What is rheumatoid arthritis?Arthritis means inflammation of joints. Rheumatoid arthritis (RA) is a common form of arthritis. About 1 in 100 people develop RA at some stage in their life. It can happen to anyone. It is not a hereditary disease. It can develop at any age, but most commonly starts between the ages of 40 and 60. It is three times more common in women than in men.
Understanding joints
Cartilage covers the end of bones. Between the cartilage of two bones that form a joint there is a small amount of thick fluid called synovial fluid. This 'lubricates' the joint which allows smooth movement between the bones. The synovial fluid is made by the synovium. This is the tissue that surrounds the joint. The outer part of the synovium is called the capsule. This is tough, gives the joint stability, and stops the bones from moving 'out of joint'. Surrounding ligaments and muscles also help to give support and stability to joints. What causes rheumatoid arthritis?RA is thought to be an autoimmune disease. The immune system normally makes antibodies (small proteins) to attack bacteria, viruses, and other 'germs'. In people with autoimmune diseases, the immune system makes antibodies against tissues of the body. It is not clear why this happens. Some people have a tendency to develop autoimmune diseases. In such people, something might trigger the immune system to attack the body's own tissues. The 'trigger' is not known. Which joints are affected in rheumatoid arthritis?The most commonly affected joints are the small joints of the fingers, thumbs, wrists, feet, and ankles. However, any joint may be affected. The knees are quite commonly affected. Less commonly the hips, shoulders, elbows, and neck are involved. It is often symmetrical. So, for example, if a joint is affected in a right arm, the same joint in the left arm is also often affected. In some people, just a few joints are affected. In others, many joints are involved. Joint symptomsThe common main symptoms are pain and stiffness of affected joints. The stiffness is usually worse first thing in the morning, or after you have been resting. The inflammation causes swelling around the affected joints. Other symptomsThese are known as 'extra-articular' symptoms of RA (meaning 'outside of the joints'). A variety of symptoms may occur. The cause of some of these is not fully understood.
How does rheumatoid arthritis develop and progress?In most cases the symptoms develop gradually - over several weeks or so. Typically, you may first develop some stiffness in the hands, wrists, or soles of the feet in the morning which eases by mid-day. This may come and go for a while, but then becomes regular. You may then notice some pain and swelling in the same joints. More joints such as the knees may then become affected.
RA can vary greatly from person to person. It is usually a chronic relapsing condition. Chronic means that it is persistent. Relapsing means that at times the disease flares-up (relapses), and at other times it settles down. There is usually no apparent reason why the inflammation may flare-up for a while, and then settle down. Joint damageInflammation can damage the cartilage which may become eroded or worn. The bone underneath may become thinned. The joint capsule and nearby ligaments and tissues around the joint may also become damaged. Joint damage develops gradually. Over time, it may lead to deformities. It may become difficult to use the affected joints. For example, the fingers and wrists are commonly affected, so a good grip and other tasks using the hands may become difficult. How is rheumatoid arthritis diagnosed?There is no single test which clearly diagnoses early RA. When you first develop joint pains, it may be difficult for a doctor to say that you definitely have RA. This is because there are many other causes of joint pains. Blood tests can detect inflammation, characteristic antibodies, and anaemia. These may suggest that you have RA, but do not prove that you definitely have it as these blood results can be caused by other conditions. Associated conditionsThe risk of developing certain other conditions is higher in people with RA. These include: heart disease, stroke, infections (joint infections and non-joint infections), gut problems, osteoporosis (thinning of the bones), and certain cancers.
