The facts
The word 'arthritis' actually means inflammation of a joint or joints. Features
of an arthritic joint include pain, swelling, warmth or tenderness. There are more
than 150 different forms of arthritis, although osteoarthritis and rheumatoid arthritis
are by far the most common.
How healthy joints work
To understand what can go wrong with joints involved in arthritis, you need to understand
how healthy joints work.
Most joints consist of the ends of two or more bones that are shaped to fit together
to bear weight and move freely. The bone ends are covered with a shiny, smooth material
called articular cartilage. This cartilage acts as a shock absorber and also provides
a smooth surface between the bones to allow freedom of movement. The joint is enclosed
and held together by a tough fibrous capsule, which in turn is lined by the synovial
membrane. This membrane produces synovial fluid, which lubricates the joint.
Osteoarthritis
In many cases osteoarthritis is related to family genes, although the severity can
vary within those families.
Dr David Hunter, a consultant rheumatologist at the Institute for Bone and Joint
Research at Royal North Shore Hospital NSW, says 50% of osteoarthritis in the hip
and knee and 70% in the hands and spine is genetic.
"But obesity is an important predisposing factor, as is occupation," he says. "People
in jobs that involve a lot of squatting and bending may be at greater risk of osteoarthritis
in the joints involved, as well as those who sustain a major injury to a joint,
often while playing a strenuous sport."
What happens in osteoarthritis
In osteoarthritis the cartilage
undergoes a gradual degeneration or wearing down. It develops cracks or fissures
and eventually pieces of cartilage may break off into the joint space. This irritates
the synovial membrane, which causes the membrane to become inflamed and produce
extra fluid (e.g. 'water' on the knee).
Natural inflammatory agents in the synovial fluid further irritate the cartilage
which, over time, thins and may break down to leave the bone exposed. As a result,
the joint cannot function smoothly. The bone responds to this stress by thickening
and sometimes producing bony spurs, called osteophytes, which give the joints a
hard, swollen appearance. All these changes contribute to the pain in osteoarthritis.
Any joint containing synovial fluid can be affected by osteoarthritis but the most
common sites are hands (especially in women), hips, knees and spine.
What you can do
Dr Hunter says symptoms may be improved and the outlook for those with arthritis
optimised with the right management techniques.
Simple lifestyle changes
Maintaining a healthy weight, to avoid placing too much stress on sore joints, is
important; as well as avoiding strenuous movements such as squatting or stair climbing
if these aggravate the affected joint.
"Improving the muscle tone around affected joints, especially the core stability
muscles in the back and the quadricep muscles above the knee will also help maintain
mobility," says Dr Hunter.
Exercise also promotes fitness and helps control weight, but remember that it is
important to find the right balance between rest and exercise. Padded footwear may
also make a difference to overall comfort levels.
How osteoarthritis is diagnosed
A diagnosis is made after:
- a general review of the person's medical history
- a physical examination taking into account the location of painful joints and the
type and pattern of the pain
- an X-ray to check for signs and severity of arthritic damage
- blood tests and fluid is taken from painful joints to rule out other types of arthritis
Symptoms of osteoarthritis
- pain in and around the joints
- stiffness and loss of movement
- bony swelling around the joints
- muscle weakness, causing joints to feel unstable and creating problems in gripping
Alternative treatments
Where appropriate, physiotherapists can recommend exercises which help with mobility,
decrease stiffness and increase muscle strength. Supplements such as glucosamine
that help maintain the health of the cartilage may be recommended. These are currently
being evaluated by mainstream medicine and may have a place in managing osteoarthritis.
Acupuncture can also be useful for pain relief for some patients.
Surgery
Joint replacement should be reserved for patients with advanced osteoarthritis when
aggressive medical management has failed. In such cases, surgery may be remarkably
effective in relieving pain and increasing mobility. Newer surgical techniques such
as joint 'resurfacing' are being employed as a far less 'invasive' form of surgery
for the right patients.
Rheumatoid Arthritis
Rheumatoid arthritis is a disease which affects 0.8% of the population. It most
often develops between the ages of 40 and 60, but can emerge in the elderly, and
affects three times more women than men. However, this difference decreases with
age. Evidence indicates that there is a genetic predisposition with this disease,
but the exact cause of rheumatoid arthritis is still unknown.
In its mild form, rheumatoid arthritis may cause no more than minor discomfort.
In its most serious form, it can cause painful, badly damaged and deformed joints
and other health problems. It is an auto-immune disease, meaning the body's immune
system attacks its own tissues.
The result is that the synovial membrane becomes inflamed and this, in turn, can
cause pain and joint damage. The inflammatory disease can also become generalised
throughout the body and cause general illness.
