What is arthritis?

Causes and Symptoms

Approximately one in six people (more than 15 percent) suffers from one of
approximately one hundred varieties of arthritis, and 2.6 percent of the
population suffers from arthritis that limits their activities. Although many
people over seventy-five years of age experience arthritis, the disease can occur
in the young as a result of infections, rheumatic conditions, or genetic
conditions. Young and middle-aged adults experience the disease as a result of
trauma, infections, and rheumatic or autoimmune reactions. Arthritis may be
located in joints, joint capsules, the surrounding muscles, or
diffusely throughout the body. Inflammation of the joint lining (synovium) can
similarly afflict the linings of other organs: the skin, colon, eyes, heart, and
urinary passage. In addition to the characteristic symptoms of joint pain and
stiffness, individuals suffering from arthritis may also experience
psoriasis and rashes, spastic colitis,
dryness of the eyes, inflammations of the conjunctiva or iris, frequent urination,
discharge and burning upon urination, and other symptoms.

Arthritis has many causes. Infectious causes of arthritis include septic
arthritis, tuberculous arthritis, viral arthritis (potentially caused by the
hepatitis virus, parvovirus B19, or human immunodeficiency virus), acute
rheumatic
fever, and Lyme disease. Primary arthritic syndromes include
rheumatoid
arthritis and juvenile rheumatoid arthritis, which
are systemic inflammatory diseases characterized by chronic destructive synovitis.
Seronegative spondyloarthropathy—such as reactive arthritis, psoriatic arthritis,
and ankylosing
spondylitis—is another primary arthritic syndrome. Reactive
arthritis is a systemic inflammatory disorder that arises one to six weeks after
an infection, most often gastrointestinal or urogenital infections. A form of
reactive arthritis called Reiter’s syndrome affects the eyes and
urethra as well as the joints. Psoriatic arthritis is associated with mild to
severe psoriasis and joint pain. Osteoarthritis is brought on by
wear-and-tear degeneration of the joints and is associated with older age. Such
wear and tear can occur in the joints after years of trauma, repetitive use, and
(especially in the obese) weight-bearing. Osteoarthritis and rheumatoid arthritis
are the most common forms of arthritis.

Additionally, uric acid crystals associated with gout can
build up in the joints, causing arthritis. Gout sufferers experience painful, hot,
tender, and swollen joints—with symptoms often beginning in the big toe. Calcium
pyrophosphate dihydrate deposition disease is also associated with crystal-induced
arthritis. Arthritis is also associated with a number of other medical conditions.
Autoimmune causes of arthritis include systemic lupus erythematosus (SLE),
Sjögren’s
syndrome, and dermatomyositis (also known as
idiopathic inflammatory myopathy). Endocrine and metabolic disorders such as
thyroid disease, Gaucher’s disease, Wilson disease, and hemochromatosis can
also cause arthritis. Arthritis may also be associated with tumors that grow from
cartilage cells, blood vessels, synovial tissue, and nerve tissue. Blood
abnormalities may give rise to hemorrhages into joints (a side effect of
sickle cell
disease and hemophilia), causing joint conditions
that can be disabling and very painful and that may require surgery. Traumatic and
mechanical derangements—sports and occupational injuries, leg-length disparity,
and obesity—may elicit acute synovial inflammation with
subsequent degenerative arthritis.

The inflammatory reactions in response to injury or disease consist of fluid
changes—the dilation of blood vessels accompanied by an increase in the
permeability of the blood vessel walls and consequent outflow of fluids and
proteins. Injurious substances are immobilized with immune reactions and removed
by the cellular responses of phagocytosis and digestion of foreign
materials, resulting in the proliferation of fibrous cells to wall off the
injurious substances and, in turn, leading to scar formation and deformities. The
chemical reactions to injury commence with a degradation of phospholipids when
enzymes are released by injured tissue. Phospholipids—fatty material that is
normally present—break down into arachidonic acid, which is further broken down by
other enzymes, lipoxygenase and cycloxygenase, resulting in prostaglandins and
eicosanoid acids. Most anti-inflammatory medications attempt
to interfere with the enzymatic degradation process of phospholipids and could be
damaging to the liver and kidneys and to the body’s blood-clotting ability.

