Arthritis is a generic term used for any of more than 100 diseases of the joints which are commonly accompanied by pain, siffness and swelling. Many get crippled by arthritis. The two chief forms of this disease are osteoarthritis and rheumatoid arthritis.
Osteoarthritis is a degenerative joint disease which occurs when a joint wears out. It is common among the elderly and it may also occur if a joint has been injured may times. The joints most frequently affected are those of the hands, hips, knees, lower back and neck. If hips and knees are badly diseased, severe disability may result. According to specialists, victims suffer pain and may feel a grating sensation when they move. This is because the cartilage between two bones breaks down, causing those bones to rub against each other. Knobs of hardened bits of cartilage and bones can develop in the joint to cause swelling and deformity.
Rheumatoid arthritis is called "the great crippler" and most of its victims are between the ages of 20 and 40. Joints become hot, painful, red and swollen. It is commonly found in wrists and knuckles, but it may strike any joint. In extreme cases it may spread throughout the body, damaging organs and connective tissue. If untreated the diseased joints eventually stiffen in deformed positions. Inflamed tissue and other substances in a joint erode the bone and cartilage though physicians believe that rheumatoid arthritis is caused by either micro organism or the body’s attack on its own tissues (autoimmunity) or both.
The other forms of arthritis include gout, ankylosing spondylitis and septic arthritis. Gout causes swellings, mostly in the joint that connects big toe and the foot (bunion joint) and is caused by the presence of too much uric acid in the blood. Ankylosing spondylitis inflames the spinal joints and is prevalent among young men. Physical therapy and drugs are recommended. Septic arthritis is caused by bacteria, occurs mostly after a lung or skin infection, surgery of the joint, or any venereal disease.
In everybody’s mind some dark thoughts arise when arthritis is mentioned. It is painful, is it chronic? Is it disabling? Does it make a patient dependent? Does it make him semi-productive or unproductive? Those suffering from this ailments are apt to lose confidence. Frustration fills the mind after prolonged treatment and best available advice.
The earliest symptom appearing is pain in a joint often referred to as rheumatism. Generally it appears in the winter season. Afflicted people resort to heat and massage. When the pain persists they visit a doctor resort to heat and massage. When the pain persists they visit a doctor. At one time or other we have all had rheumatic pain. Patients with chronic pain agree that it is easier to suffer excruciating pain for a short time. But a chronic pain, even if it is slight and dull, which is continuous is frustrating. Many sufferers take it for granted that this pain will never leave them. This is why many await their end with eagerness, praying to God again and again to lift them up from this world. One has to live the life in this world with a hundred pains, some of the body, some of the heart and some of the mind. Hindu philosophy suggests that we suffer in this life for the bed deeds in our previous life.
When the pain progresses slowly over a week or a week or a month, the person feels tired, with pain and malaise almost in all muscles. There is stiffness in the joints while getting up in the morning especially in the small joints of the hand. Later there is a swelling pain and tenderness in the joints. It generally involves bilateral joints, in both hands, wrists, elbows and shoulders. The main complaint of patients is that joints become stiff if they do not use them for sometime. As the pain continues the patient faces increasing difficulty in moving around, climbing stairs, opening a door, opening a jar a sewing. Such patients, gradually get depressed, lose some weight and sometimes may have low grade fever. The diagnosis for such a patient will be rheumatoid arthritis. It is a disease produced newly. Many develop crippling deformities of hands and feet and a crippling limitation of movements in certain joints and may need surgery for their correction, crutches and aids for walking and working.
The victim goes to bed and sleeps in good health. In the wee hours he gets roused by a severe pain in the big toe, more rarely in the knee, ankle or instep. The pain is like that of a dislocation and yet the parts feel as if cold water was poured over them. Then follows chill and shivers and some fever. The pain which was moderate at first becomes intense. With intensity the chill and shivers increase. You feel as if you cannot bear the weight of the clothes on your body. The night passes in torture, sleeplessness, often turning of the part affected to obtain abatement of the pain.
Gout may follow a trauma, alcohol, dietary overindulgence or a long walk. Initial attacks subside in a few days. The subsequent attacks takes longer to subside and may last days to several weeks. 62% of the patients have recurrent attack within a year, 16% after one to two years, 4% in five to ten years, 7% have no recurrent attacks at all.
