Rheumatoid arthritis

Rheumatoid arthritis, often referred to simply as rheumatism, is contrary to popular belief not a disease of old age, but can affect people of any age. It should also be said that rheumatoid arthritis is not a harmless disease and in some cases can take a very difficult course. In rheumatoid arthritis, a malfunction of the immune system leads to inflammation of the joints, which causes typical symptoms such as joint pain and swelling. If the disease is not treated in time and adequately, it leads to irreversible destruction of the joints or to spreading to other organs of the body. In most cases, the joints of the hands and feet are predominantly affected by the disease.

The origin of rheumatoid arthritis is not clear, but it is known that many components contribute to the development of the disease. For example, a certain genetic predisposition along with environmental factors can lead to the onset of rheumatoid arthritis.

Among the clinical picture generally referred to as rheumatism, rheumatoid arthritis is to be distinguished above all from joint wear and tear (arthrosis) and gout attacks, which are also accompanied by joint complaints.

Rheumatoid arthritis is only one of many rheumatic diseases. Other representatives of diseases associated with inflammation of the joints are Bekhterev's disease, Reiter's syndrome, and psoariasis arthritis.

Further to be distinguished is rheumatic fever, a disease caused by an immune reaction after streptococcal infections. This inflammatory disease, which occurs mainly in children, can also cause joint pain.

There are also a number of diseases of the vessels (vasculitides) and connective tissue (collagenoses) that can also lead to joint complaints. An important representative is lupus erythematosus, in which an autoimmune reaction can lead to inflammation in various organs, such as the skin, kidneys and joints. In contrast, scleroderma causes damage to organs and joints, mainly due to an increase in connective tissue.

Rheumatoid arthritis

Rheumatoid arthritis is the most common inflammatory disease of the joints, with an incidence of about 1%, whereby women are more often affected by the disease than men. Although rheumatoid arthritis predominantly affects older people, the disease occurs in all age groups.

The disease develops very inconspicuously and slowly at first, which is why it is usually not recognised immediately. However, the symptoms increase continuously and more and more joints are affected by inflammatory changes. It is of great importance to treat the rheumatoid arthritis in time and adequately, because otherwise it comes to an irreversible destruction of the joints. Reduced mobility of the joints, as well as increasing pain and joint stiffness are consequences of joint destruction. In the worst case, the disease can lead to disability and occupational incapacity.

Unfortunately, there is currently no complete cure for rheumatoid arthritis, but the disease can be brought under control and the progressive destruction of the joints reduced by early treatment. Patients themselves can also exert a positive influence on the course of the disease by taking certain measures.

In order to prevent joint damage and progression of the disease, lifelong drug therapy is necessary. In addition, gymnastics, physical therapy and special massages can have a positive influence on the course of the disease. It should be mentioned, however, that rheumatoid arthritis can be very different from person to person, which is why an individually adapted therapy and regular checks on the course of the disease are necessary. In the case of severe joint damage, surgical rehabilitation is necessary.

The development of rheumatoid arthritis is thought to have both a genetic component and to be triggered by the influence of many environmental factors. For this reason, people who have close relatives with rheumatoid arthritis have a higher risk of also developing the disease. However, the exact way in which rheumatoid arthritis develops is not yet known.

In rheumatoid arthritis, an autoimmune reaction causes inflammation of the joints. For reasons that are not clear, the immune system produces antibodies that are directed against the joint skin. These antibodies cause inflammation and subsequent damage in the joint area.

The cell decay that occurs during inflammation releases substances from the cells that increase the inflammatory process and antibody production. So-called cytokines, for example TNF-alpha and interleukin-1, are released, which have a stimulating effect on the immune system. These factors keep the inflammation going, which can even lead to damage of cartilage tissue and bone substance.

The initial symptoms of rheumatoid arthritis are very non-specific. Patients often report a lack of appetite, fatigue, increased body temperature or weight loss. Since these symptoms can indicate a variety of diseases, it is very difficult to diagnose rheumatoid arthritis at the beginning of the disease. Only gradually do the joint symptoms that are indicative of the disease appear.

Only the appearance of joint pain, heating and swelling of the joints lead in most cases to the diagnosis. However, these very typical symptoms can be very different in each affected person. For example, in some patients the symptoms begin very mildly and only increase over time, while in others they can start very violently and suddenly.

