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What is
arthritis?
The symptom of pain, swelling, or stiffness with limitation of
joint movement is called arthritis. In certain serious types of
arthritis (e.g. rheumatoid arthritis) the stiffness and limitation
of joint movement is especially worse for prolonged periods in the
mornings. Occasionally, the symptoms may be acute with red, hot
swollen joints. In chronic cases the joints may become deformed.
The term arthritis, therefore, is non-specific. By itself it does
not refer to any specific disease. It simply denotes the symptom
of some joint disease.
Only further analysis of symptoms, careful examination of the
joints and a few relevant investigations may reveal the actual
disease that may be the cause of the joint symptoms. The
speciality dealing with arthritis and related diseases is called
rheumatology. The physicians specialising in this field of
medicine are called rheumatologists. In patients with arthritis of
long-standing and who are unfortunate not to have been seen and
treated by trained and experienced rheumatologists, the joints may
get damaged and their structure completely disorganised and
destroyed. In such situations the only way out is to get the
joints replaced with artificial joints the so-called joint
transplantation. This is done by surgeons called Orthopaedic
surgeons. It is to be noted that orthopaedic surgeons specialise
in surgery but not in making the diagnosis of different types of
joint disease. The job of making a diagnosis by taking a proper
history, carrying out accurate physical examination of the
musculoskeletal system including(often called locomotor system –
see below) joints, and ordering relevant investigations with their
proper interpretation is done by a trained rheumatologist only.
Is arthritis the same as rheumatism?
Rheumatism is another non-specific term often used by lay persons
to indicate aches and pains in the joints and the related body
structures (muscles, tendons, ligaments, bursae, bones and
cartilages). Joints and related body structures are often given
the name of locomotor system of the body. Aches and pains in any
of the structures of the locomotor system, especially if chronic,
are often non-specifically referred as rheumatism. Rheumatism is,
therefore, a broader term that includes arthritis, soft tissue
rheumatism (e.g. myositis, bursitis, tendinitis, fibrositis,
fasciitis, tenosynovitis etc.), as well as bone-related symptoms.
Aches and pains in any of these, especially if chronic, are often
non-specifically referred as rheumatism. Rheumatism is, therefore,
a broader term that includes arthritis, soft tissue rheumatism
(e.g. myositis, pursitis, tendinitis, fibrositis, fasciitis,
tenosynovitis etc.), as well as bone-related symptoms.
How prevalent is the problem of arthritis
/ rheumatism in the population?
Several population studies around the world have shown that
approximately 20-30% of the visits to any health-care setting are
due to problems related to locomotor system. Therefore, locomotor
system diseases are among the most common diseases in all the
populations around the world. Fortunately, approximately 70% of
these conditions are minor, self-limiting conditions related to
trauma, injuries, sprains, wrong use or over-use of the locomotor
system including sudden unaccustomed physical work and habitual
bad posture. Another common cause of ‘rheumatism’ is the aging of
the joints called osteoarthritis. Although painful and often
disabling, this problem is fortunately not a life threatening
serious systemic disease. Interestingly, psychological problems
may often lead to aches and pains, a condition called ‘psychogenic
rheumatism’, ‘pain amplification syndromes’ or fibromyalgia. There
are other many non-specific aches and pains of minor types
(possibly due to minor viral infections) that are self-limiting
and usually disappear in about 6 weeks. These patients only need
to be seen by a physician-rheumatologist to exclude any serious
type of arthritis that may only require reassurance and/or a short
course of some symptom relieving medicines.
How serious are these conditions?
Unfortunately, approximately 30% of diseases of the joints have
the potential of becoming serious life threatening systemic
problems. This is especially so if the patient is a young woman
with symptoms persisting for more than 6 weeks. This may be the
beginning of a crippling and occasionally life threatening
systemic rheumatic disease. These diseases may cause complications
in several other organ systems in the body. Unless diagnosed early
and managed by rheumatologists the outcome may be serious.
Are there different types of arthritis?
Yes, there are a variety of different types of arthritis. One can
look at different types of arthritis according to the:
1. Age group and gender.
2. Presence or absence of inflammation in the joints, a specific
clinical feature that rheumatologists are trained to recognise by
simple history of the joint symptoms.
3. Duration of joint symptoms (<6 weeks or >6 weeks) that
classifies them into acute and chronic forms of arthritis that are
2 entirely distinct categories of diseases.
