Rheumatoid Arthritis

Overview

Several diseases of the joints and bones occur at the onset of old age due to natural degeneration of the musculoskeletal system. Arthritis is a very common disorder after the age of 60 and affects men and women equally. According to statistics produced by the Arthritis Foundation, United States, nearly 350 million people suffer from arthritic conditions all over the world. A very common form of arthritis that affects mainly aged women is rheumatoid arthritis. The occurrence of rheumatoid arthritis is 1.06% in women and 0.6% in men. Recent research findings reveal that nearly 3,00,000 children have been diagnosed with juvenile arthritis in the past year, and many rheumatoid arthritis cases were reported among them. Thus clearly, Rheumatoid Arthritis is becoming a major cause of productivity and performance loss.

What is rheumatoid arthritis?

Rheumatoid arthritis is a systemic inflammatory disease which symmetrically affects the small bones and joints of the hand and feet. It is basically an auto-immune disease and produces systemic, articular and extra-articular effects. The reason rheumatoid arthritis is called “systemic” is if one knee gets affected with the disease the other knee starts showing similar symptoms as well. Inflammation, swellin, and stiffness of multiple joints (mainly the synovial joints) result in this conditions. This disease is usually incurable and the symptoms worsen with age. Rheumatoid arthritis typically peaks between the age of 40-50 and is at present one of the leading causes of disability on a global scale.

Difference between rheumatoid arthritis and osteoarthritis

Very often people get confused between the symptoms of rheumatoid arthritis and osteoarthritis, which may lead to misdiagnosis and improper treatment. The main difference is that osteoarthritis is the progressive erosion of the joints, while rheumatoid arthritis is the inflammation of the lining of the joints.

Pathogenesis of rheumatoid arthritis

The main pathological condition that leads to rheumatoid arthritis is the inflammation and thickening of the synovial membrane, caused due to autoimmune conditions. The synovial membrane becomes infested with inflammatory cells which causes joint pain and swelling. The vascular tissue (pannus) present in the synovial lining expands over the cartilage. Subsequent erosion of the articular cartilage and underlying bone occurs due to the presence of macrophages and osteoclasts (causes bone degeneration or resorption). Local inflammation is caused by two main immunoglobulin components synthesized by plasma cells in the subsynovium. Rheumatoid nodules form in the advanced stages and are surrounded by macrophages, fibroblasts, lymphocytes and plasma cells. Granuloma formation may also occur on the surface of pleura, endocardial valves, and pericardium.

The primary causes of pain in rheumatoid arthritis are-

• Irritation of nerve endings due to chemicals produced by inflammatory cells
• Excessive stretching of the capsules due to joint swelling

Joints affected

The joints primarily affected by rheumatoid arthritis are listed below-

• Cervical spine: It can cause neck pain, stiffness, paraesthesiae or sensory changes.
• Hands and wrists: Flexion contractures and ulnar deviation of fingers are observed.
• Feet and ankles: Metatarso-phalangeal joints, talonavicular, subtalar and avicular joints are affected.
• Shoulders: Inflammation of rotator cuffs occurs.
• Elbows: Stiffness occurs.
• Hips: Progressive loss of internal rotation occurs.
• Knees
• Temporomandibular joints: Pain, tenderness, and swelling occurs

Causes of rheumatoid arthritis

Rheumatoid arthritis occurs due to multiple etiological factors which are described below-

• Autoimmune diseases which cause a destruction of the joints and bones
• The release of harmful chemicals such as cytokines (due to inflammatory response or existing pathological conditions) which directly affects the linings joints
• Natural degeneration and weakening of body muscles and joints with age
• Obesity or overweight conditions causing increased load on the knee
• Joint inflammation due to rigorous physical activities or mechanical injury
• Cigarette smoking can increase risks of joint damage
• Diet deficient in Vitamin D
• Accidental bending and twisting causing injured joints
• Existing joint diseases such as gout, osteoarthritis or septic arthritis
• Lifting excessively heavy loads
• Genetic disorders causing degeneration of synovial tissues (mediated by Protein Tyrosine Phosphatase 22 gene)
• Inflammation evoking food items such as artificial fats, processed meat, refined carbohydrates and alcohol
• Toxicity due to chemicals present in the environment can affect the joints
• Incorrect body postures

