World Arthritis Day on 12th October every year is a day set aside to raise awareness of rheumatic and musculoskeletal diseases (RMDs) among the general public and health practitioners; and to support people living with arthritis, their careers and family members with the sole aim of offering patients a comfortable life through early and comprehensive intervention.
Why is this important?
Unfortunately, many RMDs remain undiagnosed or misdiagnosed, resulting in patients suffering with prolonged symptoms and debilitating effects. This can then have a negative impact on quality of life and inclusion in society, as patients may be left with poor mobility/functional capability, inability to work, loss of income and dependence on family, friends and welfare programmes, as well as poor psychological wellbeing.
What is Arthritis?
Arthritis is a term with Greek origins, referring to joint ‘arthro’ and inflammation ‘it is’. It is a condition involving inflammation in the joints, eventually leading to destruction of joint cartilage and damage of the joint’s structures. The symptoms are commonly joint-pain and stiffness; however, other features can include redness, warmth, swelling, and reduced range of movement for the affected joints. Though in general arthritis is predominantly a disorder of the joints, there are some specific types in which other organs of the body are also affected.
Arthritis is one of the most common disorders which affect people and there are over 100 types of arthritis. Most commonly occurring is Osteoarthritis (OA), a degenerative joint disease by which 10-15% of adults over 60 years are affected. Some present as an inflammatory arthritis, of which Rheumatoid Arthritis (RA) is the most common. RA is an autoimmune disorder in which the body’s immune mechanism produces antibodies against itself, thereby attacking healthy tissue and cells. Other types of arthritis include gout, systemic lupus erythematosus (SLE), psoriatic arthritis, septic arthritis (bacterial infection in the joint) and many more. Young adults as well as teenagers and toddlers can also be affected, and research shows that 30% of all arthritis sufferers are under the age of 65 years.
What are the common risk-factors for arthritis?
In general, the cause of arthritis is multi-faceted; however, the type of arthritis one has may be associated with specific risk-factors. Some types or arthritis run in families, so you may be more likely to develop arthritis if your parents or siblings have the disorder. This is noticed particularly in children of parents with early-onset arthritis having a higher risk compared to other families where this is not the case. The increased genetic risk is also observed in families with autoimmune arthritis.
It is reported that men are more likely to develop arthritis compared to women when they are under the age of 50 years; however, this balance tilts toward women once over 50 years; and over 80 years the risk of arthritis is similar in both sexes.
Arthritis is associated with older patients due to the function of age on the joints. The cartilage structure in the joint does not regenerate and so wears away over time. The normal ageing process is thought to cause an increase in instability of the joint through multiple mechanisms that lead to increased propensity for osteoarthritis. It is often referred to as ‘wear-and-tear’ arthritis.
The ‘wear-and-tear’ arthritis is also more common in those performing intensive physical work or repetitive use of the joint due to the biomechanical stresses. This is common in knee arthritis precipitated by movements like knee-bending, kneeling and squatting, but may also occur in other joints.
A previous history of injury to a joint can predispose it to developing early or advanced secondary osteoarthritis. These tend to occur in younger age groups, where the individual may have had an accident or sporting injury at a young age.
Being overweight or obese significantly increases ones risk of developing osteoarthritis, particularly of the knee-joints as the force equivalent to three to six times the body weight is transferred across the knee-joint during walking.
Environmental and Infectious exposures have been implicated in the development of autoimmune rheumatic diseases.
How do some of the common arthritis conditions present?
OA is a chronic, slowly progressive, degenerative condition characterised by cartilage loss. It commonly affects the fingers, knees and hip-joints. It may also affect the back – in particular the cervical spine (neck) and lumbosacral spine (lower back), which is termed spondylosis.
Different mechanisms of damage occur in joints, leading to the characteristic features of pain and instability. Stiffness may occur in the affected joint, but is usually very short-lived and lasts a few minutes. In the early stages, the pain usually occurs with certain movement or activities of the joint and improves with rest; however, it becomes constant in more established disease. One may hear or feel a ‘cracking’ sound or sensation called crepitus coming from the joint on movement, and swelling may be present due to bony deformity or fluid accumulation in the joint.
Typically, osteoarthritis does not present with systemic features of fever, weight-loss or abnormal laboratory investigations. This may point to another form of arthritis or a condition requiring further evaluation.
RA on the other hand, though presenting with joint symptoms, is a heterogeneous, systemic autoimmune disorder that can cause these constitutional symptoms of: fever, weight loss, anorexia, extreme tiredness, depression and organ involvement – such as chest-pain and breathlessness.
It may occur at any age, with the most commonly affected age group being 50-60 years. It affects women more commonly than men, with a ratio of 2-3 women to every man. Clinically, it tends to develop slowly with varying intensity of symptoms over weeks and months. Commonly, it presents with joint-pain and swelling of the fingers, wrists and toes; but can also affect the larger joints such as the knees, ankles, shoulders and elbows. There is prolonged joint stiffness lasting over one hour in the mornings, or is also noticed after prolonged periods of inactivity.
Gout is one of the most common causes of chronic inflammatory arthritis due to monosodium urate (MSU) monohydrate crystals deposition in the tissues and joints. High uric acid in the bloodstream can be due to overproduction or undersecretion of urate in the body. Risk factors for developing gout are numerous; such as older age, male sex, obesity, medications, comorbid diseases, and genetics. Some modifiable ones originate mainly from diet and alcohol high in purine content. Foods that have been implicated in the development of gout are red meat, offal, sea-food/shellfish, and sweetened beverages high in fructose content.
When an attack occurs there is an abrupt onset of intense pain, swelling, redness and warmth of the affected joint. Most commonly it occurs in the big-toe, but can also affect other joints such as the ankle and knee, making walking extremely painful. It can also occur elsewhere, such as the wrist and/or elbow.
How is Arthritis treated?
Many forms of arthritis have no cure and the treatment options vary depending on type of arthritis, so it is important to seek medical attention to ensure the right diagnosis is made and correct therapy instituted. These may include physical therapy, exercise and diet, orthopaedic bracing, oral, topical and intra-articular medications, and surgery. Though an absolute cure may not be available, early intervention can provide the needed relief from symptoms and slow down the progression of arthritis in a particular joint and limit other joint and systemic involvement.
A misconception regarding arthritis is that, due to the pain, the joint must not be moved. This leads to reduction in bulk and strength of the surrounding muscle, thus causing disability of the joint. The opposite is true when regular exercise – upon guidance from a physical therapist – helps to keep the joint mobile, improve muscle-conditioning and reduces inflammation; leading to long-term improvement in pain control. Obesity if present is also controlled with regular exercise. Evidence shows that a reduction in weight of more than 5kg significantly reduces the occurrence of painful knee-OA in obese patients.
The use of appropriate footwear, walking aids and providing a safe environment at home and work form part of the care-plan for patients with arthritis.
Medical therapy should be prescribed by a physician to ensure maximum benefit for the correct type of arthritis and safe usage of drugs. In advanced cases, joint-surgery is performed to relieve symptoms and improve function.
Some foods are triggers for inflammation and others help reduce inflammation. These can be discussed further with your physician and dietician.
Arthritis is very common, with a large, often silent burden on the affected individual and society at large. With this information in your hands now, take action – seek medical attention, get a diagnosis and treat early for better health.
The writer is a Consultant Rheumatologist and Internal Physician