Rheumatoid arthritis is a chronic autoimmune disorder characterized by inflammation of the peripheral joints, leading to pain, stiffness, and joint damage and deformity over time. It is a systemic condition, meaning that inflammation may be present throughout the body, causing fatigue, low energy, anemia and in some cases involvement of body tissues beyond the joints .
RA is a relatively common disorder and affects between 0.24-1% of the world population. The incidence of the disease may even be on the rise1. In North America, the disease incidence is about 40 per 100,000. Women are affected twice as often as men.
What are the causes of rheumatoid arthritis?
The actual cause of RA is unknown, although there are many theories. There are genetic determinants as well as environmental factors that lead to the condition. It is believed that an environmental trigger, such as an infection or a toxin may trigger the immune system in susceptible persons to develop RA. The “leaky gut” theory is often considered to be a prominent factor, in which irritation of the intestinal lining as a result of ingesting certain foods, chemicals and environmental toxins may result in local inflammation that overwhelms the ability of the gut immune system to contain the irritant. This may lead to systemic immune system activation. A poor diet or the overuse of antibiotics may alter the normal intestinal bacterial population , which leads to “dysbiosis” and contributes to the leaky gut problem. Another prominent theory is the concept of “molecular mimicry”, in which the immune system becomes confused following an infection or environmental exposure and “sees” our own tissue as the foreign invader, thus beginning a continuous attack on one’s own body tissues.
What are the symptoms of rheumatoid arthritis?
Joint stiffness, pain and swelling are the classic symptoms of RA, often associated with fatigue and low energy. Stiffness is particularly common in the morning, upon arising or after a period of physical inactivity. Unlike the more common osteoarthritis, in which resting the joints generally reduces symptoms, RA patients do better with movement and activity.
RA usually presents as a symmetrical arthritis, meaning both hands, both knees, or both wrists, for example. This is a characteristic feature of RA.
Which joints are most commonly affected by rheumatoid arthritis?
The most commonly affected joints in RA are the hands and wrists, the ankles and feet, and the knees, although any of the peripheral joints can be involved. While the cervical spine( neck) may also be affected, the rest of the spine is generally not involved in RA. That is, low back and spine pain is generally not a problem for RA patients. Although less common, the hips, and elbows may be inflamed, as well. Even the clavicular joints (“collar bone”) may exhibit rheumatoid inflammation , where they articulate with the sternum ( breast bone) or shoulder.
There is also a very specific pattern of hand involvement in RA. The large knuckles ( the metacarpophalangeal, or MCP joints) and the first finger joints ( proximal interphalangeal, or PIP) joints are commonly affected with stiffness , pain and swelling. The smallest finger joints, the distal interphalangeal joints ( DIPs) and not involved, unlike in osteoarthritis of the hands, which typically spares the MCP joints and impacts the PIP and DIP joints.
In an individual patient, rheumatoid arthritis may involve multiple joints or just a few. Sometimes, a person can have severe disease and damage in one or two joints with no involvement elsewhere, while others can have mild or moderate severity, but the involvement of many joints.
What are the different stages of rheumatoid arthritis?
There are 4 stages of RA, which indicate disease severity.
Stage 1, is mild or early stage RA. In this stage, there is evidence of joint swelling and stiffness, but no deformities and the Xrays indicate no underlying boney damage.
Stage 2 is moderate disease progression. In this stage, there may be subtle radiographic signs of joint injury, such as cartilage loss or early boney changes. The joint swelling has advanced and may be impacting the range of motion of the joint, but deformity is not apparent. Some adjacent muscle atrophy may have developed. Rheumatoid nodules and soft tissue swelling may develop. These are indications of “extra-articular” involvement, meaning that there is tissue inflammation beyond the joints.
Stage 3 is advanced disease. There is joint swelling, loss of range of motion, and deformity. X-Rays reveal substantial joint damage with bone erosion and extensive loos of cartilage. There is significant muscular atrophy around the affected joints. Extra-articular disease involvement is more commonly seen in Stage 3 RA.
Stage 4 is often referred to as end-stage or terminal disease. In this case, advanced damage has developed with joint deformities and a loss of function. There may be boney “ankylosis” which means that the joints have fused together and become rigid. In this situation, there is no longer inflammation ongoing in the joint, since all the target tissue has been lost. Still, pain and stiffness persist.
How is rheumatoid arthritis diagnosed?
