Coping with Arthritis in Its Many Forms

by Carolyn J. Strange

It may begin as a slight morning stiffness. For the lucky person with arthritis, that's as far as it goes. But for millions of others, arthritis can become a disabling, even crippling, disease. Roman Emperor Diocletian exempted citizens with severe arthritis from paying taxes, no doubt realizing that the disease itself can be taxing enough.

One in seven Americans--nearly 40 million--have some form of arthritis. That number will climb as the baby boomers age. By 2020, about 60 million Americans will have arthritis, according to The National Arthritis Data Workgroup of the National Institute of Arthritis and Musculoskeletal and Skin Diseases. The disease is physical, but also exacts a mental, emotional and economic toll.

"Chronic illness impacts a person's entire lifestyle -- work, family and recreation," says Gail Wright, Ph.D., a rehabilitation psychologist at the University of Missouri, Columbia. To improve quality of life, doctors and health educators increasingly advise combining drug treatment with education, social support, and moderate forms of exercise.

Arthritis means joint inflammation. In a normal joint, where two bones meet, the ends are coated with cartilage, a smooth, slippery cushion that protects the bone and reduces friction during movement. A tough capsule lined with synovial membrane seals the joint and produces a lubricating fluid. Ligaments surround and support each joint, connecting the bones and preventing excessive movement. Muscles attach to bone by tendons on each side of a joint. Inflammation can affect any of these tissues.

Inflammation is a complex process that causes swelling, redness, warmth, and pain. It's the body's natural response to injury and plays an important role in healing and fighting infection. Joint injury can be caused by trauma or by the wear and tear of aging. But in many forms of arthritis, injury is caused by the uncontrolled inflammation of autoimmune disease, in which the immune system attacks the body's own tissues. In severe cases, all joint tissues, even bone, can be damaged.

The general term arthritis includes over 100 kinds of rheumatic diseases, most of which last for life. Rheumatic diseases are those affecting joints, muscle, and connective tissue, which makes up or supports various structures of the body, including tendons, cartilage, blood vessels, and internal organs. The Food and Drug Administration has approved a wide variety of drugs to treat the many forms of arthritis.

The most common type of arthritis is osteoarthritis, affecting more than 16 million Americans. This degenerative joint disease is common in people over 65, but may appear decades earlier. It begins when cartilage breaks down, sometimes eroding entirely to leave a bone-on-bone joint in extreme cases. Any joint can be affected, but the feet, knees, hips, and fingers are most common. It may appear in one or two joints and spread no further. Painful and knobby bone growths in the fingers are common, but usually not crippling. The disease is often mild, but can be quite severe.

Second most common is rheumatoid arthritis, which affects 2.5 million Americans. It can strike at any age, but usually appears between ages 20 and 50. The hands are most commonly affected, but it can affect most joints of the body. Inflammation begins in the synovial lining and can spread to the entire joint. Highly variable and difficult to control, the disease can severely deform joints. Some people become bedridden. Others continue to run marathons.

An autoimmune disease affecting the whole body, rheumatoid arthritis can also cause weakness, fatigue, loss of appetite, muscle pain, and weight loss. Blood tests may reveal anemia and the presence of an antibody called rheumatoid factor (RF). However, some people with RF never develop rheumatoid arthritis, and some people with the disease never have RF. In about one in six, the disease becomes severe and can shorten life. Researchers hope to find ways to predict which patients should be treated more aggressively.

Two Most Common Forms of Arthritis

Normal Joint: In a normal joint (where two bones come together), the muscle, bursa and tendon support the bone and aid movement. The synovial membrane (an inner lining) releases a slippery fluid into the joint space. Cartilage covers the bone ends, absorbing shocks and keeping the bones from rubbing together when the joint moves.

Osteoarthritis: In osteoarthritis, cartilage breaks down and the bones rub together. The joint then loses shape and alignment. Bone ends thicken, forming spurs (bony growths). Bits of cartilage or bone float in the joint space.

