Handout on Health: Rheumatoid Arthritis
This booklet is for people who have rheumatoid arthritis, as well as for
their family members, friends, and others who want to find out more about this disease.
The booklet describes how rheumatoid arthritis develops, how it is diagnosed, and how it
is treated, including what patients can do to help manage their disease. It also
highlights current research efforts supported by the National Institute of Arthritis and
Musculoskeletal and Skin Diseases (NIAMS) and other components of the National Institutes
of Health (NIH). If you have further questions after reading this booklet, you may wish to
discuss them with your doctor.
Features of Rheumatoid Arthritis
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 information box below). For
example, rheumatoid arthritis generally occurs in a symmetrical pattern. This means that
if one knee or hand is involved, the other one is also. 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 illustrations below). In addition, people with the
disease may have fatigue, occasional fever, and a general sense of not feeling well
(malaise).
Another feature of rheumatoid arthritis is that it varies a lot from
person to person. 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 disease,
with periods of worsening symptoms, called flares, and periods in which they feel better,
called remissions. Still others have severe disease that is active most of the time, lasts
for many years, and leads to serious joint damage and disability.
Although rheumatoid arthritis can have serious effects on a person's life
and well-being, current treatment strategies--including pain relief and other medications,
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 can find ways to greatly reduce the impact of this
disease.
Features of Rheumatoid Arthritis
- Tender, warm, swollen joints.
- Symmetrical pattern. For example, if one knee is affected, the other one is also.
- Joint inflammation often affecting the wrist and finger joints closest to the hand;
other affected joints can include those of the neck, shoulders, elbows, hips, knees,
ankles, and feet.
- Fatigue, occasional fever, a general sense of not feeling well (malaise).
- Pain and stiffness lasting for more than 30 minutes in the morning or after a long rest.
- Symptoms that can last for many years.
- Symptoms in other parts of the body besides the joints.
- Variability of symptoms among people with the disease.
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How Rheumatoid Arthritis Develops and Progresses
The Joints
A normal joint (the place where two bones meet) is surrounded by a joint
capsule that protects and supports it (see illustration). Cartilage covers and cushions
the ends of the two bones. The joint capsule is lined with a type of tissue called
synovium, which produces synovial fluid. This clear fluid lubricates and nourishes the
cartilage and bones inside the joint capsule.
In rheumatoid arthritis, the immune system, for unknown reasons, attacks a
person's own cells inside the joint capsule. White blood cells that are part of the normal
immune system travel to the synovium and cause a reaction. This reaction, or inflammation,
is called synovitis, and it results in the warmth, redness, swelling, and pain that are
typical symptoms of rheumatoid arthritis. During the inflammation process, the cells of
the synovium grow and divide abnormally, making the normally thin synovium thick and
resulting in a joint that is swollen and puffy to the touch (see illustration).
As rheumatoid arthritis progresses, these abnormal synovial cells begin to
invade and destroy 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. All of these effects lead to the pain and deformities often seen in rheumatoid
arthritis. Doctors studying rheumatoid arthritis now believe that damage to bones begins
during the first year or two that a person has the disease. This is one reason early
diagnosis and treatment are so important in the management of rheumatoid arthritis.
A joint (the place where two bones meet) is surronded by a capsule that
protects and supports it. The joint capsule is lined with a type of tissue called
synovium, which produces synovial fluid that lubricates and nourishes joint tissues. In
rheumatoid arthritis, the synovium becomes inflmaed, causing warmth, redness, swelling,
and pain. As the disease progresses, abnormal synovial cells invade and erode, or destroy,
cartilage and bone within the joint. Surronding muscels, ligaments, and tendons become
weakened. Rheumatoid arthritis can also cause more generalized bone loss that may lead to
osteoporosis (fragile bones that are prone to fracture).
Other Parts of the Body
Some people also experience the effects of rheumatoid arthritis in places
other than the joints. About one-quarter develop rheumatoid nodules. These are bumps under
the skin that often form close to the joints. Many people with rheumatoid arthritis
develop anemia, or a decrease in the normal number of red blood cells. Other effects,
which 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 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 may actually be
going down. Scientists are now 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 millions of dollars. Daily joint pain is an inevitable consequence of the disease, and
most patients also experience some degree of depression, anxiety, and feelings of
helplessness. In some cases, rheumatoid arthritis can interfere with a person's ability to
carry out 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. These programs are described later in the section
Diagnosing and Treating Rheumatoid Arthritis.
Searching for the Cause of Rheumatoid Arthritis
Rheumatoid arthritis is one of several "autoimmune" diseases
("auto" means self), so-called because a person's immune system attacks his or
her own body tissues. Scientists still do not know exactly what causes this to happen, but
research over the last few years has begun to unravel the factors involved.
Genetic (inherited) factors:Scientists have found that certain
genes that play a role in the immune system are associated with a tendency to develop
rheumatoid arthritis. At the same time, some people with rheumatoid arthritis do not have
these particular genes, and other people have these genes but never develop the disease.