A physician familiar with rheumatoid arthritis, usually a rheumatologist, is best suited to make a diagnosis of RA.
RA is associated with autoantibodies which can be detected with a blood test. The “Rheumatoid Factor” is an antibody observed in about 75% of people with RA. Another blood test often used is the anti-“cyclic citrullinated peptide” antibody, or CCP, which is seen in about 70% of RA patients. Together, these tests can identify over 80% of patients with RA.
That means that up to 20% or more of patients with RA have negative blood tests for the autoantibodies. We call these cases, “sero-negative” RA, meaning that the serum is negative.
For that reason, the diagnosis of RA is not solely based upon blood testing. We rely upon a constellation of signs and symptoms, which, taken together help to establish the diagnosis. The presence of a symmetrical arthritis with swelling, pain, and stiffness in characteristic joints, along with other signs, such as Xray changes and additional blood tests are taken together to make a determination. Blood testing may also reveal anemia and an elevated sedimentation rate and C-reactive protein, which are signs of inflammation in the body.
Can rheumatoid arthritis affect any other body part besides joints?
Yes, indeed! There are many “extra-articular” manifestations of RA. As mentioned above, rheumatoid nodules, which are soft tissue swelling beneath the skin may appear almost anywhere, though often found at the elbows and over the knuckles or the hands. Tenosynovitis is a swelling of the tendons, usually adjacent to affected joints. The eyes may be affected, manifested as scleritis and episcleritis, which causes red and painful eyes, photosensitivity ( light sensitivity) and visual disturbances. Rheumatoid lung is a relatively common extra-articular disease manifestation in which nodules and lung opacities may be seen on Xray.
A severe form of RA, fortunately quite rare is “rheumatoid Vasculitis” in which inflammation progresses to involve the blood vessels, causing interrupted blood flow. This often presents as ulcers on the legs and can damage the peripheral nerves, leading to sensory changes and weakness.
Some patients with RA develop Sjogren’s Syndrome, In which autoimmune inflammation affects the secretory glands of the body, leading to dryness, typically of the eyes and mouth, as tears and saliva production are impaired. Sjogren’s syndrome may also cause respiratory, nerve, skin and gastrointestinal problems and can be a struggle for the RA patient with this extra-articular disease complication.
Are rheumatoid arthritis and fibromyalgia different conditions?
Yes, they are very different. RA is an autoimmune condition primarily affecting joints in which the synovium, or joint capsular membrane becomes inflamed, causing stiffness and pain , primarily in the affected joints.
Fibromyalgia (FMS), on the other hand, is not really a joint disease at all. In fact, although patients with FMS experience significant musculoskeletal pain, the pain is generally widespread and diffuse and often affects the muscles, especially of the extremities and back. But it is not really an arthritis condition, nor is it considered to be an inflammatory or autoimmune disorder. Rather, FMS is most likely a central nervous system condition, In which abnormal sensory processing in the brain leads to hyperalgesia ( exaggerated pain sensitivity) and allodynia ( experience of pain from stimuli that ordinarily does not induce pain).
Is RA a hereditary condition?
Yes. There is clearly a familial association. A person with first-degree relative with RA has about 3 times the risk of developing the condition and those with a second-degree relative have double the risk. 2
There have been over 100 susceptibility genes associated with RA risk , most notably the HLA-DRB1 region of our genome, which is involved in immune response regulation( major histocompatibility gene complex). Certain inherited genes associated with this region are seen in over 50% of Caucasian RA patients, conferring a risk of 5-10 times the average RA risk.3
Can RA lead to multiple sclerosis?
Possibly. An association between RA and MS is not clear but has been reported. The data are mixed, but there may be a higher incidence of RA amongst patients with multiple sclerosis4
Should any dietary restrictions be implemented when suffering from RA?
Yes. This remains a controversial area, since there is no single dietary approach that has been shown to be effective for all RA sufferers. Consequently, there are no standard dietary recommendations advised by the professional rheumatology associations. That said, there are numerous published studies demonstrating improvement for RA patients following the Mediterranean diet, plant based diets, Paleo diets and others.5,6,7,8 And for years, it has been now that if RA patients fast and fed intravenously an elemental diet, they experience improvement.
So, diet and nutrition are very important, but each person with RA has to explore different dietary strategies to determine which is best for her.
