Management of Common types of Arthritis
Arthritis
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Arthritis literally means joint inflammation
More than 100 different types of inflammatory or degenerative diseases
damage the joints
Most widespread crippling disease in the world
Symptoms – pain, stiffness, and swelling of a joint .
Acute forms are caused by bacteria and are treated with antibiotics &
surgery.
Chronic forms include osteoarthritis, rheumatoid arthritis, and gouty
arthritis.
Classification
OSTEOARTHRITIS (DEGENERATIVE)
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a. Primary
b. Secondary
2.
RHEUMATOID ARTHRITIS
a. Seropositive
* Rheumatoid arthritis
* Juvenile rheumatoid arthritis
b. Seronegative
* Ankylosing spondylitis
* Reiter’s disease
* Psoriatic arthritis
* Enteropathic
3. Neuropathic arthropathy
e.g. Leprosy, diabetic
4.
Metabolic arthritis
a. Gout
b. Pseudogout
c. Alkaptonuric arthritis
5. Arthritis in systemic disease--- haemophilia
6.
Others:
a. Villonodular synovitis
b. Synovial chondromatosis.
OSTEOARTHRITIS
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It is a chronic joint disorder in which there is progressive softening &
disintegration of articular cartilage accompanied by new growth of
cartilage & bone at the joint margins (osteophytes) and capsular fibrosis.
O.A. could be
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Primary when no cause is obvious.
Secondary when it follows a demonstrable abnormality.
Pathogenesis
The earliest changes are:
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an increase in water content of the cartilage
easier extractability of the matrix proteoglycans
At a slightly later stage there is:
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loss of proteoglycans
defects appear in the cartilage
damage to chondrocytes cause release of cell enzymes & further matrix
breakdown.
Pathogenesis
Articular cartilage plays role in distributing and dissipating the forces
associated with joint loading.
When it loses its integrity these forces are increasingly concentrated in
the subchondral bone resulting in cyst formation & reactive sclerosis.
What cartilage remains is still capable of regeneration, repair and
remodeling, giving rise to bony excrescences or osteophytes.
Where stress is taken the cartilage is abraded and the joint space
becomes narrower. The vascular reaction is followed by osteophyte
formation. Cysts form at high spots of pressure.
Natural History
Primary Distribution
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Primary OA typically involves variable number of joints in characteristic
locations, as shown
Exceptions may occur, but should trigger consideration of secondary
causes of OA
Primary Distribution
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Acromioclavicular joint:
O.A. is clinically rare, though often seen on x-ray. Treatment is
conservative; only very rarely is the lateral end of the clavicle
excised.
Gleno-humeral joint:
Much rarer than is commonly supposed, but cuff lesions are often
diagnosed incorrectly as OA. If conservative measures e.g.,
physiotherapy, or injections, fail then arthroplasty is often indicated
and arthrodesis rarely.
Elbow:
OA may follow severe injuries or loose bodies. Treatment is
physiotherapy or if needed removal of loose bodies. Joint replacement
or arthrodesis are other possibilities.
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Wrist:
OA of the radio-carpal joint usually follows injury. Treatment is splintage
only rarely is arthrodesis necessary.
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Thumb:
OA of the carpo-metacarpal joint is common. MUA combined with
hydrocortisone
injection is often valuable. Arthrodesis gives excellent results.
Fingers:
Heberden’s nodes are associated with OA of the terminal finger joints.
Any pain soon disappears, but the ugly lumpiness is permanent.
Cervical spine:
OA of the facet joints usually accompanies disc degeneration and the
disease is then called spondylosis. Physiotherapy, a collar, or
manipulation without anaesthesia are useful.
Lumber spine:
OA of the facet joints may follow spinal deformities, or be associated with
degeneration of discs (spondylosis). Physiotheraphy and a corset are
the usual methods of treatment, rarely spinal fusion is used.
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Hip:
OA of the hip is a common and important clinical problem. There is pain,
often referred to the knee, stiffness and deformity. In conservative
treatment a raised heel and a walking stick are specially useful.
Arthroplasty is often indicated, osteotomy less often and arthrodesis
rarely.
Knee:
OA affects the patello-femoral section of the knee and is much more
common than the femoro-tibial. If conservative measures e.g.,
physiotherapy, a removable splint, injections, fail then arthroplasty is
often indicated, osteotomy less often and arthrodesis rarely.
Ankle:
Although the ankle is a weight bearing joint, extremes of movement are
rarely required therefore OA is uncommon. It may follow severe injury or
a loose body. If conservative measures fail, arthrodesis is the best
operation.
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Hallux:
OA of the metatarso-phalangeal joint is common (hallux rigidus). A
rockered sole usually relieves the pain. The commonest operation is
arthroplasty in which the metatarsal head or the proximal portion of the
phalanx is excised. The joint is sometimes arthrodesed.
Symptoms & Signs
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Pain is related to use
Pain gets worse during the day
Minimal morning stiffness (<20 min) and after inactivity
Range of motion decreases
Joint instability
 Bony enlargement
 Restricted movement
 Crepitus
 Variable swelling
Laboratory Tests
 No specific tests
 Routine Labs e.g. ESR
 If surgery required patient worked for G.A.
Risk Factors
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Age: 75% of persons over age 70 have OA
Female sex
Obesity
Hereditary
Trauma
 Neuromuscular dysfunction
 Metabolic disorders
Diagnosis
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History
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Physical examination
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X-ray examinations
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Conservative Management
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Management
Surgical Management
Aims of Management
Decrease pain to increase function
Prescribe progressive exercise to
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Increase function
Increase endurance and strength
Reduce fall risk
Patient education: Self-Help Course
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Weight loss
Heat/cold modalities
Conservative Management
Analgesics, warmth, a raised heel and a stick (don’t stand when you can sit,
don’t walk when you can ride).
Pharmacological Management
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Nonopioid analgesics
-First-line—Acetaminophen
-Pain relief comparable to NSAIDs, less toxicity
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-Cyclooxygenase-2 (COX-2) inhibitors
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Pain relief equivalent to older NSAIDs
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Probably less GI toxicity
Opioid analgesics
Codeine, oxycodone
Pain relief equivalent to older NSAIDs
Probably less GI toxicity
Topical agents
-Local cold or heat: Hot packs, hydrotherapy
-Liniments = methyl salicylates (e.g. Iodex)
-Temporary benefit
-Ketotop patches for severe pain interfering with daily activity and sleep
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Intra-articular agents
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Unconventional therapies
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