Arthritis is a group of conditions where there is damage caused to the joints of the body. Arthritis is the leading cause of disability in people over the age of 55.

In this article we are going to mainly cover Rheumatoid Arthritis

There are many different forms of arthritis, each of which has a different cause. The most common form of arthritis is Osteoarthritis (also known as degenerative joint disease) Other forms of arthritis are rheumatoid arthritis and psoriatic arthritis, which are autoimmune diseases in which the body is attacking itself. Septic arthritis is caused by joint infection. Gouty arthritis is caused by deposition of uric acid crystals in the joint that results in subsequent inflammation. Additionally, there is a less common form of gout that is caused by the formation of rhomboidal shaped crystals of calcium pyrophosphate. This form of gout is known as pseudogout.


History and Physical Examinaton

All arthritides feature pain. Patterns of pain differ among the arthritides and the location. Rheumatoid arthritis is generally worse in the morning whilst Osteoarthritis is classically worse at night or following rest. In elderly people and children, pain may not be the main feature, and the patient simply moves less (elderly) or refuses to use the affected limb (children).

Elements of the history of the pain (onset, number of joints and which involved, duration, aggravating and relieving factors) all guide diagnosis. Physical examination typically confirms diagnosis. Radiographs are often used to follow progression or assess severity in a more quantitative manner.

Blood tests and X-rays of the affected joints often are performed to make the diagnosis.

Screening blood tests may be indicated if certain arthritides are suspected. This may include: rheumatoid factor, antinuclear factor (ANF), extractable nuclear antigen and specific antibodies.


Rheumatoid Arthritis

Rheumatoid arthritis is a chronic, inflammatory, multisystem autoimmune disorder. It is commonly polyarticular; that is, it affects many joints. Inflammation, soft tissue swelling, and the involvement of multiple joints are common signs and symptoms that distinguish rheumatoid and other inflammatory arthritis from non-inflammatory arthritis such as osteoarthritis. The joints are usually affected initially asymmetrically and then in a symmetrical fashion as the disease progresses. The pain generally improves with use of the affected joints, and there is usually stiffness of all joints in the morning that lasts over one hour. Thus, the pain of rheumatoid arthritis is usually worse in the morning compared to the classic pain of osteoarthritis where the pain worsens over the day as the joints are used.

Extra-articular manifestations also distinguish rheumatoid arthritis from osteoarthritis (hence it is a multisystemic disease). For example, most rheumatoid athritis patients also suffer with anemia, either as a consequence of the disease itself (anaemia of chronic disease) or as a consequence of gastrointestinal bleeding as a side effect of drugs used in treatment, especially NSAIDs used for analgesia.

About 60% of patients are unable to work 10 years after the onset of their disease.


Deformities

As the pathology progresses the inflammatory activity leads to erosion and destruction of the joint surface, which impairs their range of movement and leads to deformity. The fingers are typically deviated towards the little finger and can assume unnatural shapes.


Diagnosis

- Morning stiffness of >1 hour most mornings for at least 6 weeks.

- Arthritis and soft-tissue swelling of >3 of 14 joints/joint groups

- Arthritis of hand joints

- Symmetric arthritis

- Subcutaneous nodules in specific places

- Rheumatoid factor at a level above the 95th percentile

- Radiological changes suggestive of joint erosion

At least four criteria have to be met for classification as rheumatoid arthritis.

It is important to note that these criteria are not intended for the diagnosis of patients for routine clinical care. They were primarily intended to categorize patients, for research. For example: one of the criteria is the presence of bone erosion on X-Ray. Prevention of bone erosion is one of the main aims of treatment because it is generally irreversible. To wait until all of the criteria for rheumatoid arthritis are met may sometimes result in a worse outcome for the patient. Most patients and rheumatologists would agree that it would be better to treat the patient as early as possible and prevent bone erosion from occurring, even if this means treating patients who don't fulfill the criteria.

The criteria are, however, very useful for categorising patients with established rheumatoid arthritis, for example for epidemiological purposes.

A 2005 study by the Mayo Clinic noted that patients suffer a doubled risk of heart disease,[20] independent of other risk factors such as diabetes, alcohol abuse, and elevated cholesterol, blood pressure and body mass index. The mechanism by which the disease causes this increased risk remains unknown; the presence of chronic inflammation has been proposed as a contributing factor.


Causes

There is no evidence that physical and emotional effects, stress and improper diet could play a role in the disease. Some research suggests that alcohol consumption lowers the risk of developing the disease. In addition, a Swedish study found that the risk decreased as the consumption of alcohol increased from light to moderate levels.

It is suspected that susceptibility to rheumatoid arthritis is an inherited trait.

Autoimmune diseases require that the affected individual have a defect in the ability to distinguish foreign molecules from the body's own.

