Arthritis

What is Arthritis?

Arthritis, which comes from a Greek word meaning “disease of the joints,” is a condition that involves swelling of the joints, often accompanied by pain and possible physical damage. It’s important to note that arthritis is not the same as arthralgia, which refers to joint pain irrespective of the cause, which could be inflammation or not.

Interestingly, it is known that both the Neanderthals and the Ancient Egyptians experienced arthritis. But, it was not until 1886 when Dr. John K. Spencer introduced the term “osteoarthritis.” To date, over a hundred different kinds of arthritis have been identified. The most common type is osteoarthritis, or degenerative arthritis, which doesn’t involve inflammation.

There are also different types of arthritis that are inflammatory. This kind of arthritis can happen in several circumstances, and can be caused by an immune response against the body’s own tissues (like in rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis), crystal deposits triggering inflammation (like in gout and pseudogout), or infections (such as septic arthritis and Lyme’s arthritis). Inflammatory arthritis can also happen alongside other autoimmune diseases, such as systemic lupus erythematosus, Sjogren syndrome, scleroderma, myositis, inflammatory bowel disease, celiac disease, and others.

The aim here is to offer a basic understanding of the most commonly found types of arthritis and briefly touch on important aspects of the various major disease types.

What Causes Arthritis?

The cause of arthritis changes depending on the specific kind of arthritis. For osteoarthritis, factors like getting older, being a woman, having a joint injury, and being obese can contribute. Some genetic mutations, specifically in certain types of collagen genes, have been linked to this form of arthritis.

Rheumatoid arthritis (RA) is a different story. It’s an autoimmune disorder, which means the body’s immune system attacks its own tissues. Several genetic and environmental factors, such as a type of gene called HLADRB1 and smoking, can cause the immune system to malfunction, leading to inflammation in RA.

Gout, another type of arthritis, is caused by a buildup of uric acid in the joints. This buildup can come from genetic mutations, although these cases only make up less than 10% of all gout cases. Most people with gout can’t get rid of all the uric acid their body makes. Risk factors for gout include being male, getting older, having kidney disease, alcoholism, and taking certain drugs like diuretics.

Septic arthritis, which is a sudden and severe type of arthritis, is rare but can occur more often in certain high-risk individuals. These include people with weakened immune systems, older people, those with diabetes, people with artificial joints, those with rheumatoid arthritis, and people who inject drugs.

Many autoimmune diseases often come with arthritis. It’s one of the most common symptoms in patients with systemic lupus erythematosus (SLE). Other conditions that can come with arthritis include inflammatory bowel disease, psoriasis, celiac disease, Sjogren syndrome, systemic sclerosis, dermatomyositis, and mixed connective tissue disease (MCTD).

Risk Factors and Frequency for Arthritis

Arthritis is a common condition that can be seen in medical images of over one-third of Americans, and this number is expected to rise as the average age of the population increases. There are several types of arthritis, with osteoarthritis being the most common. Knee osteoarthritis affects between 19% to 30% of adults over 45. Similarly, 27% of adults have hand or hip osteoarthritis. It is predicted that 40% of men and 47% of women will develop osteoarthritis during their lifetime, and these numbers rise to 60% if the person’s body mass index is above 30.

Gout, an inflammatory type of arthritis, is the most common in the United States, affecting over 8 million people. The overall prevalence is 3.9%, but this rises to more than 9% for those over 60 years old. Recent decades have seen more than a two-fold increase in the occurrence of gout.

Pseudogout is another form of arthritis, seen in 4% to 7% of the adult population. Over half of the people with pseudogout also have knee arthritis.

Rheumatoid arthritis is another common form of arthritis, affecting about 1% of Caucasian people. This type of arthritis is more prevalent in females, with a 3.6% lifetime risk compared to 1.7% in males. It usually starts in early adulthood and affects 5% of women over 65.

Lastly, septic arthritis has a prevalence of 0.01% in the general population and 0.7% in patients with rheumatoid arthritis. This type of arthritis is typically caused by bacteria spreading from an infection in the skin or urinary tract to an already arthritic joint.

Signs and Symptoms of Arthritis

A thorough medical history and physical examination are key in evaluating arthritis and identifying the specific type of arthritis. The pain experienced by a patient might help determine if it’s due to arthritis or another condition. Some ailments, like fibromyalgia, can cause akin pain without the telltale signs of arthritis like swelling, redness or warmth in the joints. Tendinitis, on the other hand, can result in pain around the joint, but doesn’t limit the joint’s range of motion.

