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What Is It?
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Rheumatoid arthritis is a chronic (long-lasting) inflammatory disease that causes pain, stiffness, warmth, redness and swelling in joints. Over time, the affected joint can become misshapen, misaligned and damaged. Tissue lining the joint can become thick, and may wear away surrounding ligaments, cartilage and bone as it spreads. Rheumatoid arthritis usually occurs in a symmetrical pattern, meaning that if one knee or hand has it, the other usually does, too.
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The cause of rheumatoid arthritis is unknown, although it appears to be a disease of the autoimmune system. When the body's immune system does not operate as it should, white blood cells that normally attack bacteria or viruses attack healthy tissue instead — in this case, the synovium, or joint tissue. As the synovial membrane (the thin layer of cells lining the joint) becomes inflamed, enzymes are released. Over time, these enzymes eat away at cartilage, bone, tendons and ligaments near the joint.
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Some research suggests that a virus triggers this faulty immune response. However, there is not yet convincing evidence that a single virus is the cause in all patients. At the same time, it appears that some people are more likely to get the disease because of their genetics.
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Rheumatoid arthritis, the most disabling form of arthritis, generally affects more than one joint at a time. Commonly affected joints include those in the hands, wrists, feet, ankles, elbows, shoulders, hips, knees and neck. Rheumatoid arthritis can result in loose, deformed joints, loss of mobility and diminished strength. It also can cause painless lumps the size of a pea or acorn, called rheumatoid nodules. These develop under the skin, especially around the elbow or beneath the toes.
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Generally, the pain of rheumatoid arthritis is described as a dull ache, similar to that of a headache or toothache. Pain is typically worse in the morning. It is not rare to have 30 minutes to an hour or more of morning stiffness. On days when the disease is more active, you may experience fatigue, loss of appetite, low-grade fever, sweats and difficulty sleeping.
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Because rheumatoid arthritis is a systemic disease (meaning it can affect the entire body), you also may have inflammation in other areas, including the heart, lungs or eyes. Symptoms vary between people and even in one person over time. People with mild forms of the disease are bothered by pain and stiffness, but they may not experience any joint damage. For other people, damage occurs early, requiring aggressive medical and surgical treatment. People with rheumatoid arthritis may notice worsening and improvement for no apparent reason. Although this disease most often afflicts people between the ages of 20 and 50, it may affect children and the elderly. Of the 2 million people with rheumatoid arthritis in the United States , 75% are women.
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Symptoms
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Symptoms include:
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• Pain, swelling, limited motion, warmth and tightness around affected joints, which most commonly include the hands and wrists, feet and ankles, elbows, shoulders, neck, knees and hips, usually in a symmetrical pattern. Over time, joints may develop deformities.
• Fatigue, soreness, stiffness and aching, particularly in the morning and afternoon (described as morning stiffness and afternoon fatigue)
• Lumps or rheumatoid nodules below the skin
• Weight loss
• Low-grade fever and sweats
• Trouble sleeping
• Weakness and loss of mobility
• Depression
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Is it the same as osteoarthritis?
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No, osteoarthritis is a different disease. Rheumatoid arthritis is caused by inflammation in the lining of the joint. Osteoarthritis is more like a wear process, in which the cartilage in the joint can no longer withstand the loads placed on it. Some inflammation does occur in osteoarthritis, but it is not the same as that in rheumatoid arthritis. And some wear may take place in joints which have previously been damaged by rheumatoid arthritis, but this is a complication which only occurs later in rheumatoid arthritis. The two diseases are quite different in their treatment and it is important not to confuse the two. If you have any doubt about which type of arthritis you have, ask your doctor.
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How does rheumatoid arthritis affect different people?
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Our bodies normally produce inflammation to destroy things, such as bacteria, which cause illness. We do not know what sets off the inflammation in rheumatoid arthritis, but the result is the same – unfortunately, in this case it is not bacteria or other harmful substances which are attacked but the tissues in the joints. The inflammation in rheumatoid arthritis causes damage to the cartilage and sometimes to the bone itself. It may also damage any ligaments within the joints.
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The extent to which this happens varies a great deal from person to person. Some people have little or no damage to the joints, or suffer only very minor damage to a few joints. Most people with rheumatoid arthritis have some damage in a number of joints, and a few – about 1 in 20 (5%) of those with rheumatoid arthritis – have quite severe damage in a lot of joints. The joints which are most likely to be affected by rheumatoid arthritis are shown in Figure 3.
