Rheumatoid Arthritis. How are joints in the body designed?

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1 Rheumatoid Arthritis How are joints in the body designed? There are more than 100 joints that connect the body s 206 bones. These joints allow us to move the way we do when we walk to work, throw a ball and even just eat our food. When two different bones meet, they meet at a joint. These joints are held together by ligaments (a tough band of tissue that holds together a joint). The ends of the bones are coated with a firm and rubbery tissue called cartilage. It acts as a tough shock absorber and allows the ends of the bones to glide smoothly across each other. Between the bones is a joint cavity that has a thick liquid (also called synovial fluid) that lubricates and nourishes the joint. If you have never had arthritis, your joints smoothly glide over each other and you don t even think about how these joints allow us to do all the movements that we do every day. What is arthritis? The word arthritis means inflammation (itis) of the joint (arthr). Arthritis is not just one condition, but over 100 different conditions that can cause the pain and inflammation in the joint. Arthritis affects close to 4.5 million Canadians of both sexes, every age, physical condition and ethnic background. What is rheumatoid arthritis? Rheumatoid arthritis is a type of arthritis where your own body attacks the lining of the joints. This condition is considered an autoimmune disease. An autoimmune disease is a condition where the body s immune system becomes confused and for some reason attacks healthy tissue in the body. When the immune system attacks the lining of the joints it causes fluid to build up in the joint, causing pain and inflammation in the joint. What causes rheumatoid arthritis? The exact cause of rheumatoid arthritis is unknown. Experts know it happens when the body s immune system attacks the lining of the joints. Infection, family history and hormone changes may be linked to the disease.

2 How common is rheumatoid arthritis? About 1 out of every 100 Canadians has rheumatoid arthritis. This means there are about 300,000 Canadians living with rheumatoid arthritis. What are the joints commonly affected by rheumatoid arthritis? Rheumatoid arthritis most commonly affects the following joints: Wrists Elbows Shoulders Fingers Knees Feet Ankles Rheumatoid arthritis usually affects joints symmetrically. This means that it commonly affects both sides of the body. For example, if you have it in the joints of your left foot then it is common to have it in the joints of your right foot as well. What are the symptoms of rheumatoid arthritis? The symptoms of rheumatoid arthritis vary person to person and can even change on a daily basis. It usually begins slowly and starts in a few joints and then slowly spreading to other joints over a few weeks to a few months. It normally starts with some unusual pain and stiffness in the joints.

3 The most common symptoms include: Morning stiffness which lasts more than 1 hour Joints may feel warm, tender and stiff Joint pain Loss of motion of the joint Fatigue Over time, the joint can breakdown and start to become deformed What puts me at higher risk of getting rheumatoid arthritis? Rheumatoid arthritis can affect any age group. Even children can develop rheumatoid arthritis. Most people diagnosed with rheumatoid arthritis will develop it between the ages of 30 and 60 years. Women are 3 times more likely to get rheumatoid arthritis compared to men. Some people have genes that put them at a higher risk of getting rheumatoid arthritis. Other possible triggers of rheumatoid arthritis are: Infection (bacteria or virus) Female hormones Body s response to stressful events such as physical or emotional trauma Smoking can increase the risk of getting rheumatoid arthritis How does my doctor diagnose me with rheumatoid arthritis? There is no simple test to diagnose you with rheumatoid arthritis. If your doctor suspects that you have rheumatoid arthritis they will do a physical exam where they will look at your joints for swelling, heat and pain. X-rays of the joints will also help with the diagnosis.

4 When you are in to see your physician it is important to let him know the following: All of the joints that are sore, swollen or tender If you have morning stiffness in these joints and for how long If you have trouble moving any of the affected joints Any other symptoms like fatigue, not wanting to eat and weakness Your doctor may order blood tests to help with the diagnosis. The most common tests look for inflammation in the blood, and they include: Erythrocyte sedimentation rate (ESR) C-reactive protein (CRP) Your doctor may also order the rheumatoid factor (RF) and the cyclic citrullinated peptide (CCP) antibody test to help with the diagnosis. If your doctor feels that you have rheumatoid arthritis, they will commonly refer you to an arthritis specialist called a rheumatologist. Powered by BestLifeRewarded

5 What are the goals of treating rheumatoid arthritis? Unfortunately there is no cure for rheumatoid arthritis. Your doctor will work with you to find a treatment that: Helps to control the symptoms of rheumatoid arthritis Slows the condition from getting any worse. The treatment should reduce the number of arthritic flares (where the pain gets worse) Treat the pain, stiffness, fatigue, prevent further joint damage and destruction Improve the quality of life of the person with rheumatoid arthritis How does my doctor select the best treatment for me? Like other types of arthritis the best treatment of rheumatoid arthritis is a combination of nonmedication therapies and different types of medications that target the disease. Is it safe for me to exercise with rheumatoid arthritis? Regular physical activity and exercise is very important in people with arthritis. The right amount of exercise protects the joint by strengthening the muscles and ligaments around the joint. Regular physical activity can also help to lower pain, fatigue, increase flexibility and stamina and help to improve your general sense of well-being.

