Facts about Arthritis

Facts About Arthritis

We've put together some basic information here for you about arthritis.

Arthritis:

  • dates back to ~4500 BC when it was first traced in humans
  • literally means 'inflammation of the joints'
  • is much more common in women than in men
  • is actually more than 100 different diseases that all affect areas in or around joints
  • causes pain, stiffness, and swelling in the joints
  • can affect anyone at any age, including children
  • is one of the most prevalent chronic health conditions in Canada and a major cause of illness, disability and use of health care resources. It poses major economic and health burdens, and is currently predicted to affect 1 in 5 Canadians in 20 years
  • is not well followed in the Canadian population.

The two most common types of arthritis are Rheumatoid Arthritis (RA) and Osteoarthritis (OA).


The CATCH program follows people who have a type of arthritis called Rheumatoid Arthritis (RA), which:

  • affects about 1% of the population
  • can affect some 68 joints in your body through inflammation
  • can begin very suddenly and involve many joints or slowly in just a few joints (which can make it very hard to detect - a person might just blame an activity for the symptoms they are feeling)
  • is an autoimmune disease where a person's immune system attacks their own tissues
  • doesn't have a cure, but there are a number of ways to manage living with it.

Click here for a presentation about the basics of Rheumatoid Arthritis

Rheumatoid Arthritis Symptoms

Symptoms of RA can affect different people very differently. In general, symptoms include:

  • joint tenderness, warmth, and swelling. Often both sides of your body are affected at the same time, which is called a "symmetrical pattern" of inflammation. For example, if one wrist or knee is affected, the other one is also. This is different from osteoarthritis, where it is possible for only one knee to be affected and which usually involves the small joints of the hands and feet
  • pain and stiffness that lasts for more than 1 hour in the morning or after a long rest
  • joint inflammation in the wrist and finger joints closest to the hand and small joints of the feet (although joints of the neck, shoulders, elbows, hips, knees, and ankles can be affected as well)
  • when pain, swelling, and soreness increase, it is called a "flare"
  • fatigue (i.e. being very tired), rarely fevers and a general feeling of not being well

To be diagnosed with RA, these symptoms must last for a period of time (more than 6 weeks). The symptoms of RA are often seen in other parts of the body besides the joints.

Rheumatoid Arthritis Risk Factors

The exact cause of RA is unknown, however recent research points to many factors causing RA. These include genetic factors (i.e. these are inherited from your parents), environmental factors and others. What we know about these factors is outlined below.

Genetic Factors. Certain genes that play a role in the immune system are linked with a person's chances of developing RA. However, many people with RA do not have these specific genes while other people have these genes but never develop RA. This suggests that while a person's genetic makeup is an important part of the story, it is not the sole reason for why a person develops RA.

Environmental Factors. Many researchers believe that something in a person's environment triggers RA in people who have the genetic makeup that makes them susceptible to RA. It is thought that this environmental factor could be an infectious agent like a virus or bacterium but none have been identified yet. This does not mean that RA is contagious - we know that it cannot be transmitted from person to person. Other environmental factors thought to play a role in the development of RA include smoking and exposure to excessive pollution (e.g. from traffic). Research has shown that being exposed to cigarette smoke is strongly linked with the development of RA and the severity of RA that is developed.

Other related factors. Some scientists believe that certain hormonal factors may be involved in the development of RA. It is thought that these hormonal deficiencies/changes may trigger RA in a genetically susceptible person who has been exposed to an environmental trigger.

Dietary factors. No diet has been linked to causing or improving RA symptoms. For example, there are conflicting studies regarding benefit of the Mediterranean diet and supplementation with fish oils.

Female gender. In general, RA occurs much more frequently in women than in men.

