ARTHRITIS

Background

The prevalence of arthritis (chronic damage of the joints) increases with age because the most common form, osteoarthritis, is age related, and also because chronic arthritis, particularly rheumatoid arthritis, persists into old age even when starting in early adult life (Silman and Hoch-berg). Osteoarthritis and rheumatoid arthritis are common, and represent two distinct but related mechanisms of joint disease in old age: respectively, "wear and tear" and inflammation.

The clinical features of arthritis. Pain is the predominant symptom. Most pronounced on movement, it also occurs at rest, after exercise, and at night. The other main complaint is stiffness, occurring in the morning and after exercise, when it is termed "gelling." In inflammatory arthritis, morning stiffness exceeds thirty minutes. Joint swelling is common, due to synovitis (inflammation of the joint lining), synovial effusions (swelling due to fluid in the joint cavity), and bony swelling around joints. Crepitus, grating when joints are moved, characterizes osteoarthritis. Arthritis causes muscle weakness that may be profound. Finally, there may be loss of movement due to joint swelling, muscle weakness, and deformities when joints are damaged.

The effects of arthritis. Arthritis causes disability and impairs quality of life due to the direct effect of inflammation of the synovium (synovitis). The pain, inflammation, and joint destruction of synovitis are compounded by muscle weakness and decreased sense of joint (proprioception) (British League Against Rheumatism).

Osteoarthritis

Osteoarthritis is common and, at older ages, becomes virtually universal. It is an active process, not just wearing out of joints or "degenerative joint disease" (Joint Working Group of the British Society for Rheumalology and, Research Unit of the Royal College of Physicians).

Causes and disease mechanisms. There are progressive changes in osteoarthritic cartilage. Initially the collagen (the material that provides important lining of bones) framework is damaged by changes in structural complex sugars (proteoglycans), in the cartilage matrix, and in water content. Attempted repair increases the number and activity of cartilage cells (chondrocytes). This leads to the production of degradative enzymes. Subsequent fissuring, cartilage ulceration and matrix loss makes damage irreversible. There is variable accompanying inflammation of the synovium that lines the joints, as well as changes in adjacent bone. Predisposing factors for osteoarthritis include age, female sex, family history (indicating genetic predisposition), obesity, previous trauma, repetitive occupational stress, and previous inflammation, such as rheumatoid arthritis. Osteoarthritis increases with age. By sixty-five years most people have X-ray evidence of osteoarthritis, though under 30 percent have symptoms.

Clinical features. Pain is the dominant symptom. It is usually activity related, varies in severity, and has periods of remission. Associated symptoms include morning stiffness (usually under thirty minutes), postexercise gelling, bony swelling, limited movement, and muscle weakness. Examination shows bony swelling, tenderness, and crepitus. Effusions, usually in the knees, are common.

Osteoarthritis can involve one or many joints. Generalized osteoarthritis involves the small joints of the fingers, especially those at the knuckles closest to the ends, as well as the wrists, knees, and hips.

Investigations. Blood tests are usually normal, although some elevation of tests for inflammation can be seen. Tests for the protein known as rheumatoid factor are negative. X-rays show joint space loss, and increased bone underneath and at the edges of joints, called subchondral sclerosis and marginal bony outcroppings (osteophytes), respectively. In late disease, joints can be totally destroyed. Isotope bone scanning (scintigraphy) shows increased activity of the joints in early disease.

Rheumatoid arthritis

Rheumatoid arthritis, the most common type of inflammatory arthritis, is characterized by persisting inflammatory synovitis resulting in joint damage and systemic reactions, although it can vary in its severity and general effects (Scott et al.; Sewell).

Causes and disease mechanisms. The cause of rheumatoid arthritis is unknown, but is variously attributed to autoimmunity, bacterial infection, or viral infection. The synovium is infiltrated with white blood cells called lymphocytes, which are seen where inflammation is chronic. Synovial cells proliferate and blood vessels increase markedly. Synovial fluid contains many white blood cells known as polymorphonuclear leukocytes. There are accompanying destructive changes in joint cartilage and bone.

Rheumatoid arthritis is associated with rheumatoid factor production. Several different immunoglobulin classes can be involved, especially IgM and IgA. A minority of cases remain seronegative. Rheumatoid arthritis has a genetic component. It involves three times more women than men, its prevalence increases with age, and it involves 0.25–1 percent of adults and 3–5 percent of elderly women.

Clinical features. The onset of rheumatoid arthritis is usually insidious over several months, though some cases have an acute onset. Characteristic features are joint pain, swelling, and morning stiffness lasting several hours. Typically it involves small joints of the hands and wrists in a symmetrical distribution. Large joint involvement indicates severe disease. In early disease the findings are subtle, while in late disease there are obvious changes, such as the self-descriptive swan-neck and "boutonnière" deformities in the fingers. Large joint damage causes immobility and disability.

Features apart from joint inflammation (extra-articular features) are common. Rheumatoid nodules at sites like the elbow indicate severe, rheumatoid factor–positive disease. Other extra-articular features include dry eyes and dry mouth (Sjögren's syndrome), leg ulcers, nerve damage, lung disease, and inflammation of the pericardium, sclera, and blood vessels.

Investigations. Blood tests are usually abnormal. Rheumatoid factors are antibodies produced by the individual against constituent proteins (auto-antibodies). They bind to one end of normal immunoglobulin, the Fc portion. They occur in about two-thirds of cases, as well as in other disorders with persisting immune inflammation and in many healthy individuals. Other abnormalities reflect the systemic inflammatory response. The erythrocyte sedimentation rate is elevated. Specific measures of acute inflammation, such as C-reactive protein, are also elevated. By contrast hemoglobin levels can be low.

Juxta-articular erosions, a key diagnostic finding, are next to the joint on X-rays of the hands and feet. Other changes are osteoporosis around the joints and loss of joint space. In late disease there is destruction and ankylosis (fusion of the joint due to bone growth). Scintigraphy shows increased blood flow around involved joints in early disease, though such findings are not specific.

Seronegative arthropathies

Seronegative arthropathies usually involve only a few joints, are less severe than rheumatoid arthritis, and tests for rheumatoid factor are negative, (hence the term "seronegative"). Psoriatic athritis, the most important type in elderly people, is a specific type of arthritis seen in association with psoriasis. Other disorders include reactive arthritis, colitic arthritis in inflammatory bowel disease, and the peripheral arthritis of anklyosing spondylitis, a disorder characterized by involvement of the spine.

Classification and causes. Unifying themes are the presence of an infective trigger and the genetic risk associated with HLA-B27, one of the genes found in normal human white blood cells. This is found 95 percent of cases of ankylosing spondylitis and less often in the other disorders.

Ankylosing spondylitis, colitic arthritis, and reactive arthritis usually begin in early adult life; in the elderly the predominant clinical concern is their late consequences, mainly due to joint failure. Psoriatic arthritis may present de novo in the elderly.

