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Symptoms of rheumatoid arthritis differ from one person to the next. But,there are certain hallmark signs of the disease.
The more obvious symptoms-swollen or deformed joints,reduced movement and pain-occur as the disease progresses.
Early symptoms can be much more subtle. Recent research has shown that,even as early as a year or two after onset of
the disease, rheumatoid arthritis can cause irreversible damage of joints.
Rheumatologists urge primary care providers and others to stay alert to the early sighns of rheumatoid arthritis. The
earlier that treatment begins,the better the chance of avoiding disability
The subtle early symptoms that might easily be mistaken for something else include:
1) Listlessness and fatigue.
2) Loss of appetite.
3) Soreness and some swelling in the joints.
4) Weight loss.
5) Joint stiffness,especially in the morning.
RA almost always eventually causes joints to become inflamed,making them sore and warm to the touch. The area may swell
and turn red. (redness is not a dominant feature). The joints may become painful and hard to move.
Although joint inflammation is a hallmark sign of RA,it can vary from one person to another ( same with medication response).
In some people,joint inflammation flares up and then subsides,only to flare up again. In others,inflammation is always present
and may even worsen as the disease progresses. About one person in ten experiences a single,or couple of episode or episodes
of joint inflammation and then goes into remission.
As the disease progresses,RA may also create flu-like symptoms. You may feel listless and weak,run a low-grade fever,and
have no appetite. In time,this may lead to weight loss and anemia.
Symptoms of RA may include inflamed tendons and tingling in the fingers. In about one person out of five,small bumps,known
as rheumatoid nodules,appear under the skin on the elbows or on other parts of the body. These lumps are small lumps of tissue
which develop around bony areas that are exposed to pressure (elbows are common ). It is rare,but it may even develop
internally.
You may begin to have trouble getting dressed in the morning,your hands may fumble as you button-up or you may drop something
while putting it away. It may become harder to get in and out of the bathtub,or to reach around to wash up. At work,you may
find it difficult to do certain tasks that wasn't difficult to do before.
It is important to note these changes,as well as physical. Not only will it help your rheumatologist to determine how
advanced your RA is,but it will also pinpoint activities that you may have to rethink and even learn how to do differently
so that you can continue to live a fuller life.
It is possible to recover function. Just as the physical symptoms of your disease will require medication,the life-altering
aspects can be addressed in many ways,but you must first acknowledge that a problem exists.
If you have a particularly severe form of RA or if the disease has progressed unchecked,your joints may become deformed
In some cases the disease may involve other areas:
1) Tissue in the eyes and mouth may become dry (Sjogren's syndrome.)
2) The tissues surrounding the heart may become inflamed (pericarditis.)
3) The tissues lining the lungs may become inflamed (pleuritis.)
Rarely,RA may affect blood vessels ( vasculitis ). If this happens,the skin,nerves,organs,and other tissues may be damaged.
Diagnosis is all the more challenging because RA causes different symptoms in different people. To further complicate
the picture,some symptoms-particulairly pain and stiffness in the joints-are also symptoms of osteoarthritis. The feeling
of overall weakness and lack of energy are also symptoms of other auto immune diseases such as lupus. To ensure that
a diagnosis of RA is accurate, the rheumatologist will order various medical tests to supplement what he/she observe and what
the patient have said about their symptoms.
To determine whether the symptoms are signs of RA or something else,your rheumatologist may look at the following:
1) Your medical history-the information the patient provide about duration and type of symptoms.
2) The result of a physical examination.
3) The results of blood tests,( X-rays are more useful at a later date for comparison purposes),and other medical tests.
Don't be concerned if your physician suggests that you return periodically for in-depth checkups that may involve many
of the same questions and tests. Because RA can vary vary so much from one person to another,time and reassessment offer valuable
perspectives about the course of the disease.
Although medical tests (covered in other parts of the site),the types of tests when RA is suspected may vary from the
tests ordered for the diagnosis of other types of arthritis.