Thus, in theory, the sufferer requires susceptibility to the disease through genetic endowment with specific markers and an infectious event that triggers an autoimmune response.


Treatment

There is no known cure for rheumatoid arthritis. However, many different types of treatment can be used to alleviate symptoms.

Historic treatments for this condition have included: gold salts, RICE, acupuncture, apple diet, nutmeg, some light exercise every now and then, nettles, bee venom, copper bracelets, rhubarb diet, rest, extractions of teeth, fasting, honey, vitamins, insulin, magnets, and electric convulsion therapy (ECT). Cortisone therapy has offered relief to many patients in the past, but its long-term effects have been deemed undesirable.

Anti-inflammatories and analgesics. Disease-Modifying Antirheumatic Drugs (DMARDs) have been found to produce durable remissions and delay or halt disease progression. In particular they prevent bone and joint damage from occurring secondary to the uncontrolled inflammation. This is important as such damage is usually irreversible. Anti-inflammatories and analgesics improve pain and stiffness but do not prevent joint damage or slow the disease progression.

There is an increasing recognition amongst rheumatologists that permanent damage to the joints occurs at a very early stage in the disease. In the past the strategy used was to start with just an anti-inflammatory drug, and assess progression clinically and using X-rays. If there was evidence that joint damage was starting to occur then a more potent DMARD would be prescribed. Tools such as ultrasound and MRI are more sensitive methods of imaging the joints and have demonstrated that joint damage occurs much earlier and in more patients than was previously thought. Patients with normal X-rays will often have erosions detectable by ultrasound that X ray could not demonstrate.

There may be other reasons why starting DMARDs early is beneficial as well as prevention of structural joint damage. In the early stage of the disease, the joints are increasingly infiltrated by cells of the immune system that signal to one another and are thought to set up self-perpetuating chronic inflammation. Interrupting this process as early as possible with an effective DMARD (such as methotrexate) appears to improve the outcome from the rheumatoid arthritis for years afterwards. Delaying therapy for as little as a few months after the onset of symptoms can result in worse outcomes in the long term. There is therefore considerable interest in establishing the most effective therapy in patients with early arthritis, when they are most responsive to therapy and have the most to gain.

Treatment also includes rest and physical activity. Regular exercise is important for maintaining joint mobility and making the joint muscles stronger. Swimming is especially good, as it allows for exercise with a minimum of stress on the joints. Heat and cold applications are modalities that can ease symptoms before and after exercise. Pain in the joints is sometimes alleviated by oral acetaminophen (paracetamol). Other areas of the body, such as the eyes and lining of the heart, are treated individually. However, there is no diet that has been shown to alleviate rheumatoid arthritis, although fish oil may have anti-inflammatory effects.


Pain relief

Recent research indicates that cytokines, a group of chemicals that are produced by various cells in the body, may be responsible for generating the response of chronic pain associated with Rheumatoid Arthritis. Medications that affect the release of cytokines or block the action of cytokines may reduce the response of chronic pain. Various anti-cytokine medications are now being used to treat painful disease states such as Rheumatoid Arthritis, and Crohn's Disease. In addition, research using the anti-cytokine medication, Thalidomide, is being evaluated for its effect in treating chronic pain associated with Arachnoiditis.

Food (vegetables) with higher water content should be avoided


Other therapies

Other therapies are weight loss, occupational therapy, podiatry, physiotherapy, joint injections, and special tools to improve hard movements (e.g. special tin-openers).

Severely affected joints may require joint replacement surgery, such as knee replacement.


Prognosis

The course of the disease varies greatly from patient to patient. Some patients have mild short-term symptoms, but in most the disease is progressive for life.

Around 20%-30% will have subcutaneous nodules (known as rheumatoid nodules); this is associated with a poor prognosis


Disabitity

Daily living activities are impaired in most patients.

After 5 years of disease, approximately 33% of patients will not be working

After 10 years, approximately half will have substantial functional disability.


Mortality

Estimates of the life-shortening effect of Rheumatoid Arthritis vary; most sources cite a lifespan reduction of 5 to10 years. According to the UK's National Rheumatoid Arthritis Society, "Young age at onset, long disease duration, the concurrent presence of other health problems (called co-morbidity), and characteristics of a severe form of the disease – such as poor functional ability or overall health status, a lot of joint damage on x-rays, the need for hospitalisation or involvement of organs other than the joints – have been shown to associate with higher mortality".

Positive responses to treatment may indicate a better prognosis. A 2005 study by the Mayo Clinic noted that patients suffer a doubled risk of heart disease, independent of other risk factors such as diabetes, alcohol abuse, and elevated cholesterol, blood pressure and body mass index. The reason why the disease causes increased risk remains unknown; the presence of chronic inflammation has been proposed as a contributing factor.


For further help and information follow the link to the National Rheumatoid Arthritis Society