Rheumatoid Arthritis

What is Rheumatoid Arthritis (RA) ?

RA is an autoimmune disorder that causes inflammation of the lining of the joints. The body tissue is mistakenly attacked by its own immune system. RA may also affect the skin, eyes, lungs, heart, blood, or nerves. Rheumatoid arthritis is a chronic disorder, meaning that although there may be occasional symptom-free periods, the disease can worsen over time and may never go away. Early, aggressive treatment is key to slowing or stopping its progression.

RA Symptoms

Similar to other types of arthritis, joint inflammation from RA comes with pain, warmth, and swelling. But unlike other types of arthritis, the inflammation is typically symmetrical, occurring on both sides of the body simultaneously (such as the wrists, knees, or hands). Other symptoms of RA include joint stiffness, particularly in the morning or after periods of inactivity; ongoing fatigue, and low-grade fever. Symptoms typically develop gradually over years, but can come on rapidly for some people.

Who Gets Rheumatoid Arthritis ?

RA usually strikes between ages 30-50, but younger and older people can also be affected. RA occurs 2-3 times more often in women than in men. Other risk factors include cigarette smoking and family history.

Rheumatoid Arthritis Causes

Immune cells, such as lymphocytes, normally protect the body from foreign invaders. What causes them to target healthy joints and tissue is unknown, but researchers believe some combination of genetics and environmental factors may play a role. There may be a genetic predisposition in some people who, if they develop an infection with a particular bacterium or virus, go on to develop the condition. But to date, no specific infection has been identified.

RA’s Toll on the Joints

Inflammation of the lining of the joints (called synovium) can destroy cartilage and bone, causing deformity of the joints. As the condition progresses, joints can develop considerable pain and loss of function.

RA’s Toll on the Body

Because RA is a systemic disease, it can affect organs and areas of the body other than the joints, including:

• Rheumatoid Nodules (shown here): firm lumps under the skin and in internal organs
• Sjogren's syndrome: inflammation and damage of the glands of the eyes and mouth; other parts of the body can also be affected
• Pleuritis: inflammation of the lung lining
• Pericarditis: inflammation of lining surrounding the heart
• Anemia: reduction of red blood cells
• Felty syndrome: reduction of white blood cells, associated with enlarged spleen
• Vasculitis: blood vessel inflammation, which can impair blood supply to tissues

Juvenile Rheumatoid Arthritis (JRA)

JRA is classified by how many joints are affected: oligo- or pauci- articular JRA (four or fewer joints affected), polyarticular JRA (five or more joints affected), or systemic JRA (other organs also affected).

RA and Pregnancy

Surprisingly, rheumatoid arthritis improves in up to 80% of women during pregnancy, though the disease may flare up after delivery. How and why this happens is still unclear. If you are trying to conceive, ask your doctor which RA mediations are safe for you to take. Medication adjustments may be necessary before you become pregnant and during pregnancy.

Diagnosing RA : Evaluating Symptoms

Because symptoms may come and go, diagnosing RA in its early stages is challenging. Observance of these signs and symptoms may prompt your doctor to order further tests:

• Morning joint stiffness
• Swelling/fluid around three or more joints simultaneously
• Swelling in the wrist, hand, or finger joints
• Symmetrical joints affected
• Firm lumps under the skin (rheumatoid nodules)

Diagnosing RA : Blood Tests

If RA is suspected, your doctor may order blood tests to check for markers of inflammation in the body. Other common tests are for rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP), which is present in most cases of RA.

Diagnosing RA : Imaging Tests

X-rays are helpful in diagnosing RA, to provide a baseline for comparison later as the disease progresses. An MRI or ultrasound may also be done to help detect joint damage and inflammation.

Treating RA

There is no known cure for RA. The goal of treatment is to reduce joint inflammation and pain, prevent joint destruction, and maximize joint function. Aggressive treatment should be started as early as possible. Treatment includes a combination of medication and exercises to strengthen supporting muscles around the joints. Treatment may also include surgery. Treatment is tailored to the individual, taking into account their age, affected joints, and the progression of the disease.

RA Medications

Medications used to treat RA include disease-modifying antirheumatic drugs (DMARDs) which include biologics, nonsteroidal anti-inflammatory drugs (NSAIDs), steroids, and analgesics (pain drugs). DMARDs slow progression of disease and are often used with NSAIDs and steroids in treatment.

