What is Rheumatoid Arthritis?
Rheumatoid Arthritis (RA) is a chronic inflammatory illness that can attack the entire body, but is most often is found in the joints. It is one of one of the more common forms of illnesses under the umbrella of a syndrome of diseases collectively known as arthritis. The joints that are most typically involved include the hands, wrists, knees, feet, and ankles. Besides joint inflammation and deformity, RA can lead to other systemic problems and serious complications such as lung disease, blood disorders, and osteoporosis (weakening of the bones).
RA is found worldwide, and over 2 million Americans are thought to suffer with RA. Females are three times more likely than males to come down with RA. The highest incidence is in folks between 20-50 years of age, with 80% of all cases found in the 35-50 crowd. However, RA can also afflict children and teens, as well as adults over 50.
The skeleton of the body is composed of several different types of connective tissues such as bones, cartilage, ligaments, and tendons. The joints are specialized structures that connect two or more bones and hold them together. Joints that connect and allow movement between two bones (articulating bones) are called synovial joints. Each of these articulating bones is covered by a layer of insulating tissues (“shock absorbers”)called cartilage. There is normally a slight gap between the bones called the joint cavity. The entire area (bones, cartilage, and joint cavity) is surrounded by the articular capsule,which is composed of a tough, fibrous membrane on the exterior, and the synovial membrane or synovium inside. The outer fibrous membrane may also include ligaments, which help to support the joints. The inner synovial membrane has many tiny blood vessels known as capillaries. It also produces a specialized fluid called the synovial fluid that fills the joint cavity and provides lubrication for the joint.
Hopefully I haven’t put you to sleep with this anatomy lecture, but I think a little background will help us to understand RA better. When RA strikes, white blood cells invade the area and the synovial membrane becomes inflamed. The inflammation stimulates the release of certain proteins that cause the membrane to thicken and get abnormally stiff. As the membrane loses functionality, other structures such as the cartilage, ligaments, and even the bone itself begin to deteriorate. All of these factors may combine to make normal movement very difficult and painful. Eventually joints become deformed or poorly aligned, and may even be destroyed.
What Causes Rheumatoid Arthritis?
Despite extensive research, the exact cause of RA is not known. However, there is a great deal of evidence that points to the probability that RA is an autoimmune disorder. Autoimmune disorders are conditions that cause the body to mistakenly attack healthy tissues as if they were bacterial or viral invaders that the immune system would normally seek to destroy. What triggers the body to turn on itself in this manner is not well understood. There are several leading theories. Some researchers think that RA may be the result of a viral or bacterial infection in people with an inherited tendency to get the illness. RA is itself is not thought to be inherited, but certain genes that increase an individual’s risk may be passed down through families. Certain genes may also contribute to the severity of the illness. Other theories focus on hormonal causes, nutritional factors, food allergies, and abnormal bowel permeability. Most likely the trigger for RA is probably a combination of these, and it is probably different for each patient. Diseases such as this are often called “multifactorial diseases.”
Studies have shown that smoking, especially for women, increases risk for RA by up to 200%. This is thought to be due to the fact that smoking both lowers estrogen levels (a possible hormonal connection?) and raises rheumatoid factor levels (see below) in women.
What Are the Symptoms for Rheumatoid Arthritis?
RA can begin gradually and increase in intensity over time, or it can strike quickly in acute attacks known as “flare ups” or “flares.” Sometimes symptoms will come and go at random intervals. RA seems to affect different individuals in different patterns. The following are the typically found symptoms:
- Vague joint pain, which may precede distinct joint swelling by several weeks.
- Pain and swelling in the smaller joints of the hands and feet, as well as the knees.
- Fatigue: can be severe during flares.
- Low-grade fever.
- Malaise (general sense of not feeling well)
- Poor appetite.
- Weight loss.
- Weakness, low energy levels.
- Joint stiffness and aches, especially upon rising or after a period of rest. This may be severe in some patients, lasting an hour or more after getting up in the morning.
- Symmetrical joint pain, such as in both hands, both wrists, both ankles, etc.
- Pain in multiple joints simultaneously. Only about 30% of people with RA experience pain in only one or two joints.
- Decreased range of motion in affected joints.
- Loss of strength in the muscles associated with affected joints.
