Arthritis
is so common that almost all of us know somebody who suffer
from this condition. As a hand therapist, several of my
friends and family seek me for advice on how to manage their
symptoms. Listening to their concerns, I realized that most
of them have misconceptions about arthritis. Some of them
assume a passive role in their medical treatments taking in
whatever medications are given to them without understanding
what they are for. Others assume an aggressive role trying
all sorts of different alternative treatments that they hope
will be a miracle cure. Their lack of understanding
regarding arthritis prevent them from truly taking control
of their symptoms.
I believe the first step to take, and probably the most
important one, is to invest the time to read and get as much
clinical information regarding the true nature of arthritis.
Only then can you make informed decisions regarding your
treatments. Making the right choice among the so many
medical and alternative treatments available out there
depends on your knowledge and understanding of the disease.
Let us begin to discuss some information on arthritis that I
believe every patient should understand.
There are more than 40
million Americans currently suffering from arthritis, 1
in every 6 individuals suffer from this disease. The
impact of arthritis is expected to increase dramatically
with the aging of the "baby boomers". By 2020, an
estimated 60 million Americans, almost 20% percent of
the population or 1 in every 5 individuals, will be
affected by arthritis. More than 11 million will be
disabled.
Arthritis is the number
one cause of disability in America. It limits 7.9
million Americans from doing their everyday tasks such
as dressing, cooking, or walking.
About 6 million Americans
are self-diagnosed. They believe they have arthritis,
but have not seen a physician.
Nearly 50% of people 65
years of age are affected by arthritis. Younger people
have a lower risk but it is interesting to note that
they still comprise half of all people affected by
arthritis. Nearly 3 of every 5 people with arthritis are
younger than 65 years old.
Nearly 300,000 children in
the US have arthritis.
Osteoarthritis is the most
prevalent type affecting nearly 21 million Americans,
most of whom develop the disease after age of 45. Before
age 45, more men have osteoarthritis than women, whereas
after age 45, it is more common in women.
Rheumatoid Arthritis, the
most crippling form of arthritis, affects approximately
2.1 million Americans. The average onset for rheumatoid
arthritis is between the ages of 20 and 45 years old.
Women are nearly twice as
likely as men to suffer from arthritis.
Gout, a type of arthritis
related to increased uric acid levels, tends to favor
men. Gout is twice as likely to strike African-American
men as Caucasian men, possibly because African-American
men are more likely to use medicines to lower blood
pressure. These drugs increase production of uric acid,
which can crystallize and settle painfully in joints.
Those who live in the city
are three times more likely to develop arthritis than
those who live in rural areas.
The lower your income, the
more likely you are to develop arthritis. According to
the arthritis foundation, 20.3 percent of those with
annual income of less than 10,000 had arthritis as
opposed to 13.4 percent of those who made 50,000 or
more.
The direct medical cost of
arthritis is at an estimated $15.2 billion a year, with
total costs of medical care and lost wages exceeding $64
billion.
Source: Centers for Disease Control (CDC), National
Institute of Arthritis and Musculo-skeletal and Skin
Diseases (NIAMSD), and the Arthritis Foundation.
Arthritis
literally means joint inflammation ("arthro" - joint and "itis"
- inflammation). It is frequently used as an umbrella
terminology referring to a group of so many forms of
rheumatic conditions that is characterized by pain,
stiffness, and inflammation of joints. Arthritis is
sometimes referred to as Rheumatism. There are more than a
100 different types of arthritis. Other types, such as
Rheumatoid Arthritis, affect other organ systems as well
aside from the more visible joint involvement. As such,
these types of Arthritis could be crippling and disruptive
to one's lifestyle. The destruction of the joint is the
hallmark of this disease. It may be caused by either an
inflammatory process, as seen in Rheumatoid Arthritis (RA),
or degenerative changes, as seen in Osteoarthritis (OA).
These can lead to deformities on the affected joints,
frequently seen on the hands and fingers. You should not
confuse a muscular or tendon pain (tendonitis) with joint
pain since their nature and treatment are entirely
different. Remember that the symptoms of arthritis appear
primarily on joints.
Out of
the so many types of Arthritis, let me focus on
Osteoarthritis (OA) and Rheumatoid Arthritis (RA), two of
the most common types which I often see in the clinic. One
should understand that the nature of OA and RA is different.
