Rheumatoid arthritis – NHS

Rheumatoid arthritis is a long-term condition that causes pain, swelling and stiffness in the joints. The condition usually affects the hands, feet and wrists.

There may be periods where symptoms become worse, known as flare-ups or flares.

A flare can be difficult to predict, but with treatment it’s possible to decrease the number of flares and minimise or prevent long-term damage to the joints.

Some people with rheumatoid arthritis also experience problems in other parts of the body, or more general symptoms such as tiredness and weight loss.

Find out more about the symptoms of rheumatoid arthritis.

Information:

Coronavirus (COVID-19) advice

If you have rheumatoid arthritis and you’re worried about COVID-19, you can get advice about:

When to get medical advice

See a GP if you think you have symptoms of rheumatoid arthritis, so they can try to identify the underlying cause.

Diagnosing rheumatoid arthritis quickly is important, because early treatment can prevent it getting worse and reduce the risk of joint damage.

Find out more about diagnosing rheumatoid arthritis.

Causes of rheumatoid arthritis

Rheumatoid arthritis is an autoimmune disease. This means your immune system (which usually fights infection) attacks the cells that line your joints by mistake, making the joints swollen, stiff and painful.

Over time, this can damage the joints, cartilage and nearby bone.

It’s not clear what triggers this problem with the immune system, although you’re at an increased risk if:

• you are a woman
• you have a family history of rheumatoid arthritis
• you smoke

Find out more about the causes of rheumatoid arthritis.

Treating rheumatoid arthritis

There’s no cure for rheumatoid arthritis. However, early diagnosis and appropriate treatment enables many people with the condition to have periods of months or even years between flares. This can help them to lead full lives and continue regular employment.

The main treatment options include:

• medicine that is taken long term to relieve symptoms and slow the progress of the condition
• supportive treatments, such as physiotherapy and occupational therapy, to help keep you mobile and manage any problems you have with daily activities
• surgery to correct any joint problems that develop

Find out more about treating rheumatoid arthritis.

Depending on how much pain, stiffness or joint damage you have, daily tasks may become difficult or take you longer to do. You may have to adapt the way you do everyday tasks.

Find out more about living with rheumatoid arthritis.

Complications of rheumatoid arthritis

Having rheumatoid arthritis can lead to several other conditions that may cause additional symptoms and can sometimes be life threatening.

Possible complications include:

Making sure that rheumatoid arthritis is well controlled can help to reduce your risk of these complications.

Find out more about complications of rheumatoid arthritis.

Video: rheumatoid arthritis

In this video, a rheumatologist describes the effects of rheumatoid arthritis and the symptoms and treatments.

Media last reviewed: 21 April 2020
Media review due: 21 April 2023

Page last reviewed: 28 August 2019
Next review due: 28 August 2022

What a Flare Feels Like and How to Treat It

You’re feeling good, barely thinking about your chronic pain, and then wham — an arthritis flare hits you like a Mack truck. These periods of increased disease activity take a toll on you physically and emotionally, especially because they can come on unexpectedly. If you’ve got either osteoarthritis or an inflammatory type of arthritis like rheumatoid arthritis, you probably know what we’re talking about.

So how can you deal with an arthritis flare-up when it happens? “I remind myself, ‘This, too, shall pass,’” arthritis patient Beth Bloomfield told us on Facebook. “Like a kidney stone!” another patient, Katie Resnick, joked back. Although arthritis flares are never pleasant, there are techniques that can help shorten their duration. Also important: Being able recognize when a flare is starting and avoid the triggers that may cause your flare-ups in the first place.

Symptoms of an Arthritis Flare

Joint pain

Osteoarthritis patients experience “joint pain, stiffness mostly associated with weather changes such as pressure change or cold, but usually no joint swelling,” says rheumatologist Nilanjana Bose, MD, an assistant professor at the University of Texas Medical Branch (UTMB) and a member of the American College of Rheumatology. Rheumatoid arthritis patients also experience joint pain and stiffness, as well as swelling.

Fatigue

“Fatigue can occur in the setting of flare in inflammatory arthritis, but not usually in osteoarthritis unless pain during the night is interfering with sleep,” says Dalit Ashany, MD, a rheumatologist at Hospital for Special Surgery.

Fever

In RA, “joint swelling is also associated with systemic symptoms like low-grade fevers,” Dr. Bose says. “The inflammatory cascade gets activated, including [immune system proteins called] cytokines, which leads to joint pain, swelling, and occasional systemic symptoms in severe flares.”

Causes of Arthritis Flares

Too much activity

You’re feeling good, so you overdo it, and then you end up with an arthritis flare. “Osteoarthritis often flares after overexertion of the joint or joints that are involved,” Dr. Ashany says. With OA, “unexpected activity can stress out the joints and surrounding tissues and cause pain,” Dr. Bose says. Too much activity can also lead to a flare in inflammatory arthritis patients, she notes.

Weather

“Pressure changes and humidity may play a role in exacerbating joint pain,” Dr. Bose says. If you live in a dry, hot climate, you may be less prone to the impacts of weather on your arthritis. “Patients with all types of arthritis, OA or inflammatory, often state that their joints are achier or even flare in cold or humid weather, although there is not a body of scientific data about this,” Dr. Ashany says.

Medical causes

Infections, such as respiratory viruses, can lead to flares as they affect the immune system. Medications for inflammatory arthritis, such as corticosteroids and biologics, can also make patients more vulnerable to infection; yet a “decrease in medication, either because of a deliberate reduction or patient non-compliance, can lead to flare,” Dr. Ashany says.

Stress

Although the exact mechanisms are unknown, “stress can also induce flares,” Dr. Bose says. It’s possible that stress may lead to the production of more pro-inflammatory cytokines. Try these self-care tips to minimize stress and flares.

Food

“There is no proof that a specific food causes arthritis flares, however if an individual clearly sees a relationship between a certain food and flare, then that may be relevant for that particular individual,” says Dr. Ashany. Dr. Bose advises, “I always recommend patients to avoid red meat and refined carbohydrates, which can be pro-inflammatory. Gluten can cause flares for certain patients.” Arthritis patient Anita Marie Poupa told us on Facebook that she avoids sugar, alcohol, and caffeine. Try these tips to cut out excess sugar.

Diagnosis and Treatment for Arthritis Flares

If you think you’re going through a flare that hasn’t improved after a couple of days, call your rheumatologist or primary care doctor. They will want to monitor how you feel and may want to order imaging and blood tests to see what’s going on. They can also prescribe medications to get the flare under control.

Physical tests

“The physical examination is important for determining flares,” Dr. Ashany says. “The physician will examine the patient for number of tender and swollen joints. Having more than you did at a prior visit suggests a flare.” In inflammatory arthritis, she says it’s also important that patients let her know if their current symptoms are typical of their previous flares.

Lab tests

In inflammatory arthritis, “some patients will have an elevation of inflammatory markers, such as ESR and/or CRP, during a flare,” Dr. Ashany says. “Other labs that can be altered during a flare are platelets which can become elevated or the blood count which can show anemia.” In osteoarthritis, laboratory markers are not usually altered, Dr. Bose says. Read more about the ESR, or sedimentation rate, blood test.

Common medications to treat arthritis flares

OA patients might just need some OTC pain-relieving medication such as acetaminophen, ibuprofen, or naproxen. Dr. Bose also recommends topical gels and lotions like diclofenac gel or 2 Old Goats. If that doesn’t work, Dr. Ashany says joint injections of steroids may be given. RA flares are more complicated. “In inflammatory arthritis, steroids are often used to try to quickly bring a flare under control,” Dr. Ashany says. If only one joint is involved a steroid (such as depomedrol) can be given by injection, but otherwise it can be taken orally (such as prednisone).

In inflammatory arthritis, “if flares continue to occur, this indicates that the patient’s regimen of maintenance medication is not adequate,” Dr. Ashany says. “This may lead to addition of a medication, switching one drug for another or increasing the dose of medication that the patient is currently taking.”

Tips on Coping with Arthritis Flares

Prepare ahead of time

Keep track of when your flares happen so you can learn to identify triggers. If you think, for example, that weather affects your flares, OA patients “need to prepare accordingly and use OTC pain meds,” Dr. Bose says. In addition, RA patients should stay compliant with their medication regimen. If you suspect your diet could be a culprit, monitor what foods you’re eating, says Karen Jacobs, EdD, OT, OTR, CPE, FAOTA, an occupational therapist who works with arthritis patients and a clinical professor at Boston University.

Have a plan for when flares inevitably occur. Jacobs says to arrange ahead of time with your employer to work from home or make other adjustments if needed. “An inflammatory arthritis patient will often, in time, have a sense of whether they are starting to flare,” Dr. Ashany says.

Get your rest

If you feel like you just can’t get anything done, don’t. “Rest is critical,” Jacobs says. “It might be at this point you put on your arthritis gloves and take a nap.” All the patients we talked to agreed that rest is their go-to flare fighter. “Resting, curling up with a good book or finding some comedies to watch on TV,” Brenda Kleinsasser said of her routine. Here are inspiring books that can help you cope with chronic illness.

Reduce stress

Stress can cause arthritis flares — and arthritis flares can cause stress. Learn to recognize what you can handle emotionally. “I like to just shut myself away from the world as I need all my energy getting through it,” arthritis patient Karen Nash said on Facebook. “If there is anyone around, I feel I need to pretend I am better than I am and hold a conversation, which is just too much.”

