Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic disease of the joints that causes joint inflammation, stiffness and pain. It is an auto-immune type of arthritis that is caused when the body’s immune system malfunctions by becoming overactive. When this happens, the immune system sometimes mistakes the lining of the joints as a foreign entity and attacks it.

Most commonly, RA affects joints such as the hands, knees or ankles. Even though it typically affects the small joints of the hands and feet,  any synovial joint can be involved.

RA also tends to attack the same joint on both sides of the body (e.g. both left and right knee).

This is in contrast to the other common form of arthritis, i.e., osteoarthritis. The latter usually (but not always) attacks one side of the body at a time.

In addition to joint pain, stiffness and inflammation, rheumatoid arthritis can also affect other parts of the body. This is a result of the large amounts of inflammation it produces.

Over time, the generally high level of inflammation can produce problems in the eyes or with the heart. The circulatory system (blood vessels) and lungs may also be compromised.

Causes Of Rheumatoid Arthritis

The exact reason why rheumatoid arthritis develops is not clear. It is thought to be due to a problem with the immune system. RA is believed to cause it to start attacking the healthy joints of the affected individual.

The immune system is designed to fight foreign objects that invade the body, typically viruses and bacteria. However, the immune system can sometimes become over-aggressive and start to misidentify legitimate cells as foreign invaders. This is what happens with rheumatoid arthritis.

The trigger to this whole process is thought to be a viral infection. The immune system mistakes the synovial joint lining as a foreign invader that should not be in the body.

The synovial lining is part of a healthy joint and produces a lubricant that helps the joint move smoothly.

However, when the immune system attacks this lining, it becomes thicker and inflamed. This reduces the room for the joint to move freely and makes it feel stiff, painful and tender. The skin around the joint may also start to appear red and swollen. The affected individual may start to experience difficulty moving the joint. Joint range of motion is usually reduced.

The reasons why the immune system may start to malfunction aren’t clear. Some of the factors suspected by researchers include:

• Genetic factors that are activated by environmental triggers such as a virus or bacteria. Having a family member with RA appears to increase the risk that an individual may also develop the condition;
• Physical or emotional stress.

Risk Factors

As mentioned above, the risk of developing RA increases if you have a  close family member who has developed the disease.

Other possible risk factors are physical and emotional stress.

A fourth possible risk factor is smoking.

Conditions like obesity and diabetes mellitus have also been implicated.

Gender is another risk factor. Rheumatoid arthritis tends to appear about 2 to 4 times  more often in women than in men. However, when it does develop in a man, the symptoms tend to be more severe.

RA also tends to appear in middle age between 30 – 50 years. But there are exceptions and it sometimes develops in children or the elderly.

Finally, as with other forms of arthritis, excess body weight appears to increase the risk of RA. This association appears to be particularly strong among those under the age of 55.

Symptoms of Rheumatoid Arthritis

RA normally produces the following signs and symptoms:

• Swollen and painful joints;
• Joint stiffness. As with osteoarthritis, this is normally most severe upon awakening in the morning. It is also greater after a daytime period of rest (lying or sitting down);
• A tendency to become fatigued quickly.

The first symptoms often include fatigue, flu-like symptoms, fever, sweats and weight loss. As with osteoarthritis, these symptoms do not appear overnight in most cases. Instead, they tend to develop gradually. However, some people with RA report that their symptoms appeared quite suddenly.

As the disease progresses, it can affect movement so severely that the ability to perform even routine tasks can be compromised.

Hand deformities are common. They include ulnar deviation, swan neck and Boutonniere’s deformity of the fingers. In addition, Z deformities of the thumbs and piano key deformity of the wrist may also be experienced.

Patients with RA can become so afflicted with pain that their sleep patterns can be disturbed.

In addition to the joints, RA also affects other organs like the lungs, bloodstream, nervous system, eyes and heart. These symptoms are called extra-articular manifestations.

Examples of symptoms involving these organs and other systems include pulmonary fibrosis, and anaemia. They also include splenomegaly (enlarged spleen), iritis and myocarditis (inflammation of the heart muscle).

In some cases, the impact of RA on the quality of life can cause the patient to develop depression.

Another trend that occurs in some cases is the appearance of symptoms for a temporary period. The condition then goes into remission, during which the symptoms disappear completely.

Individuals who develop the conditions listed above should contact a doctor to arrange an examination and diagnosis.

Diagnosis

Doctors will probably employ several tests to make a diagnosis of rheumatoid arthritis. The diagnosis stages will likely include:

• A review of the patient’s medical history;
• Physical examination;
• Imaging tests (X-ray); and
• Blood tests.

Diagnosis is dependent mainly on medical history and clinical examination findings, less on investigations.

Medical History

The review of the patient’s medical history will include consideration of any previous injuries of the affected joint. The doctor will need to rule out these injuries as possible causes of the joint pain and other symptoms.

Physical Examination

The doctor will ask the patient to describe his/her symptoms in detail and what makes them worse. The doctor may also perform tests to evaluate the extent of loss of joint range of motion due to stiffness.

The doctor may also palpate (examine by touch) the affected joints, looking for bumps and nodules. These bumps are called rheumatoid nodules and they can be telltale signs of the presence of RA.

Other common examination findings include:

• Swelling of three or more joints;
• Tenderness along the joint line;
• A ‘boggy or doughy’ swelling of the joint (synovitis); as well as
• Pain on gently squeezing the metacarpophalangeal or metatarsophalangeal joints together.

Imaging Tests

The imaging tests done will most likely be X Rays to reveal the extent of bone damage. X Rays can also reveal any reduction of space between joint bones as a result of swollen synovial joint lining. They can also reveal periarticular osteopenia, soft  tissue swelling as well as erosions and deformity.

Blood Tests

Blood tests can help by revealing the following possible indicators of rheumatoid arthritis:

• A low red blood cell count. This condition is known as anaemia and sometimes accompanies the development of RA;
• High levels of C-reactive protein (CRP) which tend to appear in response to high levels of inflammation in the body. As mentioned above, high levels of bodily inflammation tend to be one of the side effects of RA;
• A blood sample can also be used to perform an antinuclear test. A positive result indicates the presence of an auto-immune disease but does not specify which one. There are many possible auto-immune diseases that can affect the body (e.g. lupus) and RA is only one of them;
• Blood samples can also be used to test for anti-cyclic citrullinated peptide (anti-CCP) antibodies.  If these are present, it not only suggests the presence of RA but a more aggressive (erosive) form of the disease. This is particularly indicated if the patient is negative for rheumatoid factor and a decision is needed about starting treatment. Anti-CCP is more specific than rheumatoid factor in RA;
• Many people with RA (about 70%) have an antibody called Rheumatoid Factor in their blood samples. However, this test has a non significant false positive rate. This means the factor can sometimes be present even when the patient doesn’t have RA. This happens  in about 5% of the normal population.

Treating Rheumatoid Arthritis

As with other forms of arthritis, there is no effective treatment that will reverse or halt the progress of RA. Instead, doctors must focus on slowing the disease’s rate of progress and managing the severity of its symptoms.

All patients with suspected persistent synovitis of undetermined cause should be referred to a rheumatologist for a specialist opinion.

In choosing a treatment plan for RA, a doctor will choose from the following four categories:

• Medications;
• Rest;
• Exercise (including physical therapy);
• Surgery.

The combination chosen for a particular patient will depend on a number of factors. These will normally include the age, health and medical history of the patient.

It will also take account of how advanced and severe the symptoms are. Generally speaking, the more advanced the patient’s condition, the more likely doctors may be to recommend surgery.

Medications

This category contains perhaps the most numerous options for the treatment of RA.

Drugs To Fight Pain, Swelling & Inflammation

Doctors can prescribe any of several drugs that will directly combat joint stiffness and reduce pain. These may include:

• Non steroidal anti inflammatory drugs like aspirin, Naproxen or Ibuprofen;
• Topical pain relievers like Motion Medicine;
• Corticosteroids (which directly fight inflammation);
• Opioids

Immune Suppressant Drugs

Another class of drugs available to doctors are called disease modifying antirheumatic drugs (known as DMARDs). These suppress the immune system to reduce its tendency to attack the joint lining. They should be started as early as possible, ideally within 3 months of diagnosis.

Examples of drugs in this category include methotrexate and hydroxychloroquine.

Biologic Response Modifiers

Biologic Response Modifiers are man made proteins that have recently been approved to fight rheumatoid arthritis.

Examples of these drugs include adalimumab, etanercept and rituximab.

Rest & Exercise

This is an important component of any treatment plan for RA. Patients should rest during RA flare ups. However, during periods of remission, gentle low impact exercise such as walking or swimming can help reduce stiffness. Gentle stretches should also be part of any exercise routine as they will also help to ease joint stiffness.

A physical therapist can devise an exercise program that will help the patient maintain joint function for as long as possible.

There is not much evidence to suggest that the patient’s RA will benefit from diet or complementary therapies.

If the patient wishes to try a particular diet, the Mediterranean diet should be encouraged. This will include more bread, fruit, vegetables and fish. It will also include reducing meat consumption and replacing butter and cheese with products made from vegetable and plant oils.

Though complementary therapies may provide some short-term benefit, evidence for their long-term efficacy is poor.

Occupational therapy can help by recommending gadgets to enable the patient to cope better with activities of daily living.

Surgery

For patients for whom non invasive treatments do not work, there is a range of surgical options that can be considered. Doctors can review these options with patients and discuss the pros and cons of each.