What is rheumatoid arthritis?
Rheumatoid arthritis (RA) usually affects the hands and feet first, but it can occur in any joint. It usually involves the same joints on both sides of the body.
Common symptoms include stiff joints, especially upon getting up in the mornings or after sitting down for a while. Some people often experience fatigue and a general feeling of being unwell.
The Rheumatoid Arthritis Support Network estimate that RA affects up to 1 percent of the world's population and over 1.3 million people in America.
What is rheumatoid arthritis?
Rheumatoid arthritis causes pain, redness, and swelling in the joints and a feeling of generally being unwell.
RA is an autoimmune disease. It is also a systemic disease, which means it affects the whole body.
It occurs when a person's immune system mistakes the body's healthy tissues for foreign invaders.
As the immune system responds, inflammation occurs in the target tissue or organ.
In the case of RA, this can be the joints, lungs, eyes, and heart.
Symptoms of RA include:
- pain, swelling, and stiffness in more than one joint
- symmetrical joint involvement
- joint deformity
- unsteadiness when walking
- a general feeling of being unwell
- loss of function and mobility
- weight loss
According to the Centers for Disease Control and Prevention (CDC), the symptoms usually affect the same joints on both sides of the body
Symptoms tend to come and go. During a remission, they can disappear, or they can be mild. However, during a flare, they can be severe.
Nobody knows what causes the immune system to malfunction.
Some people appear to have genetic factors that make it more likely. One theory is that bacteria or a virus triggers RA in people who have this genetic feature.
In RA, the immune system's antibodies attack the synovium, which is the smooth lining of a joint. When this happens, pain and inflammation result.
Inflammation causes the synovium to thicken. Eventually, if left untreated, it can invade and destroy cartilage — the connective tissue that cushions the ends of the bones.
The tendons and ligaments that hold the joint together can also weaken and stretch. The joint eventually loses its shape and configuration. The damage can be severe.
The CDC note that people with a higher risk of developing RA may include those who:
- are aged 60 years or above
- are female
- have specific genetic traits
- have never given birth
- have obesity
- smoke tobacco or whose parents smoked when they were children
People with RA have a higher risk of some other conditions, including:
- heart disease
The joint damage that occurs with RA can make it difficult to perform daily activities. RA can also be unpredictable. Often, a person does not know when a flare will happen.
This uncertainty can lead to:
There is also a higher risk of developing the following conditions:
Carpal tunnel syndrome: This is a type of nerve damage that stems from compression and irritation of a nerve in the wrist. Symptoms include aching, numbness, and tingling in the fingers, thumb, and part of the hand.
Inflammation: This can affect the lungs, heart, blood vessels, eyes and other parts of the body.
Tendon rupture: Inflammation in the tendons can lead to rupture, especially on the backs of the fingers.
Cervical myelopathy: Dislocation of the joints in the neck or cervical spine can add pressure to the spinal cord. This can result in decreased mobility and pain on movement. As RA progresses, the risk of cervical myelopathy increases.
Vasculitis: Inflammation of the blood vessels can cause them to weaken, thicken, narrow and scar. This can affect blood flow to tissues and organ function may be affected.
Susceptibility to infections: There is a higher risk of developing colds, flu, pneumonia, and other diseases, especially if the person is taking immunosuppressant medications to manage RA. People with RA should ensure their vaccinations, such as flu jabs, are up-to-date.
In its early stages, it may be difficult for a doctor to diagnose RA as it can resemble other conditions. However, early diagnosis and treatment are essential to slow the progression of the disease.
The CDC recommend diagnosis and an effective treatment strategy to begin within 6 months of the onset of symptoms.
A doctor will look at the person's clinical signs of inflammation and ask how long they have been there and how severe the symptoms are. They will also carry out a physical examination to check for any swelling, or functional limitations, or deformity.
They may recommend some tests.
Erythrocyte sedimentation rate (ESR or sed rate): This test assesses levels of inflammation in the body. It measures how fast red blood cells in a test tube separate from blood serum over a set period. If the red blood cells settle quickly as sediment, inflammation levels are high. This test is not specific for RA and is a useful test for other inflammatory conditions or infections.
C-reactive protein (CRP): The liver produces CRP. A higher CRP level suggests that there is inflammation in the body. This test is not specific for RA and CRP can occur in other inflammatory conditions or infection.
Anemia: Many people with RA also have anemia. Anemia happens when there are too few red blood cells in the blood. Red blood cells carry oxygen to the tissues and organs of the body.
Rheumatoid factor: If an antibody known as rheumatoid factor is present in the blood, it can indicate that RA is present. However, not everyone with RA tests positive for this factor.
Imaging scans and X-rays
In 2010, the American College of Rheumatology recommended the following criteria for diagnosing RA:
- swelling is present in at least one joint, and it does not have another cause
- results from at least one blood test indicate the presence of RA
- symptoms have been present for at least 6 weeks
Conditions with similar symptoms
The doctor will need to distinguish RA from other conditions with similar symptoms, such as:
Pain relief and other types of medication can reduce symptoms.