More than half of the gout patients develop visible tophi and need to wear larger shoes. Tophi are formed due to deposition of sodium urate. This can also deposit in the kidney and form kidney stones.
The patient generally is in good health. It hits generally at between 30 and 60 years of age and is most common around 45 years. In women, it occurs rarely and only after menopause. It can occur following the use of oral diuretic or aggressive anti-cancer treatment.
This condition affects persons over 50 years of age. The weight-bearing joints, mostly the knee, is involved. There is deep aching pain in the afflicted joint, morning stiffness of short duration and variable joint swelling. In many cases there is crepitous sound on movement of the knee. The diagnosis is osteoarthritis. It may occur also at a younger age following major injury or repeated small injuries or prolonged immobilization, bow legs or knock knees and can involve any joint. The disease advances over the years but rarely reaches the level of severity seen in rheumatoid arthritis. A majority of people suffer from osteoarthritis after the age of 50. This is why it is called a disease of old age.
If you are under 40, if you have slowly increasing discomfort with increasing limitations over the spine, mostly the lower back and it persists over 3 months, you are likely to have ankylosing spondylitis. If you feel stiff in the morning and a lot better after exercise you may be suffering from it.
It was thought to be male dominated disease but now it is almost equally common in both the sexes in the west. It is more common in the white population. The sufferers develop a peculiar posture in their later years of the disease with the whole of spine bent forward allowing limited movement of the neck. They find it difficult to cross the road and walk fast.
Comes in 100 Guises
Arthritis is as common as the common cold. One out of every six patients visiting a general practitioner is a sufferer of arthritis. Ninety seven percent of all people above the age of sixty have arthritis. We all dread old age as arthritis produces crippling in most and we may have to be dependent on others for little things. It is a number one crippling disease. Although not a direct killer like cancer and heart disease, arthritis causes much pain, despair and suffering to more people than any other single disease. Arthritis is as old a disease as civilization itself. As soon as man stood on his two legs this disease crept in. There is a record of this disease for thousand of years. Egyptian mummies show symptoms. Ancient Romans built luxurious baths throughout the empire to help joints aching due to arthritis.
Arthritis exists in more than 100 guises and at any age. A bouncing athlete, a young housewife, even a child can be affected by arthritis. The cause of arthritis in most of the cases still remains a mystery, and so its treatment. Most arthritis is incurable. We can prevent pain, arrest progression, prevent destruction of joints, crippling and loss of function with the help of real strong drugs which have side effects and sometimes create problems for the body which are worse than the disease. Rheumatoid arthritis is most puzzling. It has an erratic course. It has been described as a river that never flows the same way twice. It can appear, lie low for a number of years then flare up like a bonfire. In 7 percent cases it can just go away all by itself and never return. It may also have an unequal distribution according to sex. Rheumatoid arthritis is more common in women. A U.S. National Health Survey has revealed that it spares most unmarried women and women over 45. Generally, it does not strike widowed men. More managerial a man’s job, the less prone he is in getting rheumatoid arthritis. Their numbers have increased since the industrial revolution and in some mysterious ways it is linked to it.
Who has not been affected by arthritis! Christopher Columbus, Julius Ceaser, John Calvin, Elizabeth Tylor, James Garner, Raymond Massey, the newsman Eric Geraried, dancer Edward Villela, athlete Joe Nawath, Dick Butkus, surgeon Christain Barnard, President Ronald Reagan. So did Nehru and Mahatma Gandhi who required to have the support of two girls on both sides while walking, in his latter part of life.
The wife of former US President Henry Ford could appear on television offering a message of hope: "I am Betty Ford and like 30 million Americans I have arthritis. Arthritis means living with pain. Everyday’s activity we all take for granted becomes unbearable. But thanks to medical advances, I can now cope with my arthritis and you can find help too".
Arthritis does not spare anybody – the rich or poor, high or low, famous or not famous, we all suffer due to arthritic pain in some part of our existence. Life is said to be full of pain.
