The combination of diet, exercise, alternative and conventional therapies ease the crippling effects of rheumatoid arthritis

Unlike the more common osteoarthritis, which is caused by damage to the cartilage of the joints, rheumatoid arthritis (RA) occurs when the body's immune system turns against itself, damaging joints and other organs. RA often occurs in a symmetrical pattern, meaning that if one knee or hand is involved, the other one is too. Typically the joints affected include the wrist and finer joints closest to the hand, with inflammation causing warmth, redness, swelling and pain.

The continuous inflammation associated with RA gradually destroys the cartilage that coats the end of the bones. This narrows the joint space and eventually damages bone. The surrounding muscles, ligaments and tendons that support and stabilise the joint also become weak and unable to work normally.

RA affects three in every 100 people in the UK. Women are commonly more affected than men, and the age of onset is 30-50 years of age. However, it can affect any age, including children.

What are the symptoms? Typical symptoms include:

• Tender, warm and swollen joints
• Joint inflammation, often affecting the wrist and finger joints closest to the hand (neck, shoulder, elbow, hip, knee, ankle and foot joints can also be involved)
• Fatigue
• Anaemia
• Occasional fever
• A general sense of malaise
• Pain and stiffness lasting for more than 30 minutes in the morning or after a long rest
• Rheumatoid nodules (bumps under the skin - often formed close to the joints - that affect about a quarter of those with RA) If you have any of these symptoms, you should visit a doctor.

The disease can affect more than just the joints, bones and surrounding muscle. About a quarter of those with RA develop rheumatoid nodules. These bumps under the skin often form close to the joints. Many people with rheumatoid arthritis develop anaemia.

Other effects, which occur less often, include neck pain and dry eyes and mouth. Very rarely, RA results in inflammation of the blood vessels, the lining of the lungs or the sac enclosing the heart. If you have RA, you may also be at increased risk for infections and gastrointestinal problems.

What causes it?
Although no one knows the precise causes of rheumatoid arthritis, it seems to develop as a result of an interaction of several factors, including genetics, environment and hormones. It does not run in families. Certain genes that are involved in the immune system are associated with a tendency to develop the disease, although there is no single 'rheumatoid arthritis gene.' Researchers think that something must happen to trigger the disease process in people who are genetically susceptible. The trigger is likely an infectious agent such as a virus or bacterium, but so far RA 'bugs' have eluded detection. However, it is not contagious.

Hormonal changes have also been proposed as culprits. These hormones, or possibly deficiencies or changes in certain hormones, may promote the development of RA in a genetically susceptible person who has been exposed to a triggering agent from the environment.

Contributing factors
Cold, wet weather may be a trigger for RA if you are already genetically predisposed. Rheumatologists claim that about two-thirds of people with RA begin their disease in the winter. Some people notice their arthritis gets worse when there is a sudden change in the weather. However, there is no evidence that a specific climate can prevent or reduce the effects. Moving to a different climate usually does not make a long-term difference to a person's rheumatoid arthritis.

How is it diagnosed?
Rheumatoid arthritis can be difficult to diagnose in its initial stages, but an early diagnosis can be crucial to limiting its progress and severity. Some studies indicate that rheumatoid arthritis causes the most joint damage in the first two years.

There is no single test to determine if you have RA. The symptoms are often similar to those of other types of arthritis and joint conditions. The types of symptoms you experience - and the severity - may differ markedly from those of another person with RA. To make matters more confusing, symptoms can vary in the same person: symptoms develop over time, and only a few of them may be present in the early stages.

Often, RA is diagnosed by recognising the type and pattern of joint involvement (if the same areas are affected symmetrically on both sides of the body, for example); this is a hallmark of RA and referred to as the 'clinical history.'

Blood tests
Some lab tests can help establish the presence of RA, and your doctor will probably order a test to detect the rheumatoid factor, which is an antibody eventually present in the blood of most rheumatoid arthritis patients. It's inconclusive, though, since not all people with rheumatoid arthritis test positive for the rheumatoid factor, especially in the early stages. You could also test positive and never develop the disease.