How rheumatoid arthritis is diagnosed
The patient's history is reviewed and a physical examination is conducted. Inflammation
tends to be symmetrical - it occurs on both sides of the body Blood tests can help
firm up a diagnosis. One of these tests is for rheumatoid factor, an antibody present
in about 80% of people with the disease. Joint fluid may be examined and X-rays may
help to determine whether damage to bones or cartilage has occurred, although this
is rare in the early months of the disease.
What happens in rheumatoid arthritis
The inflammation starts in the synovial membrane producing inflammatory fluid and
irritation of the joint's cartilage, which starts to break down. Erosion may later
develop in the underlying bone if the inflammation is not controlled. The inflammation,
however, is not limited to joints and can affect blood vessels, the lymphatic system,
eyes and sometimes the tissues surrounding the heart and lungs. Anaemia (a disorder
of the blood in which the red blood cells are defective in some way) can be a side
effect.
Rheumatoid arthritis can develop gradually or start with a sudden, severe attack.
While this disease can last a lifetime, it can occasionally go into remission.
Symptoms of rheumatoid arthritis
- joint pain and stiffness on both sides of the body
- swollen joints, particularly hands, feet and knees
- fatigue and a sense of being unwell
- muscle weakness and discomfort
- weight and appetite loss
What you can do
"It's important the patient gets a diagnosis early
from a specialist so that damage to the cartilage and bone can be minimised," says
Dr Hunter. "Persistent inflammation causes irreparable damage."
Simple lifestyle changes
As with osteoarthritis, minimising activities that cause stress or pain to joints
and taking regular but gentle exercise are important management techniques. Heat,
ice and hot baths may also help relieve pain, as may appropriate painkillers.
Medication
Anti-inflammatory medication is usually prescribed, along with disease modifying
or slow-acting, anti-rheumatic drugs (SAARDS) such as methotrexate or sulphasalazine.
However, Dr Hunter says that these drugs do produce side effects. All patients who
are prescribed these drugs should be carefully monitored.
"A relatively new and effective agent is Arava, but prescription of it is limited,"
he says. If symptoms are severe, corticosteroids such as prednisone may also be
given but Dr Hunter says that, ideally, these should be for the short-term as they
can cause side effects such as osteoporosis. He adds that there are many new biological
treatments that show promise on the horizon.
Alternative treatments
Again, exercise is beneficial for keeping joints mobile, strengthening muscles around
joints, and maintaining overall health and wellbeing. Rest is also vital to the
recovery of inflamed joints to prevent further damage.
Acupuncture may help relieve inflammation and improve mobility while bodywork methods
such as Alexander Technique and Feldenkrais will teach how to move the body with
less strain.
Surgery
As with osteoarthritis, surgical replacement or repair is an option for a joint
that has been badly damaged by rheumatoid arthritis.
Children and arthritis
Arthritis is usually associated with ageing but about 0.1% of children have juvenile
arthritis. Many children develop a transient form of arthritis, usually related
to a viral illness that disappears within weeks to months. If it doesn't, juvenile
chronic arthritis may be considered.
According to Dr Jeffrey Chaitow, head of the Department of Rheumatology at the Children's
Hospital at Westmead, 75% of these children will no longer have their arthritis
by the time they are adults and, with proper care, most will have joints that are
virtually normal.
Juvenile chronic arthritis
This disease can occur at any time throughout childhood, but usually starts between
the ages of one and four. So by the time the child with the disease starts school,
he/she will probably have had arthritis for some years.
The ailment takes a number of different forms. The most common is known as pauciarticular
arthritis. In this case only one or two (less than five) of a child's joints are
affected, normally a knee or ankle. Children with this form of arthritis are particularly
at risk from inflammation of the eyes, called iridocyclitis, and regular eye examinations
are recommended. In other children the arthritis is more widespread, affecting many
joints, and this is called polyarthritis.
Systemic onset is the most serious type of juvenile chronic arthritis. The onset
begins with high fevers, rashes and shows evidence of inflammation in many internal
organ systems as well as joints. The fever typically occurs late in the afternoon
or evening and returns to normal, or below normal, in the morning. When this happens
the child may even have to be confined to bed for part of each day for some weeks.
Approximately 10% of children with arthritis have this type.
Whichever form of the illness a child is suffering from he/she is likely to experience
joint stiffness and pain in the early mornings, for anything from a few minutes
up to three or four hours.
Treatment
Although arthritis is a serious illness, the majority of children who develop it
are able to lead normal, independent lives by the time they are adults. The choices
of drugs for children are similar to those for adult arthritis, however, the doses
must be adjusted for the size of the child.
Physical and occupational therapy can prevent disability. Splints, a regular home
exercise program or outpatient treatment are often effective. Children should participate
in regular school activities, extracurricular activities and family responsibilities
as much as possible.