4. The number of joints affected (only one joint [called
monoarthritis], 2 to 4 joints [called oligoarthritis or
pauciarthritis] or more than 4 joints [polyarthritis]
Possibly the best and the easiest way to understand them is to
remember them according to the age group and gender
Arthritis of those above 50 years:
Most persons above the age of 50 start developing wear-and-tear of
the various joints in the body with breakdown of the cartilage
cushion in the joints. This causes the bones in the joints to
become rough. This condition is known as osteoarthritis and mainly
affects the weight-bearing joints like the knees, the hips and the
joints in the vertebral column (mainly in the neck and the lower
back). The joints that may have had injuries at a younger age are
especially prone to develop osteoarthritis. There is also a
familial form that affects the hands. Osteoarthritis is seen much
more often in women than in men, especially its familial form.
Fortunately, osteoarthritis is a disease only limited to the
joints and does not involve the rest of the body. Also,
inflammation is not a major feature of osteoarthritis. Thus,
osteoarthritis may be classified as chronic non-inflammatory
arthritis mainly related to aging and wear-and-tear. Because it is
mainly a mechanical disease and not a systemic inflammatory
disease, it is not a life threatening disease.
The other older age joint disease, seen almost exclusively in men
is gout. Gout is almost never seen below 40 years of age. It is
also almost never seen in young women (before the onset of
menopause, unless there is a known underlying kidney disease) and
never seen in children. It is traditionally associated with
affluent and rich men who usually have a strong family history of
obesity, heart disease, high blood pressure, diabetes mellitus and
high blood lipids (high cholesterol etc.). They eat and drink
well. They are usually obese. They do not exercise and have a
propensity to develop the diseases mentioned above. Gout is the
commonest inflammatory arthritis of adult men in the world. It
usually appears suddenly with acute red-hot exquisitely painful
swelling of the joint at the base of the big toe. It is caused by
the presence of crystals of a chemical substance called uric acid
(urate crystals) that seems to be increased in such individuals.
The cause of increased uric acid is both familial as well as
related to the specific life-style mentioned above. It is
especially relevant to India for, a large segment of urban
population of the newly rich, is rapidly acquiring such a
life-style.
Arthritis of young and early middle-age persons (16-50 yrs.):
At this age arthritis is not very common. However, when it occurs,
it may develop into a serious disease involving many joints in the
body that may be crippling, deforming and occasionally
life-threatening due to involvement of other internal organs in
the body including blood vessels, heart, lung, kidney, brain etc.
Almost all the joint diseases in this age group are inflammatory
in nature, where the immune system of the body starts misbehaving.
Instead of protecting the body from external invaders like
infectious agents it starts attacking its own tissue. This
situation is called autoimmunity and therefore, such diseases are
called autoimmune diseases. This group includes rheumatoid
arthritis, other diffuse connective-tissue diseases (including
systemic lupus erythematosus, scleroderma, dermatomyositis,
Sjögren’s syndrome, overlap and undifferentiated connective tissue
diseases), systemic vasculitis, psoriatic arthritis, and
spondyloarthritis (including ankylosing spondylitis). While
rheumatoid arthritis and diffuse collagen diseases are seen almost
entirely in young women of childbearing age, psoriatic arthritis
and spondyloarthritis are seen both in young men and young women.
Because of their life-threatening and crippling potential these
diseases need to be seen, diagnosed and managed over the long-term
by rheumatologists specializing in such diseases. Although
supposed to be uncommon, population surveys tend to show that
approximately 1-2% of the population may have these diseases. The
lost man-hours in young persons in the prime of their lives and
the extremely expensive lifelong treatment that is required for
controlling these diseases leads to an enormous economic burden
not only on the families but on society in general.
The other type of arthritis that afflicts persons in this
age-group is related to infections. One such arthritis is caused
by gonorrhoea. Sexually active persons having unprotected sex with
multiple partners are prone to contract gonorrhoea and other
venereal infections. This may lead to acute arthritis involving
any of the peripheral joints. Such infections may lead to another
variety of severe inflammatory arthritis involving several joints
in the extremities called reactive arthritis. Reactive arthritis
can also occur after a bout of infection in the gut e.g.
gastroenteritis and dysentery.
Arthritis in childhood and adolescence (<16 yrs.):
Children or adolescents may often complain of aches and pains.
Fortunately, in most cases these are minor problems most often
related to trauma that the child might not even remember. They are
self-limiting problems not requiring any specific treatment.
Sometimes however, the joints may not only be painful but swollen
due to bleeding that is related to the injury. Yet, the child
might not recall the injury. In such situations the opinion of a
specialist may be required because rarely some serious diseases of
childhood may also cause bleeding in the joints with swelling and
pain. Specialists dealing with the diseases of the locomotor
system in childhood and adolescence are called paediatric
rheumatologists.
