A Medical Overview
A Medical Overview
Every 33 seconds—more than a million times a year—another American develops arthritis. Today, the Arthritis Foundation estimates that 40 million Americans, or one in seven, have some form of arthritis. Because arthritis tends to affect older people more often than younger people, that number is almost certain to increase in the coming years as our population in general begins to age. Current statistics indicate that the number of Americans ages 65 and older will double between 1990 and 2040.
In addition to the personal toll arthritis exacts, a tall financial bill results as well. Arthritis and related disorders cost the nation more than $50 billion every year in lost wages, medical bills, and other expenses. The National Arthritis Workgroup of the National Institutes of Health estimates that the disorders will add more than $95 billion to the nation's annual health costs by the year 2000. As it is, arthritis already accounts for an annual total of at least 26 million lost workdays and another 500 million restricted workdays every year.
What causes the disease at the root of this enormous health care problem? Who is at risk for developing it? Are there ways to prevent it? To cure it? These are the questions motivating medical researchers in laboratories around the world. If you or someone in your family suffers from arthritis, they are questions that demand an answer without delay.
The human skeleton, made up of more than 200 bones, is strong, resilient, and equipped with certain structures, called joints, that allow the body to bend, twist, and move in all the human ways to which we are accustomed. The joints of our fingers permit us to pick up utensils, to write with a pencil, and to grip a toothbrush, a golf club, or a knitting needle. Our knees bend so that we can run, kneel, and climb endless flights of stairs. Our hips pivot, making it possible for us to dance, crouch in the garden, and curl up to sleep. All of these joints as well as those of our elbows, spine, toes, and ankles allow us to perform the very movements that make us vital, active people.
As is so often true, however, we tend not to appreciate how remarkable the human body is until it begins to fail us. Most cases of arthritis begin slowly, bit by bit robbing an individual of a touch of mobility here, a moment of comfort there. Often, however, the disease progresses, eating into daily activities and imposing ever deepening levels and periods of pain. To fully understand this process, it is necessary to first examine a healthy joint and how it behaves.
THE ANATOMY OF A JOINT
Simply put, a joint is the point of intersection of two or more bones. We further characterize joints in a number of different ways. First, joints are characterized by the degree of motion they allow, from very subtle to free range of movement. The skull, for instance, contains joints along suture lines which allow very tiny movement in one direction. The joints in the hips, wrist, and ankles, in contrast, allow pretty free movement—up and down, sideways, and even a circular motion. Thus, free-moving joints are further categorized by the direction in which they move. Here are some of the major categories of free-moving joints and how they work:
Ball-and-Socket Joint. In this type of joint, the end of one bone is round and fits neatly into a cuplike socket that forms the end of another bone. Such a construction permits movement in all directions. The hip and shoulder are two examples of ball-and-socket joints.
Gliding Joint. A gliding joint is constructed in such a way as to allow for only limited, gliding movement; the ligaments and other tissues around each gliding joint limit motion. The vertebrae and the ribs are examples of gliding joints.
Hinge Joint. This type of joint permits extensive movement—but only in one direction. Elbow joints, knee joints, and the joints of the fingers are all examples of hinge joints.
Saddle Joint. So named because the opposing bones are convex and concave and fit together to form what looks like a rider upon a saddle, this type of joint can move up and down and side to side, but cannot rotate. The wrist and thumb are two examples of saddle joints.
Finally, we also refer to joints as being either weight-bearing or nonweight-bearing, depending on their function in the body. Weight-bearing joints, such as the ankles, knees, hips, and vertebrae, bear the brunt of the physical stress placed on the body. Joints in the upper body, such as the fingers, wrists, and shoulders, are considered nonweight-bearing joints.
As different in function as joints tend to be, all free-moving joints—such as those described above and the ones most commonly involved in arthritis—have similar components that, if healthy, allow movement to occur without pain or inflammation. Let's examine them one by one, then explore what happens when arthritis takes hold:
Cartilage. Cartilage is a smooth, resilient material that coats the ends of bones, forming a cushion that protects the bones from rubbing against each other. Cartilage has a slick exterior, which allows bones to slide over each other, and a spongy, compressible interior that is able to absorb shock. It is composed mostly of water and a substance called collagen (made up of long protein molecules woven together). Collagen also forms the connective tissue that makes up the white, inelastic fibers of the ligaments and bones.
