What is rheumatoid arthritis?
Rheumatoid arthritis is the most common inflammatory joint disease worldwide and is often referred to in everyday life as "inflammatory rheumatism". Originally, the term "rheumatism" comes from the Greek and means a drawing, flowing pain.
The term "rheumatism" is colloquially used for many syndromes with pain and functional limitations of the musculoskeletal system (joints, muscles, tendons, bones). From a medical point of view, these diseases are counted among the so-called "diseases of the rheumatic type". Thus, "rheumatism" may refer to more than 200 different diseases, e.g. Arthrosis, gout, psoriatic arthritis or ankylosing spondylitis. Many rheumatic diseases do not just affect the locomotor system. There may also be organs such as e.g. Eyes, lungs, vessels or the heart may be affected.
Trigger immune system
In rheumatoid arthritis (and many other rheumatic diseases), the immune system plays an important role. It is a so-called autoimmune disease. The normal function of the immune system in our body, the defense against pathogens and foreign substances, is still fulfilled. In addition, however, the defense cells then attack certain endogenous cells and tissues. This eventually leads to inflammatory-like reactions.
In rheumatoid arthritis, the immune cells attack the so-called synovial membrane. This membrane is an inner skin of the joints that surrounds the joint. In the course of inflammation (synovitis), the synovial membrane thickens like a tumor and overgrows the cartilage and the bone of the joint, which can eventually lead to joint deformity and complete destruction of the joint.
First symptom: pain and swelling
The inflammation is typically noticeable in the form of swelling and morning stiffness of the joints. In most cases, the base and middle joints of the fingers and toes on both hands or both feet are affected simultaneously. In principle, however, almost all the joints of the body can become inflamed. The onset of the disease can be both creeping and sudden. The course typically progresses in spurts.
In Germany, about one in every hundred people suffer from rheumatoid arthritis. Women are nearly twice as likely to be affected as men. Most people with rheumatism are between 45 and 65 years old at the onset of the disease. In principle, a beginning is possible at any age. In children, this is called Juvenile Idiopathic Arthritis (JIA).
In addition to a misguided immune system, genes and various environmental factors also seem to play a role in the development of rheumatoid arthritis. Thus, the disease occurs in many cases, family heaped up. In addition, it has been shown that smokers are at a higher risk of developing rheumatoid arthritis than non-smokers. Nevertheless, the interplay of possible causes is very complex and in some cases still unclear.
Good treatment options, but no cure
Rheumatoid arthritis can be treated very well today, but can not be cured. Those affected have very good prospects with very early diagnosis, early treatment and consistent medication. The course can then be delayed considerably. On the one hand, medicines are used that relieve the pain, and on the other hand also agents that prevent joint destruction. Additional therapy options, such as The physiotherapy can provide relief and support the drug treatment.
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Rheumatoid arthritis: causes and risk factors
The causes of rheumatoid arthritis are still not fully understood. However, many studies have shown that a malfunctioning immune system and certain genes and environmental factors play an important role.
The importance of the immune system
The immune system in our body has the task to ward off pathogens and pollutants that could cause harm. In order to do this work, the immune system has to differentiate between "foreign" and "self".Pathogens are recognized as foreign and rendered harmless, while sparing their own tissue.
In the so-called autoimmune diseases, which include the rheumatoid arthritis, the immune system is no longer able to distinguish between "foreign" and "self". Immune cells begin to attack one's own tissue as if it were a pathogen. The immune cells release substances called cytokines, which trigger inflammation. These include e.g. TNF-alpha or Interleukin 1 (IL-1). In addition, so-called autoantibodies are formed by some immune cells. Antibodies usually bind to pathogens to render them harmless. However, autoantibodies bind to their own tissues, which is illustrated by the prefix "auto-". This process contributes to the destruction of the body's own tissue.
In rheumatoid arthritis, immune cells migrate into the joints, where the inflammation is felt by sore and swollen joints. The cells of the synovial membrane surrounding the joint begin to multiply due to the inflammation. The proliferating synovial membrane invades and destroys cartilage, bones and ligaments. Furthermore, more fluid may leak from blood vessels and cause joint effusion.
In contrast to a normal inflammation in the body, in rheumatoid arthritis sufficient countermeasures can not be initiated to make the inflammation disappear again. Inflammatory and anti-inflammatory reactions come out of balance and the inflammation can not be controlled.
