Rheumatoid Arthritis
Rheumatoid arthritis is a chronic inflammatory disease in which the lining of the joints become inflamed, causing pain, swelling and stiffness. It is an ‘autoimmune disease’ because it occurs when our immune system, which normally fights against infection, starts destroying healthy joints. Severe rheumatoid arthritis can be very painful and even deform or change a joint. It also affects a person’s ability to perform routine activities.
The exact cause for rheumatoid arthritis is unknown and there is no definitive cure. However, a good understanding of the disease helps to better manage the disease by relieving the pain and other symptoms, and retarding the progression of the disease. Early diagnosis and treatment is important to minimize damage to the joints.
Management of rheumatoid arthritis
Several treatment modalities are available for the management of rheumatoid arthritis including medications, physiotherapy, occupational therapy, and surgery.
- Medications: There are different types of medications which include disease-modifying anti-rheumatic drugs (DMARDs)-methotrexate, infusion and injection biologic agents; pain medications such as non-steroidal anti-inflammatory drugs (NSAIDs)-aspirin, ibuprofen, and COX-2 inhibitors. The DMARDs reduce the body’s immune response against the joints whereas the NSAIDs reduce swelling and pain.
- Physical Therapy: Physical therapy exercises should be done regularly to increase the strength of the muscles and flexibility of the joints. Transcutaneous Electrical Nerve Stimulation (TENS) is a type of electrotherapy that is given to provide pain relief.
- Occupational Therapy: Occupational therapy helps patients to perform daily activities at home and at work independently through the use of equipment. It also helps you adapt to your condition using relaxation and stress-management techniques.
- Surgery: Surgical treatment is considered if you have severe rheumatoid arthritis and your symptoms do not get better with the conservative treatments. The benefits of surgery are pain relief and improvement in joint function.
Psoriatic Arthritis
Psoriatic arthritis (PsA) is an autoimmune disease that includes both psoriasis and a related form of arthritis. It is a form of inflammatory arthritis that causes pain, swelling and sometimes damage to any joint in the body.
Psoriatic arthritis occurs mostly in people who are suffering from psoriasis, a chronic skin disease characterized by scaly, reddish skin rashes on the elbows, knees and scalp.
A healthy immune system acts as natural defense, releasing antibodies against injury and disease, but in autoimmune diseases such as psoriatic arthritis, the body turns against its own tissues by releasing white blood cells and causing inflammation of the synovium. The synovium lines the joint capsule and produces synovial fluid for lubrication and smooth motion of the joints.
This inflammation thickens the synovium lining resulting in turgid, swollen joints. Over time the synovium invades cartilage, the covering at the end of bones in a joint, and this erosion causes the rubbing of bone on bone in a joint (Osteoarthritis). The inflammatory response weakens the joints and its surrounding structures such as muscles, ligaments and tendons occur.
Based on the location of the affected body joints and their specific symptoms, psoriatic arthritis is divided in five classes as:
- Symmetric arthritis is similar to rheumatoid arthritis and characterized by pain, swelling and stiffness in the joint, but with mild deformities. This condition usually affects the same joint on both sides of the body, hence it is called symmetric.
- Asymmetric arthritis is characterized by fluctuating pain and tenderness of joints anywhere in the body, such as knee, hip, ankle or wrist. In some cases, painful swelling of fingers or toes called dactylitis also develops. This form is generally mild and usually responds to medical therapy.
- Distal interphalangeal predominant (DIP) is a rare type of PsA and usually affects the distal joints of fingers and toes. It can be confused with osteoarthritis, due to similar symptoms, but nail changes, such as pitting, discoloration, crumbling or detachment are specific visible characteristic features of this form.
- Spondylitis is less common and is characterized by inflammation of the spinal column resulting in stiffness of the neck, lower back, sacroiliac or spinal vertebrae making movement painful and difficult.
- Arthritis mutilans is a severe, deforming and damaging condition affecting small joints of the hands and feet. Some people also experience neck or lower back pain.
Causes
The exact cause of developing psoriatic arthritis is not known. There are several factors found to be responsible for developing psoriatic arthritis such as genetic, environmental, and immune factors. In 40 percent of the cases, genes are responsible, having family history of either psoriasis or psoriatic arthritis. Some doctors also believe that environmental factors such as trauma or an infection such as strep throat may trigger the immune system into developing PsA.
