What are the 3-5 most common symptoms that are shared across RA, AS, and PsA?
Rheumatoid arthritis, Psoriatic arthritis, and Ankylosing Spondylitis are the three main types of autoimmune inflammatory arthritis that affect the population at peak times in life and can even begin at a young age.
Rheumatoid arthritis typically presents in the small hand and feet joints and sometimes large joints like shoulders and hips. Psoriatic arthritis can present in small or large joints, but also in and around tendons and the spine. Ankylosing Spondylitis typically presents in the axial spine, neck to lumbar, and the sacroiliac joints sometimes including large, small joints, or even tendons.
There are common shared symptoms with these inflammatory arthritis including:
- Swelling and inflammation
- Stiffness
- Pain
- Functional limitations
In addition, there are common symptoms shared across all autoimmune patients such as:
- Fatigue
- Mood Disorders
- Brain Fog
- Cardiovascular disease
RA. PsA, and AS onset is due to complex interactions between our genetics and the environment. There is an event or possibly several events that turn on genes in genetically susceptible individuals for the immune system to lose immune tolerance.
This signal informs the body that it should attack its own tissue instead of tolerating the tissue. As autoreactive immune T and B cells proliferate and invade tissue, inflammation ensues. These cells release substances called cytokines, such as TNF and Interleukins that communicate to the whole body signifying it is under attack.
This can cause systemic, whole body inflammation, as well as localized tissue inflammation. This cacophony of inflammation is responsible in part for the 8 common symptoms that will be reviewed in this article.
Can you help me understand each of these symptoms in detail? How would you work with me to ease the effects of these symptoms on my life? Are there any effective at-home treatments?
Swelling and inflammation
Seeing and touching swelling in a peripheral joint, such as a finger, may be obvious, but seeing swelling in a deep joint such as hip, sacroiliac, or spinal area may require advanced imaging just as ultrasound or MRI.
It is important to get the swelling and inflammation under control early in inflammatory arthritis to prevent damage, which can happen even as early as 6-12 weeks of symptoms. This early treat-to-target approach is critical to achieve remission, improve pain, reduce functional limitations and damage.
At Rheumission, we prioritize seeing those with inflammatory arthritis as soon as possible to start a multi-disciplinary approach to controlling swelling and inflammation. This is accomplished by partnering with our rheumatologists and an entire lifestyle medicine team.
In addition to starting short term low dose anti-inflammatory medications (NSAIDS and low dose prednisone) if needed, the team may recommend an anti-inflammatory diet, address the lifestyle pillars of health, and possibly start some evidence-based, anti-inflammatory supplements.
Most individuals will require disease modifying (DMARD) medications and or biologics to get that treat-to-target control of inflammation and achieve remission.
At home, you can start to reduce inflammation and swelling by consuming an anti-inflammatory Mediterranean diet, but you will have the opportunity to work with our autoimmune registered dietitian team here at Rheumission. Some anti-inflammatory topicals on the joints that might temporarily help are arnica, castor oil, or diclofenac cream (voltaren gel).
Stiffness
Morning stiffness of over 30 minutes is usually a sign that arthritis has an inflammatory autoimmune component. For RA, this may be stiffness in the hands in the morning while for ankylosing spondylitis this be back and buttock stiffness starting at early morning waking. Stiffness is the result of inflammation in the tissues which worsens at night while you sleep.
By reducing inflammation in the tissues, these symptoms should improve. In addition to Theumission’s plan to help swelling and inflammation as mentioned in section one, at home you can carefully apply heat: hot shower, hot bath, hot packs, hot oil rubs, to loosen the joints. Gentle range of motion exercises of the affected joints with stretching can alleviate stiffness particularly in the morning. A paced yoga or tai chi program are excellent tools.
Pain
In addition to an inflammatory cascade of immune cells and cytokines causing swelling, inflammation, and stiffness, other molecules in the tissue are released that are responsible for pain such as histamine, neurotransmitters, and substance P. In some individuals, even if the inflammation is well treated, the pain may continue because the pain signal that is releasing noxious chemicals is turned on autopilot. If unchecked, this pain can become widespread and central rather than just in the peripheral joints and nervous system.
Addressing pain early with a multidisciplined team is paramount to stop the spread and autopilot response. Usually, this requires more than just anti-inflammatories and DMARD therapy. Supportive medications and supplements may be added by your rheumatologist but Rheumission’s lifestyle medicine team will support an anti-inflammatory diet or possibly prescribe an elimination diet. Reducing stress and adopting coping skills is available by working with an autoimmune psychologist on our Rheumission care team.
Getting started at home to manage the stress response – the fight or flight sympathetic nervous system response – can help reduce the pain. This can be accomplished by trying to activate the parasympathetic nervous system; the calm, rest and digest nervous system, by doing some deep breathing exercises like the 4-7-8 breath, chanting, listening to music, waking in nature, and fostering social connection.
Functional limitations
With all the swelling, inflammation, stiffness and pain, it can be challenging for someone experiencing a flare to even get dressed in the morning or bend down to tie shoes. This functional impairment can be reversed early in disease but if inflammation is left unchecked, permanent functional limitations can happen.
That is why at Rheumission, we want to identify and treat those with inflammatory arthritis as soon as possible and treat aggressively with a multidisciplinary team approach. At home, functional limitations can be assessed with the help of an occupational therapist or physician therapist. Gentle stretching and range of motion exercises in the morning may help function improve later in the day. Balancing activity and rest will be key and joining a support group through the arthritis foundation or creaky joints may be useful.
