Rheumatoid Arthritis (RA) is more than just arthritis. Indeed, many doctors call it “rheumatoid disease” to emphasize the widespread nature of this process. The term rheumatoid arthritis is trying awkwardly to say the same thing; rheumat refers to the stiffness, body aching, and fatigue that are often termed “rheumatism.” “Rheumatoid” means “like rheumatism.”
About 0.5% of our population has rheumatoid arthritis, some 1 million individuals in the United States. Most of these people (about three-quarters) are women. The condition usually appears in middle life, in the forties or fifties, although it can begin at any age. Rheumatoid arthritis in children is quite different and is described in the next section. Rheumatoid arthritis has been medically identified for about 200 years. Bone changes in the skeletons of some Mexican Indian groups suggest that the disease may have been around for thousands of years.
Many, but not all, patients with RA have a particular set of genes that predispose to development of RA. Only about 1 out of 30 persons with these genes actually gets rheumatoid arthritis, so the disease seldom affects more than one family member. In its most severe forms, and without good medical treatment, it can result in deformities of the joints and severe disability. Fortunately, many people with RA do well and lead essentially normal lives. Fear of rheumatoid arthritis, sometimes greatly exaggerated, can be as harmful as the disease itself. (Scheller, 28).
Nodules, usually between the size of a pea and a mothball, may form beneath the skin in about 10% of patients. Each represents an inflammation of a small blood vessel. They come and go during the course of the illness and usually are not a big problem. They do tend to occur in people with the most severe kinds of RA. Rarely, they become sore or infected, particularly if they are located around the ankle. Even more rarely they form in the lungs or elsewhere in the body.
Laboratory tests sometimes can help the doctor diagnose rheumatoid arthritis. The rheumatoid factor or latex is the most commonly used test. Although this test may be negative in the first several months, it is eventually positive in about 80% of RA patients. The rheumatoid factor is actually an antibody to certain proteins and can sometimes be found in patients with other diseases.
Most patients with RA notice problems in addition to those of the joints themselves. These are usually general problems such as muscle aches, fatigue, muscle stiffness (particularly in the morning), and yet a low fever. Morning solidity is often observed as a characteristic of RA and is termed sometimes the gel phenomenon. Patients often have problems with fluid accumulation, particularly around the ankles. An anemia (low red blood cell count) is quite common, although it is seldom severe enough to require treatment. (Chen, 47)
There can be other problems due to the synovitis. A Baker cyst can form behind the knee and may feel like a tumor. It is just a fluid-filled joint sac, but it can extend down into the back of the calf and may cause pain like a blood clot. The carpal tunnel syndrome (Wrist Pain, S16) involves pressure by the synovitis on a nerve at the wrist. Both of these conditions can occur in patients without rheumatoid arthritis.
The course of patients with RA usually falls into one of three patterns. The first, and best, is that of a brief illness lasting at most a few months and leaving no disability; this course is sometimes called monocyclic. The second involves a series of episodes of illness, separated by periods of being entirely well. This is sometimes termed polycyclic and usually does not result in very much physical impairment. The third, termed chronic, is a more constant disease lasting a number of years, usually for life. (Eichenfield, et. al. 480) The great majority of patients with rheumatoid arthritis have this chronic form. Initially it is difficult to be certain which pattern will occur, but a chronic course is suggested by the presence of the rheumatoid factor on a blood test and is strongly suggested if the condition has caused problems continuously for an entire year. (Meenan, et. al. 1484)
Often it is hard for patients and relatives to appreciate that even the worst forms of rheumatoid arthritis can sometimes get better with time. The arthritis tends to become less aggressive. The synovitis becomes less active, and the fatigue and stiffness decrease. After several years the disease is less likely to spread to new joints. But even though the disease is less violent, any destruction of bones and ligaments that occurred in earlier years will remain. Deformities do not improve, even though no new damage is occurring. Hence, it is extremely important to treat the disease correctly in the early years, so that the joints will work well after the disease activity subsides.
Treatment programs for rheumatoid arthritis are often complicated and can be confusing. In this section we broadly outline techniques for sound management. The combination of measures best for patient needs to be worked out with the doctor. It has been said that the person who has himself for a doctor has a fool for a patient. In many areas of medicine, and for some kinds of arthritis, this is not true—patient can do just as well looking after himself. But with rheumatoid arthritis patient do need a doctor. Indeed, with rheumatoid arthritis. The critical early treatment can begin at the right time. Only rheumatologists are familiar with the latest and most effective treatments.