The foods we choose to eat play an important role in our health. Some foods can cause inflammation and contribute to the development and persistence of autoimmune and chronic diseases, like RA. Because we all differ genetically, when seeking an optimal diet, no single dietary approach applies to all people. Unfortunately, despite some claims to the contrary, there is no blood or other test available that can accurately identify foods that are responsible for causing inflammation in any particular person. So, determining which foods are bad for us can be very challenging. However, in most cases, people with Rheumatoid Arthritis should dispense with the “standard American Diet” which is rich in added sugars, sodium, trans-fats, starches and processed foods of all kinds. Instead, I recommend a modified, anti-inflammatory diet. This is a diet rich in whole foods and mostly plant-based with lean protein sources .
This means avoiding as completely as possible, all added sugars and artificial sweeteners as well as processed foods. Foods in a box, or most frozen meals should be minimized. Learn to read labels; if there are additives that confuse you or items listed that you cannot pronounce, avoid that product!
Whole foods are essential. Whenever possible, choose organic foods, especially when it comes to “the dirty dozen”-those foods with the most herbicides and pesticides (https://www.ewg.org/foodnews/dirty-dozen.php).
REDUCE CARBS-That means breads, bagels, muffins, crackers, pasta, cookies (anything made with flour). Whole grains are fine with many RA patients, but some patients are gluten-sensitive and should avoid even “healthy” grains. Be careful with “whole wheat” products, which are often only partly whole and largely processed with bleached flour, as well. Processed grains tend to be inflammatory . It is not clear that the culprit in grains is gluten. Other nutrient factors have been proposed but whatever the specific cause, avoiding refined grains is important.
What about fiber? Isn’t that an important feature of grains? While fiber is very important for our health, and supports a normal microbiome balance, bowel regularity and reduces colon cancer risk, you can get fiber from fruits and vegetables. Green vegetables and cruciferous veggies, in particular, are not only a great source of fiber, but provide numerous phytonutrients, antioxidants, vitamins, and polyphenols.
What about dairy products? Once again, foods such as milk, cheese and yogurt may be fine for some RA sufferers, but many other find these products can aggravate their arthritis. Dairy sensitivity differs from lactose intolerance. It is the milk proteins which in many people, are inflammatory. Elimination of dairy products from the diet often results in a reduction of joint pains and achiness, improved feelings of energy, and less allergy and mucus production.
The following food groups are also frequently cited as possessing pro-inflammatory factors in some people: eggs, corn and all corn products ( corn products are commonly used in processed foods of all kinds: read labels!), soy, legumes ( beans, lentils, chick peas, and peanuts). So, you may consider a trial of eliminating these, if you are still struggling despite avoidance of carbs and dairy.
What about NIGHT SHADE VEGETABLES and TREE NUTS? Many experts warn against the inclusion of these foods in patients with arthritis, but these are not commonly inflammatory. For most, these foods ( tomatoes, peppers, eggplant, almonds, cashews, walnuts) are really very healthy , packed with proteins, phytonutrients, antioxidants and polyphenols and “good fats”. Still, some RA sufferers do struggle with them , so it is worth considering eliminating these for a trial to see how the arthritis responds.
Is RA curable?
Not presently. But there are many medications available which can control the disease, reduce pain and joint swelling and protect against joint damage over time. In fact, over 90% of RA patients, when receiving proper treatment can live active lifestyles, remain employed and enjoy a normal family life. 9
When approaching the medical treatment of the RA patient, one must consider the goals of therapy. Some medications , such as NSAIDs and Tylenol are helpful to treat symptoms of pain, swelling and stiffness, but these do not impact the disease course. Antirheumatic agents, on the other hand, are medications that are intended to modify the disease course, reduce the risk of joint damage over time, and suppress the RA activity in the body. These medications do, in effect, relieve symptoms over time by treating the underlying disease process. These “anti-rheumatic” drugs, also called “DMARDs”(disease-modifying anti-rheumatic drugs) are the mainstay of RA treatment. Examples of these are methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine. When the DMARDs are insufficiently effective in an RA patient, the next step is the addition of biologic agents, such as infliximab ( Remicade), etanercept(Enbrel), adalimumab(Humira), abatacept ( Orencia) and others. The biologic drugs are extremely effective and have changed the lives of thousands of RA patients since their development in the late 1990s. At times, corticosteroids, such as prednisone may also be used, but generally in low doses or for a limited time period, since these medications, while extremely effective, present significant side effects with continued use.
