Rheumatoid arthritis

Rheumatoid arthritis is a chronic inflammatory disorder that most typically affects the small joints in your hands and feet. Unlike the wear-and-tear damage of osteoarthritis, rheumatoid arthritis affects the lining of your joints, causing a painful swelling that can eventually result in bone erosion and joint deformity.
An autoimmune disorder, rheumatoid arthritis occurs when your immune system mistakenly attacks your own body's tissues. In addition to causing joint problems, rheumatoid arthritis can also affect your whole body with fevers and fatigue.
Rheumatoid arthritis is two to three times more common in women than in men and generally occurs between the ages of 40 and 60. While there's no cure for rheumatoid arthritis, treatment options have expanded greatly in the past few decades.

Signs and symptoms of rheumatoid arthritis may include:

• Joint pain
• Joint swelling
• Joints that are tender to the touch
• Red and puffy hands
• Firm bumps of tissue under the skin on your arms (rheumatoid nodules)
• Fatigue
• Morning stiffness that may last for hours
• Fever
• Weight loss

Smaller joints affected first
Early rheumatoid arthritis tends to affect your smaller joints first — the joints in your wrists, hands, ankles and feet. As the disease progresses, your shoulders, elbows, knees, hips, jaw and neck also can become involved. In most cases, symptoms occur symmetrically — in the same joints on both sides of your body.

Symptoms may come and go
Rheumatoid arthritis signs and symptoms may vary in severity and may even come and go. Periods of increased disease activity — called flare-ups or flares — alternate with periods of relative remission, during which the swelling, pain, difficulty sleeping and weakness fade or disappear.

When to see a doctor
Make an appointment with your doctor if you have persistent discomfort and swelling in multiple joints on both sides of your body.


Rheumatoid arthritis occurs when your immune system attacks the synovium, the lining of the membranes that surround your joints. The resulting inflammation thickens the synovium, which can eventually invade and destroy the cartilage and bone within the joint. The tendons and ligaments that hold the joint together weaken and stretch. Gradually, the joint loses its shape and alignment.

Doctors don't know what starts this process, although a genetic component appears likely. While your genes don't actually cause rheumatoid arthritis, they can make you more susceptible to environmental factors — such as infection with certain viruses and bacteria — that may trigger the disease.

Factors that may increase your risk of rheumatoid arthritis include:

• Sex. Women are more likely to develop rheumatoid arthritis than men are.
• Age. Rheumatoid arthritis can occur at any age, but it most commonly begins between the ages of 40 and 60.
• Family history. If a member of your family has rheumatoid arthritis, you may have an increased risk of the disease. Doctors don't believe you can directly inherit rheumatoid arthritis. Instead, it's believed that you can inherit a predisposition to rheumatoid arthritis.
• Smoking. Smoking cigarettes increases your risk of rheumatoid arthritis. Quitting can reduce your risk.

Rheumatoid arthritis causes joint damage that can be both debilitating and disfiguring. Damage to your joints may make it difficult or impossible to go about your daily activities. You may find at first that tasks take more energy to accomplish. With time you may find you are no longer able to do them at all. Newer treatments may stop joint damage or prevent it so that you can continue the activities you enjoy. 

Evaluation

While you might first discuss your symptoms with your family doctor, he or she may refer you to a rheumatologist — a doctor who specializes in the treatment of arthritis and other inflammatory conditions — for further evaluation.

What you can do
Write a list that includes:

• Detailed descriptions of your symptoms, including when they started and if anything makes them better or worse
• Information about medical problems you've had in the past
• Information about the medical problems of your parents or siblings
• All the medications and dietary supplements you take
• Questions you want to ask the doctor

What to expect from your doctor
During the physical exam, your doctor will check your joints for swelling, redness and warmth. He or she will also check your reflexes and muscle strength.

In addition to the physical exam, your doctor might order imaging and laboratory tests to help determine the cause of your signs and symptoms. Rheumatoid arthritis can be difficult to diagnose in its early stages because its early signs and symptoms mimic those of many other diseases. And no one test or physical finding confirms the diagnosis.

