الاسعاف الاولي : What is rheumatoid arthritis

19‏/12‏/2011

What is rheumatoid arthritis

Authors: Quinn, Campion; Greenbaum, Larry

Title: 100 Questions and Answers About Arthritis, 1st Edition

> Table of Contents > Part One - Rheumatoid Arthritis: The Basics > 1. What is rheumatoid arthritis?

Part One

Rheumatoid Arthritis: The Basics

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1. What is rheumatoid arthritis?

The ancient Greeks were aware that joint and muscle aches were sometimes associated with colds. The word rheuma in Greek means ،°flow،± or ،°discharge,،± where this ،°flow،± refers to the watery discharge from the eyes and nose during a cold. The word arthritis is also derived from the Greek،ھspecifically, from arthron (or arthr-), meaning ،°joint,،± and itis, meaning ،°inflammation.،± Thus rheumatoid arthritis (RA) was originally thought to be a disease that resulted in painful and swollen joints and that was caused by a cold.

Today, RA is still a description for a medical condition that is characterized by painful inflamed joints, but the association with watery eyes and runny noses has been discarded by modern physicians. RA is currently understood to be a systemic inflammatory disease that affects the joints and other tissues in the body. It is both chronic and progressive.

When doctors describe rheumatoid arthritis as a chronic illness, they mean that it can last for years. In some patients, disease activity may be characterized by frequent flares. Other patients may go for long periods without any symptoms at all. For the majority of patients, however, RA symptoms are something they deal with every day. This disease is progressive in nature, meaning that it tends to get worse over time. RA also has the potential to cause chronic pain,joint destruction, and functional disability.

RA affects the joints by causing an inflammation of the specialized cells that cover the ends of bones and line the joint. These specialized cells are collectively called the synovium. The inflammation in RA is caused by a person's own immune system attacking his or her own body's tissues. This type of reaction is called an ،°autoimmune،± reaction; hence RA is sometimes referred to as an autoimmune disease.

RA affects 1% of the U.S. population, or approximately 2.1 million Americans. Currently, its cause is unknown, although

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several theories have been suggested regarding its origins. For example, scientists hypothesize that RA may be caused by a complex interaction between a person's genetic makeup and his or her environment.

2. What are the symptoms of rheumatoid arthritis?

More than 200 types of arthritis have been identified. One way that physicians distinguish one type of arthritis from another is by its characteristic location, physical findings, laboratory tests, and x-rays. Early on in the disease, making a diagnosis of RA can be difficult for your physician because your symptoms may change over time. The ،°classic symptoms،± of RA are pain, swelling, stiffness, fatigue, weight loss, and joint deformity. A patient may have all of these symptoms or just a few. The symptoms may be severe and disabling or merely annoying. During the course of the disease, new symptoms can appear and others may disappear with treatment.

The main symptom of RA is joint stiffness. This stiffness occurs primarily in the hands or feet and affects the small joints first. When more than one joint is affected, the swelling is symmetrical. That is, the swelling tends to affect the same joints in both the right and left sides of the body at the same time. This condition is generally observed in RA that has been present for a few months or longer. Very early RA may not always be symmetrical, however, which increases the difficulty of making the correct diagnosis. The swelling is usually worse in the morning and improves by midday. Stiffness that persists for an hour or more, or swelling and pain that last for more than six weeks, may also be indicative of RA.

In this disease, the lining of the joint, called the synovium, is attacked by antibodies and white blood cells. This attack causes inflammation, redness, and swelling of the joint. The joint can become exquisitely tender, making even small movements impossible. Like the stiffness associated with RA, this

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joint pain tends to be symmetrical, although sometimes a single swollen painful joint is the presenting symptom of RA. The joint pain in RA is aggravated by movement or activity, such as walking, getting up from a chair, carrying groceries, or just getting dressed.

The pain and stiffness of RA often lead to a decreased range of motion in the affected joints. Range of motion (which is often abbreviated as ROM in physicians' notes) is the extent to which a joint can be flexed or extended naturally. Thus a restricted or limited range of motion is a reduction in a joint's normal range of movement. RA can cause a limited range of motion by producing joint swelling, bone erosion, or tissue impingement. Having a limited range of motion can prevent you from getting a can off a high shelf, brushing your hair, or putting on your shoes.

