Features of Rheumatoid Arthritis
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Rheumatoid arthritis is an inflammatory disease that causes
pain, swelling, stiffness, and loss of function in the
joints. It has several special features that make it
different from other kinds of arthritis. (See “Features of
Rheumatoid Arthritis.”) For example, rheumatoid arthritis
generally occurs in a symmetrical pattern, meaning that if
one knee or hand is involved, the other one also is. The
disease often affects the wrist joints and the finger joints
closest to the hand. It can also affect other parts of the
body besides the joints. (See “Other Parts of the Body.”) In
addition, people with rheumatoid arthritis may have fatigue,
occasional fevers, and a general sense of not feeling well.
Rheumatoid arthritis affects people differently. For some
people, it lasts only a few months or a year or two and goes
away without causing any noticeable damage. Other people
have mild or moderate forms of the disease, with periods of
worsening symptoms, called flares, and periods in which they
feel better, called remissions. Still others have a severe
form of the disease that is active most of the time, lasts
for many years or a lifetime, and leads to serious joint
damage and disability.
Features of Rheumatoid Arthritis
Tender, warm, swollen joints
Symmetrical pattern of affected joints
Joint inflammation often affecting the wrist and finger
joints closest to the hand
Joint inflammation sometimes affecting other joints,
including the neck, shoulders, elbows, hips, knees, ankles,
and feet
Fatigue, occasional fevers, a general sense of not feeling
well
Pain and stiffness lasting for more than 30 minutes in the
morning or after a long rest
Symptoms that last for many years
Variability of symptoms among people with the disease
Although rheumatoid arthritis can have serious effects on a
person's life and well-being, current treatment
strategies--including pain-relieving drugs and medications
that slow joint damage, a balance between rest and exercise,
and patient education and support programs--allow most
people with the disease to lead active and productive lives.
In recent years, research has led to a new understanding of
rheumatoid arthritis and has increased the likelihood that,
in time, researchers will find even better ways to treat the
disease.
How Rheumatoid Arthritis Develops and Progresses
The Joints
A joint is a place where two bones meet. The ends of the
bones are covered by cartilage, which allows for easy
movement of the two bones. The joint is surrounded by a
capsule that protects and supports it. (See illustration.)
The joint capsule is lined with a type of tissue called
synovium, which produces synovial fluid, a clear substance
that lubricates and nourishes the cartilage and bones inside
the joint capsule.
Like many other rheumatic diseases, rheumatoid arthritis is
an autoimmune disease (auto means self), so-called because a
person's immune system, which normally helps protect the
body from infection and disease, attacks joint tissues for
unknown reasons. White blood cells, the agents of the immune
system, travel to the synovium and cause inflammation (synovitis),
characterized by warmth, redness, swelling, and
pain--typical symptoms of rheumatoid arthritis. During the
inflammation process, the normally thin synovium becomes
thick and makes the joint swollen and puffy to the touch.
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As rheumatoid arthritis progresses, the inflamed synovium invades
and destroys the cartilage and bone within the joint. The
surrounding muscles, ligaments, and tendons that support and
stabilize the joint become weak and unable to work normally. These
effects lead to the pain and joint damage often seen in rheumatoid
arthritis. Researchers studying rheumatoid arthritis now believe
that it begins to damage bones during the first year or two that a
person has the disease, one reason why early diagnosis and treatment
are so important.
Other Parts of the Body
Some people with rheumatoid arthritis also have symptoms in places
other than their joints. Many people with rheumatoid arthritis
develop anemia, or a decrease in the production of red blood cells.
Other effects that occur less often include neck pain and dry eyes
and mouth. Very rarely, people may have inflammation of the blood
vessels, the lining of the lungs, or the sac enclosing the heart.
Occurrence and Impact of Rheumatoid Arthritis
Scientists estimate that about 2.1 million people, or between 0.5
and 1 percent of the U.S. adult population, have rheumatoid
arthritis. Interestingly, some recent studies have suggested that
the overall number of new cases of rheumatoid arthritis actually may
be going down. Scientists are investigating why this may be
happening.
Rheumatoid arthritis occurs in all races and ethnic groups. Although
the disease often begins in middle age and occurs with increased
frequency in older people, children and young adults also develop
it. Like some other forms of arthritis, rheumatoid arthritis occurs
much more frequently in women than in men. About two to three times
as many women as men have the disease.
