What is Rheumatoid Arthritis?
Understanding Rheumatoid Arthritis
THE EFFECTS OF RHEUMATOID ARTHRITIS ON JOINTS.
This subject has been chosen because the writer feels the need to clarify the cause and effects of the disease Rheumatoid arthritis and dispel a few myths about it being an old peoples disease of the bones, personal experience has taught that this is not the case at all.
Most people hear the word Arthritis and think immediately of old people with bad joints. In the case of Rheumatoid Arthritis this would be far from the truth. Rheumatoid arthritis starts with a factor in the blood, believed to be passed genetically, which you are either born with or not. If you have the factor you can be totally unaware until you reach old age, equally you can become rapidly debilitated in your youth. Many researchers in the medical profession believe that an allergic reaction to something can be the key that activates this disease and personal experience seems to substantiate this.
Rheumatoid arthritis affects more than 350,000 people in Britain alone, arthritis research campaign online (2003). To give a brief description of how Rheumatoid arthritis works, a joint is where two bones meet and are covered with cartilage to allow them to move easily and without causing any friction, the cartilage also acts as a shock absorber. The joint is surrounded by the synovium (a membrane), which produces a thick fluid (synovial fluid), which acts as a lubricant to keep the cartilage slippery and mobile. The synovium also has an outer layer of ligaments that hold the joint in place and prevents too much movement, this is called the capsule.With Rheumatoid arthritis affecting the join, the synovium is inflamed and red from the increase in blood flow, which results in the joint becoming warm. Extra synovial fluid is produced and the joint becomes painful for two reasons. Firstly the capsule is stretched by the swelling of the joint and secondly the chemicals produced are irritating the nerve endings.
In about 20% of Rheumatoid arthritis sufferers the disease develops very rapidly and in most cases this occurs in the twenties or thirties. Most of you will have experienced the feeling that you have to exercise your wrist and wait for the ‘click’ that puts it back to normal. In Rheumatoid arthritis cases the ‘click’ never comes and within a short space of time other joints join in the game. Steroids and anti-inflammatory drugs and a regime of treatments can be offered. However, in another 5%, the disease gets progressively worst and can lead to severe disability. The majority of patients find that their flare-ups become less frequent over time but this does not mean there are no problems in the interim as some damage is done to joints in each episode, but apart from a few changes in life style, they should be able to live relatively normal lives.
There are four types of physical treatment to supplement any medication prescribed:
Vichy Massage is a massage given with the patient lying on a stone bed with a long bar positioned overhead that holds several showerheads. The pressure is turned up as much as the patient can endure and the heat as high as can be tolerated and the treatment begins. The therapist massages every inch of the body starting from the tips of the toes and ending with the fingers. This process helps to stimulate the circulation and mobilise each and every joint in the body.
Hydrotherapy is exercise undertaken in a hot swimming pool. The water has the effect of making you weightless, thus taking all pressure off your joints whilst you exercise and allowing you to put your joints through their full movement range without any damage and with minimum pain.
Swelling can be alleviated with either ‘hot’ or ‘cold’ regimes. In the first hot wax can be applied to the worst affected joints and infrared lamps used in the same manner. In the later, ice bags are applied and this can have the same result.
Physiotherapy can be structured to build up your muscles without putting extra pressure on your joints and to maintain maximum rotation of all joints effected. In addition there are several machines available such as Ultra Sound, which relieves swelling and pain, and Inference Treatment, which is when two electric impulses are sent through the joint in opposing directions to produce the same outcome.
Our bodies normally become inflamed due to infections such as bacterial ones although this is not caused by the bacteria itself but by the body in objection to it’s presence. In the case of Rheumatoid arthritis we do not know why the swelling is activated but the same result ensues, something is attacked and destroyed, in this case the tissue in our joints. Cartilage, ligaments and even the bone itself can suffer as a result of this attack, occasionally tendons too can be affected due to a similarity in their lubricating system to the joints and, in rare cases, even lungs and blood vessels can become inflamed.Arthritis Research Campaign online (2003). These symptoms differs from patient to patient but once joints have been damaged it is almost impossible for them to heal so the best course of action is to control the swelling as soon and as effectively as possible.