This suggests that a person's genetic makeup is an important part of the story but not the
whole answer. It is clear, however, that more than one gene is involved in determining
whether a person develops rheumatoid arthritis and, if so, 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. An infectious agent such as a virus or bacterium appears likely,
but the exact agent is not yet known. Note, however, that rheumatoid arthritis is not
contagious: A person cannot "catch" it from someone else.
Other factors: Some scientists also think that a variety of
hormonal factors may be involved. 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 aren't known, one thing is certain: Rheumatoid
arthritis develops as a result of an interaction of many factors. Much research is going
on now to understand these factors and how they work together (see the Current Research
section).
Diagnosing and Treating Rheumatoid Arthritis
Diagnosing and treating rheumatoid arthritis is a team effort between 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, orthopedic surgeons, psychologists, and social workers.
Studies have shown that people who are well informed and participate
actively in their own care experience less pain and make fewer visits to the doctor than
do other people 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 one of the NIAMS-supported Multipurpose
Arthritis and Musculoskeletal Diseases Centers. Self-management programs teach about
rheumatoid arthritis and its treatments, exercise and relaxation approaches,
patient/health care provider communication, and problem solving. Research on these
programs has shown that they have the following clear and long-lasting benefits:
- They help people understand the disease.
- They help people reduce their pain while remaining active.
- They help people cope physically, emotionally, and mentally.
- They help people feel greater control over their disease and help build a sense of
confidence in the ability to function and lead a full, active, and independent life.
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 as possible diagnoses. 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 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 his or her assessment of how the disease changes.
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 eventually present in the blood of most rheumatoid arthritis patients.
(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. And, some others who do
test positive never develop the disease. Other common tests include one that indicates the
presence of inflammation in the body (the erythrocyte sedimentation rate), a white blood
cell count, and a blood test for anemia.
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: relieve pain, reduce
inflammation, slow down or stop joint damage, and improve the person's sense of well-being
and ability to function.
Treatment is another key area for communication between patient and
doctor. Talking to the doctor can help ensure that exercise and pain management programs
are provided as needed and that drugs are prescribed appropriately. Talking can also help
in 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
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Lifestyle
This approach includes several activities that help improve a person's
ability to function independently and maintain a positive outlook.
Rest and exercise: Both rest and exercise help in important ways.
People with rheumatoid arthritis need a good balance between the two, 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 needed 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 be planned and carried out to take into account the person's physical abilities,
limitations, and changing needs.
Care of joints: Some people find that 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 patient get a splint and ensure
that 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, 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 may also 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 (mentioned in the Current Research section), there is no scientific evidence that any
specific food or nutrient helps or harms most 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. Patients should ask their doctors for
guidance on this issue.
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, or 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 about "Medications Commonly Used To Treat
Rheumatoid Arthritis" shows currently used rheumatoid arthritis medications, along
with their effects, side effects, and monitoring requirements.
Traditionally, rheumatoid arthritis therapy has involved an approach in
which doctors prescribed aspirin or similar drugs, rest, and physical therapy first, and
prescribed more powerful drugs later only if the disease became much worse. Recently, many
doctors have changed their approach, especially for patients with severe, rapidly
progressing rheumatoid arthritis. This change is based on the belief that early treatment
with more powerful drugs, and the use of drug combinations in place of single drugs, may
be more effective ways to halt the progression of the disease and reduce or prevent joint
damage.
Medications Commonly Used To
Treat Rheumatoid Arthritis (PDF file)
* 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
and 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 issue for younger 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 may also include
blood, urine, and other laboratory tests and x rays.
Osteoporosis prevention is one issue that patients may want to discuss
with their doctors as part of their long-term, ongoing care. Osteoporosis is a condition
in which bones lose calcium and become weakened and fragile. Many older women are at
increased risk for osteoporosis, and their rheumatoid arthritis increases the risk
further, particularly if they are taking corticosteroids such as prednisone. These
patients may want to discuss with their doctors the potential benefits of calcium and
vitamin D supplements, hormone replacement therapy, or other treatments for osteoporosis.
Alternative and Complementary Therapies
Special diets, vitamin supplements, and other alternative approaches have
been suggested for the treatment of rheumatoid arthritis. Although many of these
approaches may not be harmful in and of themselves, controlled scientific studies either
have not been conducted or have found no definite benefit to these therapies. Some
alternative or complementary approaches may help the patient cope or reduce some of the
stress associated with living with a chronic illness. As with any therapy, patients should
discuss the benefits and drawbacks with their doctors before beginning an alternative or
new type of therapy. If the doctor feels the approach has value and will not be harmful,
it can be incorporated into a patient's treatment plan. However, it is important not to
neglect regular health care. The Arthritis Foundation publishes material on alternative
therapies as well as established therapies, and patients may want to contact this
organization for information. (See the For More Information section.)
Current Research
Over the last several decades, research has greatly increased our
understanding of immunology, genetics, and cellular and molecular biology. This foundation
in basic science is now showing results in several areas important to rheumatoid
arthritis. Scientists are thinking about rheumatoid arthritis in exciting ways that were
not possible even 10 years ago.