By all measures, the financial and social impact of all types of
arthritis, including rheumatoid arthritis, is substantial, both for
the Nation and for individuals. From an economic standpoint, the
medical and surgical treatment for rheumatoid arthritis and the
wages lost because of disability caused by the disease add up to
billions of dollars annually. Daily joint pain is an inevitable
consequence of the disease, and most patients also experience some
degree of depression, anxiety, and feelings of helplessness. For
some people, rheumatoid arthritis can interfere with normal daily
activities, limit job opportunities, or disrupt the joys and
responsibilities of family life. However, there are arthritis
self-management programs that help people cope with the pain and
other effects of the disease and help them lead independent and
productive lives. (See “Diagnosing and Treating Rheumatoid
Arthritis.”)
Searching for the Causes of Rheumatoid Arthritis
Scientists still do not know exactly what causes the immune system
to turn against itself in rheumatoid arthritis, but research over
the last few years has begun to piece together the factors involved.
Genetic (inherited) factors: Scientists have discovered that certain
genes known to play a role in the immune system are associated with
a tendency to develop rheumatoid arthritis. Some people with
rheumatoid arthritis do not have these particular genes; still
others have these genes but never develop the disease. These
somewhat contradictory data suggest that a person's genetic makeup
plays an important role in determining if he or she will develop
rheumatoid arthritis, but it is not the only factor. What is clear,
however, is that more than one gene is involved in determining
whether a person develops rheumatoid arthritis and how severe the
disease will become.
Environmental factors: Many scientists think that something must
occur to trigger the disease process in people whose genetic makeup
makes them susceptible to rheumatoid arthritis. A viral or bacterial
infection appears likely, but the exact agent is not yet known. This
does not mean that rheumatoid arthritis is contagious: a person
cannot catch it from someone else.
Other factors: Some scientists also think that a variety of hormonal
factors may be involved. Women are more likely to develop rheumatoid
arthritis than men, pregnancy may improve the disease, and the
disease may flare after a pregnancy. Breastfeeding may also
aggravate the disease. Contraceptive use may alter a person's
likelihood of developing rheumatoid arthritis. Scientists think that
levels of the immune system molecules interleukin 12 (IL-12) and
tumor necrosis factor-alpha (TNF-α) may change along with the
changing hormone levels seen in pregnant women. This change may
contribute to the swelling and tissue destruction seen in rheumatoid
arthritis. These hormones, or possibly deficiencies or changes in
certain hormones, may promote the development of rheumatoid
arthritis in a genetically susceptible person who has been exposed
to a triggering agent from the environment.
Even though all the answers are not known, one thing is certain:
rheumatoid arthritis develops as a result of an interaction of many
factors. Researchers are trying to understand these factors and how
they work together. (See “Current Research.”)
Diagnosing and Treating Rheumatoid Arthritis
Diagnosing and treating rheumatoid arthritis requires a team effort
involving the patient and several types of health care
professionals. A person can go to his or her family doctor or
internist or to a rheumatologist. A rheumatologist is a doctor who
specializes in arthritis and other diseases of the joints, bones,
and muscles. As treatment progresses, other professionals often
help. These may include nurses, physical or occupational therapists,
orthopaedic surgeons, psychologists, and social workers.
Studies have shown that patients who are well informed and
participate actively in their own care have less pain and make fewer
visits to the doctor than do other patients with rheumatoid
arthritis.
Patient education and arthritis self-management programs, as well as
support groups, help people to become better informed and to
participate in their own care. An example of a self-management
program is the Arthritis Self-Help Course offered by the Arthritis
Foundation and developed at a NIAMS-supported Multipurpose Arthritis
and Musculoskeletal Diseases Center. (See the Arthritis Foundation
listing in “For More Information.”) Self-management programs teach
about rheumatoid arthritis and its treatments, exercise and
relaxation approaches, communication between patients and health
care providers, and problem solving. Research on these programs has
shown that they help people:
understand the disease
reduce their pain while remaining active
cope physically, emotionally, and mentally
feel greater control over the disease and build a sense of
confidence in the ability to function and lead full, active, and
independent lives.
Diagnosis
Rheumatoid arthritis can be difficult to diagnose in its early
stages for several reasons. First, there is no single test for the
disease. In addition, symptoms differ from person to person and can
be more severe in some people than in others. Also, symptoms can be
similar to those of other types of arthritis and joint conditions,
and it may take some time for other conditions to be ruled out.