It is also very typical for rheumatoid arthritis that the joint complaints are strongest in the morning. At the beginning of the disease, many sufferers report morning stiffness in the joints of the fingers and hands, which hinders them in their normal early morning activities. While the stiffness only occurs in the morning at the onset of the disease, it can occur in episodes at any time of day in later stages of the disease. Poor circulation and its consequences can also be indicative of rheumatoid arthritis.

Over time, more and more joints are affected by the inflammatory disease, which becomes noticeable through an increasing number of swollen, overheated, reddened and painful joints. As far as the course of joint inflammation is concerned, it can be said that at the beginning it is mainly the joints of the fingers that are affected and that the complaints occur at about the same time on the right and left hand. Only after a certain time are other joints affected by rheumatoid arthritis, but it is impossible to say in which joint the inflammation will occur next. As accompanying complaints of the joint inflammations at the finger and hand joints, many patients also report tendon sheath inflammations, such as the so-called carpal tunnel syndrome. In some cases, the disease also spreads to vessels or organs.

The autoimmune reaction directed against the joints leads to their destruction, which causes persistent pain. Further consequences are deformation and stiffening of the joints, which can lead to massive restriction of movement with disability. The deformations can be described differently depending on the type and the joint affected. In a quarter of patients, so-called rheumatoid nodules are also found, which are small nodules under the skin in the joint area. In order to prevent joint damage with movement restrictions, a timely and individually adapted therapy is necessary, which should best be carried out in specialized centers or by rheumatologists.

As already mentioned, the course of rheumatoid arthritis can vary from person to person. Some patients have almost no complaints, while others are constantly plagued by pain. If the symptoms increase over a period of a few months, this is called a rheumatic flare-up.

In order to influence the course of the disease as positively as possible, early detection of the disease is important. However, it is difficult to diagnose rheumatoid arthritis at the beginning of the disease, because it initially runs very unspecifically. In particular, people should think about rheumatoid arthritis whose close relatives suffer from the disease and who experience morning stiffness or circulatory problems in the finger and wrist joints.

In addition, one should go to a specialist for clarification of the disease, because this can turn out to be very difficult due to very different courses of the disease. It is best to consult an internist specializing in rheumatology.

At the beginning of the examination, the doctor will conduct a medical interview. It is important to describe the symptoms as extensively and in detail as possible so that the doctor can get a good picture of the symptoms. If rheumatoid arthritis is suspected after the consultation, a physical examination, a blood sample and imaging procedures are usually performed:

- During the physical examination, the doctor looks at the affected joints and pays attention to rheumatoid nodules, swelling, warming, pain, as well as a restriction of movement of the joints.

- Furthermore, the diagnosis can be determined by means of imaging procedures. For example, an X-ray examination of the affected joints can be performed. In the process, attention is paid to specific changes in the joints through which the diagnosis can be made. These include cartilage and bone defects, a narrowing of the joint space, a reduction in bone substance and other damage to the joints. However, these changes are not yet visible at the beginning of the disease.

Changes in the joints, such as inflammation or joint effusions, can also be visualised by means of an ultrasound examination. In the diagnosis of rheumatoid arthritis, ultrasound is very often used as a supplement due to its high availability and for cost reasons.

Another imaging technique that can be used to examine rheumatoid arthritis is scintigraphy. This investigative procedure provides good imaging of bone metabolism, which may be altered in rheumatoid arthritis.

Finally, magnetic resonance imaging should also be mentioned, by means of which the joints and adjacent structures can be depicted very well. However, MRI is not routinely used due to cost and limited availability.

- By means of a blood sample, the inflammatory activity of rheumatoid arthritis can be examined. For this purpose, the C-reactive protein (CRP) can be used on the one hand, but also a high blood sedimentation rate. Furthermore, an antibody, the so-called rheumatoid factor, can be determined in the blood of many patients with rheumatoid arthritis. However, the rheumatoid factor is not positive in all patients with rheumatoid arthritis, especially in the early stages of the disease, and may also be elevated by other diseases, such as cancer and hepatitis viruses.

A more definite result is obtained by evaluating the antibodies against cyclic citrullinated peptides (CCP antibodies). These are positive even in the early stages of the disease, which means that rheumatoid arthritis can be detected very early and therapy can be started at an early stage.

In addition, a number of other factors must be determined in the blood in order to be able to distinguish between the countless different rheumatic diseases, or to be able to distinguish rheumatic diseases from diseases with similar symptoms. Caution is also required when interpreting other parameters: for example, antinuclear antibodies (ANA) can be detected in the blood of some patients with rheumatoid arthritis on the one hand, but on the other hand these antibodies also occur in other diseases that can be accompanied by joint complaints.

