The signs & symptoms of rheumatoid arthritis
Unlike osteoarthritis, which results from wear and tear on your joints, rheumatoid arthritis is an inflammatory condition. The exact cause of rheumatoid arthritis is unknown, but it’s believed to be the body’s immune system attacking the tissue that lines your joints (synovium).
Rheumatoid arthritis is two to three times more common in women than in men and generally strikes between the ages of 20 and 50. But rheumatoid arthritis can also affect young children and adults older than age 50.
There’s no cure for rheumatoid arthritis. But with proper treatment, a strategy for joint protection and changes in lifestyle, you can live a long, productive life with this condition.
Signs and symptoms
The signs and symptoms of rheumatoid arthritis may come and go over time. They include:
* Pain and swelling in your joints, especially in the smaller joints of your hands and feet
* Generalized aching or stiffness of the joints and muscles, especially after sleep or after periods of rest
* Loss of motion of the affected joints
* Loss of strength in muscles attached to the affected joints
* Fatigue, which can be severe during a flare-up
* Low-grade fever
* Deformity of your joints over time
* General sense of not feeling well (malaise)
Rheumatoid arthritis usually causes problems in several joints at the same time. Early in rheumatoid arthritis, the joints in your wrists, hands, feet and knees are the ones most often affected. As the disease progresses, your shoulders, elbows, hips, jaw and neck can become involved. It generally affects both sides of your body at the same time. The knuckles of both hands are one example.
Small lumps, called rheumatoid nodules, may form under your skin at pressure points and can occur at your elbows, hands, feet and Achilles tendons. Rheumatoid nodules may also occur elsewhere, including the back of your scalp, over your knee or even in your lungs. These nodules can range in size — from as small as a pea to as large as a walnut. Usually these lumps aren’t painful.
In contrast to osteoarthritis, which affects only your bones and joints, rheumatoid arthritis can cause inflammation of tear glands, salivary glands, the linings of your heart and lungs, your lungs themselves and, in rare cases, your blood vessels.
Although rheumatoid arthritis is often a chronic disease, it tends to vary in severity and may even come and go. Periods of increased disease activity — called flare-ups or flares — alternate with periods of relative remission, during which the swelling, pain, difficulty sleeping, and weakness fade or disappear.
Swelling or deformity may limit the flexibility of your joints. But even if you have a severe form of rheumatoid arthritis, you’ll probably retain flexibility in many joints.
Illustration comparing rheumatoid arthritis and osteoarthritis
Osteoarthritis, the most common form of arthritis, involves the wearing away of the cartilage that caps the bones in your joints. With rheumatoid arthritis, the synovial membrane that protects and lubricates joints becomes inflamed, causing pain and swelling. Joint erosion may follow.
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As with other forms of arthritis, rheumatoid arthritis involves inflammation of the joints. A membrane called the synovium lines each of your movable joints. When you have rheumatoid arthritis, white blood cells — whose usual job is to attack unwanted invaders, such as bacteria and viruses — move from your bloodstream into your synovium. Here, these blood cells appear to play an important role in causing the synovial membrane to become inflamed (synovitis).
This inflammation results in the release of proteins that, over months or years, cause thickening of the synovium. These proteins can also damage cartilage, bone, tendons and ligaments. Gradually, the joint loses its shape and alignment. Eventually, it may be destroyed.
Some researchers suspect that rheumatoid arthritis is triggered by an infection — possibly a virus or bacterium — in people with an inherited susceptibility. Although the disease itself is not inherited, certain genes that create an increased susceptibility are. People who have inherited these genes won’t necessarily develop rheumatoid arthritis. But they may have more of a tendency to do so than others. The severity of their disease may also depend on the genes inherited. Some researchers also believe that hormones may be involved in the development of rheumatoid arthritis.
Illustration showing inflammation of rheumatoid arthritis
Rheumatoid arthritis typically strikes joints, causing pain, swelling and deformity. As your synovial membranes become inflamed and thickened, fluid builds up and joints erode and degrade.
The exact causes of rheumatoid arthritis are unclear, but these factors may increase your risk:
* Getting older, because incidence of rheumatoid arthritis increases with age. However, incidence begins to decline in women over the age of 80.
* Being female.
* Being exposed to an infection, possibly a virus or bacterium, that may trigger rheumatoid arthritis in those with an inherited susceptibility.
* Inheriting specific genes that may make you more susceptible to rheumatoid arthritis.
* Smoking cigarettes over a long period of time.