Finally, the full range of symptoms develops over time, and only a
few symptoms may be present in the early stages. As a result,
doctors use a variety of the following tools to diagnose the disease
and to rule out other conditions:
Medical history: This is the patient's description of symptoms and
when and how they began. Good communication between patient and
doctor is especially important here. For example, the patient's
description of pain, stiffness, and joint function and how these
change over time is critical to the doctor's initial assessment of
the disease and how it changes over time.
Physical examination: This includes the doctor's examination of the
joints, skin, reflexes, and muscle strength.
Laboratory tests: One common test is for rheumatoid factor, an
antibody that is present eventually in the blood of most people with
rheumatoid arthritis. (An antibody is a special protein made by the
immune system that normally helps fight foreign substances in the
body.) Not all people with rheumatoid arthritis test positive for
rheumatoid factor, however, especially early in the disease. Also,
some people test positive for rheumatoid factor, yet never develop
the disease. Other common laboratory tests include a white blood
cell count, a blood test for anemia, and a test of the erythrocyte
sedimentation rate (often called the sed rate), which measures
inflammation in the body. C-reactive protein is another common test
that measures disease activity.
X rays: X rays are used to determine the degree of joint
destruction. They are not useful in the early stages of rheumatoid
arthritis before bone damage is evident, but they can be used later
to monitor the progression of the disease.
Treatment
Doctors use a variety of approaches to treat rheumatoid arthritis.
These are used in different combinations and at different times
during the course of the disease and are chosen according to the
patient's individual situation. No matter what treatment the doctor
and patient choose, however, the goals are the same: to relieve
pain, reduce inflammation, slow down or stop joint damage, and
improve the person's sense of well-being and ability to function.
Good communication between the patient and doctor is necessary for
effective treatment. Talking to the doctor can help ensure that
exercise and pain management programs are provided as needed, and
that drugs are prescribed appropriately. Talking to the doctor can
also help people who are making decisions about surgery.
Goals of Treatment
Relieve pain
Reduce inflammation
Slow down or stop joint damage
Improve a person's sense of well-being and ability to function
Current Treatment Approaches
Lifestyle
Medications
Surgery
Routine monitoring and ongoing care
Health behavior changes: Certain activities can help improve a
person's ability to function independently and maintain a positive
outlook.
Rest and exercise: People with rheumatoid arthritis need a good
balance between rest and exercise, with more rest when the disease
is active and more exercise when it is not. Rest helps to reduce
active joint inflammation and pain and to fight fatigue. The length
of time for rest will vary from person to person, but in general,
shorter rest breaks every now and then are more helpful than long
times spent in bed.
Exercise is important for maintaining healthy and strong muscles,
preserving joint mobility, and maintaining flexibility. Exercise can
also help people sleep well, reduce pain, maintain a positive
attitude, and lose weight. Exercise programs should take into
account the person's physical abilities, limitations, and changing
needs.
Joint care: Some people find using a splint for a short time around
a painful joint reduces pain and swelling by supporting the joint
and letting it rest. Splints are used mostly on wrists and hands,
but also on ankles and feet. A doctor or a physical or occupational
therapist can help a person choose a splint and make sure it fits
properly. Other ways to reduce stress on joints include self-help
devices (for example, zipper pullers, long-handled shoe horns);
devices to help with getting on and off chairs, toilet seats, and
beds; and changes in the ways that a person carries out daily
activities.
Stress reduction: People with rheumatoid arthritis face emotional
challenges as well as physical ones. The emotions they feel because
of the disease-fear, anger, and frustration-combined with any pain
and physical limitations can increase their stress level. Although
there is no evidence that stress plays a role in causing rheumatoid
arthritis, it can make living with the disease difficult at times.
Stress also may affect the amount of pain a person feels. There are
a number of successful techniques for coping with stress. Regular
rest periods can help, as can relaxation, distraction, or
visualization exercises. Exercise programs, participation in support
groups, and good communication with the health care team are other
ways to reduce stress.
Healthful diet: With the exception of several specific types of oils
(see “Current Research”), there is no scientific evidence that any
specific food or nutrient helps or harms people with rheumatoid
arthritis. However, an overall nutritious diet with enough-but not
an excess of-calories, protein, and calcium is important. Some
people may need to be careful about drinking alcoholic beverages
because of the medications they take for rheumatoid arthritis. Those
taking methotrexate may need to avoid alcohol altogether because one
of the most serious long-term side effects of methotrexate is liver
damage.
