Diagnosis of Arthritis

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

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.

Osteoarthritis of the hands involving the end of the fingers

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
    • Glucosamine-Chondroitin
    • 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

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Hand changes from severe Rheumatoid Arthritis

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

Inflammatory Bowel Disease – a real pain in the…

December 1-7 was Inflammatory Bowel Disease (IBD) awareness week.  Though I had not launched this blog until after the week was over, those who know me know how important these illnesses are to me and my family.  I have served on the Medical Advisory Committee to the Crohn’s and Colitis Foundation of America (CCFA) both in NYC and Phoenix.  I have run 2 half-marathons (in Las Vegas and Virginia) to raise over $30,000 for the CCFA.  So even though IBD Awareness week has passed, I wanted to acknowledge it and review Crohn’s Disease and Ulcerative Colitis.

IBD is an autoimmune disease – meaning the bodies own defenses get altered and attack the intestines and other parts of the body.  IBD affects 1.4 million adults and children in the U.S.  70,000 people are newly diagnosed each year.  The peak age of onset is between 15-30 years old, and about 10% of patients are under age 18.  There is a genetic predisposition to IBD and it can run in families.  It is not clear what exactly triggers the illness in those predisposed.  Current theories revolve around an environmental trigger or an infectious one, or both.
The main symptoms of IBD are abdominal pain and diarrhea, sometimes with blood.  People with IBD can have more than 10 bowel movements per day.  One can imagine the effect this can have on a child in the early stages of development – especially socially.
The 2 most common diagnoses within IBD are Crohn’s Disease and Ulcerative Colitis (UC).  Once thought to be 2 completely different diseases, we have learned that they share some similar features and some patients have features of both Crohn’s or UC.

 

Ulcerative Colitis has the following features:
  • Diarrhea with mucus and/or blood
  • Spasms in the rectum (called tenesmus)
  • Fevers can happen when severe
  • People can usually maintain their body weight
  • Rarely develop tracts from the intestine to the skin (called fistula)
  • On a colonoscopy there are ulcerations (damage) to the surface layers of the large intestine
  • Inflammation and ulceration in the GI tract are only in the large intestine
  • For years it was thought that patients with UC were at increased risk of colon cancer, but recent studies have questioned this.
  • Eye inflammation can occur (called Iritis and Uveitis)
  • A form of arthritis in the spine, (called Ankylosing Spondylitis)
  • Painful, red skin nodules (called Erythema Nodosum)
Crohn’s Disease has the following features:
  • Diarrhea with a fatty consistency
  • Less spasms in the rectum (tenesmus)
  • Fevers
  • Fistula
  • Weight loss
  • On a colonoscopy there can be injury to any part of the GI tract, from the mouth to the anus, and the injury goes through to the deeper tissue of the intestines
  • Blockages (strictures) in the intestine from inflammation and scar tissue
  • Eye inflammation (Iritis and Uvititis)
  • Arthritis in the spine (Anklylosing Spondylitis)
  • Painful areas of skin breakdown (called Pyoderma Gangrenosum)
Both Crohn’s Disease and Ulcerative Colitis have some other associated symptoms, but they are less common.  In addition, the symptoms are not exclusive, as many people can experience either diseases symptoms as part of their illness.

 

Treatments for Crohn’s and UC include medications that reduce inflammation and balance the immune system, They are considered either non-biologic or biologic.  Examples of non-biologic treatments are anti-inflammatory (ibuprofen, naproxen), immune suppressants (6-MP, azithioprine), antibiotics and corticosteroids (prednisone).  Biologic treatments are injected or given intravenously and block certain parts of the immune system like Tumor Necrosis Factor (TNF).  Recent studies have looked at some alternative therapies like probiotics (bacteria found in certain foods like yogurt), using certain parasites (worms) to stop the immune reactions in the gut and even a “stool transplant” which is exactly what it sounds like!

 

IBD is diagnosed based on a person’s history of symptoms, a physical examination, and blood tests that can show signs of inflammation and certain antibodies that are common in IBD.  Imaging such as MRI or CT scan can be used and directly looking at the colon by a colonoscopy and obtaining biopsies is standard.

 

Why is the diagnosis important?  If the symptoms and treatments overlap, you may wonder why does making the specific diagnosis of Crohn’s Disease or Ulcerative Colitis matter rather than calling it IBD?  The diagnosis matters because certain treatments are more effective in Crohn’s vs UC and vice versa.  Additionally, since there are other symptoms outside the GI tract that are associated with specific forms of IBD, the proper diagnosis helps a doctor make the association that back pain may be due to Ankylosing Spondylitis rather than a muscle strain, or that rash on your leg may be Pyoderma Gangrenosum and not an infection.

How does this affect MY practice?

As an Internist, I will often be the first doctor someone comes to for unanswered symptoms.  So, in someone who has had ongoing symptoms that may be inflammatory bowel disease, I will order the studies that will either confirm or rule it out.  Since a colonoscopy is a necessary test in making the diagnosis, I will also refer people to a gastroenterologist who has expertise in IBD.

I also care for people who have already been diagnosed with IBD.  They also get colds, need general physicals and other everyday health services.  In addition, they often need information about new symptoms they may be experiencing – is it IBD related or something else?  Is it a side effect to their medication?  For them, I am a resource and a sounding board that sees them as a whole person, and not just an IBD diagnosis.

IBD can have multiple, seemingly disconnected symptoms.  In fact, the average time from the first symptoms to diagnosis is 2-3 years!  When the pieces are put together properly, the puzzle can be put together and reveal a diagnosis.  Knowing where you are starting from frames the conversations you have with your doctor, and help you tell your story and ask the questions you need answered to be an active participant in your healthcare.  Too often people with chronic illnesses are made to feel powerless, that health is beyond their reach and control.  In an illness that is painful, socially awkward and lifelong, information is power and can give a person a sense of control and direction.

 

The path to Wellness begins with a proper Diagnosis.
Helpful links:
Crohn’s and Colitis Foundation of America – www.ccfa.org
Center for Disease Control – IBD site – www.cdc.gov/ibd
My daughter’s video documentary of the 2010 Las Vegas Half Marathon to benefit the CCFA  –  http://youtu.be/F-1Qkoenv1E