Arthritis : The Myths and the Facts

  by drdoc on-line

 

There are several myths that abound regarding Arthritis.

Firstly, many consider Arthritis to be a single diagnosis, whereas, in fact, there are many different types of Arthritis in fact - well over 100 varieties. The approach and management for these, differ completely and this therefore, makes a proper diagnosis critical in order to receive appropriate therapy.
Secondly, the concept that Arthritis itself is not treatable - this is in fact, a fallacy. There is a pervasive attitude that Arthritis patients are doomed to be ultimately confined to wheelchairs. In fact, the aim of appropriate therapy, is for maintenance of function, by controlling the underlying disease process.
Thirdly, the perception that Arthritis is a disease of the elderly. In actual fact, many forms of Arthritis occur in children and my youngest patient is in fact, 2 years of age.
Fourthly, the notion that Arthritis is a benign disease. Whilst on the whole, this may be the case for Osteoarthritis - there are many forms of inflammatory arthritis which cause systemic disease - affecting internal organs, and this group in fact, leads to high morbidity - sickness, and even potential mortality. This makes the importance for early diagnosis important for appropriate therapy.

Broadly speaking, Arthritis can be divided into two main categories:-

1. Inflammatory
2. Degenerative.

The degenerative variety is characterized by pain through the day, with little tendency to swelling of the soft tissues and little or absent morning stiffness. The patient may complain of a stiffness after periods of rest or sitting. The most common variety of this type, is Osteoarthritis. This essentially is a disease of cartilage and has strong familial tendencies.

wpe35.jpg (10610 bytes)Bony swelling of the end joints (DIP) and middle joints(PIP) in Osteoarthritis

The Inflammatory Arthritis group are the most serious Arthritic Diseases - these include Rheumatoid Arthritis, which occurs predominantly in females and has a genetic aspect, in association with some environmental stimulant - resulting in the disease. The disease is characterized by pain, swelling and morning stiffness lasting more than an hour and symmetry of joint involvement. In addition, the symptoms are predominant in the morning and there is a tendency to fatigue through the day. Various antibody tests are detectable in the blood for investigation of the condition, but are not invariably elevated.

wpe36.jpg (11267 bytes)Early swelling of the knuckles (MCP) joints in Rheumatoid arthritis

Therefore, the clinical picture and examination is most important for diagnosis. Blood tests and X-rays may be entirely normal, and are less important than a good clinical assessment.

Another important group of conditions may affect the spine, and joints of the lower limbs. These arthritic conditions may occur in association with skin rashes - such as Psoriasis or Bowel conditions with diarrhoea, or with genital infections, discharges or other non-specific genital ulcers. This group of conditions are called the spondyloarthropathies. They are often associated with involvement of the sacroiliac joint.

wpe37.jpg (6345 bytes)Sacroiliitis in spondyloarthropathy

The arthritis that many identify with rich living - Gout, is often recognized by the patient because of it's distribution, with frequent involvement of the big toe.

wpe34.jpg (6343 bytes)Typical first toe swelling in a gout attack

However, frequently it arises in other, or even several joints. It tends to progress if neglected, and is completely controllable with appropriate therapy. to see a person disabled from Gout is a tragedy. The cause here, is from the build up of crystals in and around the joint, of uric acid. The association with alcohol and rich food is an incorrect and false assumption.
Other crystal related diseases occur, causing arthritic flares, including pyrophosphate crystal deposition with Pseudogout.

Of course - not everything that is described as pains in the joints actually are from the joints themselves, and in fact a frequent cause of joint discomfort, comes from the soft tissues around the joints. These include : Muscle, tendon, and ligaments. Perhaps the commonest problem like this is seen in young females, and is called Fibromyalgic syndrome. This is associated with headaches, migraines, and irritable colon, as well as a host of different but frequently vague and strange symptoms. The sufferer is frequently labeled neurotic. Clinically however the finding of tender points are characteristic, with no actual swelling of the joints themselves.

wpe38.jpg (3785 bytes)fibromyalgia trigger points in the neck and shoulder girdle

Another condition, often confused by patients as arthritis, is Osteoporosis, which is in fact a disease  of the bone, characterized by a tendency to fracture of the hip, spine and wrist. here there is a reduction in the density of the bone as a result of an imbalance in the normal bone recycling process. Therapeutic advances now allow us to treat the problem itself, and this has revolutionized the treatment of fractures in the elderly, and the prevention of the disease in those especially identified as higher risk.

wpe39.jpg (6921 bytes)Osteoporosis with thoracic fractures in the elderly

The therapy of the Rheumatic Diseases may be divided into symptomatic and into disease modifying categories. Symptomatic therapy - includes that of analgesia - such as Paracetamol or combinations with codeine or even stronger analgesics. The anti-inflammatories are used for those conditions characterized by inflammation - with swelling, morning stiffness or significant post-rest stiffness. These anti-inflammatories have potential side affects on the stomach or kidneys and some varieties have been designed to reduce such complications.

 

The disease modifying drugs (DMARDs) are used for various Inflammatory Arthropathies - especially Rheumatoid Arthritis, Psoriatic Arthritis, Arthritis of Inflammatory Bowel Disease or Reactive Arthritis.
The DMARDs include Methotrexate, Gold, Antimalarial therapy - Chloroquine, Penicillamine, and Sulphasalazine. The drugs themselves have been shown to have overall side effect incidence ratio’s comparable with the antiinflammatories. Immuno Suppressive Agents are preserved for life threatening complications, because these do have significant potential toxicity.

The use of alternative therapy has gained much attention in the management of Arthritis Diseases. This includes various dietary additives - Celery extracts, Green Lipped Mussel, Cartilage Extracts, Collagen, Electrical devices, Magnetic devices and Copper or other metal bracelets. In fact, there are hundreds of varieties of such therapies. Exaggerated claims as to there benefits abound. These therapies may have potential hazard to the patient, in that they may, by delaying therapy - aggravate the disease progression, by entrenching the immune system. Therefore, it is not necessarily true to say that such therapies will cause no harm. Damage done to joints in Inflammatory Disease cannot be undone and therefore, delay in therapy does represent more potential damage.

Diets should be aimed at weight control, but also minimizing animal fat intake, increasing fibre and vegetables. Patients should follow the instincts of their own bodies. Not all foods are bad for different people, as we are all individuals. If a food annoys your joints - leave it out.

Therefore, in summary, it is important to stress that multiple types of joint disease occur and that not all Arthritic diseases are the same. It is important to exclude Inflammatory Arthritis and to the treat the latter group aggressively. Thus education and self empowerment of patients are vital and I encourage my patients to ask questions. There are no such thing as stupid questions.


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drdoc on-line
Rheumatologist
Constantia Arthritis Clinic
Cape Town
South Africa