Osteoarthritis
The word "arthritis" means inflammation of the joints, and refers to a group of more than 200 diseases of the joints, which affect large numbers of people every year. Osteoarthritis is the most common type of arthritis. It is rare in people under 40 but becomes more common with age – most people with the condition are over 65.
Symptoms
The main symptoms of osteoarthritis are pain, stiffness and swelling of the joints. The joint may have restricted movement, and there may be tenderness or deformity. The joint may also crack or creak (called crepitation).
When the joint becomes severely damaged, it may become misshapen, with bony swellings, and unstable. This puts stress on the ligaments and tissues surrounding the joints, and can lead to deformity.
Wear and tear
Osteoarthritis (OA) is a degenerative disease that most commonly affects joints in the hands, knees, hips, feet and spine. As the disease progresses, the cartilage that protects the bone becomes roughened, then thins and wears away. The body tries to compensate for this, which causes the outer edges of the bones to thicken and change shape so that "outgrowths", known as osteophytes, form at the outer edges. At the same time, the membranes lining the joints can become inflamed.
With severe osteoarthritis, chalky deposits of calcium crystals can form in the cartilage. This is called calcification. These calcium crystals can come loose from the cartilage, and cause the joint to become hot, red and swollen (called pseudogout).
The knee joint
Risk factors
A number of factors make osteoarthritis more likely:
- increasing age,
- obesity (which puts added strain on some joints),
- joint injury or over-use (professional sportspeople are particularly prone),
- family history of osteoarthritis.
Some people who have rheumatoid arthritis also develop so-called secondary osteoarthritis in the joints where their rheumatoid arthritis was active.
Diagnosis
If a doctor suspects you may have arthritis, he or she will take your medical history and examine the affected joints, looking for any sign of bony swellings, creaking and instability of the joint, as well as reduced movement.
There is no blood test for osteoarthritis, but blood may be taken to exclude other types of arthritis. The most useful test for osteoarthritis is an X-ray. This can show the narrowed space between the bones in a joint that is due to cartilage loss. It can also identify any calcification.
Dealing with osteoarthritis
Reducing stress on affected joints is one of the most important things you can do to relieve osteoarthritis. Try to do the following to reduce the stress on painful joints in your feet, knees, hips and back:
- Keeping to your ideal weight – if you are overweight, try to lose the excess. This will probably involve changing your eating habits and levels of physical activity.
- Wear good shock-absorbent shoes with thick, soft soles – trainers are good. (However people worried about falling tend to be better off with thin- soled shoes, as these make it easier to "feel" the ground underfoot.)
- Where possible, avoid activities which put undue strain on your joints, such as prolonged kneeling.
- Use a walking stick to take some of the weight off your joints.
Regular exercise is also important, regardless of your age. Activities such as swimming and cycling are ideal, as they do not put a strain on the joints. You will not wear out your joints still further by exercising. In fact, exercise can help keep the joints moving and as supple as possible and exercise or physical therapy may be recommended by your doctor in some cases of hip or knee arthritis. If in doubt, talk to your GP or physiotherapist, who will help you to plan a suitable exercise routine.
Medicines
There is a range of medications for osteoarthritis, which aim to:
- relieve pain
- optimise joint function,
- limit deterioration in the joints.
Pain relief is the main reason people seek help for their osteoarthritis.
A simple painkiller is usually tried first. Combined painkillers may be effective. These are available on prescription from a doctor.
Anti-inflammatory drugs
If there is inflammation as well as pain in the joints, you may be prescribed a non-steroidal anti-inflammatory drug (NSAID). All NSAIDs have analgesic and anti-inflammatory properties to reduce pain, stiffness and swelling. They are used widely in osteoarthritis and are a great help to some people. However, NSAIDs can cause gastro-intestinal side-effects, such as indigestion and diarrhoea, and with regular use there is also a risk of bleeding in the stomach. Also, in people with asthma, they can trigger attacks.
Creams and gels containing NSAIDs are available. These are rubbed onto affected joints and may help. They do not usually have the same gastro-intestinal side-effects as NSAIDs taken orally.
COX-2 inhibitors
This relatively new class of medicines is related to NSAIDs but is intended to have fewer gastro-intestinal side-effects.
Steroid injections
Steroid injections, usually into a knee or the spine, may be an effective way of reducing the pain and swelling associated with osteoarthritis. This treatment is usually reserved for very painful joints. The effects of the injection will eventually wear off within one to four weeks, and the procedure will have to be repeated.
Complementary treatments
There are many complementary and alternative approaches to treating osteoarthritis, although the evidence that they work is usually only anectodal. The food supplement glucosamine is said to promote healthy cartilage. As it’s derived from shellfish, it may not be suitable for people with an allergy to seafood. Glucosamine comes in tablet or capsule form and is often combined with the supplement chondroitin, also said to be beneficial for the joints.
Surgery
There are two surgical techniques that can be successfully used for osteoarthritis. The first is to replace a hip or knee joint with an artificial one (a prosthesis), and the second, for arthritis affecting the spine, is to fuse (permanently join) joints in the spine. This can alleviate pain and create stability.
Hip replacements can give people a new lease of life, with improved mobility and relief of pain. Hip replacements are usually effective for at least 10 years – after this, they may need to be replaced. Replacing the knee is a more complicated procedure, since the joint is more complex than the hip, but it can also bring great improvements in quality-of-life.
These operations carry the risks associated with all major surgery, such as infection and deep vein thrombosis.
