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Rheumatoid Arthritis - A Guide

Rheumatoid arthritis is a condition that causes pain and swelling in the joints. Hands, feet and wrists are commonly affected, but it can also damage other parts of the body. Rheumatoid arthritis can make your joints feel stiff and can leave you feeling generally unwell and tired

Introduction
Symptoms
Causes
Diagnosing Rheumatoid Arthritis
Treatment
Complications
Living with Rheumatoid arthritis

See also : Arthritis Types and Osteoarthritis

Introduction

Who is affected?

The condition is estimated to affect 580,000 people in England and Wales and occurs more frequently in women than men. It is most common between the ages of 40 and 70, but it can affect people of any age.

Why does it happen?

Rheumatoid arthritis is an autoimmune disease. This is when your immune system, which usually fights infection, attacks the cells that line your joints, making them swollen, stiff and painful. Over time, this can damage the joint itself, the cartilage and nearby bone.



What are the symptoms?

The symptoms of rheumatoid arthritis usually vary over time. Sometimes, symptoms only cause mild discomfort. At other times, they can be very painful, making it difficult to move around and do everyday tasks.

When symptoms become worse, this is known as a flare-up or flare. A flare-up is impossible to predict, making rheumatoid arthritis difficult to live with.

For more information, see Rheumatoid arthritis - symptoms

Outlook

Currently, rheumatoid arthritis cannot be prevented as the exact trigger of the condition is unknown. Although viruses and bacteria may be involved, research is not yet conclusive.

There is no known cure for rheumatoid arthritis. However, early diagnosis and treatment can control symptoms and help prevent disability. See Rheumatoid arthritis - treatment for more information.

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Symptoms of rheumatoid arthritis

The symptoms of rheumatoid arthritis usually develop gradually. The first symptoms are often felt in small joints, such as your fingers and toes, although shoulders and knees can be affected early, and muscle stiffness can be a prominent early feature.

Flare-ups

The symptoms of rheumatoid arthritis vary from person to person. They can come and go, and they may change over time. You will experience flare-ups when, from time to time, your condition will worsen and your symptoms will be more intense and severe.

You can experience a flare-up at any time of the day or night. However, it is likely that your symptoms will be more painful in the morning, when you first wake up. Usually, your symptoms will begin to ease as the day progresses and you start using and flexing your joints.

Pain

This is usually a throbbing and aching sort of pain. It is usually worse in the mornings and after you have been sitting still for a while. Pain is often felt while you are resting, not after activity.

Stiffness

Joints affected by rheumatoid arthritis can feel stiff, especially in the morning. Morning stiffness associated with a kind of arthritis called osteoarthritis usually wears off within 30 minutes of getting up in the morning. However, rheumatoid arthritis morning stiffness usually lasts longer than half an hour.

Warmth and redness

The lining of the affected joint becomes inflamed, causing the joints to swell, become hot, tender to touch and painful.

Rheumatoid arthritis can also cause inflammation around the joints, such as rheumatoid nodules, and in other parts of your body. The condition can also cause inflammation of your tear glands, salivary glands, the lining of your heart and lungs, and your blood vessels.

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Causes of rheumatoid arthritis

The exact cause of rheumatoid arthritis is unknown. We know how the condition attacks the joints, but it is not yet known what triggers the initial attack. Some theories suggest that an infection or a virus may trigger rheumatoid arthritis, but none of these theories has been proven.

Autoimmune condition

Rheumatoid arthritis is an autoimmune condition. This type of condition causes the body’s immune system to attack itself. Normally, your immune system makes antibodies that attack bacteria and viruses, helping protect your body against infection. If you have rheumatoid arthritis, your immune system sends antibodies to the lining of your joints, where instead of attacking harmful bacteria, they attack the tissue surrounding the joint.

