For people living with rheumatoid arthritis (RA) and their friends,
family, and caregivers, success in managing RA's impact on daily life
begins with accurate information about the disease and its treatment.
» What is RA?
» What is the history of RA?
» What are the symptoms of RA?
» How is RA diagnosed?
What is RA?
For people unfamiliar with arthritis and its true effect on the lives of patients,
loved ones and caregivers, the disease may seem like a single affliction that strikes
certain types of people in predictable ways. In fact, there are over 100 different types
of arthritis and related diseases that can affect the lives of patients.
Most often arthritis affects the joints—the areas in the body where two or more bones meet.
In addition, there are several different parts of the joint that may be affected by arthritis,
such as the cartilage, synovium, tendons and muscles. The cartilage is a soft, protective material
that covers the neighbouring ends of bones that form the joints, cushioning them and keeping them
from rubbing together. The joint is also enclosed in a capsule and lined with a tissue called the synovium.
The synovium releases a slippery fluid that lubricates the joints and helps them to move freely.
Finally, tendons and muscles support the structure of the joint and are responsible for allowing the
joint to move. When a person has arthritis, each of these areas can be affected in very specific ways.
Importantly, arthritis does not only affect joints but also other parts of the body,
including the skin, eyes, internal organs, and mouth.
Rheumatoid Arthritis
RA is a specific type of arthritis that causes inflammation of the joints owing to abnormalities
in the body's own defence system against infection, the immune system. Affecting approximately 0.5—1%
of the population (approximately 2.9 million people in Europe), RA is more common in women than men.
In the RA disease process, inflammation involves the synovium and may cause damage to the cartilage
and bone itself. Areas that may be affected include the joints of the hands, wrists, neck, jaw, elbows,
feet, and ankles. Often RA causes the joints of the body to be affected in a symmetrical manner,
meaning that the disease attacks the same joint on both sides of the body—for example, both hands.
The signs and symptoms of RA can be relieved by a number of pharmaceutical agents. These include:
» NSAIDs
-nonsteroidal anti-inflammatory drugs that relieve the pain
and inflammation associated with RA
» DMARDs
-disease-modifying antirheumatic drugs that both relieve
symptoms and help to control RA by modifying its disease
process
» Glucocorticoids
-a group of anti-inflammatory drugs that are related to
cortisol, a natural steroid hormone produced by the body
» Biologicals
-drugs like Kineret® (anakinra) that are designed to target
specific molecules in the immune system that contribute to the
RA disease process
In addition, RA patients can find benefits in managing their disease through complementary treatments,
such as massage and relaxation therapy as well as exercise, rest, joint protection, and sometimes surgery.
What causes RA?
Today, the precise cause of RA still remains unknown, which is perhaps the primary reason that there still
is no cure for this life-altering disease. The good news, however, is that effective drug treatments do exist
and promising new therapies are under investigation. By focusing on reducing the pain, inflammation and damage
associated with RA as well as providing the support that patients may need in every day life, people living with RA
can substantially improve their ability to function and manage their disease on a daily basis.
Autoimmune Disease
Many conditions—including RA—are classified as 'autoimmune' diseases, meaning a person's own immune system is directed against
his or her own body tissues, joints or organs. In RA, the immune system attacks healthy tissue. Fluid containing cells
of the abnormally responding immune system accumulates in and around the joints. These cells cause the production of
substances such as antibodies, enzymes, and other molecules (such as cytokines) that can cause the inflammation and damage associated with RA.
For further information about the role of cytokines in RA, click here.
Researchers do not know what exactly causes the body's immune response to behave abnormally. However, they do believe that RA
develops as a result of interacting factors, including genetics, infectious agents, environment, and hormonal effects.
Genetic Factors
Genes may be important factors in determining who gets RA and why. However, the genes that are associated with developing the
disease are also common in the general population. In fact, they can also be found in many people who will never get RA.
That is why it is believed today that these genes may increase the risk for developing RA in people who carry them.
The reason why some people who carry the genes develop RA and others do not is still an area that scientists and medical experts are
studying intensely. Meanwhile, the role of other factors, such as infection, injury, the environment, and hormonal changes, are being researched.
Infectious Agents
Many researchers believe that infectious agents, such as bacteria or viruses, may be involved in the development of RA.
Although it is possible that infectious agents that everyone is commonly exposed to may trigger the immune system of people
susceptible to RA and cause it to react abnormally, there is still no solid proof to support this hypothesis.
In any case, the history of developing treatments for RA patients has long been focused on improving quality of life, and new research is ongoing all the time.
What is the history of RA?
RA has a long history of impacting the lives of patients. Recognition of rheumatic diseases may have begun
as long as 2,400 years ago when the writings of Hippocrates suggested ailments of the joints. The term 'rheuma',
meaning 'a substance that flows', was introduced in the first century AD and comes from an ancient concept
that ailments were caused by substances that flowed through the body, or 'humours'. It was believed that painful
afflictions were caused at areas of the body where humours would flow and come to a stop. Although the disease
that modern rheumatologists identify as RA may have been less common a very long time ago, evidence shows that
it has most likely existed for hundreds of years.
One of the earliest clinical descriptions of RA may have appeared in the 19th century. In 1819, for example,
Benjamin C. Brodie documented RA's slow progression, as well as its effect on the sacs containing synovial
fluid (bursae) and tendon sheaths in addition to the joints. In 1858, A.B. Garrod coined the term "rheumatoid arthritis"
and correctly proposed that this condition was neither gout nor rheumatism, but was a disease with a pathology all of its own.
In 1867, Jean-Martin Charcot distinguished gout, rheumatic fever, osteoarthrtitis, and RA as separate conditions,
but incorrectly claimed that each originated from the same cause. The first clinical description of RA is often credited to
Augustin-Jacob Landre-Beauvais in France, 1880. He too, however, was incorrect in describing the disease observed in several
women as a kind of gout, a condition that actually results from high levels of uric acid in the blood resulting in pain and swelling of the joints.
Searching for a Cause
The focus on the cause of RA as an abnormal response of the body's own immune system began with a hypothesis popularised by Frank Billings in 1912.
Billings proposed that RA was a focused response to chronic, local infections. His hypothesis triggered many lines of independent research in
subsequent years that led to the discovery of 'rheumatoid factor' in RA patients. rheumatoid factor, which is detected today by a blood test,
is an antibody that may appear in patients who have RA.
Today we understand that the presence of rheumatoid factor is not a definite indicator of the presence of RA.
The antibody is also found in many people who do not have RA, or who may have other diseases, including several inflammatory disorders.
Even though different areas of research have been vigorously pursued, it is important to note that none so far have established a clear,
single cause for the disease.
What are the symptoms of RA?
Typical symptoms of RA include:
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joint pains during the night and in the morning |
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Morning stiffness of the joints for more than 15 minutes |
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Swelling of the joints, typically in the finger joints |
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General feeling of being unwell, with fatigue and exhaustion |
In the early stage of RA, often only a few joints are affected; however, a so-called 'polyarthritis' almost always develops
after a certain time. This is characterised by inflammation of many large and small joints of the body, with frequent involvement
of the hand and finger joints. The only exception is the spinal column, which (aside from the head and neck joint) is almost never affected.
In the subsequent course of the disease, the following typical changes of the joints can develop:
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Splaying of the fingers |
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Buckling of the last finger joint downwards |
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Upward protrusion of the knuckle |
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Growth of rubber-like nodes on the extensor side of the joints |
In addition to the joints, other organs can also be affected. These manifestations can include:
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Connective tissue growth in the lungs (pulmonary fibrosis) or pleurisy |
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Pericarditis, which is an inflammation of the outer covering of the heart |
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Inflammation of various layers of the eye wall (scleritis and episcleritis), which can, in extreme cases, culminate in the perforation of the eyeball (for example, by an Ulcus cornae) |
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Rheumatic granuloma or small vessel inflammation (vasculitis) with partial large skin defects particularly on the lower leg and back of the foot |
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Chronic inflammation with dryness of mouth and eyes (sicca syndrome) |
Source: medicine-worldwide.de
How is RA diagnosed?
Diagnoses of RA are based upon the sum total of a doctor's findings as observed over time, including a comprehensive medical
history and test results. This includes evaluation of symptoms, physical examinations,
clinical data analyses, and x-ray examination.
Typical changes of the blood values include:
However, it must be noted that rheumatoid factor can be detected in only approximately 80% of the patients with
RA and that rheumatoid factor can also be present in some other diseases and even in healthy people.
Hence it is not a very specific marker.
X-rays are useful tools in detecting an increase in bone or joint cartilage loss that may be associated with RA,
but x-rays are not always reliable in detecting RA in the early stages of the disease.
Typical changes in the x-ray picture of the joints can usually be found after several years,
corresponding to the joint-destroying course of RA. Changes include:
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Juxta-articular osteoporosis, which is a calcium salt deficiency in the bone and an early sign of RA |
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Buckling of the last finger joint downwards |
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Erosions, which are small pits on the outer rim of the joint surface |
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A displacement of the vertebral bodies of the cervical spine with involvement of the head-neck joint |
X-ray photographs of the hands and feet are particularly well suited for the early recognition of typical changes.
In order to standardise the diagnosis of RA, the American College of Rheumatology put forward in 1987 the following diagnostic criteria.:
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Morning stiffness of the joints (duration at least 1 hour) for more than 6 weeks |
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Arthritis with palpable swelling in three or more joint regions for more than 6 weeks |
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Arthritis in hand or finger joints for more than 6 weeks |
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Symmetrical arthritis (simultaneously, bilaterally the same joint region) for more than 6 weeks |
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Rheumatic granuloma |
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Detection of rheumatoid factor in the blood |
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Typical x-ray changes (juxta-articular osteoporosis and/or erosions) |
At least four of these seven criteria must be met for the diagnosis of RA.
Source: medicine-worldwide.de
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