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Arthritis - Questions &
Answers
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What is arthritis?
Arthritis means inflammation of the joints. There are more
than 200 kinds of rheumatic disease often referred to as arthritis.
Some are rare, some are common. In any one year, up to 20
million people in the UK are likely to experience at least
one of these diseases. It is not just a part of the ageing
process.
There are several common types of arthritis:
- Osteoarthritis usually develops gradually and affects
most people over 55 to some extent.
- Secondary arthritis sometimes develops after an
injury which has damaged a joint.
- Rheumatoid arthritis is an inflammatory disease
mainly affecting joints and tendons. This booklet will focus
on rheumatoid arthritis, rather than the other types.
- Ankylosing spondylitis is also an inflammatory
disease which affects the joints of the lower back and may
lead to the fusion of the spine.
- Gout arises from the formation of uric acid crystals
in the joint, causing inflammation, swelling and severe
pain.
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What is rheumatoid arthritis?
Rheumatoid arthritis is a persisting inflammation of uncertain
cause, mainly affecting the synovium, the membrane
surrounding the moveable joints of the skeleton, but with
the potential in its later stages to involve many other organs,
such as the skin, lungs, nerves, blood vessels and heart.
With the passage of time, the inflamed membrane increases
in thickness to form pannus tissue, which invades bone, cartilage
and the ligaments and leads to damage and deformity. Because
it affects many body systems, rheumatologists often refer
to rheumatoid disease rather than rheumatoid arthritis.
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A healthy joint (A) and one showing some
of the characteristic changes observed in rheumatoid arthritis (B)
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How does RA start?
People usually notice symptoms of pain, swelling and stiffness
in one or more joints. In about 10 per cent of people with
rheumatoid arthritis, the onset is sudden and severe (this
is called acute onset), in 20 per cent, the disorder
develops quite quickly over a few weeks (called sub-acute
onset) while in 70 per cent, symptoms develop slowly over
a longer period of time (called insidious onset).
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Can RA affect all joints in the body?
Although RA can affect all movable joints, it is much more
common in some than others. For instance, in the hand and
wrist, the joints in the middle of the fingers and the knuckles
are affected in 80 to 95 per cent of people with RA, while
hip, elbow and jaw joints are affected in only 20 to 50 per
cent. Knee, shoulder and neck joints are somewhere in the
middle.
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How widespread is rheumatoid arthritis?
The number of adults likely to experience RA in their lifetime
is about one in 100. RA affects all races and is about three
times more common in women than men and especially affects
women of childbearing age. Most frequently, it starts between
the ages of 35 and 45, but can also affect younger people.
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What causes rheumatoid arthritis?
No single cause for RA has been identified. Current indications
are that it is an auto-immune disorder (i.e. damage caused
by the body’s immune system mistakenly attacking its own tissue).
It can be triggered particularly by some kinds of infection,
especially in individuals who are susceptible because of their
physiological and genetic make-up.
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How is rheumatoid arthritis recognised
by doctors?
Specialists in rheumatic disease have developed a set of
seven criteria to decide whether someone has RA. These are
assessed during clinical examination, laboratory tests and
through careful questioning.
In simplified form, the most recent criteria, developed by
the American Rheumatism Association, are as follows:
- 1. Stiffness lasting at least an hour after getting out
of bed before reaching the maximum improvement (‘morning
stiffness’).
- 2. Swelling of the soft tissues around at least three
joints.
- 3. Swelling of specific joints of the hand, namely the
joint in the middle of the finger, and in the knuckle and
wrist.
- 4. Symmetrical arthritis (i.e. affecting the same joints
on both sides of the body at the same time).
- 5. The presence of swellings under the skin.
- 6. A positive blood test for a substance known as rheumatoid
factor.
- 7. X-ray evidence of destruction or loss of bone in and
around the joints of the hands.
A doctor will not class a condition as RA unless there are
at least four of the above signs and symptoms. The first four
in the list must have been present for at least 6 weeks. These
criteria are 90 per cent accurate.
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Frequency of distribution of affected joints
in RA -
click
for larger
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What is rheumatoid factor and what is
its significance?
Rheumatoid factor (RF) is the name given to certain proteins
(antibodies) found in the blood of up to 85 per cent
of people diagnosed with RA. The antibodies are directed against
the body’s own defence system and may indicate an abnormal
immune response. RF is not only found in rheumatoid arthritis
but may be present in several other diseases. In fact, 5 per
cent of apparently fit people have rheumatoid factors. However,
the levels of rheumatoid factor are usually much higher in
people with RA.