When to seek medical advice
See your doctor if you have persistent discomfort and swelling in multiple joints on both sides of your body. Your doctor can work with you to develop a pain management and treatment plan. Also seek medical advice if you experience side effects from your arthritis medications. Side effects may include nausea, abdominal discomfort, black or tarry stools, changes in bowel habits, constipation and drowsiness.
Screening and diagnosis
If you have signs and symptoms of rheumatoid arthritis, your doctor will likely conduct a physical examination and request laboratory tests to determine if you have this form of arthritis. These tests may include:
Blood tests. A blood test that measures your erythrocyte sedimentation rate (ESR or sed rate) can indicate the presence of an inflammatory process in your body. People with rheumatoid arthritis tend to have elevated ESRs. The ESRs in those with osteoarthritis tend to be normal.
Another blood test looks for an antibody called rheumatoid factor. Most people with rheumatoid arthritis eventually have this abnormal antibody, although it may be absent early in the disease. It’s also possible to have the rheumatoid factor in your blood and not have rheumatoid arthritis.
* Imaging. Doctors may take X-rays of your joints to differentiate between osteoarthritis and rheumatoid arthritis. A sequence of X-rays obtained over time can show the progression of arthritis.
Rheumatoid arthritis causes stiffness and pain and may also cause fatigue. It can lead to difficulty with everyday tasks, such as turning a doorknob or holding a pen. Dealing with the pain and the unpredictability of rheumatoid arthritis can also cause symptoms of depression.
Rheumatoid arthritis may also increase your risk of developing osteoporosis, especially if you take corticosteroids. Some researchers believe that rheumatoid arthritis can increase your risk of heart disease. This may be because the inflammation that rheumatoid arthritis causes can also affect your arteries and heart muscle tissue.
In the past, people with rheumatoid arthritis may have ended up confined to a wheelchair because damage to joints made it difficult or impossible to walk. That’s not as likely today because of better treatments and self-care methods.
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Treatments for arthritis have improved in recent years. Most treatments involve medications. But in some cases, surgical procedures may be necessary.
Medications for rheumatoid arthritis can relieve its symptoms and slow or halt its progression. They include:
* Nonsteroidal anti-inflammatory drugs (NSAIDs). This group of medications, which includes aspirin, helps relieve both pain and inflammation if you take the drugs regularly. NSAIDs that are available over-the-counter include aspirin, ibuprofen (Advil, Motrin, others) and naproxen sodium (Aleve). These are available at higher dosages, and other NSAIDs are available by prescription — such as ketoprofen, naproxen (Anaprox, Naprosyn), tolmetin (Tolectin), diclofenac (Voltaren), nabumetone (Relafen) and indomethacin (Indocin). Taking NSAIDs can lead to side effects such as indigestion and stomach bleeding. Other potential side effects may include damage to the liver and kidneys, ringing in your ears (tinnitus), fluid retention and high blood pressure. NSAIDs, except aspirin, may also increase your risk of cardiovascular events such as heart attack or stroke.
* COX-2 inhibitors. This class of NSAIDs may be less damaging to your stomach. Like other NSAIDs, COX-2 inhibitors — such as celecoxib (Celebrex) — suppress an enzyme called cyclooxygenase (COX) that’s active in joint inflammation. Other types of NSAIDs work against two versions of the COX enzyme that are present in your body: COX-1 and COX-2. However, there’s evidence that by suppressing COX-1, NSAIDs may cause stomach and other problems because COX-1 is the enzyme that protects your stomach lining. Unlike other NSAIDs, COX-2 inhibitors suppress only COX-2, the enzyme involved in inflammation. Side effects may include fluid retention and causing or exacerbating high blood pressure. Furthermore, this class of drugs has been linked to an increased risk of heart attack and stroke.
* Corticosteroids. These medications, such as prednisone and methylprednisolone (Medrol), reduce inflammation and pain, and slow joint damage. In the short term, corticosteroids can make you feel dramatically better. But when used for many months or years, they may become less effective and cause serious side effects. Side effects may include easy bruising, thinning of bones, cataracts, weight gain, a round face and diabetes. Doctors often prescribe a corticosteroid to relieve acute symptoms, with the goal of gradually tapering off the medication.
* Disease-modifying antirheumatic drugs (DMARDs). Physicians prescribe DMARDs to limit the amount of joint damage that occurs in rheumatoid arthritis. Taking these drugs at early stages in the development of rheumatoid arthritis is especially important in the effort to slow the disease and save the joints and other tissues from permanent damage. Because many of these drugs act slowly — it may take weeks to months before you notice any benefit — DMARDs typically are used with an NSAID or a corticosteroid. While the NSAID or corticosteroid handles your immediate symptoms and limits inflammation, the DMARD goes to work on the disease itself. Some commonly used DMARDs include hydroxychloroquine (Plaquenil), the gold compound auranofin (Ridaura), sulfasalazine (Azulfidine), minocycline (Dynacin, Minocin) and methotrexate (Rheumatrex). Other forms of DMARDs include immunosuppressants and tumor necrosis factor (TNF) blockers.
