Joint pain can also be a symptom of other diseases. In this
case, the arthritis is considered to be secondary to the main disease; these
include:
Elements of
the history of the disorder guide diagnosis. Important features are speed and
time of onset, pattern of joint involvement, symmetry of symptoms, early
morning stiffness, tenderness, gelling or locking with inactivity, aggravating
and relieving factors, and other systemic symptoms. Physical examination may
confirm the diagnosis, or may indicate systemic disease. Radiographs are often
used to follow progression or help assess severity.
Blood tests and X-rays of the
affected joints often are performed to make the diagnosis. Screening blood
tests are indicated if certain arthritides are suspected. These might include: rheumatoid
factor, antinuclear factor (ANF), extractable nuclear antigen, and
specific antibodies.
Osteoarthritis
Osteoarthritis is
the most common form of arthritis. It
can affect both the larger and the smaller joints of the body, including the
hands, wrists, feet, back, hip, and knee. The disease
is essentially one acquired from daily wear and tear of the joint; however,
osteoarthritis can also occur as a result of injury. In recent years, some
joint or limb deformities, such as knock-knee or acetabular overcoverage or
dysplasia, have also been considered as a predisposing factor for knee or hip
osteoarthritis. Osteoarthritis begins in the cartilage and eventually causes
the two opposing bones to erode into each other. The condition starts with
minor pain during physical activity, but soon the pain can be continuous and
even occur while in a state of rest. The pain can be debilitating and prevent
one from doing some activities. Osteoarthritis typically affects the
weight-bearing joints, such as the back, spine, and pelvis. Unlike rheumatoid
arthritis, osteoarthritis is most commonly a disease of the elderly. More than
30 percent of women have some degree of osteoarthritis by age 65. Risk factors
for osteoarthritis include prior joint trauma, obesity, and a sedentary
lifestyle.
Rheumatoid
arthritis
Rheumatoid
arthritis is a disorder in which the body's own immune system starts to attack
body tissues. The attack is not only directed at the
joint but to many other parts of the body. In rheumatoid arthritis, most damage
occurs to the joint lining and cartilage which
eventually results in erosion of two opposing bones. Rheumatoid arthritis often
affects joints in the fingers, wrists, knees and elbows. The disease is
symmetrical (appears on both sides of the body) and can lead to severe deformity in
a few years if not treated. Rheumatoid arthritis occurs mostly in people aged
20 and above. In children, the disorder can present with a skin rash, fever, pain, disability, and
limitations in daily activities. Often, it is not clear why the rheumatoid
arthritis occurred. With earlier diagnosis and aggressive treatment, many
individuals can lead a decent quality of life. The drugs to treat rheumatoid
arthritis range from corticosteroids to monoclonal antibodies given intravenously. The latest drugs like Remicade can
significantly improve quality of life in the short term. In rare cases, surgery
may be required to replace joints but there is no cure for the illness.
This
adaptive immune response is initiated in part by CD4+ T helper (Th) cells,
specifically Th17 cells. Th17
cells are present in higher quantities at the site of bone destruction in
joints and produce inflammatory cytokines associated with inflammation, such as
interleukin-17 (IL-17).
Bone erosion
is a central feature of rheumatoid arthritis. Bone continuously undergoes
remodeling by actions of bone resorbing osteoclasts and bone forming
osteoblasts. One of the main triggers of bone erosion in the joints in
rheumatoid arthritis is inflammation of the synovium, caused in part by the
production of pro-inflammatory cytokines and receptor activator of nuclear
factor kappa B ligand (RANKL), a cell surface protein present in Th17 cells and
osteoblasts. Osteoclast
activity can be directly induced by osteoblasts through the RANK/RANKL
mechanism.
Lupus
Lupus is a common collagen vascular disorder
that can be present with severe arthritis. Other features of lupus include a
skin rash, extreme photosensitivity, hair loss, kidney problems,
lung fibrosis and constant joint pain.
Gout
Gout is caused by
deposition of uric acid crystals in the joint, causing
inflammation. There is also an uncommon form of gouty arthritis caused by the
formation of rhomboid crystals of calcium pyrophosphate known as pseudogout. In the early
stages, the gouty arthritis usually occurs in one joint, but with time, it can
occur in many joints and be quite crippling. The joints in gout can often
become swollen and lose function. Gouty arthritis can become particularly
painful and potentially debilitating when gout cannot successfully be treated. When
uric acid levels and gout symptoms cannot be controlled with standard gout
medicines that decrease the production of uric acid (e.g., allopurinol,
febuxostat) or increase uric acid elimination from the body through the kidneys
(e.g., probenecid), this can be referred to as refractory chronic gout or RCG.