Is Surgery an Option ?

After significant joint damage has occurred or when pain or disability becomes unbearable, some people choose surgery to improve function and relieve pain. Joint replacement is the most frequently performed surgery for RA patients -- with the knee and hip joints most often replaced. Other types of surgery, such as arthroscopy (inserting a tube-like instrument into the joint to see and repair abnormal tissues) and tendon reconstruction, can be performed as well.

Other Treatments for RA

Some RA patients have found relief in the following: moist heat, relaxation remedies, and acupuncture. There is no conclusive evidence that any herbal or dietary supplement can effectively treat RA. Consult your doctor before beginning any complementary or alternative therapy.

RA and Diet

The most important diet is a healthy one that is balanced in nutrients. Although there’s no “arthritis diet” per se, RA sufferers may find that eating or avoiding certain foods helps their symptoms. Foods high in saturated fats (bacon, steak, butter) have been shown to increase inflammation in the body. Some people with RA find a diet high in omega-3 fatty acids (salmon, tofu, walnuts) helpful. Some people feel that other foods -- such as tomatoes, citrus fruits, white potatoes, peppers, coffee, and dairy -- worsen RA symptoms.

The Importance of Exercise

It may seem counterintuitive, but regularly exercising those stiff, painful joints can reduce the overall pain of RA. Plus, it can keep bones and muscles strong, and help reverse joint stiffness. Choose exercises such as stretching, resistance training, and low-impact aerobics (swimming, water aerobics). Use caution with any exercise that puts pressure on the joints, like jogging and heavy weight lifting. See your doctor before starting an exercise program.

Osteoarthritis

Osteoarthritis: What Is It ?

Also called "wear and tear" arthritis or degenerative joint disease, osteoarthritis (OA) is the progressive breakdown of the joints' natural shock absorbers. This can cause discomfort when you use the affected joints – perhaps an ache when you bend at the hips or knees, or sore fingers when you type. Most people over 60 have some degree of OA, but it also affects people in their 20s and 30s.

Osteoarthritis: Symptoms

The symptoms of osteoarthritis tend to develop slowly. You may notice pain or soreness when you move certain joints or when you've been inactive for a prolonged period. The affected joints may also be stiff or creaky. Typically, osteoarthritis leads to morning stiffness that resolves in 30 minutes. When osteoarthritis affects the hands, some people develop bony enlargements in the fingers, which may or may not cause pain.

Osteoarthritis: Where Does It Hurt ?

In most cases, osteoarthritis develops in the weight-bearing joints of the knees, hips, or spine. It's also common in the fingers, thumb, neck, and big toe. Other joints are usually not affected, unless an injury is involved.

Osteoarthritis: What Causes It ?

Every joint comes with a natural shock absorber in the form of cartilage. This firm, rubbery material cushions the ends of the bones and reduces friction in healthy joints. As we age, joints become stiffer and cartilage is more vulnerable to wear and tear. At the same time, repetitive use of the joints over the years irritates the cartilage. If it deteriorates enough, bone rubs against bone, causing pain and reducing range of motion.

Risk Factors You Can't Control

One of the major risk factors for osteoarthritis is something none of us can control – getting older. Gender also plays a role. Over age 50, more women than men develop osteoarthritis. In most cases, the condition results from normal wear and tear over the years. But some people have a genetic defect or joint abnormality that makes them more vulnerable.

Risk Factors You Can Control

Because injured joints are more vulnerable to osteoarthritis, doing anything that damages the joints can raise your risk. This includes sports that have a high rate of injury and jobs that require repetitive motion, such as bending the knees to install flooring. Obesity is another risk factor – it has been linked specifically to osteoarthritis of the knees and hips.

Impact on Daily Life

Osteoarthritis affects each person differently. Some people have few symptoms despite the deterioration of their joints. Others experience pain and stiffness that may interfere with daily activities. If bony knobs develop in the small joints of the fingers, tasks such as buttoning a shirt can become difficult. Osteoarthritis of the knees or hips can lead to a limp. And osteoarthritis of the spine can cause debilitating pain and/or numbness.

