Joints and Arthritis

Rheumatic diseases are those that afflict the connective tissues of the body, most commonly the joints, through immune and other disorders.

Osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus (SLE), osteoporosis, gout, fibromyalgia syndrome, polymyositis & dermatomyositis, vasculitis, Raynaud’s phenomenon, Wegener’s granulomatosis, ankylosing spondylitis, scleroderma, and Sjogren’s syndrome are all rheumatic diseases monitored and treated by rheumatologists.

Osteoarthritis: is a degenerative arthritis that is the most common arthritis, and typically presents with joint pain, stiffness, and limited range of motion. (Also see: "A Closer Look At: Osteoarthritis")

Rheumatoid Arthritis (RA): is a common form of arthritis that causes inflammation of joints and that can also affect internal organ systems. (Also see: "A Closer Look At: Rheumatoid Arthritis", includes:Multiple DMARD Therapy, Biologicals Vs. Indicated Conditions)

Gout: is an inflammatory arthritis associated with elevated uric acid levels, intra-articular crystals, and sudden onset of pain and swelling of joints. Gout can affect people in different levels of intensity and frequency, sometimes consisting of one attack and no other problems. Other people may have frequent attacks, with persistent joint pain and damage in one or more joints. In some cases, the uric acid crystals can accumulate inside the joint and within the surrounding soft tissues. These deposits are called tophi and can cause significant joint damage over the years.

Although there is no cure for gout, it can be controlled with medications and with a special diet called a low purine diet. Please see this diet within our website.

Fibromyalgia Syndrome (FMS): is a common presentation of generalized muscular body pain associated with fatigue that has several signs and symptoms common to people with this diagnosis. It is not a type of arthritis nor does it have inflammation as its significant presentation.

Ankylosing Spondylitis: is a chronic, systemic type of arthritis that affects mostly the spine and sacroileac joints. Common symptoms include back pain, morning stiffness, fatigue, uveitis, and low grade anemia. There is a genetic predisposition to this arthritis, with a positive HLA B-27 in the majority of patients. This condition is most common in males, usually with onset before age 45. About 75% of patients have back pain complaints. Treatment includes range of motion and strengthening exercises, non-steroidal anti-inflammatory agents, patient education, and DMARD's (disease modifying anti-rheumatic drugs) in more aggressive cases. These agents include methotrexate, azathioprine, and sulfasalazine; further studies may support the use of leflunomide, and biological agents such as the Anti-TNF agents infliximaband etanercept.

Inflammatory Myopathies - Polymyositis & Dermatomyositis: This is a group of primary diseases that present with inflammation of the muscles. The distinct classes include polymyositis and dermatomyositis, although similar muscle inflammation can also be seen as part of any of the connective tissue diseases. The term myositis means inflammation of the muscle. The prefix ‘poly’ stands for multiple muscles and ‘dermato’ is for skin involvement in the inflammatory process. These conditions are idiopathic (no direct cause is known) and not common. There are other triggers for damaging changes of the muscles that can be linked to a specific cause, such as drugs, infections, toxins, metabolic abnormalities, endocrine or neuromuscular disorders. It is important to rule out other causes so therapy can be given appropriately.Dermatomyositis also affects children, with a predilection for females, ages older than two years. In adults, these conditions can occur in young people, and skin changes may occur before the muscle weakness is noticeable. A mild arthritis that is not deforming can also be seen. Some features of dermatomyositis include:

• Skin rashes
• Edema of eyelids and above the eyelids
• Heliotrope rash - purplish discoloration of the eyelids
• Rash over knuckles, elbows, knees (Gottron's sign)
• Calcifications under the skin (more seen in children)

Other signs and symptons common to both dermatomyositis and polymyositis include:

• Proximal muscle weakness - gradual onset, often associated with pain
(For example: having to use help to get out of the toilet seat or chair; or unable to lift arms to do hair or to shampoo)
• Gastrointestinal symptom - trouble swallowing, nasal speech
• Other heart and pulmonary problems associated with weakness
• Possible underlying malignancy in adults - routine tests recommended
(PAP smears, rectal exam, mammogram, or colonoscopy as appropriate)
• Abnormally elevated muscle enzymes
• Muscle necrosis (destruction) - seen in muscle biopsy, which is usually indicated for diagnosis
• Abnormal electromyography (EMG)

Treatment consists of high dose oral corticosteroids (prednisone), with about ¾ of patients responding well to steroids alone. In the rest of the cases, immunosuppressive medications are added, such as methotrexate, azathioprine, cyclophosphamide, and chlorambucil. All these medications can cause side effects, they improve survival rates for the patients, because the risks of the disease outweigh the risks of the side effects.