- Difficulty sleeping
The inflamed joints are usually very tender, swollen, and warm to the touch. Sometimes the skin surrounding the joints will appear purplish. As RA progresses, inflammation and pain may expand into the shoulders, hips, jaw, and neck. It most often continues its symmetrical pattern if possible. Structures called rheumatoid nodules may begin to form under the skin at pressure points such as in the elbows, hands, feet, and Achilles tendons. These might be as small as a pea, or sometimes may grow to be about the size of a walnut. Surprisingly enough, these nodules are not usually painful. Occasionally they turn up in odd places such as in the lungs, on the back of the scalp, or around the knee. Nodules in the lungs or lining of the chest (pleura) can be serious, causing shortness of breath. These lung nodules are more common in men than in women. Nodules may also appear in the tissues covering the brain and spinal chord (meninges).
Advanced RA causes the joints to become deformed, especially in the hands and feet. Joints may be difficult to straighten, and eventually become permanently bent or flexed, curving up or out abnormally. Some of the more common deformities include: swan neck, boutonniere, and cock-up toes.Approximately 50% of patients experience swan neck deformity in the knuckles of the hand.
Some sufferers experience inflammation of the blood vessels (vasculitis), which can lead to serious circulatory problems. This can result in numbness and tingling in the extremities, ulcers in the skin, and even tissue death (gangrene). RA can even be a factor in coronary disease when cardiac arteries and heart muscle tissue are inflamed.
How is Rheumatoid Arthritis Diagnosed?
Symptoms are the first clue to RA. However, there are quite a few inflammatory and autoimmune diseases that share common symptoms with RA, so it is often difficult to diagnose on symptoms alone. There are several tests that can help determine if you have RA, but none of them are fully definitive:
- A blood test known as erythrocyte sedimentation rate (ESR or sed rate) is an analysis of your red blood cells. Almost 100% of folks with RA have elevated ESR’s, but other conditions can cause elevated ESR’s too. This test can be helpful in differentiating between RA and osteoarthritis, another common form of arthritis. Osteoarthritis patients usually have normal ESR’s.
- A test for anemia (low red blood cell count) is sometimes given. RA sufferers usually are anemic, but positive results can indicate other conditions as well.
- Rheumatoid factor, an antibody that is associated with RA, can also be tested for. Approximately 66% of RA patients test positive for this, but it also shows up in patients who have other autoimmune and infectious diseases. About 5% of healthy people will test positive for Rheumatoid factor, and 10-20% of healthy folks over 65 as well.
- Synovial fluid can be drawn out and tested for certain characteristics such as abnormally high white blood cell count, increased protein, and decreased glucose levels. Appearance is also analyzed for clues that may point to active inflammation, such as buttiness or an unusually thin consistency. However, these findings are not specific to RA.
- X-rays can be helpful as well. They may reveal abnormally small joint cavities, or gaps between the bones, which can indicate RA. X-rays are also an effective tool to distinguish between RA and osteoarthritis.
What Can Be Done to Treat or Prevent Rheumatoid Arthritis?
Despite considerable amounts of research, no cure for RA has yet been found. The best way to manage RA is through a wise and healthy lifestyle including the proper diet and exercise. These choices can do a lot to minimize our chances of getting RA, and/or minimize its impact on our lives.
Mainstream medicine has a fistful of medications for dealing with the symptoms, but unfortunately many of them can have serious and long-term side effects. I would like to briefly mention some of the most popular medications:
- Nonsteriodal anti-inflammatory drugs (NSAIDs), which include aspirin, ibuprofen, and naproxen sodium, are anti-inflammatory pain medications that are very commonly prescribed for RA patients. These drugs have significant and dangerous side effects including stomach bleeding, liver and kidney damage, tinnitus (ringing in the ears), hypertension (high blood pressure), and increased risk for heart attack and stroke. How’s that for a laundry list of nasty possibilities?
- Cox-2 inhibitors are a class of NSAIDs that are supposed to be easier on the stomach, but they have many of the same dire consequences as other NSAIDs such as exacerbation of high blood pressure and increased risk of heart attack and stroke.
- Corticosteroids are steroid medications whose side effects may include abnormal bruising, cataracts, diabetes, weight gain, a “round” face, and weakening of the bones, which increases the risk for osteoporosis.
- Remember that the longer you take these drugs, the greater your chances are of experiencing significant side effects. Stop taking them as soon as possible. There are alternative ways to manage pain and other symptoms. Some suggestions are:
- Exercise daily, making sure to move each joint through its full range of motion. Swimming or other water activities are especially good. Just use common sense and avoid exercising sore or swollen joints.
- Apply heat packs or take a hot shower or bath. Sometimes cold packs are more effective during flares
- A vegetarian diet, or a diet low in animal fats and protein has helped alleviate or minimize symptoms for many people.