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Arthritis

Arthritis?

Arthritis literally means joint inflammation. But the term is often used to refer to any of the more than 100 diseases that affect the joints – where two or more bones meet to allow movements.

Osteoarthritis

It is a common degenerative joint disease in aged population. In this disease, the surface of the joint gets damaged (i.e. degeneration of joint cartilage) and the surrounding bone gets thicker

Primary Osteoarthiritis (idiopathic)

  • Hands : Nodal osteoarthiritis more than three joints involved.
  • Hip : Eccentric, concentric, diffuse.
  • Knee : Medical tibiofemoral, lateral tibiofemoral, patello femoral.
  • Spine : Apophyseal, intervertebral, spondylosis
  • Small (peripheral) joints
  • Large (central) joints
  • Mixed and spine

Secondary

  • Congenital & developmental disorders, bone dysplasias.
  • Post surgery/ injury – meniscectomy.
  • Endocrine: diabetes mellitus , acromegaly, hypothyroidism, hyperthyroidism, hyperparathyroidism, cushing syndrome.
  • Metabolic: haemochromatosis, ochronosis, marfan's syndrome, ehler-danlos syndrome, paget's disease, gout, pseudogout, wilson's disease, hurler's disease, gaucher's disease.
  • Rheumatologic : Rheumatoid arthritis.
  • Neurological : Charcot joints.
  • Hematological : haemoglobinopathies
  • Iatrogenic : Intra-articular steroids.

How Does Osteoarthritis Affect People?

Osteoarthritis affects each person differently. In some people, it progresses quickly; in others, the symptoms are more serious. Scientists do not know yet what causes the disease, but they suspect a combination of factors, including being overweight, the aging process, joint injury, and stresses on the joints from certain jobs and sports activities.

What Areas Does Osteoarthritis Affect?

Osteoarthritis most often occurs at the ends of the fingers, thumbs, neck, lower back, knees, and hips. Osteoarthritis hurts people in more than their joints: their finances and lifestyles also are affected.

Financial effects include

The cost of treatment Wages lost because of disability

Lifestyle effects include

  • Depression
  • Anxiety
  • Feeling of helplessness
  • Limitations on daily activities
  • Job limitations
  • Trouble participating in everyday personal and family joys and responsibilities.

Despite these challenges, most people with osteoarthritis can lead active and productive lives. They succeed by using osteoarthritis treatment strategies, such as the following:

  • Pain relief medications
  • Rest and exercise
  • Patient education and support programmes
  • Learning self-care and having a "good-health attitude."

Osteoarthritis Basics: The Joint and Its Parts

Most joints--the place where two moving bones come together--are designed to allow smooth movement between the bones and to absorb shock from movements like walking or repetitive movements. The joint is made up of

  • Cartilage: a hard but slippery coating on the end of each bone. Cartilage, which breaks down and wears away in osteoarthritis
  • Joint capsule: a tough membrane sac that holds all the bones and other joint parts together.
  • Synovium (sin-O-vee-um): a thin membrane inside the joint capsule.
  • Synovial fluid: a fluid that lubricates the joint and keeps the cartilage smooth and healthy.

Ligaments, tendons, and muscles:

tissues that keep the bones stable and allow the joint to bend and move. Ligaments are tough, cord-like tissues that connect one bone to another. Tendons are tough, fibrous cords that connect muscles to bones. Muscles are bundles of specialized cells that contract to produce movement when stimulated by nerves

What happens in Osteoarthritis?

Joint cartilage is a spongy material that covers the ends of the bones. It cushions the bones (absorbing shocks) and prevents them from rubbing against each other.

Any factor (repeated trauma, advanced age, obesity etc.) that cause the breakdown of joint eventfully results in loss of joint shape and alignment. Also, the ends of the bones thicken and form bony growths called ‘spurs'.

The degenerated small bits of cartilage or bone may float within the joint space causing stiffness, pain and loss of mobility in joints.

