Understanding Arthritis -- August 18, 2008 -- Dr. Christian Rhea - NewsChannel5.com | Nashville News, Weather & Sports

MEDICAL MONDAYS: News Notes
Dr. Christian Rhea, rheumatologist
BAPTIST HOSPITAL

TOPIC: Arthritis Awareness
Monday, August 18, 2008

Arthritis: Rheumatoid Arthritis Basics

Arthritis is a general term that means inflammation in a joint. Joint inflammation is characterized by redness, warmth, swelling and pain within the joint.

Rheumatoid arthritis is a type of chronic arthritis that typically occurs in joints on both sides of the body (such as hands, wrists or knees). This symmetry helps distinguish rheumatoid arthritis from other types of arthritis.

In addition to affecting the joints, rheumatoid arthritis may occasionally affect the skin, eyes, lungs, heart, blood, or nerves.

What Are the Symptoms of Rheumatoid Arthritis?

Symptoms of rheumatoid arthritis include:

• Joint pain and swelling
• Stiffness, especially in the morning or after sitting for long periods
• Fatigue

Rheumatoid arthritis affects everyone differently. In most people, joint symptoms develop gradually over several years. But in some, rheumatoid arthritis may progress rapidly and yet other people may have rheumatoid arthritis for a limited period of time and then enter a period of remission.

Who Gets Rheumatoid Arthritis?

Rheumatoid arthritis affects about 1% of the U.S. population. While it is two to three times more common in women than in men, men tend to be more severely affected when they get it. It usually occurs in middle age, however, young children and the elderly also can develop rheumatoid arthritis.

What Causes Rheumatoid Arthritis?

The exact cause of rheumatoid arthritis is unknown, but it is thought to be due to a combination of genetic, environmental and hormonal factors. With rheumatoid arthritis, something seems to trigger the immune system to attack the joints and sometimes other organs. Some theories suggest that a virus or bacteria may alter the immune system, causing it to attack the joints.

Research hasn't been able to determine exactly what role genetics plays in rheumatoid arthritis. However, some people do seem to have a genetic or inherited factor that increases their chance of developing rheumatoid arthritis.

How Does Rheumatoid Arthritis Affect the Body?

Once the immune system is triggered, immune cells migrate from the blood into the joints and joint-lining tissue, called synovium. There the immune cells produce inflammatory substances. The increased number of cells and inflammatory substances within the joint cause irritation, wearing down of cartilage (cushioning material at the end of bones), and swelling and inflammation of the joint lining. Inflammation of the joint lining stimulates it to produce excessive joint fluid within the joint.

As the cartilage wears down, the space between the bones narrows. If the condition worsens, the bones could rub against each other.

As the joint lining expands, it may invade into, or erode, the adjacent bone, resulting in irreversible bone damage. All of these factors cause the joint to become very painful, swollen, and warm to the touch.

How Is Rheumatoid Arthritis Diagnosed?

The diagnosis of rheumatoid arthritis is based on a combination of factors, including:

• The specific location and symmetry of painful joints, especially the hand joints.
• The presence of joint stiffness in the morning.
• Presence of bumps and nodules under the skin (rheumatoid nodules).
• Results of X-ray tests that suggest rheumatoid arthritis.
• Positive results of a blood test called the rheumatoid factor.

Most, but not all, people with rheumatoid arthritis have the rheumatoid-factor antibody in their blood. (Rheumatoid factors are actually antibodies that bind other antibodies.) Rheumatoid factor may sometimes be present in people who do not have rheumatoid arthritis. Other diseases can also cause the rheumatoid factor to be produced in the blood. Therefore, the diagnosis of rheumatoid arthritis is based on a combination of the joint symptoms and appearance as well as laboratory information and not just the presence of the rheumatoid factor in the blood.

A newer, more specific blood test for rheumatoid arthritis is the citrulline antibody test. When positive, it is very suggestive of rheumatoid arthritis. Citrulline antibody presence also implies a tendency toward a more aggressive form of rheumatoid arthritis.

People with rheumatoid arthritis may have a mild anemia. Blood tests may also reveal an elevated erythrocyte sedimentation rate (ESR) or elevated C-reactive protein (CRP) levels, which are markers of inflammation.

Some people with rheumatoid arthritis may also have a positive antinuclear antibody test (ANA). This test is indicative of the fact that rheumatoid arthritis is an autoimmune disease.

How Is Rheumatoid Arthritis Treated?

There are many different ways to treat rheumatoid arthritis. Treatments include medications, rest and exercise, and surgery to correct damage to the joint.