6 Your exercise program could involve a combination of different types of exercise. These may include: Range of motion exercises - These exercises are designed to keep your joints moving, reduce pain and stiffness Strengthening exercises - These exercises increase the strength of your muscles and protect your joints Stretching exercises - These exercises keep the muscles and tendons around the joint flexible Endurance exercises These exercises make your heart stronger, give you more energy, control your weight and have a very positive effect on your health For people with arthritis wanting to learn more about exercise, the Arthritis Society of Canada has a great booklet on exercise and arthritis. It can be downloaded by clicking the following link: Physical Activity & Arthritis My doctor suggested weight loss for my arthritis, will this really help? Having extra weight increases the strain on your joints. By losing weight you take some of the pressure off of these joints. Experts in the field recommend that you do a 500-1,000 calorie deficit per day because this can lead to a healthy weight loss of 1 to 2 pounds per week. What a calorie deficit means is you eat 500 calories less or burn off an extra 500 calories by exercising. There are so many diets that promise quick fixes in your weight. Experts in the field recommend a balanced diet based on Canada s Food Guide. If you want to read more on a good diet, consider looking at the Healthy Eating module on Best Life Rewarded.

7 My doctor suggested that I pace my activities, what does this mean? Pacing is a great idea for people with arthritis. When you pace your activities you first look at all the things that you have to do in a day. You plan which activities to do so you don t do all the strenuous ones right after another. Many people will put breaks in their schedule to give their body a rest so they feel comfortable doing the next strenuous activity. Here is an example of a pacing schedule for the morning of someone with arthritis: 7:15 AM - Eat breakfast 7:30 AM - Vacuum main floor 8:00 AM - Break 9:00 AM - Do a load of laundry 10:00 AM - Break 10:15 AM - Vacuum upstairs 11:00 AM - Sit at desk and pay bills 11:30 AM - Dust the main floor 12:00 PM - Lunch If I apply hot or cold to my joints will it help? Some people with rheumatoid arthritis get some relief from their symptoms by applying hot and cold to their sore joints.

8 Heat A nice warm shower or bath is a great way to lower pain and stiffness caused by arthritis. Many people with arthritis use heat to help with: Lowering pain Lowering muscle spasms and tightness Improving the range of motion of your joints If your joints are very inflamed, the heat may make things worse and you should avoid applying it directly to the swollen joint. Cold Some people find applying cold to their sore joints and painful areas on their body to help with their arthritis. Cold packs can be bought at local pharmacies, but many people prefer using the old-fashioned ice bag or a bag of frozen vegetables. Many people with arthritis use cold to help with: Lowering swelling in the joint Lowering pain of the joint When I get stressed at work my arthritis pain gets worse. What should I do? Rheumatoid arthritis like other conditions may get worse when the body is under stress. Relaxation techniques can help to lower the pain and help for the way that you are feeling. Some people find attending a meditation class or even reading a relaxation book from the library can help them relax. Small things like closing your eyes for 5-minutes, clearing your head of stressful thoughts and practicing deep breathing might really help your arthritis.

9 My doctor said something about assistive devices, what are they? Many people with rheumatoid arthritis will have symptoms in the joints in their hands, knees and feet. This can make things like holding a spoon to eat or bending over to pick up an item on the floor very difficult. There are many devices that can help to improve these simple tasks at home. Some of the most common assistive devices are listed in the table below. Assistive Devices for People with Rheumatoid Arthritis Device Fat rubber grips for things like a pen, toothbrush or a utensil Notes For people that have trouble closing their hand around a small item these fat grips can make things much easier Doorknob changes Some people have trouble turning a doorknob. Some doorknobs you only have to move up or down to open the door Leg extenders If you have a favourite chair but have trouble getting in and out of it, these extenders can raise it up to make it easier for you Spring-loaded scissors These scissors bounce back whenever you squeeze them, this lowers the work in half when using scissors Reachers or grabbers These poles have a trigger on one end and a grabbing device on the other. You can be sitting down and use the reacher to pick something off the floor Jar openers These rubber devices fit over the lid of jars to make it easier to open them

10 Grab poles for the bathroom Devices can be professionally mounted in the bathroom to help getting into and out of the tub or shower They provide something that you can grab to support yourself if you feel unstable or dizzy Raised toilet seats Raised toilet seats come in many different styles They should be firmly attached to the toilet for safety reasons These seats can make a large difference in many patients with arthritis because they may have trouble bending low enough to reach the toilet seat Sock pullers and long-handled shoe horns These devices can make it very easy to put on your socks and shoes Canes and walkers Canes and walkers are probably the most underused devices for people with arthritis They decrease the pressure on the joint, can reduce pain and make you more stable on your feet Powered by BestLifeRewarded