Clinical features. There are a number of clinical patterns of psoriatic arthritis, including oligoarthritis (arthritis that involves only a few joints); a symmetrical polyarthritis, often indistinguishable from rheumatoid arthritis; distal arthritis of the distal interphalangeal joints; and arthritis mutilans, a rare cause of severe joint damage. Other forms of seronegative arthritis predominantly involve oligoarthritis.

Investigations. There are no specific laboratory tests. Acute-phase reactants like the ESR and C-reactive protein may be elevated. Rheumatoid factor is usually negative. X-rays may show marginal erosions. Isolated destruction of individual joints with pencil and cup deformities suggests psoriatic arthritis. Axial disease with sacroilitis and spinal fusion characterize ankylosing spondylitis.

Gout

Causes and disease mechanisms. Gout is a form of inflammatory arthritis that results from the deposition of urate crystals in the synovium (Van Doornum and Ryan). Uric acid, the end product of metabolism of some important proteins, results from endogenous purine metabolism with an important, though minor dietary contribution. In other words, while diet has some impact on gout, the idea of gout as chiefly the result of too much rich food and drink (the "patrician malady") is untrue. Hyperuricemia is seen prior to episodes of arthritis and progesses to gout when large increases in body stores of uric acid make it impossible for the body to adapt. Synovial urate crystals activate inflammatory pathways either directly or after coating by proteins such as immunoglobulins.

Hyperuricemia (high uric acid levels in the blood) is common, with a male predominance; it involves 5 percent of men. Risk factors include obesity, renal disease, high alcohol intake, and diuretic use. It is also seen as part of "syndrome X," which consists of abdominal obesity and high blood pressure, and is a potent risk for arthroscelerosis and heart disease. Gout is less common, involving 0.2–0.5 percent of men.

Clinical features. Gout may be precipitated in patients with hyperuricemic gout by excess alcohol, metabolic disturbances due to surgery or trauma, or diuretic therapy. Classical gout involves the big toe (podagra), making it exquisitely painful, red, swollen, and tender. The onset may involve multiple joints, particularly those of the lower limbs. It is unusual for both lower limbs to be affected at the same time. Initial attacks often resolve after a few days and can be followed by recurrent episodes. These can progress to chronic arthritis. Some cases with established gout have subcutaenous urate crystals deposits (known as tophi) in the pinnae of the ears, fingers, and elbows.

Investigations. If joint fluid from an affected joint is aspired (which is often very difficult to do), detecting intracellular uric acid crystals under the microscope is diagnostic. Most patients have elevated serum uric acid levels, though only a minority of patients with hyperuricemia have gout. Acute attacks result in an elevated ESR and high white cell count. In established gout X-rays show punched-out erosions with sclerotic margins, often distant from the joint margins.

Calcium pyrophosphate deposition disease

Some patients have a disorder similar to gout without synovial fluid uric acid crystals (Fam). Instead they have intracellular calcium pyrophosphate dihydrate crystals, a condition known as pseudogout. Such crystals also occur in osteoarthritis and a range of arthropathies, so that they are an important cause of arthritis in older people.

Causes and disease mechanisms. Calcium pyrophosphate is widely distributed in the body, and it is unclear why it sometimes forms crystals that induce inflammation. These crystals are often associated with metabolic disturbances such as parathyroid disease and a blood disorder known as hemochromatosis. Pathologically the crystals trigger a cascade of inflammatory pathways that mirrors gout.

Pyrophosphate crystals account for up 50 percent of acute attacks of crystal arthritis. Similar crystals are seen in the cartilage of many elderly people, a condition termed chondrocalcinosis. Seen in a minority of seventy year olds but the majority of ninety year olds, its pathological significance is often uncertain.

Clinical features. As is suggested by the name, acute pseudogout is similar to classical gout and can be precipitated by metabolic disturbances such as trauma. The arthritis develops suddenly, with one or several inflamed, painful, swollen, and tender joints. It typically involves knees, shoulders, and wrists. Many patients have recurrent episodes. Some cases have chronic arthritis, often with some joint inflammation occurring over and above osteoarthritis.

Investigations. Intracellular pyrophosphate crystals are visible on polarizing light microscopy of aspirated synovial fluid. X-rays may show chondrocalcinosis, indicating crystal deposition in joint cartilage. Blood tests either are normal or show evidence of mild inflammation with a raised ESR.

Other arthropathies. Other forms of arthritis important in the elderly include septic arthritis and arthritis linked to polymyalgia rheumatica and malignancy. Septic arthritis often complicates pre-existing chronic arthritis, particularly rheumatoid arthritis, and results in an acute exacerbation of joint problems and systemic involvement. Unless there is a high threshold of diagnostic suspicion, it can be difficult to diagnose until the joint sepsis is advanced. Arthritis in polymyalgia rheumatica and malignancy is mild, polyarticular, nonerosive, and seronegative for rheumatoid factor.

Management

General principles. Management aims are controlling pain, minimizing disability, reducing progressive joint damage, and limiting functional and social handicaps. Most arthropathies can be managed by family physicians with a minority of cases needing specialist referral; the exception is rheumatoid arthritis, which invariably needs specialist input. General management principles for most forms of arthritis comprise patient education, lifestyle advice, treating pain with analgesics, and treating pain and inflammation with non-steroidal anti-inflammatory drugs (NSAIDs).

Nondrug treatments. Advice, education, and support that benefit patients or their care givers can be provided by medical and a variety of support staff (Puppione). Self-efficacy, maintaining general health and fitness, and avoiding obesity all need emphasis. Aids and appliances, such as walking sticks and footwear, have modest benefits, though not all elderly patients are willing or able to use them.

Exercise program that improve general fitness and muscle strength are effective. They involve lifestyle changes such as regular walking and specific muscle-strengthening program like quadriceps exercises. There is good evidence that they are effective in osteoarthritis, but evidence for rheumatoid arthritis and other arthropathies is less convincing.

Analgesics and NSAIDs. Simple analgesics like acetaminophen are effective and safe in all forms of arthritis in the elderly (American College of Rheumatology). One disadvantage is that patients are reluctant to take enough acetaminophen (e.g., 1 gram four times daily). Other analgesics,such as tramadol and dihydrocodeine, are effective in relieving arthritic pain, though constipation with dihydrocodeine and disorientation with both drugs limit their use. Compound analgesics, especially coproxamol (dextropropoxyphene and acetaminophen) are widely used, though there is limited evidence that they are better than acetaminophen.

Nonsteroid anti-inflammatory drugs (NSAIDs) are widely used to treat pain and inflammation. Short courses of NSAIDs reduce pain and joint swelling over several days or weeks, and maintain these benefits for several months. There is limited evidence for longer-term benefits. The drawback with NSAIDs is their frequent adverse reactions. The most important are gastrointestinal reactions, which range from mild indigestion to severe gastrointestinal ulcers, hemorrhages, and perforations. Other reactions include rashes and renal and liver impairment. There are variations in the prevalence of severe gastrointestinal reactions with different NSAIDs. Older drugs like indomethacin cause more problems than newer drugs like nabumetone. Recently introduced coxibs like rofecoxib and celecoxib, which selectively inhibit COX-2 enzymes, have greater gastrointestinal safety (Jackson and Hawkey). Gastrointestinal risks are also reduced by coprescribing prostaglandin analogues like misoprostol, proton-pump inhibitors like omeprazole, or H-2 antagonists like randitine.

