Rheumatoid arthritis

Symptoms of rheumatoid arthritis tend to fluctuate. There are times when the symptoms are severe, known as ‘flares’. The symptoms might go into ‘remission’ when they become mild. Signs and symptoms include:

• Fatigue: Fatigue or the feeling of tiredness and exhaustion is the first sign of RA, affecting a person’s everyday routine and productivity.
• Fever: Fatigue is followed by a rise in temperature, which further leads to a feeling of sickness and exhaustion.
• Loss of weight: The occurrence of fever and fatigue results in a loss of appetite, which can lead to weight loss and weakness.
• Pain and stiffness: Pain and stiffness are first felt in the smaller joints, such as those of the fingers or toes. The intensity of these symptoms increases over time. The pain often lasts for several days and is followed by gradual stiffness in the body. This stiffness intensifies after periods of inactivity, for example, after getting up from sleep in the morning.
• Swelling: Swollen hands and feet are the most common signs of rheumatoid arthritis. Inflammation in the joints causes the lining of the joints to thicken, leading to excess production of fluids in the joints. This excess fluid production puts pressure on the area surrounding the joints, resulting in irritation of the nerve endings and pain and swelling of the joints.

The immune system safeguards the body from infections and diseases by producing antibodies. However, sometimes antibodies attack the thin layer that covers the joints. This thin layer becomes inflamed and affects the surrounding bones, cartilage, tendons, and ligaments, resulting in rheumatoid arthritis.

Genes play a role in causing rheumatoid arthritis by making individuals vulnerable to infections caused by certain viruses and bacteria. This vulnerability can trigger the development of autoimmune diseases such as rheumatoid arthritis.

The exact cause of rheumatoid arthritis is yet unknown; however, researchers have identified several factors that could increase its risk:

• Genetic factors: Genes play an important role in the development of autoimmune diseases, like rheumatoid arthritis. Therefore, if a close family member has this disease, an individual has an increased risk of developing it.
• Age: Although rheumatoid arthritis can develop at any age, it is more likely to occur during middle age, particularly among senior citizens or those in their 60s.
• Sex: Women are more prone to developing RA than men because hormonal changes during pregnancy and menopause may increase susceptibility to this disease.
• Obesity/Excessive weight: Obese individuals are at a higher risk of developing rheumatoid arthritis. Excess fat tissue releases cytokines (proteins that cause inflammation) into the body, aggravating pain and increasing disease progression.
• High birth weight: Research has shown that high birth weight (greater than 4 kg) is associated with an increased risk of RA.
• Smoking: It is the most substantial known environmental risk factor for RA. The risk of RA increases with the amount and duration of cigarette use.
• Diet: Various dietary factors, such as red meat intake and vitamin D deficiency, have been found to increase the risk of RA. Excessive coffee consumption and high salt intake can also be risk factors for ACPA-positive RA, the most aggressive form of RA with a worse prognosis.
• Infections: Microbes, such as Mycoplasma, enteric bacteria, and Epstein-Barr virus, are commonly implicated infectious agents that predispose individuals to RA. In India, an epidemic of chikungunya virus infection has also contributed to the increase in RA prevalence among susceptible populations.
• Periodontitis: This chronic inflammatory disease of the gums involves the gums pulling away from the teeth and forming pockets that become infected. Various studies have shown that the occurrence and severity of periodontitis are higher in people suffering from RA, suggesting a positive correlation between these two chronic inflammatory diseases.

The signs and symptoms of rheumatoid arthritis are very similar to some other joint disorders, which makes the diagnosis of this disease difficult in the early stages. If you experience any of the symptoms, consult a doctor as soon as possible. It is essential to undergo a check-up within six months of noticing the symptoms, as this helps slow down joint damage and improves disease management.

The doctor will conduct a physical examination during which they will check the joints for:

• Redness
• Swelling
• Warmth

They may also assess muscle strength and reflexes. Specific blood tests and imaging tests, such as X-rays, are crucial for diagnosing rheumatoid arthritis (RA). The doctor will prescribe tests based on the symptoms and results of the physical examination.