The type of treatment will depend on several factors including the person's age, overall health, medical history and severity of the arthritis.

Medications

There are many medications available to decrease joint pain, swelling and inflammation. Some of these medications prevent or minimize the progression of the disease.

Medications that offer relief of arthritis symptoms (joint pain, stiffness and swelling) include:

• Anti-inflammatory painkiller drugs, such as aspirin, ibuprofen or naproxen
• Topical (applied directly to the skin) pain relievers
• Corticosteroids, such as prednisone
• Narcotic pain relievers

There are also many strong medications called disease-modifying antirheumatic drugs (DMARDs) that are used to treat rheumatoid arthritis. These medicines usually work by interfering with or suppressing the immune system attack on the joints. They include:

• Plaquenil (originally used to treat malaria)
• Immune suppression drugs such as methotrexate, Imuran, Cytoxan, and cyclosporin
• Biologic treatments, such as Enbrel, Humira, Remicade, Orencia, and Rituxan
• Other drugs, such as Azulfidine and Arava

Why Is Rest and Exercise Important?

A balance of rest and exercise is important in treating rheumatoid arthritis. During flare-ups (worsening of joint inflammation), it is best to rest the joints that are inflamed. This may be accomplished by the temporary use of a cane or joint splints.

When joint inflammation is decreased, guided exercise programs are necessary to maintain flexibility of the joints and to strengthen the muscles that surround the joints. Range-of-motion exercises should be done regularly to maintain joint mobility.

When Is Surgery Necessary?

When joint damage from the arthritis has become severe or pain is not controlled with medications, surgery may be an option to help restore function to a damaged joint.

Can Rheumatoid Arthritis Be Cured?

Although there is not yet a cure for rheumatoid arthritis, early, aggressive treatment has been shown to help prevent disability

  

  

Arthritis: Osteoarthritis Basics

Arthritis is a general term that means inflammation in joints. Osteoarthritis, also called degenerative joint disease, is the most common type of arthritis. It is associated with a breakdown of cartilage in joints and can occur in almost any joint in the body. It most commonly occurs in the weight bearing joints of the hips, knees and spine. It can also affect the fingers, thumb, neck, and large toe. It usually does not affect other joints unless previous injury or excessive stress is involved.

Cartilage is a firm, rubbery material that covers the ends of bones in normal joints. Its main function is to reduce friction in the joints and serve as a "shock absorber." The shock-absorbing quality of normal cartilage comes from its ability to change shape when compressed (flattened or pressed together).

Osteoarthritis causes the cartilage in a joint to become stiff and lose its elasticity, making it more susceptible to damage. Over time, the cartilage may wear away in some areas, greatly decreasing its ability to act as a shock absorber. As the cartilage deteriorates, tendons and ligaments stretch, causing pain. If the condition worsens, the bones could rub against each other.

Who Gets Osteoarthritis?

Osteoarthritis affects nearly 21 million Americans. The chance of developing the disease increases with age. Most people over age 60 have osteoarthritis to some degree, but its severity varies. Even people in their 20s and 30s can get osteoarthritis. In people over 50, more women than men get osteoarthritis.

What Are the Symptoms of Osteoarthritis?

Symptoms of osteoarthritis most often develop gradually and include:

• Joint aching and soreness, especially with movement.
• Pain after overuse or after long periods of inactivity.
• Bony enlargements in the middle and end joints of the fingers (which may or may not be painful).
• Joint swelling and joint fluid accumulation.

What Causes Osteoarthritis?

There are several factors that increase a person's chances of developing osteoarthritis. These include:

• Heredity. Some people have an inherited defect in one of the genes responsible for making cartilage. This causes defective cartilage, which leads to more rapid deterioration of joints. People born with joint abnormalities are more likely to develop osteoarthritis, and those born with an abnormality of the spine (such as scoliosis or curvature of the spine) are more likely to develop osteoarthritis of the spine.
• Obesity. Obesity increases the risk for osteoarthritis of the knee and hip. Maintaining ideal weight or losing excess weight may help prevent osteoarthritis of the knee and hip or decrease the rate of progression once osteoarthritis is established.
• Injury. Injuries contribute to the development of osteoarthritis. For example, athletes who have knee-related injuries may be at higher risk of developing osteoarthritis of the knee. In addition, people who have had a severe back injury may be predisposed to develop osteoarthritis of the spine. People who have had a broken bone near a joint are prone to develop osteoarthritis in that joint.
• Joint Overuse. Overuse of certain joints increases the risk of developing osteoarthritis. For example, people in jobs requiring repeated bending of the knee are at increased risk for developing osteoarthritis of the knee.