Common symptoms of arthritis include pain, swelling, stiffness, function loss, deformation, weakness, and instability. These might also be accompanied by fatigue, sleep problems, emotional instability and symptoms related to any underlying illness. Pain from arthritis generally worsens with activity and at the end of the day. Still, inflammatory arthritis also causes pain in the morning and rest periods. Fibromyalgia and myofascial pain syndrome typically cause widespread pain, while neuropathic pain can generate a tingling sensation in the affected nerve’s area. Prolonged morning stiffness can be associated with inflammatory arthritis, but it’s not exclusive to it, as patients with osteoarthritis or non-articular syndromes like fibromyalgia can also experience it.

The physical examination plays a significant role in assessing arthritis and joint pain. Inflammatory arthritis usually presents with tenderness, swelling, fluid accumulation, redness, and warmth. These symptoms are more apparent in an acute inflammatory arthritis attack but might be less obvious in chronic inflammatory arthritis. Osteoarthritis also leads to tenderness, swelling, and fluid accumulation, but the joints usually lack redness and warmth. Arthritis can also limit the joint’s range of motion and cause obvious joint deformity.

The next step involves understanding the arthritis’s onset, the number of affected joints, the symmetry and distribution pattern:

• Onset: Acute-onset arthritis is common in septic arthritis, crystalline arthritis, and reactive arthritis. Osteoarthritis typically develops slowly. Other forms like rheumatoid arthritis and psoriatic arthritis typically also have a slow onset, although some exceptions can occur. Autoimmune disorder-associated arthritis usually develops slowly as well.
• Number of involved joints: Arthritis can affect one joint (monoarticular), two to four joints (oligoarticular), or several joints (polyarticular). Infections like Lyme’s disease, bacterial, mycobacterial and Neisseria infections often cause acute monoarthritis. Monoarthritis can also occur in gout, pseudogout, hydroxyapatite disease, and trauma. Chronic monoarthritis can occur in patients with untreated infections, gout, pseudogout, and other conditions.
• Symmetry: Symmetrical inflammatory arthritis affecting the small joints in the hands and feet is a primary characteristic of rheumatoid arthritis (RA). Asymmetrical polyarthritis can be seen in a variety of conditions.
• Distribution: Distribution relates to which joints are affected. For example, osteoarthritis commonly involves the spine. On the other hand, inflammatory arthritis with axial involvement is seen in conditions like ankylosing spondylitis. Peripheral involvement can occur in conditions like RA.
• Pattern: The pattern of arthritis can vary from a progressive additive pattern where more joints get involved over time to a migratory or intermittent pattern.

Other important factors in diagnosing the type of arthritis include the patient’s family history, age of onset, skin condition and more.

Testing for Arthritis

Medical tests and screenings can help in identifying and determining how severe an arthritis condition might be.

Arthritis caused by inflammation often shows increased levels of inflammation markers like ESR and CRP in the blood tests. Anemia is also common in such cases. An abnormal number of white blood cells can indicate septic arthritis or gout. Some types of arthritis, such as rheumatoid arthritis (RA) and SLE-associated arthritis, can show reduced numbers of white blood cells and platelets. Doctors may also test for levels of uric acid if gout is suspected, however, it should not be the only test used for diagnosis. Blood tests may also be carried out to detect antibodies related to specific types of arthritis.

X-ray imaging is usually the first approach to getting a visual of the joints. The tests can reveal different characteristics of the joint based on the type of arthritis. For example, it can reveal narrowing of the joint space, presence of bone spurs in osteoarthritis, inflammation or changes in joint structure in RA, stiffening of the spine in conditions like ankylosing spondylitis, and more.

In case the X-ray images do not provide clear enough information, other imaging methods can be used. Magnetic Resonance Imaging (MRI) is one such method that can provide a better view of the inflammation and structural abnormalities. CT scans can also be used to identify changes in the joint, but are typically used if an MRI isn’t feasible. Musculoskeletal ultrasound is another option, effective in diagnosing peripheral arthritis and can aid in procedures like joint fluid extraction or injection. Lastly, a nuclear medicine joint scan can be used, but is rarely chosen due its high sensitivity but inadequate specificity. Another option is the dual-energy CT scan which is very accurate for diagnosing gout.

Examining the joint fluid is perhaps one of the most critical tests in diagnosing arthritis. The cell count in the fluid can give an insight into the type of arthritis. For example, degenerative arthritis usually shows cell counts less than 2,000 cells/mm3, whereas inflammatory arthritis might show more than 5,000 cells/mm3. More than 50,000 cells/mm3 cells and/or more than 90% neutrophils in synovial fluid analysis can suggest possible septic arthritis or gout. The joint fluid is also checked for crystals that can indicate a specific type of arthritis.

In rare cases, if all other tests fail to provide a diagnosis, a synovial biopsy may be considered.