Disease modifying antirheumatic drugs (DMARDs). These chemically diverse drugs control synovitis in rheumatoid arthritis and seronegative arthritis by modulating the immune response (Simon and Yocm). They reduce synovitis, decrease erosive damage, and improve long-term function. They are given in addition to analgesics and NSAIDs. DMARDs include methotrexate, sulfasalazine, leflunomide, azathioprine, cyclosporin, gold injections, and antimalarials (chloroquine and hydroxychloroquine). All except the antimalarials require regular monitoring for blood and liver toxicity.

DMARDs should be started soon after the diagnosis of rheumatoid arthritis has been established. Combinations of two or more DMARDs are often used, for example, triple therapy with methotrexate, sulfasalazine, and hydroxychloroquine. A recent development has been the introduction of antitumor necrosis factor (TNF) alpha immunotherapy, usually combined with methotrexate, to supplement DMARD therapy in severe disease.

Steroids. Local steroid injections benefit active inflammatory arthritis involving a single joint, irrespective of the cause, provided there is no sepsis. They can be repeated several times but should not be used excessively.

Systemic steroids, given intramuscularly or orally, are effective in acute active inflammatory arthritis, whatever the cause. They have a rapid onset of action, but their benefits may not be sustained. Their long-term use is limited by osteoporosis, thinning of the skin, increased sepsis, and other adverse reactions. It is imperative to prevent osteoporosis by giving calcium and vitamin D, with additional preventive therapy such as biphosphonates, in elderly patients on long-term systemic steroids therapy.

Other local treatments. Intra-articular artificial synovial fluid injections benefit osteoarthritis and reduce pain for up to six months. Local NSAIDs applied topically as creams or gels offer small benefits for osteoarthritis with limited adverse effects. There are similar benefits with local capsaicin, also applied topically as a cream.

Other medical treatments. Gout is treated by allopurinol, which inhibits uric acid formation. It has no value in acute gout and, because it may precipitate acute attacks, requires initial NSAID coprescription. Colchicine is an alternative approach in gout, but its efficacy is limited by diarrhea. Septic arthritis requires antibiotics; the choice depends upon the organisms involved.

Surgical treatment. The most important surgical treatment for osteoarthritis and joint failure is replacement. Many different joints can be replaced, but knees and hips are most important. Replacment reduces pain and improves function with few perioperative and postoperative complications. Most prostheses last many years. Indications for surgery include persistent pain, poor function, and anatomical evidence of joint destruction. Contra-indications include obesity, poor general health, and relative youth (as prostheses do not last indefinitely). Outcomes are better with single joint replacements, but many patients do well with multiple joint replacements. Other surgical interventions, including attempts to salvage existing joints by surface replacement, have fewer beneficial effects.

David Scott

See also Pain Management.

BIBLIOGRAPHY

American College of Rheumatology, Subcommittee on Osteoarthritis Guidelines. "Recommendations for the Medical Management of Osteoarthritis of the Hip and Knee. 2000 Update." Arthritis and Rheumatism 43, no. 9 (2000): 1905–1915.

British League Against Rheumatism. Disability and Arthritis. London: The League, 1994.

Fam, A. G. "What Is New About Crystals Other Than Monosodium Urate?" Current Opinions in Rheumatology 12, no. 3 (2000): 228–234.

Kirwan, J. R.; Currey, H. L.; Freeman, M. A.; Snow, S.; and Young, P. J. "Overall Long-term Impact of Total Hip and Knee Joint Replacement Surgery in Patients with Osteoarthritis and Rheumatoid Arthritis." British Journal of Rheumatology 33 (1994): 357–360.

Jackson, L. M.; and Hawkey, C. J. "COX-2 Selective Nonsteroidal Anti-inflammatory Drugs: Do They Really Offer Advantages?" Drugs 59, no. 6 (2000): 1207–1216.

Joint Working Group of the British Society for Rheumatology and Research Unit of the Royal College of Physicians "Guidelines for the Diagnosis, Investigation and Management of Osteorthritis of the Hip and Knee." Journal of the Royal College of Physicians (London) 27 (1993): 391–396.

Puppione, A. A. "Management Strategies for Older Adults with Osteoarthritis: How to Promote and Maintain Function." Journal of the American Academy of Nurse Practitioners 167–171.

Scott, D. L.; Shipley, M.; Dawson, A.; Edwards, S.; Symmons, D. P.; and Woolf, A. D. "The Clinical Management of Rheumatoid Arthritis and Osteorthritis: Strategies for Improving Clinical Effectiveness." British Journal of Rheumatology 37, no. 5 (1998): 546–554.

Sewell, K. L. "Rheumatoid Arthritis in Older Adults." Clinics in Geritaric Medicine 14, no. 3 (1998): 475–494.

Silman, A. J.; and Hochberg, M. C. Epidemiology of the Rheumatic Diseases. Oxford: Oxford University Press, 1994.

Simon, L. S.; and Yocm, D. "New and Future Drug Therapies for Rheumatoid Arthritis." Rheumatology (Oxford) 39, supp. 1 (2000): 36–42.

Van Doornum, S.; and Ryan, P. F. "Clinical Manifestations of Gout and Their Management." Med J 172, no. 10 (2000): 493–497.

Arthritis

Jenny’s Story

What Is Arthritis?

What Is Osteoarthritis?

What Is Rheumatoid Arthritis?

What Is Juvenile Rheumatoid Arthritis?

What Are the Other Forms of Arthritis?

Living with Arthritis

Resources

Arthritis refers to inflammation of the joints, often accompanied by pain, stiffness, or swelling. Arthritis may occur in many different diseases and medical conditions.

KEYWORDS

for searching the Internet and other reference sources

Autoimmune diseases

Inflammation

Joints

Osteoarthritis

Rheumatoid arthritis

Jenny’s Story

For many years, Jenny’s father was a dedicated runner. He got up early each morning for a 3-mile jog, and on weekends he sometimes ran as far as 10 miles or competed in road races. He even talked about training for a marathon, which would mean running more than 26 miles in one race. Gradually, however, Jenny began to hear her father mention that his knees were hurting when he ran, and that they remained painful for a few hours after he stopped. Jenny noticed that his knees looked swollen, and that he sometimes had trouble sleeping because the pain annoyed him so much.

Jenny’s father assumed the pain was simply a running injury that would get better with rest. But when the pain did not go away, Jenny’s father visited a doctor. He was told he had a type of arthritis known as osteoarthritis (os-te-o-ar-THRY-tis). This surprised Jenny, because her father was only in his forties. She thought that arthritis was only a problem for older people like her grandparents.

What Is Arthritis?