How Is Osteoarthritis Diagnosed?

The diagnosis of osteoarthritis is based on a combination of the following factors:

• Your description of symptoms.
• The location and pattern of pain.
• Certain findings on physical examination, when necessary.

Your doctor may use X-rays to help confirm the diagnosis and make sure you don't have another type of arthritis. X-rays show how much joint damage has occurred.

Sometimes blood tests will be given to determine if you have a different type of arthritis.

If fluid has accumulated in the joints, your doctor may remove some of the fluid (called joint aspiration) for examination under a microscope to rule out other diseases.

How Is Osteoarthritis Treated?

Osteoarthritis usually is treated by physical therapy with muscle strengthening exercises, oral medications, hot and cold compresses to the painful joint, removal of joint fluid, injection of medications into the joint, use of supportive devices such as crutches or canes, and weight control. Surgery may be helpful to relieve pain when other treatment options have not been effective.

The type of treatment prescribed will depend on several factors including your age, activities and occupation, overall health, medical history, location of your osteoarthritis, and severity of the condition.

What Medications Are Used to Treat Osteoarthritis?

Medications may be prescribed to reduce pain caused by osteoarthritis. Pain-relieving medications include acetaminophen (for example, Tylenol) and anti-inflammatory drugs (often called NSAIDs), such as aspirin, ibuprofen or Celebrex. Some medications in the form of creams, rubs or sprays may be applied over the skin of affected areas to relieve pain. For some people with persistent pain despite these pills or creams, steroids can be injected directly into the joint for pain relief. These injections are typically limited since prolonged use can lead to bone and cartilage deterioration and weakness.

Synvisc, Supartz, Euflexxa, Orthovisc and Hyalgan are medications given as a series of 3 to 5 weekly joint injections that can relieve pain in some people with osteoarthritis.

When osteoarthritis pain is severe and other treatments are not working, some doctors will give stronger pain pills, such as narcotics.

Unfortunately, none of these will reverse or slow the progression of joint damage caused by osteoarthritis.

How Does Weight and Exercise Impact Osteoarthritis?

Staying at your recommended weight helps prevent osteoarthritis of the knees, reduces the stress on weight-bearing joints and reduces pain in affected joints. Once you have osteoarthritis, losing weight also can relieve the stress and pain in your knees.

Exercise is important to improve joint movement and to strengthen the muscles that surround the joints. Gentle exercises, such as swimming or walking on flat surfaces, are recommended because they are less stressful on your joints. Avoid activities that increase joint pain, such as jogging or high impact aerobics. Exercises that strengthen the quadriceps muscle reduce knee pain in patients with osteoarthritis.

Are There Alternative Treatments for Osteoarthritis?

Some medical research has shown that the supplements glucosamine and chondroitin may relieve pain in some people with osteoarthritis -- especially in the knee. There is no evidence that glucosamine can help rebuild cartilage.

Some people also use methylsulfonylmethane (MSM) and S-adenosylmethionine (SAM-e) for arthritis but there is questionable medical evidence showing their benefits. MSM is a naturally occurring compound that is taken as a dietary supplement.

Acupuncture and bioelectric therapy also may be useful at relieving pain.

What Supportive Devices Are Available to Help With Osteoarthritis?

Supportive or assistive devices may be helpful to decrease pressure on the joints. Knee supports may be helpful for some people to stabilize the ligaments and tendons and decrease pain. Canes or crutches may be helpful to take pressure off certain joints.

When Is Surgery Necessary?

When osteoarthritis pain is not controlled with medications and the other mentioned treatments, or when the pain prevents you from participating in your normal activities, you may want to consider surgery.

There are several surgical procedures that could be used. They include:

• Arthroscopy to clean out the damaged cartilage, although recent studies question the effectiveness of this type of arthroscopic therapy for treatment of knee osteoarthritis.
• Joint replacement surgery to replace the damaged joint with an artificial one. Even under the best of circumstances, surgery cannot return the joint to its normal state (artificial joints do not have all of the motion of a normal joint). However, an artificial joint will diminish pain. The two joints most often replaced are the hip joint and the knee joint. Artificial joints are now also available to replace shoulders, fingers, elbows, ankles, and back joints to treat severe pain that has not responded to other treatments.
• Joint fusion removes the damaged joint and fuses the two bones on each side of the joint. This is done more often in areas in which joint replacement is not effective.