Jacobs advises stress reduction and relaxation techniques like deep breathing and meditation. “App stores have lots of great meditation apps,” she says. Try Headspace, The Mindfulness App or Calm to see which one works for you. Aromatherapy may also help.

Try heat and cold

“You might use hot or cold packs,” Jacobs says. The patients we talked to on Facebook use different kinds of temperature treatments, including ice, warm baths or showers, heating pads, paraffin wax for feet and hands, heated blankets, and hot tubs. Here are different ways to try heat therapy and different ways to try cold therapy.

Distract yourself

Mental techniques come in here as well: If you focus on the pain, it’s just going to hurt more. “Rest followed by light routine so as not dwell on the pain,” arthritis patient Amanda Edwards said on FB. “Knowing what is mine to handle.” Alex Woodward also told us: “Distraction: pain meds, PJ’s, chocolate, and laptop to either research an interesting or weird subject, or plan a road trip.”

Gentle exercise

Jacobs says that very gentle hand exercises could help reduce inflammation. If you can handle it, some light movement may make you feel better mentally and physically. Check with your doctor to see if low-impact tai chi or yoga are right for you.

Ask for help

“A lot of times we want to be these warriors and won’t reach out for people to help us, but think about what else people can do,” Jacobs says. Others might not know what you’re going through, and want to pitch in. “Speak up and communicate with family, friends, and doctors,” arthritis patient Michelle Grabarek told us on Facebook.

Call your doctor

Speaking of doctors, you may or may not need to reach out. If your symptoms are mild and go away quickly, you probably don’t need to. But, “there is no way to predict if a mild flare is going to turn into a severe flare,” says Dr. Ashany, who notes that a swollen, warm, and red joint should always lead to an immediate phone call, “as patients can also potentially develop an infected joint, which needs to be treated immediately.” If you have any questions, play it safe and call your doctor. “If a flare occurs, please contact your doctor so you can start treatment promptly if needed,” Dr. Bose says.

Keep Reading

Rheumatoid Arthritis Flares: Causes, Treatments, Prevention

For people with rheumatoid arthritis, it’s a given that flares will occur now and then. This means you’re likely to experience an increase or worsening of symptoms such as swelling and pain in certain joints as well as your hands and feet, along with fatigue, weakness, and stiffness in the morning. You probably realize that rheumatoid arthritis (RA) flares are physically and emotionally stressful, because they can take a toll on how you feel and function 24/7. But have you ever wondered why flares happen or what’s going on physiologically when they occur?

What Is a Flare?

Simply put, “flares” are episodes of increased disease activity. Because RA is an autoimmune disease, a flare basically means “the body is fighting itself more than usual,” says Stuart Kaplan, MD, the chief of rheumatology at South Nassau Communities Hospital in Oceanside, New York. “Antibody levels may go up, and markers of inflammation go up, too.”

Signs of a Rheumatoid Arthritis Flare

What’s more, “people with rheumatoid arthritis have different receptors on their immune cells — MHC receptors — which are more likely to bind to self-proteins,” explains Ashira Blazer, MD, a rheumatologist at New York University’s Langone Medical Center in New York City. “Environmental triggers can aggravate the immune system and cause these proteins to end up in the joint space, which can lead to inflammation and damage. Also, during a flare, antigens make their way into the joints, and when immune cells in the joints become activated, the linings of the joints become inflamed.” The result: Red, hot, tender, swollen joints — signs of a flare.

What Brings on a Flare?

Flares can be triggered by physical stress (such as infections, injuries, surgery, medication changes, or overexertion with exercise) or emotional stress (such as work pressure or family conflict). But sometimes they can seem to occur randomly, which may be particularly frustrating or alarming. “Rheumatoid arthritis flares can take a toll on a person’s family, work, social, and recreational life — that’s something that has to be appreciated, and patients need to have a plan for that,” Blazer says. Left untreated, flares can last for a couple of weeks; with treatment, they can ease up within a day or two.

Can Flares Be Prevented?

RA flares can happen randomly, so it’s unlikely you’ll be able to prevent every single one, but there are things you can do to reduce the likelihood of a flare. Maintain a nutritious diet, including plenty of vitamin D and omega-3 fatty acids — ask your doctor if you have questions about dietary supplements. Get regular exercise and plenty of sleep (at least 7 to 9 hours per night), and practice other good stress management skills, such as yoga or meditation.

Treatment for Flare-ups

When they do happen, pain from mild flares can often be treated with nonsteroidal anti-inflammatory drugs (NSAIDs like ibuprofen or naproxen), rest, hot or cold compresses, and gentle exercise. In addition, oral corticosteroids (such as prednisone) are often prescribed to quell the underlying inflammation and heightened immune response. “When someone with rheumatoid arthritis has a flare, it means there’s an uptick in the immune response — that needs to be treated quickly,” Blazer says.

Sometimes people try to wait out a flare to see if it spontaneously resolves, rather than increasing their medication dose or adding another one to their regimen. But that may not be the wisest approach for a major or prolonged flare, Kaplan says. In fact, intensifying treatment during flares may help prevent long-term functional disability and joint damage from RA, a result that outweighs the risk of potential overtreatment, according to a study published in the August 2015 issue of Arthritis Research & Therapy. “During a flare, it’s better to get treated sooner rather than later to get the upper hand on the flare and prevent damage to joints,” Kaplan says. Not only can this relieve your physical discomfort more quickly, but it can ease the psychological distress of a flare, too.

Medication Adjustments to Help Tame Flares

If a flare occurs while you’re taking a long-term disease-modifying agent, or DMARD, the dosage of the agent may need to be increased, or another drug such as a biologic agent can be added, says Carmen Gota, MD, staff physician in the department of rheumatology at the Cleveland Clinic, in Ohio. “In some cases, patients can experience flares while on a disease-modifying drug and a biologic agent, in which case a switch to a different biologic or disease-modifying drug is necessary.” A medication adjustment also may be in order if you’re prone to frequent flares. These realities highlight the importance of working closely with your doctor to manage RA.

Rheumatoid Arthritis, Osteoarthritis & Gout: What Causes Arthritis Flare-Ups

When you’re suffering from a painful condition like arthritis, you’re almost always looking for ways to keep your symptoms at bay.

We’ve all heard the old wives’ tale that when an achey joint is acting up it’s a sign that bad weather is on the way…but can it really be true that something like a change in weather can trigger your pain?

“It’s true — the symptoms of arthritis can recede and flare up. It’s also true that a change in weather can sometimes trigger a flare-up, which is often magnified when a certain type of arthritis is not being well-managed,” says Dr. Syed Alam, rheumatologist at Houston Methodist.

“While you can’t control the weather, the good news is that you can avoid other triggers of arthritic flare-ups — as long as you know what type of arthritis you have in the first place,” adds Dr. Alam.

Arthritis is a broad term for pain, tenderness or swelling in a particular joint (or joints), and the three most common types of arthritis are:

• Rheumatoid arthritis – when your immune system attacks the structure of your joint
• Osteoarthritis – wear and tear damage that breaks down the cushion in your joint
• Gout – when sharp crystals form and deposit in a joint

“When it comes to flare-ups of these types of arthritis, the triggers themselves aren’t actually the source of your pain. They’re just things that aggravate the underlying issues of the arthritis,” explains Dr. Alam.

What causes rheumatoid arthritis to flare up?

Rheumatoid arthritis is one of the more sinister forms of arthritis. Not only can the damage to your joints lead to swelling, stiffness and pain, there’s no way to undo it — aka, it’s permanent.

With rheumatoid arthritis, there’s likely always some low level of inflammation affecting your joints, but it can also flare up in response to stress or, believe or not, the weather — specifically, rain.

“When you’re stressed, either mentally or physically, your body is less equipped to handle the inflammation caused by your condition,” explains Dr. Alam. “Since it leads to swelling and stiffness, more inflammation means more intense pain.”

As for why a change in weather might trigger a flare up of rheumatoid arthritis, it’s all about joints under pressure.

“Changes in weather, such as rain, are often accompanied by changes in air pressure, and this change is thought to affect the pressure within your joints — making any underlying swelling feel more painful,” explains Dr. Alam.

While you can’t control the weather, you can take steps to reduce your stress levels. And when a flare up hits, you can use a cold compress to reduce the inflammation that’s causing some of your pain.

What causes osteoarthritis to flare up?

Osteoarthritis is the most common type of arthritis. It’s the “wear and tear” type of damage that affects the cartilage in your joints — which becomes more common with age.

“Like rheumatoid arthritis, osteoarthritis causes joint pain that can tend to flare up from time to time,” says Dr. Alam. “Unfortunately, it’s still not completely clear what triggers osteoarthritis to flare up, although we suspect that a primary contributor is overuse of the affected joint, either due to repetitive action or prolonged activity without sufficient rest.”

To prevent osteoarthritis flare-ups, take care to ensure you don’t overwork an arthritic joint.

And if you do experience a flare-up, you can help relieve your symptoms by using a warming pad or warm compress, taking over-the-counter pain relievers or just giving the joint some rest.

What causes gout to flare up?

Gout is a complex form of arthritis that can flare up suddenly and severely. It occurs as a result of having high levels of uric acid, which makes it easier for urate crystals to form. These sharp crystals can deposit in your joints, causing inflammation, swelling and pain.

“The most common trigger of gout is eating purine-rich foods, since high levels of purines can increase the amount of uric acid in your bloodstream,” explains Dr. Alam.