PsA occurs equally in both sexes at any time, but the peak age of onset is between 30 and 55 years.
Symptoms
Many symptoms of PsA are common with other form of arthritis, which makes the disease difficult to diagnose. The most common symptoms are:
- Painful, swollen joints generally affecting ankle, knees, fingers, toes, and lower back
- Dactylitis, a balloon like swelling along the entire length of fingers or toes
- Enthesitis, development of pain and tenderness in the area where tendons or ligaments attach the bones and is commonly seen at the heel or bottom of the foot.
- Low back pain due to the effect on sacroiliac joint
- Nail changes including pitting, discoloration, white areas, crumbling or detachment of nails
- Stiffness of joints either in the morning or after rest
- Fatigue
- Reduced range of motion of joints and limbs
- Conjunctivitis, redness and pain in the tissues surrounding the eyes
Diagnosis
The diagnosis of PsA is a difficult and time-consuming process because most of its symptoms mimic other forms of arthritis such as rheumatoid arthritis, osteoarthritis, and gout. The diagnostic process starts with a physical examination by a rheumatologist, a type of doctor specialist in arthritis and musculoskeletal diseases. Physical examination includes looking for swelling and inflammation of the joints, signs of psoriasis on skin or changes in the fingernails and toenails.
For detecting changes of the bones or joints, X-rays are ordered and certain blood tests are also included for examining factors such as C-reactive protein and rheumatoid factor, indicators of inflammation.
In some cases, joint fluid is also examined for detail analysis.
Treatment
There is no cure for psoriatic arthritis and the objective of treatment is to reduce pain and swelling of the joints, prevent joint damage, preserve joint function and control psoriasis of the skin.
Different classes of medications are available for managing symptoms of PsA such as NSAIDs and corticosteroids for reducing pain and swelling. Other classes such as disease-modifying anti-rheumatic drugs (DMARDs) and biological response modifiers are also frequently prescribed.
Participating in regular exercise is the best way to treat joint stiffness and promote muscle strength. Getting adequate rest also helps in reducing tiredness due to PsA. Applying heat or ice packs on joints can also help in reducing pain and swelling. Splints may also be recommended to support joints and reduce inflammation.
Ankylosing Spondylitis
The term ankylosis refers to loss of mobility of the spine, whereas spondylitis means inflammation of the spine. Therefore, ankylosing spondylitis is a condition where chronic inflammation of the spine and sacroiliac joint results in complete fusion of the vertebrae leading to pain and stiffness in the spine. Sacroiliac joints are located in the lower back where the sacrum part of the vertebrae joins the iliac bones.
Ankylosing spondylitis is a systemic disease affecting other tissues and organs throughout the body. It can cause inflammation of faraway joints and organs such as the eyes, heart, lungs and kidneys.
Ankylosing spondylitis is three times more common in men than in women and affects people of all age groups including children where the condition is referred to as juvenile ankylosing spondylitis.
Causes
The development of ankylosing spondylitis is believed to be genetically inherited as a majority of patients suffering from this condition are found to be born with a certain gene known as HLA-B27 gene. Other causative factors are family history, gender and certain environmental factors which can trigger immune system problems leading to chronic tissue inflammation.
Symptoms
The starting symptom of ankylosing spondylitis is pain and stiffness in the lower back which may get worse in the night or early morning. Back pain may be felt in the sacroiliac joint between the spine and pelvis. Progression of the disease can affect all or part of the spine resulting in decreased mobility of the lower spine and fatigue.
Other symptoms which are rarely seen include fever, loss of appetite, eye inflammation, and pain in heel, hip and other joints of the shoulders, knees, and ankles.
Diagnosis
The diagnosis of ankylosing spondylitis involves a physical examination to evaluate the patient’s symptoms, X-rays and blood tests. Physical examination helps the physician assess stiffness and range of motion of the spine and other related joints. X-rays are ordered for a clear view of sacroiliac joints, vertebrae, and other related bones. Certain blood tests are employed such as HLA-B27 antigen, and sedimentation rate, which is a marker of inflammation throughout the body.
