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Rheumatoid arthritis - causes, symptoms, treatment

 
Rheumatoid arthritis is a long term disease that causes inflammation and deformity of the joints.  Symptoms may come and go, or vary, but typically involve joint pain and swelling.
 
Rheumatoid arthritis is the second most common form of arthritis and, in New Zealand, affects 1-2% of the population  It is three times more common in women than men. 

General information 

Rheumatoid arthritis is a consequence of 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.
 
In a healthy joint, cartilage lines the end of the bones. The cartilage acts as a cushion and allows the bones within the joint to glide smoothly over one another. The joint is contained within a joint capsule, which is lined by a synovial membrane (synovium). The synovial membrane produces synovial fluid – a clear fluid that lubricates and nourishes the joint. Surrounding muscles, tendons and ligaments support the joint allowing it to move smoothly and without pain.
 

Rheumatoid arthritis 1

 

Rheumatoid arthritis causes the normally thin synovial membrane (synovium) to become inflamed and thickened, leading to an  accumulation of synovial fluid and causing pain and swelling. Also, the cartilage and bone ends within the joint may become damaged and eroded leading to loss of function and deformity of the joint.
 

Rheumatoid arthritis 2 

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 symmetrically (both the left and the right side of the body).
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 can develop a form of rheumatoid arthritis known as juvenile rheumatoid arthritis or Still’s disease.

Rheumatoid arthritis occurs in all ethnic groups, climates and altitudes. In New Zealand it affects about 1-2% of the population. It is three times more common in women than it is in men. 

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. Rheumatoid arthritis is characterised by periods of remission (absence of symptoms) and exacerbation or "flare-ups" (when symptoms are problematic).  Sometimes there is an obvious cause for a flare-up (physical stress, illness, emotional) 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
  • Anaemia can also occur, often compounding the feeling of fatigue and the feeling of being generally unwell

Because rheumatoid arthritis is a systemic condition (ie, it can have an effect on the whole body) symptoms may be similar to having the flu.  Rheumatoid arthritis can cause problems with other parts of the body. These include: 

  • Inflammation of the blood vessels (vasculitis)
  • Inflammation of the linings of the lung or the heart
  • Dryness of the eyes and mouth
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.

Causes

The cause of rheumatoid arthritis is unknown. It is clear, however, that many factors are involved in the development of the condition.  Possible factors in the development of rheumatoid arthritis include:

Genetic (inherited) factors:
The condition appears to run in families giving rise to the theory that genetic factors may influence its development.

Infectious agents:
It is possible that rheumatoid arthritis is triggered by the abnormal response of the body’s immune system (autoimmune response) to some infections.

Hormonal factors:
Changes or deficiencies in certain hormones may be involved in the development of rheumatoid arthritis.
 
People who smoke are more likely to develop the condition. 

Diagnosis

There is no single test that diagnoses rheumatoid arthritis. In its initial stages it may be difficult to distinguish rheumatoid arthritis from other forms of arthritis.   In order to diagnose rheumatoid arthritis a doctor will usually undertake the following: 

  • 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
Two types of blood tests commonly performed to assist in the diagnosis of rheumatoid arthritis are:

Immunological tests
These tests assess levels of proteins and antibodies in the blood, including a protein called rheumatoid factor (RF), antinuclear antibodies (ANA) and sometimes other antibodies such as anti-CCP.  Rheumatoid factor is present in up to 80% of people with rheumatoid arthritis. 

Inflammatory markers
Blood tests to assess erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) may be performed.  It is common for both of these markers to be elevated in people with rheumatoid arthritis and they can be a good indicator of the extent of the condition. 

Treatment 

Treatment for rheumatoid arthritis is aimed at treating the symptoms. Goals of treatment are to: 

  • Reduce pain
  • Reduce inflammation
  • Minimise and/or prevent joint damage
  • Maximise joint movement
To achieve these goals a combination of treatments is usually recommended. These include:

MEDICATIONS
Common types of medications used to treat the symptoms of rheumatoid arthritis include:

Non-steroidal anti-inflammatory drugs (NSAIDs)
These medications work by treating pain and inflammation.
 
Corticosteroids
These medications eg: prednisone, work to reduce inflammation.

Disease modifying antirheumatic drugs (DMARDs)
These medications are commonly used to treat moderate to severe rheumatoid arthritis.  Types of medications in this category include those used to suppress the immune system (eg: Imuran), anti-malarial medications (eg: Plaquenil), gold preparations (eg: Auranofin), Penicillamine and some medications normally used to treat cancer (eg: Methotrexate).  Methotrexate is considered by many to be the anchor drug in managing severe rheumatoid arthritis.

Tumor Necrosis Factor–alpha (TNF-a)
These medications work by inhibiting an inflammatory chemical called tumor necrosis factor. The medication used will depend on the seveity of the arthritis. If effective, the medication may be continued for a number of years. 

PHYSIOTHERAPY
A range of physiotherapy treatments are used to reduce pain, improve movement, strengthen muscles, and maintain independence.

EXERCISE AND REST
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. Exercise is important to increase muscle strength, decrease joint deformities and stiffness, and to maintain mobility. A physiotherapist can recommend an appropriate exercise regime.

CARE OF JOINTS 
Joint protection and work simplification methods can be effective in decreasing joint pain and fatigue. An occupational therapist or physiotherapist can give advice on these. 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, surgery 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, nerves or joint structures such as the synovial membrane may also be required.

COMPLIMENTARY THERAPIES
Some people find therapies such as acupuncture, meditation, relaxation techniques and homeopathy helpful in managing symptoms.  Dietary supplements such as fish oils may also be beneficial.

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.
PO Box 10-020
Wellington
Freephone 0800 663 463
Website: www.arthritis.org.nz

For branch offices please refer to the local telephone directory or the Arthritis New Zealand website.

References 

Arthritis  New Zealand (2010) Rheumatoid arthritis (Pamphlet): Arthritis  New Zealand (Inc)
Dermnet NZ (2012) Rheumatoid arthritis. New Zealand Dermatological Society Inc. www.dermnetnz.org/immune/rheumatoid.html
Meszaros, L. (2006) Rheumatoid arthritis. The Gale Encyclopedia of Medicine. Third Edition. Jacqueline L. Longe, Editor. Farmington Hills, MI. Thompson Gale.
 
Last Reviewed – 31 May 2013 

 

 

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