Rheumatoid arthritis is an autoimmune disease that attacks the joints, causing them to become red, swollen, stiff and painful. Over time, the condition worsens leading to damage to the joint, cartilage and surrounding bone. It can also lead to complications such as carpel tunnel syndrome, cardiovascular disease and cervical myelopathy.
The disease can be triggered by a number of factors, such as following on from an infection or trauma. My mother was diagnosed with it in her early 30s, after a fall from her bike lead to tearing a ligament and damaging the cartilage in her knee.
Just to make things more interesting, she was also diagnosed with osteoarthritis about 10 years ago. Like rheumatoid arthritis, this condition can also cause joints to become stiff, swollen and painful, but the cause is different. In fact, it’s not clear why it happens, only that it is more likely to develop, for example, in people who are older, obese, have had a joint injury in the past or have other conditions (such as rheumatoid arthritis).
I’ve watched my mother becoming less mobile over the years and seen how her condition impacts on the quality of her life. She can no longer knit, as her hands are now too gnarled and twisted, she can walk outside only with the aid of a rollator, and she had to have hip replacement surgery in her early 50s. To celebrate Rheumatoid Arthritis Awareness week, the ISRCTN registry and Arthritis Research and Therapy journal have teamed up to explore just some of the research being done to help people like my mum.
Early birds get to feel better
It is important to diagnose and start treating rheumatoid arthritis as soon as possible, as this may help prevent the condition from getting worse and reduce the likelihood of joint damage or complications.
For example, the results of the IMPROVED-study have recently been published, showing that early treatment with methotrexate and prednisone resulted in almost 50% of patients being in remission after two years and a further 21% not needing any drug treatment at all. Another recent study, registered with the ISRCTN registry, has been investigating whether a web-based monitoring system for recently diagnosed rheumatoid arthritis is an effective way of controlling the disease, the system allowing doctors to manage their patients’ condition remotely.
It is important to diagnose and start treating rheumatoid arthritis as soon as possible.
Unfortunately, by the time symptoms occur, osteoarthritis is already at an advanced stage; the disease itself having developed silently over many years. However, this provides a significant window of opportunity to treat joint problems before osteoarthritis becomes too severe. For example, Arthritis Research and Therapy published a paper back in 2012 that described advances in imaging and biochemical biomarkers and how they can be used to aid early diagnosis and treatment of pre-osteoarthritic conditions. And an ongoing study is looking at whether a seven day inpatient multidisciplinary rehabilitation program involving group exercise classes, individually tailored exercise programmes, and one-to-one physiotherapy sessions will lead to an improvement in pre-arthritic hip pain and hip joint function among young UK military personnel.
It’s not all about pain killers
Drug treatments for arthritis can be split into two main groups – those that treat the symptoms (such as pain) and those that help to reduce the root cause – the inflammation.
Disease-modifying antirheumatic drugs (DMARDS) are commonly used to treat patients with rheumatoid arthritis. They include rituximab, etanercept, and tocilizumab; they all work in different ways to reduce inflammation of the joints. Currently, patients are treated with these drugs on a trial and error basis to see which works best. The STRAP study, however, is investigating whether examining the joint (synovial) tissue can predict which DMARD individual patients are most likely to respond to.
Over time, osteoarthritis causes damage to cartilage, a connective tissue that covers the surface of the bone and allows the joints to move easily. This cartilage becomes progressively more damaged and may become thin or completely worn away. Over time, this can place the bone under increasing stress, leading to a stress fracture; these show up as soft spots, or lesions, with the bone marrow. Strontium ranelate is a drug that inhibits the activity of osteoclasts, cells that break down bone tissue while increasing the activity of osteoblasts, cells that make new bone tissue. Results of a study comparing strontium ranelate to a placebo was published last year, which showed that it can reduce the amount of cartilage lost and bone marrow lesions in patients suffering from osteoarthritis.
Brace-up: feet are made for walking
About 90% of people with rheumatoid arthritis have problems with their feet. These range from a general soreness and swelling, to serious damage to the joints and changes to the shape of the foot. My mother’s feet have been so badly affected, she has had to have three operations to try and relieve the symptoms.
About 90% of people with rheumatoid arthritis have problems with their feet.
Thankfully, not every patient is faced with such drastic measures. Feet orthoses, in-shoe braces designed to support the feet and improve posture, can be used to help rheumatoid arthritis sufferers with foot problems. Researchers from the University of East London are looking at whether an off-the-shelf foot orthosis can be as effective at alleviating foot pain for people who have been diagnosed with rheumatoid arthritis as a specially customized foot orthosis.
Going under the knife
Unfortunately, both rheumatoid arthritis and osteoarthritis often cause such severe damage to joints that surgery is required, for example, hip or knee replacement surgery.
A hip replacement involves removal of the damaged hip joint and femur. An artificial socket is then fitted into the hollow of the pelvis and a short metal shaft (or stem) inserted into the thigh bone. Unfortunately, around one in ten hip replacements fail, often due to the stem becoming loose within the thigh bone. University College London Hospital is currently assessing the stability of two different types of hip replacement stems using radiostereometric analysis, a highly accurate, 3D method of looking at whether there has been a loosening of the artificial joint.
There are two main types of knee replacement surgery; total knee replacement, where the entire joint is replaced with an artificial one and partial (half) knee replacement, where only half of the joint is replaced. The lower part (tibial component) of an artificial knee joint is usually a flat, metal platform with a cushion made from polyethene (plastic) laid on the top of the tibia (shinbone). Some designs, however, don’t use a metal platform, using an all-polyethene tibial component instead. This study is comparing a total knee replacement with a metal-backed tibia component with one that has an all-polyethylene tibia component.
Ending on a personal note
When I asked Mum about how arthritis affects her she said: “It can be very frustrating not to do things that you want to, but you have to adjust and live with it”.
“It can be very frustrating not to do things that you want to, but you have to adjust and live with it”.
Happily, thanks to some drug and lifestyle changes (losing weight and doing gentle exercise), her mobility issues have recently improved. And, hopefully, with increasing awareness of the condition and further research, sufferers like her won’t have to “live with” the effects of arthritis in the future. Perhaps some won’t have to stop knitting cardigans for their family.