Arthritis

Answer 1

Definition

Arthritis is inflammation of one or more joints, which results in pain, swelling, stiffness, and limited movement. There are over 100 different types of arthritis.

See also: Joint pain

Alternative Names

Joint inflammation

Causes, incidence, and risk factors

Arthritis involves the breakdown of cartilage. Cartilage normally protects the joint, allowing for smooth movement. Cartilage also absorbs shock when pressure is placed on the joint, like when you walk. Without the usual amount of cartilage, the bones rub together, causing pain, swelling (inflammation), and stiffness.

You may have joint inflammation for a variety of reasons, including:

• An autoimmune disease (the body attacks itself because the immune system believes a body part is foreign)
• Broken bone
• General "wear and tear" on joints
• Infection (usually caused by bacteria or viruses)

Often, the inflammation goes away after the injury has healed, the disease is treated, or the infection has been cleared.

With some injuries and diseases, the inflammation does not go away or destruction results in long-term pain and deformity. When this happens, you have chronic arthritis. Osteoarthritis is the most common type and is more likely to occur as you age. You may feel it in any of your joints, but most commonly in your hips, knees or fingers. Risk factors for osteoarthritis include:

• Being overweight
• Previously injuring the affected joint
• Using the affected joint in a repetitive action that puts stress on the joint (Baseball players, Ballet dancers, and construction workers are all at risk)

Arthritis can occur in men and women of all ages. About 37 million people in America have arthritis of some kind, which is almost 1 out of every 7 people.

Other types or cause of arthritis include:

• Adult Still's disease
• Ankylosing spondylitis
• Fungal infections such as blastomycosis
• Gonococcal arthritis
• Gout
• Juvenile rheumatoid arthritis (in children)
• Other bacterial infections (nongonococcal bacterial arthritis)
• Psoriatic arthritis
• Reactive arthritis (Reiter syndrome)
• Rheumatoid arthritis (in adults)
• Scleroderma
• Systemic lupus erythematosus (SLE)
• Tertiary Lyme disease
• Tuberculous arthritis
• Viral arthritis

Symptoms

If you have arthritis, you may experience:

• Joint pain
• Joint swelling
• Reduced ability to move the joint
• Redness of the skin around a joint
• Stiffness, especially in the morning
• Warmth around a joint

Signs and tests

First, your doctor will take a detailed medical history to see if arthritis or another musculoskeletal problem is the likely cause of your symptoms.

Next, a thorough physical examination may show that fluid is collecting in the joint. (This is called an "effusion.") The joint may be tender when it is gently pressed, and may be warm and red (especially in infectious arthritis and autoimmune arthritis). It may be painful or difficult to rotate the joints in some directions. This is known as "limited range-of-motion."

In some autoimmune forms of arthritis, the joints may become deformed if the disease is not treated. Such joint deformities are the hallmarks of severe, untreated rheumatoid arthritis.

Tests vary depending on the suspected cause. They often include blood tests and joint x-rays. To check for infection and other causes of arthritis (like gout caused by crystals), joint fluid is removed from the joint with a needle and examined under a microscope. See the specific types of arthritis for further information.

Treatment

Treatment of arthritis depends on the cause, which joints are affected, the severity, and how the condition affects your daily activities. Your age and occupation will also be taken into consideration when your doctor works with you to create a treatment plan.

If possible, treatment will focus on eliminating the cause of the arthritis. However, the cause is NOT necessarily curable, as with osteoarthritis and rheumatoid arthritis. Treatment, therefore, aims at reducing your pain and discomfort and preventing further disability.

It is possible to greatly improve your symptoms from osteoarthritis and other long-term types of arthritis without medications. In fact, making lifestyle changes without medications is preferable for osteoarthritis and other forms of joint inflammation. If needed, medications should be used in addition to lifestyle changes.

Exercise for arthritis is necessary to maintain healthy joints, relieve stiffness, reduce pain and fatigue, and improve muscle and bone strength. Your exercise program should be tailored to you as an individual. Work with a physical therapist to design an individualized program, which should include:

• Low-impact aerobic activity (also called endurance exercise)
• Range of motion exercises for flexibility
• Strength training for muscle tone

A physical therapist can apply heat and cold treatments as needed and fit you for splints or orthotic (straightening) devices to support and align joints. This may be particularly necessary for rheumatoid arthritis. Your physical therapist may also consider water therapy, ice massage, or transcutaneous nerve stimulation (TENS).

Rest is just as important as exercise. Sleeping 8 to 10 hours per night and taking naps during the day can help you recover from a flare-up more quickly and may even help prevent exacerbations. You should also:

• Avoid holding one position for too long.
• Avoid positions or movements that place extra stress on your affected joints.
• Modify your home to make activities easier. For example, have grab bars in the shower, the tub, and near the toilet.
• Reduce stress, which can aggravate your symptoms. Try meditation or guided imagery. And talk to your physical therapist about yoga or tai chi.

