Rheumatoid Arthritis is the second most common form of the more than 120 types of arthritis known to occur in patients.

Rheumatoid arthritis, also called R.A., is that type of arthritis which is characterized by chronic inflammation of the involved joints, and is most often accompanied by swelling, pain, deformity, and stiffness.

The cause of rheumatoid arthritis is not known. It is thought to be an autoimmune disease, in which the body attacks the joints as if they are a foreign matter.

How Does Rheumatoid Arthritis Occur?

In order to understand how R.A. occurs, a basic understanding of a joint and its function may be helpful.

A joint is the meeting of two bones. It consists of six parts – cartilage, synovial membrane, bursa, muscle, tendon and ligament. In each type of arthritis, a different part of the joint tissue is involved. In rheumatoid arthritis the synovial membrane is the part that becomes affected, and the patient suffers from synovitis or inflammation of this membrane. This synovitis of the joint membrane causes enzymes to be released. These enzymes act as an erosive type of chemical substance and cause a chronic inflammatory process within the joint lining. Over time, the joint lining swells and thickens, causing damage to the joint surface.

Who is Affected by Rheumatoid Arthritis?

According to the Arthritis Foundation, a non-profit organization that works for all people affected by arthritis, approximately two million people in the United States alone have R.A., with most being women. Rheumatoid arthritis usually occurs in mid­life (in theforties and fifties) but can begin at any age. The disease may occur in children and may be quite different from the adult onset.

Symptoms and Features of R.A.: It is important to remember that R.A., although a chronic disease (occurring over a period of 3 months or more), it is also one in which there are ups and downs where there may be periods of “flares,” when the symptoms are increased, which may alternate with periods of remission in which the symptoms may decrease or disappear entirely. These periods of remission may last months or years, and it is common for even the worst types of R.A. to lessen with time. It is very important for the patient with rheumatoid arthritis to understand that while overall symptoms may decrease over time, any destruction to joints will not improve. This fact becomes significant and is addressed later as treatments are discussed. Outlined in the table below are the symptoms, joints involved, and other features usually seen in rheumatoid arthritis.

Symptoms, joints involved and other issues:

• swelling
• pain, usually symmetrical (occurring both sides)
• redness
• warmth
• tenderness
• nodules (inflamed blood vessels)
• muscle aches and stiffness, especially in A.M. or after sitting (“gel phenomenon”)
• wrists
• knuckles
• feet
• elbows
• neck
• knees
• hips
• ankles
• may affect heart, lungs, eye
• decreased appetite
• weight loss
• fatigue
• low grade fever
• gradual or sudden onset
• bent or deformed joints over time

Common first symptoms and Diagnosis: Because the symptoms of rheumatoid arthritis may develop slowly over a period of time, the diagnosis of the disease may not be apparent at first. Signs of swelling joint(s), tenderness and warmth are taken into account, a complete medical history and laboratory tests (both blood and joint samples) will help the physician in the diagnosis.

Common tests which may be performed are:

(A) Rheumatoid factor, a blood test which identifies an abnormal substance found in the blood of approximately 80% of adult patients with R.A. The R.A. factor can be seen in diseases other than R.A. and may not be seen in some patients who have R.A. (B) SED rate or Erythrocyte sedimentation rate is a blood test which measures how quickly red blood cells settle to the bottom of a test tube. Red blood cells tend to fall or settle more quickly in patients with R.A. or other inflammatory diseases. The sed rate, while not conclusive as a diagnostic test, can be helpful in assessing the severity of the disease. (C) RBC or red blood cell count, performed to identify the presence of anemia which often occurs in R.A. and likely contributes to the fatigue many R.A. patients experience. (D) Joint Aspirations and Biopsies involve withdrawal of fluid from a swollen joint or the biopsy of inflamed joint tissue which may assist the physician in determining the presence of R.A. One or both of these tests may be performed in patients who present with symptoms of the disease. (E) X­rays may be taken, because it may take time to see changes in bone from R.A. Although x-rays may not be very helpful in the initial diagnosis, most physicians include x­rays in the diagnostic work­up because an x­ray can provide a baseline in later measuring the amount of joint damage and disease progression which the patient with R.A. experiences.

Treatment:

The treatment of rheumatoid arthritis can sometimes appear complicated and confusing to the patient and his family. While there is currently no known treatment to stop or reverse R.A., many of the current therapies available can help the patient lead a life that is closer to normal. Perhaps the most important guideline for treatment of rheumatoid arthritis is the importance of early treatment and care by a rheumatologist who specializes in the treatment of arthritis. Following this recommendation, you will be treated by a specialist who is familiar with the most current as well as the most effective treatments available for R.A.

Goals: The goals of treatment for the patient with R.A. are to reduce joint swelling and assist the patient in functioning as normally as possible. A multi­focused approach should combine medication, exercise, joint protection, rest, heat and cold therapy as well as surgery, if required. In addition, educating and helping patients to manage the stress and depression that may accompany a chronic illness such as R.A. is also a vital part of the treatment program.

