What is arthritis and autoimmune disease

Introduction

                Arthritis and pain in the musculo-skeletal system is one of the commonest ailments affecting human kind. In a community at any given point of time, irrespective of climate, place affluence and poverty, more than 13% of the population suffers from pain in one or other joint. When pain arises from the joints with swelling and changes like limitation of motion, rise in temperature over the joint, then patients is said to have Arthritis. The term Arthritis is not synonymous to a disease. Arthritis is rather a symptom of a disease. Arthritis or arthalgia (pain in the joints) can be present in more than  hundred different conditions. The mere presence of a symptom suggesting joint pain should not trigger panic. General fear associated with joint pain is unwarranted; it is the disease-producing arthritis that determines the course of the disease and not the problem arthritis parse.

There are a lot of misconceptions, misbeliefs and apprehensions regarding arthritis. The perception that there is no escape from the pain and suffering caused by arthritis has led majority of arthritis patients to get severely distressed. The distress and unnecessary panic cause more disturbances than  problem. The root cause for  this is the  incomplete information about the disease, sometime total lack of awareness about arthritis.

Arthritis and its related disease, with few exceptions, parse is rarely responsible for the death of the patients. But what arthritis can produce in long term is severe disability if not appropriately  treated. (morbidity).  The major impact of arthritis is the work disability (handicap) and reduction in the quality of life. This can be well appreciated in the words of Galen, 19th century physician. "Now is it not a disgraceful state of affairs that a human, who had an excellent constitution, should need to be carried about by other people owing to Gout. Is it not that disgraceful that a person should, by reason of that extraordinary arthritis, be unable to use his hands and should need somebody else to bring food to his mouth and to perform his toilet necessary for him. Even if one looks upon the disgraceful aspects of this, yet one cannot overlook the pain these people suffer night and a day as though their maladies were twisting them on a rack. And the cause of all these must be referred to dissipation or ignorance or both."

In contrast to an acute infective illness, a patient with a chronic disease needs to know more facts about the disease. This not only reduces the patient apprehension but also helps him to take better care of himself. Like any other prolonged disease, arthritis if cared appropriately produces less discomfort and the patient can have a better quality of life.

This book is written with an intention to provide information in simple terms. This is not a substitute to your consulting rheumatologist or physician.

 

 

Musculo Skeletal System, Joints Bone and Muscles

Movement, as we all appreciate, is the essence of life. Movement is essential for breathing and eating. With the exception of  thinking activity, movement is an essential part of every activity. Human beings have evolved as bipedal (walking on two legs) creatures with extra-ordinary  mobility of the hands. These are achieved by  specialized, complex and well evolved  joints. The main effector of movement is the human locomotor system, which is constituted by the musculo-skeletal system. Muscles of varying sizes and strengths, bones of different sizes and shapes and the joints between the bones constitute the musculo-skeletal system. In addition, to locomotion the skeletal system has an important function of maintaining the frame and support for different structures of the body.

Joints are the junction points between two or more bones. Movement occurs at these junctions. The joints are perfectly designed to accommodate, as much movement needed at that area of the body, without compromising  on the supportive function. Before we understand arthritis, a brief knowledge about a normal joint is essential. This will help in understanding arthritis better.

 

Structure of a Joint

Joints are divided into three different types: Synovial joint, Fibrous joint and Cartilagenous joint. The synovial joint is designed for high and optimal mobility and is commonly affected in majority of arthritis. The fibrous and Cartilagenous Joints are more rigid joints, they have limited movement. These joints are formed by  tough fibrous or soft gelatinous Cartilagenous tissues which bridges the bones. They are present in junctions like chest bones with ribs, between two pubic bones and so on. These joints have limited mobility and are stronger. They contributi significantly to maintain the frame. Normally they are not affected in arthritis. The synovial joints are the commonest joint and are discussed below.

Synovial Joint

The synovial joints are formed between two bones and sometime with more than two bones. These joints are lined internally by a smooth synovial membrane and hence these joints are called synovial joints. The bone surfaces which appose each other in the joint are covered by the cartilage. The cartilage are smooth, spongy tissue which covers bony surfaces opposing each other inside the joint. They are called articular cartilage. . The smoothness of the articular cartilage surfaces is responsible for reduction in friction over  greater range of force and stress generated during movement. The articular cartilage has limited blood supply and in some joints may cover only partial surface of the apposing bone. Healthy cartilage is essential for a smoother movement in synovial joints. The regrowing and repairing capability of the cartilage is limited.