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Once joints have been damaged by inflammation they do not heal very well. Because of this, modern treatment tries to suppress the inflammation as much as possible in order to limit the damage which occurs. Suppressing inflammation early is one of the important ways in which treatment of rheumatoid arthritis has advanced and is one reason why treatment is more effective than it used to be.
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Rheumatoid arthritis does not just affect the joints. Tendons are like ropes which run inside lubricated tubes. The lubricating system is very similar to that in the joints themselves, so it is not surprising that tendons can also be affected by rheumatoid arthritis. In a few people, other parts of the body such as the lungs and the blood vessels may become inflamed .
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Inflammation in the joints can make some people feel generally ill. Sometimes this leads to overwhelming tiredness or fatigue, which may be as difficult, or even more difficult, to cope with than the painful joints. 'Feeling tired' is a symptom which may get little sympathy from those around you, who must be told that this is an important symptom of rheumatoid arthritis.
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One problem with rheumatoid arthritis is that the symptoms tend to come and go with no particular pattern. You may have 'flare-ups' – periods when the joints become more inflamed and painful. Sometimes this has an obvious cause – either physical, such as unaccustomed physical exertion or another illness, or emotional, such as bereavement. Usually, though, there is no obvious cause, however hard you think about possible triggers. This unpredictability is frustrating and makes it difficult to plan ahead.
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Rheumatoid arthritis can be a serious disease with a lot of symptoms. But most people, especially if they receive appropriate treatment, will have relatively few symptoms, and will be able to lead full, normal lives.
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Who gets rheumatoid arthritis?
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Many people believe that rheumatoid arthritis exists only in places with cool, damp climates such as Britain . This is not true. It exists all over the world, although the more severe cases are found more often in Northern Europe .
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More than 350,000 people in Britain have rheumatoid arthritis. It can happen in people of any age, from children to those in their 90s, but the most common age for the disease to start is between 40 and 50. About three times as many women as men are affected.
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There is some evidence that lifestyle factors are associated with rheumatoid arthritis. These are not direct causes of the disease, but rheumatoid arthritis may be more common, for example, in people who smoke, or eat a lot of red meat, or drink a lot of coffee. Those with high vitamin C intake seem to have a lower risk of developing rheumatoid arthritis. Those who drink alcohol in moderation are at less risk than either heavy or non-drinkers.
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Does it run in families?
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Rheumatoid arthritis does seem to run in some families – but most relatives of people with rheumatoid arthritis do not develop it themselves. In particular, your children are more likely not to get it than to get it. There are lots of causes of arthritis and joint pain, many of which are more common than rheumatoid arthritis. If someone in your family develops joint pain, it may well be due to one of these other causes and it does not necessarily mean that they have rheumatoid arthritis. There are genes that increase the likelihood of developing the disease, but even the identical twin of somebody with rheumatoid arthritis, who shares all the same genetic material, only has a 1 in 5 (20%) chance of developing the disease. This shows that genes are only a part of the reason why rheumatoid arthritis develops. The severity of the disease is also often very different between affected family members.
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How does rheumatoid arthritis develop?
The start of the disease
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In most people rheumatoid arthritis starts quite slowly. A few joints – often the fingers, wrists or the balls of the feet – become uncomfortable and may swell, often intermittently. You may feel stiff when you wake up in the morning. Many people only seek help from the doctor when the symptoms become more severe or more frequent.
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For about 1 in 5 (20%) of those with rheumatoid arthritis the disease develops very rapidly. There may be a sudden onset of pain and swelling in a lot of joints, with severe morning stiffness and great difficulty doing everyday tasks.
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Along with pain and swelling in the joints you may feel tired, depressed or irritable, even with mild arthritis. You may also feel frightened about the future, and angry – 'Why has this happened to me?' At the moment there is no answer to that question, but this booklet should help you understand what is happening.
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When should I go to the doctor?
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It is very important that treatment for rheumatoid arthritis is started as early as possible in the disease. This means it is essential that you see your doctor as soon as you can if you have any symptoms, such as pain and swelling in the joints and stiffness in the mornings, which might be caused by rheumatoid arthritis. Your symptoms may not be due to rheumatoid arthritis as there are many other causes of joint pain, but it is important to diagnose arthritis as soon as possible. To help with diagnosis many rheumatology departments have 'Early Arthritis Clinics', which aim to see people very quickly when they are referred by their GP. The more we learn about the disease, the more we realize that early diagnosis and early treatment are very important if rheumatoid arthritis is to be managed effectively.