Arthritis Medication Information

Medications

Medications are an important part of managing life with a chronic illness. The different kinds of medications can be grouped in to three main types which are each described below.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Here are some basic facts about NSAIDs:

  • they are used to reduce pain and inflammation which allows patients greater flexibility
  • they do not prevent joint damage
  • the amount of time for pain and inflammation to decrease in a person after starting these medications can be a few days or even a few weeks,   and can be very different for different people
  • they come in many forms such as pills, liquids, suppositories, creams and gels
  • their most common side effects are gastrointestinal (that means, stomach and intestine) issues. This is because the chemicals used in the body to reduce inflammation are the same as the chemicals in your stomach. Burning, belching, irritations, erosions and ulcerations can occur and severe side effects can cause bleeding. Your healthcare team will monitor you when you're using NSAIDs to make sure that if you do have side effects, something that you tolerate better will be found for you to use
  • the oldest non-steroidal drug is Aspirin, but when it's used for a long time it can have negative effects, so it has been replaced with others (for example, Advil and Alleve)

Disease-Modifying Anti-Rheumatic Drugs (DMARDs)

Here are some basic facts about DMARDs:

  • they are used for inflammation, pain and treating disability. Although NSAIDs also help reduce pain and inflammation they are sometimes not enough for some patients
  • they are taken to help a patient’s immune system (and they target the entire immune system, not just one part of it)
  • they may take a few weeks or even a few months before their effects are really felt
  • they slow the development of RA, but do not cure it
  • they have been proven to reduce long-term damage for people with RA when they are taken shortly after onset of symptoms
  • they come in forms such as pills or liquids that are injected
  • they may cause side effects like nausea, diarrhea, and mouth sores. Like with NSAIDs, you need to work closely with your healthcare team if you have side effects so that the right DMARDs can be found for you.

Biologics

Biologics are the newest type of medications available for people with RA. Here are some facts about biologics:

  • they are also called biological response modifiers
  • they are more effective than DMARDs because they target specific problems in the immune system, while DMARDs target the whole immune system
  • they work much faster than DMARDs - their major effects are usually noticeable after 5 weeks
  • they are given by injection or intravenous infusion (i.e directly in to a vein)
  • their short-term side effects can include burning and itching at the needlepoint entry
  • because biologics are made by living cells and are actually proteins, they are very expensive to make and very expensively priced
  • because biologics are very new (only about 15 years old) their long-term effects are not known.
Diagnosed with Rheumatoid Arthritis - Now what?

Newly diagnosed

Many people newly diagnosed with RA feel scared for many reasons, including: feeling out of control, feeling unsure about the future, the medications you need to take, the unknowns of having a new diagnosis that is a chronic illness, and the list goes on. This fear is pretty universal - almost every one feels it. With an understanding of RA, education and open communication, that fear can begin to go away. As your RA is managed and comes under better control, hope does return.

In order for you to understand more about RA and feel less fearful about your life and future with it, we've provided you with some information to commonly asked questions and concerns that we've experienced as healthcare providers. While we've tried to keep this simple and easy to understand, there are some medical terms that we couldn't avoid. We have created a glossary of terms that you can use to help you understand some of these terms.

We mostly assume that a rheumatologist is the specialist who takes care of your RA needs, but sometimes you will be working with other health care providers such as nurse practioners, occupational and physiotherapists, and others.

Understanding RA and the disease process

Below is some information about the RA disease process.

What is rheumatoid arthritis?

RA is the most common form of arthritis in which inflammation occurs in the joints.

How does RA affect my joints?

RA's prolonged inflammation in the joints can cause damage of the bone, cartilage and soft tissues supporting the joints - this damage can't be repaired once it is done. Ultimately if this inflammation is not controlled, it will cause significant damage to joints and loss of function.

Why the inflammation & pain?

RA results because your immune system has been triggered to attack your joints and this causes inflammation to occur in these joints. Inflammation also causes chemicals to be released that 'turn on' the joint's pain receptors, and that's why swollen joints are often very painful.

Why is RA called a systemic disease and how does it affect other parts of my body?

RA can affect many organs - not just your joints. This is why it's called a systemic disease (i.e. affecting many body systems). For example patients with RA may also develop inflammation in the lungs, lose weight, and develop inflammation in glands of the eyes and mouth, which in turn can cause dryness or even affect the nerves.

Why am I so tired?

In general fatigue or extreme tiredness with diseases like RA is not fully understood, even though many people experience it. It has been well recognized that when inflammation is very active in the body and in the joints that patients feel very fatigued and when the inflammation is well-controlled that fatigue lessens significantly.