Rheumatism: the influence of genetic material and other risk factors
Apart from the role of the immune system, however, other factors also seem to be important in rheumatoid arthritis. Thus, this disease occurs familial, which suggests that the genetic material has an important influence. Researchers have been able to show that in people with rheumatoid arthritis compared to the general population, a specific gene called HLA DR4 / DRB1 can be found more frequently. This gene plays an important role in the distinction between "foreign" and "self" through the immune system. The increased occurrence of this gene variant in people with rheumatoid arthritis could explain why the immune system has difficulty distinguishing between "foreign" and "self".
In addition, recent studies have shown that tobacco smoke is a risk factor for the development of rheumatoid arthritis. Not only the amount, but also the duration of smoking seems to be decisive. It is also believed that infections such as e.g. Periodontal disease (periodontitis) may be associated with the development of rheumatoid arthritis.
When exactly and how does the process begin?
The search for reliable findings on the cause of rheumatoid arthritis has now proved to be more difficult than initially thought. On the one hand, experts assume that possibly several factors in a complex interaction contribute to the development of the disease. According to current theories, it is also likely that disease-causing processes already occur in a person's body when it is still completely healthy. Events in the present life could only years later lead to the onset of the disease. The challenge of the future will therefore be to better filter out healthy individuals with certain risk factors for rheumatoid arthritis from the general population. Investigations of such groups could help to identify the processes involved in the development of early stage rheumatoid arthritis.
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Rheumatoid arthritis: symptoms
Typically, the course of rheumatoid arthritis begins creeping with symptoms that persist for weeks and months. First, sufferers notice a stiffness in one or more joints, which is accompanied by a sensitivity to pressure and pain during movement of the joint. Often the pain is strongest at night. In most cases, five or more joints are affected, and this varies greatly for each individual.
Another way the rheumatoid arthritis can look like is a swelling that occurs in one or two joints. This swelling is in this case only a few days to weeks to find. It first disappears completely, and then reappears some time later in the same or another joint.
During the recurring inflammations, and especially when no drug treatment takes place, it can lead to malpositioning of the wrists.
Typical joint complaints
Rheumatoid arthritis usually affects the finger joints of the hand, the wrists, the metacarpophalangeal joints, and the toe joints in the foot. As a rule, this is done simultaneously on both hands or feet. One speaks in this context of a symmetry.In addition, in many people also inflame the shoulders, elbows, knee and ankle joints. With the exception of the cervical spine, the spine is generally not affected.
Characteristic is a so-called morning stiffness of the joints after sleep, which, unlike many other inflammatory joint complaints, can last up to several hours. It can also occur, for example, after several hours of motionless sitting.
Accompanying to the joint complaints tend tendonitis or so-called rheumatoid nodules. These are benign hardenings of tissue that occur in places exposed to heavy loads. Most of these are the extensor side of the hands, the tendons, the elbow or the front of the lower leg.
Non-specific symptoms of rheumatism
Before the onset of joint problems, unspecific symptoms such as tiredness, listlessness, mild fever (up to 38 ° C), malaise or loss of appetite can often occur weeks or months before. Many people confuse these symptoms with a flu infection. In particular, fatigue can be very stressful for many sufferers, as it appears completely unexpected and can subside again. The quality of life is often severely affected. So-called relapses of the disease are often characterized more by the above-mentioned nonspecific symptoms than by occurring joint complaints. They can make the diagnosis much more difficult at the beginning of the disease.
Other organs may be affected
Although the joint complaints in people with rheumatoid arthritis are almost always in the foreground, also other organs can be affected. Especially in the case of a severe course, respiratory and cardiac activity may be impaired. Also, symptoms similar to other rheumatic diseases, such as Inflammation of the connective and corneal of the eyes or dysfunction of the salivary and lacrimal glands, which can lead to dehydration of the mouth and eyes.
Finally, rheumatoid arthritis may increase the risk of other diseases such as Increase vascular calcification, infections or osteoporosis.
Rheumatoid arthritis: diagnostics
Recognizing rheumatoid arthritis, especially if predominantly unspecific symptoms occur, is complex. A quick diagnosis is complicated by the similarity of some symptoms with other rheumatic diseases. Apart from a thorough physical examination by an experienced doctor (first family doctor, later internist or rheumatologist) further diagnostic tests and imaging tests are therefore necessary.
