An autoimmune disease that doesn’t discriminate.
“Don’t crack your knuckles or you’ll get arthritis in your hands!” We often hear parents saying this to their children who may have just picked up the habit. There is actually no relation between this and arthritis, but it is still a condition that merits some concern and care, should it develop within our joints. We spoke to Dr. Ainon Mokhtar, a rheumatologist from Ara Damansara Medical Centre for more insight into rheumatoid arthritis and how it affects us.
Red, swollen, warm and painful
Dr Ainon explains that rheumatoid arthritis (RA) is the autoimmune disease that causes arthritis. Arthritis is the inflammation of one or more joints while RA causes the joints and its surrounding areas to become red, swollen, warm and painful. “Rheumatoid arthritis typically involves the small joints of the hands in the wrists, knuckles and fingers and usually occur in a symmetrical pattern,” she adds. The main site of inflammation happens in the synovium which is the tissue that lines the joint.
Dr. Ainon further explains, “When an autoimmune response happens, that is when our immune system attacks our own body cells, inflammatory substances are released that can cause synovial tissue swelling and an excess of synovial fluid in the affected region. These substances can also cause damage to the cartilage-tissue which cushions and protects joints from bone erosion.” Due to this, small joints – especially those in our hands – do not have enough space for easy movement. She adds that any tissue swelling or fluid accumulation will stretch the joint capsule causing joint swelling and pain in the affected area.
One of the tell-tale signs of RA is joint stiffness, especially in the morning. Dr. Ainon notes, “This may last one to two hours or even the whole day. Stiffness for a long period in the morning is a symptom of rheumatoid arthritis as few other arthritic conditions show this symptom.”
Other signs a patient with RA may exhibit include loss of energy, low-grade fever, loss of appetite, dry eyes and mouth associated with Sjögren’s syndrome, and firm lumps called rheumatoid nodules growing beneath the skin in places such as the elbow and hands. Dr. Ainon advises that if the patient is not treated, they could end up with joint deformity and disability.
Is it really RA?
In order to get the right diagnosis, it is best to go to a rheumatologist who can determine the best treatment plan for the patient. “Some blood tests may support the diagnosis of rheumatoid arthritis but only if the patient has symptoms of joint pain and swelling. An antibody screening for the rheumatoid factor (Rh factor) is a popular screening test done by a doctor. For patients with joint pain and swelling, the reading of their tests will be high,” says Dr. Ainon. However, she adds it may be positive in about 15% of normal people therefore, this test is not recommended in a person with no symptoms (asymptomatic).
For asymptomatic patients, a test for antibodies to cyclic citrullinated peptides (CCP) is more useful for diagnosing RA. If the patient tests positive for the CCP antibody but not Rh factor, or has low levels of both Rh factor and CCP antibody along with slight symptoms that may suggest RA, then it is likely that the patient has an early onset of the condition or that they will develop it in the future.
To help determine the degree of inflammation in patients with RA, other blood tests such as the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) can be carried out. Readings for both ESR and CRP increase when there is any inflammation in the body.
Dr. Ainon adds, “Doctors will also x-ray the hands and feet in most rheumatoid arthritis cases to look for the extent of damage to the bone caused by this disease. In some centres with appropriate facilities and expertise, the doctor can perform an ultrasound on the affected joints to look at the progression of the disease.”
Not just the elderly
Rheumatoid arthritis is not just a disease suffered by older people. According to Dr. Ainon, RA often begins between the ages of 30 and 50 but it can strike at any time — even in adolescents and children.
The symptoms of juvenile rheumatoid arthritis (JRA) in children aged 16 and younger are joint inflammation and stiffness. In some cases, people with JRA outgrow the illness; these are usually children who do not have the rheumatoid factor (Rh factor) in their bodies. Others may not be so fortunate – less than half of JRA patients have Rh factor but the presence of this factor increases the chance of the condition continuing into adulthood. In adults with RA, about 70-80% have Rh factor so the likelihood of outgrowing it is far less.
It is a myth that exercise is impossible for RA patients. Dr. Ainon advises, “It is important to be physically active most of the time but rest when the disease is active. In general, rest is helpful when a joint is inflamed. When joints are inflamed, do exercises with a gentle range of motion, such as stretching, in order to keep the joint flexible.” She adds that low-impact exercises such as walking, boosts muscle strength which will reduce pressure on the joints.
Patients should consult a physical and occupational therapist for advice on which type of activities they should engage in and at what pace or intensity.
Dr. Ainon advises friends and families of people suffering from RA to give ample support to the patient especially during flare-ups. Helping out with simple household chores, for example, can reduce their burden.
Arthritis Foundation Malaysia (www.afm.org.my) has comprehensive resources and information for people suffering from arthritis or anyone wishing to learn more about the condition
Unfortunately, there is no cure for rheumatoid arthritis but there are treatments to help prevent further damage to the joint structure. Dr. Ainon advises that treatment should begin as soon as the diagnosis is made. Treatment for RA can involve any of the following:
- Start treatment with disease modifying anti-rheumatic drugs (DMARDs) which can relieve symptoms and also slow the progression of the disease.
- Doctors may also administer non-steroidal anti-inflammatory drugs (NSAIDs) and/or low doses of corticosteroids to lower swelling, pain and fever.
- In serious cases, patients may require ‘biologic agents’ – these interfere with the biologic substances that are released by the immune system that causes or worsens inflammation.
- Surgery is usually the last option when a deformity has already occurred.