Diagnosing Osteoarthritis

To help your doctor make an accurate diagnosis, you'll need to describe your symptoms in detail, including the location and frequency of any pain. Your doctor will examine the affected joints and may order X-rays or other imaging studies to see how much damage there is, and to rule out other joint conditions. In many cases, blood tests are used to rule out other forms of arthritis.

Long-Term Complications

Unlike rheumatoid arthritis, osteoarthritis does not affect the body's organs or cause illness. But it can lead to deformities that take a toll on mobility. Severe loss of cartilage in the knee joints can cause the knees to curve out, creating a bow-legged appearance (shown on the left). Bony spurs along the spine (shown on the right) can irritate nerves, leading to pain, numbness, or tingling in some parts of the body.

Treatment: Physical Therapy

There is no treatment to stop the erosion of cartilage in the joints, but there are ways to improve joint function. One of these is physical therapy to increase flexibility and strengthen the muscles around the affected joints. The therapist may also apply hot or cold therapies such as compresses to relieve pain.

Supportive Devices

Supportive devices, such as finger splints or knee braces, can reduce stress on the joints and ease pain. If walking is difficult, canes, crutches, or walkers may be helpful. People with osteoarthritis of the spine may benefit from switching to a firmer mattress and wearing a back brace or neck collar.

Medication for OA

When osteoarthritis flares up, many patients find relief with over-the-counter pain and anti-inflammatory medication, such as aspirin, ibuprofen, or acetaminophen. Pain-relieving creams or sprays can also help when applied directly to the sore area. If pain persists despite the use of pills or creams, your doctor may suggest an injection of steroids or hyaluronans directly into the joint.

Supplements

Overall studies suggest no benefits of glucosamine and chondroitin – supplements available at pharmacies and health food stores touted for relieving pain and stiffness for people with osteoarthritis. Check with your doctor before using chondroitin, especially if you take blood-thinners.

Osteoarthritis and Weight

If you're overweight, one of the most effective ways to relieve pain in the knee or hip joints is to shed a few pounds. Even modest weight loss has been shown to reduce symptoms of osteoarthritis by easing the strain on weight-bearing joints. Losing weight not only cuts down on pain, but may also reduce long-term joint damage.

Osteoarthritis and Exercise

People with osteoarthritis may avoid exercise out of concern that it will cause pain. But low-impact activities such as swimming, walking, or bicycling can improve mobility and increase strength. Training with light weights can help by strengthening the muscles that surround your joints. For example, strengthening the quadriceps can reduce pain in the knees. Ask your doctor or physical therapist which exercises are best for you.

Is Surgery for You ?

If osteoarthritis interferes significantly with everyday life and the symptoms don't improve with physical therapy or medication, joint replacement surgery is an option. This procedure is used on those with severe OA and replaces a damaged joint with an artificial one. The knee and hip are the joints that are replaced most often.

Preventing Osteoarthritis

The most important thing you can do to ward off osteoarthritis is keep your weight in check. Over the years, extra weight puts stress on the joints and may even alter the normal joint structure. Preventing injuries is also important. Take precautions to avoid repetitive motion injuries on the job. If you play a sport, use proper equipment and observe safety guidelines.

Arthritis… Osteoarthritis vs Rheumatoid Arthritis

~ Definition

Arthritis is inflammation of one or more of your joints. The main symptoms of arthritis are joint pain and stiffness, which typically worsen with age. The two most common types of arthritis are osteoarthritis and rheumatoid arthritis.

Osteoarthritis is usually caused by normal wear and tear, while rheumatoid arthritis is an autoimmune disorder. Other types of arthritis can be caused by uric acid crystals, infections or even an underlying disease — such as psoriasis or lupus.

Treatments vary, depending on the type of arthritis. The main goals of arthritis treatments are to reduce symptoms and improve quality of life.

~ Symptoms

The most common signs and symptoms of arthritis involve the joints. Depending on the type of arthritis you have, your signs and symptoms may include:

• Pain
• Stiffness
• Swelling
• Redness
• Decreased range of motion

The two most common types of arthritis affect joints in very different ways. In osteoarthritis, the cartilage on the ends of the bones wears away — allowing bone to grate on bone. Rheumatoid arthritis is an autoimmune disorder that causes inflammation of the synovial membrane and may result in bone loss.

