Rheumatoid arthritis

Rheumatoid arthritis affects different joints in different people, and the symptoms vary from person to person too. They will depend on whether the inflammation is mild or severe and how far the rheumatoid arthritis has progressed.

The typical symptoms of rheumatoid arthritis are:

• Warm, swollen and painful joints
• Stiff joints in the morning after you wake up. They usually only become more flexible again after more than an hour.
• Weakness: Painful, stiff joints often end up not getting as much use, which can cause the muscles to get weaker over time.
• Exhaustion: Rheumatoid arthritis affects the whole body, so it often causes tiredness and general physical weakness.
• Rheumatoid nodules: As the disease progresses, small firm lumps called rheumatoid nodules sometimes develop under the skin. They're usually not sensitive to pressure or touch.

The inflammation typically affects the same joints on both sides of the body.

Rheumatoid arthritis is sometimes confused with osteoarthritis. But there are several differences between these two conditions:

• Osteoarthritis is caused by the age-related breakdown of cartilage inside the joints, and not by inflammations.
• Osteoarthritis and rheumatoid arthritis affect different joints at first.
• In osteoarthritis, moving the joint after resting it in the daytime is often painful at first. This pain may occur several times during the day, but doesn't last long.
• In osteoarthritis, the joints mainly hurt when you move them, and not when you rest them.

There are also major differences in terms of both the treatment and course of the two diseases.

Rheumatoid arthritis is an autoimmune disease in which your body's own immune system attacks the lining of the membranes that surround the joints. It is not quite understood why the immune system does this.

Genes seem to be one of the factors that determine whether or not someone gets rheumatoid arthritis. There are also theories about certain viruses or bacteria causing autoimmune responses.

Smoking is a factor in the development of rheumatoid arthritis and may have a negative effect on its further course.

In Germany, about 1% of all adults have rheumatoid arthritis. It usually develops in people over the age of 50. In rare cases it arises at a younger age, sometimes even in teenagers.

Women are 2 to 3 times more likely than men to get rheumatoid arthritis, and do so about ten years earlier on average. The disease is also often more severe in women than in men.

Rheumatoid arthritis is usually first noticed in the small joints in the middle of the fingers and at the base of the fingers and toes, and sometimes in the elbows, ankles, or knees as well. Joints close to the torso, such as the shoulder joints or collarbone, may also become inflamed.

In some people rheumatoid arthritis causes more general symptoms at first, like exhaustion or loss of appetite, or sometimes a mild fever.

Rheumatoid arthritis can progress in very different ways. In one study involving people with rheumatoid arthritis, ten years after they had developed the condition

• just under 50% of the participants reported minor limitations,
• a good 40% reported moderate limitations, and
• about 10% reported severe limitations in their everyday life.

These limitations include difficulties with things like getting up in the morning, getting dressed or preparing food – for example, opening packages, bottles or jars.

Symptoms may gradually worsen, or they might not change for a long time. Sometimes the symptoms come and go in episodes, so the inflammation and pain may suddenly get worse and then improve again after a while. During phases when the symptoms are more severe, or at more advanced stages of the disease, people might sometimes feel extremely exhausted. This is known as “ fatigue.”

The late stages of rheumatoid arthritis can lead to major joint damage. Especially the joints in the hands can become very deformed, weak and stiff. But these late consequences of the disease can usually be prevented nowadays: through early treatment with disease-modifying antirheumatic drugs (DMARDs) and regular check-ups.

The disease-related inflammation can also affect other things in the body, such as the blood vessels. Because of this, many people who have rheumatoid arthritis also have a somewhat higher risk of cardiovascular (heart and blood vessel) disease. But this risk mainly depends on other factors, like high blood pressure, diabetes, smoking and high cholesterol levels.

The tear glands or salivary glands may become inflamed too, reducing the production of tears or saliva. In very rare cases, organs like the lungs, the liver or the kidneys may also be affected.

When trying to find out if you have rheumatoid arthritis, the doctor will first ask about symptoms such as painful joints, stiff joints in the morning and general symptoms like tiredness or exhaustion. The talk with the doctor will be followed by various examinations and tests:

• Physical examination: The doctor feels the joints and checks whether they are swollen or can’t be moved properly. It is important to find out how many joints are affected and how long they've been inflamed. The doctor also looks for other signs of rheumatoid arthritis, such as inflamed tear glands or rheumatoid nodules.
• Blood tests: Blood tests are used to detect certain antibodies and signs of inflammation in the body.
• Imaging techniques: Changes in the joints can be seen in x-ray or ultrasound images.