Rheumatoid Arthritis: In rheumatoid arthritis, inflammation accompanies thickening of the synovial membrane or joint lining, causing the whole joint to look swollen due to swelling in the joint capsule. The inflamed joint lining enters and damages bone and cartilage, and inflammatory cells release an enzyme that gradually digests bone and cartilage. Space between joints diminishes, and the joint loses shape and alignment.

Ups and Downs

With so many kinds of arthritis, which can appear and progress unpredictably, diagnosis and treatment can be trying for both physician and patient. Diagnosis depends on integrating a host of factors, including the possibility that a person may have two forms of the disease.

The normal ups and downs of chronic, painful disease further complicate matters. "Just about any painful condition will wax and wane on its own," says rheumatologist Dennis Boulware, M.D., University of Alabama, Birmingham.

A worsening or reappearance of the disease is called a flare. Remissions bring welcome relief, but can also obscure whether symptoms decreased on their own or due to treatment.

Proper treatment depends on correct diagnosis of the specific disease, and varies with severity and location, as well as from person to person. But treatment need not wait for a final diagnosis because initial treatment options, such as anti-inflammatory drugs and exercise, are similar for many forms of the disease. Treatment should begin early to reduce joint damage.

The drugs used for treating most types of arthritis are drawn from many categories, but can be thought of in a few broad groups, such as anti-inflammatory drugs and disease-modifying drugs. For treating gout, there are also drugs that reduce the amount of uric acid in the blood. More than one medication may be required for treating arthritis.

Anti-inflammatory agents generally work by slowing the body's production of prostaglandins, substances that play a role in inflammation. Many have an analgesic, or painkilling, effect at low doses. Usually, higher, sustained doses are required to see sufficient anti-inflammatory activity for treating arthritis. The most familiar anti-inflammatory agent is aspirin, often a good arthritis treatment. Like aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) fight pain and inflammation. More than a dozen NSAIDs are available, most by prescription only. At press time, FDA was considering whether labeling changes to prescription-strength NSAIDs are necessary, due to gastrointestinal side effects.

FDA has approved three NSAIDs for over-the-counter (OTC) marketing: ibuprofen (marketed as Advil, Nuprin, Motrin, and others), naproxen sodium (sold as Aleve), and ketoprofen (marketed as Actron and Orudis). Although these drugs are available OTC, a doctor should be consulted before taking any medication for arthritis symptoms.

"People shouldn't be mixing these medications," says Linda Katz, M.D., of FDA's Center for Drug Evaluation and Research, and anyone regularly taking NSAIDs should carefully read the labels of OTC products to make sure they don't contain similar drugs. For example, many cough and cold preparations contain analgesics such as aspirin, acetaminophen or ibuprofen.

The most potent anti-inflammatories are corticosteroids, synthetic versions of the hormone cortisone. Like prednisone and dexamethasone, the generic names often end in "-one." They're usually reserved for short periods of use during intense flares or when other drugs don't control unrelenting disease. Relief can be dramatic, but long-term use causes side effects, such as weight gain, high blood pressure, and thinning of bones and skin. Usually given orally, they can also be injected directly into a joint to reduce side effects.

Disease modifiers slow the disease process in autoimmune diseases such as rheumatoid arthritis or systemic lupus erythematosus. Patients taking these drugs are closely monitored. It may take weeks or months to learn if a drug works. During that wait, it's important to keep taking other medications such as NSAIDs. Gold salts have been used to treat rheumatoid arthritis for 60 years, although nobody knows why this treatment works. Penicillamine, methotrexate, and antimalarials such as hydroxychloroquine are also used. Doctors usually reserve other powerful drugs that suppress the immune system for extremely serious disease.

Most people with arthritis never need surgery, but when all else fails, it can dramatically improve independence and quality of life by reducing pain and improving mobility. The surgeon may remove damaged or chronically inflamed tissue, or replace the joint entirely. Artificial replacements are available for all of the most commonly affected joints.