One of my patients, Mrs. Jaroo Meherji, 57 years, worked as Office Superintendent in Western Railway. She was afflicted by rheumatoid arthritis for twenty years. In the last 7 years it got aggravated and affected almost all the joints. The fingers got deformed. She could not move her elbow fully, the shoulders caused pain and, and, worst of all, her knee joints, made her almost crippled. The legs used to be stiff in the morning. Gradually she had difficulty walking and had to retire prematurely. She would take a long time to get up and open the door if somebody rang the bell. It was difficult for her to climb steps. She could not sit on the pillion seat of the scooter driven by her husband. Specially, it was getting embarrassing to ask for assistance from passers-by to alight from the scooter. She still managed to do cooking, but she was slow. Needle work had become almost impossible. Her sleep was disturbed and she ate poorly. She lost weight. Rheumatoid arthritis turned a bouncing personality into almost a cripple. The body had taken the brunt but what about the mind? She was disgusted and frustrated. She had lost all hopes, except in God.
It is a disease of the whole body. With it come all symptoms of a serious illness, fever, chill, loss of appetite and body weight, pain all over the body, tiredness, sweating and stiffness in the morning and after prolonged inactivity. It is common between the ages of 25 to 50, but it can strike at any age.
During a severe attack it can erode the joints. The damage is irreversible. You may have a disfiguring nodule under the skin which may vary from the size of a pea to that of a pear. The nodule can pop out anywhere below the elbow even over a bursa or tendon. They disappear with subsiding inflammation. They become less aggressive as years go by. Only one person out of six will develop crippling deformities like bent fingers or bent elbows.
What is the cause? There is no satisfying answer to this query. One medical theory holds that somehow our body’s immune system goes haywire. Instead of fighting foreign matter like germs it attacks parts of the body. Hoards of defender cells turn traitors and march on you. They surround and digest what they believe is foreign matter and digest it. This is why it has been named auto-immune disease.
There is a common belief that damp cold climate causes it. This does not seem to be true. Many patients can predict, like a barometer, when the weather will turn foul. As soon as the clouds come in the sky, the atmospheric pressure falls, humidity goes up as it happens prior to a storm. These patients immediately find that their symptoms have worsened. If you think that by shifting to, dry and hot climate like Rajasthan’s you will improve you are making a mistake.
However women, if pregnant, get a lot of relief in their pain during pregnancy. But it resurfaces after delivery. It has therefore been thought that the cause of rheumatoid arthritis is some sort of hormonal imbalance in the body. Still we do not know it for sure. The predisposing causes for an attack of rheumatoid arthritis are many like an infection, following injury directly to the joint, weakened physical state and emotional disturbance.
Emotional disturbances also play a role. Episodes of rheumatoid arthritis can be triggered by stress, says Hans Selye, a noted authority on stress and disease. Events causing stress have special effects both physical and mental. He claims that a stressful event need not always be negative. It could be an auto accident, break up of an important relationship or even wedding of a son or purchase of a new car. Many patients will tell you that their fingers become sore three days after the review of their salary, of three days after a close family member has taken ill.
In one study, rheumatoid arthritis patients were asked to keep a life chart of the onset of their attacks. Out of 293 patients forty nine percent discovered that physical and emotional stress set of f the attacks. Arnold Fox M.D. an expert on stress and nutrition feels that it is not the event but the way you react to it. Once you know how life events affect your arthritis try to concentrate on coping with them better.
Mrs. Asha Goyal in her mid seventies had been suffering from a stiff aching knee pain for 10 years. Her knees swells up a little after prolonged activity. In her younger years, she had been fairly active taking keen interest in gardening and social work, finding herself restricted. She is obese. She has trouble climbing stairs and getting out of a deep chair. But she has kept up her activities.
Lately she has been feeling dull and limp. She cannot raise her arms to wash properly and set her hair. She has trouble getting up in the morning and dressing up. She looks in the mirror and sighs that she is "getting old". She is depressed about her appearance and tired of her aches and pains. She does not sit outdoors so often any more.
It rarely draws sympathy of friends and relations. The knees and the back may ache terribly but your friends will shrug and say: "What do you expect? You are getting old" You start getting depressed emotionally because it hurts to do so many tasks you never had to think twice about doing before. Eventually some people may get such bad osteoarthritis that they may come to view a flight of stairs as equivalent to climbing Mt. Everest.
