What is Hand and Wrist Rheumatoid Arthritis?
Rheumatoid arthritis (RA) is a disease where the body’s immune system mistakenly attacks its own tissues, primarily focusing on the joints. This condition was first identified by Alfred Baring Garrod in the 1800s. In RA, the inflammation mainly occurs in the tissue lining inside the joints, which can lead to joint damage, changes in joint shape or joint deformity, and disability. This leaves a person incapable or struggling to perform daily tasks. There may also be issues outside or beyond the joints, hence the name of extra-articular manifestations.
In most cases, RA usually starts in the small joints of the hands, particularly at the knuckle joints (known as the metacarpophalangeal joints), the middle of the finger joints (known as the proximal interphalangeal joints), and the wrist joints. In this disease, both sides of the body are typically affected at the same time, making the inflammation bilateral and symmetrical.
However, RA doesn’t just affect the hands and wrists. Other joints can be involved, such as the knees, ankles, elbows, shoulders, the joints where the toes meet the foot (known as metatarsophalangeal joints), the neck area (or cervical spine), and the joints located near the ear that is responsible for talking and chewing (or the temporomandibular joints).
What Causes Hand and Wrist Rheumatoid Arthritis?
Rheumatoid arthritis, a form of arthritis that causes joint pain and damage, can be caused by a mix of different factors. These factors can be divided into three categories: genetic risks, non-genetic risks, and abnormal immune response.
Genetic risk factors refer to certain genes that can make a person more likely to develop rheumatoid arthritis. Some of these specific genes are HLA-DRB1-shared epitope and non-HLA genetic factors such as PTPN22, TRAF1-C5, STAT4, TNFAIP3, and PADI4. Epigenetic transformation, which involves changes in gene activity without changing the DNA sequence, and the creation of antigenic epitopes, which are parts of a protein that the immune system responds to, are also important genetic factors.
Non-genetic risk factors are not related to your genes but are related to your habits, lifestyle, and environment. These include being female, smoking, having certain types of gut bacteria (microbiota), eating a western diet, experiencing stress, having infections, and environmental and ethnic factors.
The abnormal immune response refers to the way the body mistakenly attacks the joints, causing inflammation and damage. The theory here is that something triggers the creation of new antigenic epitopes, which may be mostly related to environmental factors, leading to changes at the epigenetic level and causing the body to start attacking itself (autoimmunity).
Risk Factors and Frequency for Hand and Wrist Rheumatoid Arthritis
Rheumatoid arthritis is a widespread type of inflammatory arthritis. The exact global prevalence is unknown but estimates suggest that 0.5% to 1% of the population is affected, with variations depending on the region. Northern Europe and North America have a higher incidence, with 24 to 36 cases per 100,000 people. However, the figures used are mostly based on older criteria for diagnosing rheumatoid arthritis established in 1987. There’s not much data using the updated criteria from 2010.
- Rheumatoid arthritis usually affects people between 30 and 50 years old, but it can develop at any age.
- Men tend to develop it at a later age.
- The disease is more common in women, with 2 to 3 women affected for every man.
- Among identical twins, if one has rheumatoid arthritis, the other has a 12% to 15% chance of also having it. Among fraternal twins, the chance drops to 2% to 3%.
Signs and Symptoms of Hand and Wrist Rheumatoid Arthritis
Rheumatoid arthritis (RA), a type of inflammatory arthritis, can begin “silently” years before a person shows any symptoms. During these preclinical stages, certain autoantibodies linked to RA appear in the blood of those with genetic risk factors. This phase can last for 10-15 years and, while the person remains asymptomatic, it typically progresses to a stage where the individual begins to exhibit symptoms like intermittent joint pain. Researchers are actively studying this period to understand more about the development of full-blown RA.
RA manifests in different ways, but the most common pattern entails chronic inflammation of small joints in the hands and feet, occurring symmetrically. Most people with RA experience a slow onset of symptoms, but a quarter might encounter a sudden start. It can also begin with a single large joint (like the shoulder or knee) becoming affected and later spreading to other joints. It’s important to remember that if left untreated, the progression is expected even though some patients might experience periods of relief. Unfortunately, full remission without treatment after the initial few months is rare.
- Joint pain
- Swelling
- Loss of strength
- Limited range of motion
- Stiffness of joints
- Difficulty in performing daily tasks
- Fatigue and overall malaise
- Weight loss and low-grade fevers
Most of these symptoms are commonly experienced in inflammatory arthritides. In particular, RA patients often notice swelling in their hand joints and undergo stiffness in the morning, which lasts for over an hour. Families with histories of inflammatory joint diseases or autoimmune collagen vascular diseases could have a higher risk for RA.