Synovium

The synovium is a membrane (thin layer of cells) that covers each of your joints. When antibodies attack the synovium, they leave it sore and inflamed. This inflammation causes chemicals to be released, causing the synovium to thicken. These chemicals can also damage bones, cartilage (the stretchy connective tissue between bones), tendons (tissue that connects bone to muscle) and ligaments (tissue that connects bone and cartilage). The chemicals gradually cause the joint to lose its shape and alignment and, eventually, can destroy the joint completely.

Genetic susceptibility

There is some evidence that rheumatoid arthritis can run in families. Your genes may be one factor in the cause of the condition. However, having a family member with rheumatoid arthritis does not necessarily mean that you will inherit the condition. Even an identical twin of someone with rheumatoid arthritis only has a one in five chance of developing it, so genes do not explain much of the risk.

Hormones

Rheumatoid arthritis is three times more common in women than in men. This may be due to the effects of oestrogen (a female hormone). Research has suggested that oestrogen may be involved in the development and progression of the condition. However, this has not been conclusively proven.

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Diagnosing rheumatoid arthritis

Rheumatoid arthritis can be difficult to diagnose because many conditions cause joint stiffness and inflammation. Your GP will do a physical examination, checking your joints to see if they are swollen and to find out how easily they move. Your GP will also ask you about your symptoms. It is very important to tell your GP about all of your symptoms, not just the ones you think are important. This will help your GP to make the correct diagnosis.

If your GP thinks you have rheumatoid arthritis, they will refer you to a specialist (rheumatologist).

After conducting a physical examination and consulting your medical history, your GP may carry out a series of tests which may help to confirm the diagnosis, or they may refer you at the same time as requesting tests. Tests that you may have are outlined below.

Blood tests

No blood test can definitively diagnose rheumatoid arthritis. While a number of tests can indicate to your GP that you may have developed the condition, they will not necessarily prove or rule out the diagnosis. If you have persistent joint inflammation, you will need to see a rheumatologist.

Erythrocyte sedimentation rate (ESR)

In an ESR test, a sample of your red blood cells is placed into a test tube of liquid. The cells are then timed to see how fast they fall to the bottom of the tube (measured in millimetres per hour). If they are sinking faster than usual, you may have an inflammatory condition, such as rheumatoid arthritis.

C-reactive protein (CRP)

A CRP test can indicate if there is inflammation anywhere in the body by checking how much CRP is present in your blood. CRP is produced by the liver. If there is more CRP than usual, there is inflammation in your body.

Full blood count

The full blood count will measure your red cells to rule out anaemia. Anaemia is a condition where the blood is unable to carry enough oxygen, due to a lack of blood cells. Eight out of ten people with rheumatoid arthritis have anaemia. However, anaemia can have many causes, including a lack of iron in your diet. Therefore, having anaemia does not prove that you have rheumatoid arthritis.

Rheumatoid factor

This blood test checks to see if a specific antibody, known as the rheumatoid factor, is present in your blood. This antibody is present in eight out of ten people with rheumatoid arthritis. However, it cannot always be detected in the early stages of the condition. The antibody is also found in 1 in 20 people who do not have rheumatoid arthritis, so this test cannot confirm rheumatoid arthritis. If it is negative, another antibody test (for anti-CCP) may be done, which is more specific for the disease.

Joint imaging

X-rays of your joints can help differentiate between different types of arthritis. A series of X-rays can also help show how your condition is progressing. A chest X-ray may also be taken as both the disease and certain treatments (such as methotrexate) can affect the chest.

Musculoskeletal ultrasound may be used in the clinic to confirm the presence, distribution and severity of inflammation and joint damage.

Magnetic resonance imaging (MRI) scans can help show what damage has been done to a joint.

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Rheumatoid arthritis treatment

What is good rheumatoid arthritis care?

The aim of rheumatoid arthritis treatment is to reduce inflammation in the joints, relieve pain, prevent or slow joint damage, reduce disability and provide support to help you live as active a life as possible. There is good evidence that early treatment and support can reduce joint damage and limit the impact of rheumatoid arthritis. Lifestyle changes, drug and non-drug treatments and surgery can all help reduce the negative effects of rheumatoid arthritis.

