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Rheumatoid Arthritis

Rheumatoid arthritis is an autoimmune disease causing inflammation and damage to the joints. It is often a progressive condition that starts in the hands and feet, mostly usually in the wrist and knuckles, before spreading to other joints in the body.

A joint is formed at the junction of two articulating bones. The end of each bone is covered with cartilage, a smooth, slippery coating that protects the bones as they slide across each other. Around the joint is a strong membrane that encloses the joint parts in a capsule. The capsule has a thin, membranous lining, the synovium, which secretes synovial fluid to lubricate and provide nutrients to the cartilage. Outside the capsule are ligaments and tendons that keep the bones in their proper alignment.

In the case of rheumatoid arthritis (RA), the body’s immune system reacts inappropriately to an external trigger. Substances that irritate the synovium are secreted, causing it to become thicker with resultant swelling, redness and pain. This disease can eventually destroy bone and cartilage in the joint. It can also stretch the tendons and ligaments so that the joint becomes misaligned and deformed.

There is thought to be a hereditary aspect to rheumatoid arthritis. Having a family member who suffers from this condition does not mean that another member will automatically develop it. However, it is believed that an individual can have a genetic predisposition making that person vulnerable to certain viruses or bacteria that may trigger the onset of the disease.

Therefore, if there is a family history of RA, you are at increased risk. If you are female you are up to three times more likely to develop it, and if you smoke you are even more vulnerable. Although RA can develop at any stage of life, it tends to affect people between the ages of 40-60.

Symptoms can come and go and have varying degrees of severity. Times when the disease is active are known as ‘flare-ups’. They can often be interspersed with periods of remission when symptoms are much reduced or non-existent. When symptoms appear, they tend to be symmetrical, that is, present in the same places on both hands.

Typical symptoms include:
  • Aching pain in the joint.
  • Warmth and swelling around the joint.
  • Redness and puffiness of the hand.
  • Stiffness and loss of range of motion, especially in the morning, and lasting longer than one hour after getting up.
  • Firm bumps under the skin on the fingers or elbow (rheumatic nodules).
  • Soft lump on the back of the hand that moves as the fingers straighten.
  • Tiredness, low fever, appetite or weight loss.
  • Fingers start to angle away from the thumb.
  • Sudden inability to bend or straighten a finger due to tendon rupture.
  • The middle joint of the finger is bent upwards.
  • The middle joint is bent downwards and the joint nearest the nail bent upwards.
  • Wrist bones standing out.
  • Numbness or tingling in the hand.
  • Squeakiness when the joint is moved.
  • Snapping or locking of the joint.
Your doctor will take your medical history, which will include questions about any family history of rheumatoid arthritis, your symptoms and whether your daily activities are being affected.

Your hands will be assessed, with attention paid to any redness, swelling, loss of range of motion, joint deformity or nodules under the skin.

There is not one definitive test to confirm the existence of RA, but laboratory tests can point to a positive diagnosis. Blood, urine and synovial fluid can be analysed for particular antibodies and proteins that indicate the presence of the disease. X-rays are often used to view the condition of the joint, and sometimes an MRI scan is performed to provide particular detail.

Unfortunately there is no cure, but treatment can relieve symptoms and help to improve function of the hands.

There are many different medications available, and your doctor will work with you to find the best combination. Some that might be considered are:
  • NSAIDs (non-steroidal anti-inflammatory drugs) can be taken orally, or as creams or gels to be applied topically.
  • DMARDs (disease-modifying anti-rheumatic drugs) slow or stop the immune system attacking.
  • Biologics are often used in conjunction with DMARDs. They target specific proteins that are involved in an immune response.
  • Corticosteroids can be used to reduce inflammation and suppress the immune system.
  • Immunosuppressants calm an immune response.
  • TNF-alpha inhibitors suppress an inflammatory substance.
A hand therapist will assist you by finding devices to help with daily activities such as picking up objects or opening jars. Sometimes a splint to be worn during the day or at night might be recommended. Exercises can be taught to maintain and increase mobility in the hands.

Some alternative therapies that you may find helpful are:
  • Acupuncture for pain relief.
  • TENS (transcutaneous electrical nerve stimulation). This treatment interferes with pain signals being sent to the brain.
  • Counter-irritants such as menthol or capsaicin in ointment can also interrupt pain signals.
  • The medicinal herbs thunder god vine, evening primrose, borage and blackcurrant have been found to ease symptoms, as have fish oils, but always check with your doctor first. If taken with certain prescribed medicines there can be dangerous interactions.
Sometimes your doctor might feel that surgery would be the best option for you. A ruptured tendon can be repaired, the synovium removed, or a joint fused, any of which will relieve the symptoms associated with rheumatoid arthritis.

Self-help options:
  • Exercise can increase range of motion and flexibility of the joints. Tai chi, swimming and water aerobics are recommended. Hand exercises such as those listed below should be done on a daily basis, provided they do not cause new pain.
  • Soaking the hand in warm water for 4 minutes, then in cool water for 1 minute, repeated for half an hour and ending with a warm soak, has been found to ease pain.
These are to be done with the approval of your doctor, and should not cause you pain. They are designed to increase flexibility and mobility, not strength.

Bending fingers:
Relax your hand. With the fingers together and straight, and without moving the wrist and knuckles, bend the fingers at the end and middle joints. Slowly return the fingers to the starting position. Repeat with the other hand. Do this several times.
Start with your fingers spread out straight, then slowly form a loose fist and place your thumb around the outside the fingers. Don’t squeeze hard. Slowly return to the starting position. Repeat with the other hand. Do this several times.
Wide hand:
Gently spread your fingers as far apart as you can, without forcing them. Relax the fingers and slowly bring them together before spreading them out wide again. Repeat with the other hand. Gradually increase the number of times you do this exercise.
Tip touch:
With your fingers and thumb straight, touch the thumb to the pad on your palm, just below your little finger, or as far across your palm as you can. Return your thumb to the starting position, then touch the tip of each finger, in turn, to the thumb, forming an ‘O’ shape. Straighten each finger after touching the thumb. Repeat with the other hand.
Finger walk:
With the palm down on a table and the fingers slightly spread out, and keeping the wrist and thumb still, lift and move the index finger toward the thumb. Repeat with each finger in turn. Repeat with the other hand. Do this exercise several times.

Working splints and resting splints are available to reduce swelling, ease pain and prevent joint deformity. Although studies have not found conclusive evidence that they are effective, patients prefer wearing them to not wearing them, so there is some apparent benefit. Padded resting splints were found to be more comfortable than unpadded.

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