Tests and treatment

In this section, we tell you about why tests are important and how your healthcare team uses them on a regular basis to better understand and treat your RA. We also tell you a bit more about how your rheumatologist treats your RA and why he or she uses this approach.

Why all the blood tests and x-rays? What are my doctors looking for and what are the "markers" of RA?

Before your RA diagnosis, blood tests are done to confirm that you have RA. At the beginning you will have your Rheumatoid Factor measured and another test called an anti-CCP antibody test. These are both tests that can be positive in up to 60-80% of patients with RA and when your doctor looks at these results together with your joint symptoms, he or she may be able to confirm a diagnosis of RA. Not all RA patients will have a positive Rheumatoid Factor or anti-CCP antibody test.

When you are first diagnosed, blood tests will also tell your rheumatologist whether or not all of your body systems are healthy so you can be started on treatments for RA and help your rheumatologist understand how much (i.e. the severity of) inflammation you have. The blood tests for measuring your inflammation are called the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) tests. Depending on the medications you are taking, your doctor may also require you to do blood tests that show your liver and kidney function as well as 'blood counts' to make sure your medications are doing their job and not showing any negative effects (also called adverse effects).

X-rays of your joints are usually done to see if there are any signs of joint damage. When joint damage in x-rays is seen early on in your RA, this can be a sign that your RA may be aggressive and it is very important to treat it as soon as possible.

Why is early treatment important, and what is early treatment?

Research studies have shown that the earlier RA is controlled, the less chance there will be for long-term damage. Initial therapy usually includes treatment with drugs called disease modifying anti-rheumatic drugs (DMARDs). The most common DMARD first used is a medication called methotrexate.

Why is RA treated so aggressively?

Your rheumatologist knows that by treating your RA aggressively when you are diagnosed gives you the best chance of getting your RA well-controlled as quickly as possible (which may also include going in to remission). Left untreated, or not treated properly, RA is a chronic destructive disease so early optimal therapy is used to prevent your RA from becoming a chronic inflammatory process. Therapies like acetaminophen (Tylenol) or ibuprofen (Advil) (a type of NSAID) only treat the symptoms (pain, stiffness) but do not control the disease process which attacks your joints and causes inflammation. To best treat you, your RA disease process must be treated, not just the symptoms.

What is methotrexate and what does it do to RA?

Although methotrexate was first created as a kind of chemotherapy for cancer, rheumatologists use it to treat RA in weekly "mini-doses." It interferes with your body's immune response that causes chronic inflammation, and it can slow RA or can even stop the disease process. It is one of the most effective treatments of RA and can significantly help in 70-80% of patients with RA. Along with controlling inflammation, methotrexate has also been shown to improve how patients feel, improve their pain and limit RA-caused damage. Methotrexate can take a few weeks to months before its full effects are felt.

What are methotrexate's side effects and how can I deal with its side effects?

Methotrexate is tolerated quite well in at least 85% of RA patients. For some people there will be minor effects such as loose stool or slight nausea the day or two after you take your methotrexate, and sometimes there is mild hair thinning. If these side effects are significant you should tell your rheumatologist so he/she can cut back your dose, give another medication with it to minimize these effects, or put you on another medication that agrees more with you. Usually rheumatologists encourage their RA patients to continue with methotrexate whenever possible because it is so effective. It is important to know that methotrexate and other DMARDs can take a few weeks to months before their full effects are felt, so your doctor may give you treatments to relieve symptoms from methotrexate's side effects until it becomes fully effective.

Most often, methotrexate's side effects are minor and will actually lessen as your body adjusts to it with time. However some people will feel nausea that is enough to affect their appetite. Some easy remedies for nausea are: eating small meals frequently, eating soda crackers, and/or drinking gingerale. Your rheumatologist may prescribe anti-nausea therapies just before and after you take methotrexate. You will usually also be prescribed folic acid to take a couple of days after your methotrexate which usually helps limit methotrexate's side effects and your liver function properly.

Why should I avoid alcohol while taking methotrexate?