During a physical exam, healthcare providers note visibly swollen joints with a considerable reduction in the range of motion. These affected joints may be tender and warm, unlike the hard feeling of osteoarthritic changes. Several hand and wrist deformities can occur, and subcutaneous nodules (a type of lump that forms beneath the skin) may develop in certain patients, especially those testing positive for RA-specific autoantibodies.
Testing for Hand and Wrist Rheumatoid Arthritis
To confirm a suspicion of rheumatoid arthritis, doctors have to examine a patient’s medical history, conduct a physical examination, and order laboratory tests and radiographic scans.
In the laboratory, doctors will test for:
- Markers of inflammation, specifically the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), both of which often increase during disease progression
- Hematologic changes that can indicate the disease, e.g., anemia of chronic disease, leukopenia, thrombocytopenia, or mild leukocytosis and/or thrombocytosis. Patients with rheumatoid arthritis may also show signs of non-Hodgkin lymphoma.
- Rheumatoid Factor (RF) and Antibodies to citrullinated protein and peptide antigens (ACPAs) – these are substances produced by the immune system that can be indicators of rheumatoid arthritis. A high RF level is associated with more severe joint disease and increased functional disability.
- Other autoimmune indicators, like Antinuclear antibodies (ANA) and Antineutrophil cytoplasmic antibodies (ANCAs).
Following laboratory tests, doctors may need to see imaging scans of your joints.
- Simple X-rays can show if inflammation is causing damage to your bones.
- Magnetic Resonance Imaging (MRI) is a more advanced method that gives a clear picture of how well your joints are doing.
- Musculoskeletal Ultrasound (MSK US) is another method that can detect early signs of inflammation and help monitor disease progression.
To classify the severity of rheumatoid arthritis, doctors may use the ACR/EULAR classification criteria, which assign points based on the number of inflamed joints, duration of symptoms, serology (RF and ACPA), and acute-phase reactants (ESR and CRP levels).
In addition to these tests, it’s beneficial for your doctor to assess your disease’s activity and how well it’s responding to treatment regularly. This can be done through markers of inflammation, patient-reported outcomes such as Health Assessment Questionnaires, pain levels, fatigue levels, and physician-reported outcomes such as tender joint count, and swollen joint count. Such checks can provide an overall picture of how the disease is affecting you and how well your current treatment is working.
Treatment Options for Hand and Wrist Rheumatoid Arthritis
Rheumatoid arthritis (RA) is a long-term autoimmune disorder that can lead to pain and discomfort in your joints and other areas of your body. At present, there is no cure for RA, but treatments have improved significantly over the past 20 years, thanks to the development of drugs known as biological disease-modifying anti-rheumatic drugs (DMARDs).
The objective of RA treatment is to manage and reduce symptoms to provide the best possible quality of life. This may involve trying to attain and maintain complete remission, where you don’t feel any symptoms. Other goals of treatment include prevention of structural damage to your joints and early management of any associated conditions that may arise due to the effect of RA on other parts of the body.
Various medications can be used to manage RA, but predicting which one will work best for a person’s condition remains uncertain. The decision to use one therapy over another depends on the patient’s specific situation, including the severity of their disease, their overall health and personal preference.
Research indicates that a combination of multiple medications is more effective than using one medication alone. Early and aggressive therapy is often favored to relieve symptoms and then potentially less aggressive treatment once remission has been achieved.
Old medications such as gold, penicillamine, minocycline, and doxycycline are typically not used any longer. Non-steroidal anti-inflammatory drugs (NSAIDs) can help relieve symptoms in the short-term but are not recommended for long-term use because of potential side effects. Similarly, long-term use of corticosteroids is generally discouraged because of the adverse effects they can cause.
The conventional synthetic DMARDs (cs-DMARDs) and biological DMARDs (b-DMARDs) are two important categories of RA medications. Cs-DMARDs include Methotrexate (MTX), Leflunomide (LFN), Sulfasalazine (SSZ), and Hydroxychloroquine (HCQ). Methotrexate is often used as the first drug of choice because of its proven effectiveness.
On the other hand, b-DMARDs are highly specialized drugs that target the pathways of the immune system. They can be used as the first line of treatment or when cs-DMARDs fail to control the disease. These drugs are administered along with cs-DMARDs for better disease control, but cannot be used simultaneously due to possible severe side effects.
Physical activity, support from patient education programs, and occupational therapy are important non-drug approaches for managing RA. A structured exercise program can help reduce fatigue, improve cardiovascular health, and improve mental well-being. Additionally, occupational therapy can offer tips and tools to help make daily tasks easier.
