“A young lady has difficulty moving her hands in the mornings. She has painful, swollen joints which are stiff even hours after waking up. Her leg joints are red and hot. She struggles at office because of inexplicable tiredness. All these are new developments. Although still in her early forties she feels as if she has rapidly aged within a few months. Tasks that were simple a few weeks ago are seemingly
impossible now.”
Rheumatoid arthritis is one of the commonest types of joint diseases which mostly affects females between the ages of 30 and 50. There are of course, exceptional cases where the elderly and even teenagers develop this condition. If not treated properly, it can become a devastating disease, with rapid destruction of joints in a matter of weeks to months. The end result if left untreated, is deformed joints. Some patients have this mild rheumatoid, which appears intermittently and doesn’t cause much trouble. As this is an autoimmune disease, it can inflict harm not just on joints but on other organs as well, including nerves, lungs, eyes, skin and blood vessels.
Overactive Immunity
The condition is a result of an overactive immune system. As you are aware, the immune system protects against invasive germs like bacteria, viruses, fungi and parasites. A protein particle called an “antibody” is responsible for our intact immunity. Imagine what would happen if these antibodies were produced within our body against our own joints? There will be catastrophic consequences with the destruction of joints and surrounding structures. In rheumatoid arthritis, two types of antibodies namely “Rheumatoid factor” and “Anti CCP” are produced. Once we detect antibodies in the blood, it will be easier to diagnose the condition.
The same antibody-mediated process can cause harm to other organs outside joints. We call this extra-articular disease. Articular space is where two bones rub each other and create a joint. Hence, extra-articular is just outside this joint space. Overactive immunity leads to a process called inflammation, which is simply an additional and unnecessary attempt by the body to supply blood to an affected region. With this extra blood supply to cells, a destruction of that region can be caused. Sometimes rheumatoid arthritis is called inflammatory arthritis due to this.
Tissue Swelling
The most frequent complaint is joint pain with or without swelling. In fair-skinned patients, we sometimes see a bit of redness over the skin. Other problems patients encounter include joint stiffness. If you forget the pain, the joints feel as if they are pasted on one another early morning. An extra effort is needed for patients to move the joints. This gets better as the day progresses. Therefore, most symptoms in rheumatoid arthritis are seen early in the morning. Joint swelling is seen because of two reasons. There could be a collection of fluid/water inside the joints. This causes the skin surrounding the joint to balloon up. The other reason is tissue swelling. Rheumatoid arthritis affects the hands classically, in a symmetrical fashion. It can also affect wrists, elbows, shoulders, knees, ankles, toes and sometimes the jaw joint.
Tiredness is another feature of rheumatoid arthritis. Patients say this is a new onset of tiredness, which was not present months before. There could be many reasons for this condition, which is given the term ‘fatigue’ in western medicine. The chemical change created within the body can cause inappropriate tiredness. Also, if rheumatoid arthritis causes low blood cell counts or what we describe as anaemia, this in turn will contribute to tiredness as well. Together with joint disease, one might develop extra-articular problems. Very severe rheumatoid arthritis affects the eyes. It can cause harm to the outer aspects of the eyes. Sometimes, the lungs get partly destroyed. Nerve dysfunction can lead to abnormal sensation and even muscle paralysis. Skin rashes, “nodules” just beneath the skin and problems with blood vessels are some of the other manifestations of rheumatoid.
Patients need urgent attention?
As we discussed earlier, the early phases of rheumatoid arthritis do not cause much trouble apart from symptoms like pain and stiffness. If left untreated, the process called inflammation can lead to permanent destruction of joints. There is no scientific way of growing back a new joint from a destroyed joint. There is no miracle pill as such. So the prevention of rheumatoid arthritis by controlling the disease is the best option.
If an overactive immune system is the key issue in rheumatoid arthritis, joint specialists control the immune system in such a way so that a perfect balance is created. We use tablets and sometimes injections to control rheumatoid arthritis.
You might ask me, why not cure the disease rather than control it? As rheumatoid arthritis is all about immunity, complete cure means putting a halt to the functioning of the immune system. As this is impossible, what we do is control the disease, so that ultimately patients are free of symptoms and complications. This is like pushing a rubber ball beneath the surface of a pond. We keep on pushing till the water drains out of the pond one day. Then comes the question as to whether rheumatoid arthritis lasts a lifetime. The simple answer is no. In most instances, the disease disappears and the joint specialists will slowly reduce the dose of your medication.
What are the treatment options available?
First the details relating to the symptoms are gathered. A complete examination of not just the joints, but the whole area, is carried out. Ideally this is done on an examination bed. The patient is asked to move the affected joints throughout the full range and then the consultant will passively move these joints, taking care not to inflict pain.
A detailed analysis of the affected joints is then carried out where pressure is applied in a lighter fashion. Determination of whether a fluid collection is there inside the joint space is done. Certain blood tests will be ordered together with certain X-rays and scans.
The joint specialist will offer various treatment options for rheumatoid arthritis. He will also provide you with information about the side-effects of the medication. One of the most common drugs used are Disease Modifying Anti Rheumatoid Drugs (DMARDS). Methotrexate, Hydroxychloroquine and Leflunamide are some of these. These are very specific meds which will slowly control the disease process.
Steroids are also used to rapidly provide relief till the DMARDS settle in. This is called bridging therapy. Pain-relieving agents called NSAIDS (Voltaren, Brufen) are also used intermittently to control pain but do note that they are not effective in controlling rheumatoid arthritis. Injections bring quick relief to swollen joints and are also useful to bring out unnecessary fluids.
While taking medication, the specialist will also advice you on certain gentle forms of exercise that sooth the joints. Certain tips on carrying out activities of daily living are also taught. For example, how to open a jar lid, how to carry shopping bags and how to open a tin.
Physiotherapy and occupational therapy are also useful in treating rheumatoid arthritis. The consultant might arrange a meeting with the therapists based on your requirements.
There is a new form of treatment called biological agents, where the harmful antibodies are countered by artificial antibodies. These biological agents are administered as infusions or injections to patients on whom tablets have no effect.
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