~ Causes

The pain associated with arthritis is caused by joint damage. Joints are made up of the following parts:

• Cartilage. A hard, but slick, coating on the ends of bones, cartilage allows bones of the joint to slide smoothly over each other.
• Joint capsule. This tough membrane encloses all the joint parts.
• Synovium. This thin membrane lines the joint capsule and secretes synovial fluid, which lubricates the joint and nourishes the cartilage.

How arthritis damages joints
The two main types of arthritis damage joints in different ways.

• Osteoarthritis. In osteoarthritis, wear-and-tear damage to cartilage can result in bone grinding directly on bone, which causes pain and restricts movement. This wear and tear can occur over many years, or it can be hastened by a joint injury or infection.

The hip joint shown on the left side of the image is normal, but the hip joint shown on the right side of the image shows deterioration of cartilage and the formation of bone spurs due to osteoarthritis.

• Rheumatoid arthritis. In rheumatoid arthritis, the body's immune system attacks joints and inflames the synovium, causing swelling, redness and pain. The disease can eventually destroy cartilage and bone within the joint.

Rheumatoid arthritis can cause pain, swelling and deformity. As the tissue that lines your joints (synovial membrane) becomes inflamed and thickened, fluid builds up and joints erode and degrade.

~ Risk factors

Risk factors for arthritis include:

• Family history. Some types of arthritis run in families, so you may be more likely to develop arthritis if your parents or siblings have the disorder. Your genes can make you more susceptible to environmental factors that may trigger arthritis.
• Age. The risk of many types of arthritis — including osteoarthritis, rheumatoid arthritis and gout — increases with age.
• Sex. Women are more likely than are men to develop rheumatoid arthritis, while most of the people who have gout are men.
• Previous joint injury. People who have injured a joint, perhaps while playing a sport, are more likely to eventually develop arthritis in that joint.
• Obesity. Carrying excess pounds puts stress on joints, particularly your knees, hips and spine. Obese people have a higher risk of developing arthritis.

~ Complications

Severe arthritis, particularly if it affects your hands or arms, can make it difficult for you to take care of daily tasks. Arthritis of weight-bearing joints can keep you from walking comfortably or sitting up straight. In some cases, joints may become twisted and deformed.

In osteoarthritis of the spine, disks narrow and bone spurs form.

~ Preparing for your appointment

While you might first discuss your symptoms with your family doctor, he or she may refer you to a rheumatologist — a doctor who specializes in the treatment of joint problems — for further evaluation.

What you can do
Because appointments can be brief, plan ahead and write a list that includes:

• Detailed descriptions of your symptoms, including when they started and if anything makes them better or worse
• Information about medical problems you've had in the past
• Information about the medical problems of your parents or siblings
• All the medications and dietary supplements you take
• Questions you want to ask the doctor

What to expect from your doctor
During the physical exam, your doctor will check your joints for swelling, redness and warmth. He or she will also want to see how well you can move your joints.

~ Tests and diagnosis

Depending on the type of arthritis suspected, your doctor may suggest some of the following tests.

Laboratory tests
The analysis of different types of body fluids can help pinpoint the type of arthritis you may have. Fluids commonly analyzed include:

• Blood
• Urine
• Joint fluid

To obtain a sample of your joint fluid, your doctor will cleanse and numb the area before inserting a needle in your joint space to withdraw some fluid.

Imaging
These types of tests can detect problems within your joint that may be causing your symptoms. Examples include:

• X-rays. Using low levels of radiation to visualize bone, X-rays can show cartilage loss, bone damage and bone spurs. X-rays may not reveal early arthritic damage, but they are often used to track progression of the disease.
• Computerized tomography (CT). CT scanners take X-rays from many different angles and combine the information to create cross-sectional views of internal structures. CTs can visualize both bone and the surrounding soft tissues.
• Magnetic resonance imaging (MRI). Combining radio waves with a strong magnetic field, MRI can produce more-detailed cross-sectional images of soft tissues such as cartilage, tendons and ligaments.
• Ultrasound. Using sound waves to create images of both hard and soft tissues within the body, ultrasound can help determine needle placement if your doctor wants to withdraw fluid from your joint or inject medicine.

Arthroscopy
In some cases, your doctor may look for damage in your joint by inserting a small, flexible tube — called an arthroscope — through an incision near your joint. The arthroscope transmits images from inside the joint to a video screen.