Gout-sufferers can help avoid flare-ups by avoiding foods rich in purines, including:

• Red meat
• Liver
• Certain types of seafood, including tuna, scallops and trout
• Alcohol, particularly beer
• Fruit juices and other beverages that contain fructose

“Similar to rheumatoid arthritis, a flare-up of gout can be alleviated by using a cold compress on the affected joint, which helps reduce the inflammation that’s causing your pain, swelling and stiffness,” says Dr. Alam.

When to see a doctor about a flare-up

If you’re experiencing joint pain that flares up from time to time, Dr. Alam recommends being evaluated.

“For many people, arthritis starts as a flare-up, and it’s important to seek a diagnosis. Remember, you need to know the specific type of arthritis you’re suffering from to be able to prevent or alleviate future flare-ups,” says Dr. Alam.

For instance, you won’t know whether to use ice or heat to relieve your joint pain unless you know if it’s rheumatoid arthritis or gout as opposed to osteoarthritis.

“In addition, and particularly for rheumatoid arthritis, seeking a diagnosis early on gives you a better chance of avoiding the permanent joint damage this condition can cause,” explains Dr. Alam.

And even if you’ve been diagnosed, there are still times you may need to see your doctor about a flare-up.

“It’s very important to call your doctor if you’re experiencing pain in a new joint or if your flare-up is severe, since this could be a sign of arthritic infection,” warns Dr. Alam.

If you’re experiencing a mild flare-up in a joint you’re used to experiencing pain, your doctor may be able to help you manage that pain by prescribing medications over the phone — but only if he or she is already familiar with you and your condition.

Lastly, Dr. Alam recommends approaching supplements with skepticism.

“There are supplements claiming to fix just about everything these days, but there are a lot of ‘placebo effects’ when it comes to pain,” warns Dr. Alam. “Supplements aren’t treatments, and it’s important to realize that some types of arthritis can do serious damage to your joints in the meantime.”

Your Guide to Managing Rheumatoid Arthritis Flare Ups

Managing your rheumatoid arthritis (RA) is an ongoing balancing act. You’ve had your share of painful symptoms, and your rheumatologist has prescribed medication that should help you handle them. You’re also doing your best to follow your doctor’s lifestyle instructions, even though you may have hit a few bumps in the road. Overall, you think you’re on a good path.

Learn how to manage RA flare ups in your spinal joints.

And then, you wake up one morning and you can barely get out of bed. Your joints feel swollen and stiff, and it’s a challenge to even get through your morning routine. You’re likely experiencing a rheumatoid arthritis flare up, and you’re certainly not alone. Even people with well-controlled RA symptoms can be surprised by sudden flare ups.

Learning how to manage your RA flare ups will help you to better manage your overall health. By monitoring your daily activities, you can also minimize your chances of experiencing these uncomfortable episodes.

A rheumatoid arthritis flare up describes a short-term escalation of your RA symptoms. A flare up can subside within a day or two, or it can persist for several weeks or months.

An RA flare up generally involves joint stiffness and pain, although it can manifest itself as a worsening of any symptom. If the flare up is especially severe, it can affect your ability to perform your everyday activities.

Ai Mukai, MD, a physiatrist with Texas Orthopedics Sports and Rehabilitation in Austin, Texas, emphasizes that RA flare ups are a known part of rheumatoid arthritis and its course and symptoms. Dr. Mukai, who possesses board certifications in pain medicine and physical medicine & rehabilitation, is also a SpineUniverse Editorial Board member.

RA flare ups can cause varied symptoms, and not every person experiences the same ones. However, Dr. Mukai says many of her patients describe their flare up symptoms in a similar way. “Most patients describe ‘flare ups’ as a sudden increase in pain, stiffness, and swelling of the joints of the body,” she notes.

Other common RA flare up symptoms include limited joint mobility along with severe fatigue and symptoms that mimic the flu. Note that your symptoms’ frequency and severity may vary. Because there is no standard list of RA flare up symptoms, physicians may find it difficult to design standard treatment options.

Rheumatoid arthritis is a complex condition that can affect many joints. Since RA is inflammation of a joint’s synovial membrane, any joints with such a membrane are fair game, including the facet joints in the spine.

RA flare ups can affect any synovial joint, including the facet joints in your spine.

Dr. Mukai explains that although other joints are more commonly affected, the spine is not immune to RA flare ups. “The most common place in the spine affected by RA is the upper neck – near the base of the skull. The C1-2 joint at the top of the neck can become inflamed and in severe cases can become unstable or form a pannus (abnormal tissue) that sticks out the back of the spine and can start compressing the spinal cord or even the brain.” 

Dr. Mukai’s many patient interactions have helped her to identify several potential RA flare up triggers. She counts:

…as possible triggers.

Dr. Mukai also notes that many flare ups occur without an identifiable trigger.

Certain foods are thought to increase inflammation and could contribute to an RA flare up, including:

• Processed meats
• Red meat
• Dairy products
• Added sugar
• High-sodium foods
• High-MSG foods
• Gluten
• Alcohol

By avoiding these foods and sticking to a rheumatoid arthritis diet, you’ll likely reduce your RA symptoms’ severity.

Excessive physical activity can also trigger an RA flare up. If you participate in exercise or sports that could result in an injury, follow protective guidelines to keep yourself safe. By learning to identify the start of an RA flare up, you can moderate your activity accordingly.

Finally, airborne toxins can trigger an RA flare up. Besides cigarette smoke, these harmful substances include chemicals such as household cleaners. Switching to environmentally safe cleaners may help. Airborne toxins are a particular cause for concern in densely populated cities and other areas that experience air pollution and smog. To minimize your risks, stay indoors during periods of poor air quality.

When managing any chronic medical condition, it’s difficult to predict when a flare up will occur. As a result, there isn’t a foolproof strategy for preventing one.

Dr. Mukai does have some advice that should minimize your risks of an RA flare up in the back. “[Follow] a healthy lifestyle including proper nutrition (some people are proponents of eating whole unprocessed foods and avoiding pro-inflammatory foods like trans fats and high fructose corn syrup).Getting good sleep (practicing good sleep hygiene), reducing stress (meditation, regular light impact exercise), and not smoking – can all help to reduce risk of RA flareups,” says Dr. Mukai.

Finally, Dr. Mukai offers bigger-picture recommendations that should help all RA patients better manage their condition. “Patients in RA should have a good long-term relationship with their rheumatologists and understand that their disease can change over time, necessitating change in medications and need for multimodal treatment. Learning good self-care techniques early will go a long way in managing symptoms.”

Palindromic rheumatism | Causes, symptoms, treatments

Zoe Lee was diagnosed with palindromic rheumatism five years ago, but the road to getting a diagnosis wasn’t easy.

“It started off as excruciating pain and swelling in my ankles and wrists, but every time I’d manage to get a doctor’s appointment, it would be gone. I think it was one of those things where it was a bit of a grey area for them.

“I’d done some research about arthritis myself, and they just kept telling me I was too young. It just went on and on and on, until one morning I had such a swollen hand that it looked like I had been bitten by a spider.

“The GP just took one look at me and said ‘you need to go and have some bloods done, I think we’re going to have to refer you to rheumatology’.

“When I went back after being on naproxen and hydroxychloroquine for four weeks, I felt the best I’d ever felt, and I thought perhaps he was going to discharge me. But he sat me down and said I had palindromic rheumatism.

“I remember the things that they were saying to me about the blood tests, and the x-rays, and the risk of A, B, C, and D. I couldn’t take it all in. I was convinced that it was just going to go away and that I didn’t have to live with it.

“I ended up being started on methotrexate, and I came off that to have my little boy. Since having him it’s all got worse. When you’re pregnant everything clicks back into place, and you almost don’t know that you’ve got arthritis. then it came back with a vengeance after I had him, which they did warn me would probably happen.

“If I’m having a flare, the best thing for me is to try and keep moving and the pain tends to decrease a lot quicker. This can sometimes be difficult, as my flares often occur during the early hours, but you do what you can to cope.

“I do have tears some days, but my little boy can’t fend for himself. He thinks it’s great when I have to shuffle down the stairs on my bum!

“When someone says to me ‘where have you got arthritis?’ I say ‘I’ve got a strange kind of it that just jumps from joint to joint’. One week it could be my wrist, the next week it could be my knees, I could have two weeks of being absolutely fine, of not even thinking about it, and then it could be my hips.

“I wish I’d gone to the GP with the research I had done and maybe helped them realise that I am old enough, that there isn’t an age limit for arthritis and that it can happen to anybody at any age.

“I tried my hardest to not let it affect my life. But I’m finding now that I’m a mum, running a house, working and trying to live a normal life, it does sometimes get in the way. But believe it or not, the good days really do outweigh the bad.”

Rheumatoid arthritis | Causes, symptoms, treatments

What is rheumatoid arthritis?

Watch our video about what rheumatoid arthritis is

Click to watch our short animation to find out what rheumatoid arthritis is, what the treatment options are and what you can do to help yourself.

Rheumatoid arthritis is a condition that can cause pain, swelling and stiffness in joints.

It is what is known as an auto-immune condition. This means that the immune system, which is the body’s natural self-defence system, gets confused and starts to attack your body’s healthy tissues. In rheumatoid arthritis, the main way it does this is with inflammation in your joints.

Rheumatoid arthritis affects around 400,000 adults aged 16 and over in the UK. It can affect anyone of any age. It can get worse quickly, so early diagnosis and intensive treatment are important. The sooner you start treatment, the more effective it’s likely to be.

To understand how rheumatoid arthritis develops, it helps to understand how a normal joint works.

How does a normal joint work?

A joint is where two bones meet. Most of our joints are designed to allow the bones to move in certain directions and within certain limits.

