Arthritis

• 1. Introduction

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  Arthritis begins as a quiet loss. The smooth cartilage that lines a joint wears away, and bone starts grinding on bone with every movement. The word itself is built from two Greek pieces: arthr-, meaning joint, and -itis, meaning inflammation. Yet arthritis is not one disease. It is a general term covering a whole family of conditions, and the plural form, arthritides, names that collective group. In the United States, more than twenty percent of people live with some type of it. In Australia, the figure is about fifteen percent. How can a single word stretch across so many different illnesses, from a wear-and-tear ailment of old age to an immune system turning on its own body? Why does it strike weight-bearing knees in one person and the big toe in another? And how far back does its mark on the human skeleton actually reach?

• 2. A Family Of Diseases

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  Osteoarthritis and rheumatoid arthritis sit at the center of the family. Osteoarthritis is the most common form, affecting more than 3.8 percent of people, and it tends to settle in the hips, knees, shoulders, and fingers. Rheumatoid arthritis is the second most common, affecting about 0.24 percent of people, and it is an autoimmune disorder drawn to the hands and feet. Around these two cluster others that count as arthritis, including gout and pseudo-gout, septic arthritis, ankylosing spondylitis, juvenile idiopathic arthritis, Still's disease, and psoriatic arthritis. Hemarthrosis belongs here too. Joint pain alone does not settle the matter, because many conditions cause it without being arthritis. Psoriasis, Lyme disease, hepatitis, celiac disease, sarcoidosis, and systemic lupus erythematosus can all bring aching joints. So can iron overload, Sjögren's disease, and inflammatory bowel disease such as Crohn's disease and ulcerative colitis. When a case refuses to fit any known category, doctors call it an undifferentiated arthritis, possibly an early stage of a definite rheumatic disease still taking shape.

• 3. How The Damage Begins

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  Osteoarthritis grows out of damage to joint cartilage, from a prior injury or from long-term wear and tear. As the cushion breaks down, bones rub directly against each other and erode. The pain often starts as something minor during physical activity, then can become present even at rest, eventually debilitating. Increased age is the strongest predictor, likely because chondrocytes lose their ability to maintain cartilage over time. By age 65, over 30 percent of women have some degree of it. Rheumatoid arthritis works by betrayal instead of erosion. The immune system, which normally guards against infection, attacks the lining of the joint capsule, causing inflammation and swelling. Inflammation of the synovium drives much of the bone erosion, fueled in part by pro-inflammatory cytokines and a cell surface protein called RANKL, present in Th17 cells and osteoblasts. The disease is symmetrical, appearing on both sides of the body, and it can produce severe progressive deformity in a matter of years if left untreated. Gout takes a third route entirely. Excessive uric acid production leaves urate crystals depositing in joints, often in the extremities such as the toes. Purine-rich foods can raise urate levels in the blood, and so can body factors affecting how urate is cleared, a topic remaining under study.

• 4. Reading The Body

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  Pain in varying severity runs through nearly every type of arthritis, joined by swelling, joint stiffness, redness, and aching around the joints. The timing of that pain becomes a diagnostic clue. Rheumatoid arthritis is generally worse in the morning, with stiffness lasting over 30 minutes, while osteoarthritis pain starts tied to activity before turning more constant. A clinician watches for the rate of onset, the pattern and symmetry of joint involvement, locking of a joint after inactivity, and the presence of systemic symptoms. Some arthritic disorders reach far beyond the joints. Lupus is an autoimmune collagen vascular disorder, and about 90 percent of patients with it have musculoskeletal involvement, often mimicking rheumatoid arthritis in the fingers, wrist, and knee. Lupus can also bring a skin rash, extreme photosensitivity, hair loss, kidney problems, and shortness of breath from scarring in the lungs. Joint disease can announce itself through the skin too, with cutaneous nodules and vasculitis lesions, alongside features like lymphadenopathy, ocular inflammation, urethritis, and orogenital ulceration. Blood tells its own story. Doctors screen with rheumatoid factor, antinuclear factor, and extractable nuclear antigen. An elevated erythrocyte sedimentation rate or C-reactive protein level points to an inflammatory process, while anti-cyclic citrullinated peptide antibodies help confirm rheumatoid arthritis. X-rays remain the primary tool for osteoarthritis, revealing joint space narrowing, bone spurs, sclerosis, and bone cysts.

