What Is Rheumatoid Arthritis? Rheumatoid arthritis (RA), also known as rheumatoid disease is the most common form of inflammatory, chronic, autoimmune disorder that causes inflammation in the lining of the joints and other organs such as the eyes, lungs, skin and heart. It can results in complications such as joint deformities, permanent joint damage, disabilities or shorter life expectancy if not diagnose or treated early.
Autoimmune disease means that the body’s immune system which supposed to “defend and fight” against virus or infections attacked the body’s own tissues, cells or organs. When the immune system attacks the joints, the synovial membrane becomes swollen, inflamed and thickened producing excess synovial fluid. Besides, inflammation also affected the bursae and tendon sheaths resulting in joint damage.
As illustrated in Diagram A, besides the joint, the cartilage and ligaments will also be damaged eventually due to chronic inflammation, resulting in bone erosion or deformity.
Usually, rheumatoid arthritis affects the small joints in the wrists, hands and feet. However, as it develops gradually, the joints of the knees and shoulders can be affected too. It is commonly associated with the loss of functional inability and mobility when the disease is active. Daily simple activities like getting in out of the car, climbing the stairs or turning doorknobs will be of great difficulties as patients will experience extreme joint pain, joint weakness and joint stiffness.
Unlike osteoarthritis (the “wear and tear” arthritis) that affects one joint at a time, rheumatoid arthritis may affect the joints symmetrically. For example, both wrists, both hands, both knees and both ankles etc.
- Small joints: In the initial stage, rheumatoid arthritis affects mainly the small joints of hands, feet and cervical spine. Usually, it affects the joints at the base of finger, the middle joint of the fingers, the knuckles, the wrists and the joints at the base of the toes. In severe cases, synovial inflammation can lead to joint erosion, destruction of the joint surface, and if not treated can cause fusion of the joints leading to deformities. Due to hyper-extension of joints, contraction of tendons and fusion of small joints, the deformities like swan neck deformity and boutonniere deformity can be seen in advanced cases.
- Knee joint: In some cases, the knee joint will be affected alone or along with other joints. Extreme pain, swelling and restriction of movements can be experienced due to the ongoing synovial inflammation.
- Hip joint: As rheumatoid arthritis condition progresses, inflammation can affect the large weight-bearing joint such as the hip joint. In such cases, the impact of pain and immobility is greater than as in the knee joint.
8 Main Complications Of Rheumatoid Arthritis
Rheumatoid arthritis does not affect the joints only. It is a systemic disease which can cause complications to the other organs of the body such as:
- Skin: Rheumatoid nodules (free-floating lumps) develop underneath the skin which is painless and unsightly. These are markers of the inflammation and they are commonly seen on forearms, elbows, the heels or soles of the feet and fingers.
- Heart: Inflammation of the tissue lining the heart and chest cavity results in Pericarditis, Pericardial effusion and Myocarditis. These are the complications that may cause heart attacks, chest pain and dyspnoea.
- Eyes: In about 10% of the cases, the patients’ eyes are being affected. The presenting complaint will be dryness of eyes associated with irritations and mild pain. Episcleritis and Scleritis are serious complications and if neglected, can lead to vision loss. Besides, patients may also have difficulties in chewing or swallowing food due to dryness of the mouth.
- Lungs: Due to inflammation of pleura, lining around the lungs, it can cause pleural effusion resulting in shortness of breath and mild dry cough. However, it can be controlled with the usage of drugs by reducing the effect of inflammation.
- Joint deformities: Swan-neck deformity is deformity of finger joints where there is hyperflexion of distal inter-phalangeal joint – near to tip of fingers and of proximal inter phalangeal joint – near to the wrist. This is the result of the pathogenesis of rheumatoid arthritis where there are contractures and damages to the small joint tendons.
- Carpal tunnel syndrome: Carpal tunnel syndrome is one of the complications of rheumatoid arthritis. It is a compression neuropathy of median nerve located in the carpal tunnel (a narrow and bony canal located at the base of the hand). It results in numbness, weakness and tingling in the fingers, wrist, palm and thumb.
- Vasculitis: A group of disorders which affects the arteries, veins and capillaries due to the inflammation of the blood vessels. When the blood vessel becomes inflamed, it causes blockages or disruption to the blood flow. In severe cases, the blood vessels may burst and results in internal bleeding.
- Nerves system: Some patients may experience body’s numbness, weakness or tingling as RA had affected the entire nervous system.
According to the American College Of Rheumatology, 1.3 million of the US population is affected with rheumatoid arthritis. It affects 1% of the adult population and the incidence increases with age. Based on a research conducted, studies show that the prevalence cases of the disease is increasing especially in the North America and the European countries.
Risk Factors For Rheumatoid Arthritis
- Gender: Generally, women are 3 times more likely to develop rheumatoid arthritis than men.
- Age: Rheumatoid arthritis can occur at any age. The incidence rate of the disease increased as age increases. It peaks at the age of 40 years and declines after 65 years.
- Nulliparity: Woman who have just given birth to children, have never been pregnant and have not breastfeed their children are said to have a higher risk of the disease. The reason is female hormonal correlation with the disease. Interestingly, studies indicate that the onset of RA is delayed for those women who are on contraceptives pills.
- Genetics: Family history is very important especially if there are suspicious symptoms of rheumatoid arthritis which may relate to major histocompatibility antigen ‘HLA DR4‘. Genes is a significant risk factor for rheumatoid arthritis, as inheriting the genes ‘PTPN22‘ and ‘PADI4‘ increases the risk of having the disease in the next generations.
