One of the most common reasons people go to the doctor is for joint pain. “My knee hurts and swells after I walk, it hurts when it rains or it takes me awhile after I wake up before I can move well” are all often heard symptoms in patients with arthritis. In a recent Center for Disease Control publication 22.7% of adults (52.5 million people) reported being told by a doctor they had arthritis, and 9.8% (22.7 million people) stated that their activity levels were reduced because of arthritis.
But what is arthritis? Arthritis is inflammation in a joint. There are multiple causes and types of arthritis, each with its own set of symptoms, complications and treatment recommendations.
The two main types of arthritis are Osteoarthritis and Autoimmune Arthritis. They share some features and are very different in others. Common symptoms between the two types are pain, joint swelling and stiffness. Which joints are involved and the pattern of swelling and stiffness can differentiate between the two. In addition, X-ray and blood test results are different in Osteoarthritis and Rheumatoid Arthritis (the most common form of Autoimmune Arthritis).
Osteoarthritis is generally referred to as “wear and tear” arthritis. It occurs when a damaged joint fails to repair itself. Osteoarthritis can effect only 1 joint, a few joints or be generalized. It is the most common joint disorder. It’s major symptoms are:
- joint pain
- restricted movement in the joint
- loss of function
In general, osteoarthritis pain gets worse with use and improves with rest. There can be stiffness in the morning which usually improves in under 30 minutes. Usually, the appearance on an X-Ray does not match the symptoms – so a person with osteoarthritis could have significant pain but a normal X-ray. Blood tests show normal to minimally elevated signs of inflammation.
The most commonly affected joints are:
- Knees and hips
- Junction of the fingers and hand
- Finger joints and bunion joint of feet
- Joints at the base of the neck (cervical spine) and the lower back (lumbar spine)
Other joints can certainly be affected, especially in the setting of a prior injury.
Another specific characteristic of osteoarthritis is the pattern of joint pain. Osteoarthritis tends to involve one joint at a time, where as rheumatoid arthritis tends to involve joints on both sides of the body at the same time. The knee is the most common joint affected.
In terms of treatment, the guiding principle is to focus treatments based on a patient’s symptoms and functional issues.
- Weight loss and exercise can improve knee and hip pain dramatically
- NSAIDs (ibuprofen, naproxen)
- Topical pain medications (capsaicin, topical NSAIDs)
- Joint injections
- Supplements – there is some evidence but the quality of the studies is poor
- Vitamin D
- Tumeric, Paeony and Miatake have been shown to have properties similar to NSAIDs
Rheumatoid Arthritis (RA)
Like all the autoimmune arthritis syndromes, RA is an illness that affects more than just the joints. It is characterized by inflammation that causes joint tissue damage. There is a genetic predisposition as well as environmental triggers that are not well-defined. The peak age of onset is between 30-50 years of age.
A typical patient will present with some of the following:
- Pain and stiffness in multiple joints – usually the wrist and fingers first
- Morning stiffness that lasts for more than 1 hour
- Fatigue, fevers, weight loss
In 2010, the American College of Rheumatology updated the criteria for making a diagnosis of RA. It is a point based scale that take aspects of multiple features including joint pain, physical and lab features of the illness to give a score that helps make the diagnosis. The updated criteria can be found here
Blood tests for RA are not an absolute requirement, but two specific tests, Rheumatoid Factor and Anti-citrullinated protein are positive in about 50-60% of people. In addition, a test for inflammation like C-reactive protein or sedimentation rate can be used to follow disease activity.
X-rays of the hands and feet are usually done at the time of diagnosis to check for joint damage. Once the diagnosis is established, treatment should be quickly and aggressively started – studies have shown that treating aggressively early in the disease can lessen permanent damage.
The goals of treatment are:
- Minimize pain and swelling
- Prevent joint deformity and damage
- Maintain quality of life
- Control non-joint symptoms
Treatments for RA are called DMARDS – Disease modifying anti rheumatic drugs – are grouped into Biologic and Non-biologic treatments. Non-biologic treatments are medications such as methotrexate that are used to reduce inflammation. Biologic medications are newer treatments that block cytokines – chemicals that promote inflammation – such as Tumor Necrosis Factor (TNF). They are usually given either intravenously or by injection. Steroids and joint injections can also provide relief. All treatments have potential side effects that patients need to discuss with their doctors to determine their proper therapy.
Some supplements have been shown to be effective at improving symptoms – fish oil when combined with DMARDS improved results over medication alone. The supplements with NSAID like activity can also improve symptoms. Exercise has been shown to decrease inflammation in joints as well as improve joint function, and should be part of every treatment regimen.
How does this affect my practice?
It takes a good history to differentiate Osteoarthritis from RA. So working with someone to get a sense of their type of pain, and how it affects them on a daily basis is essential to a proper diagnosis. Arthritis is a diagnosis with many subtleties – each variation carries its own specific issues, treatments and side effects. The proper diagnosis provides the foundation for safe and effective treatment.
The path to Wellness begins with a proper Diagnosis