Symptoms of rheumatoid arthritis

Rheumatoid arthritis is manifested through the following symptoms-

• Morning stiffness and joint pain lasting for more than 1 hour
• Swelling of soft tissues of multiple joints
• Symmetric joint swelling
• Extreme tenderness and touch sensitivity of joints
• Redness around the joint area
• Erosion and decalcification (loss of calcium content) of joints in advanced stages
• Formation of nodules in elbows and knees (rheumatoid nodules)
• Fever and nausea
• Extreme fatigue
• General body weakness
• Loss of appetite
• Profuse sweating and few other flu-like symptoms
• Anaemia
• Dryness of eyes and mouth
• Weight loss
• Pain radiating to neighbouring regions (back)
• Bone and joint deformities (at an advanced stage)
• Throbbing pain in the joint and muscles after some activity
• Joint pain during slight movements of hand and legs
• Difficulty performing mundane activities such as walking, running or climbing stairs

Types of rheumatoid Arthritis

The International Classification of rheumatoid Arthritis is given below-

• Seropositive rheumatoid Arthritis: It includes all categories of rheumatoid arthritis except arthritis of the spine and juvenile rheumatoid arthritis.
• Felty’s syndrome: It is characterized by splenoadenomegaly and leukopenia.
• Rheumatoid vasculitis: It is characterized by inflammation of the blood vessels.

Diagnosis

The following diagnostic tests are carried out to determine the cause and degree of rheumatoid Arthritis-

• X-rays (to detect joint inflammation or cartilage destruction)
• MRI scan (to examine joint injury if any)
• Synovial fluid analysis ( to look for inflammatory cells)

Treatment and prevention

Treatment

Medication 

• Over-the-counter NSAIDs (nonsteroidal anti-inflammatory drugs) can help in relieving pain and reducing inflammation. In case, OTC (over-the-counter) medications do not have much effect on the patient, stronger NSAIDs are prescribed by the doctor.
• Medications to reduce joint pains, inflammation and joint degeneration are provided.
• Certain medications can aid in reducing the progression of rheumatoid arthritis along with reducing degeneration of the surrounding tissues.
• Medications that can target the part of the immune system that causes inflammation are called biological agents. These medications are prescribed to those who have been diagnosed with rheumatoid arthritis.

Therapy – Here the patient will have to undergo physiotherapy and occupational therapy. These therapies help the patient by reducing pain and by learning ways to manage their day-to-day activities with moderate to less pain.

Surgery 

• Synovectomy – This surgery is performed on the knees, elbows, fingers, and hips to remove the inflamed lining of the joints.
• Tendon repair – This surgery is done to repair the tendons around the inflamed joints.
• Joint fusion – When the patient is unable to undergo a joint replacement, their joints are realigned to help bring back balance and reducing their pain.
• Total joint replacement – Here the damaged joint is replaced with a prosthetic joint made of metal or plastic.

Low FODMAP diet for rheumatoid arthritis

Consuming high FODMAP foods cause common gastrointestinal problems such as bloating, gas, constipation, and diarrhea. This is because it is difficult for the gut enzymes to break these foods down and digest it, causing the intestines to bloat and absorb water while releasing gases such as carbohydrate, hydrogen and methane.

FODMAP stands for:

F – Fermentable. 

O – Oligosaccharides.

D – Disaccharides.

M – Monosaccharides.

A – and

P – Polysaccharides.

According to certain studies foods such as red meat (chorizo), wheat bread, barley induced flour, rye, sausages, milk products such as cow milk, goat milk etc. which are high in FODMAPs, can increase the symptoms of rheumatoid arthritis. Foods such as walnuts, tuna, salmon, baby spinach, kale etc. consist of low FODMAPs, and are said to help reduce the symptoms of rheumatoid arthritis.

Following a low FODMAP diet can help reduce consumption of artificially sweetened foods and fats. Consuming a low FODMAP diet can help in relieving the symptoms of rheumatoid arthritis.

Prevention – Since there are no sure shot prevention methods, there are certain risk factors that can help in maintaining the condition.

• Exposure to certain harmful minerals such as silica and or asbestos may increase the chances of developing arthritis.
• Those who are overweight seem to be at a higher risk of developing rheumatoid arthritis. This is why it is important to maintain a healthy weight.
• Cigarettes tend to contain nicotine, which has bone degenerative properties, which is why it is important that people do not smoke. If they do smoke, then quitting is the best option for a healthier lifestyle.
• Knowing your family history is necessary to understand the chances of developing rheumatoid arthritis.

References