On the other hand, a person without RF may still have rheumatoid
arthritis: patients with rheumatoid factor are often referred
to as seropositive and those without it as seronegative.
RF has very little influence on how the doctor manages the
illness, but help diagnosis in its early stages. Individuals
with active disease and high levels of RF have the poorest
long-term prospects.
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Is rheumatoid arthritis a serious disease?
In contrast to, say, a heart attack or stroke, where there
is a sudden and dramatic medical crisis, RA often progresses
gradually and is all too easy to underestimate. Most people
with RA experience a reduction in their quality of life, around
a half will eventually have significant disability and one
third will have to give up work within a few years. Those
with an aggressive form of the disease run the risk of complications
affecting the heart and circulatory system. Overall, RA may
shorten lifespan by 5 to 10 years but, fortunately, appropriate
therapy can reduce disability by 30 per cent over 10 to 20
years.
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Does RA follow the same pattern in all
people with RA?
In an unfortunate small minority of people, RA follows a
severe and aggressive course which can lead to significant
disability within months. In a more fortunate minority, the
initial symptoms clear up, or can be pushed into remission
by early treatment. Such people can be considered to be ‘cured’.
In the majority, the disease worsens slowly over a period
of years, during which cartilage and bone loss gradually increases.
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Do the genes we inherit play any part
in RA?
RA has a tendency to run in families, but many cases occur
without a family history. These are referred to as ‘sporadic
RA’. Cases that run in the family are often associated with
a gene called HLA-DR4.
However, this cannot be the whole story. HLA-DR4 occurs in
about 20 to 30 per cent of the population and yet only one
per cent develops RA. Most likely, genes that we inherit from
our parents, like HLA-DR4, make us more susceptible to an
external trigger which sets off the disease. Much evidence
has accumulated over the past 50 years suggesting that the
trigger is likely to be an infection by a virus, or possibly
a particular type of bacterium (germ). However, attempts to
identify a single organism that is responsible have so far
been unsuccessful.
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Early RA in the wrist Microfocal x-ray
of a wrist, showing early erosions (EE), erosions (E), and an erosion
with evidence of bony repair (EB). There is also evidence of some
narrowing of joint space - click
for larger
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Is RA related to hormones?
Hormone imbalance is not a cause of RA, but several lines
of evidence suggest that it can play a part in the disease,
namely:
- The higher incidence of RA in women than men (by a ratio
of 3 to 1).
- RA usually develops between the onset of puberty and the
menopause.
- RA seems to improve during pregnancy, when hormone levels
are significantly modified.
- Responses have been seen when male sex hormones are given
during treatment.
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What are the main types of medicines
used in RA?
Broadly, there are four categories of medicine used to treat
RA. These are called:
- non-steroidal anti-inflammatory drugs (NSAIDs)
- disease modifying anti-rheumatic drugs (DMARDs) which
have a slow onset of action – which is why they are sometimes
referred to as SAARDs (slow-acting antirheumatic drugs)
- corticosteroids
- biologicals, most of which are still at the clinical
trial stage.
Some of these categories can be divided into subgroups according
to their chemical properties and their ‘strength’. They may
be supplemented by pain killers to be taken as and when needed.
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Are these medicines used for different
purposes?
Generally, yes. The NSAIDs are designed to control inflammation
and pain, but do not alter the progression of the disease.
The DMARDs are often taken together with NSAIDs to contain
the disease, reduce the swelling and minimise incapacity.
However, this must be done under medical supervision, as there
can be potential side effects if they are taken together.
Steroids may be injected into a troublesome joint during a
flare-up, or in acute-onset disease. Clinical trials using
low dose steroids taken by mouth suggest that they may be
able to reduce joint erosion, but further studies are needed.
Biologicals are the most recent and exciting development,
most of them arising from the new science of genetic engineering.
Nearly all are still at the experimental or clinical trial
stage, but they are of considerable theoretical interest and,
if successful, may greatly reduce the long-term damage brought
about by RA.
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When are these medicines likely to be
used?
The most common practice is to use a ‘cascade’ approach,
beginning with a medicine to help ease the pain (an analgesic)
and possibly an NSAID to control both pain and inflammation.
The choice of NSAID is very wide and will depend to some extent
on the severity of the symptoms and on the patient’s history.
If control is not achieved, it may be necessary to switch
to a different NSAID. Increasingly, DMARDs (which include
methotrexate, gold salts, chloroquine,
penicillamine, and sulfasalazine) are being
used within the first six months, because recent experience
suggests that this may give better results.