* Immunosuppressants. These medications act to tame your immune system, which is out of control in rheumatoid arthritis. In addition, some of these drugs attack and eliminate cells that are associated with the disease. Some of the commonly used immunosuppressants include leflunomide (Arava), azathioprine (Imuran), cyclosporine (Neoral, Sandimmune) and cyclophosphamide (Cytoxan). These medications can have potentially serious side effects such as increased susceptibility to infection.
* TNF blockers. These are a class of DMARDs known as biologic response modifiers. TNF is a cytokine, or cell protein, that acts as an inflammatory agent in rheumatoid arthritis. TNF blockers, or anti-TNF medications, target or block this cytokine and can help reduce pain, morning stiffness and tender or swollen joints — usually within one or two weeks after treatment begins. There is evidence that TNF blockers may halt progression of disease. These medications often are taken with methotrexate. TNF blockers approved for treatment of rheumatoid arthritis are etanercept (Enbrel), infliximab (Remicade) and adalimumab (Humira). Potential side effects include injection site irritation (adalimumab and etanercept), worsening congestive heart failure (infliximab), blood disorders, lymphoma, demyelinating diseases, and increased risk of infection. If you have an active infection, don’t take these medications.
* Interleukin-1 receptor antagonist (IL-1Ra). IL-1Ra is another type of biologic response modifier and is a recombinant form of the naturally occurring interleukin-1 receptor antagonist (IL-1Ra). Interleukin-1 (IL-1) is a cell protein that promotes inflammation and occurs in excess amounts in people who have rheumatoid arthritis or other types of inflammatory arthritis. If IL-1 is prevented from binding to its receptor, the inflammatory response decreases. The first IL-1Ra that has been approved by the Food and Drug Administration for use in people with moderate to severe rheumatoid arthritis who haven’t responded adequately to conventional DMARD therapy is anakinra (Kineret). It may be used alone or in combination with methotrexate. Anakinra is given as a daily self-administered injection under the skin. Some potential side effects include injection site reactions, decreased white blood cell counts, headache and an increase in upper respiratory infections. There may be a slightly higher rate of respiratory infections in people who have asthma or chronic obstructive pulmonary disease. If you have an active infection, don’t use anakinra.
* Abatacept (Orencia). Abatacept, a type of costimulation modulator approved in late 2005, reduces the inflammation and joint damage caused by rheumatoid arthritis by inactivating T cells — a type of white blood cell. People who haven’t been helped by TNF blockers might consider abatacept, which is administered monthly through a vein in your arm (intravenously). Side effects may include headache, nausea and mild infections, such as upper respiratory tract infections. Serious infections, such as pneumonia, can occur.
* Rituximab (Rituxan). Rituximab reduces the number of B cells in your body. B cells are involved in inflammation. Though originally approved for use in people with non-Hodgkin’s lymphoma, rituximab was approved for rheumatoid arthritis in early 2006. People who haven’t found relief using TNF blockers might consider using rituximab, which is usually given along with methotrexate. Rituximab is administered as an infusion into a vein in your arm. Side effects include flu-like signs and symptoms, such as fever, chills and nausea. Some people experience extreme reactions to the infusion, such as difficulty breathing and heart problems.
* Antidepressant drugs. Some people with arthritis also experience symptoms of depression. The most common antidepressants used for arthritis pain and nonrestorative sleep are amitriptyline, nortriptyline (Aventyl, Pamelor) and trazodone (Desyrel).
Surgical or other procedures
Although a combination of medication and self-care is the first course of action for rheumatoid arthritis, other methods are available for severe cases:
* Prosorba column. This blood-filtering technique removes certain antibodies that contribute to pain and inflammation in your joints and muscles and is usually performed once a week for 12 weeks as an outpatient procedure. Some of the side effects include fatigue and a brief increase in joint pain and swelling for the first few days after the treatment. The Prosorba column treatment isn’t recommended if you’re taking angiotensin-converting enzyme (ACE) inhibitors or if you have heart problems, high blood pressure or blood-clotting problems.