Arthritis is a common problem for many older people, but it can affect anyone, from toddlers to centenarians*. Although people use the term as if it were only one disease, arthritis actually refers to a condition found in a large group of disorders. The major symptoms of arthritis affect the areas in and around joints, making them stiff, swollen, and often painful. In addition to the joints, certain types of arthritic diseases may affect other parts of the body, including the heart and lungs.

* centenarians

are people who are at least 100 years old.

As a group, the various forms of arthritis are among the most common medical conditions. About 1 of every 6 people, or more than 40 million Americans, have it. Arthritis usually is chronic, which means the problem can last to some degree for months, years, or the rest of people’s lives.

Arthritis affects millions of people. Although there are many types, the most common are:

• Osteoarthritis
• Rheumatoid arthritis*

* rheumatoid arthritis

(ROO-ma-toid ar-THRY-tis) is a chronic autoimmune disease characterized by pain, swelling, stiffness, and deformation of the joints.

• Juvenile rheumatoid arthritis

• Gout*

* gout

occurs when deposits of uric acid in the joints cause inflammation and pain.

• Fibromyalgia*

* fibromyalgia

(fi-bro-my-AL-ja) is a group of disorders that are characterized by achy tender and stiff muscles.

• Lupus
• Lyme disease

These conditions develop for a variety of reasons, but they are not contagious*. Some forms of arthritis, however, can develop from contagious infections, like sexually transmitted diseases or viruses that cause mumps and rubella (German measles). One form of arthritis, Lyme disease, develops from the bite of an infected tick. Sometimes arthritis occurs as one of the symptoms seen in conditions that primarily affect other organs. For example, inflammatory bowel disease may have arthritis as one of its symptoms.

* contagious

means transmitted from one person to another.

What Is Osteoarthritis?

Jenny’s father has osteoarthritis, the most common type of arthritis in adults. About 21 million Americans, almost half of those with arthritis, have this kind. Osteoarthritis is sometimes called “wear-and-tear” arthritis.

That is because the pain, stiffness, and swelling often result from the wearing down of the protective tissues within and around joints.

More than 150 possible trouble spots

The human body contains more than 150 joints that connect more than 200 bones. There are small joints in toes and fingers; larger ones in the spine, elbows, and knees; and even bigger ones like the hips and shoulders. The bones do not touch directly. Instead, a tough, smooth, rubbery layer of tissue called cartilage covers the ends of the bones. When a knee, elbow, or other joint moves, the cartilage allows the bones to slide past each other smoothly. Cartilage also is flexible and absorbs some of the weight placed upon certain joints, such as the knee.

People with osteoarthritis, however, have lost some of the smooth cartilage in their joints. Eventually, the cartilage can wear away so much that the ends of the bones touch without any cushioning. The bones also can grow small spurs or bumps, which is why some people with osteoarthritis have lumps in their joints. These lumps often are most noticeable in the hands.

Those Odd pains

Osteoarthritis usually is felt first in the knees, hips, feet, spine, or fingers. These are joints that bear much of the body’s weight or are used often for everyday activities. The pain increases as the cartilage between the bones is worn down. People often start to avoid using the joint. For example, people might exercise less if pain is in the knees. This only makes the problem worse. It leads to increased stiffness, because muscles around the joints begin to weaken from disuse.

Stress

No one is exactly sure why osteoarthritis happens, but often it results from stresses placed on the joint. In the example of Jenny s father, his years of running on hard surfaces caused damage to his knee cartilage. The pounding on pavement was too much stress for the cartilage to absorb.

Other types of stress or injury also can lead to osteoarthritis. People whose jobs involve hard physical labor (like construction workers) or repetitive tasks (like assembly line workers) can develop osteoarthritis. An injury to a knee or elbow also can increase the risk of osteoarthritis. Certain activities like football or ballet can put a person at greater risk for developing osteoarthritis.

Even the stress of too much body weight contributes to the disease. People who are significantly overweight are more prone to osteoarthritis because their weight places extra stress on joints, especially knees and hips.

Age

Many older people also develop osteoarthritis, even if they never put extra stress on their joints. That is because as people age, the rubbery cartilage tissue loses some of its ability to stretch and can become thinner. This places people at greater risk for osteoarthritis as they age.

Heredity

Not all older people develop osteoarthritis, just as not all runners or laborers do. This is one reason doctors believe heredity may play a role in determining who is at greatest risk for this type of arthritis.

Diagnosis

It is important to understand what type of arthritis people have, because treatments vary. Doctors diagnose osteoarthritis based on the symptoms they see. They might look for loss of cartilage and bone spurs with x-rays. Doctors also look for other causes of the pain. For example, blood tests can show if the problem is rheumatoid arthritis instead.

If it hurts, why do doctors want patients to exercise?

Once doctors have determined the problem is osteoarthritis, they tell patients something that might seem to make little sense. They want them to exercise the joint. This does not mean Jenny’s father should return to running. It does mean he and others with the disease need to work with their doctors to find the best way to exercise.

Appropriate exercise can strengthen the muscles around the joint and help lessen the stiffness. Often, the exercises are different from those done in the past. Some give up running for swimming or water aerobics. Others walk or ride stationary bikes. If the pain is severe, a physical therapist who specializes in helping patients learn appropriate exercises might get involved. If people are overweight, doctors advise them to take off the pounds.

The pain of arthritis is often treated with aspirin or other over-the-counter drugs that reduce swelling. There also are prescription drugs that are stronger and can help if the pain is extreme.

Often the pain of osteoarthritis decreases with treatment. For some people, however, surgery is performed to remove stray pieces of damaged cartilage, to smooth bone spurs, or in severe cases to replace damaged joints with mechanical ones. Hips and knees are the most likely candidates for replacement.

What Is Rheumatoid Arthritis?

The ancient Greeks believed the body was filled with various substances they called “humors.” Sometimes they said the humors got out of balance and caused illnesses, such as the aches and pains of swollen joints. The humors, they believed, could get back in balance, and the pain would subside. But the problems also could return. One disease the Greeks observed is what we now call rheumatoid (ROO-ma-toid) arthritis. “Rheuma” derives from a Greek word that means “flux” or “discharge.” The Greeks believed the humors were fluxing, or flowing, through the body to cause the bouts of pain.

When the body turns on itself

In a way, rheumatoid arthritis is a disease in which substances in the body are out of balance. The body fights infections with chemicals known as antibodies. But in rheumatoid arthritis, the antibodies turn against healthy areas of the body and cause the thin covering around joints to become inflamed.

The pain usually starts in the hands or feet, but rheumatoid arthritis can affect many different joints as well as other parts of the body, like the heart and lungs. The disease’s cause is unknown. Some researchers believe that the immune system s attack on healthy tissues may be caused by the body’s overreaction to viral infection.

More than 2 million Americans have rheumatoid arthritis, and most of them are women. Although it can start at any age, including a juvenile form that children get, the disease usually strikes women between the ages of 35 and 50.

It is known as the most disabling of the various diseases that cause arthritis. Rheumatoid arthritis can lead to deformed joints, extreme pain, and loss of the ability to do common tasks like walking.