OA, also referred to as degenerative joint disease, is more
prevalent. It is characterized by the progressive damage of
cartilage or lining in between the joint surfaces. The
cartilage, which is suppose to act as a padding on joint
surfaces or "shock absorber" so to speak, breaks down. The
resulting bone on bone friction contact within the joint
causes formation of bone spurs which increases pain and
deformity. Knowing this it is easy to understand that the
joints more commonly affected by OA are your high stress,
weight bearing joints such as the hips, knees, spine and
back. It can also affect the smaller joints of your fingers
since they are exposed to shearing forces on daily grasping
and pinching tasks. OA was previously described as a wear
and tear phenomenon. Recent studies however, indicate a more
complex pathologic process -- that it is not just a function
of age or wear and tear. Some
researchers believe that there are some internal and
biochemical factors that cause the cartilage to break down
faster. However, by controlling the destructive forces
placed on affected joints during heavy resistive activities,
you can control the aggravation of OA symptoms.
RA on the
other hand is a bit more complicated. The part of the joint
that gets inflamed is a lining around the joint called the
synovial membrane. Just consider this as a lubricating sac
around the joint. For some unknown reason the synovial
membrane proliferates in an uncontrollable manner until it
starts eating away the joint. The resulting damage to joint
tissues causes deformities. RA is an autoimmune disease
where the body, in the attempt of repairing the affected
joint, does not recognize healthy joint tissues and actually
attacks or destroys them even more. There are so many
theories regarding the cause of RA. Researchers think that
inherited trait alone does not cause the illness. They think
that this trait when combined with some unknown factor,
either biological or environmental, unlocks the disease.
What exactly triggers this process of "self destruction" to
occur is yet to be clearly understood however. RA is
characterized by periods of remissions and exacerbations. It
is important for you to understand that if you have RA,
there will be times when the joint pain and inflammation are
active and severe (exacerbation) and other times when the
symptoms seem to have disappeared (remission). It is common
to confuse the remission stage as having been cured of
arthritis, particularly if it coincides with a particular
treatment. The goal you should have in mind is to have a
long remission period by taking your medications regularly
and using joint protection techniques consistently to your
daily activities in order to prevent a symptom flare-up.
Related Video:
How do I
know if I really have arthritis? The tell tale signs include
joint pain and inflammation. If the pain and swelling occurs
on your weight bearing joints such as the spine, hips or
knees or the last two joints on your fingers, you probably
have OA. You may see bumpy nodules developing on these
finger joints. It is also common to feel a grinding
sensation when you move the affected joint since the
cartilage or articular surfaces within the joint are damaged
or corroded. RA on the other hand occurs more frequently on
your wrists and knuckles, particularly of the index and
middle fingers. It is frequently bilateral, meaning, it
occurs on both hands. Patients with RA often describe
affected joints as red, hot, and swollen particularly during
its initial stage. Successive joints of the wrist and
fingers that subjected to prolonged inflammation tend to
assume a collapse or zigzag deformity pattern. Hand
deformities associated with RA are typically more deforming
than OA. Patients would also complain of easy fatigability
or low energy levels at times since RA affects not only the
joints but other organ systems as well.
Unfortunately these are quite difficult to determine
for the untrained individual, particularly if the symptoms
are subtle. I have seen so many patients who mistakenly
think they have arthritis because they feel muscular pain.
Self-diagnosis is oftentimes unreliable. For this reason you
should consult your doctor immediately if you experience
constant pain occurring on your joints. Do not wait until
the symptoms get worse. People have a tendency to
procrastinate on a doctors visit until they are in severe
pain. Do not wait until you have visible deformities on your
hands or fingers as these may indicate permanent joint
damage. Remember that the earlier arthritis is properly
diagnosed and treated, the more you can prevent joint damage
and deformities. Only a qualified physician can determine
what type of arthritis you may have by using diagnostic
procedures such as radiographic examination (X-ray) and
laboratory tests (blood test). This will help your doctor
identify what type of arthritis you have and determine the
most appropriate medication that can effectively control
your symptoms ahead of time. Time is of essence if you have
arthritis. Avoid seeking herbal or other alternative
treatments without getting the professional advice of your
doctor first. Do not get side tracked by focusing on
alternative treatments that have not been clinically proven
to be safe and effective.
Related
video:
Okay, you
have frequent pain on your joints and you suspect that you
have arthritis, where do you go? Will your doctor be able to
help you? Well it depends on the expertise of your doctor.
Not all of them are familiar with the latest treatment
trends in arthritis. There are so many new and promising
treatments that are available today and not all doctors are
familiar with them. My personal advice is to get a referral
to an arthritis specialist right away. This is just the way
I think -- if I had arthritis, I would like the best
qualified doctor to see me for my condition. Doctors who
specialize in arthritis are called rheumatologists. Talk to
your primary physician and get a referral to a
rheumatologist as early as possible. I have seen patients
get referred to hand therapy services for the first time
after years of having arthritis. They come in with severe
deformities on their hands already. They would ask me
questions that confirm their lack of understanding of the
disease even at this late stage. In a situation like this, I
can't help but ask myself, what were their primary
physicians thinking?, why only now?
A rheumatologist would know the importance of
prescribing the right medications and other treatments such
as occupational/hand therapy in a timely manner. The primary
aim is to find the right treatments that work for you,
before the symptoms get worse.
Of the more than 22
million Americans who have arthritis, 12 million are not
receiving medical treatment. The overwhelming majority of
those who do receive care are treated by primary physicians,
about 70 percent of whom have had little or no special
training in arthritis and have little knowledge of the
treatment and rehabilitation techniques available.
Rheumatologists, specialists in the field of arthritis,
treat only about 3 percent of those who do receive medical
care.
Source: US National Commission on Arthritis and Related
Musculoskeletal Diseases.
I also
encourage you to take an active role during a doctor's
visit. Ask your doctor questions that will help you
understand your condition. Questions like, "What type of
arthritis do I have?", "What are the latest medications
available and how do they work?", "What are the implications
of arthritis on my daily life?" A qualified doctor will be
able to answer these questions confidently. A good doctor
will take the time during the first visit, to explain to you
what arthritis is all about. He knows that the earlier you
understand the disease, the more you can take an active role
in controlling the symptoms. If your family physician or
internist is unable to do this and seems puzzled by your
symptoms, consult a rheumatologist right away.
What is
occupational/hand therapy? Do I need it? The answer is short
and simple, yes you do. On your first doctors visit, if you
are diagnosed to have arthritis, get a referral to an
occupational therapist (OT)/certified hand therapist (CHT)
right away. OTs who specialize in hand rehabilitation are
CHTs. Try to get a therapist with an OT/CHT designation.
Good doctors are aware of the advantages of having therapy
as early as possible. OTs are the experts in knowing how
diseases affect your function in your daily activities.
While doctors focus on finding the right combination of
medications that can control your arthritic symptoms, OTs
make sure you understand the nature of the disease and its
effect on your daily life. Managing your symptoms does not
stop after taking your medications. By having occupational
therapy you will learn how to apply practical, day to day
symptom management techniques that help improve your hand
function and prevent aggravation of joint pain and
deformities. Examples of these techniques include joint
protection, energy conservation, and use of assistive
devices.
Not all exercises are good for arthritis. OT-CHTs are
hand rehabilitation experts who can teach you the right
exercises to improve joint flexibility and functional
strength without aggravating your symptoms. They can
fabricate hand positioning splints that help decrease joint
pain, soft tissue swelling and prevent progression of
deformities. Occupational therapy will empower you to take
an active role in controlling your arthritis so that you can
continue to enjoy your life once again.
It is
important for you to understand the difference between the
terms "treatment" and "cure" when considering medications
for arthritis. These terms are frequently misused by
patients, creating false expectations. A cure is a complete
correction of the root cause of a disease so that the
disease entity is completely eradicated from your system.
Treatments on the other hand are aimed at controlling or
minimizing symptoms associated with the disease. The disease
entity may still exist within your system however.
Presently, medications for arthritis are used as treatments
for this disease. They are used to control or minimize the
symptoms of joint pain and swelling. There is no medication
that can cure arthritis as of the present time. It is
important for you to understand this early on so that you
can have realistic expectations from medications you are
taking. Do not give up on a medication right away. Some
medications take a certain time to work. The effects can be
achieved anywhere from 30 minutes to three months, or more,
depending on the type of medication you are taking. However,
do not take a passive role on your daily management of
arthritis either because you are expecting a miracle cure
from your latest medication. You should be consistently
applying other symptom management techniques, such as joint
protection and use of assistive devices, that help control
your symptoms on the long run.
The lack of a cure for arthritis at this time should
not discourage you however. Arthritis research is
progressing at an unprecedented rate. Recent advances in the
field of science and medicine may allow experts to develop a
"cure" in the not so distant future. In fact innovative
treatments are currently being considered at the more
progressive medical centers. What does this mean to you who
are suffering from arthritis right now? Your goal is to
prevent progression of pain and joint swelling, so that if a
scientific breakthrough occurs, you have minimized permanent
joint damage and deformities and have successfully preserved
the function in your joints. You have to take medications
that have been prescribed to you by your rheumatologist
regularly and use joint protection techniques consistently
to avoid the deforming forces of daily hand use. By doing
this you are preventing progression of your arthritic
symptoms.
It is important that a qualified rheumatologist
determine which combination of medication and dosages are
best suited for your condition. The arthritis foundation
publishes an arthritis drug guide annually which is an
excellent reference for someone who wants to be familiar
with the latest arthritis medications. It can help you
formulate questions or queries that you can ask your doctor
to better understand the medication aspects of your
treatment. Following is a summary of medications that are
presently used for arthritis:
Nonsteroidal Anti-inflammatory Drugs - (NSAIDS)
These drugs are widely used to control arthritic pain
and inflammation. There are 20 traditional NSAIDS that are
available. Three of those are available over the counter.
Others require a doctor's prescription. Examples of NSAIDS
are ibuprofen and aspirin. All NSAIDS, even over the counter
brands, may have certain side effects. Traditional NSAIDS
when taken regularly and at high dosages can cause
gastrointestinal bleeding or ulcers. A new type of NSAID,
known as COX-2 inhibitors, help suppress joint inflammation
and pain with less stomach irritation. Examples of COX-2
inhibitors are Celebrex (celecoxib) and Vioxx (refecoxib).
With the sudden withdrawal of Vioxx from the market last
September 2004, the Food and Drugs Administration issued a
warning that all NSAIDS, including COX-2 inhibitors, may
cause an increased risk of serious blood clots, heart
attacks and stroke, which can be fatal. This risk may
increase with dose and duration of use. Patients with
cardiovascular disease or risk factors for cardiovascular
disease may be at greater risk. There are concerns however
that for many patients, the benefits of the drugs in terms
or reducing arthritis symptoms and improving their quality
of life, far outweigh the cardiovascular risks. It is always
best to consult with your rheumatologist when considering
these medications.
Analgesics
These drugs are mainly used to control pain. Unlike
NSAIDS, analgesics don't relieve inflammation. Analgesics
are the appropriate and possibly safer choice for people
whose arthritis causes pain but not inflammation. The most
commonly used analgesic is acetaminophen and is available
under a variety of brand names including Tylenol and
Excedrin. Studies in recent years suggest acetaminophen
relieves arthritis pain as effectively as NSAIDS. The
American College of Rheumatology recommends acetaminophen as
a first line option for osteoarthritis pain because of its
effectivity, safety, and low cost. In some cases, an NSAID
and analgesic combination may relieve pain better than
either alone.
Disease Modifying Anti-rheumatic
Drugs (DMARDS)
Certain types of arthritis, like rheumatoid arthritis
(RA), are considered autoimmune diseases. This means that
during prolonged inflammation, the body's autoimmune or
defense system doesn't recognize healthy joint tissues and
attacks them as if they were the foreign, invading tissues.
DMARDS are strong medicines that work by suppressing the
immune system to stop this process of "self-destruction".
Unlike NSAIDS and analgesics which do little to alter the
course of the disease. DMARDS such as gold sodium thionalate
and methotrexate, reduce inflammation and in many cases slow
down the course of the disease. Although DMARDS are usually
quite effective, they can take time to show results. Most
doctors recommend using them early, particularly on
progressive, inflammatory types of arthritis, to
aggressively prevent the damage that can result from severe
joint swelling. Because it can take months before you notice
any effects, doctors frequently prescribe an additional drug
- such as a corticosteroid or NSAID - to help control pain
and inflammation while the DMARD starts to work. DMARDS are
most commonly used in in RA, juvenile RA, ankylosing
spondylitis, psoriatic arthritis, and lupus.
Biologic Response Modifiers (BRM)
These drugs reduce damage to the joint structures by
inhibiting inflammatory components in the immune system
called Cytokines. The first two agents to receive FDA
approval for RA, etanercept (Enbrel) and infliximab (Remicade),
suppress a cytokine called tumor necrosis factor (TNF).
Elevated levels of TNF are found in the synovial fluid of RA
patients. They are believed to play a role in joint
inflammation and damage. These drugs must be infused or
injected. These drugs often work for people in whom other
drug therapies have failed. Studies showed that two-thirds of
people with RA respond favorably - some dramatically - to a
BRM. In many cases, BRMs are used together with a standard
DMARD, such as methotrexate.
Corticosteriods
Steriods are known for their fast-acting
anti-inflammatory effects. As such they are widely used for
a broad range of conditions involving inflammation. Despite
the drug's dramatic benefits they are known to have adverse
side effects -- muscle atrophy (wasting), brittle bones,
cataracts, elevated blood sugar and mood swings --
particularly if taken at high doses over a long period of
time. Some doctors avoid the systemic effect of steroids by
injecting them directly on the involved joints if there are
only a few of them. Cortisone, dexamethasone, and
hydrocortisone are examples of corticosteroids.
Source: Arthritis Foundation, 2008 Drug Guide.
Related Video:
Symptom
management does not stop after taking your medications.
There are things that you can do on a daily basis to prevent
your symptoms from getting worse. I can't help but emphasize
the importance of using joint protection techniques to your
daily tasks. Proper use of hands particularly for those with
beginning, visible deformities, is very important. One thing
you should remember is that painful, swollen joints are weak
and unstable. You have to prevent placing excessive force on
affected joints to prevent further damage. Unfortunately our
daily grasping activities, whether you are doing self-care,
housekeeping, or work related tasks, involve directional
forces that are deforming to our wrist and finger joints.
For example, holding a kitchen knife to cut food would
require bending your wrist and four fingers down to the side
which further increases what is called Ulnar Drift, a
typical arthritic deformity. Prolonged heavy tip to tip
pinching increases zigzag deformities common to the
rheumatoid thumb.
The use of joint protection techniques prevent the
deforming forces of daily hand use from further damaging
your wrist and finger joints. There are alternate ways of
using your hands to daily tasks that allow you to avoid
placing excessive load on arthritic joints. Joint protection
techniques help improve the function of the arthritic hand
and reduce symptom flare-ups on affected joints at the same
time. Theses include techniques for hand positioning and use
of assistive devices for everyday tasks which eliminate
directional forces that can make your arthritic deformities
worse. Remember that these deformities are progressive in
nature. Your conscientious and combined use of effective
medications for control of inflammation and joint protection
techniques to minimize stress and deforming forces on your
hands, are important in preventing aggravation of joint pain
and deformities.
Other types of arthritis such as rheumatoid arthritis
or systemic lupus erythematous affect other organs systems
as well aside from the more visible joint involvement.
Several of my patients would report times of easy
fatigability. One of them said, "I tried cleaning my
bathroom one afternoon and I was wiped out for several
days." Energy conservation techniques allow you to maintain
a level of function without triggering over fatigue. Having
systemic arthritis does not mean that you should avoid your
daily activities. In fact movement through function is the
best for arthritis. However, you need to be aware that the
balance of work and rest is important in preventing
flare-ups.
I have devoted a page on joint protection and energy
conservation techniques because of their importance to long
term symptom management.
Understanding the truth about arthritis leads to informed
decisions when managing your symptoms. Probably one of the
most pressing concerns of patients suffering from arthritis
is having the associated hand deformities. These deformities
have a tendency to progress in time and having them can be a
devastating experience. You need to be aware of the
deformity patterns involved in arthritis to effectively
identify and control daily activities which have a tendency
to make them worse.>>next page