Long-standing RA may lead to joint deformity. That is, the chronic inflammation of RA can cause loss of cartilage and bone in the joint. The loss of these tissues may, in turn, cause the joint to become unstable and dysfunctional. As a consequence of these changes, your physician may notice a symptom called crepitus when he or she moves your joint. Crepitus is a crackling, grinding, or grating feeling or sound in the joints when they are flexed and extended. Joint crepitus is associated with significant cartilage loss and joint destruction.

In the past, joint deformity and joint destruction were typical outcomes with long-standing RA. Now, however, thanks to newer therapies that are applied earlier, there is a dramatic decrease in the amount of joint deformity and destruction experienced by people with RA.

Not all of the symptoms of RA are associated with the joints. Early-stage RA may produce systemic symptoms such as fever, chills, excessive tiredness, or rash. Small pea-sized lumps called rheumatoid nodules may also develop in the skin. Some

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patients experience a loss of appetite that can result in significant weight loss. Anemia (that is, a low red blood cell count) is another common finding in patients with RA.

When I look back now, although I didn't realize it at the time, the first signs of my arthritis started about 17 years ago while playing tennis. It just seemed like it would take forever to warm up. My hands and wrist were weak and finally I could hardly hold the racquet. At the time, I got really frustrated, blamed it on my lack of ability and just quit playing. The next time it was an issue was a few years later when I was pregnant with my second child. My hands got so swollen that I couldn't tie my shoes or even manage to change a diaper. I still didn't attribute this to arthritis, but rather to swelling caused by my pregnancy. Finally, I started to have severe pain in my feet. I could hardly get out of bed because it was so painful to put pressure on the balls of my feet. This is when I saw my family doctor and he immediately referred me to a rheumatologist.

،ھNona

3. Is rheumatoid arthritis serious?

Yes, RA is a serious disease. While some people suffer only mild discomfort and minimal disability, medical studies have demonstrated that one third of patients are unable to work five years after they are diagnosed. At ten years, more than half of all people with RA are unable to work.

Daily joint pain is an inevitable consequence of this disease. Affected joints can become deformed, and the performance of even ordinary tasks may be very difficult or impossible. In one survey of patients with RA, 70% indicated that the disease prevented them from living a fully productive life. Respondents to that survey reported that RA interfered with their ability to carry out normal daily activities, limited their job opportunities, and decreased the joys and responsibilities of family life. Most patients also experienced some degree of depression, anxiety, and feelings of helplessness.

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The effects of RA are not just limited to joint pain and stiffness. This disease can affect many organs in the body. It can cause skin lesions, lung fibrosis, osteoporosis, eye inflammation, and blindness. Severe infections, gastrointestinal (GI) problems, low blood counts, and some types of cancers and lymphomas are all more common in patients with RA than in the general public. Similarly, diseases of the teeth and gums are more common in these patients. People with RA may be twice as likely as non-arthritic individuals to have periodontal diseases: Chronic inflammation and immune dysfunction are central characteristics of these diseases. Recent research indicates that people with RA،ھand particularly those whose disease is not well controlled،ھmay have a higher risk for heart disease and stroke. While RA is not fatal, its complications may shorten the life span of affected individuals to a significant extent.

From an economic standpoint, the costs of medical and surgical treatment, plus the expense of lost wages due to disability caused by RA, add up to millions of dollars.

Although RA is a serious disease, it is not a reason for despair. With early, aggressive treatment, the symptoms can be improved and disability can be lessened or eliminated completely.

I'll never forget that day when my doctor confirmed the diagnosis and told me that I had rheumatoid arthritis. My reaction was shock and disbelief. Sure I had all these symptoms and my hands kept swelling but I thought it had to be a temporary condition. After all, I was only 40 years young with two small children. Arthritis? How can that be? I thought it was a condition that happened to older people. I didn't want to believe it. Since that time I've tried many medications, had a lot of pain and swelling in my hands to the point where I felt handicapped for short periods, but today thanks to new drugs I seldom feel that I even have arthritis.

،ھNona

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4. What causes rheumatoid arthritis?