Stiffness in the morning

The symptoms of the disease can develop in a few days, months or years. For most people, a joint in the hands, feet, arms, or legs feels stiff, as it does in osteoarthritis and other forms of arthritis. Rheumatoid arthritis, however, has a few distinctive features. People tend to feel worse in the morning after awakening. They also can get a fever, and their joints can seem warm to the touch.

At first, the antibodies damage only the thin covering around joints. This covering contains cells that produce fluid that keeps joints lubricated and working properly. As the covering is damaged, it becomes thicker. Soon, damaging cells appear and eat away cartilage, bone, and other tissue. Swelling and pain result, and the joints become deformed. People with rheumatoid arthritis also can develop small bumps around joints, especially hands and elbows. Often, the disease flares up and then subsides on its own. Some people, however, receive no relief without treatment.

Diagnosis

Doctors diagnose rheumatoid arthritis with special blood tests. They also look for other causes of the joint problems and use x-rays to look at the spaces between bones to see if they are narrowing.

Treatment

Over-the-counter medications like aspirin can ease the pain. Stronger prescription pain relievers and anti-inflammatory drugs also are available. Weight loss is urged for people who are too heavy. Some people need surgery to replace badly damaged joints in the arms, legs, or hips.

Many people, however, learn to live with the disease through a combination of rest and exercise. When the symptoms are at their worst, patients with rheumatoid arthritis try to avoid putting stress on the joint to help reduce damage to the joint. But when the symptoms are less severe, doctors want the patients to exercise to maintain flexibility in the joints and strength in the muscles around them.

Patients with rheumatoid arthritis often learn relaxation techniques, because the disease is known to flare up in times of emotional stress.

What Is Juvenile Rheumatoid Arthritis?

Juvenile rheumatoid arthritis is one of several common forms of juvenile arthritis that cause swelling and pain in the joints. There are a great variety of symptoms among children with arthritis. The causes are unknown, although heredity is believed to play a role.

The U.S. and the World

• About 355 million people worldwide have arthritis, according to the Arthritis Foundation. Some forms, like rheumatoid arthritis, appear to be increasing in the developing nations of Africa, while their incidence appears to be decreasing in the United States and Western Europe.
• About 40 million people in the United States (15 percent of the population) were reported to have arthritis in the late 1990s. But as baby boomers age, those numbers are expected to rise. By 2020, close to 60 million people in the United States are expected to have arthritis.
• Florida has the highest percentage (almost 20 percent) of residents with arthritis. By 2020, it is still expected to lead the nation, with almost 25 percent of its residents having arthritis.
• Alaska, with about 10 percent of residents having arthritis, has the lowest percentage now. It also is expected to be the lowest in 2020.
• Arthritis affects all age groups, including more than 275,000 children underage 17.
• Almost two thirds of people with arthritis are females. Among older women, it is the most common chronic condition.
• In the United States, the estimated cost of arthritis to society is about $65 billion per year. About 25 percent is due to medical costs, and the remainder is from lost wages and productivity.
• When the new arthritis medication Celebrex was released for sale in the United States in 1999, it sold more than $600 million in new prescriptions during its first six months on the market.

Juvenile rheumatoid arthritis affects children under age 16. Although very similar to the adult form of rheumatoid arthritis, 50 to 75 percent of young patients will “outgrow” the disease. Children are treated the same way that adults are: with pain medication, exercise, and careful treatment to prevent joints from becoming deformed.

What Are the Other Forms of Arthritis?

Osteoarthritis is the most common form of arthritis, and rheumatoid arthritis is the most disabling. But there are more than 100 diseases that are accompanied by the symptoms of arthritis. Here are a few of the other major ones, as well as a couple of unusual types:

Gout

Gout causes extreme pain that develops suddenly, often in the big toe. The pain, swelling, and redness develop because uric acid crystals build up in the joint. Uric acid is a natural substance found in the body that usually is passed out through the kidneys and urine. When uric acid is not removed from the body, crystals form and settle in the joints. Gout often is associated in people’s minds with excessive eating and drinking. Although those activities, as well as obesity, increase the risk for gout, it can develop for no apparent reason. About 2.1 million Americans have gout, and about 90 percent of them are men.

Fibromyalgia

Fibromyalgia causes pain in the muscles and in the ligaments and tendons that are attached to bones around joints. Often, people with fibromyalgia are excessively tired and have trouble sleeping. The causes are unknown, although people with the disease often experience psychological stress. This does not mean the disease or its pain are not real. Unlike other forms of arthritis, fibromyalgia affects muscles and tissues around joints, not the joints themselves. It also does not lead to permanent damage. More than 3.5 million Americans have fibromyalgia, and most of them are women.

Lupus

Lupus is a disease that affects joints as well as other body parts, like the kidneys, nervous system, heart and skin. There are many symptoms of lupus, including fatigue, rashes, chest pain, fever, and sensitivity to sunlight. Like rheumatoid arthritis, lupus is an autoimmune disease with no known cause. In autoimmune diseases, the cells in the body that usually fight infections attack healthy cells and tissue instead. The disease mostly strikes women in their childbearing years. Women of African ancestry are almost three times as likely to develop lupus as women of European ancestry are. Overall, it affects as many as 500,000 people in the United States.

Lyme disease

Lyme disease is a bacterial infection spread by the bite of an infected insect known as a deer tick. The first signs are usually fever and a red rash on the skin where the bite occurred. Joint problems may follow, but the disease usually can be overcome with medication. It is a special concern for people who spend time outdoors in certain regions of the United States.

“Rheumatism”

Rheumatism is a non-medical word that many people use to refer to many different forms of arthritis, including rheumatoid arthritis. Older men and women sometimes talk about “having a touch of rheumatism” when their joints ache, especially on cold, rainy days.

Living with Arthritis

Severe arthritis can limit the ability to walk, dress, or bathe easily. There are a growing number of devices that are sold to help people with arthritis have an easier time with simple tasks. Such things as easy-to-open bottles, handles on poles to reach high objects, and electric scooters can help people with severe arthritis to live independently.

Although doctors do not yet know how to prevent arthritis, there are many things people can do to reduce its impact, including:

• maintaining a healthy weight
• exercising to maintain joint flexibility and muscle strength
• exercising carefully, especially in contact sports like football
• wearing well-cushioned sneakers when walking or running on hard surfaces
• getting adequate rest
• following the doctor s instructions about pain medications
• learning relaxation techniques to reduce flare-ups in times of stress

With a fuller understanding of arthritis, its limitations, and its treatments, people with arthritis can lead full and happy lives.

See also

Fibromyalgia

Gout

Lupus

Lyme Disease

Resources

Books

Moyer, Ellen. Arthritis: Questions You Have-Answers You Need. Allen-town, PA: People’s Medical Society, 1997. An easy-to-follow book that answers dozens of questions about many forms of arthritis.

Schwarz, Shelley Peterman. 250 Tips for Making Life with Arthritis Easier. Atlanta: Longstreet Press, 1997. Published in conjunction with the Arthritis Foundation, this book focuses on living with arthritis and describes ways to make homes friendlier to people with arthritis.