Fatigue
Chronic inflammation, immobility, pain, sleep disorders and some medication side effects can contribute to fatigue in all autoimmune diseases. In many clinical review papers, fatigue is a top symptom of autoimmune conditions. A study found that one in every two people suffering from inflammatory arthritis had significant fatigue. The good news is that in the majority of cases, early treatment of the inflammation with DMARDs or biologic can improve fatigue scores.
Here at Rheumission, we address nonpharmacologic interventions to fight fatigue which is equally important. A multi-disciplined approach using psychosocial interventions such as cognitive behavioral programs, pacing protocols, and lifestyle interventions are tools used at Rheumission. Working with an autoimmune psychologist at Rheumission may help. At home, simply acknowledging the fatigue and communicating how it affects your life to family, friends, and work environment is important. Consider pacing; planning for activities but balancing activities with appropriately timed rejuvenating breaks.
Mood disorders
Depression can be as high as 18.8-40% in those with inflammatory arthritis. Higher depression scores were associated with higher disease activity scores. Depression itself however is also associated with overexpression of inflammation and cytokines such as TNF and interleukins so there is a bidirectional relationship. Pain, fatigue, work issues, functional limitations and financial burden of disease all contribute to mood disorders. Increased stress of illness in work, family, and social situations and limitations of function can contribute to mood disorders in all autoimmune conditions.
Mood disorders in autoimmune diseases require a multidisciplinary team trained in this unique interplay of inflammation and depression. Here at Rheumission, our autoimmune psychologist works one-on-one with those who are suffering from mood disorders. Your rheumatologist and lifestyle medicine team work with you to help control inflammation, address pain, improve sleep and help to reduce stress with the goal of improving mood and quality of life. Treating the inflammation and disease aggressively at the onset may improve depression scores which was found with studies on ankylosing spondylitis patients treated with biologics.
At home, you can try to shift the inflammatory matrix in the body by adopting an anti-inflammatory diet which in clinical trials has also been shown to prevent the development of anxiety and depression. A self care or meditation practice of just 5 minutes a day can also help to alleviate the stress response that may lead to anxiety or depression.
Brain fog
Cognitive impairment such as difficulty with memory, learning new things, problem-solving, concentrating, or making decisions is very common in autoimmune diseases. Up to 70% of those with rheumatoid arthritis can experience cognitive impairments. Co-morbid mood disorders, fatigue, pain, stress, sleep disturbance, and medication side effects are just some of the factors affecting cognition in autoimmune syndromes. Systemic inflammation may also have effects on the brain. Medications such steroids and sometimes methotrexate which crosses the blood brain barrier can have cognitive effects. Teaming up with your rheumatology and lifestyle providers can aim at treating the systemic inflammation quickly and providing tailored cognitive tools and interventions to improve the brain fog. At home, addressing the pillars of health such as eating a well balanced diet, getting enough sleep, keeping up with regular movement, reducing stress, and engaging in social connections can all help reduce cognitive impairments.
Cardiovascular disease
One of the most important organ systems affected in autoimmune diseases is the cardiovascular system. The systemic inflammatory cells and cytokines released in autoimmune diseases may have causative effects on contributing to cardiovascular disease. There is also increased prevalence of traditional cardiovascular risk factors such as high blood pressure and high cholesterol in inflammatory arthritis and many other autoimmune conditions such as lupus.
Rheumatoid arthritis patients have increased risk of direct inflammation in the heart such as pericarditis, fluid around the heart, and ankylosing spondylitis patients have increased risk of aortic dilation. At Rheumission, your rheumatologist and lifestyle medicine team not only work with you to help control inflammation in the whole body, but also help to mitigate risk factors for heart disease such as high cholesterol, obesity, and smoking.
At home, taking inventory of your cardiac risk factors and taking measures to work on lifestyle factors to reduce them such as increased exercise, improved diet patterns, and quitting smoking are all good places to start.
To learn more about our Rheumission approach to care, please visit the Approach section of our site, or book a 15-minute intro call with one of our providers. The Rheumission Way helps you get back to being you, with more joy and less pain. We will listen to you and co-create a plan that works for where you are now, and where you want to be. We are always here for you.
Note: This information is for informational purposes only. No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition or treatment and before undertaking a new healthcare regimen, and never disregard professional medical advice or delay in seeking it because of something you have read on this website.
About the Author
Dr. Beth Biggee is an Integrative Lifestyle Rheumatologist at Rheumission, bridging the gap between traditional and complementary medicine. With over two decades of expertise in Rheumatology, her distinguished career is marked by triple board certifications in Rheumatology, Integrative Medicine, and Lifestyle Medicine. She earned her medical degree from SUNY Upstate Medical Center in Syracuse, NY, and completed her Internal Medicine residency at the Yale New Haven Hospital. Dr. Biggee specialized in Rheumatology through a fellowship at Tufts Medical School in Boston. Her holistic vision of health was further enriched by completing Andrew Weil's renowned Integrative Medicine fellowship at the University of Arizona and by becoming a Certified Lifestyle Physician through the American Board of Lifestyle Medicine.
Beyond her medical training, Dr. Biggee has deepened her expertise in healing modalities such as learning HeartMath, a cutting-edge neurofeedback technique for stress management, and practicing Usui Holy Fire Reiki. She also holds a certification in Auricular Acupuncture from the Helms Medical Institute. Her passion for plant-based therapies led her to enroll in the Herbal Medicine Foundations Program at Medicine Lodge Academy, and she has pursued extensive hands-on training in Ayurvedic medicine for physicians.