• 5. Easing The Pain

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  There is no known cure for arthritis and rheumatic diseases. Early treatment often starts with resting the affected joint and conservative measures such as heating or icing. Weight loss and exercise can reduce the force across a weight-bearing joint. Physical exercise of the affected joint has been shown to noticeably improve long-term pain relief, and exercise prescribed by a physical therapist has proven more effective than medications for osteoarthritis of the knee. Medication depends on the form. Acetaminophen, also called paracetamol, is the first-line treatment for osteoarthritis, while inflammatory arthritis turns to non-steroidal anti-inflammatory drugs such as ibuprofen. Topical NSAIDs may carry better safety profiles than oral ones, and severe osteoarthritis may call for intra-articular corticosteroid injections. Rheumatoid arthritis reaches further, into disease-modifying antirheumatic drugs, or DMARDs, including csDMARDs, TNF biologics, and tsDMARDs, designed to slow the disease's progression. Gout flares are managed with NSAIDs, colchicine, or glucocorticoids, while between flares patients take allopurinol or febuxostat to lower uric acid, or probenecid to help eliminate it. Surgery entered arthritis care in the 1950s, and joint replacement, known as arthroplasty, is now the primary surgical option for the shoulder, hip, and knee. A replaced joint can last anywhere from 15 to 30 years, after which patients can expect to return to activities such as swimming, tennis, and golf. For hands that struggle to turn a key or open a jar, adaptive aids can help, and it is now possible to 3-D print them as open source hardware to reduce patient costs.

• 6. A Burden Across Ages

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  Arthritis is predominantly a disease of the elderly, yet children can be affected too, sometimes presenting with a skin rash, fever, pain, and limitations in daily activities. It is more common in women than men at all ages and affects all races, ethnic groups, and cultures. A CDC survey using data from 2013 to 2015 found 54.4 million American adults, or 22.7 percent, reported doctor-diagnosed arthritis, and 23.7 million of them, 43.5 percent, had arthritis-attributable activity limitation. People with co-morbid conditions carried an even heavier load, with prevalence of 49.3 percent among those with heart disease, 47.1 percent with diabetes, and 30.6 percent with obesity. Disability from musculoskeletal disorders rose 45 percent from 1990 to 2010, and osteoarthritis is the fastest increasing major health condition. Data from Africa remain scarce. A systematic review pulling together twenty population-based and seven hospital-based studies, most of them from South Africa, found osteoarthritis prevalence as high as 55.1 percent in an urban setting, with knee osteoarthritis reaching 33.1 percent in rural South Africa. As the most common cause of disability in the United States, arthritis carries a total estimated cost close to $100 billion, almost half of it from lost earnings.

• 7. Bones Through Time

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  Dinosaurs show signs of it. Evidence of osteoarthritis and potentially inflammatory arthritis has been discovered in their remains, and the first known traces of human arthritis date back as far as 4500 BC. Early reports called it the most common ailment of prehistoric peoples, and it was noted in skeletal remains of Native Americans found in Tennessee and parts of what is now Olathe, Kansas. The disease left its mark on individuals history can still name. Ötzi, a mummy from around 3000 BC found along the border of modern Italy and Austria, carried it, as did Egyptian mummies from around 2590 BC. Understanding came slowly. In 1703, William Musgrave published the first edition of his major medical work, De arthritide symptomatica, on arthritis and its effects. Augustin Jacob Landré-Beauvais, a 28-year-old resident physician at the Salpêtrière Asylum in France, was the first to describe the symptoms of rheumatoid arthritis. He wrongly classified it as a relative of gout, but his dissertation pushed others to study the disease further. The treatment story turned a corner in the 1960s, when John Charnley completed the first total hip replacement in England to treat arthritis, a procedure that millions would later follow into operating rooms across the world.