Rheumatoid Arthritis: Causes, Symptoms, and Treatment

The most common inflammatory joint disease belonging to the rheumatic group is the so-called (seropositive) rheumatoid arthritis or chronic polyarthritis. It is a systemic, i.e., affecting the entire body, usually, progressive inflammatory disease, which affects the organs (joints, tendon sheaths, bursae) lined by a so-called synovial. In the course of the disease, joints and tendons are destroyed, which leads to deviations in shape and axis as well as restrictions in movement.

The course of the disease varies greatly. In rare cases, organs outside the locomotor system (eye, skin, vessels, lungs, heart, kidney, or gastrointestinal tract) are also affected. About 1% of the population, without significant geographical or racial differences, suffer from rheumatoid arthritis. Women are three times more frequently affected than men. Men usually contract the disease between the ages of 45 and 65, women between the ages of 25 and 35 or after the age of 50.

Causes

The cause of R.A. (= rheumatoid arthritis) is mostly unknown. However, an isolated familial clustering of the disease makes a genetic component probable. Several genetic factors are assumed which control specific immune reactions and become independent under certain conditions, thus triggering the inflammation characteristic of rheumatoid arthritis / primarily chronic polyarthritis. Various pathogens (e.g., Epstein-Barr virus) or a pathogen substance common to several pathogens (e.g., a glycoprodefen) are suspected as triggers.

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Symptoms

The misdirected immune reaction leads to inflammation of the joint mucosa lining all joints (= synovitis). This thickens and forms more synovial fluid (joint effusion). A painful swelling of the bone develops. As a result, the joint capsules and the ligamentous apparatus of the joints are overstretched, and the joints can become unstable. The inflamed and proliferating joint mucosa gradually spreads to the joint cartilage. Together with released enzymes (aggressive joint proteins), the joint cartilage is destroyed over time. In advanced stages, the inflamed tissue undermines the bone from the edges of the joint and eventually leads to the destruction or deformation of the entire joint.

Rheumatoid arthritis (R.A.) usually begins insidiously.

Typical symptoms are:

  • Pain when pressed or moved,
  • Swelling and
  • Overheating of joints.

As a rule, there is a morning stiffness lasting up to three hours, i.e., functional loss of the affected joints and subsequent “thawing” with a significant increase in function. The most common joints affected are the finger, hand, elbow, shoulder, knee, ankle, and toe joints, usually symmetrically. However, practically all fittings, including the spine, can be affected by chronic polyarthritis (cP).

Sometimes, general signs of the disease such as fever, rapid exhaustion, loss of appetite, and weakness also occur. Besides the joints, the tendon sheaths can also be affected by rheumatoid arthritis. This inflammation of the tendon sheath (tendovaginitis) usually occurs in the hand area and can lead to a torn tendon.

Furthermore, so-called rheumatic nodules occur in about 30% of patients. These are small nodules that form in the area of bony protrusions, tendons, or ligaments, and their size often depends on the inflammatory activity of the disease.

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Diagnosis

The diagnosis of rheumatoid arthritis results from:

  • Symptoms
  • Physical exam
  • Labs and X-ray

The American College of Rheumatology (ACR) established criteria for the diagnosis of rheumatoid arthritis (R.A.) in 1987. Chronic polyarthritis (cP) is considered to be present when a patient meets at least four of the seven criteria, with criteria 1-4 having been present for at least six weeks.

ACR criteria for the diagnosis of rheumatoid arthritis:

  • Morning stiffness of at least one hour’s duration
  • At least three joint areas must simultaneously show soft tissue swelling or joint effusion.
  • At least one joint swelling affects a hand joint, a metacarpophalangeal joint or a metacarpophalangeal joint
  • Symmetrical simultaneous infestation of the same joint regions on both sides of the body
  • Rheumatism – knots over bony protrusions or near joints.
  • Suction. Rheumatism – factor (R.F.) detectable in the blood
  • Radiological changes typical of rheumatoid arthritis (R.A.) on an X-ray of the hand

ACR-EULAR classification criteria for rheumatoid arthritis

In 2010, on a joint initiative of ACR (American College of Rheumatology) and EULAR (European League against rheumatism), new criteria were established, the most crucial advantage of which is the possibility of a very early diagnosis.

In contrast to the old criteria from 1987, the new criteria do not include the characteristics of morning stiffness, the symmetry of joint involvement, and rheumatic nodules. The presence of erosions in the X-ray image is considered a feature of a reliable diagnosis from the outset. A joint infestation is not only a swelling of the joint but also a painfulness of the joint under pressure.

