Rheumatoid Arthritis Center

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The Universal Guide to Rheumatoid Arthritis: Everything you ever wanted to know, straight from the experts.

In This Article: What Is Rheumatoid Arthritis?   |    RA and the Spine   |    Symptoms   |    Risk Factors   |    Diagnosis   |    Treatment  |    Lifestyle Changes   |    FAQs   |    Sources

Picture your body as a night club. Your immune system is like the security team, those big, burly bouncers stationed around and outside the club. One of its main duties is to keep out undesirables and eject the troublemakers.

But what happens healthy tissue is minding its own business and bouncers come over and tries to roust it? Inflammation, pain, and possibly even disability. In the case of RA, it’s your joint lining that’s mistakenly hassled, harried, and hurt by the immune system.

various x-ray images of areas that can become arthriticRheumatoid arthritis (RA) can affect any of the body's joints. Approximately 1.5 million people in the United States have RA. Photo Source: 123RF.com.

You won’t always get RA in your spine—in fact, RA is more common in other joints, such as your knuckles or your knees. But if your back hurts, and you also have some other body-wide symptoms such as fever and other signs of systemic inflammation, you may have RA of the spine. Here’s what you need to know about RA: what causes it and why, how to tell if you have it, and what you can do about it.   

What Is Rheumatoid Arthritis?

“Arthritis” is an umbrella term used to explain inflammation, joint pain and joint disease in one or more joints. There are more than 100 types of arthritis, and RA is the second-most common.

Signs of RA include aches and pains, stiffness, swelling and tenderness in the joints – and the symptoms can come out of the blue. It’s important that you see your doctor right away if you have these symptoms.

Often times, RA is confused with the other most common type of arthritis called osteoarthritis (OA), which you might know as wear-and-tear arthritis (in the spine it’s called spondylosis). While the two diseases both cause joint pain, osteoarthritis tends to develop over time as the joint tissue that protects the bones wears away and causes the bone to rub against bone.

On the other hand, RA is an inflammatory disease and doesn’t just affect your joints. RA symptoms develop over just a few weeks or months and often begin with cold and flu-like symptoms such as fever, weakness and fatigue. While both conditions cause morning stiffness, those with osteoarthritis are likely to feel better after a few minutes of movement, while it may take those with RA an hour or more to find relief.

Here’s how RA works specifically:

Your joints each have a casing around them called a joint capsule. The joint capsule has a thin lining on the surface called the synovium that works to produce joint fluid which helps lubricate the joint, making it easy to bend and move.

Different types of arthritis affect different parts of the joint. In a joint with RA, the synovium, or joint tissue, becomes inflamed and damaged. Usually, a healthy immune system attacks foreign “invaders” like bacteria and viruses, but with RA, immune cells mistake healthy joint tissue as the enemy. `Basically, your body attacks itself from the inside.

The first joints affected are usually the wrist and the small joints of your hands and feet. As it progresses, it can spread to other joints, including those in your spine, as well as your organs.

That may sound pretty scary, but RA doesn’t have to be. Studies suggest that early treatment can dramatically reduce your risk for severe joint damage, joint replacement, and other RA-related health problems. That’s why you need to take swift steps toward disease control.

“We always try to get the patient in remission as quickly as possible to avoid any complications, since the longer you go without treatment, the greater the risk of permanent damage,” says Robert Koval, MD, an internist and rheumatologist at Texas Orthopedics, Sports & Rehabilitation Associates in Austin, Texas.

How Does RA Affect the Spine?

The spine is divided into four regions: 

  • Cervical (neck)
  • Thoracic (upper or mid-back)
  • Lumbar (lower back)
  • Sacral (sacrum, back of the pelvis)

When RA causes spinal problems, they’re usually in the cervical spine – but even this is relatively rare.

“If it does hit the cervical spine, that means it’s a very aggressive form of RA,” says Dr. Koval.

Posterior spinal segment labeledPosterior spinal segment labeled. Photo Source: SpineUniverse.com.