Organizations

The Arthritis Foundation, 1330 West Peachtree Street, Atlanta, GA 30309. A national support organization with many local chapters. It publishes books, brochures, and fact sheets about all aspects of arthritis. Many are posted on its website. Telephone 800-283-7800 http://www.arthritis.org

The American Academy of Orthopaedic Surgeons, 6300 North River Road, Rosemont, IL 60018-4262. An organization of physicians. Its website offers detailed information about arthritis and joint replacement. Telephone 800-346-2267 http://www.aaos.org

ARTHRITIS

DEFINITION

Arthritis means inflammation of a joint. There are more than one hundred different forms of arthritis. They are similar to each other in the symptoms they produce, which includes sore, stiff, inflamed, and painful joints. Beyond these common symptoms, the various forms of arthritis are quite different from each other. Most forms of arthritis can be subdivided into three major categories: rheumatoid (pronounced ROO-muh-toid) arthritis, osteoarthritis (pronounced OSS-tee-o-ar-THRIE-tis), and gout.

DESCRIPTION

A joint is a part of the body where two bones connect with each other. A joint consists of many structures. In the simplest form, there are two bones separated from each other by a slight gap called the joint cavity. The end of each bone is covered with cartilage, a tough, elastic material.

The space between bones is covered with a thin membrane called the synovial (pronounced si-NO-vee-uhl) membrane. The synovial membrane secretes (releases) a thin fluid called synovial fluid. The synovial fluid acts like a lubricant in the joint, helping the bones move smoothly against each other.

Arthritis usually involves some form of damage to or destruction of joint parts. In the case of rheumatoid arthritis, the synovial membrane becomes inflamed. The membrane becomes thick and stiff. It is also attacked by white blood cells, which can damage or kill tissue in the joint.

In the case of osteoarthritis, cartilage begins to break down and wear away. It is no longer able to cushion the contact of bones with each other. One bone rubs directly on the other bone. It becomes very painful to move the joint.

Rheumatoid arthritis (RA) and osteoarthritis (OA) are both common disorders. They affect both men and women of all races and ethnic background. In the United States alone, about two million people are thought to have RA. Women are three times more likely to have the condition than men. About 80 percent of patients with RA are diagnosed between the ages of thirty-five and fifty. The condition appears to run in families.

OA is one of the most common causes of disability because of limited joint movement. The condition is much more common among older people than among younger people. Somewhere between 65 and 85 percent of Americans over the age of sixty-five have the condition. Some doctors believe that everyone over the age of sixty is affected to some extent by OA. By contrast, only about 2 percent of Americans under the age of forty-five have OA.

Arthritis: Words to Know

Autoimmune disorder:

A condition in which the body's immune system attacks some part of the body and treats it as if it were a foreign invader.

Cartilage:

Tough, elastic tissue that covers and protects the ends of bones.

Immune system:

A network of organs, tissues, cells, and chemicals that protects the body from foreign invaders, such as bacteria and viruses.

Joint:

A structure holding two or more bones together.

Synovial fluid:

A fluid produced by the synovial membranes in a joint that lubricates the movement of the bones in the joint.

Synovial membrane:

A thin tissue that covers the inside surface of a joint.

CAUSES

The causes of both rheumatoid arthritis and osteoarthritis are not known. At one time, doctors believed that OA was simply a part of growing old. They thought that the body's joints just wore out over time. Today, researchers are beginning to explore specific causes for both disorders.

Rheumatoid Arthritis

Current theories suggest that RA is caused by genetic factors. That is, a person is born with the tendency to develop or not develop the condition. Then something in the environment actually sets off the disorder itself. One theory is that an infectious agent, such as a bacterium or virus, initiates the onset (beginning) of RA.

Whatever the cause, RA is an autoimmune disorder. An autoimmune disorder is a condition in which the body's immune system begins to act abnormally. The immune system is a network of organs, tissues, cells, and chemicals whose job it is to protect the body from foreign invaders, like bacteria and viruses.

At times, the immune system may become confused. It may respond to some part of the body as if it were a foreign invader. It releases its whole arsenal of weapons against that part of the body. When the immune system acts against some part of the joint, RA occurs.

Osteoarthritis

Scientists recognize two forms of OA: primary and secondary osteoarthritis. Primary OA is caused by abnormal stresses on healthy joints or by normal stresses on weakened joints. The joints most commonly affected by primary OA include the finger joints, hips and knees, the lower joints of the spine, and the big toe.

There is some evidence that primary OA is caused by genetic factors. Obesity is often a contributing factor. The heavier a person is, the greater the pressure on his or her joints. Finally, some researchers believe that primary OA may be caused by bone disease, liver problems, or other abnormal conditions in the body.

DISEASE OF KINGS

Throughout history, gout has been called the "disease of kings." The reason for this name is that gout can be caused by the over consumption of rich foods. Today, we know that gout is caused by the accumulation of uric (pronounced YER-ik) acid crystals in a joint, most often the joint of the big toe.

Uric acid is produced in the body when proteins are broken down. Proteins are a class of chemicals with many important functions in the body. Uric acid is water soluble. It usually dissolves in urine and is then excreted from the body.

Some people, however, produce an unusually large amount of uric acid. Such a tendency is thought to be caused by genetic factors. When that happens, uric acid remains in the body, circulating through the bloodstream. Eventually, it is deposited as needle-like crystals in joints. These crystals cause friction when the joint is moved. The friction causes severe pain known as gout.

Secondary OA is caused by a chronic (long-term) or sudden injury to a joint. Some factors that may contribute to the development of OA include:

• Physical trauma (shock), including sports injuries
• Repetitive stress associated with certain occupations, such as construction, assembly line work, computer keyboard operation, and hair-cutting
• Repeated episodes of gout or other forms of arthritis
• Poor posture or bone alignment caused by abnormal body development

SYMPTOMS

All forms of arthritis share certain symptoms in common. These symptoms include pain, swelling, and stiffness in the joint. These symptoms may develop slowly over time or they may begin quite suddenly. After a period of time, joints may actually become deformed. Patients may find it difficult to straighten their fingers and toes, or their hands and feet may curve outward in an abnormal way. Eventually, a patient may lose the use of a joint entirely.

Patients with RA often report other symptoms also. These symptoms include increased fatigue, loss of appetite and weight loss, and, sometimes, fever. RA may also be accompanied by the development of rheumatoid nodules. Rheumatoid nodules are bumps that appear under the skin, in tissue covering the lungs and chest, or in the brain and spinal cord. These nodules can cause serious complications, including shortness of breath, poor blood circulation, gangrene (tissue decay), and damage to nerves.

DIAGNOSIS

Rheumatoid arthritis and osteoarthritis are usually both diagnosed based on a patient's history. This history typically includes an increasing occurrence of pain and stiffness in joints. The doctor can also examine the patient's affected joint for swelling, limitations on movement, pain, and a cracking sound that is sometimes heard with a damaged joint.