If a person receives a diagnosis of RA, the doctor may refer them to a specialist known as a rheumatologist, who will advise on treatment options.
There is currently no cure for RA, but treatment can help to:
- reduce inflammation to the joints
- relieve pain
- minimize any loss of function caused by pain, joint damage, or deformity
- slow down or prevent damage to the joints
Options include medications, physical therapy, occupational therapy, counseling, and surgery.
Some drugs can help to relieve symptoms and slow disease progression.
Nonsteroidal anti-inflammatory drugs (NSAIDs): These are available over-the-counter from pharmacies. Examples include Advil, Motrin, and Aleve. Long-term use and high doses can lead to side effects, such as bruising, gastric ulcers, high blood pressure, and kidney and liver problems.
Corticosteroids: These medications reduce pain and inflammation and may play a role in slowing down joint damage, but they cannot cure RA. If NSAIDs do not work, a doctor may inject a steroid into the joint. Relief is usually rapid, but the effect is variable. It can last a few weeks or months, depending on the severity of symptoms.
Corticosteroids can help with acute symptoms or short-term flare-ups. Long-term use of corticosteroids can have serious side effects. These include cataracts, osteoporosis, glaucoma, diabetes mellitus, and obesity.
Disease-modifying antirheumatic drugs (DMARDs)
DMARDs can slow the progression of the RA and prevent permanent damage to the joints and other tissues by interfering with the overactive immune system. A person usually takes a DMARD for life.
It is most effective if a person uses it in the early stages, but it can take from 4 to 6 months to fully experience the benefits.
Some people may have to try different types of DMARD before finding the most suitable one.
Examples include leflunomide (Arava), methotrexate (Rheumatrex, Trexall), sulfasalazine (Azulfidine), minocycline (Dynacin, Minocin), and hydroxychloroquine (Plaquenil).
Side effects can include liver damage and immune-related problems, such as bone marrow suppression, and a higher risk of severe lung infections.
Other types of immunosuppressants include cyclosporine (Neoral, Sandimmune, Gengraf), azathioprine (Imuran, Azasan), and cyclophosphamide (Cytoxan).
Tumor necrosis factor-alpha inhibitors (TNF-alpha inhibitors)
The human body produces tumor necrosis factor-alpha (TNF-alpha), an inflammatory substance.
TNF-alpha inhibitors prevent inflammation. They can reduce pain, morning stiffness, and swollen or tender joints. People usually notice an improvement 2 weeks after starting treatment.
Possible side effects include:
- a higher risk of infection
- blood disorders
- congestive heart failure
- demyelinating diseases, involving an erosion of the myelin sheath that normally protects nerve fibers
An occupational therapist can help the individual learn new and effective ways of carrying out daily tasks. This can minimize stress to painful joints.
For example, a person with painful fingers might learn to use a specially devised gripping and grabbing tool.
If medication and physical therapy do not help, a doctor may recommend surgery to:
- repair damaged joints
- correct deformities
- reduce pain
The following procedures are possible:
- Arthroplasty: In a total joint replacement, the surgeon removes the damaged parts and inserts a metal and plastic prosthesis, or artificial joint.
- Tendon repair: If tendons have loosened or ruptured around the joint, surgery may help restore them.
- Synovectomy: This procedure involves removal of the synovium if it is inflamed and causing pain.
- Arthrodesis: The surgeon will fuse a bone or joint to decrease pain and realign or stabilize the joint.
A number of strategies can help a person to manage RA.
When a flare-up occurs, the person should rest as much as possible. Over-exerting swollen and painful joints can make the symptoms worse.
During times of remission, when symptoms are mild, the individual should exercise regularly to boost their general health and mobility and to strengthen the muscles around the joint.
The best exercises are those that do not strain the joints, such as swimming.
Following a varied diet with plenty of fresh fruits and vegetable can help a person to feel better and maintain a healthy weight.
Applying heat or cold
Tense and painful muscles may benefit from the application of heat.
- taking a 15-minute hot bath or shower
- applying a hot pack or an electric heating pad, set at the lowest setting
Cold treatment can dull pain and reduce muscle spasms, but people with poor circulation or numbness should not use cold remedies.
- cold packs or ice in a cloth, but never put ice directly on the skin
- soaking the affected joint in cold water
Some might prefer to do both:
- Place the joints in warm water for a few minutes, then dip them in cold water for 1 minute.
- Repeat for about half an hour.
- Finish up with a warm soak.
Finding ways to relieve mental stress may help control pain. Examples include meditation, guided imagery, deep breathing, and muscle relaxation.
Massage may be one way to relieve the pain of RA.
Some people with RA use the following, but there is little scientific evidence to confirm that they work:
- nutritional supplements, for example, fish oil
It may not be possible to prevent RA, but the CDC suggest the following:
RA is a painful and chronic condition that can cause joint damage and make it difficult for a person to carry out their daily tasks.
Anyone who experiences pain and swelling in two or more joints should see a doctor, as early treatment can reduce the risk of long-term problems.