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ACR-EULAR classification criteria for R.A.:

Joint infestation

  • 1 medium/large joint: 0 points1 medium/large joint, not symmetrical: 1 point
  • 1 medium/large joint, symmetrical: 1 point
  • 1-3 small joints: 2 points
  • 4-10 small joints: 3 points
  • 10 joints, including small joints: 5 points

Serology (R.F. + ACPA)

  • Neither R.F. nor ACPA positive: 0 points
  • At least 1 test weakly positive: 2 points
  • At least 1 test strongly positive: 3 points

Duration of synovitis

  • <6 weeks: 0 points
  • 6 weeks: 1 point

Acute-phase proteins (CRP/BSG)

  • Neither CRP value nor BSG increased: 0 points.
  • CRP or BSG increased: 1 point

When 6 points are reached, an R.A. is present. Prerequisites: confirmed synovitis in at least one joint, exclusion of other diagnoses that explain the synovitis, no typical erosions in the X-ray image (then the R.A. is considered confirmed).

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Laboratory values

In the diagnosis of rheumatic diseases, a blood sample with the determination of some values is inevitable. These include, for example, the inflammation values and rheumatoid factors.

Laboratory diagnostics is used to find the diagnosis, but also to assess the progression/activity of the disease, the response to therapy, and it has a prognostic value. The laboratory values should always be evaluated in conjunction with other findings.

The rheumatoid factor (R.F.) or antibodies against citrullinated cyclic peptides (CCP antibodies or ACPA: anti-citrullinated protein antibodies) are available for diagnosis.

The rheumatoid factor is detected in the blood. It develops during the first years of the disease. It is an immunoglobulin that is produced in the joint mucosa of the diseased joints. The rheumatoid factor becomes positive in 75-80% of patients with rheumatoid arthritis / primary chronic polyarthritis during the disease. However, it can sometimes also be detected in other conditions and older age.

CCP antibodies/ACPA are more suitable for early diagnosis, as they can be detected in very early phases of the disease. The combination with a decisive rheumatoid factor increases the probability of suffering from rheumatoid arthritis to almost 100%.

The so-called rheumatoid factor (R.F.) is probably one of the best-known autoantibodies. Learn more about many other autoantibodies and their clinical pictures under the following article: Autoantibodies From a forecasting point of view, the ACPA appears to be of considerable importance. High ACPA titers increase the risk of a severe course of the disease.

Other typical laboratory findings in the blood of patients with primary chronic polyarthritis are elevated inflammation levels, e.g., CRP (C – reactive protein), and an accelerated blood sedimentation rate (BSG). The iron value, as well as hemoglobin (Hb) and leucocytes (=white blood cells), are often reduced, the copper value, gamma globulins, and thrombocytes (=blood platelets) may be elevated.

Furthermore, laboratory diagnostics serve to exclude other diseases.

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X-ray

The diseased joints should be x-rayed annually for diagnosis and especially in the first years for monitoring the progress.

The radiological changes on the x-ray image are joint space narrowing, decalcification near the joint (osteoporosis), erosion of the joint surfaces, later destruction of the joint surfaces as well as stiffening/bony deformation of the joints or joint dislocations/ malpositions.

There is a radiological stage classification on the X-ray according to the severity of the joint changes in 5 stages (classification, according to Larsen).

Other diagnostic examinations

Sonography (ultrasound) of the joints or tendons, e.g., to visualize a joint effusion at the hip joint, to visualize a Baker’s cyst (popliteal cyst) in the hollow of the knee or to visualize torn tendons in the area of the shoulder (torn rotator cuff) or the Achilles tendon (torn Achilles tendon).

However, this is only helpful for assessing the activity of the inflammation, not for making a diagnosis.

Stages of rheumatoid arthritis

Rheumatoid arthritis is a chronic inflammatory disease that is caused by an excessive reaction of the body to the body’s cells. It can be said that the immune system does not recognize the body’s cells and therefore fights them. The disease, which mainly affects the joints of the body, progresses in four different stages.

  • Stage 1: In most cases, the basic joints of the fingers of both hands are affected symmetrically, and there is swelling of the joints. In addition, patients affected by stage 1 rheumatoid arthritis complain of morning stiffness, which remains for more than 30 minutes after getting up.
  • Stage 2: There is an increasing proliferation of connective tissue in the area of the affected joints and a rising influx of inflammatory fluid into the joints. This results in a growing restriction in the mobility of the joints during movement. The joint capsule may also bulge out, which can also severely restrict the movement possibilities.
  • Stage 3: Malpositioning of the finger joints already occurs. The fingers are usually pulled in the direction of the ulna of the forearm. Due to the chronic inflammatory processes, the tendon sheaths are also gradually destroyed, with the result that the muscles that move the fingers can no longer be moved without resistance. This leads to so-called swan neck deformations of the fingers (see subheading Rheumatism hand/hands).
  • Stage 4: The last step of rheumatoid arthritis occurs in an advanced state of the disease. It shows severe deformities and destruction of the phalanges. Besides, other organs can also be affected by rheumatic disease in this state of the disease. In some cases, the heart or lungs, as well as the connective tissue, can be changed. Due to the excellent treatment options available today, very few rheumatism patients go through this stage today, since the chronic disease can be treated with medication in earlier stages.