The commonest chronic serious crippling, occasionally
life-threatening childhood disease of the joints is, however,
juvenile idiopathic arthritis (earlier called juvenile chronic
arthritis or juvenile rheumatoid) arthritis. Any arthritis in
childhood that persists for several weeks with visible swelling
and pain in the joints must be seen by a specialist namely
paediatric rheumatologist (rheumatologists specialising in
locomotor diseases of children). Like its counterpart in adults
(rheumatoid arthritis of adults, spondyloarthritis-ankylosing
spondylitis, see above) juvenile idiopathic arthritis also
requires early diagnosis and aggressive treatment to prevent
deformities, disability and other complications. Unfortunately,
this disease is quite often confused with another childhood
disease called rheumatic fever. In the latter condition, the joint
disease is usually minor and trivial and never persists for
prolonged periods. Interestingly, one of the characteristic
features of arthritis seen in rheumatic fever is that it responds
dramatically to a few tablets of aspirin. On the other hand
juvenile idiopathic arthritis does not show much relief with
aspirin. Missing the diagnosis of juvenile idiopathic arthritis
may be serious as it may cripple the child for life. It is
important to realise that juvenile idiopathic arthritis is at
least 10 times more common that rheumatic fever. Therefore, great
care must be taken to avoid missing the diagnosis of juvenile
idiopathic arthritis, as the treatment of these 2 conditions is
entirely different.
What is the treatment for arthritis?
As arthritis is not a single disease, treatment differs depending
upon its type. However, the common goal of treatment is to keep
the joints moving properly by relieving the pain and stiffness and
by reducing swelling. In general, simple pain relievers like
paracetamol, tramadol, and more ‘strong’ drugs called
non-steroidal anti-inflammatory drugs (NSAIDs e.g. aspirin,
ibuprofen, indomethacin, diclophenac, naproxen, aceclofenac,
piroxicam, meloxicam, and the newer drugs like celecoxib,
etoricoxib) are often used for short periods, especially in acute
cases, early stages and in minor forms of arthritis. NSAIDs should
never be used continuously daily over prolonged periods because
they are very toxic and have a large number of serious
side-effects. In severe systemic forms of crippling and often
life-threatening arthritides (e.g. rheumatoid arthritis, psoriatic
arthritis, systemic lupus erythematosus and others in this group)
a special group of medicines called ‘disease modifying drugs’ (DMARDs)
are given. These drugs have been proven to be highly effective,
with good safety margin especially if given under the supervision
of a rheumatologist who is well trained in their use. The newer
DMARDs include methotrexate, hydroxychloroquine, sulfasalazine,
and leflunomide. The older ones included gold-salts, D-penicillamine
and chloroquine. The newer DMARDs are highly effective in patients
with rheumatoid arthritis, and other severe systemic
life-threatening forms of arthritis. But, these drugs are required
to be usually given continuously for prolonged periods under the
supervision of rheumatologist; often life-time. There is a third
category of drugs sometimes used in severe serious forms of
arthritis called immunosuppressive drugs. This category includes
cyclosporine, cyclophosphamide, and azathioprine. Another category
of medicine that is often used in some types of arthritis is
called glucocorticoid (commonly called ‘steroids’ or
corticosteroids). These are ‘adjunct drugs’ that are always used
in combination with DMARDs during the early stage of the
initiation of DMARD-treatment only for a short period of time till
the slow-acting DMARDs start taking full effect. Glucocorticoids
are also highly effective in some of the life-threatening serious
forms of arthritis (e.g. systemic lupus erythematosus, systemic
vasculitis etc.) where they are used as ‘emergency life saving
drugs’. ‘Depot-preparations’ of glucocorticoids are also very
useful and effective in controlling inflammation in joints when
given as intra-articular injections. In fact, this method of
treatment is highly effective and safe for patients who may have
only a few inflamed joints. On the other hand, if a joint needs
repeated injections of depot-preparations of glucocorticoids
giving only temporary relief, a specialist must be consulted for
proper treatment. Glucocorticoids should also never be given as
‘stand-alone’ drugs for arthritis and they should never be given
as daily dose for prolonged periods of time, especially so without
supervision of a rheumatologist. If not used appropriately,
glucocorticoids can cause serious side effects. The latest
category of drugs for serious systemic life threatening forms of
arthritis (namely rheumatoid arthritis,
spondyloarthritis-ankylosing spondylitis, diffuse connective
tissue diseases, systemic vasculitides) are called biological
response modifiers (BRMs) or simply ‘biologicals’. These are
highly effective drugs that are changing the outcome in these
serious crippling life threatening diseases of young men and women
dramatically. Infliximab (‘Remicade’®), etanercept (‘Enbrel’®) and
rituximab (‘Mabthera’®) are already available in India. Adalimumab
(‘Humira’®), abatacept (‘Orancia’®) are likely to become available
in India in the near future. However, presently their price is
beyond the reach of common man (a single dose may cost more than 1
lakh rupees). Also, these drugs must be given only by specialist
rheumatologist with precautions to prevent adverse effects.