In many hospital clinics today, more than 50 per cent of
people with RA are treated almost from the outset with combinations
of NSAIDs and DMARDs. However, long-term follow-up studies
over many years suggest that even with this strategy, combinations
may have only a small effect on bone erosion, though they
can greatly improve the quality of life by reducing the pain
and swelling. Even so, it is very important that people diagnosed
as having RA are quickly referred by their GP to a specialist,
so that early combination treatment can be considered.
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Is it true that some people do not respond
to treatment with medicine?
Individual response to the medicines used to treat RA is
very variable. What suits one person may not suit another.
In such cases, a doctor will select an alternative NSAID from
the many available or switch the person on to a different
DMARD. However, once a response has been obtained, it can
be long lasting. In such cases, it is tempting to discontinue
therapy, but recent research has suggested that people with
RA who are doing well on their medication should still continue
to take it, as this reduces the chance of a relapse. Unfortunately,
a very small minority do not respond to a lot of the medicines
available.
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Do medicines for RA have a lot of side
effects?
NSAIDs may have a number of side effects, but how they develop
is dependent on the individual. Thus one person may find the
side effects unacceptable, while the same medicine may be
entirely satisfactory in the next. The most troublesome and
widely experienced side effects are upsets to the digestive
system – including weight loss, nausea and pain in the pit
of the stomach. In some cases, NSAIDs damage the stomach,
leading to the formation of ulcers and, rarely, to severe
internal bleeding. Different products vary greatly in their
tendency to cause these effects and a number of approaches
to lessen this problem have been explored. All the DMARDs
also have side-effects; these differ widely from medicine
to medicine, so their use has to be monitored carefully.
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Distribution of damage in the wrist and
hands in RA – a: very early, b: early, c: moderately advanced -
click
for larger
Prescribing anti-inflammatory and anti-rheumatic
medicines. Adding a DMARD is now widely practised - click
for larger
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What kind of general support is available
for people with RA?
As well as seeing a GP and a specialist in rheumatology for
treatment, there are many other forms of support available.
One is the physiotherapist, who aims to ensure that joints
are kept as flexible and mobile as possible. This may involve
sessions of:
- Electrotherapy (ultra-sound, infra-red, or pulses of short
wave energy) to help reduce inflammation and injury.
- Prescribed exercises.
- Hydrotherapy in a warm pool.
- Other relaxation, mobility and manipulative techniques.
The physiotherapist will also be able to advise on the choice
of aids for walking and on other specialised aspects such
as the use of Transcutaneous Electronic Nerve Stimulation
(TENS) for easing pain. Patients may also need to see an occupational
therapist, who can advise on special instruments to make
everyday tasks easier, such as dressing, cooking, bathing,
turning on a tap, undoing a jar, gardening, etc. (see Box
on page 9). People who feel they need this help and are having
difficulty getting a referral can turn to organisations such
as Arthritis Care, who will be able to provide guidance. They
can also contact their local social services department and
request an assessment under the NHS and Community Care Act
of 1990.
Many people also decide to try an alternative therapy such
as osteopathy or chiropractic. Before doing this, it is advisable
to discuss it with a doctor and to seek information such as
Arthritis Care’s The Balanced Approach. Such organisations
will also be able to give specific advice on aspects such
as diet, exercise and rest and how to look after joints. Arthritis
Care also runs courses in arthritis self-management with the
aim of increasing self-confidence and putting people more
in control of their lives.
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Examples of some of the many activities for which
specialist equipment is available to help in your everyday
life
- Turning taps
- Opening tins, bottles and jars
- Cutting vegetables
- Writing
- Slicing bread
- Washing
- Grating cheese
- Bathing
- Peeling potatoes
- Dressing
- Pouring drinks
- Squeezing toothpaste
- Picking things up from the floor
- Combing hair
- Cleaning
- Cutting/filing nails
- Turning keys
- Putting on shoes, socks, tights
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Are joint replacements always necessary?
Replacing joints by surgery may become necessary when their
function is almost lost or the pain becomes too intense. Joint
replacement, especially for osteoarthritis, has transformed
the quality of life for thousands of people and is now a common
procedure. Many joints can be replaced, including the fingers,
knees and elbows, but the best known and probably the most
successful is hip replacement.
The materials used, such as stainless steel, are chosen so
that they are not rejected by the body and have an acceptably
long use before needing to be replaced. Despite the success
of these operations, they are often preceded by years of pain
and suffering; the objective of the search for new medicines
to treat RA must be to develop therapies that prevent this
stage ever being reached.
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