices that help support your joints or relieve stress and pain can help you get around better. If you have RA in your hands or wrists, specially designed kitchen tools, doorknobs, and other gadgets make day-to-day tasks less painful.
Surgery
One surgical measure for the treatment of severe RA damage is joint replacement, most commonly used on the hip and knee joints. Also common is the fusing of a joint, more commonly seen in the joints of the feet and hands. The fusing of the spinal vertebrae is also sometimes done. It is recommended if the spinal cord is in danger of being compressed or damaged.
Surgeries sometimes recommended for the treatment of RA include the following:
- Synovectomy: removal of the membrane lining in which the inflammation first occurs
- Osteotomy: a surgical re-setting of a bone, sometimes requiring cutting into the bone itself
- Resection: complete removal of a bone of part of a bone
- Arthodesis: bone fusion
- Arthroplasty: joint replacement
Physical and occupational therapies
- Joint protection methods
- Therapeutic exercise regimens
- Therapeutic heat and cold treatments
- Paraffin baths
- Soft tissue mobilization
- Splinting
- Assistive equipment
- TENS (transcutaneous electrical nerve stimulator) and other pain-relief measures
Self care
- Nutritional approaches
- Activity modification
- Exercise
- Appropriate rest
Appropriate Healthcare Settings
Mostly outpatient; however, some medical procedures and operations require inpatient care.
Healthcare Professionals Who May Be Involved in Treatment
There are a number of professionals who work together to treat this condition:
- Family medicine physicians
- Internists
- Pediatricians
- Rheumatologists
- Clinical immunologists
- Hand surgeons
- Physiatrists
- Podiatrists
Activity and Diet Recommendations
The activity approach to rheumatoid arthritis has two main components: joint protection and therapeutic exercise. Joint protection instruction is often taught by an occupational therapist. Aspects of joint protection include the following:
- Heeding and respecting pain signals
- Conserving energy, alternating activity with rest
- Avoiding prolonged positions and activities
- Using larger muscles and joints to do a task when possible
- Using protective splints, to reduce pain and improve function
- Using adaptive devices, including reachers and special handles
- Wearing special footwear
Exercises should be tailored to the condition. Generally, range-of-motion and gentle, low-impact aerobic exercises may be helpful. For inflamed joints, range-of-motion work should be done very carefully. Swimming and isometric exercises may be helpful.
Diets
The role of diet in rheumatoid arthritis has been the subject of much discussion. Most agree on a diet that promotes a lean body that minimizes stress on the joints. Adequate protein may help preserve muscle bulk. For those using corticosteroid medication, extra calcium and vitamin D may help. There have been reports of improvement from eliminating certain foods from the diet, but benefits from restricting these foods (including milk products, corn, wheat, nitrates, potatoes, tomatoes, eggplant, and bell peppers) have varied from person to person. The anti-inflammatory effects of omega-3 fatty acids (fish oils, flaxseed oil) and gamma-linoleic oils (borage) have been established, but their effects may be modest.
Monitoring the Condition
It will be important to work with your doctor during both the early and long-term phases of RA. In the early phase, frequent doctor visits are needed for observation and testing. In the long term, regular doctor visits are needed to monitor the course of the disease and possible side effects of certain medications.
Possible Complications
Possible complications due to the disease:
- Joint destruction
- Inflammation of the blood vessels of the skin and of the tissue surrounding the heart and large blood vessels
- Rheumatoid nodules in the heart causing valvular abnormality
- Diseases of the connective tissue (lung, subpleural, interstitial)
- Mononeuritis multiplex (causes lesions on nerves)
- Sjgren's syndrome (sicca syndrome-- dry eyes and mouth)
- Felty's syndrome (enlarged spleen and low white blood cell count leading to easier infection)
- Nerve entrapment (such as carpal tunnel syndrome)
- Atlantoaxial subluxation (a "dislocation" of bone at the top of the neck; it may have associated spinal-cord injury)
- Cricoarytenoid (voice box) damage (sudden hoarseness and difficulty breathing)
Quality of Life
Movement is a big part of everyday life. When some movements are more limited, accommodations may be necessary. There is increasing availability of equipment, facilities, and situations for those with reduced mobility. Other considerations include the following:
- Emotional support:
Sometimes overshadowed by the physical disabilities of RA, emotional difficulties are a real concern. Because of the degenerative and progressive nature of RA, many activities may be curtailed. Therefore, a sense of loss is common in those with RA. Depending on the severity of the disease, patients might experience a loss of independence, a loss of self-esteem, a loss of social contact, and sometimes a loss of employment. Consider joining a support group, going to counseling, and participating in Arthritis Foundation activities. Local doctors will more suggestions particular to the community.
- Assistive devices:
Physicians and therapists can recommend many types of assistive devices, which can be found at medical or surgical supplies stores. An old and established assistive device, the cane, is still very useful and popular as an aid in walking. Some common daily task tools that have been reinvented as assistive devices include the following:
- Eating utensils
- Jar openers
- Toilet seats
- Brushes and combs
- Toothbrushes
Considerations for Women
Rheumatoid arthritis and osteoarthritis are more common in older women. Limited mobility from RA may increase the possibility of a fall followed by a broken bone. Elderly women may need extra care, such as assistive devices and other measures, to prevent falls.