1. Blood tests

• Rheumatoid factor (RF): This autoantibody attacks joints in individuals with rheumatoid arthritis. The RF test measures the level of RF in the blood.
• C-reactive protein (CRP): This test checks for inflammation throughout the body and helps detect rheumatoid arthritis and psoriatic arthritis.
• Antinuclear antibody: This test identifies abnormal antibodies associated with rheumatoid arthritis.
• Erythrocyte sedimentation rate (ESR): This test indicates inflammation by measuring how quickly red blood cells settle at the bottom of a test tube.
• Anti cyclic citrullinated peptide (Anti-CCP): This test detects autoantibodies linked to joint damage, commonly found in rheumatoid arthritis patients.
• Human leukocyte antigen tissue typing (HLA): This test identifies specific genetic markers indicating the likelihood of developing rheumatoid arthritis.

2. Imaging techniques

In addition to blood tests, joint scans are conducted to detect rheumatoid arthritis. These scans identify joint inflammation and damage, helping to determine the type of arthritis and the progression of the disease.

• X-rays: These help detect damage to the joints or bones due to rheumatoid arthritis.
• MRI: An MRI of the joints and musculoskeletal system provides a clear image of inflammation and damage to the joints.

Various genetic and environmental factors are responsible for rheumatoid arthritis. While the genetic factors can’t be changed, modifications in one’s lifestyle and incorporation of healthy habits will significantly reduce the risk and the damaging side effects of this disease. Here are a few ways to stay safe and prevent the worsening of this condition:

• Quit smoking: Smoking increases the risk of developing rheumatoid arthritis in individuals who are genetically predisposed to this condition, as it triggers faulty immune system functioning and accelerates symptom progression. Quitting smoking is one of the best ways to protect your overall health. If you find it difficult to quit on your own, consider seeking support from family or friends to help hold you accountable.
• Lose weight: Individuals with excess weight experience faster disease progression, increased pain, and greater disability. Obesity also raises the susceptibility to other diseases in people with rheumatoid arthritis. Engaging in low-intensity exercises, such as walking, swimming, and yoga for thirty minutes daily, can help reduce weight, alleviate pressure on the joints, and decrease the risk of developing joint diseases. These activities also enhance energy levels and improve flexibility, contributing to overall health and well-being.
• Change the diet: Modifying your diet can significantly help in preventing disease progression or reducing bodily damage. Foods to consume include:
  • Fruits
  • Green vegetables
  • Nuts and seeds
  • Whole grains
  • Low-fat dairy
  • Lean proteins
  • Small amounts of saturated fats
  • Foods rich in omega-3 fatty acids
  Spices like turmeric are known to combat inflammation, so consider incorporating them into your meals. Foods to avoid include:
  • Red meat and protein
  • Caffeine
  • Sweetened beverages
  • Excessive salt
  • Processed, packaged, and junk food
• Vitamins and supplements: Supplements containing Vitamin D, Vitamin C, and antioxidants have been shown to reduce the risk of rheumatoid arthritis.
• Dental health: There is a potential link between gum infections, such as periodontitis, and rheumatoid arthritis. Regular dental checkups, maintaining good oral hygiene, and addressing bleeding gums can help prevent the progression of minor gum diseases into periodontitis.
• Seek timely help: If you notice any signs or symptoms of rheumatoid arthritis, such as pain, tenderness, or swelling in the small joints of your hands and feet, consult a doctor immediately. Seeking prompt medical attention can prevent joint damage and facilitate better management of the condition. A rheumatologist can guide you towards appropriate treatment options and prescribe necessary tests and scans to monitor disease progression.

Rheumatoid arthritis has no cure. However, an early diagnosis can help in selecting a treatment to keep the symptoms under control. Some medications, such as disease-modifying antirheumatic drugs (DMARDs), work in slowing down the progression of the disease and saving the joints from damage. There are three methods of treating rheumatoid arthritis-related pain and symptoms:

A. Medications

These are administered based on the intensity of the symptoms and the progression of the disease.

