Rheumatoid Arthritis – Signs & Symptoms
Patients with rheumatoid arthritis typically start noticing symptoms that are very gradual in onset. So it’s not like an explosive onset where one day they have multiple tender, swollen joints and they cannot move. That can happen, it’s very unusual. But in most patients what they are experiencing is when they wake up in the mornings they’re not able to jump out of the bed like they could do before. In fact, they’re somewhat stiff. They get to the side of the bed, they walk to the bathroom, they feel like theirjoints are not well-oiled.
Some people describe it as feeling like a tin man and that the sense of stiffness of the joints actually gets better with activity and movement. So patients may feel that by the time I’ve taken a hot shower I feel really well. They may not think much about it and then kind of go on. But then what may happen is that they’re experiencing this day in and day out, and that might be the first trigger for them, what’s happening to me in the mornings? Some of the other symptoms that they may experience is that their jointscan actually be painful and they may actually see visible evidence of swelling. Many women may say you know, I cannot wear that ring anymore, or the ring that I’m wearing is tight on me, particularly in the mornings.
By the evenings my rings are loose on my fingers again, or I can put them back on, but they become tight again in the mornings. So remember that symptoms of rheumatoid arthritis are worse in the mornings, they improve as the day goes on, improve with a hot shower, improve with activity. Now, this is the typical presentation of rheumatoid arthritis. But there are patients who can have an atypical presentation where the onset can be relatively abrupt, explosive, where they’re fine a week ago and then within a week they are struggling with activities of daily living. Again pain, stiffness, swelling, small joints of hands, wrists, shoulders can be involved, the involvement of ankles and feet.
And again, remember what we mentioned about was fatigue can be a prominent part of this presentation. Stiffness can be a prominent part of this presentation. When you have inflammation, patients often have sleep disturbance so they may not sleep well. They may feel as if they have almost like a flu-like illness. All of these symptoms can be the beginning of the presentation of rheumatoid arthritis. (gentle music) Once we have our patients in remission or low disease activity, our patients are doing well. On a daily basis they may have minimal symptoms, they may have minimal stiffness, but really they’re notstruggling with their disease. But often during this period when the patients are doing very well, they may start experiencing increased disease activity. We call that a flare. A flare is described in many different ways by different patients, but typically what they’re experiencing isincreased disease activity.
That can be manifested as worsening fatigue in the mornings or throughout the day, worsening stiffness particularly in the mornings, increased joint pain, swelling, difficulty with activitiesof daily living. Some patients may experience a flu-like illness, low-grade fevers, they just don’t feel well, their energy levels drop, and that is a typical description of a flare for most patients. Many patients also experience fragmented sleep or poor sleep, they tell us that they don’t sleep well during the flare. In some patients the depression and anxiety part really kicks in during these episodes.
So yes, unfortunately, thecourse of rheumatoid arthritis can be punctuated by these periods of increased disease activity. (gentle music) This can often be triggeredby some change in medications or by medication non-compliance, or sometimes it can be triggered by increased stress in people’s life. Sometimes trauma or somekind of physical stress can also trigger flares. So patients will give us a sense of different things that can trigger aflare, but I can tell you that stress is the one thing that I often hear the most. The flares can punctuate the disease and then there’s a specific way we take care of flares. We can often increase some of the medications such as nonsteroidal anti-inflammatory medications, or we can give a short course of prednisone. Often we ask the patientsto rest more during a flare, to pace out their lifeso that if they really cannot achieve five things in a day maybe they can prioritize and do that one thing thatthey really need to do. Many of my patients tellme that when they rest they definitely feel that they can handle their flare better.
So yes, is flare a part ofliving with rheumatoid arthritis? I would say it is. Unfortunately, it can be unpredictable. Sometimes it comes from nowhere and this can be a very frustrating thing for the patients to live with. But I would say when you livewith rheumatoid arthritis and you learn to liveand manage your flares, patients can often self-management of these things. They can sometimes predict that because they’re going through a difficult time, they may have a little flare, and then they can self-manage some of their joint symptoms. But again, our goal as rheumatologists will always be for our patients not to experience any flare.
So if one of my patients is experiencing many flares within a short period of time, this is a very good time for me to sit down and evaluate whether the medications are working or not, whether I need to change medication or add more medications. So I think with that approach, even though at this point ourpatients do live with flares, I think the frequency of flares can really reduce them, we can reduce the intensity of flares so they are really notstruggling that much and we can help patients kind of self-manage some of this and reach out to their physicians when they feel that there needs to be a discussion about changing therapy, and if they feel that the medications are not working as well. (gentle music)