Diagnosis and Treatment of Rheumatoid Arthritis

The diagnosis and treatment of rheumatoid arthritis (RA) is a team effort between the patient and several types of health care professionals. A person can go to his or her family doctor or internist, or to a rheumatologist -- a doctor who specializes in arthritis and other diseases of the joints, bones, and muscles. As treatment progresses, other professionals often help: nurses, physical or occupational therapists, orthopedic surgeons, psychologists, and social workers.

Education is Important

Studies have shown that people who are well informed and participate actively in their own care experience less pain and make fewer visits to the doctor than do other people with RA. It is important to learn about RA and its treatments, exercise and relaxation approaches, patient/health care provider communication skills, and problem solving. Educational and support programs help people understand the disease and reduce their pain, to cope mentally and physically with the disease, and to have a greater sense of control.

Diagnosing Rheumatoid Arthritis

Rheumatoid arthritis can be difficult to diagnose in its early stages. There is no single test for the disease. In addition, symptoms differ from person to person and can be more severe in some people than in others. Also, symptoms can be similar to those of other types of arthritis and joint conditions, and it may take some time for other conditions to be ruled out as possible diagnoses. Finally, the full range of symptoms develops over time, and only a few symptoms may be present in the early stages. As a result, doctors use a variety of tools to diagnose the disease and to rule out other conditions.

Medical history: This is the patient's description of symptoms and when and how they began. Good communication between patient and doctor is especially important here. For example, the patient's description of pain, stiffness, and joint function and how these change over time is critical to the doctor's initial assessment of the disease and his or her assessment of how the disease changes.

Physical examination: This includes the doctor's examination of the joints, skin, reflexes, and muscle strength.

Laboratory tests: One common test is for rheumatoid factor, an antibody that is eventually present in the blood of most RA patients. An antibody is a special protein made by the immune system that normally helps fight foreign substances in the body. Not all people with RA test positive for rheumatoid factor, especially early in the disease. And some others who do test positive never develop the disease. Other common tests include one that indicates the presence of inflammation in the body (the erythrocyte sedimentation rate), a white blood cell count, and a blood test for anemia.

X rays: X rays are used to determine the degree of joint destruction. They are not useful in the early stages of RA before bone damage is evident, but they can be used later to monitor the progression of the disease.

Treatment of Rheumatoid Arthritis

Doctors use a variety of approaches to treat RA. These are used in different combinations and at different times during the course of the disease and are chosen according to the patient's individual situation. No matter what treatment the doctor and patient choose, however, the goals are the same: relieve pain, reduce inflammation, slow down or stop joint damage, and improve the person's sense of well-being and ability to function.

Rest and exercise: Both rest and exercise help in important ways. People with RA need a good balance between the two, with more rest when the disease is active and more exercise when it is not. Rest helps to reduce active joint inflammation and pain and to fight fatigue. The length of time needed for rest will vary, but in general, shorter rest breaks every now and then are more helpful than long times spent in bed. Exercise is important for maintaining healthy and strong muscles, preserving joint mobility, and maintaining flexibility. Exercise can also help people sleep well, reduce pain, maintain a positive attitude, and lose weight.

Care of joints: Some people find that using a splint for a short time around a painful joint reduces pain and swelling by supporting the joint and letting it rest. Splints are used mostly on wrists and hands, but also on ankles and feet. A doctor or a physical or occupational therapist can help a patient get a splint that fits properly. Other ways to reduce stress on joints include helpful devices like zipper pullers, and shoe horns, devices to help with getting on and off chairs, toilet seats, and beds.

Stress reduction: People with RA face emotional challenges as well as physical ones. The emotions they feel because of the disease - fear, anger, frustration - combined with any pain and physical limitations can increase their stress level. Stress may also affect the amount of pain a person feels. Regular rest periods can help, as can relaxation, distraction, or visualization exercises. Exercise programs, participation in support groups, and good communication with the health care team are other ways to reduce stress.

