Arthritis

The Facts

Arthritis is a chronic disorder that affects 1 in 7 Canadians, half of whom are between the ages of 30 to 50 years old. It is one of the major reasons people see their doctor and one of the leading causes of disability in Canada.

The word arthritis is derived from the Greek words arthron for “joint” and itis for “inflammation.” Today, the term is used for hundreds of different varieties of joint problems that have specific symptoms, such as pain, swelling, and stiffness. Arthritis means a change inside a joint. (Bursitis and tendonitis by themselves are not arthritis because they affect tissues around the joints.)

Osteoarthritis (OA) and rheumatoid arthritis (RA) are the two most common types of arthritis conditions. Other types of arthritis include gout, ankylosing spondylitis, systemic lupus erythematosus (SLE or lupus), and psoriatic arthritis.

The effects of arthritis are often mild, but in some cases they can be crippling. RA affects 1 to 2 out of every 100 people, with more women than men being affected. Joints and other organs may be affected by this form of arthritis. The Arthritis Foundation estimates that almost every person over the age of 60 years probably has OA to some degree, but fewer than half have it severe enough to notice any symptoms. OA occurs equally in both sexes but in people under 45 years of age, it is more common in men. It is also much more common in overweight people.

Causes

Some types of arthritis are genetic or inherited (i.e., they tend to run in families). Others are related to a chemical imbalance or are due to an overactive immune system. All forms of arthritis affect the joints to some degree, but others may have their most serious effects on other parts of the body.

OA is the most common form of arthritis, primarily affecting people over the age of 60 years, or in younger people who have had serious joint injuries. It is degenerative in nature – cartilage in the joints gradually wears away, causing the ends of the bones to rub against each other.

OA can develop spontaneously for no apparent reason or be due to a secondary cause, where the joint damage results from an injury or trauma. By far the greatest risk factor for OA of the hips and joints of the legs is being overweight.

Wear-and-tear is the principal sign of OA, but science has begun to unravel the specific mechanisms of the disease. Inflammation does not play as great a role as in other types of arthritis, but for some people it can be a prominent feature. An athlete who has suffered joint injuries or someone who works in a job that puts daily stress on the joints is at higher risk of developing OA later in life.

RA is caused by inflammation and thickening of the joint’s lining, called the synovium. Scientists suspect that inflammatory forms of arthritis such as RA may be triggered by bacterial or viral infections heightened by a flaw in the body’s immune system, but no proof has been found yet. The result is an abnormal immune response that destroys the body’s own tissues. In the case of RA, the joints are the primary target.

Some forms of arthritis are due to metabolic problems, called crystal-associated arthritis. These include gout and pseudogout, which are caused by crystal deposits within the joints. 80% of gout sufferers are men, but women become equally prone after menopause. Gout may be genetic, but it can also be precipitated by excessive alcohol consumption, dehydration, obesity, protein-rich diets, trauma, and conditions that suddenly break down large amounts of tissue. Gout results from the accumulation of uric acid, a waste product from the breakdown of digested proteins. Excess uric acid forms sodium urate crystals that collect in many tissues, including the joint linings, which causes inflammation. It can also lead to kidney stones.

Symptoms and Complications

Symptoms of OA include:

• stiffness (lasting less than 30 minutes) on awakening or after prolonged rest
• pain in a joint during or after use
• discomfort in a joint before or during a change in weather
• swelling and a loss of flexibility in a joint
• bony lumps (called Heberden and Bouchard nodes) that develop on the end or middle joint of the fingers

OA occurs most often in the finger joints, neck, lower back, hips, knees, or big toe joints.

Symptoms of RA include:

• pain and swelling in any joint, but usually symmetrically (if one joint is affected, the other side will soon follow)
• overall aching or stiffness, especially after sleeping or periods of motionlessness
• multiple joints that are swollen, painful, and warm to the touch during the initial attack and ensuing flare-ups
• nodules, or lumps, that most commonly occur near the elbow (but can occur anywhere)
• fatigue

Symptoms of gout include:

• Gout attacks are usually very obvious and symptoms include acute joint inflammation with severe pain, swelling, heat, and redness. It can often be difficult to differentiate it from an acute infection. Any joint can be affected, but the big toe is by far the most common. The attack may last up to a week or more without treatment, then usually resolves and gets better on its own.
• Flank or groin pain and blood in the urine (visible or only on testing) may signal a kidney stone.

Making the Diagnosis

To diagnose arthritis, your doctor will take a thorough history and conduct a physical examination to determine which joints are affected and what other organs or tissues might be involved, and to rule out other possible diseases.

The joints may not show any abnormalities or may show tenderness, swelling, redness or heat, or limited range of motion.

Because there is no specific test to diagnose arthritis, almost all kinds of arthritis are based on the clinical diagnosis of the doctor. Doctors make a firm diagnosis based on the cumulative pattern of the person’s own medical history, family history, environment, physical exam, tests, and course of condition over time.

