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Rheumatoid arthritis - causes, symptoms, treatment

 
Rheumatoid arthritis is a long-term disease that causes fatigue, pain, swelling and joint deformity. There is no cure for rheumatoid arthritis but a combination of treatments can help manage symptoms.
 
Rheumatoid arthritis is the second most common form of arthritis after osteoarthritis. In New Zealand, rheumatoid arthritis affects 1–2% of the population.  It is three times more common in women than men. 

Causes and risk factors

Rheumatoid arthritis results from changes in the body's immune system, which (for reasons not fully understood) attacks the soft tissue of the joints causing inflammation, swelling, and pain. If the process continues, damage to the cartilage and other soft tissue can cause joint deformities.
 
Your immune system’s normal function is to fight infections by producing antibodies that attack foreign invaders like bacteria and viruses that enter your body. If you have rheumatoid arthritis your immune system produces antibodies that attack the tissue that lines your joints (synovium) making it sore and inflamed.  The damage and pain can then spread to other tissue around the joints, including bones, cartilage, tendons and ligaments. 
 
 

Rheumatoid arthritis 1

 

Rheumatoid arthritis can affect any joint in the body but usually affects the small joints in the hands and feet before any of the larger joints such as hips, knees, shoulders, and elbows are affected. Joints are usually affected on both sides of the body.
 

Rheumatoid arthritis 2 

The condition can develop at any age, though it is most likely to develop between the ages of 25 and 50 years. Rarely, children under the age of 16 years can develop a form of rheumatoid arthritis known as juvenile rheumatoid arthritis or Still’s disease. 

Factors that increase your risk of developing rheumatoid arthritis include:

  • Your genes - rheumatoid arthritis appears to run in families 
  • Hormones - changes or deficiencies in certain hormones may be involved in the development of rheumatoid arthritis
  • Obesity - people who are overweight or obese appear to be at higher risk of developing rheumatoid arthritis
  • Smoking - people who smoke are more likely to develop the condition. 

Signs and symptoms

Rheumatoid arthritis can develop gradually or very quickly. Signs and symptoms can vary greatly between individuals and can range from mild to very severe. 

The disease is characterised by periods of remission (absence of symptoms) and "flare-ups" (when symptoms cause problems). Sometimes there is an obvious cause for a flare-up (eg: physical or emotional stress, illness) but usually there is no obvious trigger.
 
Fatigue can be one of the most difficult symptoms of rheumatoid arthritis for people to manage. 

Other symptoms may include:

  • Pain in the joints
  • Swelling (often accompanied by warmth and redness) of the joints
  • Stiffness in the joints (generally worse in the mornings and after periods of rest)
  • Muscle pain
  • Mild fever
  • Loss of appetite (with resulting weight loss)
  • Changes to the skin and nails.

Because rheumatoid arthritis is a systemic condition (ie: it can affect the whole body) symptoms may be similar to having the flu. The inflammation associated with rheumatoid arthritis can cause problems with other parts of the body, including: 

  • Blood vessels (vasculitis) and nerves
  • Lungs, kidney, and heart 
  • Skin, eyes, and mouth.

Anaemia (a lack of red blood cells) can also occur, often compounding the feeling of fatigue and the feeling of being generally unwell.

Around a quarter of people with rheumatoid arthritis develop small, firm movable lumps under the skin called rheumatoid nodules. These usually appear under the skin around the joints and on the top of the arms and legs. Rarely, rheumatoid nodules can occur on the tissue membranes that cover the lungs and on the lining of the brain and spinal cord. Rheumatoid nodules do not usually cause any problems and usually do not require treatment.

Approximately one in six people with rheumatoid arthritis will develop significant joint deformity as a result of damage to the cartilage, bones, and supporting structures such as the ligaments and tendons. 