Rheumatoid arthritis
Arthritis means inflammation of the joints. Rheumatoid arthritis (RA) is caused by inflammation of the joints or the lining of the joints. It can occur at any age, but is more likely in people aged over 40. RA may be very mild with few symptoms, but for around 1 in 20 people it can be severe and disabling.
What is rheumatoid arthritis?
Rheumatoid arthritis (RA) is an autoimmune disease. Normally cells called antibodies, produced by the body's immune system, attack foreign substances such as viruses and bacteria. With autoimmune diseases, the immune system mistakes the person's own tissue as foreign and attacks it.
With RA, antibodies attack the membranes around joints (synovial membranes) causing swelling, pain, stiffness and in some cases, deformity. RA also causes inflammation of the sheaths around tendons (which join muscles to bones). Eventually, there may be erosion of the smooth articular cartilage, which covers the ends of the bones in joints, or the bone itself.
Who is at risk of RA?
Women are three times more likely to get RA than men. This, plus the fact that it tends to improve during pregnancy, suggests that hormones may be involved. It appears people with a certain genetic abnormality are also at increased risk.
How does RA develop?
The first symptoms of RA tend to be felt in small joints, such as fingers or toes. Often both sides of the body are affected symmetrically. Cold, damp weather may aggravate the symptoms. People may feel generally unwell and tired. The progression of the disease varies. After an initial attack of RA, symptoms may disappear for months or years before flaring up again. Alternatively symptoms may not go away, with pain and swelling developing rapidly in other joints.
In general, of people with RA:
- 25% only ever have mild symptoms
- 40% have to change their activities to cope with joint damage
- 25% become severely disabled
- 10% need to use a wheelchair.
How is RA diagnosed?
If you suspect you have RA, it is a good idea to see a doctor, even if symptoms are mild. There is no single test that can diagnose RA, but the doctor will make an assessment based on symptoms and may carry out the following tests:
- blood tests to look for changes caused by inflammation
- a blood count, because 80% of people with RA have anaemia (low levels of red blood cells)
- a test for a blood protein called rheumatoid factor, which is found in 80% of people with RA
- X-rays of the hands and feet, which may identify changes in bone
Treatment
Medicines
There are many medicines that can help people with RA, but often they have side-effects. Different people respond better to different medicines, and most need to try a few before finding the right one.
Painkillers
Simple painkillers may help at first, although stronger painkillers are often needed.
Non-steroidal anti-inflammatory drugs (NSAIDs) are effective in some people. But these can damage the stomach if used continuously. People who are most vulnerable to stomach problems - such as those over 65 or taking corticosteroids - may be offered the new type of NSAID, such as rofecoxib, which is less likely to irritate the stomach.
Disease-modifying drugs (DMDs)
These are most helpful if started as soon as RA is confirmed. They may also be called disease-modifying anti-rheumatic drugs or DMARDs. DMDs have an anti-inflammatory effect, and also act on the immune system. They can stop the progress of RA, and are usually first prescribed by a hospital specialist (such as a rheumatologist). They can have serious side-effects, on the liver and kidneys for example, and their use must be carefully monitored. Other side-effects, such as diarrhoea, nausea, skin rash or hair loss, can make it hard for people to tolerate taking them. DMDs need to be used for several months before it can be certain they are working. If there are no improvements, other medicines can be tried. Examples of DMDs include:
- Immune suppressants may be used to reduce the immune response.
- Gold injections (sodium aurothiomalate) have been used since the 1930s. Gold tablets are also available, but are generally not as effective.
- Penicillamine is taken as tablets. Some people can tolerate it better than gold, but it can have more side- effects.
- Anti-malaria medicine also has anti-inflammatory properties. It's taken in tablet form
- Corticosteroids (steroids) can be injected into joints to treat severe arthritis, or taken as tablets for long-term control. They are normally used only if other anti-inflammatory medicine has not worked.
- Anti TNF (tumour necrosis factor) medicines are used for rapidly progressing RA. They block the antibodies attacking the lining of the joints. These medicines are through a drip or by injection.
Self-help treatment
There are ways in which people with RA can help to ease their symptoms.
Exercise is important, but needs to be carefully balanced. Very painful joints should be rested, but once the pain eases, lifting weights and stretching will build muscle and help prevent joints becoming deformed. Gentle cycling and swimming can also help relieve stiffness. A physiotherapists can design a personalised programme.
Losing weight if necessary is important, since extra weight can put added pressure on the joints.
Occupational therapy can help people learn new ways to do daily activities.
A diet low in saturated fat such as butter, and high in fish oil may help.
Heat or ice applied to joints, especially on the hands, is a traditional treatment that can help reduce pain.
Complementary therapy
There is little evidence to show that homeopathy, herbal remedies or acupuncture are effective treatments for RA.
Surgery
When RA has led to deformed joints and medicine is not helping, there are various types of surgery that may be suggested.
Removing the inflamed part of a joint lining (a synovectomy) can prevent cartilage and bone erosion.
If there has been significant bone erosion, a joint may be replaced with an artificial one (arthroplasty). Hip and knee replacements are very common, and elbow, shoulder or knuckle joint replacements are also available.
Ruptured tendons can be repaired and inflamed tendon sheaths removed (tenosynovectomy).
Surgery to fuse the joints in the neck may be necessary, to prevent paralysis caused by pressure on the spinal cord.
Living with arthritis
Rheumatoid arthritis varies from person to person. It is important to tell the doctor about how it is affecting you to make sure you get the right treatment. Having RA may mean making changes to your daily life. It can be a frustrating time for you, and for those around you. Don't be afraid to ask your doctor questions, or to ask for advice.