Rheumatoid Arthritis: The First Symptoms of Rheumatism are not Nodes. What is the Treatment?

Rheumatism is a long-term, chronic, progressive disease. Progressive means that it evolves over time, it worsens. It is one of the most common diseases in the human population.

It is most commonly associated with joint damage.

However, impairment of the musculoskeletal system, including bones, cartilage, tendons, muscles and other soft structures may also accompany the pathological process in other parts of the body, for example impairment of the eye, heart, blood vessels or lungs.

The disease is reported to shorten life expectancy by up to 10 years.

Over 100 types of rheumatic diseases are recognised.

The most common ones include:

• rheumatoid arthritis
• osteoporosis
• psoriatic arthritis
• Bekhterev disease
• fibromyalgia
• gout
• and others

Osteoporosis is a degenerative process that results in thinning of the bone tissue. It increases the susceptibility to bone fractures or spinal deformities, as well as the so-called roundback or hunchback, i.e. hyperkyphosis.

Learn more: 
Thinning of the bone
Hyperkyphosis of the spine - roundback

Psoriatic arthritis links arthritis, which affects the joints with psoriasis. It is more common in young girls from the age of 10.

Juvenile idiopathic arthritis also belongs to the group of diseases in children and adolescents.
The word juvenile = young, immature.
It is the most common systemic childhood disease.

Bekhterev disease - ankylosing spondylitis jis a disease that is manifested by visible inflammatory changes in the structure of the spine, vertebrae and other parts. The precursor of the disease is axial spondylarthritis, which is not yet detectable on X-ray.

Rheumatic diseases can affect any age group - including children.
Most commony people aged 35 to 55 years of age.
Globally, the reported percentage is 1-2% of the affected population.

Fibromyalgia is a disease of the brain (CNS - central nervous system), the main manifestation of which is a chronic painful condition. Fatigue and sleep disorders are also associated with pain.

Gout is a metabolic disease in which tiny crystals of uric acid accumulate in the joints. Inflammation and the associated pain in small joints apply to this process. It appears  mostly in the form of seizures.

And...

Rheumatic arthritis affects women 3 times more often than men. In this form of rheumatism, the age between 20 and 40 years of age is stated as the age of development of the first symptoms.

It is an autoimmune inflammation that primarily affects the joints. However, in more complicated forms, it is accompanied by extra-articular difficulties, meaning other than the joints.

What follows is a brief look at rheumatism with supplemental information on rheumatoid arthritis.
What is rheumatoid arthritis?
What is it caused by? 
WHat are the signs and symptoms? 
How does it run its course? 
How is it treated? 

Rheumatoid arthritis is...

Question:

What is rheumatoid arthritis?

The definition states that it is a long-term and serious inflammatory disease. It affects all ages, young women more often.

Chronic systemic autoimmune inflammatory disease that mostly affects tendons, joints, cartilage.

It is a progressive disease that can lead to disability.

Damage to the joints and tendons is caused by various causes, so it has a multifactorial origin. However, it is supported by the body's autoimmune response.

Autoimmune response = immune disorder. Based on excessive immune activity, the body responds to its own cells or tissues. This group of diseases includes various diseases of the skin, nerves, endocrine, respiratory or digestive systems.

The course of the disease may be diverse.

However, it is typical for the disease to have alternating periods of acute problems and reduction of signs and symptoms. The terms acute exacerbation and remission are also used.

Exacerbation = the worsening of a disease or an increase in its symptoms.
Remission = either the reduction or disappearance of the signs and symptoms of a disease.

The disease has a negative effect on the human body. However, its pathological activity is a difficult burden on mental health.

Long-term care for both the body and mental health is important. Physiotherapy, a positive attitude and an overall good lifestyle are the basis of a successful treatment.

Why the disease occurs is not known.

The cause of rheumatoid arthritis has a multifactorial basis.
There is some genetic predisposition associated with the disease.
In this context, information on the interaction with the HLA-complex is provided.

HLA genes and rheumatoid arthritis = 40 to 50% of cases.
HLA = human leukocyte antigen.