The National Institutes of Health funds a wide variety of medical research
at its headquarters in Bethesda, Maryland, and at universities and medical centers across
the United States. One of the NIH institutes, the National Institute of Arthritis and
Musculoskeletal and Skin Diseases, is a major supporter of research and research training
in rheumatoid arthritis through grants to individual scientists, Specialized Centers of
Research, and Multipurpose Arthritis and Musculoskeletal Diseases Centers.
Following are examples of current research directions in rheumatoid
arthritis supported by the Federal Government through the NIAMS and other parts of the
NIH.
Scientists are looking at basic abnormalities in the immune systems of
people with rheumatoid arthritis and in some animal models of the disease to understand
why and how the disease develops. Findings from these studies may lead to precise,
targeted therapies that could stop the inflammatory process in its earliest stages. They
may even lead to a vaccine that could prevent rheumatoid arthritis.
Researchers are studying genetic factors that predispose some people to
developing rheumatoid arthritis, as well as factors connected with disease severity.
Findings from these studies should increase our understanding of the disease and will help
develop new therapies as well as guide treatment decisions. In a major effort aimed at
identifying genes involved in rheumatoid arthritis, the NIH and the Arthritis Foundation
have joined together to support the North American Rheumatoid Arthritis Consortium. This
group of 12 research centers around the United States is collecting medical information
and genetic material from 1,000 families in which two or more siblings have rheumatoid
arthritis. It will serve as a national resource for genetic studies of this disease.
Scientists are also gaining insights into the genetic basis of rheumatoid
arthritis by studying rats with autoimmune inflammatory arthritis that resembles human
disease. NIAMS researchers have identified several genetic regions that affect arthritis
susceptibility and severity in these animal models of the disease, and found some striking
similarities between rats and humans. Identifying disease genes in rats should provide
important new information that may yield clues to the causes of rheumatoid arthritis in
humans.
Scientists are studying the complex relationships among the hormonal,
nervous, and immune systems in rheumatoid arthritis. For example, they are exploring
whether and how the normal changes in the levels of steroid hormones (such as estrogen and
testosterone) during a person's lifetime may be related to the development, improvement,
or flares of the disease. Scientists are also looking at how these systems interact with
environmental and genetic factors. Results from these studies may suggest new treatment
strategies.
Researchers are exploring why so many more women than men develop
rheumatoid arthritis. In hopes of finding clues, they are studying female and male
hormones and other elements that differ between women and men, such as possible
differences in their immune responses.
To find clues to new treatments, researchers are examining why rheumatoid
arthritis often improves during pregnancy. Results of one study suggest that the
explanation may be related to differences in certain special proteins between a mother and
her unborn child. These proteins help the immune system distinguish between the body's own
cells and foreign cells. Such differences, the scientists speculate, may change the
activity of the mother's immune system during pregnancy.
A growing body of evidence indicates that infectious agents, such as
viruses and bacteria, may trigger rheumatoid arthritis in people who have an inherited
predisposition to the disease. Investigators are trying to discover which infectious
agents may be responsible. More broadly, they are also working to understand the basic
mechanisms by which these agents might trigger the development of rheumatoid arthritis.
Identifying the agents and understanding how they work could lead to new therapies.
Scientists are searching for new drugs or combinations of drugs that can
reduce inflammation, can slow or stop the progression of rheumatoid arthritis, and also
have few side effects. Studies in humans have shown that a number of compounds have such
potential. For example, some studies are breaking new ground in the area of
"biopharmaceuticals", or "biologics". These new drugs are based on
compounds occurring naturally in the body, and are designed to target specific aspects of
the inflammatory process.
Investigators have also shown that treatment of rheumatoid arthritis with
minocycline, a drug in the tetracycline family, has a modest benefit. The effects of a
related tetracycline called doxycycline are under investigation. Other studies have shown
that the omega-3 fatty acids in certain fish or plant seed oils also may reduce rheumatoid
arthritis inflammation. However, many people are not able to tolerate the large amounts of
oil necessary for any benefit.
Investigators are examining many issues related to quality of life for
rheumatoid arthritis patients and quality, cost, and effectiveness of health care services
for these patients. Scientists have found that even a small improvement in a patient's
sense of physical and mental well-being can have an impact on his or her quality of life
and use of health care services. Results from studies like these will help health care
providers design integrated treatment strategies that cover all of a patient's
needs--emotional as well as physical.
Hope for the Future
Scientists are making rapid progress in understanding the complexities of
rheumatoid arthritis--how and why it develops, why some people get it and others do not,
why some people get it more severely than others. Results from research are having an
impact today, enabling people with rheumatoid arthritis to remain active in life, family,
and work far longer than was possible 20 years ago. There is also hope for tomorrow, as
researchers continue to explore ways of stopping the disease process early, before it
becomes destructive, or even preventing rheumatoid arthritis altogether. |