For example, the knee is the largest joint in the body and one of the most complicated. It must be strong enough to take our weight and must lock into position, so we can stand upright.

It also has to act as a hinge, so we can walk, and needs to twist and turn when we run or play sports.

The end of each bone is covered with cartilage that has a very smooth, slippery surface. The cartilage allows the ends of the bones to move against each other, almost without rubbing.

The joint is held in place by the synovium, which contains thick fluid to protect the bones and joint.

The synovium has a tough outer layer that holds the joint in place and stops the bones moving too far.

Strong cords called tendons anchor the muscles to the bones.

What happens in a joint affected by rheumatoid arthritis?

If you have rheumatoid arthritis, your immune system can cause inflammation inside a joint or a number of joints. Inflammation is normally an important part of how your immune system works. It allows the body to send extra fluid and blood to a part of the body under attack from an infection. For example, if you have a cut that gets infected, the skin around it can become swollen and a different colour.

However, in the case of rheumatoid arthritis, this inflammation in the joint is unnecessary and causes problems.

When the inflammation goes down, the capsule around the synovium remains stretched and can’t hold the joint in its proper position. This can cause the joint to become unstable and move into unusual positions.

Symptoms

The main symptoms of rheumatoid arthritis are:

• joint pain
• joint swelling, warmth and redness
• stiffness, especially first thing in the morning or after sitting still for a long time.

Other symptoms can include:

• tiredness and lack of energy – this can be known as fatigue
• a poor appetite (not feeling hungry)
• weight loss
• a high temperature, or a fever
• sweating
• dry eyes – as a result of inflammation
• chest pain – as a result of inflammation.

Rheumatoid arthritis can affect any joint in the body, although it is often felt in the small joints in the hands and feet first. Both sides of the body are usually affected at the same time, in the same way, but this doesn’t always happen.

A few people develop fleshy lumps called rheumatoid nodules, which form under the skin around affected joints. They can sometimes be painful, but usually are not.

Causes

The following can play a part in why someone has rheumatoid arthritis:

Age

Rheumatoid arthritis affects adults of any age, although most people are diagnosed between the ages of 40 and 60.

Around three-quarters of people with rheumatoid arthritis are of working age when they are first diagnosed.

Sex

Rheumatoid arthritis is two to three times more common among women than men.

Genetics

Rheumatoid arthritis develops because of a combination of genetic and environmental factors, such as smoking and diet. It is unclear what the genetic link is, but it is thought that having a relative with the condition increases your chance of developing the condition.

Weight

If you are overweight, you have a significantly greater chance of developing rheumatoid arthritis than if you are a healthy weight.

The body mass index (BMI) is a measure that calculates if your weight is healthy, using your height and weight.

For most adults, an ideal BMI is in the 18.5 to 24.9 range.

If your BMI is:

• below 18.5 – you’re in the underweight range
• between 18.5 and 24.9 – you’re in the healthy weight range
• between 25 and 29.9 – you’re in the overweight range
• between 30 and 39.9 – you’re in the obese range.

To work out your BMI, use the healthy weight calculator.

Smoking

Cigarette smoking significantly increases the risk of developing rheumatoid arthritis. If you would like to stop smoking, visit the Smokefree website.

Diet

There is some evidence that if you eat a lot of red meat and don’t consume much vitamin C, you may have an increased risk of developing rheumatoid arthritis.

How will rheumatoid arthritis affect me?

Because rheumatoid arthritis can affect different people in different ways, we can’t predict how the condition might develop for you.

If you smoke, it’s a very good idea to quit after a diagnosis of rheumatoid arthritis. This is because:

• rheumatoid arthritis may be worse in smokers than non-smokers
• smoking can weaken how well your medication works.

Physical activity is also important, as it can improve your symptoms and benefit your overall health.

Blood tests and x-rays will help your doctor assess how fast your arthritis is developing and what the outlook for the future may be. This will also help your doctor to decide which form of treatment to recommend.

The outlook for people with rheumatoid arthritis is improving all the time, as new and more effective treatments become available. It is possible to lead a full and active life with the condition, but it is important to take your medication as prescribed and make necessary lifestyle changes.

Diagnosis

A diagnosis of rheumatoid arthritis is based on your symptoms, a physical examination and the results of x-rays, scans and blood tests.

It can be difficult to diagnose because there isn’t a test that can prove you definitely have it. There are also quite a few conditions that have the same symptoms.

Your doctor will ask about your symptoms and do a physical examination. They will look for swollen joints and check how well your joints move. Rheumatoid arthritis can affect different parts of your body at once, so it’s important to tell your doctor about all the symptoms you’ve had, even if they don’t seem to be related.

If they think you have rheumatoid arthritis, they will refer you to a rheumatologist and may arrange blood tests to help confirm a diagnosis.

Blood tests

There’s no single blood test that can confirm you have rheumatoid arthritis. However, there are a few tests that can show possible signs of the condition. Some of the main tests are outlined below.

Erythrocyte sedimentation rate (ESR)

A sample of your red blood cells are put into a test tube of liquid. The cells are timed to see how long they take to get to the bottom of the tube. If the cells sink faster than usual, you may have levels of inflammation that are higher than normal. Rheumatoid arthritis is just one possible cause.

C-reactive protein (CRP)

This test can show if there is inflammation in your body. It does this by checking how much CRP there is in your blood. If there is more CRP than usual, you may have inflammation in your body.

Full blood count

A full blood count measures the number of red blood cells you have. These carry iron around your body, and a low number of red blood cells means you have a low iron content. This may mean you have anaemia (an-ee-me-er) and is common in people with RA, although having anaemia doesn’t prove you have RA.

Rheumatoid factor and anti-CCP antibodies

About half of all people with rheumatoid arthritis have rheumatoid factor in their blood when the condition starts. However, around 1 in every 20 people without rheumatoid arthritis also test positive for rheumatoid factor.

There is another antibody test called anti-CCP that you can take. People who test positive for anti-CCP are very likely to get rheumatoid arthritis. However, not everyone that has the condition has this antibody.

Scans

Scans may be used to check for joint inflammation and damage. These can be used to diagnose rheumatoid arthritis and to check how the condition is developing.

These may include:

• x-rays – these will show any changes in your joints
• ultrasound scans – a picture of your joints is created using high-frequency sound waves
• magnetic resonance imaging (MRI) scans – pictures of your joints are produced using strong magnetic fields and radio waves.

Treatment

There are a variety of treatments available for rheumatoid arthritis. The earlier that intensive treatment is started, the more likely it is to work.

There are three main ways to treat rheumatoid arthritis:

• drugs
• physical therapies
• surgery

Drugs

There are four main groups of drugs that are used to treat rheumatoid arthritis. These are:

Many people with rheumatoid arthritis need to take more than one drug. This is because different drugs work in different ways.

Your drug treatments may be changed from time to time. This can depend on how bad your symptoms are, or because something relating to your condition has changed.

Drugs may be available under several different names. Each drug has an approved name – sometimes called a generic name.

Manufacturers often give their own brand or trade name to the drug as well. For example, Nurofen is a brand name for ibuprofen.

The approved name should always be on the pharmacist’s label, even if a brand name appears on the packaging. Check with your doctor, rheumatology nurse specialist or pharmacist if you’re not sure about anything.

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Painkillers

Painkillers can help to relieve the pain caused by rheumatoid arthritis, but should not be the only treatment used.

There are many types and strengths of painkillers available – some can be bought over the counter from a pharmacy, while some are only available on prescription.

For guidance, ask a healthcare professional in charge of your care.

Disease-modifying anti-rheumatic drugs (DMARDs)

There are three types of DMARD:

• conventional synthetic DMARDs (sometimes called csDMARDs)
• biological therapies (sometimes called bDMARDs).
• targeted synthetic DMARDs (sometimes called tsDMARDS).

You will need to have regular blood tests if you take DMARDs, as they can affect your liver.

It may be a while before you notice your DMARD working – possibly a few months. It is important to keep taking your medication during this time.

The table below shows the DMARDs available for the treatment of rheumatoid arthritis.

For more information on the types of drugs used to treat rheumatoid arthritis, see our drugs content.

Steroids

Steroids are sometimes known by their full name: corticosteroids.

Corticosteroids help to reduce the pain, stiffness and inflammation caused by rheumatoid arthritis.

They can be used as:

• a tablet
• an injection directly into a painful joint
• an injection into your muscle.

They’re usually used to provide short-term pain relief. This could be during a flare-up or while you’re waiting for your DMARD medication to start working.

Corticosteroids are normally only used in this way because long-term use of corticosteroids can have serious side effects, including weight gain, osteoporosis and thinning of the skin.

You shouldn’t stop taking your steroid tablets or alter the dose unless advised to by your doctor. It can be dangerous to stop steroids suddenly.

Non-steroidal anti-inflammatory drugs (NSAIDs)

NSAIDs can be used to help control symptoms of pain, swelling or stiffness. They can be used in combination with painkillers.

NSAIDs start working within a few hours, with the effects felt for a few hours to a whole day.

Ibuprofen is a commonly prescribed NSAID.

NSAIDs can be taken as a:

• tablet
• capsule
• liquid
• suppository to be inserted into your bum
• cream
• gel.

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Research and new developments

Here, we round up some of the latest developments in rheumatoid arthritis research.

Our previous research has:

• led to the development of a new type of drug. These drugs are called ‘biological therapies’ and have transformed the lives of people with rheumatoid arthritis over the past 20 years.
• highlighted the importance of starting early, intensive treatment for inflammatory arthritis within 12 weeks of symptoms starting. It has also led to the introduction of a best practice tariff for those with rheumatoid arthritis, which means people are being diagnosed quicker.