Diagnosis

There is no single test to confirm a diagnosis of rheumatoid arthritis. In its initial stages it may be difficult to distinguish rheumatoid arthritis from other forms of connective tissue inflammation, such as gout, systemic lupus erythematosus (SLE), and fibromyalgia

To diagnose rheumatoid arthritis a doctor will usually undertake: 

  • A full medical history, including any family history of rheumatoid arthritis 
  • Discussion of current symptoms 
  • Physical assessment eg: of the joints, skin, reflexes, and muscle strength 
  • X-rays and/or MRI scans 
  • Blood tests.

The blood tests measure levels of proteins and antibodies (including a protein called rheumatoid factor (RF) which is present in up to 80% of people with rheumatoid arthritis) and indicators of inflammation. 

Treatment

Treatment for rheumatoid arthritis is aimed at managing the symptoms by: 

  • Reducing pain
  • Reducing inflammation
  • Minimising and/or preventing joint damage
  • Maximising joint movement.

To achieve these goals a combination of treatments is usually recommended. 

Medications

  • Non-steroidal anti-inflammatory drugs (NSAIDs) or corticosteroids - to reduce pain and inflammation.  
  • Disease modifying antirheumatic drugs (DMARDs) - to treat moderate to severe rheumatoid arthritis, slowing the progression of the disease and helping to prevent permanent joint damage. Methotrexate is considered by many to be the anchor drug in managing severe rheumatoid arthritis.
  • Biologic drugs - which are a newer type of DMARD that target different aspects of the immune system to help slow progression of the disease. These medications work more effectively when given together with a non-biologic DMARD such as methotrexate.

Physical therapy, exercise and rest

A range of physical therapy treatments and exercises can be used to reduce pain, improve movement, and strengthen muscles. Exercise is important to increase muscle strength, decrease joint deformities and stiffness, and to maintain mobility. A physiotherapist can recommend an appropriate exercise programme.

A balance should be reached between exercise and rest. When the disease is active more rest may be appropriate. Rest will help reduce fatigue, pain, and inflammation.  Some people find therapies such as meditation, Tai chi, and deep breathing and muscle relaxation techniques helpful in reducing stress and managing some symptoms. 

Applying heat can ease pain and relax muscles while a cold compress can reduce joint pain and swelling.

Care of joints

Joint protection and simplifying methods of working can be effective in minimising joint pain and fatigue. An occupational therapist or physiotherapist can give advice on joint care. The use of splints or joint-sparing devices such as zipper pullers or long-handled shoehorns may be suggested.

Surgery

When pain is severe or deformities disabling, and especially when medications fail to prevent or slow joint damage, surgery to repair damaged joints may be indicated. Commonly this involves hip and knee joint replacements but it may be necessary to perform other joint replacements. The repair of tendons and removal of an inflamed synovium (synovectomy) may also be required.

Further support

Rheumatoid arthritis cannot be prevented but, in most cases, an independent life can be maintained. Research is continuing to try to understand the development of the disease so that in time a cure may be possible. 

For further information and support please contact Arthritis New Zealand:

Arthritis New Zealand 
Freephone: 0800 663 463
Email: info@arthritis.org.nz
Website: www.arthritis.org.nz

References 

Arthritis New Zealand (2014). Rheumatoid arthritis (Pamphlet PDF). Wellington: Arthritis New Zealand. https://www.arthritis.org.nz/pdfs/brochures/Rheumatoid.pdf 
Mayo Clinic (2019). Rheumatoid arthritis (Web Page). Rochester, NY: Mayo Foundation for Medical Education and Research. http://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/home/ovc-20197388 [Accessed: 06/05/20] 
Ministry of Health (2018). Arthritis (Web Page). Wellington: New Zealand Government Ministry of Health. http://www.health.govt.nz/your-health/conditions-and-treatments/diseases-and-illnesses/sore-throat [Accessed: 06/05/20]Smith, H.R. (2020). Rheumatoid arthritis (Web page). Medscape Drugs and Diseases. New York, NY: WebMD LLC. http://emedicine.medscape.com/article/331715-overview?src=refgatesrc1 [Accessed: 06/05/20] 

Last Reviewed – June 2020

 

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