Arthritis
Common forms of arthritis include Osteoarthritis, Rheumatoid Arthritis, and Sacroiliac Joint Disease.
by Nicole Berardoni M.D, Paul Lynch M.D, and Tory McJunkin M.D
Arthritis is the term used to describe chronic inflammation and subsequent damage to involved joints. Arthritis can be caused by numerous distinct conditions and can affect people at any stage of life. Arthritis can be quite severe and is known to be the leading cause of disability in people over the age of 55 in the United States.
In 2007 the Centers for Disease Control (CDC) published an article stating, “Arthritis continues to burden the U.S. population as the leading cause of physical disability and affects women disproportionately: women with arthritis report greater prevalence of activity and work limitations, psychological distress, and severe joint pain than their male counterparts.” (Theiss 2007).
Anatomy
The structure affected by arthritis is the joint. A joint is defined as an area where two bones meet. Joints are critically important as they allow for mobility.
The joint consists of the following structures:
- Synovial membrane – a tissue that lines the joint and provides a seal producing the joint capsule. The synovial membrane secretes synovial fluid around the joint to lubricate or loosen it.
- Synovial fluid – a clear, adhesive fluid secreted by the synovial membrane.
- Cartilage – a connective tissue, which is made, up of different cells and fibers and is wear-resistant to reduce the friction of movement by covering the bones at the joint.
- Ligaments – elastic bands of connective tissue that surround the joint to give support and limit the joint’s movement from causing excessive extension or flexion of the joint.
- Tendons – a different kind of connective tissue on each side of a joint that attaches to the muscles that helps to control the movement of the joint.
- Bursas – fluid-filled sacs in the joint that help cushion the friction in the joint.
Pathology
Arthritis from varied sources affect the synovial joint and damage the articular cartilage involved. When a joint has sustained chronic inflammation or damage cartilage begins to break down. When this happens, there is more friction endured by the joint. This further damages the cartilage; producing pain, discomfort, and immobility. When the degree of damage is extensive, the cartilage breaks down completely and subjects the underlying bone to injury.
The symptoms of arthritis vary from patient to patient and also from the disease that actually causes the arthritis. Some of the general symptoms of the joint associated with many of the causes of arthritis are:
- Pain
- Tenderness
- Swelling
- Decreased Mobility
- Redness
- Warmth
Common forms of arthritis
- Osteoarthritis (OA) – also known as degenerative arthritis or degenerative joint disease. It is the most common cause of arthritis in the United States and is most common in women, people over the age of 55, obese people, and those with a history of previous joint trauma or disease. OA results from repetitive wear and tear of the joint causing a chronic, non-inflammatory arthritis of moveable joints. The most common joints involved in OA are the distal interphlangeal (DIP) joints of the fingers (which is the joint closest to your finger tip), and the knees. OA can affect a single joint, but patients often have pain in multiple joints. Patients typically experience crepitus (crackling popping sounds and sensations), which is created by broken down cartilage. The two rough cartilage edges come into contact with each other causing decreased range of motion and pain that worsens with activity. Most frequently the pain improves with rest. There is typically no swelling or redness seen with this cause of arthritis.
- Rheumatoid Arthritis (RA) – Unlike OA, RA is a chronic autoimmune disease that is characterized by being systemic, destructive, and inflammatory. It is most commonly seen in women between 35-50 years old, although RA can be seen in anyone at any age, including pediatric patients. Infections by viruses, and bacteria and genetic factors (HLA-DR4) are thought to possibly trigger the destructive inflammation. RA is characterized by symmetric involvement of the large and small joints. The originating cause is by a nonspecific inflammation which then produces T-cell activation (a cell of your immune system) and a pannus (a large area of fibrotic tissue) is formed. The pannus erodes into the surrounding cartilage, tendons, and even bones.
- Sacroiliac Joint (SIJ) Disease – is another major cause of pain often from osteoarthritis. The SIJ is located at the junction between the spine and the pelvis. Sacroiliac Joint (SIJ) Disease is another major cause of LBP. Many muscles and ligaments support the SIJ. This joint allows the weight of the spine and upper body to be transmitted into the pelvis and finally into the legs. The SIJ is richly innervated by free nerve endings and spinal nerve roots, explaining the severe pain caused by inflammation in the SIJ. Pain associated with SIJ can worsen with sitting for long periods of time, or twisting motions and certain movements. Often the pain begins spontaneously, while others recognize a specific traumatic event that triggered the occurrence of the pain. While conservative treatment, such as Naiad’s and physical therapy may be effective, Murakami and Tanaka reported in 2007 that the effect of periarticular lidocaine injection into the SIJ was 96% effective in pain improvement in patients with SIJ complaints with minimal complications (2007 Murakami). Arizona Pain Specialists now offer SIJ injections and longer lasting denervation procedures when warranted.
Uncommon forms of Arthritis
- Lupus Arthritis
- HLA-B27Arthritis
- Psoriatic Arthritis
- Ankylosing Spondylitis
- Gouty Arthritis
- Pseudogout Arthritis
- Septic (Infectious) Arthritis
Diagnosis
Diagnosing patients with arthritis is never straightforward and is often difficult. Many of the symptoms are similar among the varying types of arthritis, so it is important to determine the cause of arthritis to appropriately treat it. The initial step in evaluating a patient with complaints suggesting arthritis involves a comprehensive history and physical exam. Several questions will be covered in the history and some of the most common questions asked are:
- What is the location of the pain?
- How long has the pain been present?
- When and what were you doing when you first noticed the pain?
- What were you doing when you first noticed the pain?
- Is there anything you can do that alleviates the pain?
- Are you currently taking any medications for the pain? Do they work?
- Is there any family history of arthritis or other autoimmune disease?
After conducting a full history and physical exam your physician may want additional studies, including radiological films, joint aspirations, and blood work. Imaging techniques are useful because the physician is able to see the actual effect your condition may be having on the affected joint.
Common imaging techniques to evaluate arthritis may include the following:
- X-Ray – a diagnostic test which uses an electromagnetic energy ray to produce images of internal tissues, specifically, bones are well visualized.
- CT Scan – a diagnostic test that combines x-rays with computer technology to produce cross sectional views of the body. This is helpful because it helps to visualize detailed images of the body, including the bones, muscles, and organs.
- MRI Scan – a diagnostic image that uses a large magnet, radiofrequency, and a computer to produce detailed images of the structures within the body. This is even more detailed than the CT scan and X-ray.
Common laboratory tests that your physician may want to check are complete blood count (CBC), complement, antinuclear antibody (ANA), creatinine, erythrocyte sedimentation rate, rheumatoid factor, urinalysis, and a white blood cell count (WBC). Another aspect that may potentially need to be evaluated is the consistency of the fluid accumulation in the joint.
Your physician may want to perform an arthrocentesis or joint aspiration to look at the components of the fluid in the joint. This is especially crucial when gouty arthritis or a septic (infectious) arthritis is suspected.
Treatment Options
Commonly arthritis goes into remission with periods of decreased or absent symptoms. However, the pain frequently returns and causes a chronic pain syndrome. Unfortunately, arthritis is destructive to the joint and requires adequate treatment. If your pain has lasted longer than 4 weeks or is severe in nature you should see a pain specialist about the treatment options that would be beneficial for you. Treatment for arthritis is specific to the type of pathology that is present.
Treatment for arthritis includes rest, medications, and other pain relief modalities. Many people find that a combination pain relief treatment plan helps them through their daily activities. It is also believed that nutrition and physical therapy can be beneficial in the treatment of arthritis.
Although there are many surgical and interventional options for severe causes of arthritis, the most common and recommended methods to treating arthritis are conservative alternative therapy provided by a pain specialist. Staying active, physical therapy, NSAIDs (Ibuprofen like drugs), and Acetaminophen (Tylenol), have proven to be beneficial. Physical therapy has been noted to significantly improve the postural stability in male hip OA patients (Giemza 2007). Intra-articular injections are rapidly gaining popularity for use in the treatment of arthritis because of their success and long-acting effects.
OA treatment
Patients with Osteoarthritis may benefit from conservative treatments such as rest, low impact exercise, and physical therapy. Physical therapy is particularly important when large, weight-bearing joints are involved, such as the hips or knees. Weight reduction by dieting and exercising can dramatically reduce symptoms of osteoarthritis in the large joints. Physical therapists and your physician can help recommend and provide support devices, such as splints, canes, walkers, and braces as needed.
When pain persists in severe osteoarthritis after conservative treatment has been tried then a series of injections of hyaluronic acid (component of collagen) or steroids into the joint can sometimes be helpful, especially if surgery is not being considered.
In 2007 a study of 60 patients was conducted that assessed efficacy of intra-articular injection of a hyaluronic acid derivative into the knee joint in patients with osteoarthritis. Significant improvement was seen in 60% patients and the study concluded that hyaluronic acid injections are long acting, effective and safe for local intra-articular therapy of arthritis (Men’shikova 2007).
In a 2007 study, the effectiveness of steroid injection for OA of the hip was evaluated. The study determined that the corticosteroid injection is an effective treatment of pain in hip OA, with benefits lasting up to 3 months in many cases (Lambert 2007). An additional study researched the outcome of the safety and efficacy of long-term intra-articular (IA) steroid injections for knee pain related to osteoarthritis. These findings reported that there were no harmful effects of the long-term administration of steroids on the knee joint. Also, long-term treatment of knee OA with multiple steroid injections appear to be clinically effective for the relief of symptoms of the disease (Raynauld 2003).
Steroid joint injections are frequently used for pain syndromes due to common conditions such as degenerative disease and other types of degenerative arthritis. The method involves injecting a steroid medication into the joint space where the irritated structures are located. The medicine then spreads to other portions of the joint reducing inflammation and irritation. The hyaline injections work by restoring the thickness of the joint fluid, allowing better joint lubrication and impact capability.
RA treatment
The mainstay of therapy for rheumatoid arthritis are NSAIDs. Over the counter aspirin, ibuprofen and naproxen sodium are used as well as higher dose NSAIDs prescribed by your physician. Unfortunately, chronic use of NSAIDs can lead to many side effects such as stomach ulcers, damage to the liver and kidneys, and ringing of the ears. COX-2 inhibitors, another form of NSAIDs were developed because they did not affect the lining of the stomach.
Patients with RA are also encouraged to take corticosteroids, such as prednisone and methylprednisolone. These medications help reduce inflammation and pain, and slow joint damage. Side effects of taking steroids orally are easy bruising, thinning of bones, weight gain, and diabetes. Doctors often prescribe a corticosteroid to relieve acute symptoms, with the goal of gradually decreasing the dose of the medication.
Physicians may prescribe DMARDs (Disease-modifying anti-rheumatic drugs). These drugs may slow the development of the disease and save the joints and other tissues from permanent damage. Unfortunately, these medications work very slowly and are not helpful in acute attacks.
The medical industry is beginning to explore the use of alternative therapies for the treatment of chronic arthritis related pain. In 2007 an investigation was performed to evaluate the efficacy of Acupuncture in the treatment of RA. After six treatments 80.9% of the patients had an improvement in their morning rigidity, 64.3% for swelling and 87.2% for their pain. The study showed that repeated Acupuncture treatments improve outcomes in patients with RA (Wang 2007).
Alternative therapies
Some alternative therapies that are helpful in the treatment of arthritis include:
- Acupuncture
- Massage
- Exercise
- Nutritional Counseling
- Physical Therapy
- Vitamin Supplements
Sources
- Safety and efficacy of long-term intra-articular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial. Raynauld JP, Buckland-Wright C, Ward R, Choquette D, Haraoui B, Martel-Pelletier J, Uthman I, Khy V, Tremblay JL, Bertrand C, Pelletier JP. Arthritis Rheum. 2003 Feb;48(2):370-7 PMID: 12571845
-Arthritis burden and impact are greater among U.S. women than men: intervention opportunities. J Womens Health (Larchmt). 2007 May;16(4):441-53 Theis KA, Helmick CG, Hootman JM. PMID: 17521246
-Steroid injection for osteoarthritis of the hip: a randomized, double-blind, placebo-controlled trial. Lambert RG, Hutchings EJ, Grace MG, Jhangri GS, Conner-Spady B, Maksymowych WP. Arthritis Rheum. 2007 Jul;56(7):2278-87 PMID: 17599747
–The effect of physiotherapy training programme on postural stability in men with hip osteoarthritis. Giemza C, Ostrowska B, Matczak-Giemza M. Aging Male. 2007 Jun;10(2):67-70 PMID: 17558970
-[Using hyaluronic acid drugs in local intra-articular therapy of osteoarthrosis in the knee joint Ter Arkh. 2007;79(5):31-5. Men’shikova IV, Makolkin VI, Sugurova IIu. PMID: 17672072
- The role of different therapeutic courses in treating 47 cases of rheumatoid arthritis with Acupuncture. J Tradit Chin Med. 2007 Jun;27(2):103-5 Wang R, Jiang C, Lei Z, Yin K. PMID: 17710802