An early diagnosis is important
Recent studies have shown that early diagnosis of rheumatoid arthritis is very important to prevent severe progression and rapid joint destruction. Because joint damage that has already occurred, persist permanently and can not be undone. For this reason, rheumatology offices now offer consultation hours specifically for the early diagnosis of rheumatoid arthritis. In this way, rapid treatment can be initiated.
As part of the diagnostic measures, the doctor will first discuss the medical history and ask questions about the occurrence of rheumatic diseases in the family. In addition, the joints are thoroughly examined and various diagnostic tests performed to confirm a suspicion and to exclude other diseases as far as possible.
When diagnosing, the so-called criteria of the "American College of Rheumatology (ACR)" can also be consulted. These criteria were developed primarily for the worldwide standard diagnosis of rheumatoid arthritis in the conduct of clinical trials. However, they can also be helpful in helping with the diagnosis in everyday medical practice. In the criteria of the ACR, certain symptoms are weighted differently and summed up using a point system.
At the time of physical examination, the physician will scan each joint individually and be careful of pressure and pain sensitivity, mobility and signs of inflammation, i. Swelling, redness or a feeling of warmth, check. It also takes into account the number and type of joints that are affected. In addition, it is examined whether a possible joint change is more characteristic of rheumatoid arthritis or other type of joint disease, such as rheumatoid arthritis. an osteoarthritis. In a physical examination can also be checked whether typical rheumatoid nodules are present.
Blood tests for rheumatism
There is no laboratory test today that clearly confirms the diagnosis of rheumatoid arthritis. Nevertheless, the determination of the following blood values may be helpful in the diagnosis:
- C-reactive protein (CRP)
- Rate of erosion (BSG)
- Rheumatoid factor (RF)
- anti-CCP antibodies
To estimate how active the inflammation is, a doctor will usually have their blood levels of BSG and CRP determined. Increased levels suggest that there is active inflammation. It should be noted, however, that elevated levels may also be present in other inflammatory diseases and infections. Inflammation levels, however, may not always be elevated in rheumatoid arthritis. Especially at the beginning of the disease, these values are often in the normal range.
Rheumatoid factor in the blood?
Since rheumatoid arthritis is an autoimmune disease (see Causes), autoantibodies are also formed during the inflammatory process. In about 70-80% of patients, such a rheumatoid factor is present. However, this antibody is not as specific for rheumatoid arthritis as the name might suggest: it is more common in the elderly and in infections. It can also be detected in some healthy people. A positive anti-CCP value is much more specific for the presence of rheumatoid arthritis. It is present in about 60% of those affected and is associated with a more severe course.
In addition to the above-mentioned blood levels, the liver counts are also regularly monitored and kidney function checked to prevent damage from possible side effects of medication.
Ultrasound (sonography) can be used to assess the condition of the synovial membrane and detect articular effusions and tendon thickening. The latest developments in sonography or magnetic resonance imaging (MRI) allow an ever better detection of small joint damage at a relatively early stage of inflammation. X-rays of the hands and feet are particularly meaningful in the advanced stage of rheumatoid arthritis. On the basis of cartilage shrinkage, the ossification, the narrowing of the joint space or the malpositions statements about the progress of the diseases can be made.
In unclear cases, there is another method that can be used to differentiate rheumatoid arthritis from other joint inflammations. In particular, an infectious arthritis in which the joint is attacked by bacteria must be ruled out immediately. Another differential diagnosis is gout.
To distinguish the individual diseases and to initiate the appropriate correct therapy, a joint puncture is recommended in which the affected joint is pierced with a needle. The withdrawn synovial fluid is then examined in the laboratory for pathogens and inflammatory cells. The number of so-called leukocytes (white blood cells) provides information about the underlying disease. While it is already significantly elevated in rheumatoid arthritis, the value of an infectious arthritis is again ten times higher. In the case of gout, in turn, deposits of uric acid crystals can be detected.
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Treatment of rheumatoid arthritis
The prospect of completely curing rheumatoid arthritis does not exist today. However, treatment options have improved significantly over the past 50 years. Progression of the disease can be slowed down in most cases and the inflammation can be very well controlled.
The aim of the treatment is to maintain the mobility of the joints, to prevent damage to the joints and to relieve pain. To achieve this goal, a wide range of different forms of therapy are available, which include not only medical treatment but also physical and occupational therapy, psychological support or a change in diet. In this way, the treatment can be individually adapted to the personal situation and to the desires of the person concerned in order to achieve the highest possible compatibility.