Other measures to try include:

• Apply capsaicin cream (derived from hot chili peppers) to the skin over your painful joints. You may feel improvement after applying the cream for 3-7 days.
• Eat a diet rich in vitamins and minerals, especially antioxidants like vitamin E. These are found in fruits and vegetables. Get selenium from Brewer's yeast, wheat germ, garlic, whole grains, sunflower seeds, and Brazil nuts. Get omega-3 fatty acids from cold water fish (like salmon, mackerel, and herring), flaxseed, rapeseed (canola) oil, soybeans, soybean oil, pumpkin seeds, and walnuts.
• Taking glucosamine and chondroitin -- these form the building blocks of cartilage, the substance that lines joints. These supplements are available at health food stores or supermarkets. While some studies show such supplements may reduce osteoarthritis symptoms, others show no benefit. However, since these products are regarded as safe, they are reasonable to try and many patients find their symptoms improve.
• Lose weight, if you are overweight. Weight loss can greatly improve joint pain in the legs and feet.

MEDICATIONS

Your doctor will choose from a variety of medications as needed. Generally, the first drugs to try are available without a prescription. These include:

• Acetaminophen (Tylenol) -- recommended by the American College of Rheumatology and the American Geriatrics Society as first-line treatment for osteoarthritis. Take up to 4 grams a day (two arthritis-strength Tylenol every 8 hours). This can provide significant relief of arthritis pain without many of the side effects of prescription drugs. DO NOT exceed the recommended doses of acetaminophen or take the drug in combination with large amounts of alcohol. These actions may damage your liver.
• Aspirin, ibuprofen, or naproxen -- these nonsteroidal anti-inflammatory drugs (NSAIDs) are often effective in combating arthritis pain. However, they have many potential risks, especially if used for a long time. They should not be taken in any amount without consulting your doctor. Potential side effects include heart attack, stroke, stomach ulcers, bleeding from the digestive tract, and kidney damage. In 2005, the U.S. Food and Drug Administration (FDA) asked makers of NSAIDs to include a warning label on their product that alerts users of an increased risk for heart attack, stroke, and gastrointestinal bleeding. If you have kidney or liver disease, or a history of gastrointestinal bleeding, you should not take these medicines unless your doctor specifically recommends them.

Prescription medicines include:

• Biologics-- these are the most recent breakthrough for the treatment of rheumatoid arthritis. Such medications, including etanercept (Enbrel), infliximab (Remicade) and adalimumab (Humira), are administered by injection and can dramatically improve your quality of life. Newer biologics include abatacept (Orencia), rituximab (Rituxan), golimumab (Simponi), certolizumab (Cimzia), and tocilizumab (Actemra).
• Corticosteroids ("steroids") -- these are medications that suppress the immune system and symptoms of inflammation. They are often injected into painful osteoarthritic joints. Steroids are used to treat autoimmune forms of arthritis but should be avoided in infectious arthritis. Steroids have multiple side effects, including upset stomach and gastrointestinal bleeding, high blood pressure, thinning of bones, cataracts, and increased infections. The risks are most pronounced when steroids are taken for long periods of time or at high doses. Close supervision by a physician is essential.
• Cyclooxygenase-2 (COX-2) inhibitors -- These drugs block an inflammation-promoting enzyme called COX-2. This class of drugs was initially believed to work as well as traditional NSAIDs, but with fewer stomach problems. However, numerous reports of heart attacks and stroke have prompted the FDA to re-evaluate the risks and benefits of the COX-2s. Celecoxib (Celebrex) is still available, but labeled with strong warnings and a recommendation that it be prescribed at the lowest possible dose for the shortest duration possible. Talk to your doctor about whether COX-2s are right for you.
• Disease-modifying anti-rheumatic drugs -- these have been used traditionally to treat rheumatoid arthritis and other autoimmune causes of arthritis. These drugs include gold salts, penicillamine, sulfasalazine, and hydroxychloroquine. More recently, methotrexate has been shown to slow the progression of rheumatoid arthritis and improve your quality of life. Methotrexate itself can be highly toxic and requires frequent blood tests for patients on the medication.
• Immunosuppressants -- these drugs, like azathioprine or cyclophosphamide, are used for serious cases of rheumatoid arthritis when other medications have failed.

It is very important to take your medications as directed by your doctor. If you are having difficulty doing so (for example, due to intolerable side effects), you should talk to your doctor.