First of all use some common sense. Patient’s rheumatoid arthritis may be with him, on and off, for months or years. Think of how patient want to be 20 years from now. The best treatments are those that will help patient maintain a life that is as nearly normal as possible. Often the worst treatments are those that offer immediate pain relief, since they may allow joint damage to go on or may cause delayed side effects that ultimately make patient feel worse. Patient must develop some patience with the disease and with its management. Patient has to adjust patient’s thinking to operate in the same slow time frame that the disease uses. Patient and doctor will want to anticipate problems before they occur so that patient can avoid them. The adjustment to a long-term illness, with the necessity to plan treatment programs that may take months to get results, is a difficult psychological task. This adjustment will be one of patient’s hardest jobs in battling his arthritis. (Felson, 727-35)
A particularly painful joint may require a splint to help it rest. Still, patient will want to exercise the joint by moving it gently in different directions to prevent it from getting stiff, and patient will not want to use a splint for too long—patient may decide to use it only at night. As the joint gets better, begin using the joint, gently at first, but slowly progressing to more and more activity. In general, favor activities that build good muscle tone, not those that build great muscle strength. Walking and swimming are better than weight lifting, since tasks requiring a lot of strength put a lot of stress on the joint. And regular exercises done daily are better than occasional spurts of activity that stress joints not ready for so much exertion.
Common sense and a regular, long-term program are the keys to success. A return to full normal activity should be undertaken gradually, with a long-term conditioning program that includes rest when needed and graded increases in activity during non-resting periods. (Cohen, S271) Physical therapists and occupational therapists can often help with specific advice and helpful hints. The best therapists will help patient develop patient’s own program for home exercise and will teach patient the exercises and activities that will help his joints. However, don’t expect the therapist to do patient’s program for him. Patient’s rest and exercise program cannot consist solely of formal sessions at a rehabilitation facility. Patient must take the responsibility to build the habits that will, on a daily basis, protect and strengthen patient’s joints.
Medications are required by almost all patients with rheumatoid arthritis, and often must be continued for years. Great advancement has been made currently with disease-modifying antirheumatic drugs (DMARDs), bringing about a virtual revolution in the treatment of rheumatoid arthritis. These crucial drugs should be prescribed early in the course of the disease. The most important rule now is: “Don’t do too little, too late.” The traditional DMARDs are Plaquenil, Azulfidine, gold shots, oral gold, penicillamine, methotrexate, Imuran, and cyclosporine. The new DMARDs are leflunomide and the anti-tumor necrosis factor drugs, and these are substantial advances. The great majority of patients with RA should be taking one or a combination of DMARDs at all times.
Antimalarial drugs such as chloroquine or Plaquenil are often used as the first DMARDs. Gold injections are often very helpful and sometimes result in complete disappearance of the arthritis if used early enough. Penicillamine can also bring dramatic improvement. Auranofin and sulphasalazine are more recent additions to this drug category, and both are major advances. Surgery sometimes can restore the function of a damaged joint. Hip replacement, knee replacement, shoulder replacement, synovectomy of the knee, metatarsal head resection, and synovectomy of the knuckles are among the most frequent operations.
Works Cited
Chen, Steven; Gill, Mark A. Pain and rheumatoid arthritis: An update. Drug Topics, 4/3/2000, Vol. 144 Issue 7, p47.
Cohen S, Weaver A, Schiff M, Strand V. Two year treatment of active rheumatoid arthritis (RA) with leflunomide (LEF) compared with placebo (PL) or methotrexate (MTX). Arthritis Rheum 1999; 42: S271.
Eichenfield, Andrew H.; Athreya, Balu H.; Doughty, Robert A.; Cebul, Randall D. Utility of Rheumatoid Factor in the Diagnosis of Juvenile Rheumatoid Arthritis. Pediatrics, 86, Vol. 78 Issue 3, p480.
Felson DT, Anderson JJ, Boers M, et al. American College of Rheumatology: preliminary definition of improvement in rheumatoid arthritis. Arthritis Rheum 1995; 38: 727-35.
Meenan, Robert F.; Kazis, Lewis E.; Anderson, Jennifer J. The Stability of Health Status in Rheumatoid Arthritis: A Five-Year Study of Patients with Established Disease. American Journal of Public Health, 88, Vol. 78 Issue 11, p1484.
Scheller, Melanie. Living with juvenile rheumatoid arthritis…and doing fine. Current Health 2, 1998, Vol. 24 Issue 5, p28.