• NSAIDs: Nonsteroidal anti-inflammatory drugs (NSAIDs) are prescribed to reduce pain and inflammation. Over-the-counter options like ibuprofen are available, but stronger NSAIDs require a doctor’s prescription.
• DMARDs: Disease-modifying antirheumatic drugs (DMARDs) slow down the progression of the disease, helping to save joints and tissues from damage and disability. Examples include:
  • Methotrexate: An immunosuppressant that slows the activity of the immune system, reducing pain, swelling, and stiffness.
  • Leflunomide: Blocks chemical messengers that cause inflammation and swelling.
  • Hydroxychloroquine: Eases disease progression and reduces pain, swelling, and redness.
  • Sulfasalazine: Suppresses overactivity of the immune system and blocks inflammatory messengers.
• Steroids: Corticosteroids reduce inflammation and joint damage, providing pain relief. They have specific side effects, such as weight gain, diabetes, and bone thinning, and are prescribed for short durations. Prednisone is a common corticosteroid for rheumatoid arthritis patients.
• Biological DMARDs: These newer DMARDs are prescribed for swelling and redness, also known as biologic response modifiers. They block chemical messengers causing inflammation. Examples include:
  • Rituximab: Targets unwanted immune cell activity (B cells) in rheumatoid arthritis.
  • Abatacept: Blocks certain chemical messengers responsible for inflammation.
  • Tocilizumab: An anti-interleukin-6 (IL-6) medication that plays a key role in joint inflammation.
  • Anakinra: Blocks interleukin-1 (IL-1), another important messenger in rheumatoid arthritis development.
• Anti-TNF drugs: Tumor necrosis factor (TNF) is a cytokine involved in systemic inflammation and plays a major role in rheumatoid arthritis pathogenesis. Some anti-TNF drugs include:
  • Infliximab
  • Etanercept
  • Adalimumab
• Targeted synthetic DMARDs: If conventional DMARDs and biological agents are ineffective, targeted synthetic DMARDs are prescribed. Follow the doctor’s prescription and undergo regular blood tests to monitor liver, kidneys, and blood count. Examples include:
  • Baricitinib
  • Tofacitinib
  • Upadacitinib

B. Therapy

Physical or occupational therapy helps improve flexibility and alleviate joint pain. Therapists may teach ways to simplify tasks and reduce mental and physical strain and stress. They can also recommend gadgets that minimize strain on painful joints.

C. Surgery

Surgery is considered when medications and therapy fail to slow damage, improving joint function and restoring the ability to lead a productive life. A rheumatologist may recommend the following procedures:

• Tendon repair: Repairing the tendons around the joints.
• Synovectomy: Removing the inflamed lining of the joints.
• Joint fusion (arthrodesis): Fusing two or more bones in a joint to relieve pain.
• Total joint replacement surgery: Removing damaged joint parts and replacing them with a metallic or plastic prosthesis.

Although painkillers help ease the pain and inflammation, there is no cure for this condition. Therefore, making lifestyle changes, dietary changes, and managing stress are crucial in reducing discomfort and slowing down the progress of the disease. Here are a few changes that will provide relief and help live a comfortable life:

1. Home Remedies

Rheumatoid arthritis (RA) involves inflammation; therefore, adding anti-inflammatory herbs and spices will have health benefits. However, these should be taken after consulting a healthcare provider. These herbs include:

• Turmeric (haldi): This golden spice has anti-inflammatory properties and analgesic (pain-relieving) effects.
• Ginger (adrak): It has anti-inflammatory properties and may improve RA symptoms by affecting the expression of certain genes.
• Green tea: It is rich in antioxidants and can help reduce inflammation and protect joints.
• Cinnamon (chakla): This ancient spice is filled with antioxidants that can prove beneficial for tender and swollen joints.
• Garlic (lehsun): This spice can liven up any meal and has anti-inflammatory properties that reduce cytokines (known to cause inflammation) and relieve pain due to RA.
• Black Pepper (kalimirch): This simple household spice has antioxidant, antimicrobial, anti-inflammatory, and gastro-protective effects.
• Willow bark: This spice has significant anti-inflammatory properties and reduces various markers of inflammation.
• Indian frankincense: Derived from the bark of the Boswellia tree, it has strong anti-inflammatory and analgesic properties.
• Ashwagandha: Also called Indian ginseng, it is known to ease pain and joint swelling in people with rheumatoid arthritis. However, it can cause an additive effect if taken with diabetes or thyroid medications. Hence, do not consume it without consulting a physician. Pregnant women should also talk to their doctors before taking ashwagandha.

2. Physical Activity

This is the most important and effective way of reducing pain and discomfort associated with rheumatoid arthritis. Tailor an exercise program according to your schedule and health benefits with the help of a doctor or physiotherapist. Half an hour of physical activity every day is sufficient to increase stamina and flexibility. This will also improve sleep patterns and ease depression and anxiety related to rheumatoid arthritis.

3. Dietary Changes

Make informed choices about diet with the help of a nutritionist to not just reduce weight but also improve overall health. The necessary nutrients supplied through a tailored diet will improve energy levels as weight decreases. A well-balanced diet rich in antioxidants can lessen pressure on the joints and provide comfort from pain. Consult a doctor or dietitian before starting any supplements. Foods or supplements rich in the following can be beneficial:

• Omega-3 fatty acids
• Zinc
• Iron
• Folate
• B vitamins
• Calcium
• Vitamin D
• Fluoride

4. Sleep

It is of utmost importance in the fight against any disease. Eight hours of sound sleep every night helps maintain a positive mindset and eases pain. Consult a doctor if you have difficulty sleeping. Also, try taking short naps in the afternoon to energize yourself for the remainder of the day.

5. Massage

Massages increase the supply of fresh oxygenated blood to the muscles and organs and aid in the removal of waste products from the body, alleviating rheumatic disorders. It also improves flexibility and reduces soreness of the joints. Castor oil or essential oils, like black currant seed, evening primrose, lemongrass, and borage seed, can be used for massages. However, they should be tested on your skin first to ensure there is no irritation.

6. Heat and Cold

Ice packs help reduce swelling and inflammation. They can be used during flares but only for 15 minutes. Alternatively, a hot water bag or a warm towel can relax the muscles and increase blood flow to the treatment area. Hot tub baths also provide relaxation to stiff, painful muscles.

Rheumatoid arthritis affects the lining of the joints and causes gradual bone erosion and deformity. Besides these side effects, rheumatoid arthritis increases the risk of developing other ailments, such as:

• Osteoporosis: Rheumatoid arthritis and the medications used to treat it increase the risk of developing osteoporosis. In this condition, bones become weaker and are prone to fractures. Lack of exercise due to pain and swelling, along with insufficient calcium intake, are other factors that lead to loss of bone density, further contributing to osteoporosis. Osteoporosis is a disease condition in which bones thin and weaken due to low bone mass (bone density), making them fragile and increasing the risk of fractures from the slightest trauma.
• Carpal tunnel syndrome: When the nerve that serves the hand and fingers gets compressed due to inflammation, it is referred to as carpal tunnel syndrome. As rheumatoid arthritis typically affects the hands, it also impacts the wrist, putting it at a greater risk of developing this condition.
• Lung diseases: Rheumatoid arthritis increases the chances of inflammation and scarring of lung tissues, potentially leading to shortness of breath, dry cough, fatigue, loss of appetite, and weakness. Inflammation can obstruct the walls of the airway in the lungs, causing shortness of breath and chronic dry cough.
• Heart problems: Inflammation due to rheumatoid arthritis causes plaque build-up in the arteries, leading to narrowed blood vessels. This blocks blood flow and affects the heart. Furthermore, the drugs used to treat RA symptoms and the lack of exercise due to pain and swelling can increase blood pressure. Patients often have high LDL (bad cholesterol) levels and low HDL (good cholesterol) levels, all of which increase the risk of cardiovascular diseases.
• Dry eyes: Rheumatoid arthritis also affects eye health, with dry eyes being the most common side effect of this chronic disease. Dry eyes increase the risk of damage to the cornea and cause inflammation in the sclera (the white part of the eyes). Therefore, eye pain or changes in vision should be addressed promptly to prevent further damage.
• Nodules on the skin: Rheumatoid arthritis can cause rheumatoid nodules under the skin, which typically appear on the fingers, forearms, elbows, and heels. These nodules are a sign of disease progression.
• Depression or anxiety: Rheumatoid arthritis dramatically affects the patient’s emotional health. Feelings of sadness, anxiety, loss of interest, and lack of sleep can all lead to depression. Support groups and emotional bonding with family and friends can help patients cope with the condition more effectively.