There are no blood tests that strongly confirm the presence of arthritis. Many tests that can be used for RA are also positive for other disorders. One test measures the amount of a chemical known as rheumatic factor in a patient's blood. Rheumatic factor is produced by the immune system when it attacks a joint. It is found in about 66 percent of patients with RA. But it is also found in 10 to 20 percent of healthy people over the age of sixty.

A good diagnosis for OA can sometimes be obtained from X rays or other imaging techniques. An X-ray photograph may show changes in the space between bones in a joint, indicating the presence of OA.

TREATMENT

The first line of treatment for most forms of arthritis is medication to reduce inflammation, swelling, and pain. Aspirin, acetaminophen (pronounced uh-see-tuh-MIN-uh-fuhn, trade name Tylenol), and ibuprofen (pronounced i-byoo-PRO-fuhn, trade names Advil, Motrin) are all effective in this regard. In fact, people with mild cases of arthritis can often control their condition satisfactorily simply with one of these drugs.

In more severe cases of arthritis, stronger medications may be required. The most common of these is one of the corticosteroids (pronounced KOR-ti-ko-steer-oids). The corticosteroids are very effective in the treatment of pain, swelling, and inflammation. However, they have some serious long-term side effects and should be used only when milder medications are not effective.

A variety of other medications have been used against arthritis also. These drugs include gold compounds, D-penicillamine (pronounced pen-i-SIL-uhmeen), and sulfasalazine (pronounced SULL-fuh-SAL-uh-zeen). Medications used to treat malaria can also be helpful. These drugs have potentially dangerous side effects and should be used with caution.

Rest and supportive devices may also be important in the treatment of arthritis. When the pain becomes too great, patients may be advised to take to their bed and stay there until they experience relief. They may also be provided with various protective measures, such as neck braces and collars, crutches, canes, hip braces, and knee supports.

Physical therapy can also be an important component of treatment programs. Physical therapists can teach patients how to exercise their affected joints. Exercise may reduce the rate at which the joints are worsening. It may increase the patient's balance, flexibility, and range of motion. Physical therapy can also consist of massage, moist hot packs, and soaking in a hot tub.

In the most severe cases, surgery may be required. Some surgical techniques that can be used include:

• Replacement of a damaged joint
• Fusion (joining together) of spinal bones
• Scraping or removing damaged bone from a joint
• Removal of a bone chip to allow realignment of a joint

Alternative Treatment

Some types of food intolerance may contribute to both RA and OA. Patients should try to find out the foods to which they are allergic and eliminate those foods from their diets. In general, nutritionists recommend a diet high in fiber and complex carbohydrates (starches) and low in fats and refined foods.

Some food supplements have been found to be effective in treating arthritis. One substance that is commonly recommended is a combination of glucosamine (pronounced gloo-KO-suh-meen) and chondroitin (pronounced kon-DRO-i-tin) sulfate. This product is thought to help repair cartilage. Other nutritional supplements that have been suggested include vitamins A, B, C, and E, and the minerals selenium and zinc.

Traditional Chinese medicine emphasizes the use of various herbs for the treatment of arthritis. These herbs include turmeric, ginger, feverfew, devil's claw, Chinese thoroughwax, licorice, lobelia, and cramp bark.

Naturopathic treatment may include hydrotherapy (water therapy), diathermy (deep-heat therapy), nutritional supplements, and various herbs.

PROGNOSIS

About 15 percent of patients with RA experience their symptoms for only a short period of time. The symptoms then disappear with no long-term effects. For other patients, however, the symptoms never disappear and become progressively worse over time. In general, patients with RA have a shorter lifespan by three to seven years than individuals without the disorder.

Osteoarthritis is a progressive disorder without a permanent cure. The rate of progression can sometimes be slowed. Factors that may help in reducing the disorder's progress include weight loss, exercise, surgical treatment, and some alternative therapies.

PREVENTION

There is no known way to prevent arthritis. The most that can be hoped for is to slow or prevent its progress.

FOR MORE INFORMATION

Books

Aaseng, Nathan. Autoimmune Diseases. New York: Franklin Watts, 1995.

Schlotzhauer, M. Living with Rheumatoid Arthritis. Baltimore: Johns Hopkins University Press, 1993.

Shenkman, John. Living with Arthritis. New York: Franklin Watts, 1990.

Theodosakis, Jason, et al. The Arthritis Cure. New York: St. Martin's Press, 1997.

Organizations

American College of Rheumatology. 60 Executive Park South, Suite 150, Atlanta, GA 30329. (404) 633–1870. http://www.rheumatology.org.

Arthritis Foundation. 1330 West Peachtree Street, Atlanta, GA 30309. (404) 872–7100. http://www.arthritis.org.

National Institute of Arthritis and Musculoskeletal and Skin Diseases. http://www.nih.gov/niams.

Web sites

"Arthritis." [Online] http://arthritis.miningco.com (accessed on June 20, 1999).

Arthritis

Resources

Arthritis is a term that refers to the inflammation of joints (the point where the ends of two bones meet each other). Approximately 45 million American adults and children have some form of the more than 100 different types of arthritis.

Inflammation is a reaction of the body to injury. Excess fluid is directed to the affected area, which produces swelling. The fluid is meant to aid the healing process and is temporary for many injuries. However, in arthritis, the constant or recurring inflammation causes tenderness and stiffness that is debilitating over long periods of time.

In a typical joint, the ends of the bones are covered with a smooth material called cartilage. The cartilage allows the bones to move smoothly against each other. A joint is also wrapped in a network called the synovium. Fluid within the synovium (synovial fluid) helps ease the friction of bones rubbing against each other. Finally, the joint is supported and movement is possible because of ligaments, muscles, and tendons

that attach to various regions of the joint. All of these components can be subject to arthritic inflammation.

The two most common types of arthritis are osteoarthritis and rheumatoid arthritis. Osteoarthritis is the gradual wearing away of the cartilage. This commonly occurs due to overuse of the joint or because of an injury such as a fracture. As such, osteoarthritis is associated more with adults than with children or youth.

In rheumatoid arthritis, the synovium surrounding a joint becomes inflamed. Also, the body’s own immune system begins to attack and destroy the surface of the joint. This “self against self” immune reaction is typical of autoimmune diseases or conditions like rheumatoid arthritis. Both adults and children are susceptible to rheumatoid arthritis.

Nonsteroidal anti-inflammatory agents (NSAIDs) are the first line of drug treatment for osteoarthritis, as well as other types of arthritis. NSAIDs include aspirin and medicines that are closely related to aspirin. Some NSAIDs are sold over-the-counter, but those having more potent dosages are sold only by prescription and have to be monitored carefully to avoid adverse side effects.

Though aspirin and the other NSAIDs all work the same way to suppress prostaglandin production in the body, there are major differences in the way individuals will respond to particular NSAIDs. Stomach bleeding and irritation of the gastrointestinal tract are the two major drawbacks of long-term aspirin and other NSAID therapy. The COX-2 inhibitors, a newer type of NSAIDs, reduce the production of an enzyme that stimulates the immune response, thereby

KEY TERMS

Anti-inflammatories— Drugs that counteract inflammation. Corticosteroids and non-steroidal anti-inflammatory agents (NSAIDs) that reduce inflammation are used in the treatment of arthritis.