The Arthritis and Musculoskeletal Alliance (ARMA) has developed a set of standards for good arthritis care (PDF, 378Kb).

ARMA recommends that if you have rheumatoid arthritis-type symptoms, you should see a rheumatology specialist within 12 weeks of referral from your GP to confirm a diagnosis of rheumatoid arthritis.

Also, the National Institute for Health and Clinical Excellence (NICE) has produced guidance for the management of rheumatoid arthritis.

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Complications of rheumatoid arthritis


Having rheumatoid arthritis can put you at a higher risk of developing other conditions:
  • Carpal tunnel syndrome - this is a common condition in people with rheumatoid arthritis. Carpal tunnel syndrome is when there is too much pressure on the nerve in the wrist. It can cause aching, numbness and tingling in your thumb, fingers and part of the hand.
  • Inflammation - because rheumatoid arthritis is an inflammatory condition, it can sometimes cause inflammation to develop in other parts of your body, such as your lungs, heart, blood vessels or eyes.
  • Tendon rupture - tendons are pieces of flexible tissue that attach muscle to bone. Rheumatoid arthritis can cause your tendons to be become inflamed, which in severe cases can cause them to rupture. This most commonly affects the tendons on the backs of the fingers.
  • Cervical myelopathy - if you have had rheumatoid arthritis for some time, you are at increased risk of developing cervical myelopathy and you may need special assessment of your neck before any operation where you are put to sleep. This condition is caused by dislocation of joints at the top of the spine, which put pressure on the spinal cord. Although relatively uncommon, it is a serious condition that can greatly affect your mobility.
  • Vasculitis - this is a rare condition that causes inflammation of the blood vessels. It can lead to the thickening, weakening, narrowing and scarring of blood vessel walls. In serious cases, it can affect blood flow to your body's organs and tissues.

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Living with rheumatoid arthritis


Rheumatoid arthritis can be life changing. You may need long-term treatment to control your symptoms and reduce joint damage. Depending on how much pain and stiffness you feel and how much joint damage you have, you may have to adapt the way you do simple daily tasks. They can become difficult or take a little longer to complete.

Self care

Self care is an integral part of daily life. It involves taking responsibility for your own health and wellbeing with support from the people involved in your care. Self care includes the things you do each day to stay fit, maintain good physical and mental health, prevent illness or accidents, and effectively deal with minor ailments and long-term conditions. People living with long-term conditions can benefit enormously if they receive support for self care. They can live longer, have less pain, anxiety, depression and fatigue, have a better quality of life and are more active and independent.

Take your medication

It is important to take your medication as prescribed, even if you start to feel better. Continuous medication can help prevent flare-ups. If you have any questions or concerns about the medication you are taking or side effects, talk to your healthcare team.

It may also be useful to read the information leaflet that comes with the medication about possible interactions with other drugs or supplements. Check with your healthcare team before taking any over-the-counter remedies, such as painkillers, or any nutritional supplements. These can sometimes interfere with your medication.

Regular reviews

Because rheumatoid arthritis is a long-term condition, you will be in contact with your healthcare team regularly. The more the team knows, the more they can help you, so discuss your symptoms or any concerns with them.

Keeping well

Everyone with a long-term condition, such as rheumatoid arthritis, is encouraged to get a yearly flu jab each autumn to protect against flu. They are also recommended to get an anti-pneumoccocal vaccination. This is a one-off injection that protects against a serious chest infection called pneumococcal pneumonia.

Get plenty of rest during a flare-up as this is when your joints can be particularly painful and inflamed. Putting further strain on very swollen and painful joints can often make pain and inflammation worse.

Healthy eating and exercise

Regular exercise and a healthy diet are recommended for everyone, not just people with rheumatoid arthritis. They can help prevent many conditions, including heart disease and many forms of cancer.

Exercising regularly can help relieve stress and reduce fatigue. A gentle form of exercise that does not put too much strain on your joints is best. Swimming, for example, helps exercise your muscles but puts very little strain on your joints because the water supports your weight.

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