| Diagnosing and treating rheumatoid
arthritis 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 rheumatologist is a doctor who specializes in arthritis and other
diseases of the joints, bones, and muscles. As treatment progresses, other professionals
often help. These may include nurses, physical or occupational therapists, orthopedic
surgeons, psychologists, and social workers. 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 rheumatoid arthritis.
Patient education and arthritis self-management
programs, as well as support groups, help people to become better informed and to
participate in their own care. An example of a self-management program is the arthritis
self-help course offered by the Arthritis Foundation and developed at one of the
NIAMS-supported Multipurpose Arthritis and Musculoskeletal Diseases Centers.
Self-management programs teach about rheumatoid arthritis and its treatments, exercise and
relaxation approaches, patient/health care provider communication, and problem solving.
Research on these programs has shown that they have the following clear and long-lasting
benefits:
- They help people understand the disease.
- They help people reduce their pain while remaining
active.
- They help people cope physically, emotionally, and
mentally.
- They help people feel greater control over their
disease and help build a sense of confidence in the ability to function and lead a full,
active, and independent life.
DIAGNOSIS
Rheumatoid arthritis can be difficult to diagnose in its early stages for several reasons.
First, 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 rheumatoid arthritis 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 rheumatoid arthritis test positive for rheumatoid factor, however, 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 rheumatoid arthritis before bone damage is evident, but they can be used
later to monitor the progression of the disease.
TREATMENT
Doctors use a variety of approaches to treat rheumatoid arthritis. 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.
Treatment is another key area for communication
between patient and doctor. Talking to the doctor can help ensure that exercise and pain
management programs are provided as needed and that drugs are prescribed appropriately.
Talking can also help in making decisions about surgery.
Goals of
Treatment
- Relieve pain
- Reduce inflammation
- Slow down or stop joint damage
- Improve a person’s sense of well-being and
ability to function
Current Treatment Approaches
- Lifestyle
- Medications
- Surgery
- Routine monitoring and ongoing care
|
Lifestyle
This approach includes several activities that help improve a person’s ability to
function independently and maintain a positive outlook.
Rest and
exercise: Both rest and exercise help in important ways. People with
rheumatoid arthritis 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 from person to
person, 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.
Exercise programs should be planned and carried out to take into account the person’s
physical abilities, limitations, and changing needs.
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 and ensure that it fits properly. Other ways to
reduce stress on joints include self-help devices (for example, zipper pullers,
long-handled shoe horns); devices to help with getting on and off chairs, toilet seats,
and beds; and changes in the ways that a person carries out daily activities.
Stress
reduction: People with rheumatoid arthritis 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. Although there is no evidence that stress plays a role in causing rheumatoid
arthritis, it can make living with the disease difficult at times. Stress may also affect
the amount of pain a person feels. There are a number of successful techniques for coping
with stress. 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:
With the exception of several specific types of oils (mentioned in the Current Research
section), there is no scientific evidence that any specific food or nutrient helps or
harms most people with rheumatoid arthritis. 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 rheumatoid arthritis. Those taking methotrexate may need to
avoid alcohol altogether. 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 rheumatoid arthritis. Moving to a new place with a different climate
usually does not make a long-term difference in a person's rheumatoid arthritis.
Medications
Most people who have rheumatoid arthritis take medications. Some medications are used only
for pain relief; others are used to reduce inflammation. Still others—often called
disease-modifying antirheumatic drugs, or DMARDs—are used to try to slow the course
of the disease. The person’s general condition, the current and predicted severity of
the illness, the length of time he or she will take the drug, and the drug’s
effectiveness and potential side effects are important considerations in prescribing drugs
for rheumatoid arthritis. The table starting on page 20 shows currently used rheumatoid
arthritis medications, along with their effects, side effects, and monitoring
requirements.
Traditionally, rheumatoid arthritis therapy has
involved an approach in which doctors prescribed aspirin or similar drugs, rest, and
physical therapy first, and prescribed more powerful drugs later only if the disease
became much worse. Recently, many doctors have changed their approach, especially for
patients with severe, rapidly progressing rheumatoid arthritis. 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. Together they should discuss the patient’s
overall health and the effects of a surgical procedure, the condition of the joint or
tendon that will be operated on, and the reason for and cost of the surgery. Surgical
procedures include joint replacement, tendon reconstruction, and synovectomy.
Joint
replacement: This is the most frequently performed surgery for
rheumatoid arthritis, 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
rheumatoid arthritis 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: Rheumatoid arthritis 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 procedure can help 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 the disease, 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 rheumatoid arthritis
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 rheumatoid arthritis. 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 the patient cope or 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. However, it is important not to neglect regular
health care. The Arthritis Foundation publishes material on alternative therapies as well
as established therapies, and patients may want to contact this organization for
information. (See the For More Information section of this booklet.) |