X-rays may show nothing or may show characteristic changes of OA, RA, and other types of arthritis. MRI and ultrasound may show more information than an X-ray. Sometimes, it is necessary to withdraw a fluid sample from a swollen joint to examine it under the microscope and to send the sample to the lab for analysis of white blood cells and other factors.

Treatment and Prevention

Unfortunately, there’s no cure for most forms of arthritis. The goal of treatment is to reduce symptoms of pain and inflammation with the help of exercise programs, physiotherapy, and medications.

There are things everyone can do today to prevent the possibility of OA later in life. The most important change you can make is to maintain a healthy weight to limit stress on the joints. Recent studies have shown that a weight gain of only 10 to 20 extra pounds in early adulthood increases wear and tear on the shock-absorbing cartilage in joints and can lead to serious joint damage in the long run. Avoiding repetitive movements over long periods of time can help, but if repetitive motions are part of a job or leisure activities, proper training is important.

If someone has a traumatic injury to a joint, they need medical care and rehabilitation to avoid further damage. Talk to a doctor about the proper use of ice, rest, heating pads, hot water bottles, and hot baths for treating any injury.

Exercise programs to maintain muscle tone are useful for managing OA and other kinds of arthritis. These may include special exercises prescribed by your physician. A physical therapist can help you do exercises that strengthen muscles and improve range of motion. Walking is an excellent form of therapy for arthritis in the knees, but only to the point that it does not cause pain. In some cases, joint pain due to OA is often relieved with heat and rest. Cold packs are good short-term pain relievers, but they can temporarily increase stiffness.

Medications for OA include a wide range of pain relievers and anti-inflammatory medications. Acetaminophen* is generally a good choice for long-term use, but it’s important to not exceed the recommended amount (i.e., no more than 4000 mg per day). Even though it is sold over the counter, it can cause serious liver or kidney damage if used incorrectly. If acetaminophen is not effective or if inflammation is present, acetylsalicylic acid (ASA) or other non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen may be recommended. Topical analgesics, like diclofenac*, or capsaicin, are also available to help with localized OA pain. However, talk to your doctor or pharmacist before using NSAIDs as they may cause gastrointestinal bleeding with long-term use and are not recommended in those with uncontrolled high blood pressure.

Acetaminophen and some forms of ASA and NSAIDs are available without a prescription, but always check with a doctor or pharmacist before taking any of these medications. They can also have serious side effects and medication interactions if used incorrectly. Prescription narcotic pain relievers (such as various codeine derivatives) can help people who experience acute periods of pain, but they also can be harmful if not used correctly and may be habit-forming. Constipation is a common side effect of these medications if they are used regularly and you may need to treat this side effect.

If other options have failed, local injections of corticosteroid medication into the affected joints are another treatment option. These injections should not be used too often and should not be given to certain people, such as people with infection or blood problems. If someone with OA also has a history of depression or neuropathic (nerve) pain, they may consider talking to their doctor about using duloxetine* (an antidepressant). For severe cases, surgery such as a hip or knee replacement may be needed. Therapy for RA and other inflammatory types of arthritis includes specially tailored exercises and medication, such as anti-inflammatory medications including ASA and other NSAIDs.

The group of medications called disease-modifying antirheumatic drugs (DMARDs) such as hydroxychloroquine and methotrexate can be helpful for RA, but they require time (weeks to months) before they start working. DMARDs can help to prevent joint destruction. Another group of medications called biologics (e.g., abatacept, adalimumab, anakinra, etanercept, infliximab, rituximab, and others) can also help improve RA symptoms and slow down joint destruction. Corticosteroids (e.g., prednisone, methylprednisolone) may also be used sparingly to control inflammation. Many of these medications are combined with other medications to treat RA (e.g., a biologic is often combined with a DMARD). Relieving stress on joints is important to avoid further damage. Canes, walkers, splints, or crutches are sometimes needed to reduce the amount of body weight placed on certain joints.

NSAIDs are also used to treat the acute symptoms of gout, but low-dose ASA should be avoided as it affects the way the kidneys handle uric acid and may lead to kidney stones. Corticosteroids may also be used to treat acute gout. Regular use of colchicine may reduce frequency of attacks. In some cases, people are prescribed medications (e.g., allopurinol, febuxostat, probenecid, or sulfinpyrazone) to help prevent acute gout attacks.

All of these medications have serious side effects and should be carefully considered and monitored by your doctor. Make sure you understand all the risks and benefits of taking these medications before you start them. Rheumatologists are doctors that specialize in the diagnosis, treatment, and management of RA (and all other kinds of arthritis).

Living and coping with arthritis, as with any chronic disease, can be difficult. It may affect daily activities slightly, or it can be more severe and extremely debilitating. Some people may benefit from counselling or support groups to deal with the challenges of living with arthritis. There are many resources available – it’s important to take advantage of them. The Arthritis Society provides valuable resources.

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