A treatment program for the RA patient, customized by the treating rheumatologist, can be extremely effective, but is complex and requires careful monitoring to avoid side effects and ensure proper use and effectiveness.
Are physical therapies helpful? If yes, then which exercises are helpful?
Yes. Maintaining Range of motion in the joints is very important, as well as strength and flexibility of the muscles and tendons around the joint structures.
Can surgery be beneficial to a person suffering from RA?
If a joint becomes severely damaged, like that seen in stages 3 and 4 RA, joint replacements may be required. Knee and hip surgical replacements are generally quite successful, as are shoulder joint replacements. But for smaller joints, like those of the hands and feet, wrists and elbows, joint replacement surgery is not available. Some orthopedists perform ankle replacement surgery, but this procedure has mixed success. There are no surgical interventions that treat RA, per se, only end-stage joint damage.
What lifestyle changes should be followed by a person suffering from RA?
Regular exercise, low impact, such as walking, Yoga, swimming can be very helpful to maintain joint function and neuromuscular tone. RA patients become easily fatigued and require rest periods. But as they should also avoid prolonged periods of inactivity, which leads to the “gel phenomenon” in which the joints become stiffer and set like gelatin due to a lack of movement. It is also very important to get adequate sleep and manage stress, both of which can impact disease activity. Establishing a relationship with a rheumatologist to help with disease management is very important.
What are the possible complications for people with RA?
Patients with RA have a reduced healthspan and lifespan10,11. RA increases cardiovascular disease risk, even beyond the usual factors, such as hypertension, diabetes, and elevated cholesterol. RA patients also have about twice the risk for lymphoproliferative diseases, such as leukemias and lymphoma. Some of the medications used for RA treatment may have result in adverse effects and can increase the risk for infection or kidney problems, thus requiring close monitoring. In general, RA patients have frequent “co-morbidities”, that is other chronic disorders that complicate their overall health12.
REFERENCES
1Prevalence of rheumatoid arthritis in the United States adult population in healthcare claims databases, 2004-2014.
Hunter TM, Boytsov NN, Zhang X, Schroeder K, Michaud K, Araujo AB
Rheumatol Int. 2017;37(9):1551. Epub 2017 Apr 28.
2Familial risks and heritability of rheumatoid arthritis: role of rheumatoid factor/anti-citrullinated protein antibody status, number and type of affected relatives, sex, and age.
Frisell T, Holmqvist M, Källberg H, Klareskog L, Alfredsson L, Askling J Arthritis Rheum. 2013;65(11):2773.
3Genetics of rheumatoid arthritis contributes to biology and drug discovery.
Nature. 2014;506(7488):376. Epub 2013 Dec 25.
4Increased incidence of rheumatoid arthritis in multiple sclerosis. A nationwide cohort study
Medicine (2016) June:95:26(e3999)
5Diet, Microbiota, and Gut Permeability-The Unknown Triad I Rheumatoid Arthritis
Frontiers in Medicine 5:349 December2018
6An experimental study of a Mediterranean diet intervention for patients with rheumatoid arthritis
Ann Rheum Disease 2003; 62208-214
7Effects of a Very Low-Fat, Vegan Diet in Subjects with Rheumatoid Arthritis
Journal of Alternative and Complementary Medicine 2002;8:71-79
8A vegan diet free of gluten improves the signs and symptoms of rheumatoid arthritis:the effects on arthritis correlate with a reduction in antibodies to food antigens
I.Hafström, B. Ringertz, A. Spångberg
Rheumatology 2001;40:1175-1179
9Ten year outcome in a cohort of patients with early rheumatoid arthritis: health status, disease process, and damage.
Ann Rheum Dis. 2002;61(12):1055.
10The mortality of rheumatoid arthritis.
Wolfe F, Mitchell DM, Sibley JT, Fries JF, Bloch DA, Williams CA, Spitz PW, Haga M, Kleinheksel SM, Cathey MA
Arthritis Rheum. 1994;37(4):481.
11Epidemiology of rheumatoid arthritis: rheumatoid arthritis and mortality.
Myasoedova E, Davis JM 3rd, Crowson CS, Gabriel SE
Curr Rheumatol Rep. 2010;12(5):379.
12Rheumatoid Arthritis and Comorbidity
J Rheumatol. 1990;17(7):888.