~ Treatments and drugs

Arthritis treatment focuses on relieving symptoms and improving joint function. You may need to try several different treatments, or combinations of treatments, before you determine what works best for you.

Medications
The medications used to treat arthritis vary, depending on the type of arthritis. Commonly used arthritis medications include:

• Analgesics. These types of medications help reduce pain, but have no effect on inflammation. Examples include acetaminophen (Tylenol, others), tramadol (Ultram, Ryzolt) and narcotics containing oxycodone (Percocet, Oxycontin, others) or hydrocodone (Vicodin, Lortab, others).
• Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs reduce both pain and inflammation. Over-the-counter NSAIDs include ibuprofen (Advil, Motrin, others) and naproxen (Aleve). Some types of NSAIDs are available only by prescription. Oral NSAIDs can cause stomach irritation, and some may increase your risk of heart attack or stroke. Some NSAIDs are also available as creams or gels, which can be rubbed on joints.
• Counterirritants. Some varieties of creams and ointments contain menthol or capsaicin, the ingredient that makes hot peppers spicy. Rubbing these preparations on the skin over your aching joint may interfere with the transmission of pain signals from the joint itself.
• Disease-modifying antirheumatic drugs (DMARDs). Often used to treat rheumatoid arthritis, DMARDs slow or stop your immune system from attacking your joints. Examples include methotrexate (Trexall) and hydroxychloroquine (Plaquenil).
• Biologics. Typically used in conjunction with DMARDs, biologic response modifiers are genetically engineered drugs that target various protein molecules that are involved in the immune response. Examples include etanercept (Enbrel) and infliximab (Remicade).
• Corticosteroids. This class of drug, which includes prednisone and cortisone, reduces inflammation and suppresses the immune system. Corticosteroids can be taken orally or be injected directly into the painful joint.

Therapy
Physical therapy can be helpful for some types of arthritis. Exercises can improve range of motion and strengthen the muscles surrounding joints. In some cases, splints or braces may be warranted.

Surgery
If conservative measures don't help, your doctor may suggest surgery, such as:

• Joint replacement. This procedure removes your damaged joint and replaces it with an artificial one. Joints most commonly replaced are hips and knees.

Knee replacement surgery can repair damage from osteoarthritis or inflammatory conditions. The artificial joint has metal alloy caps for your thighbone and shinbone and high-density plastic to replace eroded cartilage within the joint and on your kneecap.

Gradual deterioration of cartilage that occurs in osteoarthritis is the most common reason for hip replacement surgery. Implanting an artificial joint eliminates pain and restores near-normal movement.

• Joint fusion. This procedure is more often used for smaller joints, such as those in the wrist, ankle and fingers. It removes the ends of the two bones in the joint and then locks those ends together until they heal into one rigid unit.

~ Lifestyle and home remedies

• Weight loss. If you're obese, losing weight will reduce the stress on your weight-bearing joints. This may increase your mobility and limit future joint injury.
• Exercise. Regular exercise can help keep your joints flexible. Swimming or water aerobics is often a good choice because the buoyancy of the water reduces stress on weight-bearing joints.
• Heat and cold. Heating pads or ice packs may help relieve arthritis pain.
• Assistive devices. Using canes, walkers, raised toilet seats and other assistive devices can help protect your joints and improve your ability to perform daily tasks.

Make everyday tasks easier on your joints by using assistive devices. A bench in your shower may take the strain of standing off your knee or hip if you have osteoarthritis.

~ Alternative medicine

Many people use alternative remedies for arthritis, but there is little reliable evidence to support the use of many of these products. Some alternative remedies appear to reduce the symptoms of some types of arthritis but not others. The most promising alternative remedies for arthritis include:

• Acupuncture. This therapy uses fine needles inserted at specific points on the skin to reduce many types of pain, including that caused by some types of arthritis.
• Glucosamine. Although study results have been mixed, it now appears that glucosamine works no better than placebo. However, glucosamine and the placebo both relieved arthritis pain better than taking nothing, particularly in people who have moderate to severe pain.
• Transcutaneous electrical nerve stimulation (TENS). Using a small device that produces mild electrical pulses, TENS therapy stimulates nerves near the aching joint and may interfere with the transmission of pain signals to the brain.
• Yoga or tai chi. The slow, stretching movements associated with yoga and tai chi may help improve joint flexibility and range of motion in people with some types of arthritis.