Arthritis

Introduction

Arthritis is a very common condition. The different forms of arthritis affect nearly 43
million Americans, or about one of every six people, making it one of the most
prevalent diseases in the United States.
There are more than 100 types of arthritis. The most common types of arthritis are
osteoarthritis and rheumatoid arthritis.

Anatomy:
Our bones help us stand up straight and our muscles help our bones to move together.
Bones connect at the joints. The most obvious joints are the shoulders, elbows, wrists,
hips, knees, and ankles.

We have joints between the different bones of our fingers and toes. We also have
joints that allow our vertebrae to move.
A material called cartilage, which keeps the bones from rubbing against each other
during motion, covers the ends of the bones of a joint.
There is a little bag containing a small amount of fluid called synovium between the
two pieces of cartilage in a joint.
The combination of cartilage and synovium allows for smooth, painless motion in any
given joint.

Arthritis

Arthritis occurs when the cartilage and the synovium in joints is destroyed. There are
many types of arthritis.
Osteoarthritis is due to chronic wear and tear. Osteoarthritis is more common in older
people.
Post-traumatic arthritis is due to trauma to a joint. Trauma may happen during a car
accident, sports injury, etc.
If the synovium in a joint becomes inflamed, it could end up being destroyed as well as
the underlying joint. This destruction is called rheumatoid arthritis.
Arthritis usually leads to pain and limited movement in the joint.
Rheumatoid arthritis involves swelling, redness, and tenderness
in the joint.

Signs & Symptoms

All types of arthritis involve destruction of the joints, which
typically causes pain as well as deformity of the joint.
When arthritis is very severe, both bones of the joint may
actually grow into each other, causing them to fuse together.
Rheumatoid arthritis leads to swelling, redness, and tenderness
in the affected joints.

Causes, incidence, and risk factors

Arthritis involves the breakdown of cartilage. Cartilage normally protects the joint, allowing for smooth movement. Cartilage also absorbs shock when pressure is placed on the joint, like when you walk. Without the usual amount of cartilage, the bones rub together, causing pain, swelling (inflammation), and stiffness.

You may have joint inflammation for a variety of reasons, including:

• Broken bone
• Infection (usually caused by bacteria or viruses)
• An autoimmune disease (the body attacks itself because the immune system believes a body part is foreign)
• General "wear and tear" on joints

Often, the inflammation goes away after the injury has healed, the disease is treated, or the infection has been cleared.

With some injuries and diseases, the inflammation does not go away or destruction results in long-term pain and deformity. When this happens, you have chronic arthritis. Osteoarthritis is the most common type and is more likely to occur as you age. You may feel it in any of your joints, but most commonly in your hips, knees or fingers. Risk factors for osteoarthritis include:

• Being overweight
• Previously injuring the affected joint
• Using the affected joint in a repetitive action that puts stress on the joint (baseball players, ballet dancers, and construction workers are all at risk)

Arthritis can occur in men and women of all ages. About 37 million people in America have arthritis of some kind, which is almost 1 out of every 7 people.

Other types or cause of arthritis include:

• Rheumatoid arthritis (in adults)
• Juvenile rheumatoid arthritis (in children)
• Systemic lupus erythematosus (SLE)
• Gout
• Scleroderma
• Psoriatic arthritis
• Ankylosing spondylitis
• Reiter's syndrome (reactive arthritis)
• Adult Still's disease
• Viral arthritis
• Gonococcal arthritis
• Other bacterial infections (non-gonococcal bacterial arthritis )
• Tertiary Lyme disease (the late stage)
• Tuberculous arthritis
• Fungal infections such as blastomycosis

Physical examination

First, your doctor will take a detailed medical history to see if arthritis or another musculoskeletal problem is the likely cause of your symptoms.

Next, a thorough physical examination may show that fluid is collecting around the joint. (This is called an "effusion.") The joint may be tender when it is gently pressed, and may be warm and red (especially in infectious arthritis and autoimmune arthritis). It may be painful or difficult to rotate the joints in some directions. This is known as "limited range-of-motion."