Recent studies have also shown that the prospect of a much better and complication-free course, if it begins early with a consistent drug therapy within three months of the onset of the first symptoms.
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There are generally three classes of drugs used to treat rheumatoid arthritis:
- Non-steroidal anti-inflammatory drugs (NSAIDs)
- Corticosteroids (cortisone preparations)
- disease-controlling drugs or so-called disease-modifying drugs (DMARD)
NSAIDs and Cortisone drugs are fast acting, while the DMARD can take several weeks to months to get the effect. Since it is known that the greatest damage to the joints can occur within the first two years, is often very quickly after the diagnosis with a DMARD therapy begun to stop the course of the disease.
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Non-steroidal anti-inflammatory drugs (NSAIDs)
The use of non-steroidal anti-inflammatory drugs (NSAIDs) is designed to reduce acute inflammation in the joint, alleviating joint pain and improving flexibility.Nevertheless, they alone can not change the course of the disease or protect it from destruction of the joints. There are a large number of NSAIDs that are similar in their effectiveness, but very differently tolerated.
An example of one of the oldest NSAIDs is Acetylsalicylic acid (ASA, aspirin). For rheumatism, it has been replaced by other NSAIDs over the years. Other NSARs include:
NSAIDs prevent the formation of so-called prostaglandins by inhibiting certain enzymes called cyclooxygenases Cox-1 and Cox-2. Prostaglandins promote inflammatory processes and pain in the body. But they also play a role in blood clotting, protect against acid production in the stomach and are involved in the regulation of blood flow through the kidneys.
Mostly, in the treatment of rheumatoid arthritis, a relatively high dosage of said drugs is prescribed to effectively control the inflammation. Only in rare cases are the NSAIDs prescribed in low dose, for example, with only mild joint inflammation and low pain. Another reason for a conservative dosage is a high age or stronger side effects. If the NSAID medication is not tolerated after a period of about one month of adjustment, preparations from another group must be used.
The most common side effects of NSAIDs are the gastrointestinal tract. It can cause gastric ulcer-like mucosal damage and bleeding. The additional intake of gastric protective drugs (so-called proton pump inhibitors such as Omeprazole or pantoprazole) can help to minimize these side effects. In addition, renal function disorders may occur, which may result in increased blood pressure and fluid retention.
Corticosteroids such as prednisone or Dexamethasone are known for suppressing the immune system and are therefore also an important option in the autoimmune disease of rheumatism. They can be administered either intravenously or as a tablet. They can also be injected directly into inflamed joints.
Usually cortisone drugs are given at an early stage of the disease if therapy with DMARD has not yet struck. In addition, they are prescribed in combination with other medications in the severe case. It is important that they can be discontinued only slowly, otherwise strong side effects are to be expected. Treatment with steroids can also lead to increased blood pressure, increased blood sugar levels, increased fat and water retention or bone loss (osteoporosis). To prevent these side effects, a parallel intake of Calcium and vitamin D is recommended.
Disease Control Medications (DMARD)
Both NSAID and DMARD drugs are able to improve the symptoms of active disease, but only disease-controlling DMARDs can alter the course of the disease. Treatment with this class of drugs should therefore be made as soon as possible after diagnosis.
One of the most important and effective DMARDs for the treatment of rheumatoid arthritis is methotrexate, often called MTX. It can be taken as the sole drug or in combination with other rheumatoid drugs. Methotrexate is known to interfere with folic acid metabolism by inhibiting the enzyme dihydrofolate reductase. How exactly the immune system is suppressed, however, is unclear. Methotrexate is usually well tolerated and can be administered conveniently. Nevertheless, kidney, lung and liver disorders should be ruled out before starting treatment. Special attention must be paid to interactions with other drugs in methotrexate. Blood levels should also be monitored at regular intervals during treatment, as adverse effects may be liver, kidney and bone marrow abnormalities. However, these and other side effects can be alleviated or prevented by taking folic acid.
Methotrexate should be avoided three months before pregnancy and during pregnancy as methotrexate may cause malformations in the embryo.