With osteoarthritis there are a lot of ups and downs. Typically you may wake up feeling stiff. It requires 15 minutes to half an hour for the pain to ease. As the day progresses you feel better till early afternoon. After that it starts deteriorating again and you may feel miserable by the evening. Sometimes when pain is less you may do some active housework like washing windows or digging in the garden. After a vigorous exercise the sore joints will hurt even more. You may get some swelling over it. If you sit for long and try to get up you will feel stiff.
You may feel a cracking or grinding sound in the arthritic joint but this is not serious. Many complain that they had some injury in the joint before the pain started. If you are worried and tensed up about pain it gets aggravated. If you rest and relax you feel much better.
Mr. Kashinath, a young dynamic businessman, has done well in business. Recently he branched out into another industry. People think his success results from sincerity and friendliness. He is regular in attending business conferences twice a year which last sometimes for 5 days, gives business launches and treats potential clients to good food and had drinks. At the end of the week two things always result Mr. Kashinath gets lots of friends and orders and one case of gout, that is himself. In olden times gout used to be a disease of royalty and it is best exemplified by Henry VIII who ate drank and married too often. But, to our misfortune, gout has shifted from royalty to ordinary mortals. It is a disease caused by inborn error in metabolism. Though the basis of the disease is inherited, it can be controlled to a great extent by diet and a proper life style. If you have gout that means that either your body is producing too much uric acid or producing normal quantity but which the body is not able to excrete sufficiently. Gout is caused by excessive accumulation of uric acid in the body. This stage is called Hyper Uricemia. Obesity and alcohol intake are associated with gout. The attack can last from 5 to 10 days during which time the toe gets swollen and becomes dusky red. Inside the joint the urate crystals have started a chemical reaction in the joint fluid that results in inflammation. The cells of the body’s defence system rush to the joint creating more congestion. After the attack the joint returns to normal. Even in the 18th century, most people knew that rich diet and gout were inter-related. Since 1960, we know for sure that alcohol consumption gives rise to gout though it was doubted for a long time. At the clinical Research Centre of University Hospital Pittsburgh, USA, an experiment with six men and one woman was carried out to see the effect of purine rich diet and alcohol on gout. Gerald Rodnan M.D. placed patient on purine free diet to stabilize the urate level in their blood. These patients were given large evening meals containing 2 to 5 gms. of purine. First the meals were eaten without wine and spirit the patient’s uric acid level rose somewhat. When alcohol was added to the meal the urate level rose sharply. In some cases it almost doubled from the previous level. Six of the seven patients had an acute attack of gout within the next four days. High purine foods are likely to induce gout. They are organ meats (brains, liver, kidney, hearts) meat extract, mince meat, sardines, herring, asparagus and mushrooms. They contain purine ranging from 150 to 1000 mgm for every 3 ? ounce serving but still can contribute to gout. They are dry beans and pea, lentils, meats, poultry, fish cauliflower, spinach, seafoods, yeast etc. Limit these foods to three ounces serving five days a week.The patients should be careful throughout life, and avoid excessive alcohol, high calorie diet and tension.
Ankylosing Spondylitis A leading surgeon in Gorakhpur, U.P., started having stiffness in his spine since the age of 40. It started from the lower back and gradually spread to the whole spine as far as the neck. Gradually he began stooping somewhat and his bent went on increasing. His neck movement became limited. Now he finds difficulty in crossing the road and prefers to take assistance.
25 years after the disease he still continues doing his surgery jobs. He takes on only few jobs due to the limitation of his movement, but he hardly complained of pain now. This condition is called Bamboo Spine an appropriate nickname as the spinal joints become stiff and limited in movements as the disease progresses. Ultimately turning the spine, skull, ribs and hips into one long bone that cannot bend. Hence the name.
The disease can start when one is 15 or 20 years of age. In the beginning the disease is not traumatic. It comes and goes, the pain starting in the lower back lasting for a few days. Then it completely disappears. Frequent attacks last longer. You feel more stiff. There is a feeling of being better after exercise. Slowly, the disease moves up the spine. Some joints in the arm or leg occasionally get inflamed. Appetite is lost and so is the weight. You may develop low grade fever. There is a feeling of pain and stiffness when getting out of bed in the morning. It is usually not diagnosed until about the age of 40. Generally the sacroiliac joint – that is the joint in the lower back gets affected first. Fibrosis develops in these joints. They gradually lose their movement and ultimately may get completely fused: Initially, this disease is painful, now ever once the fusion has taken place there is no more pain. When the spine and ribs have become fused deep breathing becomes difficult because of limited chest expansion.