It binds to the HLADR4 or DR1 antigen, which is further divided into other subtypes, such as HLA-Dw4, HLA-Dw10, 14, 15.

Antigen = immunogen, a substance that elicits an immune response - a reaction of the body. The antigen stimulates antibody production. The immune system recognizes the antigen and then begins to make antibodies whose job it is to defend the body.

Antigen is a blend of antibody generating.

However, the whole cascade of the pathological process is unknown and the participation of the infection, which is the trigger of the reaction, is assumed together. An example is the influence of EBV viruses - which are the cause of mononucleosis, retroviruses, parvoviruses or Borrelia and mycobacetrium, Escherichia coli, Staphylococcus, Streptococcus A, Hepatitis B virus and others.

It is reported that...
In people who are genetically predisposed, the disease is triggered by an infection by a certain microorganism.

A predisposition to increased morbidity and the influence of environmental factors are risk factors, too.

Several risk factors may be lead to the onset of the disease:

• sex - more common in women
• age with a wide range, especially between the ages of 30 and 60
• genetic predisposition and heredity
• infection
• increased susceptibility to morbidity
• being overweight and obese
• blood transfusion
• hormonal changes and short fertility - shortening the fertile period
• injury
• allergy
• stress
• smoking
• coffee consumption
  • overall lifestyle

Rheumatoid arthritis mainly affects small joints. Such as the joints of the hands, fingers, wrists or feet. For medium-sized joints, it is mainly the knee, ankles, shoulders.

This disease involves the synovial membrane.

Question: 

What is the synovial membrane?

It is the smooth and shiny surface covering the inner area of the joints. It supplies the blood vessels a nerves with nutrition. It produces a lubricant that reduces friction in the joints during movement. It regenerates them.

The inflammatory process affects this membrane, resulting in nutritional disorders and joint function. The damage affects the joint structure, tendons, and ligaments.

As the disease progresses, the joint capsule and the joint itself are damaged and destroyed.

In place of the original synovial membrane, a replacement tissue is formed on the basis of pathological processes, which gradually covers the joint capsule. Its function is secondary.

It is referred to as pannus.

Pannus is derived from the Latin for "tablecloth", and is produced by the process of excessive vascular and ligament formation. Over time, pannus may change to fibrotic or bone tissue.

The difficult form is the overgrowth of the joint and the transformation of the original tissue into bone - ossification.
The result is ankylosis.

Ankylosis is a process in which a joint grows through connective or bone tissue.
The result is limited or complete loss of joint mobility.

Moreover, characteristic of this form of arthritis are the rheumatic nodules. These arise in the subcutaneous tissue, where they are well visible and palpable.

These pathological changes are the result of joint symptoms:

• joint stiffness
  • gets worse due to inactivity
  • it is especially pronounced in the morning after waking up
  • may last for more than an hour
  • sensation of not being able to make a fist
  • difficulty walking in the morning
• typically, more than 3 joints are affected
• most commonly affected area is the joints
  1. finger joints
  2. wrist joints
  3. knee joints
  4. ankles
  5. toe joints
  6. shoulders
  7. elbows
  8. hip joints less commonly
  9. spine, cervical spine more commonly
  10. temporomandibular joints - between temporal bone and jaw - pain when chewing
• joint swelling
• joint inflammation
  • skin around the joint feels warmer
  • redness is not present, another cause must be considered (gout, infectious arthritis)
• limited mobility of the affected joints
• joint pain
  • mainly palpable joint pain - sensitive to the touch
• joint deformities at a later stage
• joint instability

Warming up and warmth can alleviate the pain.

Joint symptoms are in most cases symmetrical = they appear on both sides of the body at the same time.

In rheumatoid arthritis, the disease may initially manifest itself systemically. So, extra-articular problems aappear as the initial symptoms.
Based ony their occurrence, they can be divided into ocular, cardiac, pulmonary, neurological, hematologic, hepatic and vascular symptoms.