Climate: Some people notice that their arthritis gets worse when
there is a sudden change in the weather. However, there is no
evidence that a specific climate can prevent or reduce the effects
of rheumatoid arthritis. Moving to a new place with a different
climate usually does not make a long-term difference in a person's
rheumatoid arthritis.
Medications: Most people who have rheumatoid arthritis take
medications. Some medications are used only for pain relief; others
are used to reduce inflammation. Still others, often called
disease-modifying antirheumatic drugs (DMARDs), are used to try to
slow the course of the disease. The person's general condition, the
current and predicted severity of the illness, the length of time he
or she will take the drug, and the drug's effectiveness and
potential side effects are important considerations in prescribing
drugs for rheumatoid arthritis. The table below shows currently used
rheumatoid arthritis medications, along with their uses and effects,
side effects, and monitoring requirements.
Biologic response modifiers are new drugs used for the treatment of
rheumatoid arthritis. They can help reduce inflammation and
structural damage to the joints by blocking the action of cytokines,
proteins of the body's immune system that trigger inflammation
during normal immune responses. Three of these drugs, etanercept
(Enbrel*), infliximab (Remicade), and adalimumab (Humira), reduce
inflammation by blocking the reaction of TNF-α molecules. Another
drug, called anakinra (Kineret), works by blocking a protein called
interleukin 1 (IL-1) that is seen in excess in patients with
rheumatoid arthritis.
For many years, doctors initially prescribed aspirin or other
pain-relieving drugs for rheumatoid arthritis, as well as rest and
physical therapy. They usually prescribed more powerful drugs later
only if the disease worsened.
Today, however, many doctors have changed their approach, especially
for patients with severe, rapidly progressing rheumatoid arthritis.
Studies show that early treatment with more powerful drugs, and the
use of drug combinations instead of one medication alone, may be
more effective in reducing or preventing joint damage. Once the
disease improves or is in remission, the doctor may gradually reduce
the dosage or prescribe a milder medication.
* Brand names included in this booklet are provided as examples
only, and their inclusion does not mean that these products are
endorsed by the National Institutes of Health or any other
Government agency. Also, if a particular brand name is not
mentioned, this does not mean or imply that the product is
unsatisfactory.
Surgery: Several types of surgery are available to patients with
severe joint damage. The primary purpose of these procedures is to
reduce pain, improve the affected joint's function, and improve the
patient's ability to perform daily activities. Surgery is not for
everyone, however, and the decision should be made only after
careful consideration by patient and doctor. Together they should
discuss the patient's overall health, the condition of the joint or
tendon that will be operated on, and the reason for, as well as the
risks and benefits of, the surgical procedure. Cost may be another
factor. Commonly performed surgical procedures include joint
replacement, tendon reconstruction, and synovectomy.
Joint replacement: This is the most frequently performed surgery for
rheumatoid arthritis, and it is done primarily to relieve pain and
improve or preserve joint function. Artificial joints are not always
permanent and may eventually have to be replaced. This may be an
important consideration for young people.
Tendon reconstruction: Rheumatoid arthritis can damage and even
rupture tendons, the tissues that attach muscle to bone. This
surgery, which is used most frequently on the hands, reconstructs
the damaged tendon by attaching an intact tendon to it. This
procedure can help to restore hand function, especially if the
tendon is completely ruptured.
Synovectomy: In this surgery, the doctor actually removes the
inflamed synovial tissue. Synovectomy by itself is seldom performed
now because not all of the tissue can be removed, and it eventually
grows back. Synovectomy is done as part of reconstructive surgery,
especially tendon reconstruction.
Routine Monitoring and Ongoing Care: Regular medical care is
important to monitor the course of the disease, determine the
effectiveness and any negative effects of medications, and change
therapies as needed. Monitoring typically includes regular visits to
the doctor. It also may include blood, urine, and other laboratory
tests and x rays.
People with rheumatoid arthritis may want to discuss preventing
osteoporosis with their doctors as part of their long-term, ongoing
care. Osteoporosis is a condition in which bones become weakened and
fragile. Having rheumatoid arthritis increases the risk of
developing osteoporosis for both men and women, particularly if a
person takes corticosteroids. Such patients may want to discuss with
their doctors the potential benefits of calcium and vitamin D
supplements, hormone therapy, or other treatments for osteoporosis.
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