Understanding Arthritis Training 1
Learning Objectives At the end of this training the learner will: Be able to define Arthritis Describe the symptoms of Arthritis Understand the impact of Arthritis Know the types of Arthritis Understand the treatment options for Arthritis Table of Content History of Arthritis Quick Stats on Arthritis Common Types of Arthritis What Causes Inflammation and What Are Its Effects? What Diseases Are Associated With Inflammation? How Are Inflammatory Diseases Diagnosed? Can Inflammation Affect Internal Organs? How Are Inflammatory Joint Diseases Treated? What Drugs Are Used to Treat Inflammatory Diseases? Exercise and Therapy Surgery Long-Term Management Resources References 2
Arthritis literally means "inflammation of a joint.. Arthritis is a condition that causes inflammation of the joints and can affect anyone from young children to seniors. It is typically characterized by joint pain and stiffness that make movement painful and difficult. History of Arthritis Before the 1600 s the disease was rare. It then spread across the Atlantic during the Age of Exploration. In 1859 the disease acquired its current name. The first recognized description of rheumatoid arthritis was in 1800 by the French physician Dr Augustin Jacob Landré-Beauvais (1772-1840) who was based in the famed Salpêtrière Hospital in Paris. The name "rheumatoid arthritis" itself was coined in 1859 by British rheumatologist Dr Alfred Baring Garrod. One of the most important publications on arthritis was by William Musgrave called the De Arthritide Symptomatica in 1715. It is the earliest known text describing in detail the symptoms of RA. Source: Medicine News, 2013 Prevalence Quick Stats on Arthritis 52.5 million Adults in the United States have doctor-diagnosed arthritis (just over 1 in 5 adults). Arthritis affects all race and ethnic groups: 36 million whites, 4.6 million blacks, 2.9 million Hispanics, 280,000 American Indians/Alaska Natives, 667,000 Asian/Pacific Islanders, and 469,000 multiracial/others. The risk of arthritis increases with age and is more common among women than men. In all U.S. states, 1 in 20 working-age adults (18-64 years old) face work limitations they attribute to arthritis; among those with arthritis, 1 in 3 have work limitations. 3
An estimated 294,000 children under age 18 have some form of arthritis or rheumatic condition; this represents approximately 1 in every 250 children. Impact Arthritis is the most common cause of disability in the United States. The number of US adults reporting a disability is increasing A CDC study shows that 47.5 million US adults (21.8%) reported a disability in 2005, an increase of 3.4 million from 1999. Arthritis or rheumatism (8.6 million) continues to be the most common cause of disability, while back or spine problems (7.6 million) and heart trouble (3.0 million) round out the top three causes. 22.7 million U.S. adults have arthritis-attributable activity limitations. 8.2 million working-age (18-64 years) U.S. adults (about 1 in 20) report work limitations due to arthritis or joint symptoms. Blacks and Hispanics with arthritis have almost twice the prevalence of work limitation and severe pain compared to Whites. Comorbidity A third of obese adults have arthritis. A CDC study shows that arthritis may be an unrecognized barrier for obese adults attempting to manage their condition through physical activity. Adults with obesity and arthritis were 44% more likely to be physically inactive compared with obese adults without arthritis. More than half of adults with heart disease have arthritis. A CDC study shows that arthritis may be an unrecognized barrier for adults with heart disease attempting to manage their condition through physical activity; 29% of people with both conditions are physically inactive compared to 21% with heart disease alone. More than half of adults with diagnosed diabetes also have arthritis. A recent study found that 30% of adults with arthritis and diabetes were physically inactive, compared with 21% of people with diabetes alone. Among people with diabetes, the high frequency of arthritis appears to be an under recognized barrier to increasing physical activity, a recommended diabetes intervention. Engaging in joint friendly activities; 4
such as, walking, swimming, biking, and participating in available arthritis-specific exercise interventions can help manage both conditions. Lifetime risk of symptomatic osteoarthritis Nearly 1 in 2 people may develop symptomatic knee OA by age 85 years. Two in three people who are obese may develop symptomatic knee OA in their lifetime. 1 in 4 people may develop painful hip arthritis in their lifetime. Source: Center for Disease Control 5
Common Types of Arthritis Arthritis can be broken down into three main categories. Here are some of the most common types: Osteoarthritis (OA). Also called degenerative joint disease, this is the most frequently diagnosed form of arthritis. Osteoarthritis occurs when the cartilage inside a joint disintegrates. This form of arthritis most commonly affects the knees, hips, low back, neck, and hands, and most often occurs after the age of 40. Rheumatoid arthritis (RA). This type of arthritis occurs when the lining inside joints becomes inflamed and irritated, causing joint damage and pain. It most often occurs in small joints in the wrists, fingers, and hands. 6