Apart from taking prescribed medications, one may also follow some alternative therapies to relieve pain and stiffness. Examples of these therapies are:

• Homeopathy: Studies suggest the use of homeopathy for relief from pain and stiffness. It strengthens the immune system and controls the symptoms without the risk of side effects. However, it is essential to consult a doctor before beginning any alternative treatment.
• Acupuncture: This method uses needles to heal chronic pain and lowers the levels of chemicals that cause inflammation in the body. Since this method requires sterile needles, ask a doctor to suggest the right acupuncture practitioner.
• Chinese Medicine: Thunder god vine is a herb used as a natural remedy to ease inflammation and tenderness of joints in people with rheumatoid arthritis. However, one needs to ensure its quality. It also has certain side effects that could harm pregnant women, so caution is advised during its use.
• Tai Chi: This Chinese martial art has several health benefits. Its slow and gentle movements improve strength, flexibility, and balance. Statistically, it has shown significant benefits on lower extremity range of motion, particularly ankle range of motion, in people with RA.
• Yoga: This low-intensity, ancient Indian workout is perfect for improving flexibility, easing pain, and relieving mental stress. A few simple yoga asanas that help improve muscle strength and posture are:

• Virabhadrasana II (Warrior Pose 2)
• Marjaryasana - Bitilasana (Cat Pose - Cow Pose)
• Vrikshasana (Tree Pose)
• Setu Bandha Sarvangasana (Bridge Pose)
• Viparita-Karani (Legs-Up-The-Wall Pose)

Read more about various alternative treatments to deal with long-term pain.

Rheumatoid arthritis is an autoimmune disease. Although it doesn’t have any permanent cure, one can get the right treatment to keep the symptoms under control if detected early. Therefore, seeking early medical attention is crucial. The symptoms of this chronic disease aren’t constant. At times, they flare, while other times, they are in remission. Here are some essential things to remember when living with rheumatoid arthritis:

1. Health Care

• Start an exercise program to increase your stamina and improve flexibility.
• Maintain the right posture while sitting, standing, and walking.
• Do not lift heavy objects.
• Avoid kneeling or sitting down.
• Buy an ergonomic chair for work.
• Make dietary changes to help relieve inflammation and improve overall health.
• Seek physical or occupational therapy.
• Do not miss medications or doctor’s appointments.

2. Lifestyle Changes

• Plan the day ahead, but allow space for changes in the tasks.
• Simplify daily routines and everyday tasks.
• Cook simple meals.
• Shop online.
• Buy toothbrushes and combs/hair brushes with wide handles.
• Use a chair in the shower and install a handrail for support.
• Buy easy-to-wear clothes with large fasteners, such as buttons and zippers.
• Choose easy-to-wear footwear over ones with laces or buckles.

3. Self Care

• Make self-care a priority.
• Avoid being homebound.
• Take care of both emotional and mental health.
• Manage stress using techniques such as meditation, mindfulness practices, or deep breathing.
• Indulge in a hobby.
• Spend time with loved ones.
• Join support groups.