(gentle music) - Patients with rheumatoid arthritis typically start noticing symptoms that are very gradual in onset. So it's not like an explosive onset where one day they have
multiple tender, swollen joints and they cannot move. That can happen, it's very unusual. But in most patients what
they are experiencing is when they wake up in the mornings they're not able to jump out of the bed like they could do before. In fact, they're somewhat stiff. They get to the side of the bed, they walk to the bathroom, they feel like their
joints are not well-oiled. Some people describe it
as feeling like a tin man and that the sense of
stiffness of the joints actually gets better with
activity and movement. So patients may feel that by the time I've taken a hot shower I feel really well. They may not think much about
it and then kind of go on. But then what may happen is
that they're experiencing this day in and day out, and that might be the
first trigger for them, what's happening to me in the mornings? Some of the other symptoms
that they may experience is that their joints
can actually be painful and they may actually see
visible evidence of swelling. Many women may say you know, I cannot wear that ring any more, or the ring that I'm
wearing is tight on me, particularly in the mornings. By the evenings my rings are
loose on my fingers again, or I can put them back on, but they become tight
again in the mornings. So remember that symptoms
of rheumatoid arthritis are worse in the mornings, they
improve as the day goes on, improve with a hot shower,
improve with activity. Now this is the typical presentation of rheumatoid arthritis. But there are patients who
can have atypical presentation where the onset can be
relatively abrupt, explosive, where they're fine a week ago and then within a week they are struggling with activities of daily living. Again pain, stiffness,
swelling, small joints of hands, wrists, shoulders can be involved, involvement of ankles and feet. And again, remember what
we mentioned about was fatigue can be a prominent
part of this presentation. Stiffness can be a prominent
part of this presentation. When you have inflammation, patients often have sleep disturbance so they may not sleep well. They may feel as if they have almost like a flu-like illness. All of these symptoms
can be the beginning of the presentation of rheumatoid arthritis. (gentle music) Once we have our patients in remission or low disease activity,
our patients are doing well. On a daily basis they may
have minimal symptoms, they may have minimal stiffness, but really they're not
struggling with their disease. But often during this
period when the patients are doing very well, they
may start experiencing increased disease activity. We call that a flare. A flare is described
in many different ways by different patients, but typically what they're experiencing is
increased disease activity. That can be manifested
as worsening fatigue in the mornings or throughout the day, worsening stiffness
particularly in the mornings, increased joint pain, swelling, difficulty with activities
of daily living. Some patients may experience
a flu-like illness, low-grade fevers, they
just don't feel well, their energy levels drop, and that is a typical
description of a flare for most patients. Many patients also
experience fragmented sleep or poor sleep, they tell us that they don't sleep
well during the flare. In some patients the
depression and anxiety part really kicks in during these episodes. So yes, unfortunately the
course of rheumatoid arthritis can be punctuated by these periods of increased disease activity. (gentle music) This can often be triggered
by some change in medications or by medication non-compliance, or sometimes it can be triggered by increased stress in people's life. Sometimes trauma or some
kind of physical stress can also trigger flares. So patients will give us a
sense of different things that can trigger a
flare, but I can tell you that stress is the one thing
that I often hear the most. The flares can punctuate the disease and then there's a specific
way we take care of flares. We can often increase
some of the medications such as nonsteroidal
anti-inflammatory medications, or we can give a short
course of prednisone. Often we ask the patients
to rest more during a flare, to pace out their life
so that if they really cannot achieve five things in a day maybe they can prioritize and do that one thing that
they really need to do. Many of my patients tell
me that when they rest they definitely feel that they can handle their flare better. So yes, is flare a part of
living with rheumatoid arthritis? I would say it is. Unfortunately, it can be unpredictable. Sometimes it comes from nowhere and this can be a very frustrating thing for the patients to live with. But I would say when you live
with rheumatoid arthritis and you learn to live
and manage your flares, patients can often self-manage
many of these things. They can sometimes predict that because they're going through a difficult time, they may have a little flare, and then they can self-manage
some of their joint symptoms. But again, our goal as
rheumatologists will always be for our patients not to
experience any flare. So if one of my patients is experiencing many flares within a short period of time, this is a very good
time for me to sit down and evaluate whether the
medications are working or not, whether I need to change
medication or add more medications. So I think with that approach, even though at this point our
patients do live with flares, I think the frequency of flares
we can really reduce them, we can reduce the intensity of flares so they are really not
struggling that much and we can help patients kind
of self-manage some of this and reach out to their physicians when they feel that there needs to be a discussion about changing
therapy, and if they feel that the medications
are not working as well. (gentle music)