Despite years of research and study, the precise cause of RA is not known. Physicians have determined that the pain, stiffness, and inflammation associated with this disease result from a disorder in the body's immune system. For unexplained reasons, the body's immune system،ھin the form of white blood cells and antibodies،ھattacks the joints and other tissues in the body. The continuous inflammation in the joints accounts for the damage of joints. What triggers this abnormal immune response remains unknown, although genetic factors and infectious/environmental agents have been the targets of the most study.

Genetic Factors

There appears to be a genetic component to RA. Nevertheless, although medical studies suggest that a person's genetic makeup is an important part of the story, it is not the whole answer.

For example, scientists have found that certain genes that play a role in the immune system are associated with a tendency to develop RA. The genes that influence this tendency are more common in the families of people who have RA. Although this ،°genetic tendency،± to develop RA may be passed on to the next generation, the disease does not automatically occur in everyone who inherits the genes. At the same time, some people with RA do not have these particular genes. It is possible that the disease occurs only in people who have a genetic or inherited tendency toward the disease and who are also exposed to other ،°RA-causing agents.،±

Environmental Factors

What causes an otherwise healthy person to develop RA? What triggers the immune system to attack the body? Many rheumatologists believe that an infectious agent is the trigger that produces RA in individuals who have an underlying genetic susceptibility to the disease. An infectious agent such

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as a virus or bacterium may be responsible, but the exact agent is not yet known, despite exhaustive studies.

Other Causes

Why does RA occur more frequently in women than in men? Why does RA occur more frequently in adults than in children? Could hormones have some effect on the development of RA? Some scientists think so. They suggest that hormones, or possibly deficiencies or changes in certain hormones, may promote the development of RA in a person with ،°RA-prone genes،±who has been exposed to a triggering agent from the environment.

After decades of study, scientists don't have all the answers about what causes RA, though most believe that RA develops as a result of an interaction of many factors. In addition to identifying possible causes of this disease, researchers have been able to exclude certain agents as causes of RA. According to scientific evidence now available, RA is not caused by any of the following factors:

Environments that are cold and damp
Changes in weather or ambient air pressure
Diet،ھespecially a lack (or excess) of vitamins or any other dietary elements such as fats, sugars, acids, or metals
Exposure to mercury, arsenic, or other heavy metals
Faulty absorption or elimination of substances from the bowel
Infections in the internal organs of the body
Exposure to radiation or magnetic fields
The effects of mold or yeast in the environment or in the blood

If you have further questions regarding the causes of RA, discuss them with your rheumatologist, who is an expert in that area.

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5. What is the course of rheumatoid arthritis?

Rheumatoid arthritis may begin at any age, but the most common age range during which onset begins is the twenties to fifties. Morning stiffness is a hallmark symptom of RA. People with RA often report having a half hour or more of stiffness in the morning. The same symptoms frequently occur after short periods of inactivity such as driving or sitting. For older people, symptoms of weakness or falling may be more common.

For the majority of people, RA begins insidiously, emerging over a period of weeks to months. Typically, a person can only approximately recall when his or her arthritis problems began. Some first notice joint symptoms such as stiffness,joint swelling or pain, puffy hands, or diffuse aches and pains in the muscles. For others, the first problems are systemic symptoms such as fatigue or malaise.

A minority of people with RA experience a sudden onset of severe pain and joint swelling over the course of a few days. Some patients develop their arthritis over an intermediate period of time. Older patients sometimes present with polymyalgia rheumatica (PMR) and progress to RA. PMR is characterized by severe stiffness and aching of the shoulders and hips. I often think of PMR as a limited case of RA. Although PMR is a fairly common disease, only a small percentage of these patients develop RA.

A very few patients have a ،°palindromic،± onset of disease. Palindromic rheumatism is characterized be short, intense episodes of arthritis that typically involve only one or two areas of the body, such as one hand or one foot. These episodes are very painful, but last only a day or two and get better even without treatment. In between episodes, the person is completely free of symptoms or signs of arthritis.This disorder may go on for years, may resolve spontaneously, or may progress into RA or other diseases. It is frequently misdiagnosed as gout.