11 What types of medications are used for the treatment of rheumatoid arthritis? People with rheumatoid arthritis are normally treated with disease modifying antirheumatic drugs or DMARDs. These medications are very different from standard pain relievers because they may slow the rheumatoid arthritis from getting worse. Rheumatologists will normally start every person with rheumatoid arthritis on a DMARD as soon as they are diagnosed. They want to start early as possible because these medications can actually slow the disease. The biggest problems with DMARDs are that these drugs take several months to reach their full effect and many are linked to serious side effects. Other pain reliever medications such as non-steroidal anti-inflammatory drugs and steroids are used with DMARDs to give extra pain control. These pain relievers help control pain and swelling, but do NOT slow the arthritis from getting worse. What are the most common DMARDs used for rheumatoid arthritis? There are many different types of DMARDs available to help slow the course of rheumatoid arthritis. The most common drugs used are: Methotrexate Azathioprine (Imuran ) Leflunomide (Arava ) Hydroxychloroquine (Plaquenil ) Sulfasalazine The most commonly used DMARD is methotrexate. It is usually the drug of first choice for people with rheumatoid arthritis.

12 What should I know about DMARDs? DMARDs usually work well in most people with rheumatoid arthritis. These medications will take several weeks to several months until their full effect is reached. Some rheumatologists will use two or three DMARDs to control the arthritis and others will use them with pain relievers to give extra pain relief. Each DMARD has some risk with taking them. Some DMARDs can cause side effects with the liver, blood cells, stomach or your eyes. Your rheumatologist will balance the benefit of these drugs against the risk of serious side effects. The good news is for most of these side effects your doctor will be monitoring your blood regularly to make sure you don t run into any problem. If you have a problem taking the DMARD that your specialist prescribed then make sure you tell him/her. There are many different DMARD choices and it is important to find the right one for you. Do anti-inflammatory drugs work for arthritis relief? How do anti-inflammatory drugs work? Anti-inflammatory drugs (also called NSAIDs) are commonly used to treat arthritis pain. Antiinflammatory drugs lower pain, inflammation and swelling. What are the common side effects of anti-inflammatory drugs? Anti-inflammatory drugs are linked to some adverse effects that can be a problem in some people. Taking these medications long-term puts a person at higher risk of stomach problems like nausea, vomiting and even stomach bleeding. They can also have an effect on blood pressure and the kidneys. For this reason these drugs are avoided or used very carefully in people with active stomach ulcers, congestive heart failure, kidney disease and asthma.

13 What are some of the important things to know about anti-inflammatory drugs? Ibuprofen and naproxen are both available over-the-counter without a prescription. There are many other anti-inflammatories that are only by prescription Do not take these medications without talking with your doctor There is very little evidence that one anti-inflammatory is better than any other There are some anti-inflammatories that have a lower risk of stomach problems (e.g. celecoxib) Anti-inflammatory drugs do not prevent the rheumatoid arthritis from getting worse How do steroids work for arthritis? When people hear the word steroids they think of body builders or athletes t hese types of steroids are not used for arthritis. Steroids used, help to lower the pain and swelling from the rheumatoid arthritis. Steroids are often used short-term to get control of the inflammation and pain until the slow-acting DMARD starts to work. How do steroids work? When steroids are prescribed for arthritis they help to lower the pain and swelling of the sore joints.

14 What are the common side effects? Steroids are linked to many different types of side effects. Fortunately most of these side effects are only common in people that take the medications longer-term (more than 3 months). Some of the side effects linked to steroid use are: Stomach upset High blood sugar in a person with diabetes Increase in appetite High blood pressure Weight gain around the waist Cataracts Increase risk of infections What are some important things to know about steroids? Many people will get some pain and swelling relief in just a few days of taking a steroid It is very important you take the steroid exactly as your doctor prescribes it Since steroids are linked to serious long-term side effects, most doctors prescribe the lowest dose of steroid possible for the shortest period of time. Steroids do not prevent the rheumatoid arthritis from getting worse

15 My doctor wants to prescribe an expensive injection for my arthritis, do they work? The newest class of medications to treat rheumatoid arthritis are drugs called biological agents. These drugs are specifically designed to treat the inflammation and help prevent the damage to the joint caused by rheumatoid arthritis. These biological agents can be used with DMARDs like methotrexate. The biological agents that are currently used for rheumatoid arthritis are: Adalimumab (Humira ) Certolizumab (Cimzia ) Etanercept (Enbrel ) Golimumab (Simponi ) Infliximab (Remicade ) Rituximab (Rituxan ) Abatacept (Orencia ) Anakinra (Kineret ) Tocilizumab (Actemra ) Biological agents are usually very helpful in most people with rheumatoid arthritis. They can take some time to work. Some people can see the benefit in a few days to a week and other may not see any benefit for at least 3 to 6 months.

16 What do I need to know about biological agents? Biological agents are highly effective, but expensive treatments for rheumatoid arthritis. They are commonly used when a person does not get relief from DMARDs. These drugs are administered by injection. Some are given by an intravenous infusion that is a slow-drip into a vein in your arm. Others are given by injections into your belly (abdomen) or your thigh. Biological agents work by slowing down the immune system. For this reason, they can make it harder to fight off common infections. It is very important to let your doctor know if you are prone to frequent infections.