Methotrexate has been associated with changes in the liver similar to those seen with cirrhosis of the liver (cirrhosis means liver damage and it can be caused by excessive use of alcohol, and is irreversible). To limit this rare effect, your doctor will advise you to avoid drinking alcohol when you are taking methotrexate. Just like alcohol does to the liver enzymes, methotrexate can also elevate these enzymes. If you take methotrexate and drink alcoholic beverages together, these can have a compounding effect on the liver.

Are there any medications I should not take with methotrexate?

We do not recommend the use of sulpha containing antibiotics with methotrexate.

Coping with RA

In this section we tell you a bit about how you can take as much control as possible in your life with RA.

How can I be an informed, active partner with my doctor in my health care?

Your doctor and your healthcare team are your partners in helping you manage and control RA. To make the most of your time with your rheumatologist and your healthcare team, you should:

  • Come prepared to your appointments with lists of questions, concerns, and any observations you have made about your RA
  • Make sure you get answers that you understand to all of your questions about RA and its treatments
  • Make sure that you to understand why and how to take your medications as described by your rheumatologist
  • If your health has changed since your last visit, be sure to let your rheumatologist know about any other diagnoses that have been made and any other medications you might be taking for things besides your RA
  • No questions are off limits - you can ask about nutrition, sleep, fatigue, exercise, medications, how you are coping mentally. If you don't share how you feel or are concerned, your healthcare team can't help you with these things.

You should also call your rheumatolgist if you have any prolonged fevers or symptoms that are unusual when you start taking any new medications.

Can I and should I exercise with RA?

It is important to keep as mobile as possible with RA. Exercise also strengthens the muscles that support your affected joints and keeps your bones, joints and muscles healthy. Exercise helps to improve your mood; helps you keep a healthy weight, regain strength and muscles and can help reduce your pain levels.


At the beginning of your diagnosis and while your RA is being brought under control, exercise may be easiest for you in water. In many communities there are exercise programs (such as in the pool) for people living with arthritis. It can be very helpful to contact a physical therapist to help set up a special exercise program for you to help you to keep your strength and muscles (especially at first when your RA is coming under control) and to help you to exercise properly. There are also many ways for you to adapt exercises based on your RA and any limitations you have because of it. If you haven't exercised much in the past, make sure you get some help getting started - your healthcare team can provide some recommendations for this.


Your rheumatologist may recommend that you see a physical therapist to help you with some range of motion exercises and to help keep your joints as flexible as possible.

One of the simplest and most helpful books CATCH recommends is Exercise Beats Arthritis by Valerie Sayce & Ian Fraser.

How can a physical therapist or occupational therapist help me?

Your rheumatologist may suggest you see a physical therapist. A physical therapist is a trained health professional who can assess your physical abilities by looking at things such as your joint swelling, pain, range of motion, muscle strength, flexibility, balance and coordination. A physical therapist will design a program just for you, providing exercises for you to do and treatments (for example, posture recommendations, mobility devices, general fitness and wellness, and relaxation techniques). They may also show you how using hot and cold packs can help your joints and muscles feel better.

An occupational therapist is a trained health professional who helps you cope with your everyday activities. Even for people who have mild RA, things like dressing, bathing, grooming and easy household chores can be very challenging. Occupational therapists can help you keep your independence by providing you with information about aids that can help with these tasks. They can also offer advice on splints (wrist and hand), supportive and comfortable shoes and orthotics, and suggestions for your home and work that will help you do what you need to do.

What about complementary therapies to help treat my RA?

Treatments that fall outside of the scope of traditional medicine are considered to be integrative medicines. These are complementary therapies, such as homeopathic medicine, acupuncture, massage, special herbs or supplements and meditation. While some of these therapies may provide relief and comfort, they will not cure RA or protect joints from real damage. Also, many of these treatments have not been scientifically studied well or at all. Some types of herbs and supplements can even cause harm or interfere with your prescribed treatments.

If you are considering using any of these complementary therapies - alone or with the medications prescribed by your rheumatologist - ensure that you speak to your rheumatologist about them. These methods should not be used in place of the therapies that your rheumatologist prescribes.