 Both the bones are wrapped into a joint cavity created by a capsule. The capsule hold bones tightly and attaches to either side bones closer to joint and forms a sequestrated space from surrounding area. This cavity is filled by a thin layer of viscous secretion, called synovial fluid, which acts as a lubricant, and also supplies nutrition to the structure. The synovial fluid is actively secreted by the membrane covering the joint called synovial membrane. The capsule is made of both tough collagens as well elastic fibers and can expand up to 4 and 6 times its normal size. The capsule is reinforced, at appropriate points, by thick bands of fibrous structures called ligaments. Ligaments are most often found outside joint cavities. With few exceptions, ligaments are responsible for stabilizing joints at different postures. In addition, ligaments limit the joint mobility at certain critical positions to avoid instability. (The representative knee joint picture shows these structures). The joint capsule has nerve supply which carry pain and also the information about the position of the joints. In the joint the capsule and ligaments when stretched generate pain in addition to surface of the bone. The cartilage and bone do not sense pain.

The human joints, especially those of the hands, are some of the most wonderful creations of nature.  Robotic research has been trying to imitate the manipulate power of human hands with limited success to date. This fact illustrates the importance to conserve the joint architecture for effective functioning.

The Bones

The bones are the toughest organs, reinforced by deposition of calcium. They constitute the framework of the body and are hence designated as the skeletal system. The muscles, with a few exceptions, are attached onto either side of a joint, as shown in figure 2. The contractile nature of these structures, on receiving stimuli (signals) from the nervous system, help in movement. The muscles, in co-ordination with signals from the higher nervous system, move the limbs at the joints and execute movement.

Nervous system

 joints, muscles and bones  together form the effector apparatus for a smooth and health movement.. Another important system, which actively guides the movement, is the nervous system, which initiate and maintain the movement and gets input by perceiving  positions, speed and pain through their sensory apparatus..

One has to appreciate the difference between all these four elements, nervous system, muscles, bones and joints, which are responsible for movement.  Quiet often, one may be confused wether the pain and limitation in movement faced is  from  bone, nerves muscles or joints. No doubt, pain can arise from any one of these. But, when we speak of arthritis, it is often with reference to the joints. In addition to joint, the bones may be affected. These are explained in another section.

 

Immune System, Autoimmunity and Joint Disease

We live in a very hostile atmosphere, surrounded by dust, chemical and microorganisms i.e., virus, bacteria and fungi. They tend to invade and inflict injury. Our body constantly defends itself against these insults and injury. This function is effectively carried out by the Immune system. In addition to defense function, the immune system takes part in several regulatory functions.

The immune system consists of cells, lymphoid organs and several proteins and non-proteins products. Lymphocytes, neutrophils, macrophages and other white blood cells form the immunologically active cells. The lymph nodes and spleen are the epicenters of immunological reaction. The Thymus and the bone marrow are the key locations where the immune-competent cells undergo development, selection and training before they are released into the circulation. These cells spread all over the body, sparing few sites.

The defense system is equipped with an inbuilt mechanism to identify self from non-self elements. They identify invading organisms and mount  appropriate immunological response. The entire attack is down regulated gradually once the invading organism is cleared. Subsequently, healing takes place. Thus an attack is precise and specific. In addition the immune system keeps them in memory for quiet a long time. The memorized response help in developing immunity against second time attack and also assist  the immune system  to better it's response if  similar situation  recurs. This principle is exploited in vaccination.

Despite such precise mechanism of identifying self and nonself  the immune system may mount an immunological response against some of  the self-constituent body tissue. This phenomenon of mounting an immunological reaction against self elements is called autoimmunity.

The question: ‘What triggers autoimmunity?" remains unanswered. The causes for autoimmunity are many. The breakdown in regulatory mechanism is said to be one of the most common reasons. Other reasons include: genetic susceptibility, molecular mimicry between host and infective micro-organisms, nonspecific stimulation of the immunological system by viral and other infections, may trigger autoimmunity.

In  19th century, when scientists described the immune system, they thought that immune  system should work without any inherent problems. The tendency of the system to develop a reaction against self was underestimated. From several studies, it is now very clear that the autoimmune response occurs at a frequency much higher than estimated. Fortunately, the majority of autoimmune reactions do not develop into serious illness. The diseases produced by autoimmunity depend on various factors. If the target is a single organ like the thyroid, autoimmunity either damages the organ and reduces its function or stimulates and increases it. For example, the destruction of the thyroid gland produces hypothyroidism (reduced production of the thyroid hormone). These kind of autoimmune diseases are called organ-specific autoimmunity. When the target is not specific and involves several organs, then it is called non-organ specific autoimmunity. In a majority of non-organ specific autoimmunity, a few of the common targets involved are the joints, the kidneys, and the eye. Other systems are also involved. Such preferential involvements of these organs are attributed to several anatomical and physiological factors.