It can be difficult to diagnose rheumatoid arthritis at an early stage because the symptoms are often very mild in the first few weeks and months, and may not be typical. It is easier to diagnose rheumatoid arthritis in someone who has had it for a longer time. This is because, in addition to the typical physical symptoms, it's often already easy to see changes in the joints.

If it's thought that someone might have rheumatoid arthritis, specialized doctors known as rheumatologists can be consulted.

Rheumatoid arthritis can be treated with medication, physical therapy and occupational therapy. There are also various support aids that can make some everyday tasks easier. People are advised to do regular exercise or sports too.

The treatment options will depend on things like

• how severe the inflammation and symptoms are,
• how far the disease has progressed,
• the predicted further course of the disease, and
• how well previous treatments have worked.

There is currently no cure for rheumatoid arthritis. But medication can

• reduce inflammation,
• stop the disease from getting worse,
• relieve symptoms like pain and swelling, and
• help people move their joints more easily again or maintain joint mobility for as long as possible.

Physical therapy and sports can help improve or maintain mobility, strength and joint function. Examples of suitable types of sports include cycling, brisk walking, dancing, doing exercises (e.g. gentle strengthening exercises), swimming and aqua aerobics.

The main aim of occupational therapy is to maintain your mobility and hand strength, and to learn how to get by with rheumatoid arthritis in daily life.

Psychological treatments can help relieve pain and minimize the impact it has on everyday life. They are also supposed to help relieve disease-related anxiety and depression that some people develop.

If medication is not able to relieve the symptoms and the arthritis keeps getting worse, the thin layer that lines the joint (synovium) can be surgically removed. Surgery can reduce the pain and symptoms caused by severe joint damage resulting from rheumatoid arthritis. That may involve implanting an artificial joint or fusing the joint (arthrodesis), for example.

In advanced arthritis, various aids can compensate for many physical limitations and help you to carry out everyday activities. These include orthopedic shoe inserts, grabbing aids and specially designed cutlery.

Rehabilitation may be considered in people whose rheumatoid arthritis wasn't well managed for a longer period of time. The aim of rehabilitation is to cope better with the disease in everyday life, to start getting out of the home again, and to continue working or be able to go back to work again. But it may also be suitable for retired people. Rehabilitation can help them to be as independent as possible and prevent the need for nursing care.

A number of different specialists are involved in rehabilitation, including rheumatologists, physical therapists, occupational therapists, social workers and psychologists. Rehabilitation usually lasts about three weeks. Having inpatient rehabilitation means that you will stay at the hospital or rehabilitation center the entire time. In outpatient rehabilitation, you live at home and visit the center during the day.

Depending on the goals of rehabilitation, the costs will be paid by statutory pension, health or accident insurance (in Germany). Rehabilitation treatment will only be possible if a doctor has said that it is necessary and if the rehabilitation application has been approved by the insurer.

Rheumatoid arthritis and associated problems like pain, exhaustion, drug side effects and physical limitations can all have a major impact on everyday life.

Many people who have rheumatoid arthritis need more time for everyday activities and also need more and longer breaks to rest. There are a number of different time-consuming things that they have to take care of: frequent visits to the doctor, taking their medication correctly, and getting hold of support aids. High levels of exhaustion can also mean that people who have rheumatoid arthritis need more sleep, have difficulties concentrating and find it hard to stay active. The disease is often associated with feelings like anxiety about the future and sadness about the loss of physical abilities, as well as anger at having rheumatoid arthritis. These feelings can be hard for others to fully understand.

But many people learn to manage their disease so that they can cope better with the symptoms and are still able to live a fulfilled life despite the limitations.

There are a number of different options for people with rheumatoid arthritis to find support within Germany, including support groups and information centers. Support services are often organized quite differently from region to region, though. Our list may help you find and make use of local services.

When people are ill or need medical advice, they usually go to see their family doctor first. In our topic “Health care in Germany” you can read about how to find the right doctor. Our list of questions can help you to prepare for your appointment.