Use It or Lose It

In the past, doctors often advised arthritis patients to rest and avoid exercise. Rest remains important, especially during flares. But doing nothing results in weak muscles, stiff joints, reduced mobility, and lost vitality. Now, rheumatologists routinely advise a balance of physical activity and rest. Exercise offers physical and psychological benefits that include improved overall fitness and well-being, increased mobility, and better sleep.

For example, twice a week for three years, Elsie Sequeira, 81, of Concord, Calif., has attended a water-based exercise class sponsored by the Arthritis Foundation. "It's helped me a lot," she says. Sequeira has rheumatoid arthritis in her shoulders and legs. She had also had a mild stroke and got to her first classes with the help of a walker and an attendant.

A few weeks passed before she saw any improvement, but within a few months she no longer needed either the walker or the attendant. "The warm water is very soothing and we can do things in the water that we couldn't do on land," Sequeira says. She enjoys the social contact, and feels better able to take care of herself. "I don't feel so hamstrung," she says.

Joints require motion to stay healthy. That's why doctors advise arthritis patients to do range-of-motion, or flexibility, exercises every day--even during flares. Painful or swollen joints should be moved gently, however.

Strengthening and endurance activities are also recommended, but should be limited or avoided during flares. Arthritis patients should consult their doctors before starting an exercise program, and begin gradually. Exercises must be individualized to work the right muscles while avoiding overstressing affected joints. Doctors or physical therapists can teach proper ways to move.

Muscle strength is especially important because strong muscles better support and protect joints. "Several studies show that if you improve muscle strength, you decrease pain," Boulware says. Joints will probably hurt during exercise, but shouldn't still hurt several hours later.

"There's a fine line between doing too much and too little," says rheumatologist William Ginsburg, M.D., of the Mayo Clinic, Jacksonville, Fla. "Sometimes people have to be reminded to slow down and listen to their disease."

Support groups and arthritis education can help people learn how to listen to their disease, and cope with it. "The psychological aspects are very important because that's what changes people's lives," Ginsburg says.

Participants learn practical things, such as how to: get up off the floor after a fall, protect joints with careful use and assistive devices, drive a car, get comfortable sleep, use heat and cold treatments, talk with their doctors, and cope with emotional aspects of pain and disability. They may also learn to acquire and maintain what health experts have long touted--a positive attitude.

Health education not only improves quality of life, but also lowers health-care costs, and the benefits are lasting, according to studies at Stanford University, Palo Alto, Calif. Four years after a short Arthritis Self-Management Program, participants still reported significantly less pain and made fewer physician visits, even though disability increased. The benefits came, not from the specifics taught, but from improved ability to cope with the consequences of arthritis--in other words, confidence. "It's the same thing that any good coach tries to instill," says Halsted R. Holman, M.D., Stanford University.

Avoiding Fraud

Learning to understand their disease can also help make people less likely to fall victim to fraud. Because they have a painful, incurable condition, people with arthritis are among the prime targets for fraud and spend nearly a billion dollars annually on unproved remedies, largely diets and supplements.

A claim describing the relationship between a nutrient or dietary ingredient and a disease, such as arthritis, cannot be made on the label or in labeling of a food or dietary supplement unless the claim is authorized by FDA. In order for FDA to consider authorizing the use of a health claim, there must be significant agreement among qualified experts that the health claim is scientifically valid. As of December 1996, FDA had not authorized any health claims for a relationship between any food or dietary supplement ingredient and arthritis. Sometimes, however, food or dietary supplement products are found on the market with unauthorized claims.

"If the claim sounds too good to be true, it probably is. Talk to your doctor or other health professional," says Peggy Binzer, a consumer safety officer in FDA's Center for Food Safety and Applied Nutrition.

Some remedies, such as vinegar and honey or copper bracelets, seem harmless. But they can become harmful if they cause people to abandon conventional therapy. Others, such as the solvent dimethyl sulfoxide (DMSO), can be outright dangerous.

It's tempting to conclude that arthritis pain gets better or worse because of what was added or eliminated from the diet the day or week before. However, gout is the only rheumatic disease known to be helped by avoiding certain foods. The unpredictable ups and downs of arthritis make it hard to establish a relationship between diet and disease. Scientists have only recently begun to study nutritional therapy for arthritis, and the American College of Rheumatology (ACR) urges continued research.