Blood tests
People with rheumatoid arthritis tend to have an elevated erythrocyte sedimentation rate (ESR, or sed rate), which indicates the presence of an inflammatory process in the body. Other common blood tests look for rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP) antibodies.

X-rays
Your doctor may recommend X-rays to help track the progression of rheumatoid arthritis in your joints over time.


There is no cure for rheumatoid arthritis. Medications can reduce inflammation in your joints in order to relieve pain and prevent or slow joint damage. Occupational and physical therapy can teach you how to protect your joints. If your joints are severely damaged by rheumatoid arthritis, surgery may be necessary.

Medications
Many drugs used to treat rheumatoid arthritis have potentially serious side effects. Doctors typically prescribe medications with the fewest side effects first. You may need stronger drugs or a combination of drugs as your disease progresses.

• NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain and reduce inflammation. Over-the-counter NSAIDs include ibuprofen (Advil, Motrin, others) and naproxen sodium (Aleve). Stronger versions of these NSAIDs and others are available by prescription. Side effects may include ringing in your ears, increased bruising, gastric ulcers, heart problems, stomach bleeding, and liver and kidney damage.
• Steroids. Corticosteroid medications, such as prednisone and methylprednisolone (Medrol), reduce inflammation and pain and slow joint damage. Side effects may include easy bruising, thinning of bones, cataracts, weight gain, a round face and diabetes. Doctors often prescribe a corticosteroid to relieve acute symptoms, with the goal of gradually tapering off the medication.
• Disease-modifying antirheumatic drugs (DMARDs). These drugs can slow the progression of rheumatoid arthritis and save the joints and other tissues from permanent damage. Common DMARDs include methotrexate (Rheumatrex, Trexall), leflunomide (Arava), hydroxychloroquine (Plaquenil), sulfasalazine (Azulfidine) and minocycline (Dynacin, Minocin). Side effects vary but may include liver damage, bone marrow suppression and severe lung infections.
• Immunosuppressants. These medications act to tame your immune system, which is out of control in rheumatoid arthritis. Examples include azathioprine (Imuran, Azasan), cyclosporine (Neoral, Sandimmune, Gengraf) and cyclophosphamide (Cytoxan). These medications can increase your susceptibility to infection.
• TNF-alpha inhibitors. Tumor necrosis factor-alpha (TNF-alpha) is an inflammatory substance produced by your body. TNF-alpha inhibitors can help reduce pain, morning stiffness, and tender or swollen joints — usually within one or two weeks after treatment begins. Examples include etanercept (Enbrel), infliximab (Remicade) and adalimumab (Humira). Potential side effects include injection site irritation, congestive heart failure, blood disorders, lymphoma, demyelinating diseases and increased risk of infection.
• Other drugs. Several other rheumatoid arthritis drugs target a variety of inflammatory substances produced by your body. These drugs include anakinra (Kineret), abatacept (Orencia) and rituximab (Rituxan). Potential side effects include injection site reactions, decreased white blood cell counts, headache and an increase in upper respiratory infections.

Therapy
An occupational therapist can help you find different ways to approach everyday tasks in order to take stress off your painful joints. For instance, if your fingers are sore, pick up an object using your forearms. Lean into a glass door to force it open, rather than pushing on the door with sore arms.
Assistive devices can make it easier to go about your day without stressing your painful joints. For instance, using specially designed gripping and grabbing tools may make it easier to work in the kitchen if you have pain in your fingers. Try a cane to help you get around. Your doctor or occupational therapist may have ideas about what sorts of assistive devices may be helpful to you. Catalogs and medical supply stores also may be places to look for ideas.

Surgery
If medications fail to prevent or slow joint damage, you and your doctor may consider surgery to repair damaged joints. Surgery may help restore your ability to use your joint. It can also reduce pain and correct deformities. Rheumatoid arthritis surgery may involve one or more of the following procedures:

• Total joint replacement (arthroplasty). During joint replacement surgery, your surgeon removes the damaged parts of your joint and inserts a prosthesis made of metal and plastic.
• Tendon repair. Inflammation and joint damage may cause tendons around your joint to loosen or rupture. Your surgeon may be able to repair the tendons around your joint.
• Removal of the joint lining (synovectomy). If the lining around your joint (synovium) is inflamed and causing pain, your surgeon may recommend removing the lining of the joint.
• Joint fusion (arthrodesis). Surgically fusing a joint may be recommended to stabilize or realign a joint and for pain relief when a joint replacement isn't an option.

Surgery carries a risk of bleeding, infection and pain. Discuss the benefits and risks with your doctor.

Self-care Measures

You can take steps to care for your body if you have rheumatoid arthritis. These self-care measures, when used along with your rheumatoid arthritis medications, can help you manage your signs and symptoms.

Exercise regularly
Gentle exercise can help strengthen the muscles around your joints, and it can help fight fatigue you might feel. Check with your doctor before you start exercising. If you're just getting started, begin by taking a walk. Try swimming or gentle water aerobics. Public pools and health clubs in your area may offer classes.
Avoid exercising tender, injured or severely inflamed joints. If you feel new joint pain, stop. New pain that lasts more than two hours after you exercise probably means you've overdone it. If pain persists for more than a few days, call your doctor.
Apply heat or cold
Heat can help ease your pain and relax tense, painful muscles. One of the easiest and most effective ways to apply heat is to take a hot shower or bath for 15 minutes. Other options include using a hot pack or an electric heating pad set on its lowest setting.
Cold may dull the sensation of pain. Cold also has a numbing effect and decreases muscle spasms. Don't use cold treatments if you have poor circulation or numbness. Techniques may include using cold packs, soaking the affected joints in cold water and ice massage.
Many people with rheumatoid arthritis find relief by soaking their aching joints in warm water for four minutes and then in cool water for a minute. Repeat the cycle for a half-hour, ending with a warm-water soak.
Relax
Find ways to cope with pain by reducing stress in your life. Techniques such as hypnosis, guided imagery, deep breathing and muscle relaxation can all be used to control pain.

Complementary medications

Some common complementary and alternative treatments that have shown promise for rheumatoid arthritis include:

• Thunder god vine. Preparations made from the peeled root of this plant are used in traditional Chinese medicine to treat inflammatory and autoimmune diseases. Studies indicate that it may be helpful in treating rheumatoid arthritis. Side effects include diarrhea, menstrual changes and hair loss.
• Plant oils. The seeds of evening primrose, borage and black currant contain a type of fatty acid that may help with rheumatoid arthritis pain and morning stiffness. Side effects may include nausea, diarrhea and gas. Some plant oils can cause liver damage or interfere with medications, so check with your doctor first.
• Fish oil. Some preliminary studies have found that fish oil supplements may reduce rheumatoid arthritis pain and stiffness. Side effects can include nausea, belching and a fishy taste in the mouth. Fish oil can interfere with medications, so check with your doctor first.
• Tai chi. This movement therapy involves gentle exercises and stretches combined with deep breathing. Many people use tai chi to relieve stress in their lives. Small studies have found that tai chi may reduce rheumatoid arthritis pain. When led by a knowledgeable instructor, tai chi is safe. But don't do any moves that cause pain.

MSM for arthritis pain: Is it safe?

Few studies have examined the long-term effects of the dietary supplement called methylsulfonylmethane (MSM). One study suggested that it's safe to take MSM for up to 12 weeks. But further research is needed to assess its safety for long-term use.
There's no conclusive evidence that MSM is effective in reducing arthritis pain. Two small studies have suggested that MSM may reduce joint pain in people with osteoarthritis. Side effects of MSM may include stomach upset, diarrhea and headache.
Although there is great interest in using MSM to treat a variety of conditions, including arthritis, more research is needed to determine its potential benefits and risks.

Coping and support

The degree to which rheumatoid arthritis affects your daily activities depends in part on how well you cope with the disease. Talk to your doctor or nurse about strategies for coping. With time you'll find what strategies work best for you. In the meantime, try to:

• Take control. With your doctor, make a plan for managing your arthritis. This will help you feel in charge of your disease. Studies show that people who take control of their treatment and actively manage their arthritis experience less pain and make fewer visits to the doctor.
• Know your limits. Rest when you're tired. Rheumatoid arthritis can make you prone to fatigue and muscle weakness. A rest or short nap that doesn't interfere with nighttime sleep may help.
• Connect with others. Keep your family aware of how you're feeling. They may be worried about you but might not feel comfortable asking about your pain. Find a family member or friend you can talk to when you're feeling especially overwhelmed. Also connect with other people who have rheumatoid arthritis — whether through a support group in your community or online.
• Take time for yourself. It's easy to get busy and not take time for yourself. Find time for what you like, whether it's time to write in a journal, go for a walk or listen to music. Use this time to relieve stress and reflect on your feelings.

Remember, you don't have to make all of these changes at once. By gradually incorporating these methods into your day-to-day activities, you're more likely to stick with them.
Keep an open mind about how you do everyday tasks. You might have to change some old habits, but the reward is that your joints may cause you less pain.

Joint protection: Tips for managing rheumatoid arthritis pain

To avoid unnecessary joint strain and increased rheumatoid arthritis pain, consider these tips for protecting your joints.
Move each joint through its full pain-free range of motion at least once a day
This will help you maintain the active motion of your joints. The amount you're able to move each joint without pain may vary from day to day — take care not to overdo it. Keep movements slow and gentle — forcing a motion past the point of a tolerable stretch can damage your joints.
Learn to understand and respect your rheumatoid arthritis pain
Understand the difference between the general discomfort of rheumatoid arthritis and the pain from overusing a joint. By noting when an activity causes joint pain, you can then avoid repeating that movement or think of ways that you can modify the task. Pain that lasts more than an hour after an activity may indicate that the activity was too stressful. Remember that you're more likely to damage your joints when they're painful and swollen.
Be careful how you use your hands
You use your fingers in many ways during your day-to-day activities. You can perform most tasks in easier ways that put less deforming forces on your joints.

• Avoid positions that push your other fingers toward your little finger. For instance, avoid tasks that require forceful or prolonged gripping or pinching. Finger motions should be in the direction of your thumb whenever possible. For example, when opening jars use a gripping aid and direct the force through the palm of your hand rather than just through your fingers. There are several types of jar opening devices available.
• Avoid making a tight fist. Use tools with thick or ergonomically designed handles, which make the tools easier to hold.
• Avoid prolonged pinching items between your thumb and your fingers. Hold a book, plate or mug in the palms of your hands. If you're reading for long periods, use a book holder. Instead of a clutch-style purse, select one with a shoulder strap.

Use good body mechanics
The way you position your body largely affects how much strain you put on your joints. Proper body mechanics allow you to use your body more efficiently and conserve energy.

• When you're sitting, the proper height for a work surface is 2 inches below your bent elbow. Make sure you have good back and foot support when you sit. Your forearms and upper legs should be well supported, resting level with the floor.
• If you type at a keyboard for long periods and your chair doesn't have arms, consider using wrist or forearm supports. An angled work surface for reading and writing is easier on your neck.
• When you're standing, the height of your work surface should enable you to work comfortably without stooping.
• Increase the height of your chair to decrease stress on your hips and knees as you get up and down.
• To pick up items from the floor, stoop by bending your knees and hips. Or sit in a chair and bend over.
• Carry heavy objects close to your chest, supporting the weight on your forearms.
• Maintain good posture when standing or sitting. Poor posture causes uneven weight distribution and may strain your ligaments and muscles.

Use the strongest joint available for the job
Save your smaller, weaker joints for the specific jobs that only they can accomplish. Throughout the day, favor large joints. For example, carry objects with your palm open, distributing the weight equally over your forearm. Slide objects along a counter or workbench rather than lifting them. When opening cabinets or heavy doors, use a loop that you can pull with your wrist or forearm to decrease stress on your fingers.
Avoid keeping your joints in the same position for a prolonged period of time
Don't give your joints the chance to become stiff — keep them moving. When writing or doing handwork, release your grip every 10 to 15 minutes, or when your hand feels fatigued. On long car trips, get out of the car, stretch and move around at least every one or two hours. While watching television, get up and move around every half-hour.
Balance periods of rest and activity during the day
Effectively managing your workload throughout the day can help you avoid overworked joints. Take time to organize your daily tasks. Work at a steady, moderate pace and avoid rushing. Rest before you become fatigued or sore. Alternate light and moderate activities throughout the day. And take periodic stretch breaks.