Controlling the weight AND REDUCING will reduce strain on
weight-bearing joints. Exercise and physiotherapy help in keeping
the muscles strong and movement of the joints as normal as
possible. Proper occupational therapy would prevent further
damage, maintain muscle power and help in coping with the
functions of daily living. Severely damaged hips and knees may
need to be surgically replaced by specialist orthopaedic surgeons.
That is the stage at which the consultation with Orthopaedic
specialists is required. Specific treatment for the commonest form
of arthritis i.e. osteoarthritis (the arthritis of ‘joint aging’),
is fairly simple in the early stages. Weight reduction, avoiding
activities and posture that further damage the joint, regular
exercises to build up the muscles that support the involved joints
(under the guidance of a trained physiotherapist), and the
occasional use of simple anti-inflammatory drugs (non-steroidal
anti-inflammatory drugs, mentioned above) prescribed by a
physician, is all that is required. In advanced cases joint
replacement surgery is a fairly safe and highly effective method
of treatment with excellent long-term results.
Rheumatoid arthritis and other systemic inflammatory arthritides
like psoriatic arthritis and arthritis related to diffuse collagen
diseases need the expertise of rheumatologists for prolonged,
intense, and specialized form of treatment with disease modifying
drugs (mentioned above). Ignoring or delaying appropriate
consultations and treatment may lead to serious complications. The
same is true of juvenile chronic arthritis seen in childhood and
juveniles. Joint infections are acute rheumatological emergencies.
They require prompt diagnosis and appropriate antibiotic and
surgical treatment including drainage of pus from the joints. Any
delay may lead to permanent damage. Treatment of gout needs
special mention because the disease is preventable. Although the
tendency to develop gout is hereditary, there are several
life-style related factors that predispose the person to attacks
of gouty arthritis. These include sedentary habits, lack of
exercise, obesity, excess food intake especially of rich refined,
high-calorie food including sea-food, a lot of red meat, some
forms of alcoholic drinks especially beer, fermented food (that
contain yeast e.g. ‘Mughlai food’). An acute attack is usually
precipitated after a late-night party with a lot of eating and
drinking, or sometimes after an injury or any other stress like
surgery, or infection. Thus, in persons with a family history of
gout, a diet restricted in calories, with lots of fruits and
salads (high in soluble as well as insoluble fibres), complete
avoidance of sea-food, red meat and fermented food, regular
exercise to keep the weight under control, abstinence from
alcoholic drinks (especially beer), prevents attacks of gout. This
would also prevent the other diseases often associated with gout
such as, high blood pressure, abnormalities of blood lipids
(including high ‘bad’ cholesterol [LDL-cholesterol], and high
triglycerides) that may lead to heart attack and stroke, and
diabetes. Certain drugs (e.g. diuretics for the treatment of fluid
retention) also predispose to gouty attacks. However, if despite
these restrictions the person gets an acute attack of gout; it
must be considered a rheumatological emergency. Urgent
consultation with a rheumatologist is necessary. Strong
non-steroidal anti-inflammatory drugs and local injection of
depot-preparation of glucocorticoids into the joint bring about
immediate and dramatic relief. An important point to remember is
to avoid a drug called allopurinol, which is the standard drug for
preventing accumulation of uric acid in the body of persons with a
tendency to develop gout. Giving this drug for in the early stages
of an up-coming acute attack of gout will rapidly worsen the
condition.
Can arthritis be prevented?
Some kinds of arthritis are preventable but others are not. Thus,
the progression of osteoarthritis can be arrested with appropriate
exercises, weight reduction and preventing posture and movement
that worsen the disease. Similarly, as mentioned above, gout is
preventable with changes in life-style. Avoiding unprotected sex
prevents gonorrhoea-related arthritis and most cases of so-called
‘reactive arthritis’. Avoiding gastroenteritis (not eating in
restaurants, especially where the hygiene is questionable) may
also prevent ‘reactive arthritis’. In children with a definite
history of rheumatic fever, avoiding crowded quarters (where there
is increased chances of throat infection), and regularly taking
penicillin treatment may prevent further attacks.
Unfortunately, the most serious crippling, and occasionally
life-threatening form of arthritis like rheumatoid arthritis,
psoriatic arthritis and diffuse collagen diseases including
systemic lupus erythematosus are not preventable because their
root-cause is in the genes and the genes cannot be changed or
removed from the body (at least till now!). Fortunately the
progressive damage to the joints and other organs in the body can
be prevented with early correct diagnosis and aggressive modern
treatment.
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