An overview of Arthritis

by Dr. Vinaya Kunjir

Arthritis - Concept & Classification

The term 'arthritis' refers to disease of the joints, characterized by pain, inflammation & swelling of the joints. Rheumatism is a broad based term which describes diseases affecting joints and associated soft tissues like tendons, ligaments and muscle attachments.

The effects of arthritis are different for each person. Some people are affected over many years, others for only short periods. Symptoms vary in severity as do the number and type of joints affected. The age, circumstances and attitude of people with arthritis often affects how well they cope.

Arthritis can be broadly classified into the following groups :-

Non-infective inflammatory Arthritis :

Rheumatoid Arthritis :- It is a systemic chronic disease, characterized by symmetric polyarticular joint pain and swelling, morning stiffness, malaise & fatigue. It occurs in about 1% of world's population with twofold to threefold female predominance. Rheumatoid Factor,immunoglobulins & auto-antibodies are the main serological markers found in about 80% patients. During the past 10 years, epidemiological studies have unearthed information about the true potential of this disease.
Rheumatoid Arthritis is a chronic disease that leads to joint damage within first 2 years of onset, causes marked functional limitation and 30% loss of work within first 5 years and shortens life by 5-7 years. Hence, this aggressive disorder demands the early institution of an equally aggressive therapeutic approach aimed at altering the disease course and maintaining function.

Childhood Rheumatic Diseases :- The rheumatic diseases of childhood represent a diverse group. A majority of these result from the combination of genetic predisposition, autoimmunity and unknown environmental factors.To be designated juvenile rheumatoid arthritis (JRA),the arthritis must start before the age of 16 years and must last for more than 6 weeks. The common forms of chronic synovitis in childhood are Juvenile Idiopathic Arthritis, Rheumatic fever arthritis, spondyloarthropathies and arthritis associated with vasculitis.
Unless diagnosed early and treated adequately,some forms of the disease may lead to crippling disability and blindness from chronic eye complaints. However, with combined efforts of a multidisciplinary health care team, education and support of the family members, most young patients can now hope to lead a near normal life and keep away from the confines of a wheel chair.

Connective Tissue Diseases :

Systemic Lupus Erythematosus(SLE) :- It is a multisystem disease with a spectrum of clinical manifestations and a variable course characterized by relapses & remissions. SLE is marked by multiple autoantibodies that may participate in tissue injury. Fever,skin rash and arthralgia are the main clinical presenting features of this disease. The most common organs affected are skin, heart, lungs, eyes, brain and gastro-intestinal tract.

Systemic Sclerosis or Scleroderma :- It literally means hard (skleros) skin (derma) and consists of both, disease restricted to the skin (localized scleroderma), and disease with internal organ involvement (diffuse scleroderma). Diffuse scleroderma is also called as systemic sclerosis. Systemic sclerosis is an acquired noncontagious disease that occurs worldwide in sporadic cases.

Sjo''gren's Syndrome :- It is a chronic inflammatory disease associated with inflammation of exocrine glands. Dry eyes and dry mouth are the 2 characteristic findings of this disease. Sjo''ren's syndrome can be primary or secondary depending upon the absence or presence of connective tissue disorders. Rheumatoid arthritis and SLE are the most common connective tissue disorders seen in association with secondary Sjo''gren's syndrome..

Polymyositis (PM) and Dermatomyositis (DM) :- It is an inflammatory disease of skeletal muscles. Sometimes when a characteristic rash is present, the term used is Dermatomyositis. PM occurs at any age but mostly between 40-60 years with mild female preponderance. A childhood form of DM is also recognized. Current thoughts relate to abnormal changes in immune system that lead to development of cells capable of injuring muscles. The presenting features are proximal muscle weakness,characteristic skin rash of DM and elevated serum muscle enzymes.

Vasculitis :- It is a heterogenous group of diseases which consist of inflammation & necrosis of the walls of blood vessles. Vasculitis may be a primary process or secondary to other diseases such as SLE, RA. Early recognition and prompt treatment of vasculitis is essential. If the condition is unrecognized, infarction of vital organs, renal failure and death may follow.

Spondyloarthropathies :

Ankylosing Spondylitis (AS) :- It is an inflammatory disorder of unknown etiology that primarily affects the spine, axial skeleton and large proximal joints of the body. The distinctive feature of the disease is the progressive fibrosis and ankylosis of involved joints. Most commonly affected are young men in the age group of 20 to 40 years. AS has a strong association with HLA B27 histocompatibility antigen.
Although AS is not curable, most patients who maintain disciplined exercise and posture programmes and take antiinflammatory medication can lead relatively normal & active lives with minor adjustments in life style.

Enteropathic Arthritis :- It is an inflammatory arthritis that occurs 1-3 weeks after an acute intestinal infection with certain bacteria (Shigella, Salmonella, Yersinia species). The larger joints of extremities are usually affected. It is usually seen in a patient positive for HLA B27.