The ACR Position Statement on Diet and Arthritis advises, "Until more data are available, patients should continue to follow balanced and healthy diets, be skeptical of 'miraculous' claims and avoid elimination diets and fad nutritional practices."

Research Under Way

New treatments are likely to stem from better understanding of the underlying causes and destructive processes of the disease. Overuse, injury and obesity are contributing factors in osteoarthritis, and researchers have implicated a faulty gene in the breakdown of cartilage. Heredity plays a role in other forms of arthritis, too, increasing susceptibility in some people. Potential genetic therapy approaches are still far off, however.

Increased knowledge of immunology and the inflammatory process offers more immediate promise. Researchers have developed a drug that blocks the effects of TNF-alpha, an inflammatory protein responsible for reactions resulting in joint damage. In short-term preliminary trials, the drug significantly reduced symptoms in rheumatoid arthritis patients.

Such results are encouraging, but the ultimate goal is to understand what starts the immune response in the first place. "Until you know the real cause, you're not going to have the right drug," Ginsburg says.

That quest continues and offers hope. But short of a cure, enlightened coping may be the most promising avenue to a less taxing life for people with arthritis.

Common Types of Arthritis

Of more than 100 different kinds of arthritis, these are the most common:

Osteoarthritis

Also called degenerative arthritis. Occurs when the cushioning cartilage in a joint breaks down. Commonly affects feet, knees, hips, and fingers. Affects 16 million Americans, mostly 45 and older. About half of those 65 and older have this form.

Rheumatoid Arthritis

Immune system attacks the lining, or synovial membrane, of the joints. Joint damage can become severe and deforming. Involves the whole body, and may also cause fatigue, weight loss and anemia, and affect the lungs, heart and eyes. Affects about 2.1 million Americans, three times more women than men.

Gout

Causes sudden, severe attacks, usually in the big toe, but any joint can be affected. A metabolic disorder in which uric acid builds up in the blood and crystals form in joints and other places. Drugs and attention to diet can control gout. Affects about 1 million Americans (70 to 80 percent men), with first attack starting between 40 and 50 years of age.

Ankylosing Spondylitis

A chronic inflammatory disease of the spine that can result in fused vertebrae and rigid spine. Often milder and harder to diagnose in women. Most people with the disease also have a genetic marker known as HLA-B27. Affects about 318,000 Americans, usually men between the ages of 16 and 35.

Juvenile Arthritis

The most common form is juvenile rheumatoid arthritis. Arthritis diagnosis, treatment, and disease characteristics are different in children and adults. Some children recover completely; others remain affected throughout their lives. Affects about 200,000 Americans.

Psoriatic Arthritis

Bone and other joint tissues become inflamed, and, like rheumatoid arthritis, it can affect the whole body. Affects about 5 percent of people with psoriasis, a chronic skin disease. Likely to affect fingers or spine. Symptoms are mild in most people but can be quite severe. Affects about 160,000 Americans.

Systemic Lupus Erythematosus

Involves skin, joints, muscles, and sometimes internal organs. Symptoms usually appear in women of childbearing age but can occur in anyone at any age. Also called lupus or SLE, it can be mild or life threatening. Affects at least 131,000 Americans, nine to ten times as many women as men.

Other forms

Arthritis can develop as a result of an infection. For example, bacteria that cause gonorrhea or Lyme disease can cause arthritis. Infectious arthritis can cause serious damage, but usually clears up completely with antibiotics. Scleroderma is a systemic disease that involves the sin, but may include problems with blood vessels, joints, and internal organs. Fibromyalgia syndrome is a soft-tissue rheumatism that doesn't lead to joint deformity, but affects an estimated 5 million Americans, mostly women.

Carolyn Strange is a freelance writer. This article originally appeared in the FDA Consumer magazine, published by the U.S. Food and Drug Administration, in 1997.