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How will it progress?
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This is the single question that most people want answered. For each individual patient the answer is 'We cannot tell for sure.' However, from the study of a large number of people with rheumatoid arthritis we can give some general guidelines (see Figure 4). Blood tests and x-rays will help your doctor to assess how fast the arthritis is developing and how quickly it is likely to progress in future. This in turn will help him or her to decide which form of treatment to recommend.
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Some people, maybe as many as 1 in 5 (20%), always have very mild rheumatoid arthritis which causes few problems.
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Most people follow a pattern of flare-ups with periods of months or even years in between when there is little inflammation. This does not mean there are no problems at all between flare-ups, as some damage is done to the joints every time they are inflamed. People whose disease follows this pattern will have some problems with their joints and may have to modify their activities a little, but overall they will lead normal lives.
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A few people, no more than 1 in 20 (5%), will have rheumatoid arthritis which becomes progressively worse, often quite quickly. These are also the people who tend to have inflammation in other parts of the body besides their joints.
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One problem in looking at how rheumatoid arthritis affects other people is that you will tend to notice the ones who do badly much more than the ones who do well. Because their disease is more severe, you are more likely to see them at your doctor's surgery or in the hospital. And because they may have some signs of disability, you are more likely to notice them in everyday life. Always remember that they are a small minority, and that you are more likely to be among those who do well than those who do badly.
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Are other parts of the body involved?
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Although 'arthritis' means inflammation of the joints, it is not just the joints that are affected. Most people have some general problems such as fatigue and stiffness. A lack of red blood cells (anaemia) is very common – occasionally this can be a side-effect of the drugs used to treat rheumatoid arthritis, but it is more often caused by the disease itself. Some people with uncontrolled rheumatoid arthritis lose weight, and many complain of hotness and sweating brought on by the inflammation.
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Sometimes other organs are involved. There may be inflammation in the eyes, and they quite often become dry and irritable. Inflammation may also affect the lungs and, rarely, the membrane around the heart. Rheumatoid nodules may appear. These are fleshy lumps which usually occur just below the elbows, but may appear on hands and feet as well. They may occur in other places but this is rare. If there is any doubt about the cause of the lumps, the doctor can if necessary remove a piece from them which allows them to be easily checked and identified under a microscope. (This is known as a 'biopsy'.)
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It has also become apparent recently that people with rheumatoid arthritis are more at risk of heart attack and strokes. arc is currently funding research on this link. It seems to be an effect of the inflammation and the risk is probably reduced by controlling the disease, for example, with drugs. The risk is not very great, but it needs to be taken into account along with other risk factors such as high cholesterol and smoking. It is a very good idea to stop smoking if you develop rheumatoid arthritis.
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How do doctors diagnose rheumatoid arthritis?
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There is no single test which can make a certain diagnosis of early rheumatoid arthritis. Doctors have to make what is known as a 'clinical diagnosis', where they put together all the information from listening to you and examining you, and come to a diagnosis based on this information. This is one of the reasons why you should tell your doctor all the symptoms you have had, not just the ones you think are important.
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There are two kinds of test which may help in confirming the diagnosis:
• blood tests
• x-rays and other imaging techniques.
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How can rheumatoid arthritis be treated?
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We have not yet found a cure for rheumatoid arthritis, but treatment is improving all the time. A team of health professionals will work with you to try to get the best possible result. However, you are by far the most important person in the team, and one way you can help is by understanding as much as possible about your disease and its treatment. Reading this booklet is part of that process, but you will find further useful information in the other arc booklets which are referred to here.
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There are three main ways of treating rheumatoid arthritis:
• Taking care of your joints
• Treatment with drugs
• Surgery
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How can I take care of my joints?
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Balancing rest and exercise
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One of the most important balancing acts you will need to achieve is the balance between rest and exercise. We have known for centuries that resting inflamed joints makes them more comfortable. However, the joints and muscles are parts of the locomotor system , the parts of the body which are involved in movement. Without movement your joints will stiffen and your muscles will waste away. So what should you do? The most important thing is to use your muscles and joints as much as possible without harming them. This helps retain movement and stops muscles wasting away. We also know that exercise is a good thing in general, and that exercise helps you feel better.
