by Hope Starkman, MD
The term arthritis is a very general one that includes more than 100 different types of joint diseases. Arthritis, in general can be divided into two main groups. Degenerative arthritis or osteoarthritis is a wear and tear condition that is associated with degeneration of the cartilage. It can be compared to the wearing of a gasket between two pieces of metal.
Inflammatory arthritis is a second large group comprised of multiple forms of arthritis, of which rheumatoid arthritis composes large percentages of the cases. Rheumatoid arthritis is a chronic, ongoing inflammatory arthritis that affects 1 percent of the population in general. There are some populations that have a higher incidence of RA. Approximately 2.1 million Americans suffer from rheumatoid arthritis. This disorder can occur anytime from early childhood thru late adulthood. It is associated with joint and muscle pain, swelling, limited range of motion deformity and dysfunction.
Hands and wrists are commonly involved limiting ability to perform routine activities of daily living. The cause of rheumatoid arthritis is unknown and may vary from person to person. There may be and probably is a genetic propensity to develop rheumatoid arthritis. It is clear that Rheumatoid arthritis results from an improperly and overly reactive immune system to self. A person own body becomes like an enemy of itself. Antibodies to self are formed and results in joint, organ and tissue damage. The immune system is very complicated in this way.
The joints are most commonly affected in rheumatoid arthritis but other organ systems may be affected as well, including the heart, lungs, skin, blood vessels, eyes to name a few. Fever can be present as well as weight loss and fatigue. Over time, rheumatoid arthritis can affect the ability to turn over new blood cells resulting in anemia of chronic inflammation. Patients with longstanding rheumatoid arthritis can develop a condition called Felty’s syndrome with the development of other low blood counts, infections, large spleen, and leg ulcers. Nodules may develop over bony prominences like the elbows or even in the lungs and eyes. The joints are the areas where bone connects with bone. This differs from osteoarthritis which is primarily a disease of joints. The hallmark of inflammatory arthritis is post rest or morning stiffness lasting more than an hour. This does not occur in osteoarthritis where pain and dysfunction progresses as the day go on. In rheumatoid arthritis, pain and stiffness generally improves as the day goes on.
In rheumatoid arthritis, as opposed to degenerative arthritis, the pattern of joint involvement involves those closer to the body for example the wrists and knuckles as opposed to the joints at the tips of the fingers. Very frequently it is impossible to make the diagnosis of rheumatoid arthritis on a first visit. It may take weeks to months for the condition to declare itself and symptoms must be ongoing for at least 6 weeks before a formal diagnosis of rheumatoid arthritis is made.
In order to make a diagnosis of rheumatoid arthritis in a patient with ongoing symptoms for more than 6
weeks, four out of the following seven criteria should be met:
- Morning stiffness lasting at least an hour
- Pain and swelling of at least three different joint areas(small joints of the hands, wrists,feet and ankles) observed by a physician
- At least one involved area should include a joint in the hand or wrist
- The involvement must be symmetrical, approximately but not exactly the same on both sides of the body i.e. both wrists , both knees
- The presence of Rheumatoid Nodules
- The presence of a positive Rheumatoid Factor
- Radiographic (Xray) changes classic for rheumatoid arthritis i.e. erosions, osteoporosis around the joints, fusion
Because many patients do not always meet four out of the seven criteria for rheumatoid arthritis initially, sometimes a diagnosis of rheumatoid arthritis is difficult to make. The earlier the diagnosis of rheumatoid arthritis is made the better the potential outcome due to early treatment interventions.
Over the years, the treatment of rheumatoid arthritis has evolved considerably. Many years ago patients were sent to hot springs to recuperate and it was not possible to alter the progression of the disease. The progression to deformity and disability was often a given. The possibility of death related to rheumatoid arthritis was also greater. Fortunately, we now have, in our hands, the ability to alter the progression of rheumatoid arthritis, to prevent deformity and improve activities of daily living and quality of life.