Psoriatic Arthritis :- It is an inflammatory arthritis occurring in 5% to 7% patients with psoriasis. Some patients may have co-existing psoriasis and rheumatoid arthritis. Family studies suggest an extremely high (>50%) risk in first degree relatives of patients with arthritis. The patients present with asymmetrical involvement of distal joints of hands, psoriatic skin changes & nail changes. The severity of arthritis tends to parallel the severity of skin disease. Milder forms have good prognosis. Approx 5% of patients develop severe disabling and deforming arthritis.

Crystal Arthropathies :

Gout :- It is the name given to clinical manifestations caused by deposition of crystals of uric acid in the tissues. This results in acute arthritis or chronic deforming arthritis associated with deposits of uric acid in the subcutaneous tissues (tophi) or renal stone disease. Gout is mainly a disease of adult men and post menopausal women. Risk factors for development of gout include obesity, family history of gout, renal insufficiency, diuretic drugs, high alcohol intake & exposure to lead.

Pseudogout :- It is an inflammatory arthropathy with acute & chronic forms caused by deposition of calcium pyrophosphate(CPPD) crystals in the joints. Aging, OA,genetic defects and certain metabolic diseases cause changes in cartilage that enhance deposition of CPPD crystals. These crystals are shed in the joints & cause inflammation in the joints.
Although pseudogout itself has no known effects on life expectancy, associated diseases carry their own prognosis. Joint symptoms can be controlled by antiinflammatory therapy.

Arthritis Associated With Infections :

Infectious or septic arthritis :- The micro - organisms, commonly bacteria, invade the synovial membrane and joint space, and cause inflammation and tissue destruction and subsequently loss of joint function.

Rheumatic fever arthritis :- Rheumatic fever arthritis is preceeded by infections with specific types of bacteria in the throat and upper respiratory tract. These bacteria evoke an abnormal immune response in the joints & sometimes in the heart & kidney also.

Arthritis associated with degenerative, metabolic and endocrine disorders :

Osteoarthritis (OA) :- It is the most common musculoskeletal problem in people over age of 50 years. It may be initiated by multiple factors like genetic, aging,metabolic and traumatic causes. OA is characterized by joint pain, tenderness,limitation of movement, crepitus and variable degrees of local inflammation. The most commonly affected joints are knees, spine, hip, small joints of hands and feet.

The prognosis of OA is variable. Disease of weight bearing joints is likely to cause disability. Orthopaedic surgery is performed in the treatment of chronic arthritis with disabiling deformities to relieve pain and improve function and quality of life.

Osteoporosis (OP) :- It is a condition in which bone mass is below normal for a personís age, sex and race. This leads to defects in the bone structure and susceptibility of bones to fractures. Nutritional deficiency, smoking, alcoholism, diabetes, chronic illness, menopause and long term use of drugs are the risk factors of OP.

Endocrine Arthropathies :- The musculoskeletal manifestations in endocrine diseases like diabetes, hypo or hyper thyroidism are variable. They include muscle pain or weakness, neuropathies and osteopenia.

Soft tissue Rheumatism (STR):

STR describes a number of syndromes which are characterized by widespread pain and diffuse tenderness. The syndromes are :-

Fibromyalgia (FM) :- FM is a painful, non-inflammatory condition characterized by tender points at discrete regions of the body. Factors such as physical trauma,infection, autoimmune disorders, endocrine disorders and emotional stress seem to be capable of "triggering" the development of FM. Although FM is a chronic illness, most patients can lead a relatively normal life with proper management.

Occupational Overuse Syndrome (OOS) :- Due to repeated movements (usually work related), muscles become stiff and painful. Pain causes more muscle tension & so the muscle keeps on paining even after the work is stopped. A painful and stiff muscle causes the surrounding muscles to do the same in sympathy. For example - a farmer has pain in forearm muscles, as he makes repeated use of the hand while reaping & cutting, but the pain may spread to muscles of neck & shoulders also.

Regional Myofascial Disorder :- In this disorder,the pain is more limited in distribution. It may be confined to a particular region, for example, pain in heels and calf due to prolonged standing.
Any form of arthritis can be effectively treated with modern therapeutic and supportive regimens. The therapeutic success in chronic forms of arthritis depends upon the state of disease at which long term treatment has begun. Arthroscopy of certain joints may be surgically done to remove the cause of pain and disability. A totally useless but painful joint may be replaced by an artificial prosthesis to restore painless function.
A lot of research is being done to formulate new medicines which will cure arthritis at an early stage without causing many side effects. New methods are being developed to correct the 'immunological' abnormalities which cause damage to the joints in arthritis.
But the success of treatment depends not only on drugs but also on the support of the family members of the patient, regular exercises and positive change in mental attitude of the patients.