Joint Capsule. Also called the synovial sac, the joint capsule completely encases the ends of bones and cartilage. Lining the joint capsule is the synovial membrane, a thin, delicate lining rich in blood vessels and nerve endings. In a healthy joint, this membrane produces a clear, viscous fluid that acts to lubricate the joint and nourish the cartilage, which has no blood supply of its own.
Connective Tissues. Thick, cordlike fibers called ligaments, anchored to the bone on either side of the joint, help form the outside of the joint capsule. Ligaments help to keep the bones in correct alignment. Strong fibrous bands called tendons attach muscles to bones. Muscles are tissues made up of fibers that are able to contract, allowing the parts and organs of the body to move.
Bursae. Just outside the joint capsule lie small fluid-filled sacs called bursae. Bursae produce a lubricating liquid that helps muscles, tendons, and bones slide over one another.
When all of these components work together as they should, the human body is able to move smoothly and with remarkable flexibility and grace.
The Process of Arthritis: Causes and Risk Factors
As discussed in Chapter 1, arthritis is a term used to describe a group of diseases that affect one or more of the structures in and around the joint, including the synovial membranes, cartilage, muscles, tendons, ligaments, muscles, bones, and/or bursae. In medicine, the suffix -itis means inflammation. Inflammation is actually the immune system's response to infection or injury. Most forms of arthritis involve this immune system reaction. Following is a discussion of some of the most common categories of arthritis according to the structures that are most involved:
Joint Membrane Inflammation. This type of arthritis involves inflammation of the synovial membrane, the thin lining of the joint. When this occurs, the normally smooth, thin, inner membrane becomes thickened and swollen. Both the joint fluid and the synovial lining become inundated with white blood cells—cells of the immune system produced when injury or infection occurs. In addition to the pain this process causes, the white blood cells may also produce substances that can wear away the bone's protective cartilage to form gaps called erosions. Eventually, if the condition goes untreated, so much cartilage can wear away that the ends of the bones become exposed and rub together. Eventually bone erosion and destruction may also occur. Also called synovitis, these processes are the hallmarks of rheumatoid arthritis, the second most common form of arthritis (after osteoarthritis).
Cartilage Breakdown. Degeneration of cartilage, the material that covers the ends of bones, is a major characteristic of osteoarthritis. When cartilage breaks down, it becomes cracked and uneven, exposing the bones and allowing them to rub against each other. The bones may then thicken, cysts (pockets of fluid) may form, and joint space may narrow further. A degenerative joint disease most associated with aging or a previous injury to the joint, osteoarthritis may or may not involve inflammation as part of its process.
Metabolic Disorders. In this type of arthritis, tiny crystals form in the joint space when the level of certain blood chemicals becomes too high. White blood cells rush to the site, causing the joint to become inflamed and painful. Gout is the most common form of this type of arthritis and occurs when too much uric acid, a blood protein, is present in the body.
Infections. A number of infectious agents, including viruses and bacteria, can invade the joint spaces, resulting in inflammation. The most common types of infectious arthritis are acute and caused by bacteria, particularly the gonococcus (which causes gonorrhea) and staphylococcus (which causes several different types of disease). A recently identified type of chronic infectious arthritis is called Lyme disease, named after the town in Connecticut that reported the first cases. Caused by an organism called a spirochete, Lyme disease is transmitted to humans through the deer tick. Its symptoms range from transitory flulike symptoms to severe, persistent joint pain. Generally speaking, however, acute infectious arthritis is not a common disease, and most cases occur in people who have preexisting arthritis or a disease (such as cancer) that lowers their immune response to these invading organisms.
Traumas and Injuries. Over time, undue stress placed on the joints can result in inflammation of the tendons and muscles, as well as the joint capsule, causing pain and stiffness. Damage to knees caused by the stress that being overweight places on these joints is one example of trauma-induced arthritis; bone changes in the feet of runners and basketball players is another.
Connective Tissue Disorders. Connective tissue diseases involve inflammation of tissues that support and connect tissues and body organs. Connective tissue is the major component of bone, cartilage, skin, and blood vessles. A systemic arthritis, such as rheumatoid arthritis or systemic lupus erythematosus, often affects connective tissues throughout the body, causing achiness and fever in addition to local joint inflammation. Sometimes, these diseases can cause damage to other body organs as well.