It is 8 times more common it is generally associated with small joint pains of hands and toes. Most sufferers live a normal active life and do not miss many working days. The spine will become rigid in the position in which it has become ankylosed and the patient should cooperate in the programme to prevent persisting spinal deformity. He must sleep on a hard bed and with a low pillow and try to keep his spine as straight as possible. The disease normally becomes inactive 10-15 years after it has started and in more than half the cases it does not spread beyond the lower back.
If there is a sore or stiff joint which persists for a month or two, you ought to see a doctor. He will see it for movement, feel for heat, prod it for swelling and listen for any grinding or creaking noises. Before he makes a diagnosis he may like to take a few tests. These may include X-ray, Erythrocyte, Sedimentation Rate, Rheumatoid factor test and HLA-B 27 for Ankylosing Spondylitis
- X-rays are a common took in diagnosing osteoarthritis. They will show the wear and tear of the bone and bone spurs that develop during the course of osteoarthritis. We can find the narrowing of the joint space which indicates that the cartilage protecting the end of the bones has begun to wear away. In ankylosing spondilytis we find reduced joint space in sacroiliac joint and it may get almost fused in advanced stages. Degeneration and erosion of the joints can be seen in rheumatoid arthritis and gout. Punched out lesion is characteristic of gout. Because X-rays expose to dangerous radiation, avoid them if possible. Often a doctor can tell as much about the joint by physically examining it.
- Erythrocyte Sedimentation Rate. This test is done most commonly in all arthritic cases. The blood is drawn from the patient and put into a test tube. The solid cells of the blood settle down and separate from liquid serum in which they float – separate into layers. The distance that the cells settle in one hour is the sedimentation rate. A high "sed rate" means onset of inflammation. By periodic tests, a doctor can tell whether the inflammation in the joint is getting better or worse.
In the case of osteoarthritis it is usually normal and in case of rheumatoid arthritis it is usually high. It is elevated in most cases of ankylosing spondylitis but may be normal in few cases. It is also raised in gout.
- Rheumatoid factor test. This is done only in rheumatoid arthritis. It is positive in most of the cases. This factor is something the body’s immune system produces to fight off rheumatoid disease.
This test is positive in gout Uric acid levels are higher than normal levels. Normal values for non-vegetarians are usually higher than vegetarians. Somehow it has been seen that arthritis is more common among non-vegetarians especially those who take non-vegetarian in their meals and very few vegetables or salads or none at all.
This test is of some significance in case of ankylosing spondylitis. It is positive in 95% cases of white people suffering from it. It is an expensive test and not necessary.
A needle is inserted in the sore joint and a few drops of joint fluid (synovial fluid) are drawn out. It tells a lot about the disease of the joint. In osteoarthritis it is clear and sticky. If it contains crystals of uric acid it is most likely gout.
"The art of medicine consists of amusing the patient while nature cures the diseases". (Voltaire) When there is a severe aching knee which persists for several weeks, you may need to consult a rheumatologist. He may decide you have osteoarthritis. He prescribes aspirin. You feel annoyed and probably cheated. Your knee is hurting badly and you are asked to take the common aspirin.
Yes, aspirin is preferred for arthritis. In case of osteoarthritis it kills the pain but in rheumatoid arthritis when taken in right doses reduces the inflammation. When taken at regular intervals it enters the blood stream and reaches all parts of the body, reducing swelling in the joints and helping the inflammation to subside. People with rheumatoid arthritis often take 10-12 or 15 tablets a day, under doctor’s supervision, because it can cause some severe side effects. This drug so commonly used by all form of aches and pains in the body is available in different combinations under different brand names.
The most common side effects are gastrointestinal problems. You may get a sour stomach, nausea, vomiting and even ulcers. The most serious of all is gastric or intestinal bleeding if you are taking them in high doses. Quite a few times the side effects are diagnosed late and may be fatal.
