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| ABOUT RHEUMATOID ARTHRITIS |
Introduction

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 the 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, although it is thought to be an autoimmune disease, one in which the body attacks the joints as if they are a foreign matter.

How Does R.A. 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 R.A.?

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. Most people with R.A. are women. Rheumatoid arthritis usually occurs in mid life between the forties or fifties, but can start at any age. It also can occur in children and in these cases is quite different from the adult onset.

Symptoms and Features of R.A.

It is important to remember that R.A., although a chronic disease, is also one in which there are ups and downs. Periods of "flares," when the symptoms are increased, may alternate with periods of remission in which the symptoms may decrease or go away 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. However, it is very important for the patient with rheumatoid arthritis to understand that while overall symptoms may decrease over time, any prior destruction to joints that are involved will not improve. This fact becomes very important in the later discussion of treatment for the diseases

Outlined in the table below are the symptoms, joints involved, and other features usually seen in rheumatoid arthritis.

SYMPTOMS
JOINTS INVOLVED
OTHER FEATURES

  • 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

*Usually first symptoms

Diagnosis

Because the symptoms of rheumatoid arthritis may develop slowly over a period of time, the diagnosis of this disease may not be apparent at first. The diagnosis of R.A. is based on the overall symptoms, medical history, and specific tests the physician orders.

  • The initial physical exam - During this exam, the physician may well try to identify signs of joint swelling, tenderness, and warmth. A complete medical history performed by the physician may also aid in the diagnosis.
  • Laboratory tests - Both blood and joint samples may be used to assist the physician in diagnosing the disease. Common tests performed are listed below.
    • Rheumatoid factor - This blood test is helpful in identifying an abnormal substance found in the blood of approximately 80% of adult patients with R.A. However, this factor can be seen in diseases other than R.A. and may not be seen in some patients who have R.A.
    • SED rate or Erythrocyte sedimentation rate - This blood test measures how quickly red blood cells settle to the bottom of a test tube. These 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.
    • RBC or red blood cell count - This blood test is performed to identify the presence of anemia which often occurs in R.A. and may contribute to the fatigue many R.A. patients experience.
    • Joint Aspirations and Biopsies - The withdrawal of fluid from a swollen joint or the biopsy of inflamed joint tissue 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
  • X-rays - Because it may take time to see changes in bone from R.A., X-rays may not be very helpful in the initial diagnosis. However, most physicians include x-rays in the diagnostic work-up because they can provide a baseline in later measuring the amount of joint damage and disease progression a patient with R.A. experiences.

Treatment

The treatment of rheumatoid arthritis can sometimes appear complicated and confusing to the patient and his family. No current treatment can stop or reverse the R.A. process but many of the current therapies available can help the patient lead a life that is as normal as possible.

Perhaps the most important guideline for treatment of rheumatoid arthritis is the importance of realizing that with R.A. it is strongly felt that you should be seen early in the disease process, and that you should be evaluated and followed by a rheumatologist, a physician who specializes in the treatment of arthritis. By 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
  • Assist the patient in functioning as normally as possible

In order to achieve these goals, treatment of the patient with R. A. is multi focused. It combines medication, exercise, joint protection, rest, heat and cold therapy, and surgery when needed. In addition, educating patients and helping them to manage the stress and depression that can accompany a chronic illness such as R.A. is also a vital part of the treatment program.

  1. Medications - Medications are almost always required by patients with R.A.. Multiple medications are available and it may take several attempts to find the correct medication for each individual.

  • Aspirin or NSAIDS (non-steroidal anti-inflammatory drugs) - These medications reduce joint pain,swelling, and stiffness. They may be given in pill or liquid form. There are many different types of these medications and it may be necessary to try several of them before finding the one that works best.

  • Corticosteroids -These are strong hormone medications and are used only when the disease is active and not responding to other medications. When given over long periods they are taken in the smallest possible dosage. Sometimes corticosteroids can be injected directly into a joint to bring short-term relief, but again this is not done repeatedly if other options are available.

  • Slow-Acting 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 slow-acting antirheumatic drugs work more slowly, but can slow the disease process in some cases. Examples of SAARDS include gold salts, plaquenil, penicillamine, Azulfidine, and immunosuppressive drugs such as Imuran and Methotrexate.

  1. Exercise - Regular exercise helps keep joints flexible, muscles strengthened, and improve 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 you work with a physical therapist to help identify the best program for you as an individual.

  1. Joint Protection - Learning how to perform daily routines while placing the least amount of stress on your 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 self-help devices for bathing, dressing, and managing household tasks. An occupational therapist who is specially trained in this area may be someone your physician recommends for assistance in this area.

  2. 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 to know that this will occur and to try planning your activities based on this knowledge.

  3. 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 is something that certainly should be done with your physician or therapist.

  4. Nutritional supplements

  • There are many over-the-counter nutritional supplements that claim they can improve the symptoms of arthritis. These supplements should be discussed with your physician. Many of these supplements have not been scientifically studied or proven to be of benefit to the patient.

  • 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.

  1. 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 FDA-approved studies.

  • It is believed that electrical stimulation may stimulate the body to repair cartilage.

  1. 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.

  1. Various surgeries may be beneficial to patients with rheumatoid arthritis. These surgeries may help to relieve pain and restore function to a damaged joint. Surgeries which can be performed are:
  • 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 everyday across the country. It is hoped that through these continued efforts new and even more effective treatments will become available to all patients who are diagnosed with this disease.


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

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