Joints are not the only part of the body to be affected. Apart from the usual pain and stiffness and tiredness we have already covered, Anaemia (lack of red blood cells) is quite common as are uncontrollable weight loss and hot sweats. ‘Dry’ eyes, when the eyes become inflamed ,are a less common symptom and in some rare cases the lungs have been found to be the target. Very worryingly the membrane around the heart has been found to be susceptible. Rheumatoid nodules may also appear just below the elbow and sometimes on the hands and feet. These are fleshy lumps, which can easily be identified by biopsy under a microscope.
Inflammation of the joints leads to a general feeling of being unwell and a fatigued state which is probably the most difficult to come to terms with. People can usually tell by the way that you are moving that you have joint problems and will sympathise with your pain but, if tiredness is the major player, they will often think you are just feeling sorry for yourself or being lazy which is far from the case. Rheumatoid arthritis suffers may find they need to sleep for a couple of hours during the day, especially during a flare-up and friends and employers are not often understanding of this need. For this reason many suffers do not work in permanent employment as they find the constant explaining just too much of an emotion strain, although the equal opportunities laws now make things easier for a them to disclose their condition on their initial application forms without fear of jeopardising their chances.
Sufferers who find their flare–ups become less and less regular can often pinpoint the causes for them. Viral infections can often trigger attacks and obviously add to the time it takes to recover from their sickness period, emotional upset such as a bereavement can have the same effect as can a period of unaccustomed exercise or exertion. To limit the amount of times they have to endure these episodes some move to warmer climates where there symptoms seem less severe but this does not work for everybody.
Medicines prescribed to Rheumatoid arthritis suffers fall under the following categories: analgesics , non-steroidal anti-inflammatory drugs, disease- modifying anti-rheumatic drugs and corticosteroids.
Although analgesics are not strong enough to control the pain of Rheumatoid arthritis on their own, they are often used as a top-up. The only side effect known is constipation, which on occasions can be quite severe.
Non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin can be given in large doses to control the pain and reduce swelling . Side effects can be indigestion and even bleeding from the stomach in rare cases so, to counteract these problems, other drugs are given alongside which are know as Proton Pump Inhibitors which protect the stomach and reduce indigestion.
Disease modifying anti-rheumatic drugs (DMARDs) are intended to slow down the effects of the disease rather than treat the symptoms. The introduction of these drugs is a big step in combating the disease and the side effects are rare and non serious. These drugs include: Sulphasalazine, Gold injections, Penicillamine, Methotrexate, Azathioprine and Leflunomide.
The latest discovery comes in the research into biological therapies where scientists have developed drugs that target individual molecules involved in the inflammation and damage of joints. A substance called TNF has been identified as having a major part in the inflammation process and so a range of drugs known as anti-TNFs have been developed. Infections are the only side effect.
Other forms of treatment are Anti-IL-1 drugs such as Anakinra which works by inhibiting a messenger substance in the body called Interleukin (IL-1).
Corticosteroids (steroids) are probably the best-known drugs for this disease. Unlike Anabolic steroids which sportsmen have been known to user to build up their bodies, these are manufactured from natural hormones and have a very powerful effect on inflammation. They still, unfortunately, have been proven to induce several side effects if taken in high doses or over long periods of time, such as Osteoporosis (crumbling of the bones). Researchers are still trying to eliminate the side effects whilst maintaining the effectiveness of these drugs. Steroids can be injected directly into the affected joint or given either intravenously or intramuscularly to counteract a severe flare-up, equally they can be administered orally.
Inflammation is the body’s defence mechanism against bugs and any other foreign body, cells ‘leak’ out of the blood vessels to counter attack, blood flow is increased to raise the temperature and help destroyed germs or substances that can be secreted by them. The cells call other cells in by means of a chemical messenger, producing chemicals to destroy the foreign body and anti-bodies to help the battle. The chemical messengers are the target of the afore mentioned biological therapies. In the case of Rheumatoid arthritis it is widely believed that the body recognises part of itself as an invasive substance and sets out to destroy it, damaging both cartilage and bone in the joint. As this is an autoimmune disease it does not know when to stop and can continue destroying indefinitely. As stated earlier, the capsule is stretched in this process and remains so, allowing the joint to shift into unnatural positions. An example of this would be an older person with what could be described as ‘gnarled hands’.
