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General Concepts > Rheumatoid Arthritis What is Arthritis? Approximately 40 million people are affected by arthritis. The term arthritis refers to a group of disorders which involve the body’s joints and have similar symptoms. The symptoms of arthritis include pain, stiffness and swelling of the joints and the surrounding area. Arthritis affects each person differently. It may attack one or more joints suddenly or gradually and may be constant and progressive or seem to come and go. Unfortunately the effects of arthritis are usually chronic, meaning that they will last a long time, perhaps for a lifetime. How much arthritis will affect a patient’s ability to function will be determined by the severity of the condition, which joints are affected, and for how long. A physician must examine each patient and carry out the appropriate blood tests and X-Rays to determine what type of arthritis a patient has and how best to treat it. There are many medical, rehabilitative and surgical treatments that can help lessen the pain, increase or preserve joint motion and even slow the progress of the disease. When first confronting the diagnosis of arthritis, the patient should gain an appreciation of the type of arthritis that he or she has and understand that the condition will probably last for a very long time, that it may affect different joints at different times and that medication adjustments may be required over time. There are over 100 different types of arthritis and they are usually categorized as degenerative or inflammatory in nature. What is Rheumatoid Arthritis? Rheumatoid (roo-mah-toid) arthritis is the most common form of inflammatory arthritis. It primarily affects the synovium, the thin membrane that lines and lubricates a joint. Rheumatoid arthritis causes the membrane to thicken and produce chemical substances that damage the cartilage and bone within the affected joint and the supporting soft tissue structures such as capsule, ligaments and tendons. Rheumatoid arthritis affects 2.5 million people in the U.S. alone. The disease may involve men or women of any age, but it is most commonly seen in females in their 20’s and 30’s. It often first involves the hands, feet or wrists, but over time may include the ankles, knees, hips, elbows, shoulders, spine or jaw. The disease usually affects joints in a symmetrical fashion, that is, when a joint on one side of the body is involved, the same joint on the opposite side of the body will be affected. Some patients with rheumatoid arthritis experience constant symptoms while others have an “up and down” course of bad periods or “flares” and good periods called remissions. The Body’s Joints In most joints, two bones meet end-to-end. In the area where they oppose each other, they are covered with a gliding surface called articular cartilage. Cartilage is a slippery, smooth substance that assures an even, fluid motion of the joint with minimal friction. Each joint is surrounded by a thin capsule which is lined by a membrane called synovium, which produces a lubricating fluid known as synovial fluid for each joint. The stability of each joint is maintained by its ligaments, which are short strips of fibrous tissue that originate and connect to opposite sides of the joint and have differing amounts of tightness depending on the position of the joint at a given time. Joint movement is produced by the contraction of muscles and the movement of their tendons. The muscles and tendons pass near the joints and insert into bone beyond the joint. Muscle contraction moves the tendons, which in turn, produce bending or straightening of the joints over which the tendons pass. Joints have different configurations depending on the motion they need to produce. Some – like the knee, elbow and finger joints -- work like a hinge – up and down. Others – like the hip and shoulder – are more like a swivel or ball and socket -- and have several planes of rotation and sideways movement. Some joints, such as the wrist, are actually comprised of many bones and small joints which combine to produce very complex, multiple plane motions. Different types of arthritis affect the joints in different ways. The cartilage may be damaged, narrowed and lost by a degenerative process or by inflammation, as in osteoarthritis and rheumatoid arthritis respectively, the two most common forms of arthritis. Bone substance may be lost in the area next to a joint and cysts may result. Spurs around the joints may result form new arthritic bone formation or from the erosion of adjacent bone. Joint deformities and instability often result from the stretching or rupture of supporting ligaments and from the asymmetric loss of cartilage. Causes of Rheumatoid Arthritis? No one knows exactly what causes rheumatoid arthritis, but there are many thoughts about what might contribute to it. Heredity, or the genes you get from your parents, may be a factor in determining who gets rheumatoid arthritis. Some researchers think certain infections or chemicals might cause the disease. Many studies are being done to see if this can be determined. Some people think hormones may play a role. But this, too, is still uncertain, even though women are more apt to suffer from rheumatoid arthritis than are men. Rheumatoid arthritis is an autoimmune disease, which