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How do you know if you are doing harm? Some people have been told it is best to stop as soon as something hurts. This is not necessarily true. The signs to stop are if a particular activity causes one or more of your joints to become warm and swollen or if there is severe pain. If neither of these things happens, keep going.
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There is no magic formula which can tell you how to balance rest and exercise – it is something you will need to discover for yourself. However, there are some things worth bearing in mind. If you are having a good day, avoid overdoing things. This particularly applies to tasks such as housework or gardening. Many people suffer the next day because of overexertion on a good day. Do make it clear to family, friends and colleagues at work that not all days are the same. They must realize that activities you find easy on a good day may be impossible on a bad one. If a particular activity always causes problems, ask yourself if it is really essential and, if it is, could it be done in an easier way (or by somebody else)? But above all try to use both periods of activity and periods of rest to their best advantage.
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Protecting your joints
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Protect your joints from unnecessary strain. There are different ways of carrying out many everyday activities, so use the methods which put the least strain on your joints. Your occupational therapist can give you detailed advice about this, and also about ways of avoiding some tasks or using simple aids or adaptations to make them easier. Help of this sort can often allow you to continue many activities despite having rheumatoid arthritis. Do ask for, and listen to, advice which will help you increase the activities you can undertake.
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Which drugs are used?
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1. Analgesics
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These drugs are painkillers. They are not sufficient by themselves as a treatment for rheumatoid arthritis, but they are useful to 'top up' the pain-relieving effects of other, more specific, drugs. Paracetamol is most often used. It may be given by itself, or alongside codeine tablets, or as combination tablets in which it is combined with codeine or other drugs. For example, co-codamol is a tablet which contains paracetamol and codeine. Some stronger painkillers such as tramadol are now available. The most common side-effect of analgesics is constipation, which can occasionally be severe.
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2. Non-steroidal anti-inflammatory drugs (NSAIDs)
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The first drug in this group was aspirin, which used to be given in very large doses to treat arthritis (10–20 tablets a day). There are now about 20 drugs of this kind available. They reduce pain and swelling and start working within a few hours. The effect of some will only last a few hours but others are effective all day. Your doctor will help you to find the preparation and the dose that are best for you.
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Although NSAIDs are very useful drugs, they do have a tendency to cause indigestion and, rarely, bleeding from the stomach.
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3. Disease-modifying anti-rheumatic drugs (DMARDs)
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As their name suggests, these drugs do not treat the symptoms of rheumatoid arthritis but reduce the effects of the disease itself. They do improve symptoms over time, but they are not painkillers – they only reduce pain and stiffness by reducing the underlying rheumatoid process in the joints. They also appear to slow down the effects of the disease on the joints, especially if they are taken early in the course of the disease.
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These drugs are our most important weapons in combating rheumatoid arthritis. They do not act quickly, taking weeks or even months to become effective. It is important to continue taking them, even if they do not seem to be working at first. They are taken for long periods, usually many years. Not everyone with rheumatoid arthritis will need one of these drugs, but most people with rheumatoid arthritis should expect to take drugs of this type, sometimes for the rest of their lives. They can all cause side-effects, which very rarely may be dangerous. Because of this they all require regular supervision by doctors and nurses who understand them. This often includes regular blood and urine tests. These are important, as they ensure your safety. With careful, knowledgeable supervision, these drugs are not only safe but also very effective in treating rheumatoid arthritis. There are a number of drugs in this group, and new ones are on the way. A few of the more commonly used ones are described below.
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What is inflammation?
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Inflammation is a normal body defence mechanism. If you did not have it you would die. It is there to help fight off invasion of the body, especially by viruses, bacteria and other 'bugs', and to deal with the chemicals they produce. Your body recognizes that something abnormal is present. It responds by increasing the blood flow to the affected area in order to bring in the body's defences and to raise the temperature, which also helps in dealing with the unwanted germs or substances. The blood vessels become more leaky so that cells can move out of them to join in the attack.
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The cells themselves produce chemical messengers which call other cells to join them in the immune response. These chemical messengers are the targets of the biological therapies mentioned earlier. The cells also produce chemicals designed to destroy the invader, and antibodies to help in the fight. The messengers, chemicals and antibodies are all the focus of research which may lead to new treatments for rheumatoid arthritis.
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So why does inflammation occur in rheumatoid arthritis?
