Misconceptions about just what "arthritis" is--and isn't--are common. Many patients believe that any chronic pain in their bones or muscles automatically means they have arthritis. They fear that a permanent, age-related, irreversible, disabling process has begun. But it's not uncommon for such pain to be caused by other ailments, such as bursitis, tendinitis, or peripheral nerve compression. Precisely defined, arthritis is any acute or chronic abnormality of a joint caused by an inflammatory process. A "joint," is a moveable part of the body made up of a bone attached to one or more bones. A "joint capsule" encloses the joint, protecting both the "cartilage" (the smooth surface that covers the end of bones) and joint fluid (a lubricating liquid), allowing for smooth motion of bones over one another. The various "arthritises" share one common feature -- damage to the joint. The causes and effects of this damage vary by type of arthritis.

Osteoarthritis
Degenerative joint disease (DJD) is the most common form of arthritis. DJD is also known by the terms "osteoarthritis" and "osteoarthrosis", although these terms are somewhat misleading since osteoarthritis implies that primary bone is destroyed and osteoarthrosis implies that joints are fused. Neither occurs with DJD.

The primary problem in DJD is loss of cartilage. Even though many people suffer from this process, it should not be considered an inevitable or "normal" part of the aging process (cadaver studies show that healthy cartilage can be observed in even the oldest people).

Causes
The causes of DJD are not always clear. Animal studies show that inflammation is one culprit, but traumatic injury also appears to be an important trigger that spreads the degenerative process. Most people who suffer from DJD have few if any symptoms. If symptoms do develop, there is often little or no overt inflammation. By the time that a patient presents with the typical symptoms of osteoarthritis, progressive cartilage degeneration has been occurring for at least several years, if not decades.

Treatments
Unfortunately, usually all that can be offered as treatment for DJD are measures aimed at symptom reduction. Since pain is the most common symptom, pain relievers such as acetaminophen (Tylenol) and aspirin are most commonly used. Aspirin is the best known and oldest member of a group of medicines known as non-steroidal anti-inflammatory drugs (NSAIDs).

Recently, a new class of anti-inflammatory medications called Cox-2 specific inhibitors have been developed. These medications have fewer gastrointestinal side effects than conventional NSAID's and may be of some value in acute pain syndromes.

A more invasive treatment offers relief that may last 2 to 3 months. Injection of a corticosteroid medication directly into the joint blocks inflammation. Unfortunately, the treatment is progressively less effective in patients who have consecutive injections. Moreover, since scientific study has yet to determine just how frequently these injections may be given safely, most clinicians limit their use. Arbitrarily, I limit corticosteroid injections to no more than 3 to 4 at the same site per year. Problems with this have been rare.

Alternative Therapies
Since the publication of a best selling book, "The Arthritis Cure," by Jason Theodasakis, MD in 1997, there has been widespread popular interest in dietary supplements and other "non-drug" treatment for DJD. So far, there is little scientific evidence that these treatments work. Studies do show, however, that supplements such as glucosamine may help relieve pain from DJD as well as NSAIDs do. My practice is to inform patients about these agents without overtly recommending them. The cost of these supplements (around $30 per month) usually is not covered by insurance.

A new therapeutic intervention involves injection of thick liquids such as Hyalgan and Syndics into the joint. Joints affected by DJD lose the benefit of a low-friction milieu that allows smooth motion. Wear and tear make rough the once near-perfect smooth joint cartilage, and the clear, colorless, viscous fluid that bathes normal healthy joint cartilage becomes discolored and of lower viscosity. The "viscosupplementation" products now available are forms of hyaluronic acid, a substance found in abundance in normal cartilage. These were originally marketed as an alternative to corticosteroid injections. My personal experience has been that severely affected patients are not offered any special help by this very expensive and cumbersome intervention. Moderately affected patients respond best, but these patients also tend to respond well to corticosteroid injections.

Another approach to therapy is the use of tetracycline antibiotics. There is some evidence that these antibiotics inhibit certain enzymes that are found in increased amounts in the early stages of osteoarthritis. Clinical testing with human subjects suffering from DJD has been limited, but tetracyclines have been well tested and have been found to be effective in rheumatoid arthritis. Relief from pain caused by DJD may be obtained in the form of a pepper extract known as capsaicin. Used topically, the cream does provide some pain relief, but its use is limited by the need for multiple daily applications and by tolerance that develops to the cream's effect.

Adjunctive Treatment
Physical therapy is of great importance in reducing pain, improving the function of the body and enhancing a sense of well being. Assistive devices such as canes and braces are often helpful as well. Finally, there is orthopedic surgery. Appropriate orthopedic interventions for degenerative joint disease range from washing joints with a fiberoptic instrument called an arthroscope, in less severely involved cases, to total joint replacement for worse cases. The technique of total joint replacement has improved to the point that for properly selected patients, this procedure does dramatically improve their status. The best results are seen with hip and knee replacements.

Rheumatoid Arthritis
Rheumatoid arthritis (RA), the next most common kind of arthritis, affects an estimated 1 to 2% of the world's population. RA is defined as a chronic, symmetric, polyarthritis (an arthritis involving more than 5 separate joints). Distinguishing characteristics include a positive blood test for rheumatoid factor in most patients, additional laboratory evidence of inflammation, lumps under the skin ("rheumatoid nodules"), specific joint involvement, and "proliferative" joint destruction. Even so, diagnosis is not always obvious.

Medical therapy includes symptom-relieving agents such as NSAIDs, but in contrast to DJD, medications that actually slow the course of the disease play a vital role. RA that has been present for more than 6 months to a year -- especially if there has been evidence of joint space damage and/or deformity -- almost inevitably leads to marked joint destruction, disability, and even premature death. This poor prognosis has spurred a more aggressive approach to the treatment of RA over the past 20 years, and led to development of "disease modifying agents" (DMARDs).

DMARDs are rapidly-acting agents which may safely halt the progression of rheumatoid arthritis. Since their introduction just over 50 years ago, "systemic" corticosteroid medicines have been used in RA. The precise role of corticosteroids in treatment of RA is unclear. Since they work rapidly, some experts consider them to be DMARDs; unfortunately, however, they do not alter the course of RA. Apart from use directly in the joints, which is nearly universally accepted, most contemporary rheumatolgists reserve their use for short term relief of symptoms while other medicines are allowed to work. Currently, the most popular DMARD is methotrexate. This medicine was originally used in the treatment of cancer (it still is widely used in breast cancer). Other medicines used as DMARDs include gold salts, antimalarials, sulfasalazine, tetracyclines, cyclosporine, and newer agents such as leflutamide (Arava), infliximab (Remicaide) and etanercept (Enbrel). The chances for control of the disease and resumption of a normal life have improved and can be expected to improve further as new agents and therapeutic techniques are developed.

Reference Source 104

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