Systemic Lupus Erythematosus (SLE): is an inflammatory disease that can affect joints, skin, muscles, and other internal organs. Variants of this condition include discoid lupus, drug-induced lupus, limited cutaneous LE, and mixed or overlap syndromes. (Also see: "A Closer Look At: Lupus")

Osteoporosis: is a condition that causes weakening of the bridges that keep the bones strong. These bridges are called trabeculae. Some of these bridges break microscopically and makes the bones more susceptible to fractures. The most commonly known osteoporosis is post-menopausal, in which the balance between breakdown of bone and new bone formation (remodeling) favors loss of bone. There is a precursor to osteoporosis called osteopenia. There are secondary causes of bone loss, such as use of prednisone or other corticosteroids, other drugs (heparin, high thyroid hormone replacement, phenytoin), alcoholism, low testosterone, gastrectomy, hypogonadism, hyperthyroidism, or osteogenesis imperfecta. Risk factors are:

• Increased age
• Caucasian or Oriental race
• Female
• Lack of exercise
• Family history
• Early menopause
• Thin body build
• Low dietary intake, especially of calcium rich foods
• Smoking
• Alcohol intake
• No pregnancies
• Excess protein and fiber in diet
• Lack of breast-feeding
• Excess intake of phosphate in diet (sodas)

The diagnosis of osteoporosis usually requires some basic laboratory tests. A specialized x-ray called a Bone Density Study may be helpful in the diagnosis as well as to follow up on the progress of the therapy. After the diagnosis is made, treatment includes biphosphonates (alendronate, risedronate) or calcitonin, calcium and vitamin D supplementation, and hormonal replacement therapy when appropriate. Sometimes treatment is started as a preventive measure in cases of osteopenia or when the persons is at high risk for osteoporosis, such as in chronic prednisone use.

Scleroderma:Scleroderma means "hard skin" and is rare. There are two forms of this disease, 1.) Localized, and 2.) Generalized, the first one being the most common form. Generalized scleroderma is referred to medically as progressive systemic sclerosis (PSSc), and has two subtypes, a.) Limited cutaneous systemic sclerosis, and b.) Diffuse systemic sclerosis.

Sjogren’s Syndrome: Sjogren’s syndrome is a complex of signs and symptoms that include dryness of the eyes, mouth, and skin, and inflammatory arthritis.

Raynaud's Phenomenon: This condition is seen in several connective tissue diseases, such as systemic lupus erythematosus and scleroderma. This is a vasospasm or clamping down of the vessels of fingertips and toes. Cold exposure and emotional stress can trigger this reaction. The color changes with cold make the fingers or toes turn white and blue-purple. In some cases, the lack of circulation to the tissues from sustained vasospasms can cause infarction (skin death), digital scars, infections, and true gangrene. Treatment involves avoidance of injury or any triggering factors, keeping hands and feet warm and covered, and careful local care of any cut or ulcer that occurs (including antibiotics, if needed). Nifedipine, blood thinners, topical nitroglycerin paste, and other medications to improve circulation can be helpful. Smoking is very harmful for patients with Raynaud’s phenomenon, and can cause severe vasospasms.

Vasculitis: Vasculitis is a group of diseases for which the etiology is generally unknown. There is a theory that states that these vasculitides are immune-complex mediated. To support this, there is some evidence for circulating immune complexes , decrease of serum complements, and findings of immunoglobulin deposits in the tissues involved. Another theory suggests an infectious cause for these conditions, such as Hepatitis A, B and C, cytomegalovirus (CMV), human T cell lymphoma virus, human parvovirus B-19, herpes zoster, Lyme disease & HIV infection. Another possible explanation is malignancy, such as hairy cell leukemia.The classification of vasculitis is quite complex, and involves different parameters. These include vessel size, location of vessels, type of vessel involved, histologic or microscopical picture, response to medications, and specific clinical characteristics. The major vasculitic classes are as follows:

• Polyarteritis group -- systemic

- Classic polyarteritis nodosa

- Allergic granulomatosis

- Overlap

• Hypersensitivity group

- Serum sickness

- Henoch-Schonlein purpura

- Essential mixed cryoglobulinemia

- In relation to malignancies

- In relation to other primary diseases

• Wegener’s granulomatosis

• Lymphomatoid granulomatosis

• Giant cell arteritis

- Temporal arteritis

- Takayasu’s arteritis

• Miscellaneous

- Thromboangiitis obliterans

- Mucocutaneous lymph node syndrome

- Behcet’s disease

- Weber-Christian disease

- Relapsing polychondritis

Therapy is tailored to each individual disease and can be quite complicated. Sometimes anti-inflammatory agents can help (NSAID’s), but in most cases prednisone or corticosteroids are needed. In Wegener’s Granulomatosis, cyclophosphamide has been instrumental in prolonging the life of patients. Other cytotoxics, such as methotrexate, cyclosporine A, and azathioprine , as well as gamma globulin can also be useful in the treatment of vasculitis.

There are medications available that can prevent and treat osteoporosis. In addition to exercise, Vitamin D, and calcium supplementation, these include biphosphonates, estrogen, calcitonin, and selective estrogen receptor modulators.

Bone mineral densitometry (BMD) studies are useful as diagnostic tools for osteoporosis and for monitoring effectivity of therapy as well as progression of disease.

There are many herbal and over-the-counter remedies that have been greatly publicized during the past decade. Some products may have a role in improving symptoms of arthritis and have been used in Europe for many years. However, scientific proof of the effectivity of these products is still in question. Some claim to “cure” arthritis, which is a very ambitious claim with no scientific data to support it. Healthy diet and exercise, as well as supplementation of calcium and vitamin D have been shown to help maintain healthy bones and improve the quality of life of people living with arthritic conditions. There are some preliminary studies regarding chondroitin sulfate and glucosamine sulfate that suggest improvement of symptoms in osteoarthritis of the knees. Please consult your physician and let them know which herbal supplements you are taking, as this could help in caring for your health as a whole. Also, please bear in mind that none of these herbal remedies or alternative therapies should be viewed as a substitute for professional medical care and scientifically proven medications.