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The normal process of inflammation described above starts off with some sort of foreign substance, such as a bug, invading the body. The process ends when the invader is overcome. Inflammation in rheumatoid arthritis is unusual for two reasons. First, nobody knows what starts it off. It seems that in rheumatoid arthritis the body thinks that a part of itself is an invader and therefore attacks it. Why this happens is unknown. Finding out why is a key to discovering a cure for rheumatoid arthritis. Because the body attacks itself in rheumatoid arthritis, it is known as an 'autoimmune' disease. Secondly, the inflammation in rheumatoid arthritis is unusual because it does not stop of its own accord – it becomes a long-lasting (chronic) process.
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The main site of inflammation in rheumatoid arthritis is the lining (synovium) of the joints. This becomes swollen and full of cells. The destructive process may then attack the cartilage and bone in the joint. The swelling causes the tough capsule to stretch. When the swelling goes down the capsule remains stretched and fails to hold the joint in its proper position. As a result the joint becomes less stable and can move into unusual or deformed positions.
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Can complementary therapies help?
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Many people with rheumatoid arthritis take 'complementary', 'alternative', or 'natural' therapies. It is quite understandable that people with rheumatoid arthritis want to do as much as possible to help themselves. Unfortunately, the promises made by most of these remedies are not borne out in reality. Certainly none of them offers either a cure or a reduction in the joint damage caused by rheumatoid arthritis. Many are also very expensive, and add a financial burden to that of the disease.
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Cod liver oil and other fish oils, evening primrose oil .Herbal remedies are usually safe to use, but some may interfere with your anti-rheumatic medication. A good herbal practitioner will be able to advise you about this. Do remember also that some herbal remedies can have unpleasant side-effects.
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Treatments such as acupuncture, which some people find helpful, are now generally available on the NHS, though there may be a long waiting list. Homoeopathy is also available on the NHS in some places, but sadly has proved ineffective in treating rheumatoid arthritis. Massage is often very soothing and relaxing, although there is little evidence that specific oils add any particular benefit.
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Most complementary therapies are harmless, and, as mentioned above, some may be of some help. But be careful what you buy, as unfortunately some 'traditional' medications, especially Chinese remedies, sold in this country have been found to contain large quantities of steroids and other drugs. Be critical about whether you are getting a benefit from what you are doing. Do discuss any remedies you are thinking of taking with your doctor, nurse or pharmacist, and do remember the general rule: 'Things that seem too good to be true are too good to be true'.
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Is there a diet which will help my rheumatoid arthritis?
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There is a lot of publicity for diets which claim to cure rheumatoid arthritis. None do, although there is some scientific evidence that diets may help the symptoms in some people. A few people notice that individual foods tend to make their arthritis flare up. The foods which do this vary from person to person. If you suspect that an individual food causes your joints to flare up, then try avoiding it, but do not give up anything because it makes someone else's joints flare up .
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Do any diets help everyone?
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Probably not, but the ones most likely to help are low in saturated fats and high in unsaturated fats, especially fish oils. Supplements of fish oils are likely to help. We recommend 3 grams of fish oil (i.e. fish body oil, not fish liver oil) daily. You can achieve this by eating oily fish, taking fish oil supplements, or a combination of the two. There is some evidence that a very strict vegetarian diet can help, although the reasons for this are not clear, and that there may be a small increase in the risk of rheumatoid arthritis among people who eat a lot of red meat. However, you should consult your doctor or a dietitian before starting any strict diet as the disadvantages may outweigh the advantages. There is some evidence that increasing your intake of vitamin C may also help. It is a good idea to make sure you keep your weight down. You put the equivalent of four times your body weight through your joints when you are just walking, so keeping your weight down will help reduce that stress.
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Should I move to a different climate?
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The weather does affect the symptoms of some people with rheumatoid arthritis, but it does not affect the progression of the disease. Many people who are affected find warm weather better than cold, although damp heat often makes people uncomfortable. For some people, cold crisp winter days are the best of all.
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If you do think of moving, try the new climate in all seasons before you make your final move. Also weigh up the consequences of leaving your friends and family, as well as the support of your familiar health care system. Above all, remember that a change of climate will not affect the disease itself and will not prevent it progressing.
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Why me? What have I done to get rheumatoid arthritis?
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You have done nothing to bring on your disease. It is just random bad luck that means you have got it. Do not waste your energy trying to think how you or someone else could have caused your disease. Use your energy instead to fight the disease and to learn how to do as much as possible to minimize the effects it has on you. Modern drugs and a helpful rheumatology team make an enormous difference but the difference you make is just as great, so make sure you make the strongest possible contribution to your own care.
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