* Joint replacement surgery. For many people with rheumatoid arthritis, medicines and therapies can’t prevent joint destruction. When joints are severely damaged, joint replacement surgery can often help restore joint function, reduce pain or correct a deformity. You may need to have an entire joint replaced with a metal or plastic prosthesis. Surgery may also involve tightening tendons that are too loose, loosening tendons that are too tight, fusing bones to reduce pain or removing part of a diseased bone to improve mobility. Your doctor may also remove the inflamed joint lining (synovectomy).
* Steroid use: Balancing the risks and benefits
* Are COX-2 drugs safe for you? An interview with a Mayo Clinic specialist
* Knee replacement: Surgery can relieve pain
Treating rheumatoid arthritis typically involves using a combination of medical treatments and self-care strategies. The following self-care procedures are important elements for managing the disease:
Exercise regularly. Different types of exercise achieve different goals. Check with your doctor or physical therapist first and then begin a regular exercise program for your specific needs. If you can walk, walking is a good starter exercise. If you can’t walk, try a stationary bicycle with little or no resistance or do hand or arm exercises. A chair exercise program may be helpful. Aquatic exercise is another option, and many health clubs with pools offer such classes.
It’s good to move each joint in its full range of motion every day. As you move, maintain a slow, steady rhythm. Don’t jerk or bounce. Also, remember to breathe. Holding your breath can temporarily deprive your muscles of oxygen and tire them. It’s also important to maintain good posture while you exercise. Avoid exercising tender, injured or severely inflamed joints. If you feel new joint pain, stop. New pain that lasts more than two hours after you exercise probably means you’ve overdone it. If pain persists for more than a few days, call your doctor.
* Control your weight. Excess weight puts added stress on joints in your back, hips, knees and feet — the places where arthritis pain is commonly felt. Excess weight can also make joint surgery more difficult and risky.
* Eat a healthy diet. A healthy diet emphasizing fruit, vegetables and whole grains can help you control your weight and maintain your overall health, allowing you to deal better with your arthritis. However, there’s no special diet that can be used to treat arthritis. It hasn’t been proved that eating any particular food will make your joint pain or inflammation better or worse.
* Apply heat. Heat will help ease your pain, relax tense, painful muscles and increase the regional flow of blood. One of the easiest and most effective ways to apply heat is to take a hot shower or bath for 15 minutes. Other options include using a hot pack, an electric heat pad set on its lowest setting or a radiant heat lamp with a 250-watt reflector heat bulb to warm specific muscles and joints. If your skin has poor sensation or if you have poor circulation, don’t use heat treatment.
* Apply cold for occasional flare-ups. Cold may dull the sensation of pain. Cold also has a numbing effect and decreases muscle spasms. Don’t use cold treatments if you have poor circulation or numbness. Techniques may include using cold packs, soaking the affected joints in cold water and ice massage.
* Practice relaxation techniques. Hypnosis, guided imagery, deep breathing and muscle relaxation can all be used to control pain.
* Take your medications as recommended. By taking medications regularly instead of waiting for pain to build, you will lessen the overall intensity of your discomfort.
The degree to which rheumatoid arthritis affects your daily activities depends in part on how well you cope with the disease. Physical and occupational therapists can help you devise strategies to cope with specific limitations you may experience as the result of weakness or pain. Here are some general suggestions to help you cope:
* Keep a positive attitude. With your doctor, make a plan for managing your arthritis. This will help you feel in charge of your disease. Studies show that people who take control of their treatment and actively manage their arthritis experience less pain and make fewer visits to the doctor.
* Use assistive devices. A painful knee may need a brace for support. You might also want to use a cane to take some of the stress off the joint as you walk. Use the cane in the hand opposite the affected joint. If your hands are affected, various helpful tools and gadgets are available to help you maintain an active lifestyle. Contact your pharmacy or doctor for information on ordering items that may help you the most.
* Know your limits. Rest when you’re tired. Arthritis can make you prone to fatigue and muscle weakness. A rest or short nap that doesn’t interfere with nighttime sleep may help.
* Avoid grasping actions that strain your finger joints. Instead of using a clutch purse, for example, select one with a shoulder strap. Use hot water to loosen a jar lid and pressure from your palm to open it, or use a jar opener. Don’t twist or use your joints forcefully.
* Spread the weight of an object over several joints. For instance, use both hands to lift a heavy pan.
* Take a break. Periodically relax and stretch.
* Maintain good posture. Poor posture causes uneven weight distribution and may strain ligaments and muscles. The easiest way to improve your posture is by walking. Some people find that swimming also helps improve their posture.
* Use your strongest muscles and favor large joints. Don’t push open a heavy glass door. Lean into it. To pick up an object, bend your knees and squat while keeping your back straight.
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