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Early in the course of RA, the small joints of the fingers, wrists, and toes are involved. Large joint involvement typically develops later in the course of the illness. RA is typically a ،°symmetrical،± arthritis, meaning that the right and left sides of the body are affected fairly equally. This is almost always the case in long-standing arthritis, but the symmetry may not be so obvious early in the course of the disease. People with RA sometimes say things such as ،°Only my right hand is involved,،± but upon examination a physician will usually find that both hands are affected; the confusion arises because the findings in the other hand may be more subtle and easier to ignore. The dominant hand generally has more severe symptoms, probably because it is used more frequently. Paralysis is a major exception to this general finding. Individuals who are weak or paralyzed on one side of the body, perhaps because of a stroke or other neurological problem, typically have much milder arthritis symptoms on that side, presumably because they no longer use that side of their body very much. Muscle atrophy and weakness around affected joints is a common early finding of RA.

For a fortunate few, RA may spontaneously get better. For the majority of patients who visit arthritis clinics, however, the disease gets worse if it isn't treated in an appropriate and timely fashion. For some patients, severe joint damage can occur within a few years; other individuals may experience a much slower progression of their disease.

As a generalization, people who develop RA early in life have a faster and more severe course. Those who develop their RA later in life tend to have a slower progression of their disease.

If you develop RA symptoms such as joint pain, swelling, and fatigue, you should see your primary care physician as soon as possible. If the diagnosis is uncertain, you should ask for referral to a rheumatologist. Early diagnosis and treatment

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are the best course of action to minimize the damage that this disease can cause.

It has been quite a roller coaster ride for me these past 17 years; from the initial shock of my diagnosis to finding drugs that work. I've probably tried over 15 different medications.Some would work for a while but then the swelling in my hands would get worse so we would have to try something else. The pain in my feet went away after a very short time and I've never been bothered with that again. I can honestly say that my arthritis has never stopped me from doing any of the activities I love for very long. I am an avid skier, hiker and I'm even playing tennis again. I am responding so well to my medication that I hardly feel I have arthritis. Initially, my flare ups left my hands quite deformed, but now it's really hardly noticeable. It's really now just a little inconvenience that I can certainly live with. Of course, who knows what the future may hold but I've just got to keep on doing everything I love to do now and not worry about what may lie ahead.

،ھNona

6. Will I lose the ability to walk?

Untreated RA can cause severe damage to the hips, knees, and feet. However, with current treatments, RA shouldn't progress to the point that you cannot walk. You and your doctor can work together to limit any joint damage and maintain your mobility.

Inability to walk owing to severe RA may involve factors other than RA. Obesity or previous joint damage may lead to secondary osteoarthritis, particularly in the knees. Treatment with corticosteroids (prednisone or Medrol) is sometimes necessary to curb the intense inflammation and stiffness associated with RA. Unfortunately, these drugs are a ،°doubleedged sword،±: They can cause significant weight gain, which in turn contributes to arthritis of the legs. Bacterial joint infection (septic arthritis) can also cause severe permanent

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joint damage. Fortunately, this is a very infrequent complication of RA.

Chronic treatment with corticosteroids may lead to muscle weakness that can complicate walking-related problems. These medications are also a risk factor for the development of osteoporosis. Falling،ھor fear of falling،ھcan also dissuade patients from walking. Adaptive devices such as canes, walkers, or Rollators (a rolling walker with a seat) can make a world of difference, although younger patients are sometimes reluctant to use these devices.

Managing RA frequently requires a team approach. For example, your team may include your rheumatologist, primary care physician, orthopedic surgeon, rehabilitation specialist (or physiatrist), and physical and occupational therapists. Not everyone needs the care of every member of the treatment team at the same time, of course. As on any team, each member has a specialty that he or she brings to bear as the patient's symptoms dictate.

All patients with a diagnosis of RA should be involved in an exercise program to maintain their strength and flexibility. A physical therapist can help determine your need for therapy and teach you the exercises you should perform every day.

When joint pain is severe or the range of motion in the joint is limited, consultation with an orthopedic surgeon may be necessary. Hip or knee replacement can create dramatic improvements in the quality of life for patients with severe arthritis of those joints. While orthopedists are skilled in the treatment of severely damaged joints, they should not be solely in charge of the management of a patient with RA. This situation frequently leads to too many surgeries and too little use of disease-modifying drugs.

