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Rheumatoid Arthritis or Osteoarthritic Fingers

My grandmother had big knuckles in her fingers, Herberden's nodes, and when I turned thirty, many years before even finding my first grey hair, I noticed hard nodules on my own knuckles. There was family history clearly, but was this rheumatoid arthritis or might it be osteoarthritis in the fingers, and why does it matter? The differences is that rheumatoid arthritis is inflammatory, an autoimmune condition, which can lead to significant disfigurement and disability, while osteoarthritis can also be quite disabling, but it results more from long-term wear-and-tear.


Rheumatoid arthritis (RA) is the most common inflammatory arthritis and like many autoimmune diseases, its underlying cause is multifactorial (Wasserman, 2011) but it impacts about 1% of people. We can be genetically vulnerable, with the human leukocyte antigen-DR4 and DRB1, as well as a variety of alleles playing a role. The STAT4 gene and CD40 locus have also been implicated in RA. Smoking is a major trigger, especially when genetics also plays a role. Infections often unmask autoimmune responses as well, but no particular pathogen has been linked to RA.



Rheumatoid arthritis is a chronic inflammatory disorder that can affect more than just your joints. In some people, the condition can damage a wide variety of body systems, including the skin, eyes, lungs, heart and blood vessels. Like all autoimmune diseases, rheumatoid arthritis occurs when your immune system mistakenly attacks your own body's tissues, a sort of over-zealous immune system response. Unlike the wear-and-tear damage that occurs with osteoarthritis, rheumatoid arthritis affects the lining of your joints, causing a painful swelling that can eventually result in bone erosion and joint deformity. The inflammation associated with rheumatoid arthritis can also damage other parts of the body.


Rheumatoid Arthritis


Individuals with rheumatoid arthritis notice tender, warm, and swollen joints. They also have stiffness, usually worse in the mornings after inactivity, and many times, fatigue, fever, and loss of appetite (Wasserman, 2011). Early rheumatoid arthritis tends to affect your smaller joints first, such as those in your hands and feet. As the disease progresses, this may spread to your wrists, knees, ankles, elbows, hips and shoulders. Many times, these symptoms are specific to just one side, but they can be on both sides of the body as well.


About half of people who have rheumatoid arthritis, also experience signs and symptoms beyond the joints, such as inflammatory flare-ups on their skin, in their eyes and lungs, heart and kidneys, even salivary glands, nerves, bone marrow and blood vessels. These symptoms, similar to most all other autoimmune diseases, vary in severity and may seem to resolve at times, but then flare-up again. Over time, joints can deform or shift out of place.


Women are much more commonly those who suffer with rheumatoid arthritis (Wasserman, 2011), and any other autoimmune diseases as well. This can present at any age, but more often in middle age. Pregnancy often causes remission, as it does most all autoimmune diseases, because the immune system is less triggered during pregnancy, in effort to tolerate the growth of the child. The more pregnancies as well, the less significant rheumatoid arthritis, and breastfeeding also decreases risk so that breastfeeding just 24 months decreases your risk of RA in half. Menstruating prior to 10 years of age however, increases risk and if cycles are irregular, risk is even higher. Use of oral contraceptive pills does not seem to impact risk.


Smoking is a significant trigger and also makes the disease much more worse. Obesity also seems to trigger rheumatoid arthritis. When RA does present, it can increase the risk of osteoporosis. It is also associated with rheumatoid nodules, or firm bumps of tissue that are often on pressure points, but can also form in the heart and lungs. Dry eyes and mouth, even Sjogren's syndrome, is associated with rheumatoid arthritis.


If at least one joint is identified as swollen, not related to trauma or another disease, then testing should be initiated. We might see involvement in just one large joint or one to three smaller joints. The clinician will use a scoring system to assign points for screening based on the number of joints impacted, as well as draw blood to identify markers for RA. Ultimately, autoimmune diseases such as RA are often characterized by the presence of autoantibodies. The Anti-citrullinated protein antibody is more specific for RA, with about 50 to 80% of people having positive findings for rheumatoid factor, anti-citrullinated protein antibody, or both. Individuals with RA may also have a positive antinuclear antibody test (ANA), which is especially important when testing little ones. C-reactive protein is another inflammatory marker we look for when we suspect rheumatoid arthritis, as well as erythrocyte sedimentation rate.


An overall wellness panel should accompany more specific testing for RA because we want to evaluate the overall health of the physical body. The kidneys and liver are important evaluations, as is anemia as many with chronic disease also suffer anemia or even gastrointestinal disease. X-rays are also an important evaluation, of both hands and feet, to evaluate erosive changes over time.


Functional Medicine Approach to Rheumatoid Arthritis


Largely this is about protecting and supporting the immune system and rheumatoid arthritis can be lead into remission. The earlier RA is identified and addressed, the easier this is but functional approaches can improve symptoms, even when remission is not attained.


Infections in themselves, trigger autoimmune responses so avoiding influenza, pneumonia, shingles, and COVID-19 are important. Maybe this is done via vaccine, but minimizing overall inflammation is key. We can start to address this through a clean diet, specifically vegetarian or a Mediterranean diet. My preference is MRT testing and LEAP therapy, and then moving towards Mediterranean so we can eliminate inflammation in the gut.


Improving detoxification pathways through knowledge of personal epigenetics and support of the liver and kidneys can also be helpful. Glutathione, alpha lipoic acid, NAC, and flavanoids otherwise would be great support for the immune system. Addressing the lymph system through massage, sauna work, even acupuncture may prove beneficial.


Botanicals can be very supportive as well, of the immune system, but also the nervous system. Autoimmune disease is very life altering so certainly that fight-or-flight response can be triggered and then the immune system and nervous system begin to trigger one another. Evening primrose oil and black currant seed oil are often used for inflammatory conditions, and each of these, along with Thunder God Vine or Tripterygium wilfordii have demonstrated effectiveness with treating RA (Wasserman, 2011).


Improving body composition, the proportion of fat to lean muscle, is important for those with rheumatoid arthritis or even osteoarthritis. Muscle mass is the energy resource for our immune system, so those with lower muscle mass will do more poorly. Exercise training programs are tricky because we have to identify a plan that doesn't aggravate joint pain. Restorative yoga is my go to here, or even chair yoga. Keep in mind, yoga is not about becoming flexible. It's about checking in with your body and finding what works for you. This practice looks different for everyone, but it absolutely can serve everyone.


Carpel tunnel syndrome can be a consequence of rheumatoid arthritis, as the swelling in the wrists can compress the nerves that most often serve your hand and fingers. Even arteries in your heart can become inflamed and in time, harden and suffer blockage. Lungs, too, can become inflamed and scared, and lymphomas are twice as likely in those with RA (Wasserman, 2011). Those with RA live three to 12 years less than the general population, which is largely related to accelerated cardiovascular disease.


Conventional therapy is challenging especially in childbearing women as these medications can have deleterious effects on pregnancy (Wasserman, 2011). Our goal is to minimize joint pain and swelling, prevent future deformity or worsening of it, as well as prevent radiographic damage such as erosions. Maintaining quality of life is vital, both personal and work, as about half progress towards disability within 10 years of diagnosis. Disease-modifying antirheumatic drugs (DMARDs) are the mainstay of conventional therapy for RA, with methotrexate being the first-line of treatment. Azulfidine or Plaquenil is often used when disease activity is mild and there isn't fear of poor prognosis features. Combination therapy is also more effective than a single approach, but of course, adverse effects are then greater. Many times anti-inflammatory agents, such as NSAIDs and corticosteroids are used for controlling pain and inflammation, but really these should be very short-term, again, with the DMARDs being the preferred therapy. Joint replacement surgery may prove necessary for some.


Potential Misdiagnosis


Clinicians always create a list of diagnosis that are potentials in any case we encounter, and we call this the "list of differentials." When we are looking at someone presenting with suspected RA, we must also consider lupus erythematosus, systemic sclerosis, and psoriatic arthritis, particularly when findings are present on the skin (Wasserman, 2011). If there is shoulder or hip involvement, we might think polymyalgia rheumatica, even temporal arteritis which can be very serious. A chest x-ray can help us evaluate for sarcoidosis.


Complaints of back pain may relate to inflammatory bowel disease, or if presenting with inflammatory eye disease, then we may think spondyloarthropathy (Wasserman, 2011). When symptoms have been more recent, less than six weeks, then this may simply be viral. Joint pain are often the only symptom of any particular virus, such as parvovirus. Recurrent, self-limiting episodes of joint swelling suggest crystal arthropathy, and arthrocentesis should be performed to evaluate for monosodium urate monohydrate or calcium pyrophosphate dihydrate crystals.


When numerous myofascial trigger points and somatic symptoms are present, think fibromyalgia, which can coexist with RA (Wasserman, 2011). A referral to a rheumatologist may be helpful in these cases.


Osteoarthritis in the Hands


I've written about osteoarthritis before, but we often forget the hands can be part of this presentation. Too often this goes undiagnosed, but osteoarthritis is the most common form of arthritis, and unlike rheumatoid arthritis, OA affects the entire joint, including cartilage degradation, bone remodeling, oteophyte formation, and synovial inflammation, leading to pain, stiffness, swelling, and loss of normal joint function (Koasinski et al., 2022). My suspicion is that my own finger arthritis results from long days of typing at my computer and I suspect into the future, we will see more of this, although my grandmother's may have resulted from lots of handwriting.


The underlying cause is inflammation here too, with osteoarthritis of the fingers, but this isn't an autoimmune response. This presentation is more from wear-and-tear, so while we look still at weight loss and yoga or tai chi for reducing inflammation, as well as the diet and grounding in nature as an overall approach to full body wellness, when we want to address osteoarthritis specifically in the hands, heat, therapeutic cooling, cognitive behavioral therapy, acupuncture, kinesiotaping, paraffin, NSAIDs, steroids, tramadol, duloxetine, and chondroitin are all common approaches to treatment. Most recommendations eliminate botanical approaches unfortunately, nor really address supporting the immune system which is the mainstay of the functional medicine approach, but certainly this would be part of my own approach, as my clients agree. Fish oil and vitamin D are important here as well.


Finger arthritis, either from rheumatoid arthritis or osteoarthritis, is important to diagnose and treat early to prevent disfigurement and disability. Connect if you'd like to address this as part of your own wellness plan.


References

Fuggle, N., Bere, N., Bruyere, O., Rosa, M. M., Yerro, M. C. P., Dennison, E., Dincer, F., Gabay, C., Haugen, I K., Herrero-Beaumont, G., Hiligsmann, M., Hochberg, M. C., Laslop, A., Matijevic, R., Maheu, E., Migliore, A., Pelletier, J-P., Radermecker, R. P., Rannou, F., Uebelhart, B., Uebelhart, D., Veronese, N., Vlaskovska, M., Rizzoli, R., Mobasheri, A., Cooper, C., & Reginster, J-Y. (2022). Management of hand osteoarthritis: from an US evidence-based medicine guideline to a European patient-centric approach. Aging Clinical and Experimental Research, 34, 1985-1995.

Kolasinski, S. L., Neogi, T., Hochberg, M. C., Oatis, C., Guyatt, G., Block, J., Callahan, L., Copenhaver, C., Dodge, C., Felson, D. Gellar, K., Harvey, W. F., Hawker, G., Herzig, E., Kwoh, C. K., Nelson, A. E., Samuels, J., Scanzello, C., White, D., Wise, B., Altman, R. D., DiRenzo, D., Fontanarosa, J., Giradi, G., Ishimori, J., Misra, D., Shah, A. A., Shmagel, A. K., Thoma, L. M., Turgunbaev, M., Turner, A. S., & Reston, J. (2020). 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Care & Research, 72(2), 149-162.

Wasserman, A. M. (2011). Diagnosis and management of rheumatoid arthritis. American Family Physician, 84(11), 1245-1252.

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