Other
Infectious arthritis is another severe
form of arthritis. It presents with sudden onset of chills, fever and joint
pain. The condition is caused by bacteria elsewhere in the body. Infectious
arthritis must be rapidly diagnosed and treated promptly to prevent
irreversible joint damage.
Psoriasis can
develop into psoriatic arthritis. With psoriatic arthritis, most individuals
develop the skin problem first and then the arthritis. The typical features are
of continuous joint pains, stiffness and swelling. The disease does recur with
periods of remission but there is no cure for the
disorder. A small percentage develop a severe painful and destructive form of
arthritis which destroys the small joints in the hands and can lead to
permanent disability and loss of hand function.
Treatment
There is no
known cure for either rheumatoid or osteoarthritis. Treatment options vary
depending on the type of arthritis and include physical
therapy, lifestyle changes (including exercise and weight control), orthopedic bracing, and medications. Joint replacement surgery may be
required in eroding forms of arthritis. Medications can help reduce
inflammation in the joint which decreases pain. Moreover, by decreasing
inflammation, the joint damage may be slowed.
Physical
therapy
In general,
studies have shown that physical exercise of the affected joint can have
noticeable improvement in terms of long-term pain relief. Furthermore, exercise
of the arthritic joint is encouraged to maintain the health of the particular
joint and the overall body of the person.
Individuals
with arthritis can benefit from both physical and occupational therapy. In arthritis the joints
become stiff and the range of movement can be limited. Physical therapy has
been shown to significantly improve function, decrease pain, and delay need for
surgical intervention in advanced cases. Exercise
prescribed by a physical therapist has been shown to be more effective than
medications in treating osteoarthritis of the knee. Exercise often focuses on
improving muscle strength, endurance and flexibility. In some cases, exercises
may be designed to train balance. Occupational therapy can provide assistance
with activities as well as equipment.
Medications
There are
several types of medications that are used for the treatment of arthritis.
Treatment typically begins with medications that have the fewest side effects
with further medications being added if insufficiently effective.
Depending on
the type of arthritis, the medications that are given may be different. For
example, the first-line treatment for osteoarthritis is acetaminophen (paracetamol)
while for inflammatory arthritis it involves non-steroidal anti-inflammatory
drugs (NSAIDs) like ibuprofen. Opioids and
NSAIDs are less well tolerated.
Rheumatoid
arthritis (RA) is autoimmune so in addition to using pain medications
and anti-inflammatory drugs, this type uses another category of drug called
disease modifying anti-rheumatic drugs (DMARDS). An
example of this type of drug is Methotrexate.
These types of drugs act on the immune
system and slow down the progression of RA.
Other
treatments
Arthroscopic surgery for osteoarthritis
of the knee provides no additional benefit to optimized physical and medical
therapy.
A Cochrane
review in 2000 concluded that transcutaneous electrical
nerve stimulation (TENS) for knee osteoarthritis was more effective in
pain control than placebo.
PEMF - Pulsed
Electromagnetic Field Therapy has been shown to effectively treat pain
associated with arthritic conditions. The
FDA has not approved PEMF for the treatment of arthritis. In Canada, PEMF
devices are legally licensed by Health Canada for the treatment of pain
associated with arthritic conditions. These devices consist of cylindrical
coils of wire that are energized by frequency generators to produce an
electromagnetic field.
Epidemiology
Arthritis is
predominantly a disease of the elderly, but children can also be affected by
the disease. More than 70% of individuals in North America affected by
arthritis are over the age of 65. Arthritis is more common
in women than men at all ages and affects all races, ethnic
groups and cultures. In the United States a CDC survey based on data
from 2007–2009 showed 22.2% (49.9 million) of adults aged ≥18 years had
self-reported doctor-diagnosed arthritis, and 9.4% (21.1 million or 42.4% of
those with arthritis) had arthritis-attributable activity limitation (AAAL).
With an aging population, this number is expected to increase.
History
While
evidence of primary ankle (kaki) osteoarthritis has been discovered in
dinosaurs, the
first known traces of human arthritis date back as far as 4500 BC. In
early reports, arthritis was frequently referred to as the most common ailment
of prehistoric peoples. It
was noted in skeletal remains of Native Americans found
in Tennessee and
parts of what is now Olathe, Kansas. Evidence of arthritis has been found
throughout history, from Ötzi, a mummy (circa
3000 BC) found along the border of modern Italy and Austria, to the
Egyptian mummies circa 2590 BC.
In 1715, William
Musgrave published the second edition of his most important medical
work, De arthritide symptomatica, which concerned arthritis and its
effects.