The worst thing you can do is to ignore your disease. Medical studies have shown that early treatment of RA can halt its

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progression and reduce the risk that you will suffer permanent joint damage.

7. Will I become disabled and unable to work?

It is impossible to predict the course of RA for a particular person, so it is equally difficult to tell if someone with RA will become disabled. However, the pattern of disease can influence the risk of disability.

For 10% of patients, RA symptoms disappear completely on their own. If disease remissionrheumatoid factor (RF) in their blood (Question 47 discusses rheumatoid factor). For other individuals, recurrent explosive attacks of joint pain and swelling are followed by periods of little or no symptoms.The most common pattern, however, is one of persistent and progressive disease activity that waxes and wanes in intensity. occurs, it usually takes place within the first six months after the onset of symptoms. Remissions occur more commonly in those patients who do not have

Risk factors for disability in RA include the following:

Long duration of disease
Many joints involved
High severity of inflammation of the joints
Presence of high levels of rheumatoid factor in the blood
Presence of high levels of cyclic citrullinated peptide (CCP) antibody in the blood (Question 55 discusses CCP antibody)
High sedimentation rate (Question 26 discusses sedimentation rates)
Family history of RA

In studies performed before the new therapies became available, approximately one third of patients were disabled after five years and 60% of patients were unable to work after having RA

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for ten years. These kinds of statistics prompt many patients to ask, ،°Isn't rheumatoid arthritis the ،®crippling arthritis،¯?،±

Fortunately, the news is not so bad these days. If RA is diagnosed and treated promptly there is no reason why patients should become ،°crippled،± or disabled. The large majority of patients who are unable to work become disabled during their first few years of the disease. This fact merely emphasizes the importance of seeking early treatment during this window of opportunity to control the disease process. Early treatment can prevent permanent joint damage and muscle weakness. By contrast, a lack of adequate treatment or noncompliance with treatment (that is, not taking your medications as prescribed) are leading factors contributing to disability.

Obviously, a person with RA may find it more difficult to continue to perform a physically demanding job, such as factory work, than to stay with a more sedentary job. If you think you won't be able to continue to work at your current job, it might be a good idea to take stock of the other sorts of job skills you have or to consider retraining. Government vocational rehabilitation training programs can be a good resource for you. Obtaining Social Security disability benefits is a very slow and frustrating process and should be considered a last resort.

I became disabled and unable to work at age 58. I do agree with your risk factors in this question. But in my own case not taking medications as prescribed was not a factor. Not taking meds as prescribed is a fool's errand.

،ھJim

8. Is rheumatoid arthritis a genetic disease?

Rheumatoid arthritis is affected by genes, but this disease is not controlled by a single gene. As a result, RA generally does not run in families. Instead, scientists believe that RA develops as a result of a complex interaction of genetic and

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environmental factors. Each person is born with a unique genetic code and has unique environmental exposures.Therefore, even if one of your family members has this disease, your own chances of developing RA are still quite low.

Examining studies of RA development in twins may help to illustrate this point. In some studies of twins, concordance was found،ھthat is, both twins developed RA. If the twins were identical and one twin developed RA, then the chance that the other twin would develop RA was 30%. If the twins were fraternal (not identical) and one of them developed RA, then the chance that the other twin would develop RA was only 5%. From these studies, we can see that while genes have some influence on the chance of developing RA, the risk is still small.

Human leukocyte antigens (HLAs) are proteins on the surface of white blood cells that are associated with the body's immune system. These markers serve as a sort of genetic fingerprint, helping the body recognize infections or tissue transplants that are considered ،°foreign.،± Some HLA markers, such as HLA-DR4, are associated with more severe RA or with complications of RA such as vasculitis (an inflammation of the blood vessels).

Because many people with RA don't have these markers in their blood, and because many people without RA do have these markers in their blood, HLA-based tests do not provide conclusive proof that someone has RA. Therefore doctors don't typically order this type of test; rather, the tests are generally used for research purposes. HLA-DR4 is one of the best-known genetic associations with RA, but other, less common associations have been identified as well.

Many people know that their parents had arthritis, but a reliable diagnosis of the parent's condition is not available. Your chances of،°inheriting،± RA from your parents are small, but if you have questions, consult your doctor.