Auto immunity more or less resembles a mutiny, where the army is attacking its own country. Conceptually unimaginable, it took  long time even for medical scientists to accept this. But, it occurs and recurs in a frequency greater than anticipated. It is a stranger way of getting a disease than anticipated by a majority of the patients.

These diseases are often seen in clusters within a family. The risk of developing this disease in an individual is higher with one of his parents being affected. The risk is 5-10 times than an individual without a family history. This is one of the most common apprehensions we see in patients, especially a concerned mother. The only reassuring words we pass on is that, the risk of getting a similar disease by her child is little higher than her normal neighbor. As it is not caused by any contagious, infective organism it does not spread from individual to individual.

Certain facts are interesting and should be remembered in autoimmune disease.

·         The defect is within the system and no extrinsic factors are continuously acting

·         The exacerbation and remission are characteristic features seen in a majority of these diseases.

·         In general, immune suppression and immune modulator drugs are used to manage them.

·         The prognosis of the disease depends upon the target organs involved, the extent and the severity of autoimmunity.

The involvement of a joint either as a direct target or as an additional one is commonly seen in several non-organ specific autoimmune diseases. The vascular permissiveness and the tendency of immune complexes to deposit in these areas are the probable explanations for predilection  joints in these disease. In some conditions like rheumatoid arthritis, the predominant target is the joint. Whereas, in diseases like systemic lupus erythematosus, the targets  are kidneys,. Thus autoimmune disorders that may  present initially with joint pains, need to be managed individually. The treatment plans in such diseases usually involves certain drugs that interfere with the functioning of the immune system. The treatment no doubt has certain risk, but, if used appropriately, gives a good result.

Arthritis – What is it?

The word arthritis, in medical terminology, means there is  inflammation in a joint. When there is only pain, it is called arthalgia. But in common layman terminology,  pain in a joint is often called as arthritis. . The term arthritis is often confused ( meaning : joint pain) as a distinct disease entity in lay public. We need to be clear here that  term arthritis is used   with reference to joint pain and represent a symptom. Throughout the discussion term arthritis is sometime used in place of arthralgia to avoid confusion.

Any pain in and around a joint is called joint pain.(quiet often misunderstood as arthritis). Pain referring to a joint may arise from bone, muscles and ligaments or from the other surroundings structures. Hence, one has to remember that pain in a joint does not always mean pain  arising from the joint. . The important fact is  arthritis perse doesn't specify any disease. The joint may ache because of different diseases. The term Arthritis is like term Fever- a symptom.. Fever, as all of us know, is a state, where body temperature rises above normal. Fever can be because of viral fever, tuberculosis, and several other conditions. Similarly, when there is a joint pain or arthritis, we need to know what is responsible for producing joint pain or arthritis.. Recognizing the condition responsible for joint pain leads to  diagnosis.

There are some arthritis conditions that heal themselves. Some of them may persist for longer time. Hence, as soon as there is some pain in joint, one need not panic. At the same time, one should not neglect it. While analysing the pain in joint we have  to differentiate a true pain arising out of joint to common pains which may be because of excessive abuse of a joint. In the management of arthritis, a physician or rheumatologist exercises his/her skill in evaluating the joint pain to make a diagnosis. The diagnosis of an arthritis is the most critical step in the management of arthritis related disease..

Arthritis anyway – What difference it makes?

All disease producing arthritis are not chronic and all arthritis do not behave similarly. As  mentioned earlier, arthritis is only a manifestation of a disease but not a disease itself. The pain perceived by the patient  arising out of Joint draws a lot of  concern and attention.  The joint pain should not be neglected since these arthritis conditions can damage either the joints or any other organ if not adequately attended early.  But at the same time  there are many arthritic disorders, which are benign and may produce very minimal or no disability and need not cause apprehension. . This differentiation of a benign arthritis from a serious variety is very important while managing arthritis and its related problems. Some cases have been illustrated how differentiation of diagnosis could have changed the very outlook for the patients.