Despite advancements in medication, surgery may still be necessary in some extreme cases of RA where medication is not effective. Surgical options include synovectomy (removal of the inflamed synovium), tendon realignment, joint replacement and joint fusion. However, these options are rarely needed due to the effectiveness of current medical treatments.
What else can Hand and Wrist Rheumatoid Arthritis be?
Diagnosing rheumatoid arthritis (RA) isn’t straightforward. There isn’t a single test that can confirm this condition with complete certainty. Instead, the diagnosis is based on a combination of factors, like the patient’s symptoms, lab test results, and what their X-rays show. A number of other health problems can mirror the symptoms of RA, but careful evaluation of the patient’s history, physical exam, and other testing can rule out these other conditions.
Here are some diseases that can mimic the symptoms of rheumatoid arthritis:
Infections, such as:
- Hepatitis B, Hepatitis C, Parvovirus B19, HIV
- Lyme disease
- Widespread bacterial infections and infectious arthritis
- Subacute bacterial endocarditis, a form of heart infection
Osteoarthritis, including:
- Osteoarthritis affecting the hands
- Hand osteoarthritis with inflammation
Conditions called seronegative spondyloarthropathies, like:
- Psoriatic arthritis
- Reactive arthritis
- Inflammatory arthritis that comes along with inflammatory bowel disease
- Ankylosing spondylitis that also affects other joints apart from the spine
Crystalline arthropathies, which are joint conditions caused by crystal deposits, such as:
- Polyarticular gout, a type of gout affecting many joints
- CPPD arthropathy or pseudogout, conditions causes by calcium pyrophosphate crystal deposits
Other autoimmune and connective tissue diseases, including:
- Systemic lupus erythematosus
- Sjogren syndrome
- Systemic sclerosis
- Mixed connective tissue disease
- Behçet’s disease
There are also other diseases that can mimic RA, such as:
- Hemochromatosis (a disorder causing too much iron in the body)
- Relapsing polychondritis (a condition causing inflammation and damage to cartilage)
- Sarcoidosis (an inflammatory disease affecting various organs)
- Hypertrophic osteoarthropathy (a condition causing swollen joints)
- Amyloid arthropathy (a condition caused by abnormal protein deposits)
- Hemoglobinopathies (diseases of the blood like sickle cell disease)
- Hyperlipoproteinemias (conditions caused by high cholesterol or high triglycerides in the blood)
- Rheumatic fever (an inflammatory disease)
- Langerhans cell histiocytosis (a rare disorders that can damage tissue or organ)
- Arthritis associated with cancers or with immune checkpoint inhibitors (drugs used in cancer treatment)
What to expect with Hand and Wrist Rheumatoid Arthritis
Rheumatoid arthritis is a health condition that may have different outcomes for different people. Some factors contribute to a tougher journey with this disease, and these include various aspects such as a continuous increase in inflammatory markers like ESR (Erythrocyte Sedimentation Rate) and CRP (C-Reactive Protein) in your bloodwork.
If a person tests positive for rheumatoid factor and ACPA (Anti-Citrullinated Protein Antibodies), and particularly when their levels are quite high, it’s another indication of a challenging prognosis. This is also the case when the disease is not responding to two or more disease-modifying drugs.
Finding erosive disease or consistent inflammation through radiology imaging studies also points towards a more difficult prognosis. Your genetic history also plays a role – if many of your family members have the same condition, it could make yours more difficult to manage. Extra factors like smoking and starting treatment late can also worsen your prognosis, as well as high disease activity indices, which refers to a score resulting from tests to gauge the severity and activity of your disease.
Possible Complications When Diagnosed with Hand and Wrist Rheumatoid Arthritis
Taking early action against rheumatoid arthritis may help in controlling the disease and improving the patient’s ability to perform everyday tasks. However, there could be challenges in responding to therapy due to complications from the disease itself or the treatment. This can include heart and digestive system problems, weakening of the bones, lung issues, frequent infections, cancer, kidneys problems, and mental health issues. These additional health problems, along with the side effects of medication, can interfere with how effective the treatment can be, how well the patient can tolerate the medication, and ultimately, the patient’s life span.
List of Potential Complications:
- Heart problems
- Problems with the digestive system
- Weakening of the bones (osteoporosis)
- Lung issues
- Frequent infections
- Cancer
- Kidney problems
- Mental health issues
Preventing Hand and Wrist Rheumatoid Arthritis
A well-planned program for managing long-term diseases plays a crucial role in treating patients with Rheumatoid Arthritis (RA). This program includes patient education, support initiatives, self-assessment methods, paired with consistent follow-up and documentation. It’s integral to ensure that the patient understands their disease, receives necessary support, has ways to self-monitor their symptoms and that their progress is regularly recorded and reviewed.