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Hydroxychloroquine / chloroquine
Hydroxychloroquine (e.g., Quensyl®) or chloroquine is another DMARD used in the treatment of rheumatoid arthritis. Originally, this drug was developed for the treatment of malaria, but also shows effect in rheumatism. The mechanism of action is still largely unknown. It is believed that the drug causes changes in the immune system. In the goal of stopping the destruction of the joints, hydroxychloroquine and chloroquine have been shown to be less effective than methotrexate. They are therefore more likely to be prescribed for a milder course in combination with other medications. Side effects of these drugs are very rare. However, when they do occur, especially the eyes are affected. Therefore, eye checks should be performed once a year.
A very important and effective DMARD is sulfasalazine (e.g., Pleon® RA).Its effectiveness is slightly lower than that of methotrexate. However, studies have shown that this drug can greatly inhibit disease progression, including joint damage. It is often given in combination with hydroxychloroquine and methotrexate in people who do not respond to methotrexate alone. There may be occasional allergic reactions or mild gastrointestinal symptoms when taking sulfasalazine. The side effects on the liver are very low, which is why this drug is preferred to concomitant liver disease methotrexate.
The DMARD leflunomide (for example Arava®) also has a very good effect and is often prescribed as an alternative if methotrexate causes too much side effects. The mechanism of action is not fully understood. Leflunomide may inhibit the biosynthesis of so-called pyrimidines, which i.a. Are components of the genetic material. An inhibition of pyrimidine biosynthesis could stop an increase in activated immune cells and thus reduce joint inflammation.
The side effects of leflunomide are relatively low. It can cause hair loss and mild gastrointestinal discomfort. Nevertheless, regular blood tests should be done. Similar to methotrexate, special caution should be exercised in pregnancy as malformations of the embryo may occur.
Treatment with so-called biologics takes place in most cases only after six months with methotrexate no treatment success is recorded. Biologics are biotechnologically produced inhibitors of the immune system, which are directed against specific immune cells or cytokines (see Causes and risk factors). These include the following active ingredients:
- Infliximab (Remicade®, TNF-alpha inhibitor)
- Etanercept (Enbrel®, TNF-alpha inhibitor)
- Adalimumab (Humira®, TNF-alpha inhibitor)
- Anakinra (Kineret®, interleukin-1 competitor)
- Tocilizumab (RoActemra®, Interleukin-6 antibody)
- Rituximab (MabThera®, B-cell antibodies)
- Abatacept (Orencia®, T-cell activation inhibitor)
For each individual patient, the appropriate preparation must be carefully selected after weighing possible side effects. The aim of these medicines is also to find a suitable dose that is strong enough to allow effective treatment of the disease but weak enough to prevent unnecessary side effects.
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Physiotherapy & Ergotherapy
The goal of physiotherapy or physiotherapy is to improve the mobility of the joints, to train muscles, to prevent malpositions and to relieve pain. With the help of special methods, joint blockades can be resolved and muscle tensions can be treated with massages.
Also, cold and heat applications can be used concomitantly. While applying chills in an acute episode can relieve severe inflammation, it is helpful to apply heat, especially during a chronic stage. Due to the heat, muscle tension can be released, and a better elasticity of the tissue can be achieved. Heat applications can therefore be used before a sporting activity. People with cardiovascular disease, however, should first consult the doctor before a heat treatment.
With electricity and water for rheumatism
Even a current treatment, the so-called electrical stimulation with alternating currents and direct currents can be supportive in rheumatoid arthritis, to relieve pain. While high-frequency applications are in principle equivalent to a deep-action heat treatment, lower frequencies have an analgesic and circulation-promoting effect. In people with a pacemaker or metal implants, this therapy should be limited or possibly not performed at all.
A so-called balneotherapy or hydrotherapy is a fairly old method of treatment for the treatment of rheumatic diseases. The goal of this therapy is to strengthen the muscles, to release muscle tension and to improve the general condition of the affected person. By relieving the joints in the water, certain exercises can be performed easily and thus the muscles and joints are gently strengthened. The heat promotes blood circulation. In addition, this treatment ensures relaxation and thus has a positive influence on well-being.
Occupational therapy can also contribute to living an active and independent life both at home and at work with rheumatoid arthritis. In the process, the handling of walking aids and aids is trained. Also, measures are discussed to protect the joints as much as possible.
Diseases not only affect the body but also the soul. Above all, people who have little social contact or are prone to depression can have great difficulty coping with their suffering. Relaxation and pain relief techniques can help you find your way through everyday life. In addition, many clinics, in collaboration with physiotherapists, psychologists, rheumatologists, orthopedists and social workers, offer patient trainings and self-help groups in which affected persons can find out about and exchange information on various topics.