Other complicationsOther complications which may develop include:
What are the treatments for rheumatoid arthritis?RA can be cured occasionally. It can be treated to reduce pain, stiffness, and damage to joints. The main aims of treatment are:
Treatment aim 1 - to reduce pain and stiffnessDuring a flare-up of inflammation, if you rest the affected joint(s) it helps to ease pain. Special wrist splints, footwear, gentle massage, or applying heat may also help. Medication is also helpful. Drugs which may be advised by your doctor to ease pain and stiffness include the following: Non-steroidal anti-inflammatoriesThese are sometimes just called 'anti-inflammatories' and are good at easing pain and stiffness and also help to reduce inflammation. There are many types and brands. Each is slightly different to the others, and side-effects may vary between brands. To decide on the right brand to use, a doctor has to balance how powerful the effect is against possible side-effects and other factors. Usually one can be found to suit. However, it is not unusual to try two or more brands before finding one that suits you best. PainkillersParacetamol often helps. This does not have any anti-inflammatory action, but is useful for pain relief in addition to, or instead of, an anti-inflammatory. Codeine is another painkiller that is sometimes used. SteroidsSteroids are good at reducing inflammation. However, because of the problem of possible side-effects, steroids are not recommended for routine use. This is not to say that they are never used. The main side-effects from steroids occur when they are used for more than a few weeks. Therefore, a short course of steroid tablets such as prednisolone is sometimes used. This may be prescribed to treat a flare-up which has not been helped much by a non-steroidal anti-inflammatory. A short course of steroids may also be used whilst waiting for a disease modifying drug (see below) to take effect. Disease-modifying drugsThere are a number of drugs called disease-modifying antirheumatic drugs (DMARDs). These are drugs that ease symptoms but also reduce the damaging effect of the disease on the joints. They work by blocking the way inflammation develops in the joints (by blocking certain chemicals involved in the inflammation process). DMARDs include: sulfasalazine, methotrexate, gold injections, gold tablets, penicillamine, leflunomide and hydroxychloroquine. It is these drugs that have improved the outlook (prognosis) in recent years for many people with RA. Newer disease modifying drugsA new class of drugs which have recently been developed are drugs that modify the effect of TNF-alpha. The chemical TNF-alpha plays an important role in causing inflammation in joints. Blocking the effect of TNF-alpha has been shown to reduce damage to joints, and reduce symptoms. Drugs which modify or block the effect of TNF-alpha include: etanercept, infliximab, adalimumab, and anakinra. They show promise but their long-term benefits are still being evaluated. Treatment aim 3 - to minimise disability as much as possible
Treatment aim 4 - to reduce the risk of developing other diseasesGeneral measures to help treat fibromyalgia/rheumatoid arthritis/osteoarthritis/spondylitis/spondylosisExercise
If possible, exercise regularly. This helps to strengthen the muscles around affected joints, to keep you fit, and to maintain a good range joint movement. Swimming is ideal for most joints, but any exercise is better than none. Many people can manage a regular walk. Weight control
If you are overweight, try to lose some weight as the extra burden placed on back, hips, and knees can make symptoms worse. Even a modest weight loss can make quite a difference.
These measures slightly alter the distribution of weight and pressure on the knee joint, which is why they are thought to ease symptoms in some cases. A podiatrist or physiotherapist can advise exactly how to use them. Daily walking for 30 to 45 minutes with or without Walking aids
If you have OA of your hip or knee, when walking try using a cane (walking stick). Hold it in the hand on the opposite side of the body to the affected joint. This takes some pressure off the affected joint and helps to ease symptoms in some cases. Diet - Vitamins, minerals, calcium should be obtained from natural dietary resources and not by 'vitamin tablets/capsules' which can increase your risk of 'medicinal side-effects'. Fruits, Salads, green vegetables/leaves, Sprouts -250 grammes Curd/Yoghurt -250 grammes, Lemon juice with little salt/sugar. Water -5-6 lit per day or more, daily slow sustained yoga type physiotherapy exercises as given in website is essential for good health of bones and body. Daily brisk/speed walking for 1 hour, getting enough vitamin D from your diet, sunlight will decrease your risk. Cycling outdoors and non-gym outdoor exercises such as brisk walking, using stairs at home and office, walk at work bring overall improvement in health, well being besides controlling and curing many diseases such as Hypertension, diabetes, depression, cancer, osteoporosis, arthritis, muscular pains and joint pains. Physical activity. Not exercising and being inactive or staying in bed for long periods can increase your risk. Smoking. Smokers harm their blood circulation, damage all tissues in body by free radicals of smoke and absorb less calcium from their diets. Medications. Some commonly used medicines can cause loss of bone mass. These include steroids used to control arthritis and asthma; some drugs used to treat seizures; some cancer drugs; and, too much thyroid hormone. Low body weight. Women who are very thin – and small-boned – are at greater risk for osteoporosis.Physiotherapy help if unable to follow correct exercises
Sometimes advice or treatment from a physiotherapist is helpful. For example:
Manipulation and stretching around affected joints may be helpful. This is something that physiotherapists may also be able to help with. Occupational therapy
An occupational therapist may be able to help if you need aids or modifications to your home to cope with any disability caused by OA. Special devices, such as tap turners to help with turning on a tap, may mean that you can carry out tasks around the house more easily. Other therapiesMedicines used to treat fibromyalgia/rheumatoid arthritis/osteoarthritis/spondylitis/spondylosis
Paracetamol
Paracetamol is the common medicine used to treat OA. It often works well to ease pain. It is best to take it regularly to keep pain away, rather than 'now and again' when pain flares up. A normal adult dose is two 500 mg tablets, four times a day. It usually has little in the way of side-effects, and you can take paracetamol long-term without it losing its effect. Anti-inflammatory painkillers
You may find that a topical preparation of an anti-inflammatory painkiller that you rub onto the skin over affected joints is helpful instead of, or in addition to, paracetamol tablets. This may be particularly helpful if you have knee or hand OA. Compared to anti-inflammatory tablets, the amount of the drug that gets into the bloodstream is much less with topical preparations, and there is less risk of side-effects (see below).