Other common tests include one for reactive protein or plasma viscosity, which indicates the presence of inflammation in the body, plus a white blood cell count and a blood test for anaemia, which is present in 80 per cent of cases. Your doctor may want to have X-rays taken, as these can help determine the extent of joint destruction.

How is it treated?
Treating rheumatoid arthritis really means relieving symptoms and slowing the disease's progress. Although there is no cure, you and your doctor can develop strategies for managing the disease. You'll probably use a variety of approaches, but all have the same basic goals: relieving pain, reducing inflammation, slowing down or even stopping joint damage and improving your ability to function.

Your treatment plan will most likely include drugs to relieve pain and/or reduce inflammation, with a rheumatologist and a GP governing the treatment plan but including other health carers, particularly a physiotherapist and occupational therapist.

Although there is no cure, disease-modifying anti-rheumatic drugs (DMARD) may slow the course of the disease. In the past, doctors often hesitated to prescribe strong drugs until the disease had become relatively advanced. But this approach is changing, especially for those who suffer from severe, rapidly progressing rheumatoid arthritis. The use of drug combinations may be the best way to halt RA's progression and reduce or prevent joint damage.

Drug treatments include non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen and naproxen, help diminish pain, swelling and inflammation. Side effects can include stomach upset, ulcers, increased tendency to bruise, fluid retention (except aspirin) and, in rare cases, liver and kidney damage. You should have periodic blood tests if you remain on NSAIDs for an extended period of time.

Two relatively new NSAIDs are targeted more directly at neutralising an enzyme called COX-2, which triggers pain and inflammation, while sparing an enzyme called COX-1, which helps maintain the normal stomach lining. The pills are celebrex, which is approved for both osteoarthritis and rheumatoid arthritis, and vioxx, approved for osteoarthritis, acute pain and menstrual pain.

These drugs come with the same potential side effects but they may be less than those of other NSAIDs. They are only recommended for UK patients who are intolerant of other NSAIDs, or if they have a history of gastro-intestinal bleeding.

DMARDs are used to alter the course of the disease and prevent joint and cartilage destruction. They can produce significant results, but no one is sure exactly how they work. You may need to wait weeks - perhaps even months - before seeing any effect, and you may use some or all of the drugs, depending on the specifics of your condition.

DMARDs include gold salts, traditionally given by injection but now available in tablet form. Antimalarials (such as hydroxychloroquine) can also be used, as can penicillamine, which has been prescribed for over 50 years and is taken by mouth. Sulfasalazine, a drug distantly related to the antibiotic penicillin (also taken by mouth) may be helpful.

Pay attention to how your body responds to these drugs. Not only do you need to make sure the medications are effective (efficacy may diminish over time), but you need to be alert to any problems arising from the drugs.

Gold salts can cause skin rash, mouth sores, upset stomach, kidney problems and low blood count. Antimalarials are associated with upset stomach and - in rare instances - eye problems, and sulfasalazine can also cause an upset stomach.

Immunosuppressants drugs are DMARDs used to restrain the overly active immune system that causes RA. This class of drugs includes methotrexate, azathioprine, ciclosporin and cyclophosphamide. These drugs can be effective, but they also can prove extremely toxic and often have severe side effects ranging from upset stomach, potential liver problems, low white blood-cell count and increased cancer risk.

Arava (leflunomide) is a recently approved DMARD for treating active RA, and it reduces the signs and symptoms of RA in about 40-50 per cent of patients. Side effects include diarrhoea, elevated liver enzymes, alopecia (hair loss), rash and bone marrow toxicity.

Corticosteroids such as prednisone and methylprednisolone have both anti-inflammatory and immunosuppressive properties. Since they can effect dramatic improvements in a very short time, doctors often use them while waiting for DMARDs to kick in. They may be an option if your RA doesn't respond to NSAIDs and DMARDs. These medications also have serious side effects, especially at high doses, including osteoporosis, mood shifts, fragile easily bruised skin, fluid retention and weight gain, muscle weakness, onset or worsening of diabetes, cataracts and increased risk of infection.

Biological alternatives
Two new biologic response modifiers to be used under specialist supervision include enbrel or etanercept - a genetically engineered protein that helps reduce the symptoms of severe RA in adult patients who have not responded well to other treatments.