SURGERY AND OTHER APPROACHES

In some cases, surgery to rebuild the joint (arthroplasty) or to replace the joint (such as a total knee joint replacement) may help maintain a more normal lifestyle. The decision to perform joint replacement surgery is normally made when other alternatives, such as lifestyle changes and medications, are no longer effective.

Normal joints contain a lubricant called synovial fluid. In joints with arthritis, this fluid is not produced in adequate amounts. In some cases, a doctor may inject the arthritic joint with a manmade version of joint fluid. The synthetic fluid may postpone the need for surgery at least temporarily and improve the quality of life for persons with arthritis.

Expectations (prognosis)

A few arthritis-related disorders can be completely cured with treatment. Most are chronic (long-term) conditions, however, and the goal of treatment is to control the pain and minimize joint damage. Chronic arthritis frequently goes in and out of remission.

Complications

• Chronic pain
• Lifestyle restrictions or disability

Calling your health care provider

Call your doctor if:

• Your joint pain persists beyond 3 days.
• You have severe unexplained joint pain.
• The affected joint is significantly swollen.
• You have a hard time moving the joint.
• Your skin around the joint is red or hot to the touch.
• You have a fever or have lost weight unintentionally.

Prevention

If arthritis is diagnosed and treated early, you can prevent joint damage. Find out if you have a family history of arthritis and share this information with your doctor, even if you have no joint symptoms.

Osteoarthritismay be more likely to develop if you abuse your joints (injure them many times or over-use them while injured). Take care not to overwork a damaged or sore joint. Similarly, avoid excessive repetitive motions.

Excess weight also increases the risk for developing osteoarthritis in the knees and possibly in the hips. See the article on body mass index to learn whether your weight is healthy.

References

D'Cruz DP, Khamashta MA, Hughes GR. Systemic lupus erythematosus. Lancet. 2007;369(9561):587-96.

Glass GG. Osteoarthritis. Dis Mon. 2006;52:343-362.

Gregory PJ, Sperry M, Wilson AF. Dietary supplements for osteoarthritis. Am Fam Physician. 2008;77:177-184.

Smolen JS, Aletaha D, Koeller M, Weisman MH, Emery P. New therapies for treatment of rheumatoid arthritis. Lancet. 2007;270(9602):1861-74.

Answer 2

Definition

Arthritis is inflammation of one or more joints. A joint is the area where two bones meet. There are over 100 different types of arthritis.

See also: Joint pain

Alternative Names

Joint inflammation

Causes, incidence, and risk factors

Arthritis involves the breakdown of cartilage. Cartilage normally protects a joint, allowing it to move smoothly. Cartilage also absorbs shock when pressure is placed on the joint, such as when you walk. Without the normal amount of cartilage, the bones rub together, causing pain, swelling (inflammation), and stiffness.

Joint inflammation may result from:

• An autoimmune disease (the body's immune system mistakenly attacks healthy tissue)
• Broken bone
• General "wear and tear" on joints
• Infection, usually by bacteria or virus

Usually the joint inflammation goes away after the cause goes away or is treated. Sometimes it does not. When this happens, you have chronic arthritis. Arthritis may occur in men or women. Osteoarthritis is the most common type. See: Osteoarthritis

Other, more common types of arthritis include:

• Ankylosing spondylitis
• Gonococcal arthritis
• Gout
• Juvenile rheumatoid arthritis (in children)
• Other bacterial infections (nongonococcal bacterial arthritis)
• Psoriatic arthritis
• Reactive arthritis (Reiter syndrome)
• Rheumatoid arthritis (in adults)
• Scleroderma
• Systemic lupus erythematosus (SLE)

Symptoms

Arthritis causes joint pain, swelling, stiffness, and limited movement. Symptoms can include:

• Joint pain
• Joint swelling
• Reduced ability to move the joint
• Redness of the skin around a joint
• Stiffness, especially in the morning
• Warmth around a joint

Signs and tests

The health care provider will perform a physical exam and ask questions about your medical history.

The physical exam may show:

• Fluid around a joint
• Warm, red, tender joints
• Difficulty moving a joint (called "limited range of motion")

Some types of arthritis may cause joint deformity. This may be a sign of severe, untreated rheumatoid arthritis.

Blood tests and joint x-rays are often done to check for infection and other causes of arthritis.

Your doctor may also remove a sample of joint fluid with a needle and send it to a lab for examination.

Treatment

The goal of treatment is to reduce pain, improve function, and prevent further joint damage. The underlying cause cannot usually be cured.

LIFESTYLE CHANGES

Lifestyle changes are the preferred treatment for osteoarthritis and other types of joint inflammation. Exercise can help relieve stiffness, reduce pain and fatigue, and improve muscle and bone strength. Your health care team can help you design an exercise program that is best for you.

