Dr Stuart Myers

Osteoarthritis v Inflammatory Arthritis


Cartilage is the smooth surface covering the ends of the bones in a normal joint. It allows the bones to move freely against each other and acts as a cushion.

             

The joint is surrounded by a Capsule. Thickenings of the capsule are called Ligaments and they provide stability to the joint.

The Synovium is a layer of tissue on the inside of the capsule. The synovium produces fluid which lubricates the joint and provides nutrition to the cartilage. Only a tiny amount of fluid is present in a normal joint ( eg 1/2ml in a knee).

 A normal  immune system acts as a natural defense, releasing antibodies against injury and disease. In autoimmune diseases such as Rheumatoid  arthritis, the body turns against its own tissues by releasing white blood cells and causing inflammation of the synovium. 

 

Arthritis:


Arthritis literally means inflammation of a joint. There are more than a 100 different types of arthritis. The most critical distinction is between Osteoarthritis and Inflammatory arthritis. Over time any type of arthritis can eventually result in damage to the cartilage and eventually result in bones rubbing against bones. There is no cure for arthritis. It can be “managed” with drugs and other therapies but like the treatment for High Blood pressure it is not curative.

  

Types of Arthritis:


1. Osteoarthritis

- “old age” or “wear and tear” arthritis.
- May follow an injury but usually genetically based  and runs in families.
- Effects the end joints of the fingers ( Bony swellings called Heberdens Nodes ) and the basal thumb joint.
- Typically results in pain with activity
- Pain fluctuates and may reduce as the joint gets stiffer
- Blood tests are normal

 

   

 

                         Osteoartritis                                          Rheumatoid Arthritis                               Normal

 

         

2. Inflammatory Arthritis

There are 100 different types of rheumatic conditions. The diagnosis early on may be difficult to confirm. An autoimmune disease is where the immune cells attack the body's own healthy tissues. The immune system is involved normally in fighting infection. In this case the immune system attacks the Synovium in joints and also around tendons. The synovium produces fluid containing enzymes which can eat away the joint surface and also result in tendon ruptures.

Features which assist in differentiating these conditions include;


- The Pattern of the arthritis – single or multiple, large joints or small, symmetrical or asymmetric   etc


- The Duration of the arthritis


- Associated clinical features 

                - Rashes,, Psoriasis,

                - Fever,

                - Bladder or Bowel disease,

                - Recent viral illnesses etc


- Blood tests

      - ESR and CRP  -  Non specific tests which lets you know that “ something is going on”

      - Uric acid – elevated in Gout

      - Rheumatoid factor & CCP – may be normal in 15% of patients with Rheumatoid Arthritis.

      - ANA = ( Anti Nuclear Antibody) 

                – a frustrating test positive in Lupus and other connective tissue diseases.

                - Often only slightly elevated and hence difficult to interpret. Titres-  80 , 160 , 320 , 640, 1280, 2560

      - Iron studies - elevated in Haemachromatosis

       - HLA B27 - Ankylosing Spondylitis

Common types of Inflammatory Arthritis:


Rheumatoid arthritis
Gout
Psoriatic arthritis
Lupus, SLE
Seronegative arthritis ( ie “Blood test negative” ) eg related to Crohn’s disease, Ulcerative colitis
Ankylosing spondylitis
Polymyalgia Rheumatica

Drug Types: “The treatment Ladder”

Many patients state that they are "Not pill takers". In Osteoarthritis one is treating the pain and the medications do not alter the natural history of the disease.

In Inflammatory arthritis medications CAN change the natural history of the disease and CAN prevent joint damage.

In this regard there is a significant Side Effect to Not taking medications prescribed by a Rheumatologist and that is progressive joint damage.

The natural history of Inflammatory arthritis has profoundly changed in the last 30 years due to  improved medical treatrment. Because of this the number of patients requiring surgical treatment for inflammatory Arthritis has decreased greatly.

The drug / Medical treatment starts with simple anti-inflammatories ( NSAIDS) and if the disease is controlled no further treatment is required. If the disease is not controlled then one "climbs" the ladder. The higher one goes the more effective the medications ( ie "The better the View") but the potential side effects may also increase ( (ie "Farther to Fall")

 

1. Analgesics (painkillers)


2. NSAIDs (nonsteroidal anti-inflammatory drugs such as Celebrex and Voltaren)


3. Corticosteroids (such as prednisone)


4. DMARDs (disease-modifying anti-rheumatic drugs such as methotrexate)


5. Biologics (Humira , Simponi)

Treatment for Osteoarthritis:

- Rest, Fish oil , Diet
- Panadol occasionally
- Panadol Regularly
- NSAIDS – “anti-inflammatories” – beware irritation of stomach. Always take with food.
- Heat packs, exercises to retain range of movement and muscle tone.
- Splints
- Cortisone injections
- Surgery – Arthroscopy
- Arthroplasty – replacing the basal thumb joint with tendon
- Arthrodesis – fusing or permanently stiffening a joint to remove the arthritis.
- Glucosamine – No credible evidence that this makes a long-term difference in osteoarthritis