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I have a fraternal twin brother who had the same RA and was on the identical medication. He didn't follow the doctor's advice and died of a massive heart attack in 1999. (This was a man on a fool's errand.)

،ھJim

9. Is rheumatoid arthritis caused by cigarette smoking?

The results of several large studies conducted in the past two decades support the association between cigarette smoking and the development of RA.

In one study, researchers in Finland studied 512 patients with RA. They found that men who smoked in the past but had stopped smoking were 2? times more likely to develop RA than those who never smoked. For men who were currently smoking, the risk of RA was almost 4 times greater.

In Manchester, England, medical scientists evaluated the risk of smoking in pairs of twins where one twin had RA and the other did not. These scientists used a questionnaire to record information about the twin's smoking history. They found that if one of the pair of twins smoked, the other was also likely to smoke. In those twin pairs where one twin smoked and the other didn't, the smoker had a much higher risk of developing RA than the twin who didn't smoke. This was true in both identical twin and fraternal twin pairs.

In the United States, doctors studied the medical records of more than 30,000 women between the ages of 55 and 69 years who had enrolled in the Iowa Women's Health Study. These physicians found that the incidence of RA was almost double in those women who were currently smokers as compared to the incidence in nonsmokers. The risk of developing RA also appeared to be lower for former smokers as compared to current smokers; the risk of RA was higher in

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the former smokers as compared to those who never smoked. For women who had stopped smoking at least ten years prior to the start of the study, however, this risk was decreased to the same level as the risk for women who had never smoked. The U.S. doctors were not able to give a definitive reason for the association between smoking and RA in women. Some investigators in this study suggested that an interaction between the inhaled smoke and the woman's immune system might be the culprit. Others suggested that smoking might lower the level of estrogen, which in turn might increase the risk of RA. These researchers also mentioned that in other related studies, smoking was shown to raise the level of rheumatoid factor in the body.

These studies indicate that cigarette smoking significantly increases the risk of RA in both men and women. This risk of developing RA can be added to the long list of problems associated with tobacco use, such as lung, mouth, and throat cancer; emphysema; and heart disease. If you use tobacco, please discuss options for quitting with your physician. Quitting can save your joints and your life.

10. Can gum disease cause rheumatoid arthritis?

In the early part of the twentieth century, many people believed that RA was caused by dental infections. Infections of the teeth and gums were thought to spread to the joints, causing inflammation and other symptoms of RA. For example, researchers made correlations between increases in the rate of diagnosis of RA and increases in sugar consumption (a factor in periodontal disease) in England and the United States between the years 1765 and 1859.

This belief was so common that, when a patient was diagnosed with RA during this era, dentists were often employed to find and treat the dental infections that supposedly were causing it. Often, all of a patient's teeth would be removed

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in an effort to eradicate the infection and ،°cure،± the arthritis. While this procedure wasn't effective in curing RA, belief in the infectious theory of RA persisted. Over time, interest in this theory eventually waned as studies revealed that RA was controlled by the body's immune system. Therapy was then directed at controlling the inflammation rather than looking for dental infections.

Studies of large populations still show an association between RA and diseases of the teeth and gums, however. Medical researchers, however, have proposed alternative theories about the source of this observed association of RA and diseases of the teeth and gums. Perhaps gum disease and RA occur together because RA makes using a toothbrush difficult. Tooth and gum disease might result from being unable to effectively brush and floss one's teeth. Furthermore, patients who have RA take many medications that can affect the teeth.

Many studies have been undertaken to compare the rates of tooth plaque and dental caries (cavities) in two populations،ھone group consisting of patients with RA and the other group consisting of age- and sex-matched people without RA. While researchers found that the rates of dental caries and plaque were the same, RA patients had a higher level of periodontal disease and a higher rate of tooth loss. Based on these findings, some scientists have suggested that bacterial infections around the teeth can trigger a chain of events in genetically susceptible individuals that ultimately results in RA. The bacteria interact with proteins and white blood cells in the body, ،°tricking،± the white blood cells into creating an inflammatory reaction with the body's connective tissue.

While some intriguing evidence supports this theory, the jury is still out on whether it is a significant cause of RA.