Understanding Arthritis
“AT NIGHT, I LOOK AT MY DEFORMED FEET AND HANDS AND I CRY.”—MIDORI, JAPAN.
ARTHRITIS has plagued humans for centuries. Egyptian mummies give evidence that the disease existed centuries ago. Explorer Christopher Columbus evidently suffered from it. And millions today are afflicted. Just what is this crippling disease?
The word “arthritis” is taken from Greek words meaning “inflamed joints” and is associated with a group of well over 100 rheumatic diseases and conditions. * These diseases may affect not only the joints but also the muscles, bones, tendons, and ligaments that support them. Some forms of arthritis can damage your skin, internal organs, and even your eyes. Let us focus on two diseases commonly associated with arthritis—rheumatoid arthritis (RA) and osteoarthritis (OA).
Joint Architecture
In the case of rheumatoid arthritis (RA), the body’s immune system launches an all-out attack on its joints. For some unknown reason, a large volume of blood cells—including T cells, which are key players in the body’s immune system—rushes into joint cavities. This triggers a cascade of chemical events that result in the joint becoming inflamed. The synovial cells may begin to proliferate uncontrollably, forming a tumorlike mass of tissue called a pannus. The pannus, in turn, produces destructive enzymes that destroy the cartilage. Bone surfaces may now stick together, causing restricted motion—and excruciating pain. This destructive process also weakens the ligaments, the tendons, and the muscles, causing the joint to become unstable and partially dislocated, oftentimes leaving a deformed appearance. Usually RA affects joints in a symmetrical pattern, afflicting the wrists, knees, and feet. Upwards of 50 percent of individuals diagnosed with RA also develop nodules or bumps under the skin. Some develop anemia and dry, painful eyes and throat. Fatigue and flulike symptoms, including fever and aching muscles, accompany RA.
RA is highly variable in effect, onset, and duration. In one person the pain and stiffness may come on slowly over a period of weeks and even years. For another, the onset may be quite sudden. For some people, RA lasts for a few months and then leaves without noticeable damage. Others may experience periods of worsening symptoms called flares, followed by periods of remission during which they feel better. And in some patients the disease continues active for many years, relentlessly disabling them.
Who are at risk for RA? “It’s most common in women in their middle years,” notes Dr. Michael Schiff. However, Schiff further states that “it can affect anyone at any age including children, as well as men.” For those with relatives who have rheumatoid arthritis, the risk increases. Several studies further suggest that smoking, obesity, and a history of blood transfusion are all significant risk factors.
Osteoarthritis
“Osteoarthritis,” states the Western Journal of Medicine, “is in many ways like the weather—ubiquitous, often unnoticed, sometimes dramatic in its effects.” Unlike RA, osteoarthritis (OA) rarely spreads to other body parts but concentrates its erosive influence in one or just a few joints. As cartilage is slowly eroded, bone begins grinding against bone. This is accompanied by bony outgrowths called osteophytes. Cysts may form, and the underlying bone thickens and becomes deformed. Other symptoms include knobby knuckles, grating and grinding sounds that emanate from arthritic joints, and muscle spasms, along with pain, stiffness, and loss of mobility.
In times past, OA was thought to be just another consequence of old age. However, experts have abandoned that long-held belief. The American Journal of Medicine states: “There is no evidence that a normal joint, subject to common stresses, will break down over the life of a person.” Then what causes osteoarthritis? Efforts to understand its exact cause are “plagued by controversy,” according to the British magazine The Lancet. Some investigators propose that damage to a bone, such as microfractures, may occur first. This, in turn, may trigger bony outgrowths and cartilage deterioration. Others think that OA starts in the cartilage itself. As it degenerates and frays, they reason, stress increases on the underlying bone. Pathological changes occur as the body attempts to repair the damaged cartilage.
Who are at risk for OA? While age alone does not cause OA, the loss of joint cartilage is experienced more frequently with increasing age. Others at risk may include those who have some abnormality in the way their joint surfaces fit together or who have weak leg and thigh muscles, legs of unequal length, or a misalignment of the spine. Trauma to a joint caused either by an accident or by an occupation in which repetitive motions overuse a joint can also set the stage for osteoarthritis. Once deterioration begins, being overweight can exacerbate OA.
Dr. Tim Spector states: “Osteoarthritis is a complex disease that has definite environmental risk factors but there is also a strong genetic component.” Particularly susceptible to OA are middle-aged and older women with a family history of the disease. Unlike the disease osteoporosis, high rather than low bone density precedes the occurrence of OA. Some researchers also cite damage from free oxygen radicals and a deficiency of vitamins C and D as factors.
Treatment
Treatment for arthritis usually involves a combination of medication, exercise, and life-style modification. A physical therapist may initiate a therapeutic exercise program. It may incorporate range-of-motion, isometric, aerobic, and isotonic or weight-bearing exercises. These have been shown to improve a multitude of symptoms including joint pain and swelling, fatigue, malaise, and depression. The benefits of exercise are seen even in the very elderly. Exercise can also limit bone-density loss. Some claim that a measure of pain relief has also been achieved through various forms of heat and cold therapy and acupuncture.
Because weight loss can significantly reduce joint pain, diet can be a major component of arthritis management. Some have also claimed that a diet that includes calcium-rich foods such as dark, leafy green vegetables, fresh fruits, and cold-water fish rich in omega-3 fatty acids—and that cuts down on processed foods and saturated fats—can not only help achieve weight loss but also reduce pain. How? Some say that such a diet inhibits the inflammatory process. There are also claims that diets that eliminate meat, milk products, wheat, and vegetables belonging to the nightshade family, such as tomatoes, potatoes, peppers, and eggplant, have also been effective for some.
In some cases a surgical procedure called arthroscopy is recommended. This involves inserting an instrument right into a joint, allowing a surgeon to remove the synovial tissue producing the destructive enzymes. This procedure has limited effectiveness, however, as inflammation often recurs. Even more drastic a procedure is joint arthroplasty, in which the entire joint (usually a hip or a knee) is replaced with an artificial one. This surgery has a longevity of 10 to 15 years and is often highly effective in eliminating pain.
More recently, doctors have tried less invasive treatments, such as viscosupplementation, where hyaluronic fluid is injected directly into a joint. This is most commonly performed on the knees. Injecting substances that stimulate cartilage repair (chondroprotective agents) has also had a measure of success, according to some European studies.
While no drug has been found to cure arthritis, many drugs reduce pain and inflammation, and some have shown promise in slowing the progression of the disease. Analgesics, or painkillers, as well as corticosteroid therapy, nonsteroid anti-inflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs (DMARDs), immunosuppressants, biologic response modifiers, and drugs genetically engineered to interfere with the immune response are all part of the arsenal being used to provide relief from the debilitating symptoms of arthritis. However, relief may come at a high price, as all of these types of drugs can cause serious side effects. Weighing the potential benefits and risks presents a challenge for both the patient and the doctor.
How have some who have suffered the ravages of arthritis been able to cope with this painful disease?
ALTERNATIVE THERAPIES
Some therapeutic agents are thought to be safer, with fewer side effects, than traditional treatments. Among these are oral type II collagen, which some researchers claim has had success in reducing swollen joints and pain in rheumatoid arthritis (RA). How? By inhibiting proinflammatory and destructive cytokines, namely interleukin-1 and tumor necrosis factor α. A few natural nutrients have also reportedly shown some ability to inhibit these same destructive elements. They include vitamin E, vitamin C, niacinamide, fish oils that are high in eicosapentaenoic acid and gammalinolenic acid, borage seed oil, and oil of evening primrose. In China, Tripterygium wilfordii Hook F, an herbal remedy, has been used for years. Reportedly, it has had a measure of success in reducing the effects of RA.
BURSA
MUSCLE
CARTILAGE
TENDON
JOINT CAPSULE
SYNOVIAL MEMBRANE
SYNOVIAL FLUID
BONE
RHEUMATOID ARTHRITIS JOINT
LOSS OF SPACE
BONE AND CARTILAGE DESTRUCTION
INFLAMED SYNOVIAL MEMBRANE
OSTEOARTHRITIS JOINT
LOOSE CARTILAGE PARTICLES
CARTILAGE DESTRUCTION
BONE SPUR
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