Healthful diet: Studies have shown that the omega-3 fatty acids in certain fish or plant seed oils may reduce RA inflammation. However, many people are not able to tolerate the large amounts of oil necessary for any benefit. Other than these, there is no scientific evidence that any specific food or nutrient helps or harms most people with RA. However, an overall nutritious diet with enough, but not an excess of, calories, protein, and calcium is important. Some people may need to be careful about drinking alcoholic beverages because of the medications they take for RA. Patients should ask their doctors for guidance on this issue.

Climate: Some people notice that their arthritis gets worse when there is a sudden change in the weather. However, there is no evidence that a specific climate can prevent or reduce the effects of RA. Moving to a new place with a different climate usually does not make a long-term difference.

Medications

Most people who have RA take medications. Some are for pain relief; others are used to reduce inflammation. Still others, called disease-modifying antirheumatic drugs, or MARDs, are used to try to slow the course of the disease.

RA therapy traditionally involved an approach in which doctors prescribed aspirin or similar drugs, rest, and physical therapy at first, and then prescribed more powerful drugs later if the disease became much worse. But recently many doctors have changed their approach, especially for patients with severe, rapidly progressing RA. This change is based on the belief that early treatment with more powerful drugs, and the use of drug combinations in place of single drugs, may be more effective ways to halt the progression of the disease and reduce or prevent joint damage.

Surgery

Several types of surgery are available to patients with severe joint damage. These procedures can help reduce pain, improve the affected joint's function and appearance, and improve the patient's ability to perform daily activities. Surgery is not for everyone, however, and the decision should be made only after careful consideration by patient and doctor.

Joint replacement: This is the most frequently performed surgery for RA, and it is done to relieve pain, improve or preserve joint function, and improve appearance. In making a decision about replacing a joint, people with RA should consider that some artificial joints function more like normal human joints than do others. Also, artificial joints are not always permanent and may eventually have to be replaced. This may be an issue for younger people.

Tendon reconstruction: RA can damage and even rupture tendons, the tissues that attach muscle to bone. This surgery, which is used most frequently on the hands, reconstructs the damaged tendon by attaching an intact tendon to it. This helps to restore some hand function, particularly if it is done early, before the tendon is completely ruptured.

Synovectomy: In this surgery, the doctor actually removes the inflamed synovial tissue. Synovectomy by itself is seldom performed now because not all of the tissue can be removed, and it eventually grows back. Synovectomy is done as part of reconstructive surgery, especially tendon reconstruction.

Routine Monitoring and Ongoing Care

Regular medical care is important to monitor the course of RA, to determine the effectiveness and any negative effects of medications, and change therapies as needed. Monitoring typically includes regular visits to the doctor. It may also include blood, urine, and other laboratory tests and x rays.

Osteoporosis prevention is one issue that patients may want to discuss with their doctors as part of their long-term, ongoing care. Osteoporosis is a condition in which bones lose calcium and become weakened and fragile. Many older women are at increased risk for osteoporosis, and their RA increases the risk further, particularly if they are taking corticosteroids such as prednisone. These patients may want to discuss with their doctors the potential benefits of calcium and vitamin D supplements, hormone replacement therapy, or other treatments for osteoporosis.

Alternative and Complementary Therapies

Special diets, vitamin supplements, and other alternative approaches have been suggested for the treatment of RA. Although many of these approaches may not be harmful in and of themselves, controlled scientific studies either have not been conducted or have found no definite benefit to these therapies. Some alternative or complementary approaches may help reduce some of the stress associated with living with a chronic illness. As with any therapy, patients should discuss the benefits and drawbacks with their doctors before beginning an alternative or new type of therapy. If the doctor feels the approach has value and will not be harmful, it can be incorporated into a patient's treatment plan. The Arthritis Foundation (800-283-7800) publishes material on alternative therapies as well as established therapies.

Information provided by the National Institutes of Health

Each year, Medical College of Wisconsin physicians care for more than 180,000 patients, representing nearly 500,000 patient visits. Medical College physicians practice at Children's Hospital of Wisconsin, Froedtert Memorial Lutheran Hospital, the Milwaukee VA Medical Center, and many other hospitals and clinics in Milwaukee and southeastern Wisconsin.