The most-common type of arthritis

Published 10:30 pm Friday, May 18, 2018

Arthritis is typically used to mean joint pain associated with inflammation, stiffness, pain, reduced or lost function, and often, deformity. There are more than 100 different types of arthritis in humans. In fact, if there are currently 326 million people living in America, there are more than 90 million with some form of the disease.

By far the most common forxm is osteoarthritis.

Though often thought of as “wear and tear” arthritis, it is much more complex in cause and progression. It is truly a disease of the entire joint, and not simply where bones come together.

It is true that it is strongly associated with aging, genetic history, trauma and most often begins in middle-aged or older people. Younger people with prior joint surgery or fractures, deformities or other systemic disease may get OA at much younger ages. Older medical literature has grossly underestimated the frequency of OA in our population, and there are likely more than 70 million cases in the United States alone. Most people are over 40 years old.

Signs and symptoms of OA include joint pain that is frequently aggravated by use and relieved by rest. Over time, it will start with occasional sharp pain, but later become more constant, interfering with daily activity and may end up with severe constant pain that results in severe loss of function of the involved joint(s). The pain can be achy, intermittent or always present. Frequently, the joint(s) enlarge, may swell and feel weak as the disease progresses, becoming unstable. Many have pain and stiffness in the morning, after inactivity, in the evening and with usage. Severe disease also hurts at night. Most pain is over the joint line, but can be referred away from larger joints. Usually OA joints are not hot and red.

OA has a predilection for certain joints that is not well understood. The end joints of the fingers, the middle joints of the fingers, the base of the thumb and joint of the thumb are often involved in the hands. In the feet, the base of the first toe is a common site. Weight bearing joints are frequently involved, including low back, hips, knees and neck. But it can be seen in the shoulders, elbows, ankles, wrists, and practically any movable joint, especially with repetitive use or prior joint trauma. It is more common as well with obesity, prior surgery on the joint, strong genetic history of OA and certain other diseases. It often comes on slowly, and may involve only a few joints or many. It varies from minimal, annoying to incapacitating pain.

Differentiating this type of arthritis from other types, such as rheumatoid arthritis, gouty arthritis, etc., involves the distribution of joint pain, appearance of the involved areas, imaging the involved areas with X-ray, MRI or other techniques and laboratory testing. There is currently no specific blood test that proves OA, though there are some that could argue for or against the diagnosis. There is also some variability in how OA looks and feels on exam. Analyzing joint fluid can also be helpful. It is often seen in association with other disease, including different forms of arthritis.

Most treatments are designed to reduce pain and functional restriction, improve joint usage and alleviate associated symptoms such as depression or sleep disturbance. Sadly, the overall treatment is relatively unsophisticated due to poor understanding of all the things that generate the disease and specific therapies that modify or prevent progression. The treatment of rheumatoid arthritis has undergone a relative awakening in the last 20 years, but not so for OA, which is probably 20 times more common.

Education about OA is certainly helpful and should always be done. Regular exercise as able, weight management, goal setting and medical management of other diseases that aggravate the OA (such as diabetes or obesity) must be attempted. Non-pharmacologic therapy can also include physical therapy, walking aids, braces and splints.

Pharmacologic therapy for OA is dependent upon the severity of the disease, number of joints involved, overall health of the patient, other medications and compliance. In most cases, initial therapies are started when patients fail the non-pharmacologic ones. Oral and topical non-steroidal anti-inflammatory drugs, including aspirin, ibuprofen, naproxen, are used as non-prescription initially, often used with or without acetaminophen (Tylenol). The doses are adjusted for the patient’s age and other medical problems. Prescription NSAID, such as higher dosages of ibuprofen or naproxen, celocoxib (celebrex), meloxicam, nabumentone, diclofenac, sulindac, diflunisal and others are also used to help manage pain, swelling and stiffness as appropriate.

The NSAIDs are often helpful, very widely used and available, but pose certain risks especially of gastric ulcers, GI bleeding, kidney impairment, allergic reactions, aggravation of blood pressure and interactions with other medications, so they must be used cautiously and under supervision. Occasionally, duloxetine (cymbalta) is used for arthritis pain though it is most commonly used for depression or neuropathic pain. Intra-articular steroids have been used for more than 50 years and are still widely used, but should be avoided more than three or four times per year due to risk of steroid side effects. Viscosupplements (lubricants) such as synvisc, supartz or gel 1, are occasionally used for OA of the knees but are expensive and often ineffective. Narcotic pain meds are avoided but often used in severe cases with intractable pain.

Sadly, there are no supplements, including glucosamine, chondroitin, fish oil, turmeric or others that demonstrate a clinically important benefit in scientific studies. Some patients seem to get a mild analgesic benefit from them, however. Alternative treatments including chiropractic and acupuncture are often done, especially for spine involvement.

Surgical treatment is reserved for the most advanced cases and can be highly effective in many requiring joint replacement. This is typically reserved for knees, hips and shoulders, where many are performed annually. Other joint replacements are less common and less successful. Spinal surgery is often used to treat pain and nerve compression associated with advanced OA.

OA tends to be a progressive disease over time, is common and very variable in presentation and involvement. Most will respond to one or more modality discussed, but the true renaissance of treatment that can halt progression, heal damage and help avoid surgery is not yet here.

Randal White, M.D., FACP, FACR, works with Vidant Rheumatology.