means your own immune system starts to attack some of your tissues. Symptoms of Rheumatoid Arthritis? Rheumatoid arthritis may involve body systems other than joints, and produce fatigue, low grade fever, weight loss, dryness of the eyes and mouth, color changes of the fingers and toes, and inflammation of the eyes, heart, lungs skin and nerves. Sometimes lumps of tissue develop near the affected joint, usually near the elbow joint. These are called rheumatoid nodules. Your doctor will determine what type of arthritis you have. He or she will ask you about your symptoms and any related illnesses and it will be important for you to tell the physician about where, when and how long you have had pain, whether there is any swelling or redness in the involved joints and if there is any history of arthritis in your family. The doctor will perform a careful examination of your joints to determine if there is any swelling, redness, tenderness or loss of motion. X-Rays will allow the doctor to see inside your joints and determine if there has been any destruction of cartilage with narrowing of the normal joint space or wear and tear on the bones. Blood tests may also be of value in differentiating rheumatoid arthritis from osteoarthritis and other types of arthritis. Regardless of the type of arthritis that a person has, many patients will experience some difficulty functioning at home, at work or at play because of joint pain, stiffness, and loss of motion. Arising from bed in the morning, buttoning buttons, writing, sewing, meal preparation, dressing, sleeping, walking, climbing stairs, arising from a chair or a toilet seat, and attending to matters of personal hygiene may all be impaired to some degree by arthritis. Oftentimes, impairment of function is more distressing to patients than the pain of arthritis and a major goal of all arthritis treatment is the preservation or improvement of function. Treatment of Rheumatoid Arthritis? Several general principles for living with arthritis should be mentioned. Weight control - with diet and appropriate exercise – is extremely important to decrease the stress on the arthritic joints. Exercise in particular, is an important part of any therapy prescribed for patients with arthritis. Range of motion exercises and strengthening exercises are important to maintain or improve joint mobility and to increase the strength of the muscles around the joints and minimize the stress on those joints. Aerobic exercise, such as walking or riding a stationary bike helps to decrease fatigue, improve cardiovascular health, and create a sense of well being. These aerobic exercises may be difficult for those patients who have pain in their hips, knees and feet, and a water exercise program or protocol specifically designed for comfortable movement by a physical therapist may be more tolerable for those individuals. Even though exercise is extremely beneficial to the successful treatment of patients with arthritis, rest is of paramount importance as well. This may involve splinting a particularly painful or swollen joint, or resting the body in general by getting adequate amounts of sleep at night and with daytime naps. During periods of increased symptoms or flares, patients will require more rest than during periods when their arthritis is under good control. Your doctor may ask you to be evaluated by an occupational therapist to make splints for joints that are swollen, painful or becoming affected by arthritis. He or she can also instruct you in easier ways to perform activities in order to minimize stress on joints, pain or fatigue. Recommendations may be given for adaptive equipment, which will make the work of certain activities less stressful. Jar openers, modified writing and kitchen utensils, and special shoehorns are examples of devices that can be beneficial for patients with arthritis. The use of special shoes, braces and walking aids such as canes, crutches or walkers may also favorably affect a patient’s ability to remain functionally independent. Several other measures are available for the relief of joint pain and stiffness. Many patients shower upon arising in the morning in order to lessen the duration of their morning stiffness. After showering, when the muscles are warm, it is easier to carryout stretching and range of motion exercises. The local application of heat or cold packs is also helpful for pain control. Most patients prefer heat but it should not be too hot or applied for more than 20 to 30 minutes, as longer periods may produce muscle spasm. Heat may be applied three or four times a day, but you should never go to bed with a heating pad on a joint! Medications for Rheumatoid Arthritis? Medications may help with the pain and inflammation of arthritis and treatment usually begins with milder drugs that have the fewest side-affects. Over-the-counter medications such as acetaminophen (Tylenol), ibuprofen, and aspirin can all be used as necessary or on a regular basis to control joint pain. Topical creams and ointments may also provide some temporary relief of joint discomfort. When over-the-counter pain medications fail to adequately control symptoms, your doctor may prescribe anti-inflammatory medicines referred to as non-steroidal anti-inflammatory drugs or NSAIDS because they attempt to control inflammation without the use of cortisone