Spinal Stiffening. In a form of arthritis known as ankylosing spondylitis, the ligaments and tendons attached to the vertebrae become inflamed, thickened, and scarred. The bones in these joints may grow into one another, eventually becoming fused, resulting in stiffness and loss of mobility. Ankylosing spondylitis is often related to other disorders, such as Reiter's syndrome (characterized by urinary, eye, and joint inflammation) or ulcerative colitis (a chronic inflammatory disease of the large intestine and rectum).
As you can see, several things can go wrong with the joints and surrounding tissues in your body. Still mysterious, even to doctors, are the reasons why such damage occurs. Are you at risk for developing one or more of these conditions? Take the self-test below to see how arthritis might affect you, today or in the future:
Rheumatoid arthritis is a degenerative condition. It begins with inflammation of the synovial membrane (a) and progresses to the erosion of cartilage (b and c). Eventually, the joint cavity is destroyed, the bones rub together and erode, and the joint may be fused (d).
Arthritis Risk Factor Quiz
Answer yes or no to the following questions:
1. Have you always maintained a healthy weight?
2. Does any form of arthritis run in the family?
3. Have you sustained a traumatic or repetitive strain injury to any of your joints?
4. Have you been diagnosed with an autoimmune disease, such as lupus?
5. Do you exercise on a regular basis?
6. Do you eat a varied diet rather than a few of the same foods over and over again?
7. Do you have any allergies or food sensitivities?
8. Are you taking any medications on a regular basis, particulary for high blood pressure?
How did you do? Your answers may indicate that you may well be at risk for developing arthritis or for making a minor condition worse. Let's see what your answers might mean to the future of your health.
Excess Weight. The most common form of arthritis is osteoarthritis, a condition that can be triggered or exacerbated by the added stress and strain to the joints caused by carrying too much weight. When someone with osteoarthritis or, in fact, any type of arthritis, is overweight, he or she places an additional burden on joints already made vulnerable by disease. Maintaining a healthy weight, therefore, can help you to both prevent the onset of arthritis and limit the number and intensity of flare-ups if you already suffer from the disease.
Heredity. It has long been observed that arthritis tends to run in families. That is, if your parents, grandparents, or siblings suffer from one type of arthritis, you may have a greater risk of developing the disease than someone without a family history. Indeed, genetics—the study of the principles and mechanics of heredity—may well provide the biggest clue to the mystery of arthritis so far uncovered. Several years ago, scientists discovered that some common arthritic diseases are associated with the presence of certain genetic markers known as human leukocyte antigens (HLAs). Most people with rheumatoid arthritis, for example, carry the genetic marker HLA-DR4, while those with ankylosing spondylitis carry HLA-B27. The presence of these markers may indicate that the affected individual has a greater risk of developing arthritis than someone without the marker.
However, it must be stressed that having a family history of arthritis or even having one of the genetic markers that indicate a predisposition to the disease, does not mean that you are doomed to develop it. In fact, researchers believe that genetics and some other trigger—such as an infection, allergy, injury, exposure to chemicals, or an autoimmune response—must work together in order to stimulate the arthritic process. Avoiding or limiting your exposure to these triggers may well prevent you from developing arthritis, no matter how strong your family history of arthritis is.
Trauma and Injury. Several different types of arthritis appear to be triggered or exacerbated by trauma or injury, either to the joint itself or to the surrounding ligaments, bursae, muscles, and tendons. Worth special mention are repetitive strain injuries, caused by performing the same movement over and over again, such as typing at a computer console or lifting heavy packages on a loading dock. Over time, such injuries may cause constant low-grade inflammatory reactions that end up permanently damaging joints.
Infections. Infectious arthritis occurs as a complication of a disease caused by a virus, bacterium, fungus, or other agent. In most cases, it results in a case of acute arthritis that dissipates once the infection is treated. Among the most common infectious triggers are the sexually transmitted chlamydial disease and gonorrhea, as well as Salmonella and Shigella, two bacteria known to cause gastrointestinal disorders. As far as chronic arthritis goes, the most common infectious trigger is Lyme disease, carried by deer ticks. Protecting yourself from exposure to these infectious agents is one way to help cut down your risk of developing arthritis or avoid flare-ups should you already have the disease.