Systemic or extra-articular symptoms:

• rheumatic nodules
• skin rash
• muscle and tendon pain
• swelling of the pulmonary pleurae
• inflammation of the heart pericardium - pericarditis
• heart valve damage
• inflammation of and enlarged lymph nodes
• enlargemed spleen
• stomach ache
• reduction in the number of white blood cells
• anemia
• vascular inflammation
• eye inflammation and ocular manifestations
• overall weakness
• tiredness, increase in body temperature
• weight loss
• sleep disorder
• anxiety or depression

Table: Impairment of the Joint by Percentage

If a person has a more severe form of the disease, the quality of his or her life is significantly reduced. The disease can limit the performance of normal daily activities, which has an impact on the mental wellbeing and may cause social isolation.

History taking, clinical picture and physical examination are important in diagnosis. Doctors from the fields of rheumatology, orthopedics, general medicine and physiotherapy cooperate.

Diagnosis helps determine the presence of 4 of the 7 symptoms listed:

1. morning stiffness of the joints
2. arthritis 3 and more areas
3. arthritis of the joints of the hand
4. symmetrical or bilateral arthritis
5. rheumatoid nodules
6. presence of rheumatoid factor
7. changes on the X-ray

Subsequently, it is important to perform laboratory tests. In this case, CRP and FW (blood sedimentation) are performed. Furthermore, serological testing, such as latex-fixation test (up to 80% positivity).

The ELISA assay is used to determine IgM, IgG, IgA, IgE. However, this method may show false positives, as it is also found in other diseases. Alternatively, these values will not be identified at an early stage.

Anti-CCP - antibody against cyclic citrullinated peptide, APF (anti-nuclear factor), ANF (anti-nuclear factor), ANA (anti-nuclear antibodies) and others will be added.

Biochemistry, blood counts and urine tests will also be performed. Alternatively, genetic testing, synovial fluid analysis is chosen.

Imaging methods, especially an X-ray, are important.

The X-ray is used for staging:

Another type of staging is to determine whether the condition is early or late.

Early = soft tissue proliferation, joint enlargement, initial osteoporosis. 
Late = marked narrowing of the joint space, advanced osteoporosis, bone deformities, up to ankylosis. 

Table: ACR/EULAR Criteria for Rheumatoid Arthritis

ACR - American College of Rheumatology. 
EULAR - European League Against Rheumatism. 

The course of the disease can be variable and also depends on the severity.

Rheumatoid arthritis can be asymptomatic, i.e. without symptoms. On the contrary, it can have an abrupt onset of extra-articular symptoms when there is severe weakness, fatigue, fever and nausea associated with weight loss.

Alternatively, mostly symmetrical joint problems arise first.
These are symptoms that appear on both sides of the body at the same time.
As a typical morning joint stiffness, swelling and joint pain.
These are primarily small joints of the hands and feet.

And for example...

Alternatively, the joints of the cervical spine may also be affected. There may be radiation of difficulties such as cervico-cranial or cervico-brachial syndrome, i.e. associated headache and weakness in the upper limbs, including limited mobility of the cervical spine.

Learn more: 
Vertebrogenic algic syndrome
Pseudoradiculopathy
Cervical spine and difficulties associated with it

Rheumatoid arthritis is characterized by periods of flare-ups. This means that there are stages of acute flare-ups which then resolve. This is called a relapsing-remitting oranexacerbating-remitting disease.

The onset of difficulties is usually in the winter months until March and April.
In most cases, the onset is slow and gradual in about 50-70 percent of cases.
Acute outbreaks occur in 15% of cases.
About 20 percent of diseases run a subacute course.

Complications are extra-articular problems associated with other organs. Examples are rheumatic nodules (several centimeters in size and painfully subcutaneous nodules), eyes (eye irritation, inflammation), skin (rash), but also heart, lung problems or abdominal pain.

Did you know? 
Rheumatic nodules form in the subcutaneous tissue,
especially in areas under greater pressure,
for example, the joints on the hands, elbows, and soles.
They occur in approximately 20% of affected people.

The course of arthritis can be classified into three types:

1. monocyclic - an exacerbation cycle followed by a remission cycle
   • the resting stage lasts more than 1 year
2. polycyclic - slow course, which is interrupted by incomplete remission
   • the most common form
3. progressive - the course of the disease is severely progressing, i.e. progressing without remission