Is there a special diet I can follow? What advice can you give me on nutrition and RA?

There is no one diet for RA. However there are studies that have shown some benefits from certain ways of eating. For example, one study has shown the Mediterranean diet has helped arthritis in people who lived in a southerly region, but when this was tried in a non-Mediterranean location the results could not be reproduced. This diet is high in vegetables and fish. The paleolithic diet has not been studied at all in RA. No studies have proven yet that being gluten free is helpful. Several studies show anti-inflammatory benefits of omega-3 fatty acids and when used in high amounts they have an effect similar to NSAIDs. These are high in cold water fish, flax oil. No one has yet shown that removal of certain foods from your diet works for everyone with RA. For example, many people feel that removing certain foods (such as those containing gluten) has helped their arthritis but in general, people do not eliminate foods entirely for life. It is important for anyone to follow a well-balanced, portion-controlled diet of nutritious food with lots of vegetables and fruits. You should aim for your body mass index (BMI) to be under 30 and ideally it should be between 20 and 25. If you have questions about how to improve your diet to help your arthritis, you should discuss this with your healthcare team, and you may also wish to see a nutritionist.


CATCH highly recommends the book In Defense of Food by Michael Pollan.

I'm so tired – is this normal and what can I do about this?

Many people who have RA also experience fatigue or extreme tiredness, even after taking good care of themselves, including getting a good night's rest. Some people describe this as feeling like the flu is coming on everyday – simply feeling like they're constantly under the weather. Fatigue is hard to describe to someone who doesn't experience it, but you should definitely not feel that it's just you- this is something very common to people with RA.

Let your rheumatologist know that you are experiencing fatigue – there may be some real physiological causes to it that can be treated, or maybe there are some other ways that you can cope. Your rheumatologist may order blood tests to check that you aren't fighting an infection, and to make sure that your electrolytes are balanced (these are parts of the cell that help with energy), your thyroid hormone levels are correct, and your iron levels are correct (many people with RA have anemia). If there is a direct cause related to one of these, your rheumatologist will be able to decide how to help you.

If your fatigue is something else, your rheumatologist or arthritis specialist can help with some suggestions, too. These suggestions may include: exercise, eating more nutritiously, ensuring you take breaks throughout the day to pace your activities, trying to keep your stress level low, using braces/canes if you need them, and getting a good night's sleep. Learning to listen to your body about fatigue is like any other part of your RA and taking care of it.

What about surgery? How will this help me?

Your rheumatologist may recommend surgery to treat your RA. This usually occurs when he/she feels that it will help relieve severe pain and improve function of joints that haven't responded to medicine and physiotherapy, and if joints are so severely damaged that medication or physical modes of therapy are not likely going to help the pain. Joint and tendon surgery can be minor or major like a complete joint reconstruction that will restore enough joint motion to help you with your daily activities. Like any of your other treatments, make sure you talk this over with your rheumatologist and healthcare team so that any of your questions and concerns are answered and that you understand them before you decide this is an option that is right for you.

What about the other things RA affects like my family, friends, and work? What can I do about those?

As you know, RA affects more than just you. RA will affect your family, your friends, your work, and how you're feeling overall about life. RA can affect your confidence in yourself and in your ability to plan for life events. It's important for you to know that there are a lot of resources and programs that your healthcare team can provide you if you have questions about any of these. Sometimes friends and families don't really understand your experience and you can feel alone. You may find there is a time when you experience a low mood or even depression at some point during the course of the illness. This is not unusual. Opening the lines of communication about your experience with your family and loved ones can help you all through the tougher times. Remember this is a disease that you and your spouse and family can and should tackle together. Most rheumatologists are more than happy for you to bring your partner along to visits.

