Rheumatoid Arthritis Prevention-Management-Recovery
The first section of this article lays out the most common tests and treatments for RA. For the Fundamental Integrative Approach, and how diet plays a part, please skip down to the section titled Treating more than just the symptoms…
Musculoskeletal injuries and conditions are so common that in 2010, 1 out of 3 Americans sought treatment. Many of these were short term, sports or exercise related injuries like ankle sprains or back related injuries, but 1 in 5 out of these complaints are diagnosed cases of arthritis. An individual with arthritis may not be able to exercise important parts of the body, which could lead to further injury. The multi-faceted approach to rheumatoid arthritis has not been communicated effectively on a big enough scale to prevent over 1.5 million Americans from being diagnosed in 2010, according to the CDC (2010). Much higher figures are projected as the baby boomer generation reaches ages where 55% adults have some form of arthritis. Enough information is proven to help prevent, manage, or recover from rheumatoid arthritis, but it involves an integrated approach of nutrition, physical therapy and stress management, rather than a single modality. The good news is that it is simpler than most realize. Above all of the following research and statistics, one should walk away with this simple message; stretch often, eat well, and remember to breathe.
Rheumatoid arthritis is a musculoskeletal condition that is caused by inflammation of tissues surrounding joints. It causes the synovial lining of the joints to swell and become inflamed. This lining is invaded by white blood cells which fire off a variety of chemicals intended to destroy foreign invaders, but due to multiple variables, begin to attack self. Inflammation is a natural immune response to injury, irritation, or invasion by a pathogen orally or cutaneously. Immune cells rush to the site and signal other immune cells to join in efforts to defend and repair the injury. It is possible and increasingly common, however, for this system to become too anxious, if you will, and can cause considerable damage to surrounding tissues. In rheumatoid arthritis, pro-inflammatory immune cells “. . . attack the lining of the joint capsule, a tough membrane that encloses all the joint parts. This lining, known as the synovial membrane, becomes inflamed and swollen. The disease process can eventually destroy cartilage and bone within the joint” (Mayo Clinic, 2012) .
Unless it is diagnosed and treated early, it can cause significant damage to joints over time, leading to deformity and disability. The most common locations are the hands and the wrists. Tendons become inflamed, resulting in rupture and/or ulnar drift, where tendons and ligaments move out of proper position due to swelling, which leads to the commonly seen ulnar drift, where the fingers bend towards the pinky.
Just as the inflammation of the synovial lining degrades tendons and ligaments, it can do the same to local muscles. Muscle soreness and stiffness is an oft-reported symptom of Rheumatoid arthritis. This condition can also cause muscles to spasm.
Laboratory tests can analyze different types of body fluids and help pinpoint the type of arthritis you may have. “Fluids commonly analyzed include blood, urine and joint fluid. To obtain a sample of your joint fluid, your doctor will cleanse and numb the area before inserting a needle in your joint space to withdraw some fluid (aspiration).
Imaging tests can detect problems within your joint that may be causing your symptoms. Examples include:
- X-rays. Using low levels of radiation to visualize bone, X-rays can show cartilage loss, bone damage and bone spurs. X-rays may not reveal early arthritic damage, but they are often used to track progression of the disease.
- Computerized tomography (CT). CT scanners take X-rays from many different angles and combine the information to create cross-sectional views of internal structures. CTs can visualize both bone and the surrounding soft tissues.
- Magnetic resonance imaging (MRI). Combining radio waves with a strong magnetic field, MRI can produce more-detailed cross-sectional images of soft tissues such as cartilage, tendons and ligaments.
- Ultrasound. This technology uses high-frequency sound waves to image soft tissues, cartilage and fluid-containing structures such as bursae. Ultrasound also is used to guide needle placement for joint aspirations and injections.
In some cases, your doctor may look for damage in your joint by inserting a small, flexible tube — called an arthroscope — through an incision near your joint. The arthroscope transmits images from inside the joint to a video screen.
Arthritis treatment focuses on relieving symptoms and improving joint function. You may need to try several different treatments, or combinations of treatments, before you determine what works best for you.
The medications used to treat arthritis vary depending on the type of arthritis. Commonly used arthritis medications include:
- Analgesics. These types of medications help reduce pain, but have no effect on inflammation. Examples include acetaminophen (Tylenol, others), tramadol (Ultram, others) and narcotics containing oxycodone (Percocet, Oxycontin, others) or hydrocodone (Vicodin, Lortab, others).
- Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs reduce both pain and inflammation. Over-the-counter NSAIDs include ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve). Some types of NSAIDs are available only by prescription. Oral NSAIDs can cause stomach irritation, and some may increase your risk of heart attack or stroke. Some NSAIDs are also available as creams or gels, which can be rubbed on joints.
- Counterirritants. Some varieties of creams and ointments contain menthol or capsaicin, the ingredient that makes hot peppers spicy. Rubbing these preparations on the skin over your aching joint may interfere with the transmission of pain signals from the joint itself.
- Disease-modifying antirheumatic drugs (DMARDs). Often used to treat rheumatoid arthritis, DMARDs slow or stop your immune system from attacking your joints. Examples include methotrexate (Trexall) and hydroxychloroquine (Plaquenil).
- Biologics. Typically used in conjunction with DMARDs, biologic response modifiers are genetically engineered drugs that target various protein molecules that are involved in the immune response. Examples include etanercept (Enbrel) and infliximab (Remicade).
- Corticosteroids. This class of drug, which includes prednisone and cortisone, reduces inflammation and suppresses the immune system. Corticosteroids can be taken orally or be injected directly into the painful joint” (CDC, 2006)
The above tests and treatments are proven ways to diagnose symptoms and provide solutions to symptoms, but they are all temporary and do not treat the cause. Additionally, medications such as NSAIDs have been proven to increase intestinal permeability, which could have been one of the first dominos in the onset of RA to begin with. When choosing how to approach RA, take only absolutely necessary medications to control damage and pain, but also be vigilant in getting your body what it needs and remove what may be hurting it.
Recent discoveries in immunology, gastroenterology, psychoneuroimmunology, and physical therapy lay out a bigger picture scenario where the condition would have a difficult time existing in the body. First and foremost, we have to know what to do and what NOT to do so that we can incorporate the right foods, exercises, and stress management techniques into our lifestyles. We look to the source of the inflammation to find solutions.
Treating more than just the symptoms…
Not too long ago, it was accepted that the immune system could not be controlled pre-emptively, but we now know that what we eat and put into our bodies can affect our immune system through our gut. Our stress level and frequency influence immune cells just as significantly. Seeking treatment for symptoms of RA is certainly warranted, but it should be a way to buy time while seeking to address the cause.
The fundamental integrative approach of diet, stress management and physical therapy should take highest priority in the education of RA patients. To begin, we must understand the pathophysiology of the small intestine and the resulting circulating immune complexes.
Increased Intestinal Permeability:
What could the small intestine have to do with inflammation of the joints? The answer is Circulating Immune Complexes, which are formed from the integral binding of an antibody to a soluble antigen. This act in itself is normal and crucial to immune function. Immune complexes may themselves cause disease when they are deposited in organs and are a prominent feature of several autoimmune diseases, including systemic lupus erythematosus, cryoglobulinemia, rheumatoid arthritis, scleroderma and Sjögren’s syndrome. Studies have shown that CICs and “. . . immunological abnormalities typically found in established RA are found in the earliest phase of the disease we were able to investigate” (Hay, et al. 1983).
One place where these CICs can originate is in the epithelial cells of a damaged small intestine. The simple columnar epithelial cells of the small intestine play a very important role in the breakdown and absorption of molecules from food. These cells are the final disassembly line before molecules enter the bloodstream. Partially degraded proteins and other substances enter through endocytosis at the apical membrane, encapsulated in lysosomes, broken down, and released as amino acids and fully hydrolyzed molecules into the bloodstream that can be used as raw material for the body. They are fully broken down and cannot be recognized as foreign cells. Some molecules, such as water and glucose, can pass through the tight junctions between these cells. In other words, intestinal permeability is normal. (see figure 2)
When the epithelial cells fail to fully breakdown proteins and/or the tight junctions between these cells lose integrity, the permeability of this membrane is increased and macromolecules make it through to the bloodstream, where the immune system identifies the proteins as foreign and responds accordingly. This is ground zero for the production of CICs, and it has been demonstrated in numerous studies. Chronic intestinal permeability “. . . may permit the excessive absorption of many food proteins, leading to the formation of antigen-antibody complexes and autoimmunity” (Cunnigham-Rundles, 1981).
Increased intestinal permeability leads to increased antigen uptake. Once the immune system has identified a protein as a foreign invader, it creates an antigen to destroy it. These antigens do not simply disappear when they are done doing their job, with many of them congregating in the connective tissues around the joints. The macromolecules circulating in the bloodstream trigger the response, and these antigens become active, leading to inflammation in the areas in which they are present.
Amongst the debate between scientists on how to diagnose this issue, one consistency has emerged; maintaining a healthy gut, or healing a damaged one is paramount to one’s health. Some substances that damage the membrane include “. . .antibiotics, alcohol, caffeine, parasites, bacteria, some food preservatives and additives, and allergic states such as gluten sensitivity and lactose intolerance, corticosteroids, non-steroidal anti-inflammatory drugs, refined carbohydrates, oral contraceptives, and fungi” (MLO, 2007). Systemic Candidiasis has also been implicated. These sources can damage the protective coat that aids the body’s ability properly eliminate harmful substances. It is interesting to me that many chronic inflammatory disorders can actually be exacerbated by anti-inflammatories, yet this is what is typically prescribed and recommended. Avoiding many of these substances requires vigilance in label reading and proper education from an integrative or complementary and alternative medical professional. Clearly, addressing the actual cause of this issue requires a holistic approach, rather than a symptom oriented one.
Avoiding harmful substances is crucial to prevention, and is also the first of a number of steps to healing. Oral supplementation with probiotics and digestive enzymes help restore intestinal permeability. Probiotics, including Lactobaciilus acidophiius, Propionibacterium freudenreichii shermanii, and Bifidobacterium bifidum, maintain good bacteria in the small intestine. These macrophages aid in the breakdown of food particles and other bacteria and toxins considerably. The recommended dosage is 6 to 18 billion bacteria used three times daily. Digestive enzymes, also made in the body, can be supplemented to boost the speed of the breakdown of food into molecules of manageable size.
“Substances that promote healing include high-fiber foods rich in antioxidants, such as cabbage, cauliflower, beets, and onions; omega-3 fatty acids found in salmon and flaxseed, multi-mineral supplements and digestive enzymes such as bromelain and pancreatin” (MLO, 2007). Chinese herbal medicine, used for centuries, has actually been studied for the treatment of IBS with good results. In a randomized, double-blind placebo-controlled study of a 20 herb formula developed by a Chinese medicine practitioner, the individualized treatment group showed 75% improvement after 6 months, the group receiving a standardized formula, 63%, and the placebo group, only 32% (Kiefer & Ali-Akbarian, 2004).
More studies are needed to pinpoint various mechanisms of gastrointestinal originating auto-immunity, but enough is known to begin to educate the public today about the important of maintaining a healthy gut by avoiding harmful toxins, drugs, caffeine, refined carbohydrates, and food chemicals, and by obtaining more fiber rich vegetables and fruits with antioxidants, maintaining intestinal flora balance with probiotics, and a proper balance (1:2) of anti-inflammatory omega-3 PUFAs to pro-inflammatory omega-6 PUFAs. Remember that around 70% of the immune system is housed in Peyer’s Patches and the surrounding area in, on, and around the intestinal tract. Your gut is the front line and should be prioritized as such.
The connection between mind and body is not like a set of wires plugged into specific sockets, it’s in every cell. Our emotions influence neuropeptides, our perception of events effects our hormones, our immune system produces and receives all of the above, and all of these effect each other and every body system down to the cell through chemical reactions, conditioned behavior and nerve impulses.
Stress is now recognized as an important risk factor in the pathogenesis of autoimmune rheumatic diseases by considering that the activation of the stress response system influences the close relationships existing between the hypothalamic-pituitary-adrenal axis, the sympathetic nervous system and the immune system. The stress response results in the release of neurotransmitters (norepinephrine), hormones (cortisol) and immune cells which serve to send an efferent message from the brain to the periphery.
“In a recent analysis, evaluating 3,000 patients with RA from 27 independent observational studies on minor stress, minor stress was related to an increase in disease activity. In 2 prospective studies on RA, disease flare-ups were linked to a higher number of interpersonal minor stressors few days prior to the visit. In addition, a longitudinal study over a period of 5 years showed that RA patients with a higher daily stress level at baseline had a poorer outcome and significantly more bony erosions after 5 years” (Cutulo, 2006).
We must remind ourselves, our patients, friends, and families that any life event, major or minor, is only as stressful as we perceive it to be. People considered “high-strung” such as those with type-A personalities, are at greater risk due to their reaction to daily stimuli. Stress management can be recommended as a way to reduce risk of RA as well as many forms of cancer and heart disease. Some well studied stress management modalities include specifically stress-tailored Yoga therapy, meditation, guided imagery, and in more extreme personalities, anger management.
In a study on the effects of a stress reducing yoga therapy program on RA, “Participants reported decreased pain, fatigue, swelling, and flares; increased energy; pain-free range of motion and strength around affected joints; and a heightened sense of well-being” (Stewart, 2013).
Stress has been proven to be alleviated by the other aforementioned therapies as well, and lower stress means lower cortisol, which means less-no inflammation. In addition to the dietary protocols, stress management appears to be a very effective tool in the RA prevention and management kit.
Keeping the joint, muscles, tendons, and ligaments conditioned and maintaining range-of-motion can also buy some time while the cause is addressed. The following treatments are the most promising, although more studies are needed to conclusively prove their efficacy.
- “Acupuncture. This therapy uses fine needles inserted at specific points on the skin to reduce many types of pain, including that caused by some types of arthritis.
- Glucosamine. Although study results have been mixed, it now appears that glucosamine works no better than placebo. However, glucosamine and the placebo both relieved arthritis pain better than taking nothing, particularly in people who have moderate to severe pain.
- Transcutaneous electrical nerve stimulation (TENS). Using a small device that produces mild electrical pulses, TENS therapy stimulates nerves near the aching joint and may interfere with the transmission of pain signals to the brain.
- Yoga or tai chi. The slow, stretching movements associated with yoga and tai chi may help improve joint flexibility and range of motion in people with some types of arthritis.
- Massage. Light stroking and kneading of muscles may increase blood flow and warm affected joints, temporarily relieving pain. Make sure your massage therapist knows which joints are affected by arthritis” (CDC, 2006).
The most important thing we can take from this fundamental integrative approach is that most of the power is in our hands. It is important to consult your doctor to determine if your pain stems from RA, or another condition entirely. That being said, you can immediately take steps to avoid damaging and begin healing the gut, reducing stress, and maintaining joint ability on your own while waiting for diagnosis and symptom management aids. To some, this may all seem complicated, but in essence, it is a very positive and rather simple message: You can control your RA, and in some cases stop it entirely, by making changes to your diet and lifestyle. An ounce of prevention is worth a pound of cure, and a few hours of education can save so much time and money while removing or preventing pain from you or your loved one’s life.
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