Alternative and herbal remedies
In addition to the drug treatment many people with rheumatic diseases also use alternative healing methods such. Homeopathy, Naturopathy or Traditional Chinese Medicine. Thus, e.g. the acupuncture or acupressure in many sufferers show a good effect.
In naturopathy is known that the devil's claw has been used for many centuries for the treatment of rheumatic diseases. Investigations could prove an analgesic and anti-inflammatory effect. Also anti-inflammatory and pain-relieving potential, for example, the stinging nettle, the cat's claw and the ginger awarded.
For many sufferers of rheumatic diseases, Tai Chi can also help ease pain and improve mobility. Tai Chi is a Chinese martial art that involves gentle flowing movements and meditation, as well as certain breathing techniques.
Diet and habits
Although there is no specific diet for the treatment of rheumatoid arthritis, it is known that foods rich in so-called antioxidants can relieve inflammation. Also, studies have shown that foods containing high levels of omega-3 fatty acids may be effective in reducing pain and morning stiffness. An example of this is the so-called eicospentaenoic acid (EPA), which inhibits the action of arachidonic acid in the body. As a result, fewer pro-inflammatory substances can be formed.
A lower intake of arachidonic acid can also be achieved by a low-meat diet, since larger amounts of this substance are contained in the meat. In addition, a calcium-rich diet is recommended to prevent osteoporosis.
In addition, overweight and overweight can be reduced through a healthy and balanced diet, and weight reduction also has a positive effect on the joints.
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Operative treatment options
In many cases, operative measures are never needed. However, in the case of a severe course of surgery, the pain can sometimes be alleviated and the mobility of joints significantly improved. However, before an OR is seriously recovered, the objectives of such treatment and general health should be discussed in detail with the family doctor and specialist.
Various operational methods can be used, which are briefly presented below.
The synovial membrane is a kind of inner skin of the joint capsule. Removal of the enlarged synovial membrane (synovectomy) can provide relief for many sufferers. However, the success usually does not last long. An exception is the wrist, where treatment is recommended if synovial membrane synovitis is unsuccessful despite 6-12 months of medication.
With strong accumulations of joint fluid, a joint puncture can provide relief.
Arthroplasty, in simple terms, is the removal of the painful articular cartilage and then the surgical lining with replacement tissue to absorb the pressure. Such joint resections in well-functioning ligaments but destroyed articular surfaces can be promising, especially on the finger base joints, wrists and elbow. An intervention on supporting joints, such as e.g. hips or knees are not recommended due to the high stress they are subjected to.
A joint replacement can allow for pain-free movements again with heavy wear. In this procedure, either only the condyle or the socket is replaced by prostheses made of metal, ceramic, titanium or polyethylene. Note the condition of the bones in this operation. If these are already severely damaged or brittle, the success of the treatment may be impaired.
Today's treatment methods allow many people with rheumatoid arthritis to live a normal life and maintain a good quality of life. With the help of medicines and other suitable treatment methods, all the activities of everyday life can be mastered so well in the long term.
Nevertheless, it is very difficult to predict the course for each individual, since the development of rheumatoid arthritis has not yet been sufficiently researched. While some sufferers experience a severe chronic course with many episodes, on the other hand there are people whose course is characterized by long periods of relapses and / or symptoms with few complications. Factors influencing the prognosis
Although the course can not be predicted, there are still some factors that may indicate a mild or severe course. For example, It is known that an early onset of therapy within the first three months after onset of the disease favors a positive course. It is also possible to observe a better prognosis in people who do not smoke, eat healthily, and regularly take their medication. Rheumatoid patients who do not quit smoking, however, have a statistically less favorable prognosis.
The presence of anti-CCP autoantibodies in the blood or the onset of the disease in young adults can lead to a more aggressive disease. However, this does not apply to Juvenile Rheumatoid Arthritis, which occurs in childhood.
So a good prognosis can promote bottom line in that one pays attention to his diet and weight, quit smoking, regularly taking the drug and adheres to the treatment plan. Exercising is also very important to maintain flexibility.
Author: Dr. Julia Spengler
- Arthritis Research UK:
- Johns Hopkins Division of Rheumatology:
- Kavuncu and Evcik, Physiotherapy in Rheumatoid Arthritis, MedGenMed 2004:
- Arthritis Foundation: