Arthritis is a pain in a joint, any joint, from the big toe to the jaw. To say that a patient has arthritis therefore means very little. The cause of the arthritis and the type of arthritis must be determined before the correct treatment can be commenced.
There are many different types of arthritis, some common, others very rare, and it may take a number of blood, X-ray and other tests before the final diagnosis can be made. Sometimes a disease may be in its early stages or occur only fleetingly, in which case treatment of a non-specific nature may be started while awaiting further developments that will allow a more definite diagnosis and appropriate treatment.
Many injuries, from sport, work, motor vehicle or domestic accidents, can cause joint pain, and these traumatic forms of arthritis can be treated simply and effectively with combinations of hot/cold packs, rest, physiotherapy, anti-inflammatory drugs, pain-killers, liniments and immobilization. Some of these injuries (usually only a very small percentage) may progress to a more chronic form of arthritis, and a patient who is experiencing prolonged problems after an injury should bring these to the attention of their general practitioner sooner rather than later.
Osteoarthritis is a degeneration of one or more joints. It is a disease limited to these affected joints, and differs from rheumatoid arthritis in that there are no effects from the disease elsewhere in the body. It is the most common form of arthritis and affects up to 15% of the total population, most of them being elderly. It is caused by a degeneration in the cartilage within joints, and inflammation of the bone exposed by the damaged cartilage. There is a hereditary tendency to the disease, which is aggravated by injury and overuse of joints.
The symptoms are usually mild at first, but slowly worsen with time and joint use. Any joint in the body may be affected, but particularly vulnerable are the knee, back, hip, feet, and hands. Stiffness and pain that are relieved by rest are the initial symptoms. As the disease progresses, limitation of movement, deformity and partial dislocation (subluxation) of a joint may occur. The joint may become swollen during acute episodes, and a crackling noise may come from the joint when it is moved. Nodules (Bouchard’s or Heberden’s nodes) may develop on the fingers in severe cases.
There are no blood tests available to confirm the diagnosis, but X- rays show characteristic changes from a relatively early stage. Repeated X-rays over the years are used to follow the course of the disease.
The mainstay of treatment is to avoid any movement or action that causes pain in the affected joints. If the leg or back are involved, climbing stairs and carrying loads should be avoided or minimized. An overweight patient is constantly carrying a load, and weight reduction may give considerable relief to a weight-bearing joint. Heat to the affected joints gives considerable relief, and may be best applied by hot wax baths administered by a physiotherapist.
Non-steroidal anti-inflammatory drugs such as aspirin, Indocid, Naprosyn, Voltaren, Feldene, etc., may be used to reduce the pain in a damaged joint. They often must be used in the long term, and may cause indigestion or stomach ulceration in some patients. Pain-relieving medications of varying strength that can be used as required are the only other form of drug treatment available.
Surgery to replace major joints affected by osteoarthritis is very successful. The most common joints to be totally replaced by steel and plastic prostheses are the hip and knee. Previously crippled patients are often able to walk normally again within a couple of months of the operation. Surgery to the joints in the back is sometimes necessary, but these joints have to be fused together to prevent movement between them, as they cannot be replaced. Spinal fusion and laminectomy can give enormous relief to patients who have chronic lower back pain from osteoarthritis.
Injections of steroids into an acutely inflamed joint may give rapid relief, but this ‘treatment cannot be repeated frequently because of the risk of further damage to the joint caused by the side effects of the steroid.
The prognosis of osteoarthritis is variable, depending on the joints involved and the severity of the disease. Quite remarkable cures can be performed by joint replacement surgery, but other patients can achieve reasonable control with medications. In any one joint, the general prognosis is a slow and steady deterioration, but some severely affected joints can become relatively pain-free with time.
Rheumatoid arthritis is a disease that affects the entire body in different ways and is not limited to the joints. The cause is unknown, although there are many theories that include hereditary factors, unidentified viruses, environmental factors and combinations of these. It causes inflammation (swelling and redness) of the smooth moist membrane that lines joint surfaces.
Rheumatoid arthritis occurs in one in every 100 people, and females are three times more likely to develop it than males. It usually starts in the prime of life, between 20 and 40 years of age, while the other common arthritis, osteoarthritis, is worse in the elderly.
The early symptoms include early morning stiffness in the small joints of the hands and feet, loss of weight, a feeling of tiredness and being unwell, pins and needles sensations, and sometimes a slight intermittent fever. The onset is slow and insidious, and it may be months or years before the symptoms are bad enough to take the victim to a doctor. Occasionally the disease has a sudden, acute onset, with severe symptoms flaring in a few days, often after emotional stress, or a serious illness that may lower the body’s natural defenses.
As the disease worsens, it causes increasing pain and stiffness in the small joints, progressing steadily up the arms and legs to larger and larger joints, the back being only rarely affected. The pain becomes more severe and constant, and the joints become swollen, tender and deformed. Other manifestations of the disease can include wasting of muscle, lumps under the skin, inflamed blood vessels, heart and lung inflammation, an enlarged spleen and lymph nodes, dry eyes and mouth, and changes to the number and type of cells in the bloodstream.
The diagnosis is made on the results of blood tests, X-rays and the clinical findings. A ‘rheumatoid factor’ (RF) can be found in the blood of 75% of patients with rheumatoid arthritis, but this can also occur in some other rare diseases, so is not an absolute diagnosis. The level of RF and other indicators in the blood stream can give doctors a gauge to measure the severity of the disease and the response to treatment.
X-rays show characteristic changes around the affected joints, but sometimes not until the disease has been causing discomfort to the patient for some time. Examination of the fluid drawn out from an affected joint may also be used to confirm the diagnosis.
There is no cure for rheumatoid arthritis, but effective controls are available for most patients, and the disease tends to burn out and become less debilitating in old age. Treatment will be prolonged and require the careful control by doctors, physiotherapists and occupational therapists. The severity of cases varies greatly, so not all these treatments will be tried in all patients, and the majority will only require minimal medical care.
Rest of both body and mind are important, as it has been shown that emotional problems and anxiety, as well as physical exhaustion, can cause a deterioration in the disease. Rest of the affected joints in splints is also important, provided physiotherapists control regular passive movement of the joints to prevent permanent stiffness developing, and apply heat or cold as appropriate to reduce the inflammation. After the acute stage has passed, carefully graded exercise, again under the care of a physiotherapist, is vital for the long-term control of the disease in a particular joint.
Medication will be prescribed by doctors to relieve the painful swollen joints. Aspirin and more sophisticated non-steroidal anti-inflammatory drugs are the mainstays of treatment. A wide variety of these are available, and there may be some trial and error necessary to find the one that is most beneficial to an individual patient. Unfortunately, all these drugs have some tendency to cause irritation and bleeding in the gut, and occasionally ulcers, so they must be used with some caution.
A number of unusual drugs are also used for this form of arthritis, and in most cases their mode of action is unknown, and their successful use in rheumatoid disease has been found by chance rather than research. Gold, as a salt, can be given by injection or tablet on a long-term basis to stop the progression of the disease, but regular blood tests and physical examination is necessary to avoid toxic effects. Antimalarial drugs such as chloroquine have also been found useful in high doses, but they occasionally cause eye pigmentation, so regular examination by an eye specialist is necessary while using them. Penicillamine (not an antibiotic) is also used, but it has significant side effects in some patients. The dosage is started at a very low level and slowly built up over several months to avoid toxicity. A number of cell-destroying drugs may also be tried in very severe cases but must be used with great care, under strictly supervised conditions.
Steroid drugs such as prednisone give dramatic, rapid relief from all the symptoms of rheumatoid arthritis in most patients. There are few short-term side effects, and patients are keen to keep taking them, but they do have severe long-term side effects (e.g. bone and skin thinning, fluid retention, weight gain, peptic ulcers, lowered resistance to infection, etc.), and doctors must carefully balance the benefits against the risks. Usually, the lowest possible dose is used for constant treatment, or better still, they are given for a short period of time in high doses to control flare-ups of the disease. In some cases, steroids may be injected into a particularly troublesome joint.
Surgery to isolated, painful joints can be useful in a limited number of patients. The small finger joints can be replaced by artificial ones, as can most of the major joints of the body. Removing the lining of the joint surgically is sometimes performed, but the results have been only fair. Joint destruction and fusion can also be performed.
The prognosis of rheumatoid arthritis is extremely variable. Some patients have irregular acute attacks throughout their lives, others may have only one or two acute episodes at times of physical or emotional stress, while others steadily progress until they become totally crippled by the disease. Even in severe cases, there are cases of sudden, total remission and recovery, but this is uncommon.
The vast majority of patients can be controlled by the above measures to the point where they can lead comfortable, useful, and long lives.
Septic arthritis is a bacterial infection of a joint. It is a serious condition that requires urgent and effective medical treatment to prevent long-term damage to the joint. The disease starts with the sudden onset of severe pain in a joint that is tender to touch, swollen, hot, red, and painful to move. The patient usually has a fever, and the knees, hips and wrists are the most commonly involved joints. Other joints may become painful intermittently before, and during, the acute stage of the disease.
A number of different bacteria may be responsible for the disease, and they usually enter the joint through the bloodstream. Occasionally, obvious injury to the joint or adjacent bone can allow a route of entry for the bacteria. It may follow the injection of drugs into a joint, or the draining of fluid from a swollen joint.
It is a relatively uncommon disease, and the average general practitioner would see less than one case a year. Premature babies are at a particularly high risk of developing the disease.
Blood tests can show that an infection is present in the body, but they are not able to identify the location or type of bacteria. Fluid drawn from the joint through a needle can be cultured, and the offending bacteria can be identified to give a definite diagnosis. X-rays do not reveal the early stages of the disease, but only show changes after the bacteria has eaten away part of the bone that forms the joint.
Investigations should be started before treatment is commenced, so that the infecting bacteria can be correctly identified. While awaiting results, the doctor will usually start the patient on a potent antibiotic. This may be changed at a later time when the results become available. The appropriate antibiotic to treat the disease can then be chosen. Antibiotics may need to be given by injection initially.
Removal of the infected fluid from the joint by needle aspiration on a regular basis is also necessary. Hot compresses, elevation and immobilization of the joint, and pain relieving medication complete the necessary treatments.
As the joint recovers, movement of the joint, without causing pain, should commence under the supervision of a physiotherapist to prevent later limitation of movement.
Recovery within a week to ten days is normal with adequate care, but joint destruction, severe chronic arthritis, or complete fusion and stiffness of a joint can occur if the disease is not treated correctly.
Still’s disease (juvenile rheumatoid arthritis)
Still’s disease is a rare condition that is also known as juvenile rheumatoid arthritis. In simple terms, it is a rheumatoid arthritis- type disease that occurs in children and teenagers. The cause is unknown. There are several forms of the disease that vary in their symptoms, severity and outcome.
Still’s disease is characterized by a widespread measles-type rash, a fever that rises and falls rapidly, enlarged lymph glands, spleen and liver, and one or more hot, red, painful, swollen joints. Nodules may develop under the skin near joints, and the heart, lungs and muscles may also become inflamed. The knees, hips, elbows and ankles are the joints most commonly affected. The onset is rare under one year of age and over fourteen, and girls are twice as likely as boys to develop the disease. Blood tests show signs of generalized inflammation, but the tests that diagnose adult rheumatoid arthritis are usually normal.
Treatment involves prolonged rest, with passive movement of affected joints by physiotherapists on a regular basis. Heat often relieves the pain and swelling. Drug treatment includes aspirin, other anti-inflammatory drugs, and in severe cases, steroids. The course may be prolonged, but most children eventually recover. Unfortunately, some have chronic joint damage and deformity that can cause long term problems. A large number of other diseases can cause arthritis, including ankylosing spondylitis, gout, lupus erythematosus, polymyalgia rheumatica, pseudogout, psoriasis, Reiter’s syndrome, rheumatic fever, Ross river fever, scleroderma, Sjogren’s syndrome.