21/8-2017 
 
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Arthritis

Rheumatoid Arthritis - RA

Definition and causes of Rheumatoid Arthritis - RA

Rheumatoid arthritis (RA) is a chronic arthritis, which is often accompanied by symptoms from the rest of the body. The affected joint becomes rigid and swells, as a result of an inflammation in the synovial membrane, which is the lining on the inside of a joint. If the inflammatory condition persists, the bone and the articular cartilage will also be damaged. Tendons and ligaments that support and keep the joint in its correct position, can also be damaged, and there may be deformity and malposition of the joint.

In most cases rheumatoid arthritis involves several joints. The disease usually starts at the joints in the fingers, wrists, elbows and shoulders and toes, ankles and knees. There is a tendency for the disease to be symmetrical and thus affecting the same joints in both sides of the body. Hip joints and the vertebral joints are more commonly affected by osteoarthritis.

RA is a chronic disease that typically takes periods lasting from several weeks to months to manifest itself, with relatively disease-free episodes in between. It is not known why but the symptoms of the disease are often worse during winter. The disease is relatively frequent, as it is found in 1 in 100 adults. It is most common in people over 40 years of age and are three times more common in women than in men.

RA is an autoimmune disease, i.e. is the result of the body's own immune system for unknown reasons attacking the synovial membrane, and in some cases, other body tissues. The disease has a tendency to accumulate in certain families, i.e. there is a hereditary component. It is not known to what extent environmental factors such as lifestyle, diet and other external factors influence the risk of getting the disease.
 

Symptoms of RA

The symptoms of RA develop in 2/3 of the patients gradually over a few months, whereas it in 1/3 of the patients have a more acute debut with sudden developing over few days or weeks.

The symptoms may include:

  • Symptoms from the joint: stiffness, pain and restriction of movement. The rigidity is especially present in the morning because of fluid retention in the joint. It improves with movement during the day as it is gradually removed from the joint. Typically the basic joints as well as the joints of the hand are first affected, and later involvement of the elbow, shoulder, knee and ankle joints will be present.
     
  • The general condition is often affected e.g. poor appetite and weight loss, mild temperature increase and fatigue.
     
Symptoms outside the joints may also occur.

The most common symptoms outside joints are:

  • Formation of characteristic inert nodules in your skin. These nodules occurs especially in the vicinity of joints, over protruding bone or on top of the hands and feet.
     
  • Muscular weakness as a result of the joint problems.
     
  • Some patients may experience eye problems e.g. lack of tear formation also called Sjögrens syndrome.
     
  • As RA can be both painful and debilitating, depression is common among people with RA.
     

Precautions and diagnosis

If you have longer lasting pain, stiffness, or swelling of one or more joints, you should contact your doctor to determine whether you rheumatoid arthritis or another form of arthritis.

Diagnosis is typically made based on medical history and a thorough examination of the body. A blood test that tests for the presence of a particular antibody, called rheumatoid factor, which often is present in the blood from RA patients can be performed. X-rays may be performed to assess possible damage to the joints.

Internationally a set of specific criteria has been established to determine when a patient is suffering from RA. The criteria are used mostly for scientific studies and are less useful to make the diagnosis early in the course of the disease.

Criteria for RA:

  1. Morning stiffness of joints for more than an hour.
  2. At least three joints must be involved.
  3. Involvement of the wrists or two of the basic finger joints.
  4. Symmetrical involvement of the same joints in both sides of the body.
  5. Rheumatic nodules.
  6. Positive blood test for rheumatoid factor.
  7. Typical changes in the joints, which can be seen on an X-ray.
The first four criteria must be present for at least 6 weeks. To make the diagnosis RA a minimum 4 of the 7 criteria must be present.
 

Treatment of RA

There is no curative treatment of RA. Treatment aims to control symptoms and prevent further damage to the joints by halting the development of the disease.

There are several drugs available to treat RA. Which substance that is best for the individual patient depends on the severity of the disease, age and general health. This choice is made by the physician.
  • If the symptoms are generally mild, your doctor may prescribe mild analgesics and inflammatory preparations, the so-called non steriod anti inflamatory substances (NSAID).
     
  • If the symptoms are more severe, one or more drugs from the group of so-called antirheumatic medicines, which provides more long-term anti inflammatory effect may be employed. These drugs can slow down the development of the disease, but should usually be taken over longer time before full effect is reached.
     
  • If the disease is not controlled with the above treatments, it is also possible to use the newer Biological anti reumatika, made specifically to reduce the immune response against the body itself. These preparations are often very effective and can be given with substances from the above group of traditional antireumatika. In some cases, this treatment completely halts further development of the disease and prevents further damage to the joints.
     
  • Besides medical treatment, it is also important that people with RA are instructed and trained to prevent further joint damage. This training is carried out by occupational therapists and physiotherapists who can instruct in a more prudent use of the affected joint, the use of special aids, etc. Training in a warm water basin can provide higher functionality, also in the longer term.
     
  • Surgical treatment can also be used in cases where the above drugs are not working properly. Hand surgery may be used in cases where hand function is greatly reduced.

Prognosis

Disease development in the long term is very difficult to predict because it is very different from person to person. In some cases just a single episode of RA is seen, but in most cases, the disease has a more chronic course, with lengthy, often lifelong disease. The disease progression also varies greatly with either a slow progression or a more aggressive development with fast acute deterioration.

The life span for RA patient is typically reduced by 8 to 10 years compared with the average population. An early diagnose is crucial for a good prognosis of the disease and early commencement with an effective medical treatment also positively improves the prognosis.
 

Complications

There is increased risk of infections due to a generally reduced immune system and also risk of inflammation impact in the joints rendering them prune to infections. If the joints become increasingly reddish, swollen and painful it is important to seek urgent medical assistance (see Septic arthritis in joints).

Over time osteoporosis might occur resulting in an increased tendency for bone fractures partly as a result of the disease itself but often also because of decreased mobility.

Bursitis might also develop which is an inflammatory condition in the small fluid filled sacs found in the joints.

Swelling around the wrist can cause carpal tunnel syndrome, where one of the hand nerves is pinched resulting in tingling and prickling sensations in the hand.

Joint malformations may also result to other tissue and structures near the joint. For example the joint capsule might bulge and form a bulge behind the knee which is called Baker’s cyst. The joint tendons might also be damaged and possibly burst resulting in reduced mobility in for example a finger. (see tendon injuries and tendon rupture)

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