Important feature include the following:

  • It usually beings after the age of 40 and develops slowly over a periods of years.
  • It mainly affects the weight-bearing joints like the knees and hips. However, it may also involve small joints of finger (e.g. in typists and computer operators due to overuse of finger joints) and the spine (e.g. in old people).
  • Pain in the affected joint. The pain in knees may become worse after suddenly rising form a “prolonged sitting posture” and sometimes in damp or rainy seasons (possibly due to change in joint pressure with change in atmospheric pressure.
  • Early morning stiffness for not more that 30 minutes.
  • Creaking in the affected joint and a grinding sensation with joint motion
  • Joints are usually cold as there is no inflammation.
  • Heberden's nodes (bony enlargement of the small joint at the end of the fingers) and Bouchard's nodes (bony enlargement the middle joint of the finger) are characteristic of osteoarthritis .
  • Does not effect the overall health of the person.

What are the investigation to be carried out

Apart from a detailed medical history and physical examination, the doctor will recommend various tests to evaluate and diagnose the condition. These include :

  • Blood test for C-reactive protein (elevated in Osteoarthritis). It is also a good predictor of progression of Osteoarthritis.
  • ESR and test for Rheumatoid factor to exclude Rheumatoid arthritis.
  • X-ray of the affected joint which may show loss of joint space, bony marginal lipping and bony projection (spurs)
  • Synovial fluid examination to rule out infection. Presence of cartilage cells in synovial fluid is an indicator of OA.
  • Arthroscopy: TO visualize the joint internally.
  • CT scan or MRI of the affected joint

Management of Osteoarthritis

  • Controlling body weight
  • Taking medication regularly as advised by the doctor.
  • Eat healthy: Take high intake of antioxidants specially vitamin C that reduces the progression of osteoarthritis. Calcium and vitamin D intake should be adequate.
  • Taking adequate rest
  • Avoiding joint overuse or repetitive injury
  • Exercise : Isometric (physical exercises in which muscles are made to act against a fixed object) strengthening of supporting muscles around joints may be helpful. Swimming is the best form of aeobic exercise for those with osteoathritis of hip or knees. Running should be avoided.
  • Yoga and other alternative therapies have been scientifically documented to complement the use of drugs. ( To see the proper scientific and validated yogic protocol for Arthritis, log on to www.bestonhealth.com )

Non Medicinal Management

A.Effective Exercise Programme
B.Heat Therapy

  • Moist heat is better than dry heat.
  • Application of deep heat before starting exercises.
  • Therapies like short wave, microwave & ultrasound are most commonly used.

C.Hydrotherapy

  • Hubbard tank hydrotherapy.

D. Patellar tapping

  • Patello femoral joint pain is relieved by patellar tapping to pull it medially, followed by quadriceps exercise to strengthen the vastus medialis portion particularly.

E.Wedging the heel & sole

  • Lateral wedging.

Semi Invasive Techniques

  • Intra articular steroids like cortisone
  • I ntracuticular Hyaluronic acid
  • Arthroscopic knee washouts

Medicinal

  • NSAIDS ( Non Steroidal Anti-inflammatory drugs)
  • Glucosamine
  • Chondroitin
  • Antioxidant Vitamins

Surgery

For patients where the comprehensive medicinal & non-medicinal management has been ineffective, surgical intervention like

  • Soft tissue release.
  • Osteotomy of bones.
  • Arthoplasty – THR(Total Hip Replacement),TKR(Total Knee Replacement), etc.

Surgical options available are

  • Arthroscopy & Arthroscopic debridement
  • Osteotomy (Alteration of joint biomechanics by joint realignment)
  • Joint replacement (Total Joint replacement, hemiarthroplasty, unicompartmental arthroplasty)
  • Arthrodesis (Surgical fusion of the joint)

Aims of artificial joints are

  • Patient should be able to perform all activities of daily living.
  • Joint replacement should last more than the life of the patient.
  • The patient should be able to play sports.
  • The total joint should be a cost saving surgery.