Pregnancy
Physicians need to be notified if a pregnancy is planned. Some drugs used to treat RA may need to be discontinued not only during pregnancy but also months before attempting conception. Some drugs also affect men.
Pregnancy itself often reduces some of the inflammation of RA. However, after childbirth, there may be flare-ups that can add to the demands of caring for a baby.
Nursing mothers
Physicians need to be notified if breastfeeding is planned. Many of the drugs used to treat RA pass into the breast milk. Long-term breastfeeding may not be an option in some cases.
Considerations for Children and Adolescents
Juvenile rheumatoid arthritis (JRA) affects children. Its features include joint swelling and pain, fever, and a characteristic rash. It is diagnosed and treated somewhat differently than the rheumatoid arthritis seen in adults. Consult a pediatrician for special advice about this disease.
Considerations for Older People
RA can sometimes co-exist with osteoarthritis, since older people are more prone to that disease. Since both are chronic conditions, older people may have had a longer duration of illness and therefore more impairment. Some of the side effects of drugs used for RA and osteoarthritis may require more consideration for older people.
Current Therapies Available
The range of therapies available for rheumatoid arthritis include medication, physical and occupational therapies, exercise, special assisting equipment, other self-care measures, and surgery. Most RA cases are treated with a combination of approaches.
Medications are frequently used to help manage this condition. They are prescribed according to the "pyramid model," in which the safest, best-tolerated drugs are given first. If those don't work, the prescribing doctor will work through the pyramid of drugs, until the right combination is found.
Supplements
Fish oil: Eating cold-water fish high in omega-3 fatty acids may help prevent rheumatoid arthritis. Fish-oil capsules offer the same benefits. In one study, New York researchers gave 66 rheumatoid arthritis sufferers either supplemental corn oil or fish oil (9 g/day) for 30 weeks. The fish-oil group wound up with less pain and fewer other symptoms. [1]
Herbs
Ginger: Ginger is an age-old treatment for pain and inflammation. Indian researchers had arthritis sufferers (28 with rheumatoid arthritis, 18 with osteoarthritis) take ginger powder daily (500 mg to 4,000 mg). Two years later, most of the group reported significant pain relief with no side effects. [2]
Relaxation
Reduce your stress. In one study, 141 people with rheumatoid arthritis received standard care, but some also took a stress-management class that taught meditation and other relaxation techniques. After 10 weeks, the stress-management group reported less pain and more success in coping. [3]
Your Diet
Vegetarianism can help. Finnish researchers told 20 people with rheumatoid arthritis to eat their usual diet, while 20 others were placed on a vegan diet (no meat, fish, poultry, or dairy). Three months later, those eating the vegan diet had less pain, fewer swollen joints, and generally better health. They also lost an average of 13 pounds. [4]
In another study, Indian researchers in New Delhi placed 14 rheumatoid arthritis sufferers on a vegan diet for almost a year. Ten of the group members (71%) reported significantly less pain. [5]
Sources
1 Kremer, J.M., et al. "Effects of High-Dose Fish Oil on RA After Stopping NSAIDs: Clinical and Immune Correlates," Arthritis and Rheumatism (1995) 381107.
2 Srivastava, K.C. and T. Mustafa. "Ginger in Rheumatism and Musculoskeletal Disorders," Medical Hypotheses (1992) 39:342.
3 Parker, J.C., et al. "Effects of Stress Management on Clinical Outcomes in Rheumatoid Arthritis," Arthritis and Rheumatism (1995) 38:1807.
4 Nenonen, M., et al. "Effects of Uncooked Vegan Food on Rheumatoid Arthritis: A 3-Month, Controlled Trial," American Journal of Clinical Nutrition (1992) 56:762.
5 Beri, D., et al. "Effect of Dietary Restrictions on Disease Activity in Rheumatoid Arthritis," Annals of Rheum. Dis. (1988) 47:69.
Self-Care Measures
Caring for yourself is an essential part of arthritis treatment. Through diet, exercise, and lifestyle changes, you can significantly decrease arthritis symptoms and increase your enjoyment of life.
- Move around. Try not to stay in one position for long periods of time.
- Invest in household items that spare your joints. Try items such as an electric can opener, a raised toilet seat, various step stools, or extra-large handles instead of doorknobs. Buy large-handled, lightweight kitchen utensils. Place frequently-used items on shelves you can reach easily.
- Use extra pillows at night.
- Try some assisted living devices. Consider using a cane, an extended shoehorn, and devices that help pull your socks on.
- Avoid overexertion. Learn your limits and don't push yourself beyond them. Be kind to your body.
- Eat more fish. At the Fred Hutchinson Cancer Research Center in Seattle, researchers analyzed the diets of 1,500 women, 324 of whom had rheumatoid arthritis. Those free of the disease ate significantly more cold-water fish: salmon, tuna, mackerel, trout, sardines, and herring. These fish contain oils rich in omega-
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