We’re currently funding research projects to find out what causes rheumatoid arthritis, and to develop new and improved treatments. For example:

• our centre for genetics and genomics is trying to understand how genetic factors determine whether certain people are at risk of developing inflammatory arthritis, and what happens when they do
• our rheumatoid arthritis pathogenesis centre of excellence is looking at why rheumatoid arthritis starts, why it attacks the joints, and why the inflammation carries on rather than switching off
• investigating how the organisms that live on our skin and in our gut differ in those with rheumatoid arthritis and how this affects a person’s response to treatment.

Keri’s story

I was diagnosed with rheumatoid arthritis at the age of 21.

I was in my third year of university, studying to be a primary school teacher. Suddenly, one morning, my thumbs became very painful. Then my elbows became stiff and sore, and I couldn’t straighten my arms.

At first I only had symptoms in the morning, but eventually I had them all the time. Quite a few of my joints were stiff and painful, which meant I couldn’t get around very well. I was also tired a lot. When this happened, my GP referred me to a rheumatologist.

I graduated from my teacher training course two years later than planned, but have not been able to work as a teacher yet, due to my arthritis. However, I have used my teaching skills to volunteer for Versus Arthritis, leading self-management courses in Northern Ireland, which I find extremely enjoyable and rewarding. I am also the Chairperson of my local Versus Arthritis support group.

Baking is one of my hobbies, although using certain kitchen equipment can be difficult. Being social is important to me too and I enjoy going to cafés to catch up with my friends. When I’m in pain, I can distract myself by reading or listening to music.

Exercise is important to me too, as I find that doing some gentle exercises makes my joints less painful. There are a few chair-based exercises I do regularly and I also enjoy going for short walks.

Swimming is great too and I find that doing exercises in the heated water of the hydrotherapy pool makes me feel less stiff and sore.

Medication-wise, I’m currently using a biological injection called Enbrel. I’ve been using it for five years and inject myself once a week. It’s really helped to control my condition and my flare-ups happen less often.

At the moment, I’m doing ok. There are good days and bad days. I still experience pain every day, but am doing much better than when I was first diagnosed. I have fewer flare ups, which shows that the medication I’m using is really helping me.

My advice to anyone who has recently been diagnosed with rheumatoid arthritis would be to join a support group. Talking to another person who has the same condition as you and knows what you’re going through is really useful and reassuring. It’s helped me a lot in my journey.

I’d also say that getting a good night’s sleep is important, as it can help your body recover from the effects of your arthritis. It’s also important for me to learn more about my condition, as it helps me to understand what my body is going through. I really do believe that knowledge is power!

Rheumatoid arthritis – symptoms, causes and treatments for rheumatoid arthritis

Rheumatoid arthritis

Rheumatoid arthritis is a chronic systemic disease of the connective tissue. Considered as an autoimmune disease. Affects mainly peripheral small joints. Rheumatoid arthritis is of infectious and inflammatory origin. The disease is characterized by:

• progressive course;
• joint immobility;
• destruction of articular tissue.

Reasons for the development of rheumatoid arthritis

Among the reasons for the development of rheumatoid arthritis are:

• hereditary predisposition;
• infectious diseases (herpes virus, rubella, hepatitis B, Epstein-Barr, etc.).

The provoking factors are trauma, food allergies, a history of surgery.

Symptoms of the disease

Rheumatoid arthritis is a systemic disease in which not only joints, but also various organs and systems can be affected.The severity of the clinical picture depends on many factors: the severity of the disease, the presence or absence of complications, the localization of the pathology. According to statistics, 70% of cases of exacerbation of rheumatoid arthritis occur in the cold season.

The disease mainly affects the small joints of the hands and feet. As the progression progresses, other organs and systems are involved in the pathological process. The latent period of the disease is expressed by weakness, fatigue, weight loss, muscle pain, fever, sweating.

• Subacute onset is more common in rheumatoid arthritis. It is accompanied by the following symptoms:
• Joint pain. Aching, undulating flow. It is stopped by taking anti-inflammatory drugs. It is localized more often in the small joints of the feet, hands, wrist, knee and elbow.
• Muscle pains. They are aching in nature, persist for a long time.
• Fever. The level of increase in body temperature depends on the activity of the inflammatory process.
• Morning stiffness. Lasts for 30-60 minutes.

Extra-articular manifestations of rheumatoid arthritis

Rheumatoid arthritis affects not only joints, but also other organs and systems:

• Leather. The main symptoms are dryness and thinning of the skin, brittle nails, small subcutaneous hemorrhages. Also, the disease is characterized by rheumatoid nodules – subcutaneous formations up to 2 cm in diameter.
• Gastrointestinal tract.It is expressed in a decrease in appetite, the appearance of flatulence, rarely abdominal pain, heaviness in the epigastric region.
• Respiratory system. Rheumatoid arthritis affects the pleura and interstitial tissue. This is expressed by dry or exudative pleurisy.
• Cardiovascular system. The rheumatoid process can affect all layers of the heart.
• Urinary system. The defeat manifests itself in the form of glomerulonephritis.
• Nervous system. The rheumatoid process, which has spread to the nervous system, is expressed by impaired sensitivity, paralysis, impaired sweating, thermoregulation.

Diagnosis of rheumatoid arthritis

Laboratory diagnostics

Diagnosis of rheumatoid arthritis begins with a blood test.

In the general analysis of blood, close attention is paid to the level of hemoglobin, leukocytes, ESR. This examination allows you to assess the severity of the inflammatory syndrome.

In the biochemical analysis of blood, the level of fibrinogen, CRP, haptoglobin, sialic acids is studied. Specific markers for rheumatoid arthritis are as follows:

• Rheumatoid factor in the blood.Increases in 60% of cases.
• ACCP (antibodies to cyclic citrulline peptide). One of the most sensitive methods for early diagnosis of the disease. Revealed in 80-90% of cases.
• Antinuclear antibodies. Determined in 10% of cases.
• Analysis of synovial fluid. The study assesses its transparency, color, number of leukocytes.

Instrumental diagnostics

Arthroscopy is a modern informative and low-traumatic method for diagnosing various joint diseases.The examination is carried out using a special optical device – an arthroscope. Thanks to the procedure, it is possible to assess the prevalence of pathology, to carry out differential diagnosis of rheumatoid arthritis with other diseases (tuberculosis, sarcoidosis). During arthroscopy, it is possible to take material for histological examination.

X-ray of joints is the main method of instrumental diagnostics of rheumatoid arthritis. There are several methods for assessing the stage of X-ray changes in the joints.Doctors of the multidisciplinary clinic “Health” can apply any technique that is most suitable in each case.

Joint scintigraphy is a study involving the use of a radioactive substance – technetium. Depending on its content in the joint, the activity of the pathological process is assessed.

A biopsy of the synovial membrane of the joint is rarely performed. The procedure is prescribed for the purpose of differential diagnosis with other diseases.

MRI is a high-precision method of instrumental diagnostics.Allows to assess the degree of joint deformation, the prevalence of the pathological process, its localization.

Ultrasound of joints and internal organs is prescribed for severe progressive course of the disease. With the help of an ultrasound examination, it is possible to assess the condition of the heart, liver, spleen, pancreas and other organs.

Criteria for the diagnosis

Rheumatoid arthritis is diagnosed if 4 or more of the following criteria are met:

• morning stiffness;
• defeat of small joints;
• symmetrical joint damage, swelling;
• the presence of rheumatoid nodules;
• the presence of rheumatoid factor in the blood;
• characteristic radiological changes in joints and bones.

Drug treatment for rheumatoid arthritis

There are 2 stages in the treatment of rheumatoid arthritis:

1. Relief of exacerbation.
2. Supportive therapy.

To eliminate the acute phase of the disease, non-steroidal anti-inflammatory drugs are prescribed. Thanks to them, it is possible to reduce the severity of pain, relieve swelling and inflammation, and local redness of tissues. Among the features of this group of drugs are:

• the onset of the effect after 3-4 days of admission;
• sequential drug selection;
• replacement of the drug in the absence of effect;
• unwanted combination of two or more drugs of the NSAID group;
• the need to take it strictly after meals;
• strong irritant effect on the mucous membrane of the gastrointestinal tract.

Selective COX-2 inhibitors are aimed at inhibiting an enzyme that is involved in the onset of the inflammatory process. They have fewer side effects in comparison with non-steroidal anti-inflammatory drugs. They can be prescribed in the presence of diseases of the gastrointestinal tract, liver and other internal organs.

Glucocorticosteroids are hormones of natural or synthetic origin. They have anti-inflammatory and immunosuppressive effects.GCS are used when non-steroidal anti-inflammatory drugs are ineffective. When prescribing glucocorticosteroids, the doctor takes into account the age and sex of the patient, the state of the immune system, blood pressure indicators, and the state of electrolyte balance.

It is necessary to take GCS in a strictly defined dose. Treatment begins with low dosages with a gradual increase in the amount of the drug. A gradual dose reduction is performed after a therapeutic effect is achieved.

Pulse therapy

Pulse therapy is a method of treatment based on the administration of large doses of drugs.Severe acute inflammatory process cannot be stopped by usual doses of drugs. Therefore, pulse therapy for rheumatoid arthritis is one of the methods of treatment.