The initial evaluation of the patient with RA should document symptoms of active disease (i.e.,presence of joint pain,duration
of morning stiffness,degree of fatigue},functional status,objective evidence of disease activity (i.e., synovitis,as assessed
by tender and swollen joint counts,and the ESR and CRP level) mechanical joint problems (i.e., loss of motion-joint instability,
malalignment,and/or deformity), the presence of extraarticular disease and the presence of radiographic damage. The presence
of comorbid conditions should be assessed.
The patient's and physician's global assessment of disease activity and a quantitative assessment of pain using a visual
analog scale or other validated measure of funcion or quality of life are useful parameters to follow during the course of
the disease. This baseline information greatly facilitates assessment of these progression and response to treatment.
Baseline laboratory evaluations should include a complete blood cell count (with white blood cell differential and platelet
counts),rheumatoid factor (RF) measurement,and measurement of ESR or CRP. Evaluation of renal and hepatic functions is necessary,since
many antirheumatic agents cause renal or heptic toxicity and may be contrainindicated if these organs are impaired.
Since the hands and feet are so frequently involved in RA,radiographs of these joints as well as other affected joints establish
a baseline for future assessment of structural damage. Arresting and preventing structural damge is the primary goal of therapy.and
radiographic studies of major involved joints may be needed periodically.
Selection of the treatment regimen requires an assessment of prognosis. Poor prognosis is suggested by earlier age at
disease onset,high titer of RF,elevted ESr,and swelling of >20 joints. Extraarticular manifestations of RA,such as rheumatoid
nodules,Sjogren's syndrome,episcleritis and scleritis,interstitial lung disease,pericardial involvement , systemic vasculitis
and Felty's syndrome,may also indicate a worse prognosis,but have not been widely adopted for clinical practise.
The ACR criteria for 20 % clinical improvement (the ACR 20 ) requires a 20 % improvement in 3 of the following parameters;patient's
global assessment,physician's globl assessment,patient's assessment of pain,degree of disability,and level of acute-phase
reactant. These criteria have been expanded to include criteria for 50 % and 70 % improvement measures (i.e.,ACR 50,ACR 70).
Other criteria,such as Paulus criteria,have bee employed. More recently,radiographic progression (e.g., the Sharp score )
has been utilized as an outcome measure.
Rheumatoid arthritis may be better classified into four different types: spontaneous remitting disease,remitting,remitting
progressive,and progressive.
Spontaneous remission means that without treatment or just with NSAIDs,the symptoms of the disease disappear. They may
return later,and you may need to start taking NSAIDs again,but for a while you have complete relief or almost. In rare cases,about
5 to 10 % of people with RA,the symptoms never return.
Remitting disease means that the person has a series of flare-ups with a return to normal in between. This can
be difficult to deal with,because it is not known when a remission is going to occur and when the symptoms will return. DMARDs
may be needed to prevent joint damage during the flare-ups
People suffering from remitting progressive disease experience flare-ups but never quite return to normal in between.
There is a good chance that the joints with this type of disease will be damaged without DMARD therapy.
The person with progressive disease never experiences remission or flare-ups,just a gradual increase in the pain,swelling,and
joint damage over time. Usually the progression is slow,but in some cases one can become disabled rather quickly.
New ACR guidelines recommended DMARD therapy to all RA patients upon diagnosis.
Factors that correlate with prognosis: More favorable factors; Onset at a younger age,absence of rheumatoid nodules (small
bumps over pressure points),absence of,or few,manifestations outside of joints,absence of rheumatoid factor in the blood and
perhaps male gender.
Less favourable prognosis : Rapid onset at a older age,high levels of rheumatoid factor,early in the disease,early involvement
of large joints,female,presence of rheumatoid nodules,early appearance of erosions in the joints,vasculitis (blood disorder
).manifestations outside of the joints,and scleritis. It was once though that the marker HLA-DR4 in the blood was a indicator
of severe disease,but some recent research suggests it may not be related to severe disease. It remains debateable among researchers.
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