A physician bases the diagnosis of arthritic disease on the patient’s medical
history and a physical examination. Specific procedures such as joint aspiration,
laboratory studies, and X-ray or magnetic resonance imaging (MRI) may help to
establish the diagnosis and the treatment. The history will elicit the onset of
pain and its relation to time of day and difficulties performing the activities of
daily living. A functional classification has evolved that is similar to the
cardiac functional classification: Class 1 patients perform all usual activities
without a handicap; class 2 patients perform normal activities adequately with
occasional symptoms and signs in one or more joints but still do not need to limit
their activities; class 3 patients find that they must limit some activities and
may require assistive devices; and class 4 patients are unable to perform
activities, are largely or wholly incapacitated, and are bedridden or confined to
a wheelchair, requiring assistance in self-care.

A person’s medical history or surgical conditions and the medications that he or
she is taking can influence the physician’s diagnosis and prescription for
treatment. Patients may present a picture of the body to the physician showing the
joints involved in their symmetry (whether distal or proximal, and whether
weight-bearing or posttraumatic in distribution). Physicians may ask (verbally or
by questionnaire) for a history of other system complaints, which can then be
checked more thoroughly. During a physical examination, the physician will check
the joints, skin, eyes, abdomen, heart, and urinary tract. The neuromuscular
evaluation may reveal localized tenderness of the joints or muscles, swelling,
wasting, weakness, and abnormal motions. Joints may have weakened ligamentous,
muscular, and tendinous supports that could give rise to instability or grinding
of joints, with subsequent roughening of cartilage
surfaces.

Joint pathology is generally associated with some limitation in the range of
motion. Sensation testing, muscle strength, and reflex changes may also indicate
nerve tissue damage. Nerves occasionally pass close to joints and may be pinched
when the joint swelling encroaches upon the passage opening. This condition may
result in carpal
tunnel syndrome, in which the median nerve at the wrist
becomes pinched, causing pain, numbness, and weakness in the hand. Pinched nerves
may also be associated with tarsal tunnel syndrome, in which the nerve at the
inner side of the ankle joint may be compressed and cause similar complaints in
the feet. Other nerves may be constricted in exiting from the spine and when
passing through muscles in spasm.

Arthritis of the spine can lead to a progressive loss in motion. The amount lost
can be measured by comparing the normal motion with the restricted motion of the
patient. The neck may be limited in all directions, rotation of the head to the
sides can restrict driving ability, and the head may gradually tilt forward. The
lower back may also exhibit restriction in all directions; for example, it may be
limited in forward bending because of spasms in the muscles in the back. Tilting
backward of the trunk may be limited and painful when the vertebral body
overgrowth of degenerative arthritis restricts the space for the spinal cord. The
nerves pinched in their passage from the vertebrae may thus cause radiculitis,
irritation of the nerves as they exit from the spine that leads to pain and muscle
involvement. Circumferential measurements of the involved joints and the
structures above and below can confirm swelling, atrophy from disuse or inaction,
or atrophy from a damaged nerve supply. When measurements are repeated, they can
indicate improvement or deterioration. One type of arthritis that most often
affects the spine, ankylosing spondylitis, occurs predominantly in
males in their late teenage and early adult years.

Testing of blood for cells, chemicals, or enzymes is helpful. One test—the
erythrocyte sedimentation test (EST)—measures the inflammatory markers in the
blood. When the sedimentation rate exceeds the normal range, active inflammation
in the body is indicated. Comparisons of results from ESTs performed at different
stages can reveal the disease’s rate of progression or improvement. Blood tests
may also measure uric acid for gout and rheumatoid factor (RF) for rheumatoid
arthritis. Blood tests for immune substances and antibodies are also possible. The
joint fluid can be aspirated and analyzed, particularly for appearance, density,
number of blood cells, and levels of sugar. Cloudy fluid, the tendency to form
clots, a high cell count, and lower-than-normal levels of sugar in the joint fluid
(compared to the overall blood sugar level) indicate abnormalities. With
inflammatory arthritides, the X-rays will show the results of synovial fluid and
cellular overabundance. Clumps of pannus break off and may destroy the cartilage
and bone. Bones about these joints, because of increased vascularity and blood
flow, have less minerals and will appear less dense, a condition known as
osteoporosis.

Deformities in inflammatory arthritis may be the result of unequal muscle pulls or
the destruction or scarring of tissues; such deformities can occasionally be
prevented by the use of resting splints, which is most important for the
hands.

Degenerative and posttraumatic arthritis show joint narrowing, thinning of the
cartilage layer, hardening of the underlying bone (called eburnation), and
marginal overgrowth of the underlying bone (called osteophytes), resulting in
osteoarthritis. Osteophytes, or marginal lipping in the back, may enhance symptoms
of lower back
pain. The cushions between the vertebrae, called discs, are
more than 80 percent water, a figure which diminishes with aging, bringing the
joints in the back (the facets) closer together and compressing the facet joints
between the vertebrae. Irritation and arthritis of these joints are the result.
Other organ structures may be involved as well.

Treatment and Therapy

Treatment of arthritis depends on the type and the severity of the arthritis and
may vary from home treatment to outpatient treatment to hospitalization for
surgical and/or rehabilitative care. Education regarding the patient's condition,
prognosis, treatment goals, and methods of treatment is necessary. Patients must
be made aware of warning signs of progression, drug effects, and local and
systemic side effects of drug therapy. Surgical treatment such as joint
replacement, may be considered for the treatment of severe joint damage or if
symptoms are unsatisfactorily controlled with medical management. Postoperative
restrictions in the range of motion must be given prior to surgery; in
hip
replacement, for example, hip bending should not exceed
ninety degrees. The rotation and overlapping of legs must be limited initially
after surgery.

Some physicians provide a questionnaire that outlines the activities of daily
living and recommends how a patient should perform such activities and how much
time should be spent at rest. The goals generally are to maintain function, to
alleviate pain, to limit the progression of deformities, to prevent complications,
and to treat associated and secondary disease states. In patients with
degenerative arthritis—most often the elderly, who are at risk for other organ
failures—arthritides associated with systemic diseases and other organ
involvements may require care.

Medication is used for symptom control. Nonsteroidal anti-inflammatory drugs
(NSAIDs), such as aspirin and ibuprofen, are often used to ease pain and reduce
swelling. Short-term use of oral corticosteroids may also be prescribed to reduce
joint tenderness and pain. Topical capsaicin cream also reduces discomfort.
Disease-modifying antirheumatic drug (DMARDs), such as abatacept and tocilizumab,
are recommended as the first-line therapy for rheumatoid arthritis. Cyclooxygenase
2 (COX-2) inhibitors may also be used in the medical management of
osteoarthritis.

Other therapies can include assistive devices, counseling patients and their
families regarding home management, heat therapy, range-of-motion and
strengthening exercises, and biofeedback. The aim is to reduce the need for and
frequency of medical care, through a balance between rest and activity and between
effective drug dose and physical modalities. To protect joints and allow function,
various braces and assistive devices may be needed. Posture training may alleviate
postural muscle fatigue. In acute stages of inflammation, the treatment choices
are rest, ice, compression, and proper positioning and medicinals for pain and
inflammation.

Physicians may offer physical therapy, occupational
therapy, assistive devices for self-care, ambulation, or home
and automobile modifications. Assistive devices may include reachers, an elongated
shoehorn handle, thickened handles for utensils, walkers, canes, crutches, and
wheelchairs. Homes may require ramps for easier access, widened doors to allow
wheelchair passage, grab bars in bathtubs, or raised toilet seats for easier
transference from a wheelchair.

Heat therapy may reduce the pain, loosening tightened tissues. Patients frequently
will be stiffer after protracted rest periods (for example, on waking) and feel
better after some activity and exercise. Heated pools offer an excellent heating
and exercise modality. The type of heat modality used will depend upon the depth
of heating desired. Hot packs and infrared lamps will heat predominantly the skin
surface areas and some underlying muscles. Diathermy units heat the muscular
layers, and ultrasound treatments heat the deepest bony layers. Ultrasound (but
not diathermy) can even be used in patients who have metallic implants such as
joint replacements.

Perspective and Prospects

Historically, arthritis was treated with warm baths or sands. Some experimental
treatments presently being tried include transcutaneous electrical nerve
stimulation (TENS) to bring about reductions in intra-articular pressures and in
the fluid and cellular content in joints. Exercises continue to maintain and
improve strength, dexterity, the range of motion, and endurance. Good health
habits—including adequate rest, good nutrition, nutritional supplements, and
weight
management—can be beneficial.

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