Hip:- Ball & Socket joint.

  • Ball : attached to the top of the femur
  • Socket : Part of the pelvis

RHEUMATOID ARTHRITIS

Rheumatoid arthritis (RA) is an inflammatory disease that causes pain, swelling, stiffness, loss of function an deformity in the joints.

As it is a systemic disease, areas outside the joints may also get involved for example membranes surrounding internal organs, such as the heart, lungs or eyes. RA tends to run in families, Moreover Women are three times more prone to develop rheumatoid arthritis. But with advanceing age the ratio of women to men becomes almost equal.

What happens in Rheumatoid Arthritis?

Rheumatoid arthritis is an autoimmune disorder. Normally, a healthy immune system is programmed to protect the body from harmful foreign bodies like bacteria and viruses but in rheumatoid arthritis the immune system (defense system) of the body, for unknown reasons, starts attacking the body's healthy tissue. The reaction results in inflammation of joints causing reduction in joint space and loss of normal joint shape and alignment.Important features of Rheumatoid arthritis:

  • It may begin by age 25 and usually before 50 years of age but some times seen in children too.
  • May develop suddenly within a period of weeks/ months but is usually gradual (slow onset)
  • Involves the joints symmetrically i.e. joints on both sides of the body are involved
  • Usually affects the small joints of the hand, foot, wrist, elbow, shoulder or ankle.
  • Causes inflammation resulting in pain and swelling of joints where the joint is warm and tender.
  • Early morning stiffness lasting for more than one hour
  • Causes symptoms in other organs of body besides the joints such as lungs, heart & eyes.
  • May cause overall tiredness, weight loss and occasional fever
  • Finger deformities (‘swan neck' deformity and ‘boutonniere' deformity) are characteristics of RA.

Investigations

Apart form a detailed medical history and physical examination the doctor will recommend various tests to evaluate and diagnose the condition. These includes: · Blood test for ESR (increase in RA) and blood cell count (shows increase in white blood cells and platelets because of inflammation) · Serology test for Rheumatoid factor (an abnormal antibody), which is present in 70-80% of RA cases. X-ray is usually done to find out the degree of damage that the joint has suffered and later to monitor the progress of the disease. Synovial fluid examination to rule out infection.

Management of Rheumatoid Arthritis

Becoming aware about the disease · Taking the medications regularly · Take a diet low in fat, moderate in sugar, rich in Gamma linolenic acid (found in nuts and fish, promrose oil) and omega 3 fatty acids like nuts and fishes like salmon, mackerel, and herring. · Controlling body weight · Taking adequate rest. Acutely involved joints must be given rest or splint to reduce inflammation. · Regular exercise to strengthen muscles (as advised by the doctor) surrounding the involved joints. Yoga and other alternative therapies have been scientifically documented to complement the use of drugs. (To see the proper scientific and validated yogic protocol for Arthritis, log on to www.bestonhealth.com ) .

Medications

NSAIDs These drugs are mainly used for Pain relief and Anti-inflammatory action. DMARDs: Methotrexate (Oral & I/V), Salzopyrine, Hydroxychloroquine, Leflunomide. Earlier medicines in this group included Gold salts, D-Penicillamine are less used now

Advanced treatment of Rheumatoid arthritis.

  • The Biological: The biologicals are injectible drugs – Tumor necrosis factor Alfa (TNF Alfa) blocking agents and interleukin – 1 receptor antagonist (IL-1ra) are new drugs for RA treatment. They are expensive but have been found to benefit otherwise inadequate response patients.
  • The anti TNF Alfa agents – Infliximab, Etanercept and adalimumab have set new standards for RA therapy.
  • Stem Cell implantation: is another new, promising area for the hopeless patients. It is embryonic and adult type – principle is once implanted stem cell has potential to replicate and grow more healthy cells and hence cure the disease.