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Physical examination

In addition to the symptoms mentioned above such as morning stiffness, joint pain, rapid fatigue, the physician finds characteristic clinical changes or deformities (rheumatism – caused deviation of the joints) during the physical examination in chronic polyarthritis (cP).

The examination usually includes the analysis of the:

  • Hand/hands
  • Foot / Feet
  • Knee
  • Hip
  • Shoulder
  • Elbows
  • Spine
  • Laboratory values
  • X-ray
  • Further diagnostic investigations

Rheumatoid arthritis at various locations

Gooseneck deformation

There is the painful swelling of the joints of the hand, the base of the finger and the middle finger joints, usually symmetrically on both sides of the body. The joints are sensitive to pressure, e.g., when shaking hands. Movement of the hand and finger joints may be restricted so that the fist is no longer completely closed. The musculature of the ball of the thumb and little finger, as well as the muscles of the palm, may be diminished and powerless. Tendon swellings or tendon tears occur. In advanced stages of the disease, typical deformities of the hands occur:

  • Hand scoliosis: Deviation of the wrist root outwards (ulnar = ulnar),
  • Caput ulnae – syndrome: protrusion and hypermobility of the ulnar head on the wrist
  • Buttonhole deformity: fixed flexion position in the middle finger joint and hyperextension of the finger end joint
  • Gooseneck deformity: hyperextension in the middle finger joint and fixed flexion position in the end finger joint
  • 90° / 90° deformation of the thumb: fixed flexion position in the metacarpophalangeal joint of the thumb and hyperextension of the end joint of the thumb

Rheumatoid arthritis of the feet

There is painful swelling of the foot and toe joints, usually symmetrical on both sides of the body. The joints are sensitive to pressure. Tendon swelling occurs on the extensor side and behind the inner or outer ankle. In advanced stages of the disease, typical deformities occur in the area of the feet:

  • Hallux valgus: deviation of the big toe outwards
  • Hallux rigidus: Arthrosis of the metatarsophalangeal joint of the big toe with painful mobility and possibly hyperextension of the end joint of the big toe
  • Hammertoes: fixed flexion of the toe end joints
  • Splayfoot
  • Windmill forefoot: Deviation of all toes to the outside, due to rheumatic attack of the tendons and ligaments of the foot
  • Flat and twisted feet: also due to softening of the connective tissue caused by rheumatism

Rheumatoid arthritis in the knee

Usually, there is soft tissue swelling and joint effusion with a dancing patella (the effusion in the knee joint lifts the patella, which results in elastic resistance when pressure is applied to the kneecap), sometimes there is also a Baker’s cyst in the hollow of the knee. The mobility during flexion and extension is limited—muscle reduction of the thigh muscle. Increasing instability can lead to the O – leg or X – leg. The consequences are usually gonarthrosis (arthrosis of the knee joint). This often requires the implantation of an artificial knee joint.

Rheumatoid arthritis in the hip

A swelling is usually not visible or palpable. Pressure pain is located in the groin or above the outside of the thigh and the giant rolling mound (greater trochanter). The mobility of the joint may be limited. If this restriction occurs mainly in the morning, it is called morning stiffness.

The consequences of long-standing rheumatism are usually arthrosis of the hip joint (coxarthrosis). Frequently, the hip socket moves into the pelvis (protrusio actetabuli). In severe cases, an artificial hip joint must be implanted.

Rheumatoid arthritis in the shoulder

There is a pressure-painful swelling, most likely to be palpated from the front, as a relatively strong muscle mantle covers the shoulder joint at the back. The mobility of the joint is limited. The tendons surrounding the shoulder joint are usually pressure-painful, as is the acromioclavicular joint.

Rheumatoid arthritis in the elbow

Also, in the area of the elbow, there is a swelling that causes pressure pain and restricts the movement of the joint, usually an extension deficit.

Rheumatoid arthritis of the spine

Pressure pain occurs in the area of the spinous processes and in the musculature adjacent to the spinous processes—restriction of movement of the head and trunk. Depending on the position of the head, discomfort can occur in the arms, legs, or trunk. Sensory disturbances and muscle weakness of the arms and legs occur, as well as dizziness, nausea, or even swallowing or breathing disorders.