RA of the cervical spine can cause called C1-C2 instability, meaning the first two vertebrae up at the top of the spine are more affected, Dr. Koval explains. “It’s thought there is more synovium [joint lining] in that area, so that’s why they’re more affected than other areas [of the spine],” he adds.

RA can loosen ligaments, erode bone, or cause thickened tissue around the atlantoaxial joint (between the C1 and C2 vertebrae, aka the atlas and the axis, respectively).

The good news is that most back problems aren’t caused by RA. If you do have arthritis-related back pain, it’s more likely due another condition, such as:

  • Ankylosing spondylitis, a chronic inflammatory disease
  • Psoriatic arthritis, which often involves the skin as well (psoriasis)
  • Spinal osteoarthritis or spondylosis, which occurs when your cushiony joint cartilage wears away
  • Spinal stenosis, a narrowing of the spinal canal usually due to a herniated disc
  • Polymyalgia rheumatica, which causes causing widespread pain and stiffness
  • Fibromyalgia, an arthritis-related condition that causes muscle pain and fatigue
  • Osteoporosis, which causes brittle bones and possibly spinal fracture

What Are Rheumatoid Arthritis Symptoms ?

If you’re one of the 1.5 million Americans with RA, you’ll likely have joint stiffness in the morning that lasts more than 30 minutes, and it’ll go on for at least six weeks. You can also experience other symptoms, such as: 

  • Fatigue: Inflammation throughout the body can result in physical weakness, drowsiness and fatigue. Many say this is one of the most difficult parts of having RA.
  • Fever: A low-grade fever is also a result of inflammation throughout the body, however, a fever could also indicate an infection.
  • Loss of appetite: During flare-ups, one of the first symptoms some people experience is loss of appetite. Some even notice weight loss, too.

What Are Risk Factors for RA?

Scientists don’t know exactly why some people develop RA, but they believe it’s due to a combination of factors. These include:

  • Rheumatoid factor (RF). This is a normal component in blood, but about 80% of patients with RA have higher-than-normal levels of RF. These patients are called seropositive.
  • Age. Rheumatoid arthritis can develop at any stage of life, but onset is usually between 30 and 60 years of age in women. Men tend to develop RA later in life.
  • Gender. About 75% of RA patients are women, though cervical spine involvement is more common in men.
  • Family history. You’re more likely to develop RA if a family member has it.
     
  • Genes. Certain genetic markers, including human leukocyte antigens, or HLAS, are believed to play a role. However, they don’t determine whether you’ll get RA. Genetic makeup is only one ingredient in the mix.
  • Smoking. Numerous studies show smoking is a clear risk factor for RA, including one Swedish study that suggests smoking could contribute to up to 20% of RA cases.
  • Obesity. Obesity is often seen alongside RA. One Mayo Clinic study found that people with obesity are 25% more likely to develop rheumatoid arthritis than people of normal weight.

How Is Spine Rheumatoid Arthritis Diagnosed?

If your doctor suspects RA is affecting your cervical spine, expect a hands-on physical exam that involves neck movement in all directions. Your doctor will assess:

  • Joint inflammation or tenderness
  • Difficulty moving
  • Pain severity
  • Range of motion (how far your joints move)
  • Instability
  • Misalignment
  • Deformity

Your doctor will also note symptoms of fatigue, stiffness, and weakness, and ask how the symptoms affect your daily life. Be prepared to answer any questions about your symptoms and history, such as how long you’ve had the discomfort and whether or not any of your family members have RA or any other autoimmune disease. 

In addition to a physical exam and history, you may get blood tests that measure:

  • C-reactive protein
  • Rheumatoid factor
  • Anti-citrullinated protein antibodies
  • Antinuclear antibodies
  • Erythrocyte sedimentation rate

One or more of these markers may be elevated in people with RA, but not always.

Images of your joints may be taken with X-rays, CT scan, or MRI. These will tell if the bones have shifted, are damaged, or if there is unusual bone or tissue growth.

If you are ultimately diagnosed with RA in your spine, it’s probably a long-standing, active form of the disease, explains Joseph Martinez, MD, an internist and rheumatologist at Texas Orthopedics, Sports & Rehabilitation Associates in Austin, Texas. “This can contribute to instability of the vertebra of that area of the spine and cause the pain,” he says. 