You may have questions and concerns about some of the following that you'll want to discuss with your rheumatologist or ask for recommendations of resources. Some of these concerns are noted below:

  • How you're dealing with RA emotionally – different people deal with their diagnosis differently. If you are having trouble dealing with it, let your rheumatologist know.
  • Friends and family – how to talk to them about your friends and family about your RA, what it is, how it affects you, and how you also know it affects your relationships with them.
  • Work – e.g. if/when to tell co-workers/employers, how to have a conversation about your work environment changing to accommodate your RA (for example, basic ergonomic adjustments if you work at a computer, potential for days off/reduced hours, etc.). Deciding who to tell and when is a personal decision, and not everyone chooses to share their diagnosis with their employer or co-workers. Having a discussion with your rheumatologist about this can help you decide if you wish to do so, and if you do, how you can approach this topic.
  • Finances – how to access disability resources, special drug programs if required.
  • Travel – what paperwork or other considerations you might need to travel with your medications (such as, do you need to store them with a cold-pack?), how to prepare for flares while away, and how you can access care when travelling.

It's also important for you to understand that you don't have to deal with your diagnosis by yourself and if you feel that your RA is overwhelming, reach out to your healthcare team for help.

Will I ever be the same?

RA is still a chronic disease and you will live with for the rest of your life. Ideally rheumatologists treat people with RA with the aim to put them in remission or to minimize the impact of RA, but in some people there will be some ongoing joint inflammation. You will learn to live with RA and adapt as you need to, and this is something you will continue to do over time. For example, if you are a runner, you may need to switch to cycling. If you are pianist, you may have to limit your practice times. An occupational therapist can provide good advice for adapting your usual activities because of inflammation or damage. Over time you will learn to cope with your different way of living and being. RA does not only affect your physical being and functioning - it affects all aspects of your life, and you may wish to seek out resources to help you with emotionally coping with RA, too.

Reliable sources of information about RA and its treatment

Like anything else on the internet, use caution about the reliability of sources - we recommend you click here to find reliable sources of information about RA, and you can also use these trusted resources below to help better inform you about your RA.

Books

Exercise Beats Arthritis by Valerie Sayce & Ian Fraser
In Defense of Food by Michael Pollan

Articles

In 2013, Dr. Bykerk answered New York Times readers' questions on RA – the series can be found by following these links:
Introduction
Part 1
Part 2
Part 3

Videos

At the 2011 EULAR meeting, Dr. Bykerk discusses the importance of early RA treatment

At the 2014 CRA meeting, Dr. Bykerk has a discussion with Ms. Cheryl Koehn (a person who lives with RA)

Goals of RA Management

There are very effective ways to manage RA and many people with RA live very productive and full lives, while researchers continue searching for a cure. Studies such as the CATCH program have provided important evidence on early treatment of RA so that people can achieve remission or a low level of disease activity with the help of their rheumatologist and healthcare team.

The ultimate goals in managing RA are to:

  • prevent or control joint damage,
  • prevent loss of function by controlling inflammation and swelling, and
  • decrease pain.

In order for your RA to be managed at all, you must be: diagnosed with RA, have your 'baseline' evaluated by your rheumatologist  (this is a thorough understanding of how you are doing health-wise when you are diagnosed, which is considered your baseline), and have your prognosis estimated by your rheumatologist  (this is when your rheumatologist makes an assessment based on your symptoms as to how your RA will progress). In most cases, symptoms are identified first by you as not being normal, and then your family doctor as some form of arthritis. After that, most people are sent to a rheumatologist so that their arthritis can be taken care of by this expert. While rheumatologists aim to treat their patients so that they can be in remission, this does not happen often. Complete remission is a disease state in which the RA symptoms are so mild that it does not even feel like the RA is present, and medically this is defined as the absence of:

1) symptoms of active inflammatory joint pain (as opposed to mechanical joint pain),
2) morning stiffness,
3) fatigue,
4) synovitis on joint exam,
5) progression of x-ray (also called radiographic) damage on sequential radiographs (this means radiographs that are back to back),
6) elevation of the erythrocyte sedimentation rate or C-reactive protein levels.

If complete remission is not achieved, the disease management goals are to, as much as possible, control disease activity, decrease pain, maintain function for activities of daily living and work, and maximize quality of life. You will work with your rheumatologist and healthcare team to find the most best and most effective combination of pharmacologic therapy and analgesics (that is, medications) and rehabilitation support (for example, physiotherapy and occupational therapy).