Treatment
The treatment of ankylosing spondylitis involves the use of certain medications to help reduce inflammation, suppress immunity, and prevent progression of the disease. Different classes of medications available for treatment include NSAIDs, corticosteroids, or other new classes having anti-inflammatory and pain relieving effect.
Other treatment options are physical therapy and exercise. These are very effective measures that help alleviate many symptoms. Eat a healthy whole food diet and avoid drinking alcohol and smoking cigarettes.
In cases where severe damage of the joints or spine occurs, surgery can be performed.
Gout
Gout is a very common, painful form of arthritis which causes swelling, redness and stiffness of the joints. Gout is caused by increased levels of uric acid in the tissues and blood from abnormal metabolism. Eating certain foods rich in purines such as liver and dried beans can elevate the body’s level of uric acid. These Increased levels of uric acid can also cause kidney stones. Gout usually affects the big toe and can later attack ankles, heels, knees, wrists, fingers, and elbows. If untreated, gout can result in permanent joint and kidney damage.
Pseudogout is a condition having similar symptoms, but is different from gout because it is caused from calcium phosphate rather than uric acid.
Causes
The exact cause for the development of gout is unknown. In gout, there is increased production and decreased metabolism of uric acid, resulting in formation of uric acid crystals around the joints and in organs such as the kidneys.
Gout is more common in people having a family history of gout, those who drink alcohol, and taking certain medications, which can raise the level of uric acid in blood. The probability of developing gout is more in men and also in women after menopause.
People suffering from conditions such as diabetes, kidney disease, obesity, sickle cell anemia, leukemia and other blood cancers are more prone to develop gout. This is because the medication used for treating such conditions can interfere with removal of uric acid from the body.
Symptoms
Symptoms initially seen with gout include warm, red, swollen joints, commonly in the big toe but can also involve other joints such as knee, ankle, and small joints of the hands. resulting in joint pain and tenderness.
Initially such symptoms may affect one or two joints, lasting for 1-2 weeks, but as the disease progresses, multiple joints can be affected for a longer duration.
For patients with gout, the development of kidney stones and formation of uric acid crystals outside joints occurs more frequently. Such crystals, known as tophi, are painless but useful in diagnosis and may be found in earlobes, elbows and Achilles tendon.
Diagnosis
In gout uric acid level increases, therefore different tests are employed for assessing the level of uric acid in blood and also in urine. Along with this, synovial fluid analysis which shows uric acid crystals as well as synovial biopsy may be done.
X-rays of the painful joint is recommended for accessing the underlying joint damage due to gout. It is to be noted that high levels of uric acid does not always indicate gout.
Treatment
The treatment of gout includes medications having painkiller and anti-inflammatory effect such as NSAIDs, colchicines, and corticosteroid. In addition, certain medications such as allopurinol and probenecid reduce the level of uric acid in the blood.
In cases where severe damage of the joint has taken place due to lack of efficient treatment, surgery may be recommended.
Prevention
For preventing a gout attack, patients should eat a healthy diet, avoid alcohol, and if obese should try to lose weight. Try to limit eating purine-rich foods especially anchovies, oils, organ meat, legumes, mushrooms, spinach and cauliflower. Fatty foods should be avoided, and increased carbohydrate diet may be recommended.
Reactive Arthritis
Reactive arthritis involves swelling and joint pain of the knees, ankles and feet that occurs as a result of a bacterial infection in another part of the body, usually the urinary tract, intestines or genitals.
There may be accompanying eye inflammation and urinary difficulties along with the joint pain and swelling. Symptoms may come and go, lasting for approximately a year.
When you present to your doctor’s office with the above symptoms, your joints are examined for warmth, swelling and tenderness, and your eyes are checked for inflammation. Fluid from your inflamed joints may be obtained, and tested for infection and inflammation. Blood tests may reveal antibodies for other types of arthritis or genetic markers for reactive arthritis. X-rays may also be helpful for differentiating between other types of arthritis.
Your treatment is focused on the underlying infection with symptomatic treatment of the reactive arthritis. Your doctor will prescribe antibiotics to treat the infection, steroids and nonsteroidal anti-inflammatory drugs to reduce inflammation, and rheumatoid arthritis drugs to relieve pain and stiffness. Physical therapy may be recommended to reduce joint stiffness and improve strength.
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