Therapy should be carried out in a stationary environment under the supervision of a physician. This is due to the fact that taking high doses of drugs can contribute to the development of undesirable reactions that must be quickly eliminated. Pulse therapy can be used with the following groups of drugs:

• Glucocorticosteroids.The effect of the treatment can be noticeable as early as 3-5 days. As a result of therapy, the severity of pain and edema syndromes decreases. After achieving the desired effect, treatment is transferred to maintenance doses of the drug.
• Cytostatics. The frequency of admission is selected on an individual basis. Cancellation of drugs is carried out one year after reaching a stable remission.

Biological therapy

Biological therapy is considered a new treatment for rheumatoid arthritis.The goal of therapy is to uncouple the pathogenetic chain responsible for the onset of the inflammatory response. Thanks to modern technologies, biologically active substances have been created that show good results in the treatment of various autoimmune diseases.

Local treatment

Local treatment involves the use of ointment and cream. The main objective of this method is to target the inflamed tissue around the affected joint. The most commonly used drugs are based on non-steroidal anti-inflammatory drugs.

Physiotherapy

Physiotherapy procedures are prescribed as part of the complex therapy of rheumatoid arthritis. The main tasks are to relieve pain, increase activity, eliminate morning stiffness. Physiotherapy for rheumatoid arthritis can include galvanic currents, ultrasound, paraffin or ozokerite applications, infrared irradiation.

Despite the positive effect of this method, physiotherapy procedures cannot be used as an independent method of treatment.

Drug treatment of rheumatoid arthritis in remission

During the period of remission, treatment consists in taking cytostatic drugs. Cytostatics are drugs, the action of which is aimed at inhibiting the vital activity of body cells, mainly capable of intensive division. The drugs have anti-inflammatory, antitumor, immunosuppressive effects. They are used with extreme caution.

There is a huge variety of drug groups and methods of their use.Self-medication can lead to complications. Therefore, the appointment of therapy should be done by an experienced doctor. This takes into account complaints, the results of laboratory and instrumental studies.

Doctors of the multidisciplinary clinic “Health” select an individual treatment plan for each patient. This approach allows you to achieve results in a minimum amount of time.

Prevention of rheumatoid arthritis

In order to reduce the risk of developing or exacerbating rheumatoid arthritis, doctors advise you to follow the following guidelines:

• Perform physiotherapy exercises.To maintain range of motion in the joints, it is enough to do light exercises.
• Muscle massage. It is prescribed in the presence of ankylosis (complete immobility of the joint). Massage helps to maintain normal tone and muscle mass.
• Spa treatment. With rheumatoid arthritis, balneotherapy has a positive effect. However, this method of treatment is recommended for mild disease.
• Reception of prescribed therapy. If necessary, the doctor will prescribe methotrexate.The dosage is selected individually.
• Reorganize chronic foci of infection. It implies the timely treatment of angina, pneumonia, pyelonephritis, sinusitis and other diseases.
• Use of orthopedic splints supporting devices. They allow to prevent further deformation of the joint with its existing instability.

In the presence of a diagnosis of rheumatoid arthritis, it is necessary to visit a rheumatologist once every 6 months for routine observation.

In the multidisciplinary clinic “Health”, qualified rheumatologists are employed. The doctors of our center have many years of experience in this area. Specialists regularly improve their professional skills and knowledge in specialized courses. This is evidenced by numerous diplomas and certificates. On the territory of the clinic, there is the largest open-type express laboratory in Russia. All examinations are carried out as soon as possible. For diagnostics, modern equipment from a European manufacturer is used.

Rheumatoid arthritis is a serious disease that requires timely diagnosis and correct treatment. Therefore, when the first signs of illness appear, make an appointment with your doctor. We are glad to see you at any time convenient for you. You can make an appointment, as well as ask any questions of interest, by phone.

90,000 Rheumatoid arthritis: description of the disease, causes, symptoms, cost of treatment in Moscow

A type of chronic form of arthritis is rheumatoid arthritis.Its difference is affecting the joints on both sides of the body. This type of arthritis does not go unnoticed. In addition to the fact that the joints are affected, the functioning of the internal organs is disrupted. The disease is considered to be autoimmune, when small peripheral joints are affected. Rheumatoid arthritis has an erosive and destructive nature.

Facts about the disease

• Refers to a dangerous autoimmune disease that leads to an inflammatory process in the joints of the upper and lower extremities.

• The disease can appear in any person, no matter how old he is.

• In some cases, it is not possible to determine the root cause of the disease.

• With rheumatoid arthritis, frequent remissions, periods of exacerbation.

• In most cases, symmetrical joint damage occurs.

• The disease can progress either slowly or rapidly.

• The result of therapeutic measures is possible with the timely detection of the disease.

• It is very rare to meet when rheumatoid arthritis goes into spontaneous remission.

Taking into account the clinical and anatomical signs, some types of the disease can be distinguished:

1.polyarthritis, monoarthritis, oligoarthritis.

2. in the presence of severe systemic symptoms.

3. diffuse lesion of connective tissues, which is accompanied by deforming osteoarthritis.

4. a special nonspecific form observed in children under 15 years of age.

Given the immunological signs, rheumatoid arthritis can be seronegative when rheumatoid factor is absent in the serum of the joint fluid, and seropositive when rheumatoid factor is present.

If we talk about the course of the disease, some features can be distinguished:

• In most cases, the disease has a chronic form, and can haunt a person for many years, negatively affecting the quality of life. There are situations when symptoms are completely absent, which happens in extremely rare cases. Rheumatoid arthritis, in the course of its progression, makes a person a disabled person.

• The inflammatory process occurs in the articular tissue, which is located near it.In addition, damage to muscles, ligaments, tendons can occur.

• In some cases, the disease provokes the destruction of cartilage, ligaments, bones, severe deformation of the joint. As a result of multiple studies, it was revealed that joint deformity can develop at the initial stages of the disease, without taking into account the severity of symptoms.

• The disease can appear even in those people who lead an active lifestyle, eat right, play sports.This indicates that the disease has a hereditary factor.

Why does rheumatoid arthritis

appear?

One of the reasons why the disease develops and progresses is the presence of an autoimmune disease, when the fight of immune cells against various negative factors (bacteria and viruses) stops, and the immune system begins to attack healthy tissues. The joints are primarily affected. They are perceived by lymphocytes as a foreign body.A similar aggressive reaction can appear due to any disease. This includes acute respiratory viral infection, sore throat, flu. Infectious or reactive arthritis can cause rheumatoid arthritis. The underlying cause is injury or hypothermia.

Another version of the onset of the disease is emotional shock. Not a small number of patients diagnosed with rheumatoid arthritis notice that the onset of the disease is associated with severe stress.A hereditary factor can cause the development of the disease. The conditional cause of arthritis is the environmental factor. Smoking and eating plants that have been treated with chemicals can lead to this disease.

How does the disease manifest

The main signs of rheumatoid arthritis include:

• The first stage of the disease is characterized by the defeat of small joints on the arms, legs, feet, wrists, legs, elbows.

• Symmetrical seizure of the joints (both upper or lower extremities are affected, which distinguishes rheumatoid arthritis from other joint diseases).

• The patient develops painful sensations that can disappear after active movement. This is a fundamentally important symptom, due to which, rheumatoid arthritis differs from rheumatic arthritis. After some time, the disease begins to progress, as a result of which the performance of active movements does not bring results.

• Soreness, in most cases, appears in the morning or afternoon, as a result of which it is difficult for a person to brush his teeth, make breakfast or do other usual procedures. When the evening comes, the painful sensations subside, but resume in the morning. If the disease is at a more advanced stage, soreness will accompany a person at any time of the day.

• In the morning, a person’s body is constrained.

• If the disease is in an exacerbation stage, the skin around the affected joint turns red and becomes hot to the touch.

• Large joints are affected by the inflammatory process.

• A person notices that his condition has worsened, body temperature rises systematically, appetite worsens, constant weakness is present, as a result of which body weight decreases.

• Subcutaneous nodules located at the site of the affected joint. They tend to disappear and reappear temporarily. Such nodules resemble a circle in shape, and do not exceed two centimeters in diameter. They are distinguished by their mobility and density. In some cases, the localization of such nodules can be the back of the head, forearm, lungs, myocardium.

• The joints are deformed, blood circulation is disturbed, muscles slowly atrophy.Due to the loss of joint mobility, a person develops disability and lack of self-care.

• In some cases, the symptomatology is nonspecific, when the salivary glands are affected. The person notices that the eyes began to hurt, the limbs began to numb, and discomfort appeared in the chest area with a deep breath.

• With the course of the disease, a person becomes dependent on weather conditions.Painful sensations intensify if the weather, atmospheric pressure, season change.

• Decreases the sensitivity of the hands or feet.

With long-term treatment of rheumatoid arthritis, the following symptoms may appear:

1. The defeat of large muscles (femoral, gluteal muscle), forearm extensors.

2. the skin becomes dry and thin.

3. the formation of necrosis under the nail plates, which threatens the development of gangrene. The nail plate becomes brittle, covered with stripes.

4. the gastrointestinal tract is affected. In addition, dysfunction of the nervous, pulmonary and visual systems is observed. The work of the heart and blood vessels is impaired.

5. the formation of rash, ulcers, uterine and nosebleeds.

What are the stages of the disease

According to some criteria, the stages of development of the disease are classified.However, the results of an x-ray are considered informative.

The initial stage is characterized by the appearance of the first sign – the bone thickens. This is the only manifestation that is noticeable on x-ray examination. There is a compaction of soft tissues around the finger joint. In some cases, you can notice the presence of light spots that are present on the bone tissue. Such places are cysts. If the joint space is narrow, then the disease progresses, as a result of which the next stage begins.