In order to be diagnosed with rheumatoid arthritis, at least four of the following criteria must apply:

- Inflammation of three or more joints at the same time.

- Inflammation of the finger and wrist joints

- morning stiffness lasting at least one hour

- appearance of rheumatic nodules

- Detection of characteristic changes in the joints using imaging techniques

- Rheumatism factors can be detected in the blood

- Joint inflammation at the same joint of the left and right side of the body

Since the causes for the development of rheumatoid arthritis have not yet been clarified, there is also no therapy that enables a complete cure. However, with an early and well-adjusted therapy, the course of the disease can be positively influenced and a worsening of the symptoms can be counteracted. In this case, the immune system, which causes the joint inflammation, is mainly influenced by medication, whereby the destruction of the joint can be reduced or even completely prevented. These drugs, also known as basic therapeutics (DMARD = Disease Modifying Anti-Rheumatic Drugs), include:

- Methotrexate

- azathioprine

- Gold compounds

- sulfasalazine

- cyclophosphamide

In addition to these basic therapeutics, painkillers and anti-inflammatory drugs can be administered to alleviate the symptoms.

In order to influence the course of the disease as positively as possible, it is important to begin therapy in the first few months of rheumatoid arthritis, as this is when the progression of the disease is most progressive. However, if treatment is started in the first 6 months, the prognosis can be significantly improved. Since each patient may react differently to each basic therapeutic agent, it is of great importance to have the treatment performed by a rheumatologist in order to find the appropriate drug therapy.

Complementary to the basic therapy, additional measures can counteract the symptoms. For example, physiotherapy, surgery and alternative methods can improve the symptoms. A good coordination between medicinal and complementary therapy is necessary in order to find a suitable concept for each individual patient.

If rheumatoid arthritis is diagnosed and treated at an early stage, the symptoms can usually be brought under control and slowed down. However, a great deal of cooperation is required from those affected themselves, because the course of the disease can only be improved with good cooperation between doctor and patient. Since the disease is constantly progressing, it is of great importance that the patient always goes to check-ups, follows the therapy measures and also makes sure that he or she gets plenty of exercise. Of course, not every form of sport is suitable for people with rheumatoid arthritis. Here too, a suitable concept between physiotherapy and other types of sport should be drawn up with the doctor looking after the patient. So, a lot of discipline and commitment is required from the sufferers to avoid progression of the disease and disability. It was also shown that patients who knew a lot about their own disease were able to cope with it much better and could thus also positively influence the course of the disease.

Unfortunately, however, there are also people with rheumatoid arthritis who, despite early therapy and accompanying measures, have a poor prognosis and a reduced life expectancy because the course of the disease is too severe.

If close relatives suffer from rheumatoid arthritis, they should go to a specialist for clarification at an early stage when symptoms occur. People who already suffer from rheumatoid arthritis should definitely visit their doctor regularly to check the course of therapy and possibly have their medication readjusted. The best way to do this is to visit rheumatism centres, where a combination of medical care and physiotherapy, as well as other complementary measures, is offered. To learn more about rheumatoid arthritis and how to cope with the disease, support groups are a good way for patients to learn how to manage their daily lives.

It is also important to go to physiotherapy regularly and to do gymnastic exercises on your own at home. Home exercises can be learned from physiotherapists, but there are also a number of videos and books that are suitable for training at home. It is also very important to get regular exercise. It is best to discuss with your doctor which sports are suitable and which should be avoided.

Whether diet has a positive influence on rheumatoid arthritis has not yet been scientifically confirmed. However, patients report again and again that the complaints have improved with them by changing the diet. Here, too, it is advisable for everyone affected to find out for themselves whether a different diet has a positive influence on the disease:

For example, meat should be avoided as much as possible because it contains higher amounts of arachidonic acid. The body can form substances from this unsaturated fatty acid that are important for pain and inflammatory reactions. If less arachidonic acid is supplied through the diet, a reduced formation of these inflammatory substances is said to alleviate the disease process.

On the other hand, it has been proven that osteoporosis can also occur in the course of rheumatoid arthritis, especially with cortisone therapy. In order to counteract osteoporosis, one should consume sufficient vitamin D and calcium. If this is not possible through conventional food intake, a wide variety of nutritional supplements can be used.

Many sufferers report that their symptoms improve with reduced food intake. However, fasting is not expected to lead to a lasting reduction in symptoms; rather, the lack of intake of important nutrients can lead to further symptoms in the long term.