RA is an autoimmune disease that usually strikes between the ages of 30 and 50. Women are most often affected, though children may also develop RA. Juvenile arthritis (JA). This includes any type of arthritis that strikes children younger than age 18. What causes arthritis to develop at such an early age is unknown, but it occurs more often in girls than boys. JA typically strikes the ankles, knees, and wrists, and may also affect the hips, neck, jaw, and shoulders. There are many types of juvenile arthritis, the most common being juvenile rheumatoid arthritis, or JRA. There are three specific forms or juvenile rheumatoid arthritis: polyarticular (many joints) JRA, pauciarticular (four or fewer joints), and systemic onset (affecting the whole body). What Causes Inflammation and What Are Its Effects? 7
Inflammation occurs when chemicals from the body's white blood cells are released into the blood or affected tissues to protect your body from foreign substances. This release of chemicals increases the blood flow to the area of injury or infection, and may result in redness and warmth. Some of the chemicals cause a leak of fluid into the tissues, resulting in swelling. This protective process may stimulate nerves and cause pain. The increased number of cells and inflammatory substances within the joint cause irritation, swelling of the joint lining and eventual wearing down of cartilage (cushions at the end of bones). What Diseases Are Associated With Inflammation? 8
Some, but not all, types of arthritis are the results of misdirected inflammation. Arthritis is a general term that describes inflammation in the joints. Some types of arthritis associated with inflammation include the following Rheumatoid arthritis Psoriatic arthritis Gouty arthritis Other painful conditions of the joints and musculoskeletal system that may not be associated with inflammation include osteoarthritis, fibromyalgia, muscular low back pain, and muscular neck pain. What Are the Symptoms of Inflammation? Inflammation is characterized by: Redness Swollen joint that's warm to the touch Joint pain Joint stiffness Loss of joint function Often, only a few of these symptoms are present. Inflammation may also be associated with general "flu-like" symptoms including: Fever Chills Fatigue/loss of energy Headaches Loss of appetite Muscle stiffness 9
How Are Inflammatory Diseases Diagnosed? Inflammatory diseases are diagnosed after careful evaluation of the following: Complete medical history and physical exam with attention to the location of painful joints Presence of joint stiffness in the morning Evaluation of accompanying symptoms and signs Results of X-rays and laboratory tests Can Inflammation Affect Internal Organs? Inflammation can affect organs as part of an autoimmune disorder. The type of symptoms experienced depends on which organs are affected. For example: Inflammation of the heart (myocarditis) may cause shortness of breath or fluid retention. Inflammation of the small tubes that transport air to the lungs may cause an shortness of breath. Inflammation of the kidneys (nephritis) may cause high blood pressure or kidney failure. Pain may not be a primary symptom of an inflammatory disease, because many organs do not have pain-sensitive nerves. Treatment of organ inflammation is directed at the cause of inflammation whenever possible. How Are Inflammatory Joint Diseases Treated? 10
There are a number of treatment options for inflammatory diseases including medications, rest, exercise, and surgery to correct joint damage. The type of treatment prescribed will depend on several factors, including the type of disease, the person's age, type of medications he or she is taking, overall health, medical history, and severity of symptoms. The goals of treatment are the following: Correct, control, or slow down the underlying disease process Avoid or modify activities that aggravate pain Relieve pain through pain medications and anti-inflammatory drugs Maintain joint movement and muscle strength through physical therapy Decrease stress on the joints by using braces, splints, or canes as needed What Drugs Are Used to Treat Inflammatory Diseases? There are many drugs available to decrease joint pain, swelling and inflammation, and possibly prevent or minimize the progression of the inflammatory disease. The medications include the following: Nonsteroidal anti-inflammatory drugs (NSAIDs, such as aspirin, ibuprofen or naproxen) Corticosteroids (such as prednisone) Antimalarial medications (such as hydroxychloroquine) Other oral drugs, including methotrexate, sulfasalazine, leflunomide, azathioprine, penicillamine, cyclophosphamide, and apremilast Biologic drugs such as infliximab, etanercept, adalimumab, certolizumab, golimumab, abatacept, tocilizumab, and rituximab Some of these medications are traditionally used to treat other conditions such as cancer or inflammatory bowel disease, or to reduce the risk of rejection of a transplanted organ. However, when "chemotherapy" drugs (such as methotrexate or cyclophosphamide) are used to treat inflammatory diseases, the doses are significantly lower and the risks of side effects tend to be less than when prescribed in higher doses for cancer treatment. Patients with those prescribed any medication, are advised to meet with their doctor regularly so he or she can detect the development of any side effects. Exercise and Therapy 11
Canes, crutches, walkers, or splints may help relieve the stress and strain on arthritic joints. Learning methods of performing daily activities that are the less stressful to painful joints also may be helpful. Certain exercises and physical therapy may be used to decrease stiffness and to strengthen the weakened muscles around the joint. Surgery In general, an orthopedic surgeon will perform surgery for arthritis when other methods of nonsurgical treatment have failed to relieve pain and other symptoms. When deciding on the type of surgery, the physician and patient will take into account the type of arthritis, its severity, and the patient's physical condition. There are a number of surgical procedures. These include: Removing the diseased or damaged joint lining Realignment of the joints Fusing the ends of the bones in the joint together, to prevent joint motion and relieve joint pain Replacing the entire joint (total joint replacement) Long-Term Management 12
In most cases, persons with arthritis can continue to perform normal activities of daily living. Exercise programs, anti-inflammatory drugs, and weight reduction for obese persons are common measures to reduce pain, stiffness, and improve function. In persons with severe cases of arthritis, orthopedic surgery can often provide dramatic pain relief and restore lost joint function. Some types of arthritis, such as rheumatoid arthritis, are often treated by a team of health care professionals. These professionals may include rheumatologists, physical and occupational therapists, social workers, rehabilitation specialists, and orthopedic surgeons. 13
Arthritis Resources American Academy of Orthopaedic Surgeons (AAOS) http://www.aaos.org/ AAOS provides education and practice management services for orthopedic surgeons and allied health professionals. The academy also serves as an advocate for improved patient care and informs the public about the science of orthopedics. American College of Rheumatology (ACR) http://www.rheumatology.org/ ACR is the professional organization of rheumatologists and associated health professionals who share a dedication to healing, preventing disability, and curing the more than 100 types of arthritis and related disabling and sometimes fatal disorders of the joints, muscles, and bones. American Pain Foundation (APF) http://www.painfoundation.org The American Pain Foundation is a nonprofit information resource and patient advocacy organization serving people with pain. Its mission is to improve the quality of life of people with pain by providing practical information for patients, raising public awareness and understanding of pain, and advocating against barriers to effective treatment. Arthritis Foundation http://www.arthritis.org The mission of the Arthritis Foundation is to improve lives through leadership in the prevention, control, and cure of arthritis and related diseases. The foundation provides grants to researchers to help find a cure, prevention, or better treatment for arthritis. It also provides a large number of communitybased services nationwide to make life with arthritis easier. Association of Rheumatology Health Professionals (ARHP) http://www.rheumatology.org/arhp/index.asp Members of the ARHP are non-physician healthcare professionals specializing in rheumatology. The ARHP a division of the American College of Rheumatology includes nurses, occupational therapists, physical therapists, psychologists, social workers, and other healthcare professionals. Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion 14
http://www.cdc.gov/arthritis/ In the Arthritis: The Nation's Leading Cause of Disability section, the CDC discusses the prevalence of arthritis and presents a comprehensive public health approach to reducing the burden of this disease in the United States. Hospital for Special Surgery http://www.hss.edu/ The Hospital for Special Surgery is one of the premier hospitals for orthopaedics, rheumatology, and rehabilitation in the United States. Johns Hopkins Arthritis Center http://www.hopkins-arthritis.org/ The Johns Hopkins Arthritis Center provides a high-quality, interactive, educational program for healthcare professionals about diseases that cause arthritis and their treatments. This Web site focuses primarily on rheumatoid arthritis and osteoarthritis since these diseases serve as prototypes for inflammatory and degenerative joint diseases, respectively. National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) http://www.nih.gov/niams/ NIAMS leads the federal government's research effort into the causes, treatment, and prevention of arthritis and musculoskeletal and skin diseases; the training of basic and clinical scientists to carry out this research; and the dissemination of information on research progress to improve public health. References 15
The Arthritis Foundation, Association of State and Territorial Health Officials, Centers for Disease Control and Prevention (1999). National Arthritis Action Plan: A Public Health Strategy. Accessed at http://www.cdc.gov/nccdphp/pdf/naap.pdf. U.S. Department of Health and Human Services. Physical Activity and Health: A Report ofthe Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996. Marieb, E. N. (1998). Human Anatomy & Physiology 4th edition. Menlo Park, CA: Addison Wesley Longman Inc. American College of Rheumatology. Guidelines for the management of rheumatoid arthritis: 2002 Update. Arthritis and rheumatism. 2002 Feb; 46(2):328-46 16