Exercise programs may include:

• Low-impact aerobic activity (also called endurance exercise)
• Range of motion exercises for flexibility
• Strength training for muscle tone

Physical therapy may be recommended. This might include:

• Heat or ice
• Splints or orthotics to support joints and help improve their position; this is often needed for rheumatoid arthritis
• Water therapy
• Massage

Other recommendations:

• Get plenty of sleep. Sleeping 8 to 10 hours a night and taking naps during the day can help you recover from a flare-up more quickly and may even help prevent flare ups.
• Avoid staying in one position for too long.
• Avoid positions or movements that place extra stress on your sore joints.
• Change your home to make activities easier. For example, install grab bars in the shower, the tub, and near the toilet.
• Try stress-reducing activities, such as meditation, yoga, or tai chi.
• Eat a healthy diet full of fruits and vegetables, which contain important vitamins and minerals, especially vitamin E.
• Eat foods rich in omega-3 fatty acides, such as cold water fish (salmon, mackerel, and herring), flaxseed, rapeseed (canola) oil, soybeans, soybean oil, pumpkin seeds, and walnuts.
• Apply capsaicin cream over your painful joints. You may feel improvement after applying the cream for 3-7 days.
• Lose weight, if you are overweight. Weight loss can greatly improve joint pain in the legs and feet.

MEDICATIONS

Medications may be prescribed along with lifestyle changes. All medications have risks, some more than others. It is important that you are closely monitored by a doctor when taking arthritis medications.

Generally, over-the-counter medications are recommended first:

• Acetaminophen (Tylenol) is usually tried first. Take up to 4 grams a day (two arthritis-strength Tylenol every 8 hours). Do not take more than the recommended dose or take the drug along with a lot of alcohol. Doing so may damage your your liver.
• Aspirin, ibuprofen, or naproxen are nonsteroidal anti-inflammatory drugs (NSAIDs) that can relieve arthritis pain. However, they have many potential risks, especially if used for a long time. Potential side effects include heart attack, stroke, stomach ulcers, bleeding from the digestive tract, and kidney damage.

Prescription medicines include:

• Biologics are used for the treatment of autoimmune arthritis. They include etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), abatacept (Orencia), rituximab (Rituxan), golimumab (Simponi), certolizumab (Cimzia), and tocilizumab (Actemra). These drugs can improve the quality of life for many patients, but can have serious side effects.
• Corticosteroids ("steroids") help reduce inflammation. They may be injected into painful joints or given by mouth.
• Disease-modifying anti-rheumatic drugs (DMARDs) are used to treat autoimmune arthritis. They include methotrexate, gold salts, penicillamine, sulfasalazine, and hydroxychloroquine.
• Immunosuppressants such as azathioprine or cyclophosphamide are used to treat patients with rheumatoid arthritis when other medications have not worked.

It is very important to take your medications as directed by your doctor. If you are having difficulty doing so (for example, because of side effects), you should talk to your doctor. Also make sure your doctor knows about all the medicines you are taking, including Vitamins and Supplements bought without a prescription.

SURGERY AND OTHER TREATMENTS

In some cases, surgery may be done if other treatments have not worked. This may include:

• Arthroplasty to rebuild the joint
• Joint replacement, such as a total knee joint replacement

Expectations (prognosis)

A few arthritis-related disorders can be completely cured with proper treatment.

Most forms of arthritis however are long-term (chronic) conditions.

Complications

Complications of arthritis include:

• Long-term (chronic) pain
• Disablity
• Difficulty performing daily activities

Calling your health care provider

Call your doctor if:

• Your joint pain persists beyond 3 days.
• You have severe unexplained joint pain.
• The affected joint is significantly swollen.
• You have a hard time moving the joint.
• Your skin around the joint is red or hot to the touch.
• You have a fever or have lost weight unintentionally.

Prevention

Early diagnosis and treatment can help prevent joint damage. If you have a family history of arthritis, tell your doctor, even if you do not have joint pain.

Avoiding excessive, repeated motions may help protect you against osteoarthritis.

References

D'Cruz DP, Khamashta MA, Hughes GR. Systemic lupus erythematosus. Lancet. 2007;369(9561):587-96.

Hunter DJ, Lo GH. The management of osteoarthritis: an overview and call to appropriate conservative treatment. Med Clin North Am. 2009;93:127-43, xi.

Huizinga TW, Pincus T. In the clinic. Rheumatoid arthritis. Ann Intern Med. 2010 Jul 6;153(1):ITC1-1-ITC1-15.

Reviewed By

Review Date: 02/14/2011

Michael E. Makover, MD is a professor and attending in rheumatology at the New York University Medical Center, New York, NY. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.