Therapy

There are some guidelines for the treatment of rheumatoid arthritis. They are all based on treating the complaints and symptoms with the so-called DMARD (“disease-modifying antirheumatic drug”) treatment. #

The DMARD treatment is an anti-inflammatory drug treatment with a non-steroidal anti-inflammatory drug such as ibuprofen or diclofenac and a therapy with a steroidal anti-inflammatory medication. These include cortisone, which usually accounts for a large part of the treatment of rheumatoid arthritis.

The Leiltinie stipulates that treatment with an anti-inflammatory drug and with cortisone in combination should be started immediately if the diagnosis of rheumatoid arthritis is considered inevitable. Treatment should only be given under close supervision. The aim should be to contain the disease activity as quickly as possible. If necessary, the drug treatment must be adjusted. Cortisone preparations should be started with a low initial dosage as the starting dose. If there is no rapid improvement of the symptoms, the medication should be quickly increased.

DMARD treatment also includes the drug methotrexate, which is also used and helps to suppress the immune system.

If the treatment with a DMARD does not achieve the desired success, a supplementary treatment with a so-called biological should be started.

If symptoms improve under the individual or combined treatment, consideration should be given to gradually reducing the medication. However, it may be necessary to keep a certain amount of essential medicines in place to prevent the symptoms from recurring as soon as possible.

Biologics

The so-called biologicals have been used in the treatment of rheumatoid arthritis for several years. This term is used to describe biotechnologically produced drugs. In the treatment of rheumatoid arthritis, synthetically produced antibodies are used in particular to counteract the excessive immune system that causes the symptoms of rheumatoid arthritis.

This includes adalimumab, also known under the trade name Humira.

These so-called biologicals, which are also used for other diseases, are costly drugs. Since they would not reach their destination if taken in tablet form, they are administered in the form of an injection. In most cases, the drugs are injected into the muscle in the way of a depot syringe. A booster is given every few weeks or months. As a rule, the drugs are well tolerated.

Methotrexate

Methotrexate (MTX) is an antagonist of folic acid and inhibits a specific receptor. The drug is used in the treatment of cancer as well as autoimmune diseases. It ensures that the excessive immune system is throttled, thereby reducing the severity of rheumatic attacks or even preventing them from occurring at all.

In the treatment of rheumatoid arthritis, Methotrexate is used when ibuprofen or diclofenac or cortisone do not lead to an improvement to the desired extent. MTX can be taken in tablet form or injected. While taking MTX, blood levels should be checked regularly, and if there are any abnormalities, the dose should be changed, or Methotrexate discontinued.

MTX is generally well tolerated by patients. However, some side effects should be considered. These include increased susceptibility to infections, pulmonary fibrosis, nausea and vomiting, hair loss, blood count changes, kidney and bladder damage, and inflammation of the mucous membranes. In rare cases, a disorder of the central nervous system may also occur. Before taking Methotrexate, pregnancy must have been ruled out. The drug is prescribed by a rheumatologist.

Naturopathy

In addition to the conventional medical treatment of rheumatoid arthritis, some naturopathic approaches can be given at least as a supplement to traditional medicine. In recent years, naturopathic approaches have been used more and more. Naturopathic substances should always be provided parallel to conventional medicine. This combination ensures that the effect of the traditional medical drugs is improved, but also that the side effects of these drugs can be reduced.

Hydrotherapy has long been used in the accompanying treatment of rheumatism. This includes bath therapy as well as the well-known Kneipp therapy.

Hydrotherapy also uses treatments with medicinal mud (fango) and cold and warm sprays. They ensure that rheumatic attacks occur less frequently and heal more quickly after they occur. The intensity of rheumatic attacks is also reduced under hydrotherapy.

The correct diet is also part of the naturopathic treatment. Above all, it should contain little meat and fat and plenty of fish. All products that are rich in arachidonic acid and omega 3 fatty acids are very suitable for a diet that counteracts rheumatoid arthritis. Fasting is also always mentioned when it comes to the effects of diet on the development of rheumatism. Prior medical advice is essential. The start of a fast should be carefully considered.

Summary

Rheumatoid arthritis is the most common rheumatic disease with chronic inflammation of the synovial membranes, tendon sheaths, and bursae. The course of the disease is usually progressive in phases. Beginning with painful swelling and overheating, sensitivity to pressure, and restricted movement of joints, rheumatoid arthritis / chronic polyarthritis can lead to the destruction of joints and tendons.

The diagnosis is based on the symptoms and the physical examination findings. To support the diagnosis, laboratory values, and x-rays of the affected joints should be taken.

The therapy is drug-based on the one hand, but on the other hand, there are various surgical procedures available. The treatment aims to slow down the inflammatory process, to relieve pain and, if possible, to maintain the function and strength of the joints. Accompanying physiotherapy, ergotherapy, and physical measures are used.

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