Rheumatoid arthritis (RA) is a chronic inflammatory disease that causes pain, stiffness, and swelling around the joints. RA is often confused with osteoarthritis, which is a condition of wear and tear on the joints.

RA is not a condition of wear and tear that occurs with aging or injury. It is a disease known as an "autoimmune" disease in which your own immune system mistakenly attacks healthy tissue, causing inflammation that damages your joints. Normally, the immune system fights against infections and keeps a person’s body healthy. However, in the case of RA, the immune system attacks cells in the joints, causing pain and swelling. Over time, people with RA often find that their joints are stiff and do not move properly, causing them considerable pain and discomfort.

WHAT CAUSES RHEUMATOID ARTHRITIS RA?
Scientists and doctors do not know why people develop rheumatoid arthritis (RA). However, researchers are learning more every day. The latest scientific findings suggest that RA may be caused by a combination of genetic, environmental, or hormonal factors.

Genetic Factors: One interesting theory is that the tendency to develop RA is genetic, which means that it runs in families. In one study of identical twins, when one twin has RA, up to 30% of the second twins will develop RA in the future. Researchers have found that the tendency to develop RA is related to specific genes. However, not all people who have these genes will develop RA, and people who do not have these genes can still develop the condition. These findings suggest that other factors also play an important role in the development of RA. Environmental Factors: Another theory is that RA is caused by environmental factors, such as exposure to bacteria or a particular diet that may occur naturally in certain locations. For example, some scientists have found that patients with RA are more likely than those without it to have been exposed to a bacterium called Proteus mirabilis. Other bacterial or viral infections also may trigger RA.

Researchers also have discovered that some autoimmune diseases, like RA, are more common in certain areas of the world. For example, scientists have suggested that environmental factors, such as not being able to get enough vitamin D, may be part of the reason that people living in Scandinavian countries are more likely to develop diabetes and arthritis. While theories such as this warrant further research, the cause of RA remains unknown.

Hormonal Factors: A third theory is that RA may be affected by hormones. Researchers have found that hormones, like estrogen and progesterone, increase during pregnancy but decrease afterward. This may explain why onset of RA often occurs following child birth or why women with RA who become pregnant often experience significant symptom improvement during pregnancy but have flare ups of RA once they have given birth.

RECOGNIZING THE SYMPTOMS
There are a few simple things that people can do to see if they might have rheumatoid arthritis (RA). However, to get an early diagnosis, it is important to talk to a rheumatologist, a physician who specializes in the treatment of arthritis. A primary care physician can provide a referral to a rheumatologist.

People with RA have joints that are tender, warm, and swollen. This occurs in a "symmetrical" pattern, meaning that if the left knee is affected, the right knee also is affected. RA often affects the wrist and finger joints closest to the hand, but neck, shoulders, elbows, hips, knees, ankles, and feet also may be affected. Other symptoms include pain or stiffness lasting for more than 30 minutes in the morning or after long rest and lack of activity. Patients with RA also may experience fatigue, an occasional fever, or a general sense of not feeling well.

HOW IT OPERATES
The joint pain and inflammation of rheumatoid arthritis (RA) begins when white blood cells, which are a part of the immune system responsible for fighting infection, accumulate in the synovial (sin o’ vee uhl) tissue. The synovium is a layer of cells that lines the joints and produces synovial fluid, which is a clear fluid that nourishes and lubricates the cartilage and bone in the joint. The white blood cells produce cytokines (site’ o kynes), which experts have described as "the messenger molecules of the immune system." Cytokines can cause inflammation, which can result in pain and swelling, which is a normal healthy process when your body has an infection but is inappropriate when no infection exists. They also attract other immune cells and cause the production of excess synovial fluid.

Researchers at the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) have suggested that an imbalance between cytokines that promote inflammation and those that perform healthy functions within the immune system play a key role in the development of many autoimmune diseases. In RA, several cytokines, including tumor necrosis factor-á, interleukin-1, and interleukin-8, appear to contribute to the ongoing destruction of cartilage, bone, and other joint-related tissues.

ENTERING A NEW ERA OF DISCOVERY AND TREATMENT
Scientists have advanced their understanding of the process of rheumatoid arthritis (RA), and this knowledge has led to the successful development of medicines that slow or inhibit joint damage. According to leading scientists J. Bruce Smith, MD, and Mark Haynes, PhD, "the newer treatments represent the 'tip of the iceberg,' and as our basic knowledge increases, so too, will the armamentarium [the complete range of weapons] with which we can fight rheumatoid arthritis and other similar autoimmune diseases."

Richard Shirley is but one example of how this continuing research is helping patients with RA. After receiving a biologic DMARD (disease-modifying antirheumatic drug), he reports "I am doing better now than I have in many years." He also finds that he has dramatically less pain, is able to walk long distances, and can do light housework and minor repairs around the house. As he said so simply, "I enjoy my life."

QUESTIONS TO ASK YOUR DOCTOR

1. Do I have arthritis?
2. What type of arthritis do I have?
3. What is happening to my body as a result of my arthritis?
4. What are my options to relieve pain? (exercise, medication, alternative therapies?)
5. What medications might slow down the rate at which my disease worsens?
6. Can a blood test help determine what type of arthritis I have?
7. Can an X-ray show if my disease is getting worse?

GETTING DIAGNOSED PROPERLY

There is no single test that doctors can use to determine if someone has rheumatoid arthritis (RA). Experts recommend that doctors perform several tests to accurately diagnose RA. In fact, the American College of Rheumatology (ACR) has developed guidelines for diagnosing RA. The ACR guidelines have been reviewed by rheumatologists (specialists), primary care providers who practice rheumatology, and other health care professionals. According to these experts, a doctor may do all or some of the following to diagnose RA:

• Ask the patient about the amount of joint pain they have, which joints are affected, how long any fatigue or morning stiffness lasts, and if they have problems completing everyday activities like housework or exercise
• Perform a physical examination to count how many joints are tender or swollen and to evaluate mechanical joint problems, such as loss of motion and/or deformity
• Perform blood tests for signs of RA
• Take X-rays of selected joints that appear to be affected by RA

The ACR guidelines also suggest that additional tests be performed to assess liver function and evaluate overall health before beginning treatment for RA and to monitor disease progression as treatment continues over time.

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