Exercise. Exercise—perhaps the single most important factor in maintaining the health of our joints, bones, and supporting structures—is often the most neglected aspect of our daily lives. As well as helping the heart, brain, and other internal organs stay healthy and fit, exercise has special advantages as far as the joints are concerned. By moving your joints daily, you'll keep them fully mobile and supple. Joint movement also helps to transport essential nutrients and waste products to and from your cartilage. Weight-bearing exercises help to strengthen your muscles, providing your joints with extra support, as well as help to reduce your chances of developing osteoporosis, a disease characterized by thinning bones and often associated with arthritis.
Varied Diet. Food allergies and sensitivities may be more common than we realize. By eating a varied diet, rich with vitamins and minerals, you'll stand a greater chance of providing your body with all the raw ingredients it needs to be healthy. If your diet is deficient in one or more essential nutrients, however, you may be putting your joints at risk for deterioration and pain. In addition, eating too much sugar, drinking too much alcohol, and consuming too much caffeine may also have an impact on the health of your joints and your body in general.
Allergies or Food Sensitivities. The link between allergies, particularly those caused by the foods we eat, and arthritis remains the subject of intense investigation by scientists around the world. Allergies result from an overstimulated immune system, the same body system implicated in the process of arthritis. If you suffer from allergies, then you may be at increased risk of developing arthritis or of provoking flare-ups should you already have the disease. Furthermore, you may be eating foods that, unbeknownst to you, exacerbate your condition. Foods of the nightshade family, such as eggplant and tomatoes, are among those most closely linked to arthritis.
Medications. In rare cases, it appears that some medications may trigger the onset of certain arthritic diseases, including systemic lupus erythematosus and gout. In most cases, the arthritic symptoms disappear once the person stops taking the offending medication. If you take any of the following medications and suffer from symptoms of arthritis, check with your doctor to make sure you are not experiencing a drug reaction:
Isoniazid and ethambutol (used to treat tuberculosis)
Hydralazine (used to treat high blood pressure)
Procainamide (for heart rhythm problems)
Chlorpromazine (used for a variety of problems, including migraine headache and nausea)
Aspirin (if taken on a regular basis, may cause buildup of uric acid, leading to gout)
As you can see, the causes and courses of arthritis are varied and often hard to pinpoint. In some cases, the aches and pains we feel will never receive a definitive diagnosis at all, but will be labeled "arthritis" or "rheumatism" simply because no other conclusion can be reached.
If that's the case, you may ask, why bother to see a doctor at all? Without alarming you unduly, there are some serious medical problems that have chronic joint pain as one of their symptoms, including viral and bacterial infections and certain cancers. Ruling out these conditions, as well as pinpointing exactly which joints are currently involved in the arthritic process and to what degree, are among the reasons you should see your physician if you experience joint pain.
If you're like most people, your primary care physician will be the first to consider your symptoms. Because arthritis is such a common condition, he may be experienced enough to make an accurate initial diagnosis. Depending on the severity of the disease and the level of his expertise, he may then refer you to a rheumatologist, a specialist fully trained in general internal medicine who has studied arthritic diseases an additional two or three years. Another specialist you may consult, especially if your problem is injury-related, is an orthopedist. An orthopedist is a surgical specialist in the treatment of joints, muscles, and related structures. Should your doctor suspect that nerve damage has occurred, he may refer you to a neurologist, a specialist in the study and treatment of diseases of the central and peripheral nervous system. If you also have rashes and other skin problems, as is often the case with lupus, you may decide to see a dermatologist, a doctor specializing in the skin.
Internal medicine, rheumatology, orthopedics, neurology, dermatology—the list of specialities involved in the treatment of arthritis seems daunting. In fact, this highlights a crucial aspect of disease as viewed by mainstream, Western medicine. According to this perspective, each part of the body is considered a distinct and separate entity, largely unconnected to the others. Alternative medicine, on the other hand, views the body as an integrated whole: To distinguish between a problem that causes a rash and a problem that causes joint pain—simply because two different areas of the body are involved—is considered an arbitrary and meaningless procedure within this tradition. Furthermore, and perhaps even more fundamentally, alternative medicine does not, as so often does mainstream medicine, make a sharp distinction between the physical and emotional. An alternative medical practitioner is likely to view the state of your mental and emotional health as equal in importance to the state of your physical being. In fact, you may be surprised at how much time you spend discussing personal issues and habits with an alternative practitioner.