In some autoimmune forms of arthritis, the joints may become deformed if the disease is not treated. Such joint deformities are the hallmarks of severe, untreated rheumatoid arthritis.

Tests vary depending on the suspected cause. They often include blood tests and joint x-rays. To check for infection and other causes of arthritis (like gout caused by crystals), joint fluid is removed from the joint with a needle and examined under a microscope. See the specific types of arthritis for further information.

Treatment

Treatment of arthritis depends on the particular cause, which joints are affected, severity, and how the condition affects your daily activities. Your age and occupation will also be taken into consideration when your doctor works with you to create a treatment plan.

If possible, treatment will focus on eliminating the underlying cause of the arthritis. However, the cause is NOT necessarily curable, as with osteoarthritis and rheumatoid arthritis. Treatment, therefore, aims at reducing your pain and discomfort and preventing further disability.

It is possible to greatly improve your symptoms from osteoarthritis and other long-term types of arthritis without medications. In fact, making lifestyle changes without medications is preferable for osteoarthritis and other forms of joint inflammation. If needed, medications should be used in addition to lifestyle changes.

Exercise for arthritis is necessary to maintain healthy joints, relieve stiffness, reduce pain and fatigue, and improve muscle and bone strength. Your exercise program should be tailored to you as an individual. Work with a physical therapist to design an individualized program, which should include:

• Range of motion exercises for flexibility
• Strength training for muscle tone
• Low-impact aerobic activity (also called endurance exercise)

A physical therapist can apply heat and cold treatments as needed and fit you for splints or orthotic (straightening) devices to support and align joints. This may be particularly necessary for rheumatoid arthritis. Your physical therapist may also consider water therapy, ice massage, or transcutaneous nerve stimulation (TENS).

Rest is just as important as exercise. Sleeping 8 to 10 hours per night and taking naps during the day can help you recover from a flare-up more quickly and may even help prevent exacerbations. You should also:

• Avoid positions or movements that place extra stress on your affected joints.
• Avoid holding one position for too long.
• Reduce stress, which can aggravate your symptoms. Try meditation or guided imagery. And talk to your physical therapist about yoga or tai chi.
• Modify your home to make activities easier. For example, have grab bars in the shower, the tub, and near the toilet.

Other measures to try include:

• Taking glucosamine and chondroitin -- these form the building blocks of cartilage, the substance that lines joints. These supplements are available at health food stores or supermarkets. While some studies show such supplements may reduce osteoarthritis symptoms, others show no benefit. However, since these products are regarded as safe, they are reasonable to try and many patients find their symptoms improve.
• Eat a diet rich in vitamins and minerals, especially antioxidants like vitamin E. These are found in fruits and vegetables. Get selenium from Brewer's yeast, wheat germ, garlic, whole grains, sunflower seeds, and Brazil nuts. Get omega-3 fatty acids from cold water fish (like salmon, mackerel, and herring), flaxseed, rapeseed (canola) oil, soybeans, soybean oil, pumpkin seeds, and walnuts.
• Apply capsaicin cream (derived from hot chili peppers) to the skin over your painful joints. You may feel improvement after applying the cream for 3-7 days.

MEDICATIONS

Your doctor will choose from a variety of medications as needed. Generally, the first drugs to try are available without a prescription. These include:

• Acetaminophen (Tylenol) -- recommended by the American College of Rheumatology and the American Geriatrics Society as first-line treatment for osteoarthritis. Take up to 4 grams a day (2 extra-strength Tylenol every 6 hours). This can provide significant relief of arthritis pain without many of the side effects of prescription drugs. DO NOT exceed the recommended doses of acetaminophen or take the drug in combination with large amounts of alcohol. These actions may damage your liver.
• Aspirin, ibuprofen, or naproxen -- these nonsteroidal anti-inflammatory (NSAID) drugs are often effective in combating arthritis pain. However, they have many potential risks, especially if used for a long time. They should not be taken in any amount without consulting your doctor. Potential side effects include heart attack, stroke, stomach ulcers, bleeding from the digestive tract, and kidney damage. In 2005, the U.S. Food and Drug Administration (FDA) asked makers of NSAIDs to include a warning label on their product that alerts users of an increased risk for heart attack, stroke, and gastrointestinal bleeding. If you have kidney or liver disease, or a history of gastrointestinal bleeding, you should not take these medicines unless your doctor specifically recommends them.

