Arthritis and Other Joint Diseases - Rheumatoid arthritis
Rheumatoid arthritis occurs at a much earlier age than osteoarthritis, appearing at any time from infancy to old age, but most commonly afflicting persons between the ages of 20 and 45. Women are three times as likely to be victims of rheumatoid arthritis as are men, although men seem to lose that advantage after the age of 50. All races seem to be equally vulnerable. Recent studies suggest a tendency to develop the disease may be inherited in some people. It is also thought that allergies, infections, or homonal disturbances play a role in initiating the disease.
Rheumatoid arthritis can begin as part of an acute illness, with high fever and intense inflammation of the joints, or it can develop insidiously with little or no discomfort except for fatigue, loss of appetite, weight loss, and perhaps a mild fever. Sometime later the victim becomes aware of aches and pains in the joints and muscles and seeks medical attention. Frequently, deformities develop before the patient realizes that rheumatoid arthritis may be the cause of swollen joints, pain, redness, or excessive warmth about the affected area.
The inflammation of a joint caused by rheumatoid arthritis may continue for weeks or it may last for a period of years. During inflammation, tendons become shortened and muscles lose their normal balance. The result is the deformity of joints commonly associated with rheumatoid arthritis, such as a swan-neck shape in the fingers. Muscular weakness develops and there is a loss of grip strength in the hands when that area is affected. Patients may be unable to make a tight fist.
A common symptom of rheumatoid arthritis is a stiffness that develops during periods of rest but gradually disappears when activity resumes. After a night's sleep, the stiffness may persist for a half hour or much longer. The stiffness may result, at least in part, from the muscular weakness that accompanies the disease.
Although the effects of rheumatoid arthritis are most commonly observed in the hands or feet of patients, other body joints such as the elbows, shoulders, knees, hips, ankles, spine, and even the jawbones may be involved. It is possible for all of a patient's joints to be involved, and the involvement often is symmetrical; that is, both hands will develop the symptoms at the same time and in the same pattern.
The exact cause of rheumatoid arthritis is unknown, although a variety of factors have been associated with the onset of the disease. Emotional upsets, tuberculosis, venereal disease, psoriasis, and rheumatic fever are among conditions associated with the beginnings of the disease. Various viruses and other microorganisms have been isolated from the inflamed tissues of patients, but medical researchers have been unable to prove that any of the infectious agents is the cause. Efforts have also been made to transmit rheumatoid arthritis from a known victim to a normal volunteer by transfusions and injections of substances found in the victim's tissues, but without success in tracing the causative factor.
The symptoms of rheumatoid arthritis intensify or abate spontaneously and unpredictably. Available methods of treatment do not cure the disease but relieve the symptoms so that the pain is reduced and some normal movement is facilitated. Proper nutrition, heat, rest, and exercise are also helpful. A number of drugs can reduce the inflammation of the joints, but they may have undesirable toxic side effects. Accordingly, before any drug therapy is embarked upon, the patient should seek the advice of a physician specializing in arthritic disorders.
The most common drug used to treat all kinds of arthritis is aspirin, an analgesic; it is also the most economical. Occasional side effects, such as irritation of ulcers or other gastrointestinal upsets, as well as buzzing in the ears, can result from aspirin use, especially in massive doses; such complications can sometimes be avoided by the use of specially coated aspirin tablets. The size of the dose usually is started at a minimum level and gradually increased until the physician finds a level that is most helpful to the patient but does not result in serious side effects. Celebrex, a new type of analgesic that is less irritating to the stomach, was approved for use in 1999.
There are several other drugs used in the treatment of rheumatoid arthritis. Non-steroidal antiinflammatory drugs (NSAIDs) such as ibuprofen, fenoprofen, naproxen, and indomethacin work about as well as aspirin but with less severe side effects. NSAIDs do however have side effects such as abdominal pain, nausea, and constipation. Most NSAIDs are generally taken twice a day. In 1993 the FDA approved oxaprozin (sold as Daypro), which needs to be taken only once a day.