Codeine
Codeine is sometimes combined with paracetamol for added pain relief. Constipation is a common side-effect from codeine. To help prevent constipation, have lots to drink and eat a high fibre diet. Capsaicin cream
This cream is made from chilli peppers and it works by blocking the nerve signals that send pain messages to the brain. It may be helpful if you have knee or hand OA. It takes a while for the effects of this cream to build up and may take around one month to get the maximum benefit. You should rub in a pea-sized amount of cream around the affected joint four times a day, and not more often than every four hours. An injection of antiinflammatory medicine
An injection directly into a joint is useful if a joint becomes badly painful / inflamed. Treatments that are not normally recommendedGlucosamine, cartilage regenerative drugs are Usually not helpful in long term as no reliable studies on them. besides they may affect liver function and kidneys.Hyaluronic acid
The use of regular injections of hyaluronic acid directly into a joint is a relatively new treatment that has been tried for OA. The theory is that it may help with 'lubrication' and 'shock absorption' in a damaged joint. It may produce a small beneficial effect in some people. However, the National Institute for Health and Clinical Excellence (NICE) has looked at the use of hyaluronic acid as a possible treatment for OA and does not recommend its use. This is because there is little evidence that it is effective. Chondroitin
This is another food supplement that has become popular as a potential treatment for OA. It is a chemical that is part of the make-up of normal cartilage. A recent big study showed that chondroitin has little, or minimal, effect on reducing symptoms in people with OA. Also, NICE does not recommend the use of chondroitin for the treatment of OA. This is because they could find no clear evidence from studies to show that it is an effective treatment. Surgery for osteoarthritis/spondylitis/fibromyalgia/rheumatoid arthritis/osteoarthritis/spondylitis/spondylosis Most people with OA/spondylitis do not have it badly enough to need surgery. However, OA of a joint may become severe in some cases. Some joints can be replaced with artificial joints. Hip and knee replacement surgery has become a standard treatment for severe OA of these joints. Some other joints can also be replaced. Seldom is surgery used to treat spondylosis. Most patients respond well to non-surgical treatment for spinal osteoarthritis.As mentioned, if you have RA you have an increased risk of developing diseases such as heart disease, stroke, osteoporosis, and certain cancers. Therefore, you should consider doing what you can to reduce the risk of these conditions by other means.
See leaflets called 'Preventing Heart Disease and Stroke' and 'Osteoporosis' for more details. ImmunisationsTo prevent certain infections, you should have:
Other treatmentsSome people try complementary therapies such as special diets, bracelets, acupuncture, etc. There is little research evidence to say how effective such treatments are for RA. In particular, beware of paying a lot of money to people who make extravagant claims of success. For advice on the value of any treatment it is best to consult a doctor, or contact one of the groups below. What is the outlook (prognosis)?The outlook regarding joint damage is perhaps better than many people imagine.
However, these figures are probably becoming out of date as treatment has improved in recent years. Symptoms can often be well controlled with medication. Because of the newer and better drugs, in particular the newer disease modifying drugs, the outlook for a person who is diagnosed with rheumatoid arthritis these days is likely to be much better than it was a few years ago. Follow up studies of people being treated with the newer drugs should give a clearer idea of prognosis over the next few years. In summary
Arthritis Research Campaign - ARCCopeman House, St Marys Court, St Marys Gate, Chesterfield, Derbyshire, S41 7TD. Arthritis Care18 Stephenson Way, London, NW1 2HD National Rheumatoid Arthritis Society (NRAS)Unit B4 Westacott Business Centre, Westacott Way, Littlewick Green, Maidenhead, Berks, SL6 3RT References
|