Remicade has been approved for use in combination with methotrexate to treat RA patients who have had inadequate response to methotrexate alone. This drug, which improves signs and symptoms in about 50 per cent of patients, must be given intravenously. Patients usually receive eight infusions the first year and six thereafter. Potential side effects include upper respiratory tract infections, headache, nausea, sinusitis, rash and cough.

Surgical options
Surgery may be an option if you have severe joint damage. In the right circumstance it can help reduce pain, improve the affected joint's function and appearance, and enhance your ability to perform daily activities. However, it is not the right course of action for everyone. The most common type of surgery is joint replacement. One thing to consider is that the artificial joints can wear out, necessitating additional surgery.

Tendon reconstruction, most frequently performed on the hands, reconstructs the damaged tendon by attaching an intact tendon to it. It can restore some hand function, particularly if it is performed before the tendon is completely ruptured.

In synovectomy, the inflamed synovial tissue is removed. As a stand-alone procedure, synovectomy has become less common in recent years, since not all of the tissue can be removed and the removed tissue eventually grows back. However, it is often part of reconstructive surgery.

Support therapies
While doctors must be involved in your care, there are a number of lifestyle changes you can make to help manage RA. Experts suggest that eating a healthy diet can enhance your overall health and thus help you better manage the condition. Avoiding alcoholic beverages may be necessary, depending on the RA medications you are taking, especially the often-prescribed methotrexate. Check with your doctor. Stress reduction is also important, since your stress level may affect the amount of pain you feel.

When symptoms do occur, you can take steps to lessen their severity. Protecting your joints from undue stress can help. You may find that using a splint around a painful joint (generally wrists and hands) helps reduce pain and swelling. The splint supports the joint and lets it rest. Your doctor can help you obtain a properly fitting splint.

Self-help
You may want to talk to an occupational therapist about self-help devices that can help reduce stress on the joints while you participate in everyday activities. Zip pullers, long-handled shoehorns and products that help you get on and off chairs, toilet seats and beds can all ease the strain on your joints.

Exercise and rest are both important to your health. When your RA is active, you will want more rest, but remember that exercise is critical to healthy muscles, joint mobility and flexibility. Exercise may seem unappealing if you're experiencing frequent pain, but there are a number of techniques to help you get through a programme, usually under the guidance of a physiotherapist. These include:

• Moist heat supplied by warm towels, hot packs, a bath or a shower can be used at home for 15-20 minutes three times a day to relieve symptoms. Applying heat before exercise can be a good way to start. A physiotherapist can apply deep heat using short waves, microwaves and ultrasound to relieve non-inflamed joints.

• Cold supplied by a bag of ice or frozen peas wrapped in a towel helps to stop pain and reduce swelling when used for 10-15 minutes at a time. It is often used for acutely inflamed joints.

• Hydrotherapy (water therapy) can decrease pain and stiffness. Exercising in a large pool may be easier because water takes some weight off painful joints. Most hospital physiotherapy departments will have a specialist hydrotherapy pool. Some patients also find relief from the heat and movement provided by a jacuzzi.

• Mobilisation therapies include traction (gentle, steady pulling), massage and manipulation (using the hands to restore normal movement to stiff joints). When done by a trained physiotherapist, these methods can help control pain and increase joint motion and muscle/tendon flexibility.

• TENS (transcutaneous electrical nerve stimulation) may also provide some pain relief. Patients can wear a TENS device during the day and turn them on and off as needed for pain control.

• Relaxation therapy also helps to reduce pain. You can learn to release the tension in muscles to relieve pain, and physiotherapists can teach relaxation techniques.

• Glucosamine is being hailed as the latest alternative supplement. It is a naturally occurring form of glucose that keeps joints healthy and has none of the side-effects of conventional DMARDs.

• Acupuncture is a traditional Chinese method of pain relief. A medically qualified acupuncturist places needles in certain sites on the body. Researchers believe that the needles stimulate deep sensory nerves that tell the brain to release natural painkillers (endorphins). Acupressure is similar to acupuncture, but pressure is applied to the acupuncture sites instead of using needles.