Prescription medicines include:

• Cyclooxygenase-2 (COX-2) inhibitors -- These drugs block an inflammation-promoting enzyme called COX-2. This class of drugs was initially believed to work as well as traditional NSAIDs, but with fewer stomach problems. However, numerous reports of heart attacks and stroke have prompted the FDA to re-evaluate the risks and benefits of the COX-2s. Celecoxib (Celebrex) is still available, but labeled with strong warnings and a recommendation that it be prescribed at the lowest possible dose for the shortest duration possible. Talk to your doctor about whether COX-2s are right for you.
• Corticosteroids ("steroids") -- these are medications that suppress the immune system and symptoms of inflammation. They are commonly used in severe cases of osteoarthritis, and they can be given orally or by injection. Steroids are used to treat autoimmune forms of arthritis but should be avoided in infectious arthritis. Steroids have multiple side effects, including upset stomach and gastrointestinal bleeding, high blood pressure, thinning of bones, cataracts, and increased infections. The risks are most pronounced when steroids are taken for long periods of time or at high doses. Close supervision by a physician is essential.
• Disease-modifying anti-rheumatic drugs -- these have been used traditionally to treat rheumatoid arthritis and other autoimmune causes of arthritis. These drugs include gold salts, penicillamine, sulfasalazine, and hydroxychloroquine. More recently, methotrexate has been shown to slow the progression of rheumatoid arthritis and improve your quality of life. Methotrexate itself can be highly toxic and requires frequent blood tests for patients on the medication.
• Biologics-- these are the most recent breakthrough for the treatment of rheumatoid arthritis. Such medications, including etanercept (Enbrel), infliximab (Remicade) and adalimumab (Humira), are administered by injection and can dramatically improve your quality of life. Newer biologics include Orencia (abatacept) and Rituxan (rituximab).
• Immunosuppressants -- these drugs, like azathioprine or cyclophosphamide, are used for serious cases of rheumatoid arthritis when other medications have failed.

It is very important to take your medications as directed by your doctor. If you are having difficulty doing so (for example, due to intolerable side effects), you should talk to your doctor.

SURGERY AND OTHER APPROACHES

In some cases, surgery to rebuild the joint (arthroplasty) or to replace the joint (such as a total knee joint replacement) may help maintain a more normal lifestyle. The decision to perform joint replacement surgery is normally made when other alternatives, such as lifestyle changes and medications, are no longer effective.

Normal joints contain a lubricant called synovial fluid. In joints with arthritis, this fluid is not produced in adequate amounts. In some cases, a doctor may inject the arthritic joint with a manmade version of joint fluid. The synthetic fluid may postpone the need for surgery at least temporarily and improve the quality of life for persons with arthritis.

Prevention

If arthritis is diagnosed and treated early, you can prevent joint damage. Find out if you have a family history of arthritis and share this information with your doctor, even if you have no joint symptoms.

Osteoarthritis may be more likely to develop if you abuse your joints (injure them many times or over-use them while injured). Take care not to overwork a damaged or sore joint. Similarly, avoid excessive repetitive motions.

Excess weight also increases the risk for developing osteoarthritis in the knees, and possibly in the hips and hands. See the article on body mass index to learn whether your weight is healthy.

References

Krishnan E. Reduction in long-term functional disability in rheumatoid arthritis from 1977 to 1998: a longitudinal study of 3035 patients. Am J Med. 2003; 115(5): 371-376.

Maini SR. Infliximab treatment of rheumatoid arthritis. Rheum Dis Clin North Am. 2004; 30(2): 329-347.

Marx J. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 5th ed. St. Louis, Mo: Mosby; 2002:1583-1599.

Simon LS, Lipman AG, Jacox AK, etc. Pain in osteoarthritis, rheumatoid arthritis and juvenile chronic arthritis. 2nd ed. Glenview (IL): American Pain Society (APS); 2002.