In 1998 the first of a new class of drugs was approved for the treatment of rheumatoid athritis. Etanercept, an intravenous medication marketed as Enbrel, blocks the activity of tumor necrosis factor, believed to play a part in the inflammation process. This new class of drugs represented a major breakthrough in treatment; patients using it reported significantly less pain and swelling. Side effects include rashes at the site of injection and upper respiratory tract reactions.
Another new class of drugs, called disease modifying anti-rheumatic drugs, were also approved in the late 1990's. Leflunomide, sold as Arava, was the first of this new class to be marketed. It affects the function of immune cells known as T lymphocytes. Arava too can cause side effects, some of which can be very serious. It can cause intestinal distress, hair loss, or reversible liver damage. It has also been shown to cause birth defects; therefore, premenopausal women who take it also have to use birth control. Women taking the drug who decide to have a baby must discontinue using it and undergo a drug elimination process under doctor supervision.
Many other drugs promising relief for victims of arthritis have made their appearance in recent years. For example, penicillamine (trade name: Cuprimine) was found to help patients with rheumatoid arthritis. Experiments with many other drugs—including aclofenac, flurbiprofen, and proquazone—are under way.
The cortisone-type (steroid) drugs have proven effective in controlling severe cases of rheumatoid arthritis. They can be given orally or injected directly into the affected joints. However, these drugs generate a number of undesirable side effects, and withdrawal often results in a severe recurrence of the original symptoms. Thus, steroid drug therapy is a long-term process that can make the patient totally dependent on the medication. Some physicians are reluctant to inject steroid drugs into the joints because the effect is temporary and there is a danger of introducing infection by repeated use of the needle. In addition, some patients do not seem to respond to the steroid drugs and X-ray studies of the joints may show progressive destruction of the tissues despite the medications.
Bed rest is recommended for acute cases and up to 10 hours of sleep per day is advised for mild cases of rheumatoid arthritis. The patient also should take rest periods during the day whenever possible, reducing fatigue and stress on the affected joints. As in severe cases of osteoarthritis, the patient should try to adjust his daily work habits to avoid strain on weight-bearing joints.
Patients tend to avoid moving arthritic joints because of pain and stiffness. Exercise of an arthritic joint, however, helps prevent the adjoining muscles from shrinking and weakening. A program of physiotherapy—including hot packs and exercise—can be extremely helpful.
The exercise program should carry the joints through their normal range of movement. Exercises should be performed every day but not carried to the point of fatigue. In addition to exercises intended to prevent limitation of normal joint movement, isometric-type exercises should be used to maintain or increase muscle power in other parts of the body that might otherwise be neglected because of limited activity by the patient.
The patient should be encouraged to maintain proper posture as much as possible, through correct positioning of the body when standing, sitting, or reclining in bed. A sheet of thick plywood may be used under a mattress to prevent it from sagging. Chairs should be firm with straight backs. Pillows should be avoided whenever possible.
Crutches, canes, leg braces, and other devices may be needed by the patient in advanced stages of rheumatoid arthritis. In some cases, orthopedic surgery is recommended to help reconstruct the limbs and joints as a part of rehabilitation.
Massages or vibrating equipment are not recommended as part of the therapy for rheumatoid arthritis patients. Heat in the form of hot baths, hot compresses, or heating pads, however, may be helpful. Paraffin baths are particularly helpful in treating hands or wrists.
While osteoarthritis patients are advised to lose as much weight as possible, rheumatoid arthritis patients tend to suffer from weight loss and nutritional deficiencies. Part of the cause may be a loss of appetite that is a characteristic of the disease and part may be the gastrointestinal problems that frequently accompany the disorder and that may be aggravated by the medications prescribed. Some physicians advise that rheumatoid arthritis patients include adequate amounts of protein and calcium in their diets as a preventive measure against a loss of bone tissue.