During the second stage, bones are affected. Elbows and wrists are primarily affected. When the erosive area is located near the cartilage, its mobility is limited. There may be no deformation of the cartilage tissue, but atrophy of the muscles surrounding the affected joint develops. The bursa is swollen and inflamed. With an exacerbation, it becomes hot, and the patient notes the appearance of painful sensations and aches.

The third stage of the disease is characterized by marked damage and thinning of the bone.The X-ray shows that the muscles are rapidly atrophying, the joint is deformed. If salts began to be deposited in the early stages of the disease, then when the third stage occurs, the X-ray shows clear calcification. The deposit differs in size and shape, the structure is dense and loose. During this period, there is a significant limitation of joint movement.

At the fourth stage, a bone disorder is noticed. During the X-ray examination, the presence of osteoporosis, erosions, cysts is recorded.In addition, fusion of cracks, complete deformation of the joints, atrophy of muscles and soft tissues can occur. The disease affects both the upper and lower extremities. The person begins to complain of severe persistent pain.

Arthritis: Causes, Symptoms and Treatment | Health Blog

Pain during movement can be caused by a huge number of diseases. The reason may be trauma, nerve diseases, tumors, congenital structural anomalies. A common culprit for pain in adults is arthritis, an inflammation of the joints.

What is arthritis?

This name refers to a whole group of diseases in which inflammation spreads to all parts of the joint. The disease can occur in one joint or in several, with acute pain or in a chronic form, as well as provoke tissue destruction.

The disease has two classifications. By involvement:

• monoarthritis – inflammation occurs in only one joint;
• polyarthritis covers several joints at once (the same on both sides or random in different parts of the body).

And Downstream:

• Acute – begins suddenly and is accompanied by severe pain;
• Chronic – develops rather slowly, may appear after an acute form with insufficient treatment.

There is also an international rheumatological classification, in which the following types of arthritis are distinguished:

• infectious – with the development of the disease after infection;
• dystrophic – caused by the destruction of joints and bones;
• traumatic – after mechanical damage to the joint;
• associated with other diseases of the body – can be caused by tumors, diseases of the digestive tract and others.

Symptoms of arthritis. How to distinguish one species from another?

Despite the various manifestations, some symptoms of arthritis always appear. Regardless of what caused the illness, the patient observes:

• edema and swelling around the affected joint,
• redness of the skin and an increase in its temperature,
• limitation of movement in the joint, accompanied by crunching and pain.

In addition, there are symptoms that can be used to distinguish types of arthritis from each other.They depend on the cause and nature of the course:

• with chronic arthritis deformity of diseased joints begins;
• Infectious arthritis is accompanied by fever, chills, weakness and headache;
• dystrophic arthritis develops slowly, joint pain gradually increases. It can spread not only to the limbs, but also to the spine;
• traumatic arthritis is similar in symptoms to dystrophic arthritis, but its development is preceded by serious injury or constant stress on the joint;
• with arthritis caused by allergies, tumors, disorders of the gastrointestinal tract, all the symptoms that caused the disease will be observed.

If, in addition to the listed symptoms, there are tears of muscles and tendons, as well as numbness of the extremities, the disease has started and complications have begun that require immediate treatment.

Causes of the disease

Some causes of arthritis lie in poor lifestyle choices:

• insufficient amount of nutrients and vitamins,
• unbalanced diet,
• alcohol consumption,
• overweight,
• load on the joints.

Others are more serious and are unlikely to be avoided with routine prophylaxis:

• bacterial, fungal, viral infections;
• constant interaction with allergens;
• joint injuries;
• diseases of the nervous and immune systems;
• metabolic disorders;
• pathology of the endocrine gland;
• hereditary predisposition;
• some diseases: gout, gonorrhea, tuberculosis.

Women suffer from arthritis more often than men.Constant stress, past illnesses and surgical interventions often provoke the first attacks of arthritis. Also, the risk of getting sick increases with age.

What does the diagnosis of arthritis include?

Arthritis manifests itself very clearly – even a layman will notice it. To accurately determine the causes of the disease, after a visual examination, the doctor may prescribe the following procedures:

• a general analysis of blood and urine will show the presence of infections and the degree of inflammatory processes;
• analysis of synovial fluid – it can be used to determine the presence of inflammatory and septic processes;
• arthroscopy – endoscopic insertion of the sensor into the articular cavity for visual examination;
• Ultrasound of the joints will help determine the extent of the lesion and detect the main areas of the disease;
• X-ray of the joint and limb will show the condition of the bones and joints, reveal the changes caused by arthritis;
• computed tomography of the joint is one of the best tools for assessing the condition of bones and joints;
• Magnetic resonance imaging will help to examine the condition of bones and joints, as well as surrounding tissues.

If arthritis is accompanied by abdominal discomfort, headaches, weakness – be sure to tell your doctor. This may indicate a serious illness in which joint inflammation is just one of the symptoms.

How is the treatment going?

Therapy includes getting rid of the pain syndrome, eliminating the cause of the disease and restoring the diseased joint.

• the doctor can prescribe painkillers and anti-inflammatory drugs,
• in advanced cases, they perform operations to restore destroyed joints,
• physiotherapeutic procedures have proven themselves well: massage, ultrasound therapy, laser therapy,
• many patients are advised to do light gymnastics: it should be developed by a doctor Exercise therapy taking into account the course of the disease.

Arthritis treatment cannot be complete without lifestyle changes: pay attention to the quality of your diet, avoid weight gain, avoid alcohol and a lot of salt.

If you start therapy in the initial stages, the disease can be easily treated. The most important thing is to pay attention to all changes in the body in order to consult a doctor in time and prevent the development of complications.

90,000 Rheumatoid arthritis. Treatment, symptoms

Rheumatoid arthritis is an autoimmune joint disease.This disease is very difficult to treat and can last for years. Inflammatory processes in the joints that accompany rheumatoid arthritis lead to their deformation, poor mobility and limited range of motion.

The main cause of rheumatoid arthritis is a malfunction of the immune system. Immune cells, whose task is to recognize and destroy viruses and bacteria that have entered the body, suddenly begin to perceive the cells of their own body as enemies, and attack them.This attack has been going on for years.

The appearance of rheumatoid arthritis is provoked by :

• joint injuries,
• latent sluggish infections,
• strong emotional upheavals,
• prolonged stress.

Symptoms of rheumatoid arthritis in the initial stage

• more than 3 inflamed joints;
• the presence of inflammation of the metacarpophalangeal and metatarsal-phalangeal joints;
• the duration of morning stiffness is more than 30 minutes.

Laboratory blood tests for initial rheumatoid arthritis.

The presence of high rates is likely:

• rheumatoid factor titers,
• increase in ESR,
• increase in C-reactive protein.

However, at an early stage of the disease, these tests are often within the normal range, so negative laboratory test results do not exclude the diagnosis of rheumatoid arthritis.

Treatment of rheumatoid arthritis

Proven efficacy in two approaches to the treatment of rheumatoid arthritis:

• Drug therapy – relieves the patient’s suffering through potent and hormonal anti-inflammatory drugs.

• Computer reflexology – restores the immune system and, subsequently, the structure and function of the joints.

Treatment of rheumatoid arthritis m with single drug therapy.

With this method, doctors can significantly alleviate the suffering of the patient, for which they prescribe hormonal therapy and anti-inflammatory drugs. But the immune system has not yet recovered with medication, despite numerous studies. Therefore, the disease, as a rule, progresses, the doses of prescribed drugs increase, the joints become deformed, and the range of motion decreases. Unfortunately, drugs used in drug therapy have many side effects: the gastrointestinal tract, liver, and kidneys are destroyed.

Treatment of rheumatoid arthritis with computer reflexology.

It is possible to restore the immune system and make the patient’s recovery as close as possible with the help of computer reflexology. Treatment is based on the dynamic restoration of neuro-immuno-endocrine regulation and subsequent restoration of the structure and function of the joints.

Treatment is carried out by exposure to ultra-low direct current on the system of biologically active points connected into a single network with the brain through the human autonomic nervous system.This is a comprehensive, non-drug treatment for rheumatoid arthritis. As a result of the treatment of rheumatoid arthritis by the method of computer reflexotherapy, the body stops the destruction of its own joints and gradually recovers.

Treatment of rheumatoid arthritis by the method of computer reflexology gives a pronounced clinical effect:

• reduction of joint pain;
• restoring sleep and improving performance;
• restoration of range of motion;
• reduction in the number of medications taken, and reduction of their dose until complete cancellation;
• decrease in the number and severity of exacerbations, until relapses stop.

Leave a contact and a consulting physician will contact you

It is important not to miss the time, when it is still possible to stop joint deformity, completely restore range of motion and get rid of pain without taking anti-inflammatory drugs. To avoid irreversible changes in the body – do not postpone treatment, send to the registry

A consultant doctor will contact you.

The information on the site is not intended for self-diagnosis and self-medication.If unwell, do not run the disease, seek qualified medical help.

• To come for treatment to the Gavrilova Clinic from another city, do not waste time thinking how to organize all this, call 8-800-55-00-128 from Russia for free, to call from other countries dial +7 846 374-07 -08 or +7 927 725 -11-44 (WhatsApp, Viber, Telegram). The consultant’s assistant will promptly answer your questions and help you organize your trip as comfortably as possible.
• To make an appointment with a doctor, contact the reception by phone +7 (846) 374-07-08, or via.

