Rheumatoid Arthritis.

Rheumatoid Arthritis is a unique disorder, in the sense that, it is caused by the auto immune system of our body itself. The auto immune system is the mechanism which acts as defense force of our body, protecting it from external invasive forces (eg bacteria). Rheumatoid Arthritis is thus a result of our own auto immune system.

What is Rheumatoid Arthritis.

Rheumatoid Arthritis is chronic, progressive inflammatory disorder which attacks the smaller synovial joints of the hands and feet and can cause synositis and erosion of the cartilage of the joints. Sometimes bigger joints like the shoulder and knees can also get involved. This inflammatory process  can also extend to the lungs, heart, skin and the eyes.

Rheumatoid arthritis picture.

Rheumatoid Arthritis Causes.

In RA, the auto immune mechanism inadvertently attacks the tissues of the body itself, causing inflammation and damage. However, why this happens is still unknown.

Rheumatoid Arthritis Symptoms.

Symptoms of Rheumatoid Arthritis are related to the target of damage and accordingly manifest themselves. However, there are periods of remissions, when the patient feels well but when the condition flares up, the symptoms reappear.

• Joints in Rheumatoid Arthritis: As mentioned above, small synovial joints are more commonly affected like the joints of the hands and the feet. The joints manifest signs of inflammation and get painful, swollen, stiff and become tender. More than one joints are affected. Rarely, only  a  single joint may get affected. A typical feature in RA is early morning stiffness and Rheumatoid Arthritis Pain which later is relieved by movements. This pain and stiffness typically also appears after a period of inactivity being again relieved by movements. This is a differentiating point with Osteoarthritis where the pain is aggravated by movement and only one of the larger joint is involved. The tendons, the cartilage and the bone surfaces of the joint get eroded leading to limitations of movement and deformity of the joint. It becomes increasingly difficult to perform daily minor tasks like holding a glass or a spoon.

Rheumatoid arthritis picture of deformity of joints.

• Low grade fever in rheumatoid arthritis.
• Loss of appetite in rheumatoid arthritis  leading to weight loss and weakness.

Rheumatoid Arthritis Signs and Complications.

As mentioned above, RA may also affect other organs and parts of the body, besides the joints.

• Skin: Small rheumatoid nodules appear subcutaneously ( below the skin).They may vary in size from a few millimeters to a few centimeters. They usually appear on the bony prominences. Reddish or purplish discoloration patches appear on the skin due to vasculitis of the small blood capillaries.
• Glands around the eyes and throat become enlarged due to inflammation leading to dryness of the eyes and the throat.
• Inflammation of the Pleura ( lining of the lungs) leads to Pleurisy which gives rise to symptoms of chest pain which increases on deep breathing, cough and shortness of breadth.
• Inflammation of the Pericardium due to  RA  causes chest pain due to pericarditis,
• Patients of RA are prone to atherosclerosis, thereby making them more inclined to get a heart attack or a stroke.
• Anaemia is also caused by RA because it causes reduction in the red blood cells in the blood.
• Carpal Tunnel Syndrome is caused due to pinching of the median nerve as a result of the swelling of the wrist joints.
• Osteoporosis (reduced  bone density) results due to immobilization of the joints  and can also occur due to side effects of medication given for RA. ( such as steroids).

Rheumatoid Arthritis Diagnosis.

Diagnosis of Rheumatoid Arthritis is based on the following:

1) Medical history of Rheumatic Arthritis:

If the  history elicits Rheumatoid Arthritis signs and symptoms of joint involvement as explained above, one can be more or less sure it is RA.

(2) Blood Tests for Rheumatic Arthritis:

• ESR is raised due to presence of  inflammation.
• RBC count is reduced due to presence of anaemia as explained above.
• Platelet count is increased due to inflammation. However, it can be reduced due to side effects of drugs.
• C – Reactive proteins (CRP) are raised, again due to inflammation.
• RA factor is present in about 80% of RA patients. Higher  levels of RA factor indicate higher levels of inflammation.
• Anti nuclear antibodies (ANA) is raised in about 40% of the RA cases. However, this is not a specific test for RA as ANA can be found raised in other diseases as well.