Treatment Options for Arthritis

Treating joints affected by osteoarthritis focuses on relieving pain and improving function. Both non-drug treatments and medications are often combined for the best results. Non-drug treatments could include specific exercises, physical therapy, bracing, acupuncture, and losing weight. Drug treatments can involve using creams and pills. Commonly used drugs include non-steroidal anti-inflammatory drugs (NSAIDs) used orally and topically, capsaicin cream, and duloxetine. Corticosteroids can be injected directly into the painful joint.

Usually, the first step involves using creams such as NSAIDs or capsaicin. If these creams don’t bring enough relief, or if the arthritis affects more than one joint, oral NSAIDs may be needed. Duloxetine can be a helpful option for patients who cannot take NSAIDs due to other health issues. It is particularly beneficial for arthritis in the knees. If none of these methods work, corticosteroid injections into the joint might alleviate symptoms. Strong painkillers such as opioids should be avoided. If symptoms keep worsening without getting better, surgery to replace the affected joint(s) might be an effective option, with physical therapy following surgery to help with recovery.

When treating rheumatoid arthritis and certain types of related conditions, the focus is on stopping the disease early and preventing lasting damage to the joints. It’s more effective to start using disease-altering drugs (DMARDs) and biologics early on than to rely on corticosteroids and NSAIDs. While the disease is still active, anti-inflammatory drugs can be used to reduce inflammation. Regular symptom monitoring and drug dose adjustments continue until symptoms disappear. If symptoms spike, corticosteroids may be needed.

Gouty arthritis can cause painful and severe flare-ups. Anti-inflammatory drugs can greatly alleviate this pain, especially if they’re started within 24 hours of a flare-up. These include oral corticosteroids, NSAIDs like indomethacin or high-dose naproxen, or colchicine. Corticosteroid injections into the joint may be helpful if only a few joints are affected. If the patient can’t take oral medications, corticosteroids can be given by muscle injection or intravenously. Drugs that lower uric acid levels don’t help with acute flare-ups, but are recommended for patients with recurrent flare-ups, chronic kidney disease, kidney stones, or particular types of nodules. The ultimate aim is to decrease the uric acid level in the blood and joints, which will relieve gout symptoms.

Treating septic arthritis involves draining the infected joint and using antibiotics. The specific antibiotic used is guided by lab testing of the joint fluid.

What else can Arthritis be?

Arthritis can sometimes be confused with other conditions that also cause pain, such as fibromyalgia (widespread muscle pain), myofascial pain syndrome (chronic discomfort in the muscles), neuropathy (nerve damage), tendinitis (inflammation of a tendon), and complex regional pain syndrome (a condition causing severe, ongoing pain usually following an injury).

The doctor can tell the difference between arthritis and these other conditions through a physical examination, and by using lab tests and medical imaging like x-rays.

There are actually more than 100 different kinds of arthritis that have been identified. That’s why it’s crucial to accurately diagnose the specific type of arthritis before starting any treatment.

What to expect with Arthritis

Osteoarthritis is a continuously developing condition for which there isn’t a cure. Whether it worsens quickly or slowly depends on the number and severity of the affected joints. It often worsens more rapidly if you’re older, overweight, if your joints are misaligned, or if you have multiple affected joints. After you receive a joint replacement, you can generally expect a positive outcome. However, artificial joints don’t last forever, so you may need another surgery after 10-15 years.

Thanks to recent advancements in treatments, the outlook for rheumatoid arthritis has gotten much better. Despite this, people with rheumatoid arthritis generally experience more health problems and have a higher risk of death than the general population. This is mostly due to complications that affect parts of the body other than the joints.

Recovery from Arthritis

Exercise programs have been found to provide significant benefits for people suffering from osteoarthritis (OA) and RA. These benefits may include better fitness levels, stronger and bigger muscles, improved joint and functional mobility, and less pain.

However, it’s important to keep in mind the type, intensity, and duration of the exercise. This is because people with these conditions could risk damaging their joints by doing too much or repeating the same activities too often. Research has pointed out the danger of injuries from sports, so exercises may need to be adapted to keep people safe during physical activities. Additionally, research has shown that people who are in the early stages of their arthritis condition tend to respond more positively to exercise than those in advanced stages.

A well-rounded program should consist of aerobic conditioning, strength training, and balance exercises, tailored to the person’s specific needs and goals. It’s crucial for therapists and practitioners to work together to ensure the care provided is coordinated and effective.

Preventing Arthritis

Educating patients is crucial in managing their health. This involves helping them understand their illness, what makes it worse, and what signs and symptoms to keep an eye on. Learning about changes to adopt in their lifestyle is also key. This can include losing weight, doing more exercise, and strengthening muscles. These education aspects could lead to better long-term health results for patients dealing with various kinds of arthritis.