As Rheumatoid arthritis is a long-term disease, many are tempted to try complementary therapies rather than rely on drugs for the rest of their lives but few of these have any significant effect. Acupuncture has been said to help some and is now, therefore, available on the NHS. Homeopathy is a doubtful aid as there is nothing to prove externally administered oils can influence the body internally in any way. If taken orally, some oils such as cod liver oil & evening primrose oil appear to induce a mild improvement but the success of Chinese remedies has been attributed to the fact they contain large amount of steroids.
For a time it was though that certain diets could cure Rheumatoid arthritis, but this has since been discredited by medical research. Cheese and other dairy products are thought to have an adverse effect on some patients but this is entirely an individual thing. Some people find other foods cause them to suffer more symptoms and so cut these out. Of course, any sort of weight loss diet could be a help as the less weight you carry the less pressure on your joints. You put the equivalent of four times your body weight through your joints when you are just walking… Arthritis Research Campaign. Online (2003)
Although diagnosis is more commonly reached through the GP listening to the patient’s account of their symptoms, confirmation can be sought by blood tests and X-rays. Any damage caused by Rheumatoid arthritis could be seen on an X-ray but this would be much more apparent on an MRI (magnetic resonance imaging) scan. A normal knee joint on MRI is seen above in fig 5. Ultra sound is another way of picking up damage to joints and doctors want to make these two tests more readily available to detect damage earlier.
Blood test will reveal Rheumatoid arthritis by either a positive test for anaemia (80% of suffers are anaemic) or by changes in the blood caused by inflammation. The testing of blood started with the Erythrocyte Sediment Rate check (ESR) and has since been joined by the Plasma Viscosity test (PV) and C-reactive protein test (CRP). These will all indicate inflammation if a high reading is detected. A blood protein called ‘Rheumatoid factor’ is also a good confirmation of the condition although many early sufferers do not have a reading high enough to register and presence of the factor does not automatically confirm the diagnosis, a small percentage (5%) of these people are not Rheumatoid arthritis sufferers. New test are still being developed to aid the diagnosis of this condition.
In the most severe cases surgery can be the final option. Operations can vary from a simple one, to release a nerve or tendon, to a major joint replacement operation.
Operations include: Carpal tunnel release – to relieve pressure on this major hand nerve, Synovectomy – removal of the thickened synovium in joints and around tendons, Arthrodesis – fusion to stiffen a painful joint, Bone removal – removal of misplaced or sharp edges of bones that could otherwise cause damage to tendons, Tendon reconstruction – Grafting of snapped tendons as a repair, Tendon rebalancing – to correct deformities of fingers and Artoplasty – Joint replacement.
Hip replacements are the most common and have been successfully carried out since the early 1960’s NRAS online (2003). Knee replacement has only caught up in the late 1970’s as the joint itself is so much more complex. Hinges were originally inserted onto knee joints but these proved to loosen under stress and were very large contraptions, meaning a lot of bone had to be removed to make room for them. This caused major problems if they failed to resolve the situation as there would not be enough of the original joint left to maintain any stability. Now days very little of the original bone is removed and the remaining joint is ‘re-surfaced’ which has proved a greater success than the hip replacements with very few cases of loosening resulting. The main reason for requesting a knee replacement is the pain it generates but a decision to operate is only likely to be made if the range of movement is severely compromised and an operation could only hope to generate movement of approximately 110 degrees so surgery still remains a last resort.
In essence this disease is varied in its effects on peoples lives. Some people manage to control the disease to the extend of dropping all medication and simply avoiding the trigger if identified. Others may suffer such severe damage to their joints that they become registered disabled persons and remain so for the rest of their lives. At either end of the scale, further research is the best hope anybody can have for a cure being found in our lifetime.
Arthritis Research Campaign (online) available from:www.arc.org.uk (accessed 8th June 2003)
NRAS (online) available from www.rheumatoid.org.uk (accessed 8th June 2003)