Even the coated aspirin has similar effect, though advertisements will not say it. If you drink alcohol with aspirin there is twice more chance for you to get ulcers. Alcohol increases the ulcer causing potential of aspirin. It may cause noises in the ear followed by loss of hearing.
Aspirin or similar anti-inflammatory drugs play havoc with nutrition. Even in small doses, aspirin can cause to excrete 3 times more vitamin C in the urine. Routine use can lead to folate deficiency which is one of the vitamin B complex vitamins. In one study of 51 patients with rheumatoid arthritis, 71 percent had a low level of folate in blood. It also prevents blood from clotting.
The common practice of taking aspirin for colds is not right. Aspirin, in fact, prevents the body from fighting off colds, by blocking the effect of interferon a substance normally produced in the bodies.
Scientists at Duke University and Burroughs-Welcome Research Laboratories indicated that interferon cannot do its work of fighting viruses when aspirin is present. These scientists worry that taking aspirin for cold may allow the number of cold viruses to multiply more rapidly. Taking aspirin may you more vulnerable to an entire host of virus caused diseases.
New Arthritis Drugs
If aspirin is dangerous what can be done to relieve pain? There are many new drugs flooding the market – they are called non steroidal antiinflammatory drugs. They are mild pain relievers and fight inflammation.
The grand daddy of this group is Indocin (Indomethacin) which was introduced in 1963. It is effective in rheumatoid arthritis, osteoarthritis, ankylosing spondylitis and gout. It is not recommended to children under 14 years, pregnant and nursing mothers, patients who have peptic ulcer and gastritis, and patients who are allergic to this drug. Doctors generally agree that it is not any more effective than aspirin. It does however have more serious side effects than aspirin. In fact 35 to 50 per cent of people who take it develop bizarre symptoms such as total loss of appetite, nausea abdominal pain, painful ulceration of upper gastrointestinal tract which sometimes perforates leading to haemorrhage and anaemia. It can cause hepatitis, jaundice or servere bone marrow depression. Medical literature cautions: "drug not to be used routinely"
There are many more entrants in the market like Brufen, Ibuprofen, Naprosyn (naproxen), Nalfon (fenoprofen) and tolmetin. They are all non steroidal anti inflammatory drugs. They are taken orally and absorbed directly into the blood stream within one hour. Though they have similar effect but are chemically different, some people react better to one than the other. Usually after a week you will be able to assess whether any of these drugs is going to harm your stomach.
Brufen and Ibuprofen were introduced in 1960. They are weak but effective anti-inflammatory drugs. They pass in the joint fluid and remains long after the amount in blood stream has diminished. They are supposed to have less side effects than aspirin. Still 15% patients produce severe symptoms, severe enough to cause them to discontinue. They may report thinning or loss of hair.
It is easier to live with Naprosyn (naproxen) than aspirin. Twice a day, it is effective in rheumatoid arthritis and ankylosing spondylitis. It gives a lesser side effect than aspirin. Butazolidine (phenylbutazone) is effective in osteoarthritis, ankylosing spondylitis and gout. It depresses bone marrow. It is advised for those taking this drug to have a regular blood count done. It causes irritation of the stomach and can produce ulcers. It causes sodium and fluid retention in the body. It must not be administered in cardiac cases and dermatitis. It can cause jaundice, blured vision, asthma attacks. As many as 45 percent of people will develop side effects. Tandril (oxyphenbutazone) is closely related to this drug and is equally dangerous.
Gout responds quickly to this drug. Inflammation and pain subside quickly. It can produce nausea, diarrohea, can suppress bone marrow and produce anaemia, leucopenia and thrombocytopenia. It can cause liver cell damage. Not to be given to a patient suffering from liver or kidney disease.
It is a uricosuric agent. It helps to reduce uric acid in blood and is usually prescribed to those suffering from gout. Once started it has to be taken life long. It should be accompanied by weight reduction, low fat diet and complete absence from alcohol. Probenecid helps to block the reabsorption of uric in the kidney and thus more uric acid passes out in the urine. It has side effects like vomiting, skin rash, drug fever. Urate stones may get formed in the kidney and cause severe colic.
It acts by inhibiting the enzyme xanthine oxide which prevents the final step in the production of uric acid. It can produce gastric irritation, dermatitis, blood dyscrasias and is toxic to liver.