What is rheumatoid arthritis?

Rheumatoid arthritis is a puzzling illness, producing inflammation and swelling of the joints. It occurs in about one to two people out of 100 and is more common in women, affecting them three times more frequently than men.

Many people have it mildly, requiring only intermittent treatment for minor discomfort and it does not lead to serious joint deformity. In its most serious form it can cause painful, badly damaged joints, but only about one in six people with rheumatoid arthritis develop deformed joints.

Rheumatoid arthritis may begin at any age but most commonly it first occurs between the ages of 35 and 45. It is not hereditary in the sense that it passes directly from parent to child, but it may occur more often within some families.

Rheumatoid arthritis is a long term disease although some people will only be affected for a few months, after which time it resolves, never to recur. For some others it may disappear for several months or years before recurring. For the majority it will persist for many years and be characterised by flares and remissions.

Most people can continue with their usual occupation, but there may be times when you are particularly tired and when pain can lead to feelings of frustration, depression and anger. Don't ignore such feelings, there are many avenues of help and support. You will benefit from talking openly with family, close friends, your doctor and Arthritis New Zealand's Field Officer about your concerns.

What causes rheumatoid arthritis?

The cause is not yet known. A great deal is known about what is happening in the joints, but not why. There are a number of theories about what causes or 'triggers' the disease. Research is continuing to find a cause, and ultimately a cure.

Rheumatoid arthritis results from changes in the body's immune system. For reasons not fully understood, the body's immune system attacks its own organs, in this case the tissues of the joints.

This auto-immune reaction causes inflammation of the joints, particularly of the synovial membrane that lines them. This causes an over-production of synovial (joint) fluid which, combined with the inflammation, causes the joints to become swollen and painful. If the process continues, damage to the cartilage and other soft tissue can cause joint deformities.

One sure fact is that there is no way of preventing it and you could have done nothing to stop it occurring, however you can reduce the effects by early diagnosis and treatment.

What happens in rheumatoid arthritis?

The effects differ from person to person. Most people first become aware of pain, swelling and stiffness in the small joints of the hands or feet, but other joints can be involved. The joints commonly affected are those at the base of the fingers, the middle joints of the fingers, the wrists and the joints at the base of the toes.

Others involved may be the elbows, shoulders, feet and knees. It may involve the neck, but it is very unusual for rheumatoid arthritis to affect other joints in the back.

The joints are often most painful and stiff in the morning. As the day progresses, there may be some slow improvement, although they can be more painful again in the evening. You may notice that you have some difficulty in picking up objects and that your grip is much weaker.

There may be pain under the ball of the foot when walking if the joints of the toes are involved. Often the same joints on both sides of the body become affected.

Rheumatoid arthritis does not only involve the joints it does have other features, often described as 'flu-like' symptoms. These are called systemic features, which are tiredness, lack of energy, loss of appetite, perhaps some weight loss and even a low fever.

The muscles are also often quite painful and uncomfortable. These features are more marked when the arthritis is very active and when it is controlled, they disappear.

Tendons, which are structures connecting muscles to bones, may also be involved, most commonly those connecting the muscles in the forearm to the ends of the fingers. These tendons allow the fingers to be straightened and bent.

The lining around the tendons is made of cells similar to those lining the joints so the inflammation can affect them as well. If the tendons become inflamed, the major effect is to produce stiffness in the fingers so that you cannot make a fist properly.

Rheumatoid nodules are little lumps about the size of a pea that form under the skin in about one quarter of people with rheumatoid arthritis. They usually appear on the elbows, along the forearm and in different areas where there is pressure on the skin. They are usually quite painless, may come and go during the course of the arthritis, and usually do not need treatment. If they are a nuisance, or become painful, they can be injected with corticosteroids or removed by surgery.

Dry eyes and mouth (Sjogren's syndrome) may occur in some people.

Diagnosis

When rheumatoid arthritis first begins it may be difficult to distinguish it from other forms of arthritis. Sometimes it is several months before blood or x-ray changes occur that help a doctor to make a definite diagnosis of rheumatoid arthritis together with a clinical picture.

Diagnosis will be made on an evaluation of the symptoms and tests including a physical examination which will look at each joint for signs of inflammation or other problems. The blood tests and x-rays, as well as helping with the diagnosis, also help in monitoring the progress of the disease and the effectiveness of treatment.

Blood tests
The rheumatoid factor is the most commonly used blood test. Although this test may be negative in the first several months, it is eventually positive in about 80% of people with rheumatoid arthritis.

ESR (erythrocyte sedimentation rate) does not help in the diagnosis of arthritis but it does confirm the presence of inflammation and help assess the severity of the disease. A high sedimentation rate (over 40 or so) suggests the disease is quite active. It is also a useful test to measure the effectiveness of treatment.

Haemaglobin is the measure of the number of red blood cells. If these are low, you may be anaemic. Anaemia occurs in rheumatoid arthritis when it is active and may be one of the causes of tiredness.

White cell count; these cells help in preventing infection. There are some drugs used in the treatment of rheumatoid arthritis that can affect the production of white blood cells by the bone marrow. Regular blood tests can detect any decrease in these numbers early before they produce problems.  

X-rays are used to determine whether joint or cartilage damage has occurred or, used as a base line to compare with other x-rays, to monitor progressive joint destruction.

Other laboratory tests may be done at various stages to monitor the effects of some drugs on organ functions. The doctor may also drain fluid from the joint to make sure the arthritis does not come from an infection.

Management of rheumatoid arthritis

Because rheumatoid arthritis is a chronic disease, lasting for many years, treatment consists of many other factors beside medication.

Treatment generally involves a combination of medication to modify the disease; physiotherapy and exercise to help maintain normal joint movement and prevent deformities; rest and occupational therapy to show you more efficient ways of using your joints, and how to cope with arthritis in daily living.

Your doctor may involve other health professionals in the programme development; physiotherapist, occupational therapist, podiatrist, nurse, dietitian.

For the small portion of people who have a more serious form, that treatment can't control well, joints may become damaged and unstable. These people can often be helped by surgery.

Medication

For more information about medications for treating rheumatoid arthritis click here.

Exercise and rest

The proper balance between rest and exercise is important. Rest reduces inflammation, and this is good. But rest also lets joints get stiff and muscles become weak. Moderation is the basic principle and it helps to know your body signals. If it hurts too much, don't do it.

If you don't seem to have too much of a problem with an activity, go ahead. As a general rule, if you continue to have pain brought on by exercising for more than two hours afterwards, you have done too much.

The physiotherapist can help you plan a suitable exercise programme that may include stretch and flex exercises for those times when the disease is very active, water-based exercise which will assist with increased movement and muscle relaxation, and appropriate aerobic activity for general fitness, without unduly stressing affected joints.

Your local Arthritis New Zealand Arthritis Educator can also help you plan and find opportunities which will assist in your exercise programme.

Physiotherapists are also trained to help you with resting your joints and reducing pain and inflammation through the use of splints. Resting splints are usually worn at night or when you are resting during the day. Working splints support the wrist, knee and other joints, relieving physical stress and pain while the joint is being used.

Remember, it is important to start exercise and proper use of your joints BEFORE you have problems.

Using your muscles and joints efficiently

To reduce stress, pain and fatigue you need to learn to use your muscles and joints efficiently. Proper attention to joint protection can solve many potential problems ahead of time.

Talk to your occupational therapist or Arthritis New Zealand Arthritis Educator about what you can do to 'spread the load' and manage your daily tasks more efficiently.

Original material provided by Arthritis New Zealand. Reviewed by everybody, July 2005.