compounds. These drugs are used for treating both rheumatoid and osteoarthritis as well as other types of arthritis. Although these anti-inflammatory drugs have not been shown to be more effective than high-dose aspirin (12 or so per day), they are generally easier and safer to use than aspirin. Depending on the particular drug, they may be taken once to four times a day. Disadvantages and Side Effects of Anti-inflammatory Drugs? These medications are more expensive than aspirin and have potential serious side effects including high blood pressure, fluid retention, easy bruising, kidney and liver abnormalities, gastritis, and stomach and intestinal ulcers. A new class of NSAID medications known as Cox-2 inhibitors are effective in the management of arthritic conditions and appear to be less likely to produce gastrointestinal problems. Depending on your age and other medical conditions, your doctor will monitor you periodically with blood tests in order to check for the potential development of side effects from the medications that you are taking. What are DMARDs? For patients that have rheumatoid arthritis that has failed to respond adequately to NSAIDS, your doctor will consider a different class of medication called disease-modifying drugs or DMARDS. This category of drugs includes hydroxychloroquine (Plaquenil), gold, sulfasalazine (Azulfidine), minocycline (Minocin), methotrexate, penicillamine, and leflunomide (Arava). These drugs differ from each other and from other arthritis medications in their onset of action, method of administration, cost, potential side effects, and the need for monitoring for potential side effects. The severity of the arthritis, previous response to other medications, and history of other health problems will help determine which drug or combination of drugs will be prescribed for you. Some of the more recent medications that have been developed for patients with rheumatoid arthritis include etanercept (Enbrel) and infliximab (Remicade). These medications are administered either be subcutaneous injection (Enbrel) or by intravenous infusion (Remicade) and represent a new class of compounds called anti-tumor necrosis agents. These medications are presently very expensive and are generally reserved for patients with severe rheumatoid disease who have failed treatment with other strong drugs such as methotrexate. It is not unusual that several months are required in order to identify the medication and dosage that will be most beneficial for treating a patient with rheumatoid arthritis. Corticosteroid medications – sometimes known as cortisone or prednisone may be used to make patients more comfortable and functional during severe flare-ups or while other medications are being initiated. Corticosteroid drugs are potent, rapidly acting anti-inflammatory drugs which may be injected into a joint or given orally. Side Effects of Corticosteroid (Cortisone) Drugs?
Surgery For Arthritis? Surgery may also be helpful for patients with arthritis. Nerves and tendons compressed by inflammation within closed spaces can be decompressed. Chronic, destructive synovium can be surgically removed with the hope of slowing the progression of the disease at specific sites. Tendon transfers may restore function when tendons have ruptured over arthritic spurs. Procedures can be done to change the weight distribution to a partially arthritic joint so that the good, remaining cartilage can bear more of the load. Deformed or unstable joints may be fused - joined into a single bone without a joint. Soft tissue procedures or combination of bone and joint removal and soft tissue reconstruction can be carried out to stabilize joints, relieve pain and preserve motion. And finally, technology now exists to replace many arthritic joints with new articulating metal and plastic components that can restore painless motion. Dramatic improvement in function and lifestyle can be expected from procedures such as total hip replacement, total knee replacement, total shoulder replacement, total elbow replacement, total wrist replacement, total ankle replacement, and the replacement of deformed metacarpophalangeal or proximal interphalangeal finger joints with flexible implants. Living With Arthritis? There are many important considerations for “living with arthritis”. Successful treatment involves exercise, rest, the maintenance of ideal body weight, the local application of heat or cold, medication, and surgery. A positive mental outlook and the support of friends and family members is essential in minimizing the effect of arthritis upon a patient’s well-being and ability to perform daily activities. Each patient will have to adapt to his or her own abilities and limitations and remain committed and optimistic about the ability to manage his or her arthritis through good medical, surgical and rehabilitative care. For many people, support groups may also help. You can contact the National Arthritis Foundation at 800.283.7800 to find some groups near you. Or find the chapters near you by visiting their Web site at http://www.arthritis.org/offices/ The information provided herein is not intended to be a substitute for professional medical advice. You should not use this information to diagnose or treat a health problem or disease without consulting a licensed physician. © 2000 DynoMed.com, LLC, Indianapolis, IN |