Medications: One or more medications are almost always required by patients with R.A.. Numerous medications are available and it may take several attempts before the most effective medication or combination of medications is found. Current medications include the following (new medications are also being tested):

(1) Aspirin or other NSAIDS (non­steroidal anti­inflammatory drugs) which reduce joint pain,swelling, and stiffness. They may be given in pill or liquid form. It may be necessary to try several of these available medications before finding the one that works best.

(2) Corticosteroids, strong hormone medications which are used only when the disease is active and not responding to other medications. When taken over extended periods they are prescribed in the smallest possible dosage. Sometimes corticosteroids can be injected directly into a joint to bring short­term relief, but this is not done routinely if other options are available.

(3) Slow­Acting Antirheumatic Drugs (SAARDS) – While NSAIDS and corticosteroids can provide quick relief from pain and swelling in patients with R.A., they do not slow the disease process. The slow­acting antirheumatic drugs work more slowly, but in some cases can slow the disease process. Examples of SAARDS include gold salts, plaquenil, penicillamine, Azulfidine, and immunosuppressive drugs such as Imuran and Methotrexate.

Exercise:

Regular exercise helps keep joints flexible, muscles strengthened, and improves overall fitness. For patients with R.A., this is extremely important. The ideal program for this type of patient is one which includes a combination of range of motion exercises to prevent joint stiffness, muscle strengthening exercises to provide support to joints, and endurance exercises to improve overall fitness. As with any exercise program, it is important to check with your doctor before initiating any routine. It may also be recommended that the patient work with a physical therapist to help identify the best program for that individual.

Joint Protection:

Learning how to perform daily routines while placing the least amount of stress on joints is the goal of a joint protection program. This may involve the use of assistive devices such as canes, walkers, or splints. It may also involve the use of self­help devices for bathing, dressing, and managing household tasks. An occupational therapist who is specially trained in this area may be recommended for assistance in this area.

Rest:

An important part of R.A. treatment is knowing how to balance rest and activity. During an acute flare of the disease, more rest will be needed. During other times, less rest and more exercise will be required. In general, it is important for the patient to be aware that such flares and remissions will occur so that he or she can manage daily activities without stress.

Heat/Cold Therapy:

Heat can be used to relieve pain and soreness in joints, while cold applications may reduce swelling and help to numb an area of pain. Many methods, from warm showers, hot packs, cold compresses or even creams or ointments may be used to achieve relief.

Discussing which treatment may be best should be done with a physician or therapist.

Nutritional supplements: There are many over­the­counter nutritional

supplements which claim they improve the symptoms of arthritis. Such

supplements should be discussed with a physician as many supplements

have not been scientifically studied or proven to be beneficial. Recently,

much interest has been generated in the use of glucosamine, chondroitin

sulfate, or a combination of these substances. Laboratory and clinical

studies have suggested that these materials, which are the building blocks

for cartilage, may have a positive effect on cartilage and arthritis. One

nutritional supplement, Cosamin DS, is a patented combination of these

two materials. We are currently involved in a study to test the use of this

combination in the treatment of OA. Preliminary studies indicate that it may

also be effective in the treatment of rheumatoid arthritis, but more studies

are needed.

Electrical Stimulation Therapy: Pulsed electromagnetic therapy has been

used to stimulate healing in the treatment of fractures. Although it has been

approved for a number of orthopaedic applications in more than 20

countries throughout the world, it is not approved for use in the United

States except for those patients enrolled in FDA­approved studies. It is

believed that electrical stimulation may stimulate the body to repair

cartilage.

Education and Managing Stress and Depression: Living with a chronic

disease such as R.A. can be a mild inconvenience or a frustrating and

perhaps depressing experience at times. Learning about the disease and

strategies to assist in coping with it can help you to feel better about

yourself. Many patients find it useful to learn relaxation techniques and

other methods to assist them in reducing the stress or anxiety which may

occur as a result of their R.A. Others may find it beneficial to join a support

group of R.A. patients who can identify with their feelings and possibly offer

new ideas on coping with the disease. By contacting your local Arthritis

Foundation Chapter you may also learn of other aids available to help you

with your disease.

Surgery may help to relieve pain and restore function to a damaged joint:

•Arthroscopic debridement • Hemi arthroplasty • Total hip replacement •

Total knee replacement • Total shoulder replacement • Synovectomy of the

knee • Synovectomy of the knuckles.

The Future of R.A.: Medical research into the cause and treatment of

rheumatoid arthritis as well as other forms of arthritis continues nationwide

every day. It is hoped that through continued efforts new and more

effective treatments will become available to those with R.A.

References: 1. Lorig, K., Fries, J., The Arthritis Helpbook, 4th ed., Addison-
Wesley Publishing Co., 1995 2. Siegel, I., All About Bone – An Owner’s

Manual, Demos Medical Publishing, Inc., 1998 3. Theodosakis, J., Adderly,

B., Fox, B., Maximizing the Arthritis Cure, St. Martin’s Press, 1998 4.

Arthritis Information Rheumatoid Arthritis, The Foundation,1983,1987,1990