Health State Descriptions for Canadians
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Musculoskeletal diseases

Context

Introduction

Summary table

Back pain

Repetitive strain injury

Osteoarthritis

Rheumatoid arthritis

Systematic lupus erythematosus

Fibromyalgia

References

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Rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic autoimmune disease in which the body’s immune system attacks healthy joint tissue rather than foreign cells. This causes the synovial lining (the envelope that lines the joint and produces the fluid that lubricates the joint) to become inflamed. This inflammation produces a lot of pain, stiffness and swelling of the joints, which limit the ability to use the joints normally. Over time, inflammation leads to damage in the joints, causing progressive deformities (especially of the hands and feet) and reduced ability to move the joints. RA is a systemic disease, resulting in significant fatigue and possibly affecting other parts of the body. It can affect any joint, generally in a symmetrical pattern (i.e., both sides at the same time); the joints most often affected are those in the hands and feet.

The disease varies from person to person: in some people it can be mild, with some pain, but limiting function only slightly (such as having to cut back on leisure activities) and with little or no deformities of the joints; in others, it can be severe, impairing an individual’s ability to do even the most basic tasks such as dressing and washing, and leading to severe deformities of the joints. For most people the disease is chronic, with some active inflammation on an ongoing basis, but with fluctuations in the symptoms (pain, swelling, stiffness, fatigue). Periods of acute exacerbations of the symptoms are called “flare-ups” and these can last from a few days to a few weeks. The goal of ongoing treatment is to achieve remission, but complete remission is not often reached. The disease rarely goes into remission on its own. Over time, particularly if the disease is not well controlled, people develop progressively more damage to the joints, with severe joint deformities, loss of joint mobility and progressive loss of physical function. This section will describe the typical case of RA at each stage: an acute flare-up, chronic active inflammation, and the advanced damage stage. Individuals typically move in and out of these stages. There may also be periods of little or no activity (remission), but this is most likely to occur in the first year of the disease; the probability of remission decreases as time progresses. During periods of remission, the disease is almost or completely inactive; therefore, this health state will not be described in this section.

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In most cases, the onset of RA is between the ages of 20 and 50, but it can occur at any age, even in childhood (young children can have a form called juvenile RA). About 1% of Canadians are affected with RA,⁴ incidence increases with advancing age, in all races and ethnic groups. Women are about three times as likely as men to develop the disease. The predominant symptoms include pain, prominent swelling, and stiffness in the affected joint(s). The pain and stiffness, which are worse in the morning and after prolonged rest or immobility, last for at least 30 minutes upon rising, with increasing duration and intensity when the disease is more active. Increased pain and stiffness in the morning can last up to several hours when the disease is very active. There can also be systemic effects, such as fatigue, malaise, weakness, weight loss, anemia, and occasional fever. Rarely, RA can affect other organs of the body besides the joints (eyes, skin, nerves, lungs). As the disease progresses, additional joints become affected, with gradual loss of function. Long-term prognosis of RA is poor; approximately 80% of patients experience a reduction in functional capacity within 20 years of disease onset.²⁵ Complications include progressive joint destruction, loss of mobility, and deformity. The continuous inflammation in the joints accounts for the damage or destruction of the joints. Life expectancy is reduced by between 5 and 10 years in individuals with RA²⁶ due to both rheumatoid complications and an increase in non-specific causes of death. Cardiovascular disease is the most common increased cause of death in individuals with RA.^27,28

The causes of RA are largely unknown, but genetic factors likely play a role: the presence of certain genes (associated with the immune system) may increase the risk of developing RA and may predispose the individual to more severe disease.^29-31 Environmental factors also play a role. Diagnosis is based on the overall pattern of the symptoms, physical examination, laboratory tests and x-rays; there is no single test for diagnosing the disease. However, a set of criteria developed by the American College of Rheumatology is typically used in clinical research. An individual is diagnosed with RA if they have at least four of the following seven criteria: morning stiffness in and around the joints lasting at least one hour before maximal improvement; soft tissue swelling (arthritis) of three or more joint areas as observed by a physician; arthritis of finger or wrist joints; symmetric swelling (arthritis in the same joint areas on both sides of the body); rheumatoid nodules; the presence of serum rheumatoid factor; and radiographic erosions in hand and/or wrist joints. The first four criteria must have been present for at least six weeks.³²

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Goals of treatment are to relieve pain, reduce inflammation, stop or slow down joint damage to prevent long-term complications, and improve function and well-being. This involves a combination of medication, rest, exercise, and methods of protecting the joints. Anti-inflammatory drugs can reduce the swelling, pain and stiffness, but they do not prevent damage to the joints. Disease-modifying anti-rheumatic drugs (DMARDs) are a key component of modern treatment because they interfere with the underlying autoimmune rheumatoid process, thereby preventing inflammation in the joints (thus reducing pain, stiffness and swelling) and also preventing damage to the joints (thus slowing the effects of the disease on the joints).³³ DMARDs need to be started early after onset of RA, before irreversible joint damage occurs, and need to be taken continuously throughout the course of the disease. Approximately 90% of patients with RA are treated with DMARDs within three years of diagnosis.³⁴ Corticosteroids can also be used during periods of flare-ups, or while waiting for DMARDs to take effect. Physiotherapy is an important adjunct therapy. Rest, joint protection, icing and heat can decrease the pain and to a lesser extent, swelling around the inflamed joints. Regular exercise is also essential for maintaining the range of motion of the joints and for strengthening the muscles surrounding the joint, which improves mobility, function, and helps maintain stability of the joints. Use of splints, orthotics and assistive devices also help to reduce pain and improve function. Self-management strategies and patient education are very important to allow people to learn how to live with their disease and how to cope with daily pain, fatigue and other symptoms. When joints become severely deformed or dysfunctional, surgery is necessary. Common surgeries include hand and foot reconstruction (to straighten the fingers and toes), tendon repair, and joint replacements.

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