(3) Radiology Studies for Rheumatoid Arthritis.

1)     X rays of the  involved joints show loss of bone density, erosion of the cartilage and edges of the bones. On x ray, this shows as reduced  joint space. Inflammation of soft tissues around the joints is also seen.

2)     MRI is particularly useful in detecting the erosion of cartilage and bones of RA in the early stages.

3)      Ultrasound

4)     Bone Densitometry to detect osteoporosis which occurs in RA.

Treatment of Rheumatoid Arthritis.

Rheumatoid Arthritis Treatment aims to stop the inflammation and pain, prevent further bone damage and improve the function of the affected joint. Treatment details are given here for your information only and has to taken with due advice of your doctor.

Rheumatoid Arthritis Treatment.

(A) Therapy for Rheumatoid Arthritis.

1. Physiotherapy for Rheumatoid Arthritis is where the physio guides you to exercise the muscles of the affected joints to maintain the mobility and reduce pain

2. Occupational Therapy for Rheumatoid Arthritis advices the patient to carry on his everyday routine in ways that will not put the affected joints under strain. For example,  a door can be opened by leaning on it instead of opening it with your hands whose  joints are inflamed.

(B)Rheumatoid Arthritis Medications.

Rheumatoid Arthritis Drugs are basically used for relief of symptoms and to suppress the auto immune system which causes Rheumatoid Arthritis.

1. Non steroid anti inflammatory drugs (NSAIDs) such as Ibuprofen and Naproxen sodium helping reducing pain and inflammation.

2. Steroids such as Prednisolone are given to reduce inflammation. Side effects of steroids are to be watched for  and these drugs are given in a tapering dosage.

3. Diseases modifying anti rheumatic drugs (DMARDs) act to stop the progressive damage that is taking place of the joints and tissues. Methotrexate for Rheumatoid Arthritis is a commonly used drug. Treatment with DMARDs is prolonged and taken over 2 to 3 months and due to their serious side effects were  formerly  reserved for patients who have joint damage. However, in choosing lesser of the two evils, nowadays, therapy with DMARDs is started soon after diagnosis and is given in combination with another drug. This lessens the seriousness of the side effects. It is to be noted here that, DMARDs do not succeed in every patient, but in most of them.

4. Immunosuppressants: As Rheumatoid arthritis is due to our own autoimmune system, immunosuppressants  are used to modify our autoimmunity. They block the action of certain proteins of our autoimmune system. This prevents further damage to the affected joints. These drugs are often given in combination with DMARDs. Combination helps in two ways:  gives better effect and  reduces the side effects of these two drugs.

5. Prosorba column is a device which filters out the anti bodies, which cause inflammation of the joints, from the blood. This therapy is now not used due to its ineffectiveness.

(C) Surgery for Rheumatoid Arthritis.

1. Joint replacement is done by replacing the joint with a metal one.

2. Synovial sac is removed surgically when it is damaged due to chronic inflammation.

3. Tendon repair is carried out when the tendon is badly damaged.

4. Joint fusion is carried out when joint replacement is not an option.

Rheumatoid Arthritis Prognosis|Living with Rheumatoid Arthritis.

Rheumatoid arthritis is characterized by periods of remissions and flares.

• In some patients, after an initial attack, there may be a period of many years with no symptoms
• In some patients, there may be periods of remissions alternating with periods of flares.
• In most of the patients, RA stays on to be chronic and progressive. These patients have to take prolonged treatments.

Alternative Treatment for Rheumatoid Arthritis.

This does not play a significant role in RA and cannot be relied upon solely. This is because  after the onset of RA,  prompt treatment to stop bone damage immediately is essential.  Herbal remedies  for Rheumatoid Arthritis do not offer such prompt results.

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