Cartilage— The tissue that surrounds a joint and degenerates in osteoarthritis.

Synovial fluid— Thick, clear, and viscous fluid that is found in bone joints, and is used to identify different types of arthritic conditions.

relieving arthritic inflammation, without blocking the enzyme that protects the stomach lining, thereby reducing stomach irritation. Acetaminophen relieves pain without stomach irritation, but it is not an anti-inflammatory, nor does it reduce the swelling that accompanies arthritis.

A second line of drug treatment, involving corticosteroids, is often needed for treatment of rheumatoid arthritis and other forms of the disease. Corticosteroids are used to reduce inflammation. These drugs, such as cortisone, simulate hydrocortisone, a natural chemical produced in the adrenal cortex. The function of compounds like corticosteroids is to try to slow the disease down or make it go into remission. This is done by suppressing the immune response that is key to the damage caused by rheumatoid arthritis.

The length of treatment can range from several days to years. Taken either as a pill or through injection, dosages vary according to the type of arthritis and the needs of the individual. Corticosteroids are used for both osteoarthritis and rheumatoid arthritis. These medicines are injected into a specific site, such as a finger joint or the knee, for quick relief from pain and inflammation. In addition to blocking prostaglandin production, they also reduce the number of white blood cells that enter into the damaged area of the joint.

Because suppression of the immune system can leave someone vulnerable to other infections, and because steroid compounds can have unwanted side effects that are more severe than those produced by the NSAIDs, the use of corticosteroids and other similarly-acting compounds to treat arthritis must be monitored under a physician’s care.

As of 2006, research was underway to try to understand the basis of the autoimmune responses that are

important in the establishment and progression of rheumatoid arthritis. Preliminary evidence indicates that a bacterial or viral infection may be one trigger of the autoimmunity. Whether the affected individuals have some genetic predisposition that makes them more susceptible has not been determined.

See also Autoimmune disorders; Carpal tunnel syndrome; Physiology.

Resources

BOOKS

Lorig, Kate, and James F. Fries. The Arthritis Handbook: A Tested Self-Management Program for Coping with Arthritis and Fibromyalgia. Cambridge, MA: Da Capo Press, 2006.

McNeil, M. E.A. The First Year-Rheumatoid Arthritis: An Essential Guide for the Newly-Diagnosed. Washington, DC: Marlowe & Company, 2005.

Nelson, Miriam E., et al. Strong Women and Men Beat Arthritis. New York: Perigee Trade, 2003.

Bryan Hoyle

Arthritis

Arthritis is a term that refers to the inflammation of joints (the point where the ends of two bones meet each other). Upwards of 43 million American adults and children (1 out of every 6 citizens) have some form of the more than 100 different types of arthritis.

Inflammation is a reaction of the body to injury. Excess fluid is directed to the affected area, which produces swelling. The fluid is meant to aid the healing process, and is temporary for many injuries. However, in arthritis, the constant or recurring inflammation causes tenderness and stiffness that is debilitating over long periods of time.

In a typical joint, the ends of the bones are covered with a smooth material called cartilage. The cartilage allows the bones to move smoothly against each other. A joint is also wrapped in a network called the synovium. Fluid within the synovium (synovial fluid) helps ease the friction of bones rubbing against each other. Finally, the joint is supported and movement is possible because of ligaments, muscles, and tendons that attach to various regions of the joint. All of these components can be subject to arthritic inflammation.

The two most common types of arthritis are osteoarthritis and rheumatoid arthritis. Osteoarthritis is the gradual wearing away of the cartilage. This commonly occurs due to overuse of the joint, or because of an injury such as a fracture. As such, osteoarthritis is associated more with adults than with children or youth.

In rheumatoid arthritis, the synovium surrounding a joint becomes inflamed. Also, the bodies' own immune


system begins to attack and destroy the surface of the joint. This "self against self" immune reaction is typical of autoimmune diseases or conditions like rheumatoid arthritis. Both adults and children are susceptible to rheumatoid arthritis.

The first line of drug treatment for osteoarthritis, as well as other types of arthritis, is nonsteroidal anti-inflammatory agents (NSAIDs), including aspirin and medicines that are closely related to aspirin. Some NSAIDs are sold over-the-counter. But those having more potent dosages are sold only by prescription and have to be monitored carefully to avoid adverse side effects.

A second line of drug treatment involving corticosteroids is often needed for treatment of rheumatoid arthritis and other forms of the disease . Corticosteroids are used to reduce inflammation. These drugs, such as cortisone, simulate hydrocortisone, a natural chemical produced in the adrenal cortex. The function of compounds like corticosteroids is to try to slow the disease down or make it go into remission. This is done by suppressing the immune response that is key to the damage caused by rheumatoid arthritis.

The length of treatment can range from several days to years. Taken either as a pill or through injection, dosages vary according to the type of arthritis and the needs of the individual . Corticosteroids are used for both osteoarthritis and rheumatoid arthritis. These medicines are injected into a specific site, such as a finger joint or the knee, for quick relief from pain and inflammation. In addition to blocking prostaglandin production, they also reduce the amount of white blood cells that enter into the damaged area of the joint. Though aspirin and the other NSAIDs all work the same way to suppress prostaglandin production in the body, there are major differences in the way individuals will respond to particular NSAIDs.

Stomach bleeding and irritation of the gastrointestinal tract are the two major drawbacks of long-term aspirin and the other NSAID therapy. A newer form of NSAIDs called COX-2 inhibitors reduce the production of an enzyme that stimulates the immune response, thereby relieving arthritic inflammation, without blocking the enzyme that protects the stomach lining, thereby reducing stomach irritation. Acetaminophen relieves pain without stomach irritation, but it is not an anti-inflammatory, nor does it reduce the swelling that accompanies arthritis. Because suppression of the immune system can leave someone vulnerable to other infections, and because steroid compounds can have unwanted side effects that are more severe than those produced by the NSAIDs, the use of corticosteroids and other similarly-acting compounds to treat arthritis must be monitored under a physician's care.

See also Autoimmune disorders; Carpal tunnel syndrome; Physiology.

Resources

books

Mayo Foundation. Mayo Clinic on Arthritis Rochester, MN: Mayo Foundation for medical Education & Research, 1999.

Trien, S.F., and D.S. Pisetsky. The Duke University Medical Center Book of Arthritis. New York: Fawcett, 1995.

organizations

Arthritis Foundation. PO Box 7669, Atlanta, GA 30357-0669. (800) 283-7800. <http://www.arthritis.org>.

Bryan Hoyle

KEY TERMS

Anti-inflammatories

—Drugs that counteract inflammation. Corticosteroids and non-steroidal anti-inflammatory agents (NSAIDs) that reduce inflammation are used in the treatment of arthritis.

Cartilage

—The tissue that surrounds a joint and degenerates in osteoarthritis.

Synovial fluid

—Thick, clear, and viscous fluid that is found in bone joints, and is used to identify different types of arthritic conditions.