Video about treatment in the clinic

Examples of treatment of various diseases

Rheumatoid arthritis

What is rheumatoid arthritis

Rheumatoid arthritis is not only a joint disease, it is a systemic disease.

The disease is based on complex autoimmune processes that ultimately lead to damage and deformation of mainly small joints.However, with early treatment, complete joint destruction can be prevented.

Our movements, including walking, dancing and jumping, are made possible by the complex interactions of muscles, joints, ligaments and tendons. If one of 140 joints is inflamed or damaged, the entire musculoskeletal system becomes imbalanced. Any joint inflammation is referred to as “arthritis”. The inflammation can be acute or chronic. With rheumatoid arthritis, the patient has to live with chronic inflammation of the joints.

Symptoms

Symmetrical joint inflammation is a classic symptom of rheumatoid arthritis, that is, the same joints become inflamed on both limbs at the same time. This is manifested by a local increase in temperature in the area of ​​the joints, pain and swelling. At the same time, the mobility of the joints decreases. Usually, the small joints of the arms and legs are affected first. Then the pathological process can spread to large joints: knee and shoulder.

Quite often, an additional amount of fluid, the so-called effusion, is filled into the joint cavity. The onset of pain during rest is characteristic. Movement relieves pain.

At the initial stage, the disease can manifest itself with nonspecific general symptoms, for example:

• fatigue
• increased fatigue
• loss of appetite
• weight loss
• increased body temperature

Risk factors and causes

Rheumatoid arthritis is an autoimmune disease.This means that the body perceives its own tissues as foreign and begins to fight them through the immune system, which is manifested by inflammation of the “foreign” tissue.

The main predisposing factors for the perverse perception of own tissues are:

• Smoking
• Viruses and bacteria
• Heredity

The action of several factors simultaneously increases the risk of rheumatoid arthritis.

Prevention

There is no targeted prevention of rheumatoid arthritis. However, a healthy lifestyle, sports activities in combination with a balanced diet are factors that counteract the development of the disease.

And … don’t smoke!

Treatment

Traditionally, complex therapy gives the best result. The ideal is an individualized treatment plan prescribed by a doctor.In addition to drug therapy, therapeutic exercises, physiotherapy and orthotics are used. In some cases, rheumatologists resort to the help of surgeons. Surgical treatment consists in correcting the deformity of the joint, including by replacing the joint with an artificial one.

Occupational therapy is a special form of treatment – it is a modern method of rehabilitation that helps patients understand how to adapt to everyday life, having this or that limitation on the part of the musculoskeletal system.

Braces and orthoses have been shown to be effective in the treatment of rheumatoid arthritis, especially in occupational therapy. They stabilize the joints, reduce swelling and pain.

Discuss all treatment options with your doctor so that they can help you choose the one that is best for you.

Diagnostics and treatment

Causes and symptoms of joint problems

Joint pain

Human body

Human joints differ in shape

Joints

Nothing found for Revmatoidnyj Artrit% 3Flang% 3Dru

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90,000 what is the difference and how to treat

“Every month more than 6,000 people ask the question about the difference in the terms“ arthrosis ”and“ arthritis ”, according to the Yandex.Wordstat service.

Understanding the main symptoms of these diseases helps you get the right treatment in a timely manner and avoid complications, which is why we have detailed the differences in this article.

An accurate diagnosis is possible after examination:

• general analysis of blood and urine,

• biochemical blood test,

• rheumatic tests and X-rays of the affected joint

• MRI and study of synovial fluid – if necessary.

About arthritis

Arthritis is a disease that is triggered by an infection, a malfunction of the immune system or metabolism. The main symptom of arthritis is inflammation: swelling, redness of the skin and a rise in temperature in the area of ​​the affected joint. The negative effect of arthritis can extend not only to the joints: the heart, kidneys and liver are at risk.

Symptoms

The first signs of the disease are usually:

• sharp pain – in a state of motion or rest,

• edema in the area of ​​the diseased joint – persistent or recurrent,

• redness and fever of the affected area – can be felt by touch,

• stiffness of movements in the morning hours.

Arthritis can occur in a latent form – in this case, the symptoms appear after exposure to provoking factors: stress, overwork, hypothermia or infection.

Symptoms also include manifestations of the inflammatory process in the body:

• increase in body temperature to 38-39 degrees;

• loss of strength and chills;

• conjunctivitis;

• change in the blood test indicator: for example, increased ESR and high leukocyotosis;

• pain when urinating.

Arthritis can vary in severity and progress is not necessarily rapid. However, if you do not pay attention to the problem, arthritis flows into a chronic form and can lead to disruption of the functioning of internal organs and disability: disability, alteration of joints and limbs.

Treatment and prevention

The treatment prescribed will depend on the severity of the diagnosis. If, during the diagnosis, no damage to the internal organs is found in the patient, the treatment is relatively simple.The patient can be assigned:

• anti-inflammatory and analgesic drugs,

• physiotherapy procedures,

• dieting and avoiding alcohol,

• reduction of physical activity on the affected joint.

In the event that a disease has affected organs, the patient undergoes an additional treatment program to support them:

• additional examinations,

• drug therapy,

• special diet.

Among the various forms of arthritis, there are some serious diseases that are important to diagnose in time:

• Rheumatism is an inflammatory disease of the connective tissue that affects large and medium joints, and also has specific manifestations: it can manifest itself sharply and pass on different joints, as if moving from one to another.

Rheumatism does not deform the joints, but the absence of treatment is fraught with serious complications: for example, kidney disease and heart disease.

The cause of occurrence can be transferred infectious diseases: tonsillitis, otitis media and the like. The risk group most often includes children aged 7 to 14 years. Heredity also affects the development of the disease.

• Rheumatoid arthritis is a chronic disease in which the inflammatory process affects both the joints and many organs. For example, eyes, lungs, heart and blood vessels. It belongs to the group of systemic connective tissue diseases. Most often, the disease affects women after 60 years.

Progresses slowly, affects several joints at once and spreads symmetrically. As the disease progresses, the joints lose mobility, ache and swell. Characteristic nodules appear on the joints affected by inflammation.

A feature of the diagnosis of rheumatoid is the use of special laboratory tests, which make it possible to establish an accurate diagnosis. It is difficult to treat rheumatoid arthritis, with the use of potent drugs. Therefore, it is very important to suspect and diagnose this disease at an early stage.

• Gouty arthritis or gout is a progressive joint disease that occurs due to a violation of the metabolism of uric acid in the blood and the deposition of salts in the joint tissues. Most often begins with involvement of the big toes.

Usually elderly people, mainly men, suffer from gout. But there are also cases of the disease at a younger age.

Treatment of rheumatism, systemic diseases, gout differs from treatment, for example, allergic or reactive arthritis.Only a doctor can make the correct diagnosis and prescribe adequate treatment.

It is easier to prevent a disease than to cure, so we recommend that you take care of prevention and carefully monitor your state of health:

• give up bad habits – smoking, alcohol consumption, poor nutrition;

• develop the habit of rational sports activities – exercise, stretching, balanced training;

• Strengthen immunity – consult a doctor regarding mineral and vitamin complexes, flu shots.

About arthrosis

70% of cases of the disease occur in people over 65 years of age.

Osteoarthritis is a disease that leads to deformation and destruction of the joint capsule. The articular surface is the cartilage that covers the surface of the joint and prevents the bones from touching each other: it allows free and painless movement. Most often, arthrosis develops in old age.

It is also called “the disease of pianists and athletes” who often suffer from arthrosis due to constant stress on the wrists and joints of the legs: hip, knee, ankle.

Osteoarthritis, unlike arthritis, affects only the joints and is not inflammatory.

Symptoms

Symptoms of arthrosis appear gradually, as the disease progresses. At the beginning of development, they are absent at all. This is the main reason for seeking medical attention in the later stages.

The first symptoms of arthrosis manifest themselves:

• immobility of the joint after sleep or long rest, which quickly disappears with movement;

• crunching, grinding and clicking, which are accompanied by a dull sound;

• pain on movement and exertion.

In the later stages of arthrosis, the symptoms become more noticeable: joint immobility and pain syndrome increase, and “hard joint” syndrome develops – the replacement of soft cartilage tissue with bone growths.

The development of a chronic form of the disease leads to the inability to move one or more joints.

Treatment and prevention

Osteoarthritis responds better to treatment in the initial stage of the disease. Also, the chances of recovery depend on age – up to 40 years old, getting rid of the disease is much easier.

Under these conditions, the patient is assigned to control the loads on the diseased joint, drug and shock wave therapy – short-term exposure to bone and connective tissue with acoustic impulses of significant amplitude of low frequency: from 16 to 25 Hz. Other procedures can also be used: for example, mud applications, electrophoresis with drugs.

The chronic form of the disease, as well as arthrosis in old age, cannot be completely cured.However, competent and regular therapy helps to control the disease as much as possible: to stop the destruction of the joint and improve the patient’s quality of life.

In the course of such therapy, the doctor prescribes medication that activates the regeneration process, and also gives recommendations on the way of life.

Primary prevention helps prevent the development of arthrosis. Basic Principles:

• weight control – excess weight increases the load on the joints;

• regular physical activity – gymnastics, stretching and moderate exercise;

• selection of high-quality and comfortable shoes – improper load distribution provokes increased pressure on the joints;

• strengthening immunity and protection against hypothermia.

Side-by-side comparison

Above, we have described the main causes, symptoms and treatments for arthritis and arthrosis. In this block, we briefly answer the question of the difference between diseases: