The skeletal system of the body is made up of different types of strong, fibrous tissue called connective tissue. Bone, cartilage, ligaments, and tendons are all forms of connective tissue that have different compositions and characteristics.
The joints are structures that hold two or more bones together. Synovial joints allow for movement between the bones being joined, the articulating bones.
The simplest synovial joint involves two bones, separated by a slight gap called the joint cavity. The ends of each articular bone are covered by a layer of cartilage. Both articular bones and the joint cavity are surrounded by a tough tissue called the articular capsule.
The articular capsule has two components: the fibrous membrane on the outside and the synovial membrane, or synovium, on the inside. The fibrous membrane may include tough bands of tissue called ligaments, which are responsible for providing support to the joints.
The synovial membrane has special cells and many tiny blood vessels called capillaries. This membrane produces a supply of synovial fluid that fills the joint cavity, lubricates it, and helps the articular bones move smoothly about the joint.
In rheumatoid arthritis, the synovial membrane becomes severely inflamed. Usually thin and delicate, the synovium becomes thick and stiff, with numerous infoldings on its surface. The membrane is invaded by white blood cells, which produce a variety of destructive chemicals.
The cartilage along the articular surfaces of the bones may be attacked and destroyed, and the bone, articular capsule, and ligaments may begin to erode. These processes severely interfere with movement in the joint.
RA exists all over the world and affects men and women of all races. In the United States alone, about two million people suffer from the disease.
Women are three times more likely than men to have RA. About 80% of people with RA are diagnosed between the ages of 35 and 50. RA appears to run in families, although certain factors in the environment may also influence the development of the disease.
Causes and symptoms
In late 2001, researchers announced discovery of the genetic markers that predict increased risk of RA. The discovery should soon aid research into diagnosis and treatment of the disease.
Recent research has also shown that several autoimmune diseases, including RA, share a common genetic link. In other words, patients with RA might share common genes with family members who have other autoimmune diseases like systemic lupus, multiple sclerosis, and others.
Many researchers are examining the possibility that exposure to an organism (a bacteria or virus) may be the first event in the development of RA. The body’s normal response is to produce cells that can attack and kill the organism, protecting the body from the foreign invader.
In an autoimmune disease like RA, this immune cycle spins out of control. The body produces misdirected immune antibodies, which accidentally identify parts of the person’s body as foreign. These immune cells then produce a variety of chemicals that injure and destroy parts of the body.
Reports in late 2001 suggest that certain stress hormones released during pregnancy may affect development of RA and other autoimmune diseases in women.
Researchers have observed that women with autoimmune disorders will often show lessened symptoms during the third trimester of pregnancy. The symptoms then worsen in the year after pregnancy. Further, women appear to be at higher risk of developing new autoimmune disorders following pregnancy.
RA can begin very gradually or it can strike without warning. The first symptoms are pain, swelling, and stiffness in the joints. The most commonly involved joints include hands, feet, wrists, elbows, and ankles.
The joints are typically affected in a symmetrical fashion. This means that if the right wrist is involved, the left wrist is also involved. Patients frequently experience painful joint stiffness when they first get up in the morning, lasting perhaps an hour.
Over time, the joints become deformed. The joints may be difficult to straighten, and affected fingers and toes may be permanently bent. The hands and feet may also curve outward in an abnormal way.
Many patients also notice increased fatigue, loss of appetite, weight loss, and sometimes fever. Rheumatoid nodules are bumps that appear under the skin around the joints and on the top of the arms and legs.
These nodules can also occur in the tissue covering the outside of the lungs and lining the chest cavity (pleura), and in the tissue covering the brain and spinal cord (meninges).
Lung involvement may cause shortness of breath and is seen more in men. Vasculitis, an inflammation of the blood vessels, may interfere with blood circulation. This can result in irritated pits (ulcers) in the skin, gangrene, and interference with nerve functioning that causes numbness and tingling.
Diagnosis
However, this test is also positive in a variety of other diseases. Tests for anemia are usually positive in patients with RA, but can also be positive in many other unrelated diseases.
Rheumatoid factor is an autoantibody found in about 66% of patients with RA. However, it is also found in about 5% of all healthy people and in 10–20% of healthy people over the age of 65. Rheumatoid factor is also positive in a large number of other autoimmune diseases and other infectious diseases.
A long, thin needle can be inserted into a synovial joint to withdraw a sample of the synovial fluid for examination. In RA, this fluid has certain characteristics that indicate active inflammation.
The fluid will be cloudy, relatively thinner than usual, with increased protein and decreased or normal glucose. It will also contain a higher than normal number of white blood cells. While these findings suggest inflammatory arthritis, they are not specific to RA.
Treatment
There is no cure available for RA. However, treatment is available to combat the inflammation in order to prevent destruction of the joints and other complications of the disease. Efforts are also made to provide relief from the symptoms and to maintain maximum flexibility and mobility of the joints.
A variety of alternative therapies have been recommended for patients with RA. Meditation, hypnosis, guided imagery, relaxation, and reflexology techniques have been used effectively to control pain. Acupressure and acupuncture have also been used for pain; work on the pressure points should be done daily in combination with other therapies.
Bodywork can be soothing and is thought to improve and restore chemical balance within the body. A massage with rosemary and chamomile, or soaking in a warm bath with these essential oils, can provide extra relief.
Stiff joints may also be loosened up with a warm sesame oil massage, followed by a hot shower to further heat the oil and allow entry into the pores. Movement therapies like yoga, t’ai chi, and qigong also help to loosen up the joints.
A multitude of nutritional supplements can be useful for RA. Fish oils, the enzymes bromelain and pancreatin, and the antioxidants (vitamins A, C, and E, selenium, and zinc) are the primary supplements to consider.
Many herbs also are useful in the treatment of RA. Anti-inflammatory herbs may be helpful, including turmeric (Curcuma longa), ginger (Zingiber officinale), feverfew (Chrysanthemum parthenium), devil’s claw (Harpagophytum procumbens), Chinese thoroughwax (Bupleuri falcatum), and licorice (Glycyrrhiza glabra). Lobelia (Lobelia inflata) and cramp bark (Vibernum opulus) can be applied topically to the affected joints.
Homeopathic practitioners recommend Rhus toxicondendron and bryonia (Bryonia alba) for acute prescriptions, but constitutional treatment, generally used for chronic problems like RA, is more often recommended.
Yoga has been used for RA patients to promote relaxation, relieve stress, and improve flexibility. Nutritionists suggest that a vegetarian diet low in animal products and sugar may help to decrease both inflammation and pain from RA.
Beneficial foods for patients with RA include cold water fish (mackerel, herring, salmon, and sardines) and flavonoid-rich berries (cherries, blueberries, hawthorn berries, blackberries, etc.). The enzyme bromelain, found in pineapple juice has also been found to have significant anti-inflammatory effects.
RA, considered an autoimmune disorder, is often connected with food allergies or intolerances. An elimination/challenge diet can help to decrease symptoms of RA as well as identify the foods that should be eliminated to prevent flare-ups and recurrences.
Hydrotherapy can help to greatly reduce pain and inflammation. Moist heat is more effective than dry heat, and cold packs are useful during acute flare-ups. Various yoga exercises done once a day can also assist in maintaining joint flexibility.
Allopathic treatment
Nonsteroidal anti-inflammatory agents and aspirin are used to decrease inflammation and to treat pain. While these medications can be helpful, they do not interrupt the progress of the disease.
Low-dose steroid medications can be helpful at both managing symptoms and slowing the progress of RA, as well as other drugs called disease-modifying antirheumatic drugs. These include gold compounds, D-penicillamine, antimalarial drugs, and sulfasalazine.
Methotrexate, azathioprine, and cyclophosphamide are all drugs that suppress the immune system and can decrease inflammation. All of the drugs listed have significant toxic side effects, which require healthcare professionals to carefully compare the risks associated with these medications to the benefits.
Total bed rest is sometimes prescribed during the very active, painful phases of RA. Splints may be used to support and rest painful joints. Later, after inflammation has somewhat subsided, physical therapists may provide a careful exercise regimen in an attempt to maintain the maximum degree of flexibility and mobility.
Joint replacement surgery, particularly for the knee and the hip joints, is sometimes recommended when these joints have been severely damaged. Another surgery used to stop pain in a stiff joint, such as the ankle, is the fusion of the affected bones together (arthrodesis, or artificial anklylosis).
Prognosis
About 15% of all RA patients will have symptoms for a short period of time and will ultimately get better, leaving them with no long-term problems. A number of factors are considered to suggest the likelihood of a worse prognosis. These include:
- race and gender (female and Caucasian)
- more than 20 joints involved
- extremely high erythrocyte sedimentation rate
- extremely high levels of rheumatoid factor
- consistent, lasting inflammation
- evidence of erosion of bone, joint, or cartilage on x rays
- poverty
- older age at diagnosis
- rheumatoid nodules
- other coexisting diseases
- certain genetic characteristics, diagnosable through testing
Patients with RA have a shorter life span, averaging a decrease of three to seven years of life. Patients sometimes die when very severe disease, infection, and gastrointestinal bleeding occur. Complications due to the side effects of some of the more potent drugs used to treat RA are also factors in these deaths.
Prevention
There is no known way to prevent the development of RA. The most that can be hoped for is to prevent or slow its progress.
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