What Is the Best Rheumatoid Arthritis Treatment?

When it comes to RA, the answer to questions about the best treatment will always be, “It depends.” It depends on your overall health, your level of disability, your risk tolerance and more. That said, you’re going to have a number of treatment options, and you and your treatment team will be able to choose the best RA treatment for you.

Disease modifying medication is crucial to slowing or stopping the march of RA through your body. But many people don’t want to take medications at all – especially after they see the ads on TV that list “very rare side effects of these medications that we typically do not see,” says Dr. Koval.

To reduce your risk of all side effects, not just the worst of them, you and your doctor will work together on a drug regimen that’s right for you. “We will typically have patients get on a lower grade medication fairly quickly, see how they do, and then adjust,” Dr. Koval says. “Many people with RA will have to try multiple medications to figure out the best treatment option that will drive them into remission.”

One thing you shouldn’t do: Go off your medications out of frustration. In fact, it may never be a great idea to stop taking them. “At least 90 to 95% of patients that have RA will always flare up if they come off medication, so I never recommend people come off of their medications,” says Dr. Koval.

He’s referring to disease-modifying drugs, but there are several other types that may also be important if you have RA. Here are the broad categories of RA drug treatments.

  • Disease-modifying anti-rheumatic drugs (DMARDs): Methotrexate is one example of a common, first-line DMARD to slow disease progression. A DMARD may be combined with a nonsteroidal anti-inflammatory drug (NSAID), which addresses the symptoms while the DMARD works on modifying the disease. You may not notice improvement in two to four months. If you haven’t improved much after about six months, you may need to add another drug to your regimen – or go off methotrexate and take something else.  
  • Biologic drugs: Anti-TNFs (Tumor Necrosis Factor)/TNF Inhibitors. Biologic drugs called TNF inhibitors block the action of TNF, a protein that promotes inflammation. TNF inhibitors include adalimumab (Humira) and etanercept (Enbrel). TNF inhibitors are usually suggested after trying other RA medications, but they can also be used in combination with traditional DMARDs.
  • Other biologics. These drugs work on different components of the immune system and are usually given when other disease-modifying drugs haven’t worked well enough. Most non-TNF biologics, such as abatacept (Orencia), will need to be used in conjunction with other medications to ensure maximum efficacy.
  • Janus Kinase Inhibitors (JAK). This newer class of drug targets JAK pathways that are involved in the immune response. They may be a good option for those who don’t respond well to other medications or who experience serious side effects of other RA medications. Tofacitinib (Xeljanz) belongs to this drug class.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs). Prescription and over-the-counter NSAIDs, including ibuprofen (Advil) and naproxen (Aleve), can reduce pain and inflammation. Most people with RA will have more success with higher doses of these medications. NSAIDs should be taken with food to reduce the risk of stomach upset and stomach bleeding.
  • Corticosteroids. These drugs, including prednisone, can significantly reduce inflammation can slow joint damage for those in the early stages of RA. Corticosteroids are generally not used long-term. Side effects can include bone thinning, bruising, weight gain, and high blood pressure.
  • Antidepressant drugs. Research suggests more than 40 percent of those with RA will experience symptoms of depression such as sadness, low energy levels and loneliness. In addition, depression can often make the pain associated with RA worse. Antidepressants can offer some relief on both fronts.

What Are Some Lifestyle Changes You Can Make to Improve RA?

To reduce your risk of getting RA or having severe symptoms, put “make healthy choices” at the top of your to-do list. That doesn’t mean adding a green smoothie to your fast-food diet, or occasionally taking a long walk. A healthy lifestyle means consistent, conscious choices to eat well, exercise (short walks count), reduce stress, and get ample, restful sleep.

“We know there is a genetic factor to it and there’s no way to stop that portion of it. However, environmental and lifestyle factors [may] lead to RA’s development if you have the generic exposure,” Dr. Koval says. Those are the parts you can control.

  • Eat well. There’s no single diet for RA, but Mediterranean-style eating has been shown to reduce symptoms. The diet focuses on adding more unprocessed foods and healthy fats while cutting back on red meat and processed foods. Mediterranean-style eating  includes foods like vegetables, fish and olive oil which contain fiber, beta carotene, magnesium and omega-3’s. These properties have been suggested to help control inflammation throughout the body, and in turn, common RA symptoms.

    Following a Mediterranean-style eating plan can also help you keep your weight under control. Being overweight or obese can make the symptoms of RA worse, cause the condition to progress more quickly, and up your risk for a variety of other health issues like diabetes and heart disease. Having excess fat tissue as a result of extra weight or obesity causes increased levels of cytokines, or proteins that cause inflammation.
  • Control your stress. “High stress levels of stress events have been shown to bring out some of the symptoms of RA or [even trigger] the disease,” says Dr. Koval. That’s because when you’re stressed, your body naturally responds and your muscles tense up, your heart rate increases and your breathing quickens to help you cope. Although it can help in the moment, over time, the increased tension on your muscles can make the pain and discomfort worse. And stress can also cause inflammation throughout the body, leading to joint damage in the those with arthritis.

    Find what works for you to reduce the stress in your life: meditation, yoga, talk therapy, tai chi, or medications are all good options, alone or in combination with each other.
  • Exercise. When you have back pain, you don’t want to exercise. But the fact remains that exercise is among the best things you can do for your long-term spine health and preservation of your mobility.

    Keeping your spine healthy will allow you to move comfortably well into your later years. Good examples of exercises for people with RA include:
  • Flexibility and strengthening moves
  • Aerobic exercise such as walking and biking
  • Hydrotherapy, or water-based exercises 
  • Practice good posture. When you’re exercising and throughout your day, be sure to practice good posture. Good posture does more than keep your spine in healthy alignment; it helps prevent spinal injury. Proper posture supports the spinal muscles that keep you upright. Practice good posture now, and your spine will support you for years to come.
     
  • Use heat and cold therapy. Cold therapy can decrease swelling during painful flare-ups. Heat therapy can relax your tired joints and speed up blood flow to the painful area. Extra blood delivers extra oxygen and nutrients.
     
  • Gentle massage. Research shows it can also improve chronic neck pain – independent of other treatments. Check with your doctor or physical therapist to find out if you need to know about any limitations in pressure or style of massage.
     
  • Improve your sleep. People with RA often get poor-quality sleep, often due to pain. That kicks off a vicious cycle, since poor sleep makes pain worse. Getting your disease under control with medications has been shown to help. But what if it doesn’t help enough? Talk to your doctor, who may recommend other strategies, medications, or a visit to a sleep medicine specialist.

It may seem like RA requires a lot of work to manage, but the reward can be great. Dr. Martinez wants people with RA to know that there is largely no reason you can’t get to an optimal level of control and improve your physical condition. “Patients go on living their life to a largely normal degree,” he says. You might not be running a marathon any time soon, but all kinds of activities – from lifting your grandchild to hitting the slopes to getting in and out of a car with ease – can all be within reach once again.

If you’re having symptoms, it’s important to see your doctor right away, since seeking treatment early can keep your symptoms at bay, but also lower the risk of the arthritis spreading to the spine. Remember there are very successful treatment options, and that a few lifestyle habits, like healthy eating, regular exercise and de-stressing can all help minimize your symptoms, too.

FAQs

What are the first signs of rheumatoid arthritis?

Early signs of RA include fatigue, swelling, pain and joint stiffness.

What is the difference between osteoarthritis and rheumatoid arthritis?

Though they both carry the title “arthritis,” osteoarthritis and rheumatoid arthritis are vastly different. RA is an autoimmune disease, while OA is a result of age and wear-and-tear.

How do you get rheumatoid arthritis?

Researchers don’t know the exact cause of RA. They suspect it’s a combination of age, gender (women are more likely to have it), genetics and environmental factors such as obesity and smoking.

Sources

Intro: Centers for Disease Control and Prevention. (2020) “Rheumatoid Arthritis.” https://www.cdc.gov/arthritis/basics/rheumatoid-arthritis.html

 Arthritis Foundation.“Rheumatoid Arthritis.” https://www.arthritis.org/diseases/rheumatoid-arthritis

National Institutes of Health. (May 21, 2019) “Understanding rheumatoid arthritis at the cellular level.” https://www.nih.gov/news-events/nih-research-matters/understanding-rheumatoid-arthritis-cellular-level

Harvard Medical School. (N.d.) “Explain the pain – Is it osteoarthritis or rheumatoid arthritis?” https://www.health.harvard.edu/pain/explain-the-pain--is-it-osteoarthritis-or-rheumatoid-arthritis

RA and Spine: International Journal of Rheumatology. (2015) Rheumatoid Arthritis and the Cervical Spine: A Review on the Role of Surgery.”  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4553335/

Arthritis foundation. (N.d.) “When Back Pain May Mean Arthritis.” https://www.arthritis.org/health-wellness/about-arthritis/where-it-hurts/when-back-pain-may-mean-arthritis

Symptoms and Risk Factors: Arthritis Foundation. (N.d.) “Rheumatoid Arthritis.” https://www.arthritis.org/diseases/rheumatoid-arthritis

Best Practice & Research, Clinical Rheumatology. (2017) “Genetic and environmental risk factors for rheumatoid arthritis.” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5726551/#__ffn_sectitle

National Center for Biotechnology Information. (2020) “Rheumatoid arthritis: Living and dealing with fatigue” https://www.ncbi.nlm.nih.gov/books/NBK384467/

Arthritis Foundation. (N.d.)“How Fat Affects Rheumatoid Arthritis.”  https://www.arthritis.org/health-wellness/about-arthritis/related-conditions/other-diseases/how-fat-affects-rheumatoid-arthritis

Arthritis Foundation. (N.d.) “How Stress Affects Arthritis.” https://www.arthritis.org/health-wellness/healthy-living/emotional-well-being/stress-management/how-stress-affects-arthritis

Medications: Johns Hopkins Medicine. (N.d.) “Rheumatoid Arthritis Treatment.” https://www.hopkinsarthritis.org/arthritis-info/rheumatoid-arthritis/ra-treatment/#NSAID

American College of Rheumatology. (N.d.) “TNF Inhibitors.” https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Treatments/TNF-Inhibitors

Journal of the American Medical Association. (September 20, 2016) “Non–TNF-Targeted Biologic vs a Second Anti-TNF Drug to Treat Rheumatoid Arthritis in Patients With Insufficient Response to a First Anti-TNF Drug.” https://jamanetwork.com/journals/jama/fullarticle/2553449

Arthritis Foundation. “Your RA is in Remission! Now What?“ https://www.arthritis.org/health-wellness/treatment/treatment-plan/disease-management/your-ra-is-in-remission!-now-what

Arthritis Foundation. “Can Antidepressants Help People With Rheumatoid Arthritis?” https://www.arthritis.org/health-wellness/healthy-living/emotional-well-being/anxiety-depression/antidepressants-with-rheumatoid-arthritis

Lifestyle: Arthritis Foundation.“Rheumatoid Arthritis.” https://www.arthritis.org/diseases/rheumatoid-arthritis

Clinical Journal of pain. (2009) “Randomized Trial of Therapeutic Massage for Chronic Neck Pain.” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2664516/   

Journal of Clinical Medicine. (2018) “Sleep Quality in Patients with Rheumatoid Arthritis and Associations with Pain, Disability, Disease Duration, and Activity.” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6210607/

Arthritis Foundation. (n.d.) “Mediterranean Diet for Osteoarthritis.” https://www.arthritis.org/health-wellness/healthy-living/nutrition/healthy-eating/mediterranean-diet-for-osteoarthritis

Updated on: 11/03/20
Robert Koval, MD
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What Is Rheumatoid Arthritis?

Rheumatoid arthritis (RA) is the most debilitating type of arthritis because it can cause deformity and disability. RA may affect the cervical spine and cause the facet joints in the neck to become inflamed and painful.
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