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Arthritis is a general term that means inflammation of the joints. There are many types of arthritis, and of these, osteoarthritis (OA) is the most common type. In the United States and around the globe, osteoarthritis has been one of leading causes of disability and a lower quality of life. In the 2016 Global Burden of Disease Study by the Institute for Health Metrics and Evaluation, the incidence (the number of new cases of a disease) of osteoarthritis was found to be higher among high-income areas and among Caucasians compared to African Americans. The incidence also increases with age, especially in those between 50 and 70 years of age, and is higher in women compared with men. According to the Centers for Disease Control and Prevention (CDC), in 2015, it is estimated that over 30 million adults in the U.S. are affected by osteoarthritis. Worldwide, the most recent data from the Osteoarthritis Research Society International (OARSI) estimates that about 240 million people are affected.
The pain and joint dysfunction seen in osteoarthritis is often the result of abnormal changes in the joint tissues. A rubbery material called cartilage can be found where two bones meet and it allows bones to slide over each other without causing pain. In the early stages of osteoarthritis, this cartilage begins to swell in the areas that experience the most weight load.
This swelling occurs as surrounding protein structures draw in water and expand. Chondrocytes, which are the cells that make up cartilage, rapidly multiply and form clusters. As the disease worsens, there is increased production of enzymes that breakdown the cartilage (proteases) and proteins that promote inflammation (cytokines). The cells begin to die leading to a loss of cartilage. Due to a poor blood supply, cartilage has a limited ability to repair itself and once the cartilage is lost, it is not replaced. Over time, protein fibers called collagen produced by the chondrocytes abnormally harden or thicken which results in the formation of bone spurs at the ends or edges of the bone. In osteoarthritis, other parts of the joint are also affected including the ligaments, menisci in the knee, synovium and synovial fluid, and the joint capsule. The synovial fluid that surrounds the cartilage and helps to reduce friction can also become inflamed (synovitis). The joint capsule that surrounds the synovial fluid can thicken and is responsible for the joint enlargement seen in osteoarthritis.
In addition to old age and female gender, other risk factors of osteoarthritis include obesity, injury to the joint, genetics, and joint shape and alignment. It is believed that the changes associated with aging such as thinning of cartilage, less hydration, and an abnormal buildup of protein and calcium, contribute to osteoarthritis. Among women, especially in the years after menopause, the loss of estrogen is believed to play a role in the development of osteoarthritis. Obesity or excess body weight not only increases load on a joint but new evidence suggests that the fat hormone Leptin responsible for the feeling of fullness when eating can also promote inflammation and higher levels of this hormone in the blood and joints is seen in early arthritis. A type of osteoarthritis, called posttraumatic osteoarthritis, has also been known to develop after injury to a joint. Overuse, tears in the surrounding tissues, and bone fractures will often lead to swelling and overtime, the breakdown in collagen. Genetic studies have also found mutations in collagen types that have resulted in early osteoarthritis affecting teens and young adults as well as genes that may be responsible for abnormal joint shape. This abnormal joint shape which, for example, can be seen in the hip joint, may be present at birth, in addition to abnormal leg alignment where the joints of the knee point inward or outward. These deformities can place increased stress on the joint tissues, again leading to inflammation and joint damage.
The signs and symptoms seen in osteoarthritis can vary greatly and can range from having no symptoms but is seen on x-rays and on physical examination, to severe disability affecting movement, balance, and ability to perform daily activities. Osteoarthritis can affect one or multiple joints and most commonly affects the joints in the hands, feet, knee, hips, and spine. In the spine, arthritis contributes to lower back pain, spinal stenosis, knee pain, neck pain. The main symptoms of osteoarthritis include joint pain, stiffness, and decreased range of motion or flexibility. Pain is the most frequently reported symptom and is worse with joint use and improved with rest. This pain can be worse in the morning after waking up but can also be severe in the afternoon or early evening. Tenderness, or pain when the area is touched, can be present along the joint line which reflects disease where the cartilage meets, or away from the joint line which suggests damage in the surrounding tissues. Bone swelling may be seen as changes occur in the cartilage and bone spurs form. In advanced stages of the disease, the joint may appear deformed. Movement of the joint often becomes limited and can become unstable or “give way,” such as in knee osteoarthritis. In later stages of osteoarthritis, patients may experience muscle weakness and poor balance.
The diagnosis of osteoarthritis is often made based on characteristic signs and symptoms; however, when the diagnosis is unclear, different types of imaging methods can be used to assess its presence and severity. Radiography, or the use of x-rays, can detect the typical features of osteoarthritis including joint space narrowing from cartilage loss, bone spurs, and bone thickening. Magnetic resonance imaging (MRI) is not always necessary for patients with classic symptoms or have x-rays that already show the typical features but it is useful in identifying early stages of the disease and abnormalities in surrounding structures such as the ligaments, synovium, and the accumulation of fluid (effusions) not seen on x-ray. Similarly, ultrasonography can also be used to detect changes in the joint such as bone spur formation, effusions, and synovitis.
Osteoarthritis can have a great and often negative impact on mood, sleep, and can lead to problems in personal relationships, work performance, and participation in recreational activities. The management of osteoarthritis is largely directed at improving pain and functional ability. It should be ongoing and selected based on the individual patient’s, needs, values, and goals. There are multiple interventions that can be used in the management of osteoarthritis, depending on which joint or joints are affected, and can include pharmacologic options (where medication is used), nonpharmacologic options, and surgery. The management of osteoarthritis should always begin with nonpharmacologic therapies. Weight loss through diet and exercise has been associated with lower back pain reduction in the overweight and obese. Aerobic and strengthening exercises, tailored to each patient, can help prevent or reduce overall disability and improved shoulder pain or knee pain. Walking aids such as a cane and the use of orthotics (braces and splints) can provide support and may help to reduce pain. For those patients who have not responded well to these measures, medications or pharmacologic therapy may be considered and can be used in combination with the nonpharmacologic interventions. When only one or a few joints are affected, patients should start with topical (those applied on the skin surface) nonsteroidal anti-inflammatory drugs (NSAIDs) or topical capsaicin given their similar benefit and level of safety compared to NSAIDs taken by mouth (oral). If these topical treatments fail to provide enough symptom relief or if more several joints are affected, oral NSAIDs (e.g. ibuprofen, naproxen, meloxicam, diclofenac, indomethacin) may be considered next but taken on an as needed basis given their known risk for harmful side effects including those affecting the cardiovascular (heart and blood vessels), gastrointestinal (digestive tract), and renal (kidney) systems. If patients with osteoarthritis affecting multiple joints are unable to use NSAIDs, the antidepressant duloxetine may be tried as it has shown some benefit in lessening musculoskeletal and nerve pain. A steroid injection into the joint is another option for more moderate to severe osteoarthritis which has shown to provide short-term pain relief; however, it should not be used repeatedly because of the possibility of the opposite, negative effect of worsening cartilage damage. Knee pain and shoulder pain associated with arthritis may sometimes respond to steroid injection.
In the event that severe symptoms exist and are still unrelieved with conservative interventions as discussed, patients can be referred to a surgeon to be evaluated for possible total or partial joint replacement or correcting joint alignment and deformity. In looking at all of these options, consideration is given to the patient’s existing comorbidities (other diseases or medical conditions) such that if these treatments were used, they would not cause more harm. Furthermore, the creation of a successful plan should always include a discussion of the expectations of treatment, an explanation of the risks and benefits, an understanding of the patient’s previous experiences, the patient’s ability to cope, and the patient’s preference and goals.
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