Despite what might be considered shortcomings in the mainstream approach to a chronic condition like arthritis, modern medicine does offer the best technological tools for making a diagnosis—at least from a purely mechanical perspective. When you visit your doctor for an evaluation, you will probably be taken through an exam consisting of some or all of the following:
Taking a Medical History
The first step in almost every medical exam—mainstream or alternative—consists of the physician or practitioner asking you several questions about your current medical condition, your past experiences, and your family history of disease. He will also delve into aspects of your lifestyle—what kind of work you do, your hobbies, the amount of stress under which you live, and what kind of diet you consume on a regular basis, among other issues—at least to some degree. Generally speaking, an alternative practitioner will pay far more attention to these matters than will a mainstream physician.
Of special importance is a thorough and accurate description of your joint pain and other symptoms. Your doctor is likely to ask you some or all of the questions listed below. Before your first appointment, take a look at these questions and think about how you'll answer them. The more accurate you can be about your symptoms and what you think may contribute to them, the closer your doctor can get to a realistic diagnosis and treatment plan.
Things to Think About Before You See Your Doctor
1. Which of your joints hurt?
2. When is the first time you remember having pain? Did it follow an injury or trauma?
3. Has the joint pain spread to more than one joint?
4. Is the pain sharp or dull?
5. What makes the pain get worse?
6. What makes the pain go away?
7. What time of day is the pain at its worst?
8. Do your joints lock or give way?
9. Do you feel stiff in the morning?
10. Do you have fever? Have you noticed a rash?
11. Have you lost or gained weight?
12. What past medical treatment have you had, for this problem and for others?
13. Are you currently taking drugs (either prescription medication or illegal substances)?
14. Does your arthritis affect your ability to work?
15. Do you feel unusally tired during the day?
16. Do you have symptoms of depression (listlessness, sadness, helplessness, loss of appetite) or anxiety?
After you and your doctor sort through these issues and discuss all aspects of your past medical history, you will likely embark upon the second part of the evaluation procedure: the physical examination.
THE PHYSICAL EXAM: WHAT TO EXPECT
As you might suspect, the doctor will want to take a careful look at the way you move in general, the way your joints react to specific movements, and how much pain these movements cause you. Your physician will probably begin her evaluation by systematically examining all of your joints on both sides of your body. Most likely, she will start with your hands, since the hands are involved in many different types of arthritic conditions. As the doctor touches your joints, she will be looking for signs of inflammation, including redness, swelling, and/or tenderness, especially of the synovial membrane (joint lining). Synovial inflammation may also cause the joint to become thickened and rubbery, a state that the doctor can feel by pressing gently on the affected joint.
The doctor will also pay careful attention to your hips, knees, spine, and specifically any joints that have caused you the most trouble in the past. She may ask you to perform certain movements, like bending down to touch your toes or taking deep breaths to see how flexible your spine is. Because joints can lose function as a result of severe inflammation or cartilage degeneration, your doctor will need to assess the range of motion of your joints. Range of motion is usually measured in degrees. The knee joint, for example, can normally be extended to a straight line, or 180 degrees. If the knee is damaged, the doctor may describe the problem as a 30-degree lack of extension.
Some forms of arthritis produce easily recognized signs of illness, some of which are permanent and others reversible. Lupus, for example, often involves a characteristic facial skin rash as well as a related blood vessel problem (known as Raynaud's syndrome) that results in fingers turning blue and white in the cold. Rheumatoid arthritis can produce characteristic changes in the shapes of the fingers, which may become crooked or drift to the side. Osteoarthritis may produce knobby enlargements in the joint of the fingertips—called Heberden's nodes—which may appear in one or more fingers of an afflicted individual. By assessing such changes, and other accompanying symptoms, your doctor can further define your medical condition.
Finally, depending on the conclusions your doctor reaches from your medical history and physical exam, he or she may suggest you undergo one or more of the following laboratory tests. Generally speaking, however, only a fe
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