- Smoking: Smoking can increase the risk of rheumatoid arthritis, as it can trigger few mutations related to it. Smokers who already have positive family history of the disease should be alerted about the increased chance of getting the disease with severe conditions and they should be advised to quit smoking.
- Occupational hazards: Typically, men who are constantly exposed to organic or mineral dusts, vibration, asbestos and asphalt have a higher risk of developing RA.
Causes Of Rheumatoid Arthritis
Even though the exact cause of rheumatoid arthritis is not known, it is suspected that the cause can be attributed to the various triggering factors below:
- Genetics: The inheritance of certain genes is believed to increase the risk of developing rheumatoid arthritis.
- Environmental: Environmental factors like colder climates seems to play a role factor in triggering the onset of rheumatoid arthritis. Some studies also reported that smoking tobacco and chronic periodontitis add on to the risk.
- Hormonal: Female hormones have a strong correlation with the development of the disease. It is observed that 70% of the affected individuals are females. When there is genetic inheritance in both male and female, the female have thrice the increased chance of getting the disease.
- Autoimmune: Autoimmune disease pathogenesis lies in, acting of one’s own immune system against the specific protein present in the body. Though the exact protein in which the lymphocytes (immune cell) act against is not known, the lymphocytes produce inflammatory response by generating cytokines like ‘Tumor necrosis factor’ and ‘Interleukin-1’. These cytokines cause the inflammation in the synovium of joints, which is the exact pathology that lies behind the severity of the disease.
- Infections: It is proposed by some researchers that bacterial and viral infections may have triggered the disease but this cause is not confirmed. According to some studies, it seems to link with autoimmune pathology.
- Stress: Both physical and emotional stress adds on the tendency of autoimmune activation and further inflammation of the joints.
Symptoms Of Rheumatoid Arthritis
The hallmark symptom of RA is early morning stiffness which lasts for an hour. Generally, the common symptoms are pain and swelling which affect many joints at the same time, accompanied by redness and tenderness.
In RA, the hands, wrists and feet are the most common affected joints in the early stage. However, as the disease progresses, the symptoms will spread to the ankles, knees, hip and shoulders.
Other symptoms include fatigue, weight loss, mild fever and loss of appetite are also frequently experienced during periods of active inflammation (flare-up). Occasionally, patients may experience inactive inflammation (remissions), which the pain or inflammation subsided and the symptoms disappear.
Diagnosis Of Rheumatoid Arthritis
As the symptoms of rheumatoid arthritis such as joint stiffness and inflammation are similar to other arthritis conditions, it is difficult to diagnose the disease especially in the early stage.
Generally, the rheumatologist will perform a physical examination by examining the joints and look for symptoms of inflammation, swelling, tenderness, rheumatoid nodules and bone deformity. In fact, patients are advised to voice out any other signs or symptoms which they experienced so that a more accurate diagnosis can be deduce.
Next, the rheumatologist will adopt the appropriate diagnostic tests which are necessary in the diagnosis of rheumatoid arthritis. Some of the common test of RA are as below:
- Erythrocyte sedimentation rate (ESR)
- C-reactive protein (CRP)
- Joint X-rays/ MRI (magnetic resonance imaging) scans
- Rheumatoid factor
- Antinuclear antibodies (ANA)
- Synovial fluid aspiration (also known as joint fluid analysis)
Treatment For Rheumatoid Arthritis
As there is no cure for rheumatoid arthritis, the underlying aim of the treatment is to control the symptoms, protect the joints from further damage and improve or maintain mobility of the patient’s. Usually, a customized treatment plan based on the affected joints, health conditions, severity of the disease, age and occupation is implemented to monitor the progress of the treatment.
The rheumatologist, who is the overall in-charge will prescribe and monitor the drug therapy as well as coordinating the expertise of other specialists under the treatment program. The primary role of drug therapy is to reduce joint inflammation, relieving joint pain as well as slowing down the course of the disease.
Drugs like nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids are given in the initial stage of rheumatoid arthritis to control the pain and swelling of the joint. If needed, DMARDs (disease-modifying antirheumatic drugs) like Hydroxychloroquine and Methotrexate may be prescribed to slow down the progression of joint damage.
To minimize the impact of immobility or disability due to weak muscles or painful joints, the physiotherapist plays a vital role in advising the correct types of exercises which can be done at home. Besides, splints or braces will be recommended for joint protection or to maintain the joint position.
For patients who are facing difficulties in performing daily activities, the occupational therapist is the one who provide advice on the appropriate assistive aids or devices to use, without straining the joints. Sometimes, when the joint function is lost and pain or symptoms are not relieved by drugs, joint surgery is the last option. The orthopedic surgeon will advised on the appropriate surgeries like synovectomy, anthrodesis, arthroscopy or osteotomy.
Since RA is an autoimmune disorder, it can also cause damages and swelling of the tendon sheaths which restrict the joints movement affecting the wrists, hands or feet. In such cases, tenosynovectomy is performed to remove the inflamed tendons. If in the event that the tendon ruptures, then usually another tendon is being “borrow” and “transfer” to replace it. This procedure known as tendon transfer is most commonly done at the hands.
If you are a patient of RA, educating yourself on what is rheumatoid arthritis is a vital factor in the overall treatment program as it promotes your understanding on the disease and alleviates any fear or stress. As such, you will learn to accept the disease and make any adjustments in your daily lifestyle to lead a normal life with their families. In fact, the success rate of the treatment depends greatly on the proximity relationship between you, the rheumatologist as well as the support from your family members.
Though there is no cure, tremendous progress in recent decades on the field of medical science has greatly improved the outlook for rheumatoid arthritis. Many RA patients has reaped the benefits of these developments and continued to live on, overcoming the challenges living with rheumatoid arthritis.