Case 1: Master Y was a 16 year old boy who had an episode of joint pain at the age of 5 yrs (i.e. 11 years before). He had no swelling and no limitations of movement. He had loose motion two or three days before his joint pain started. He consulted his pediatrician who asked for an electrocardiogram, which was normal, C-reactive protein was also normal. ASLO titre was elevated (abnormal). He diagnosed the child as having rheumatic fever and advised the child to take penidure injections once  every 3 weeks (pencillin prophylaxis tp prevent relapse of rheumatic fever)e. This was regularly continued till he grew  16 years. The parents were always apprehensive about his heart. He was restricted from playing and other activities for the fear of heart problems. He was referred to  rheumatologist for re-confirmation of rheumatic fever. When evaluated, what child had was reactive arthritis. Reactive arthritis  does not afflict the heart and needs no Penidure injection. This over diagnosis often results in lot of apprehension to the patient.

But, it is worthwhile to err on the side of caution. Quiet often, mild to moderate joint pain may be an indicator of rheumatic fever. If extra caution is not exerted and diagnosis is overlooked, it may result in severe heart (valve) problems too.

The story of Mrs.R was also similar. She was an elderly lady of 62 years, who presented with pain, swelling and stiffness in her hand joints. It was more following rest. There was minimal pain in knee and ankle joins. The pain and stiffness was restricted to early few minutes of work. Her rheumatoid factor (RF) was positive, HB was 10 Gm% and Erythrocyte sedimentation Rate (ESR) was 15mm per hour. She was diagnosed as having Rheumatoid arthritis and was put on methotrexate. But, later, when evaluated appropriately, she was diagnosed as having osteoarthritis, which has to be managed differently.

The above two cases illustrate how important it is to know the type of arthritis and what are the consequences if not diagnosed appropriately.

It is often though that any arthritis is either rheumatic, or rheumatism. These terms are often misquoted and inappropriately used. The term rheumatism is applied to any condition producing pain in the musculo-skeletal system, including the joints. The term rheumatic arthritis refers to a distinct entity. Use of these terms may often confuse the patient's  and doctors while communicaing..

The precision of identifying the problem responsible for the pain in a joint will help in better management.

Diagnosing Arthritis

Arthritis is diagnosed depending on various clinical symptoms, signs and laboratory markers. When a patient attends a clinic, with a complaint of pain around a joint, the physician collects data on the problem. Several questions (which may appear relevant or irrelevant) are asked to gather adequate information. The doctor will examine you to determine any observable differences and clues i.e., swelling, pain on applying pressure, skin rashes, or any other relevant features. This will give  doctor certain reasonable information to make a possible diagnosis. Since they are often subjective and need to be clarified, he takes the help of investigations. In circumstances other than an emergency, he waits for the reports to come. Active participation of patients or attendant in this process of history taking will help to make the right diagnosis. The details doctor ask may even date back as late as your childhood. Sometime in women information about the events during pregnancy may be a clue to diagnosis. The investigations done in previous consultations if any, medical documents or any other source which can help doctor to understand your illness and will be of great help in making diagnosis. The clarity of information will help. If the patient is not clear about an event, it is better to mention as per the fact one can recollect rather than giving emphatic misleading information's.

Arthritis when it is advanced can be diagnosed with history and clinical examinations. However, in early stages it may be difficult to conclude the diagnosis. At this point physician may request for  tests.. The most common are Hemoglobin, total count and erythrocyte sedimentation rate (ESR), Rheumatoid Factor (RF), C - reactive protein (CRP), Anti-Streptolysin O titre (ASLO), Urine Routine examination, and X-ray of a relevant joint. When ESR and CRP are elevated, they suggest that your joint symptoms are secondary to inflammation or inflammation exists in some part of the body. Rheumatoid Factor is used often as a marker of Rheumatoid arthritis, but does not suggest a diagnosis. This is a common perception amongst patients, that his/her blood that has been tested for Rheumatoid factor so he has rheumatoid arthritis (often called Rheumatoid arthritis Factor). This is a misconception. Rheumatoid factor can be positive in  conditions other than rheumatoid arthritis.l. Therefore, it is preferable to allow the physician to decide on a diagnosis. These instances in rheumatologists practice are common. The patients becoming panic  because his rheumatoid factor was positive is very common. If the patient has a  main complaint is of back pain and it became worse on straining suggest that the disease was not rheumatoid but was a back strain syndrome.  The rheumatoid factor will be positive, as seen in 5% of the normal population, and hence mere presence of RF donot suggest the diagnosis of rheumatoid arthritis..Even followup studies indicate a very marginal increase in incidence of rheumatoid arthritis in individuals who t are RF positive in comparison to an otherwise factor negative population. Other specialized tests like Antinuclear Antibodies (ANA), Anticytoplasmic Antibodies (C-ANCA), Anti ds-DNA tests are advised depending upon the associated clinical features. These discussions are beyond the scope of this book (please refer appropriate books in the series).

In addition to blood test, X-ray of joints like those of hands - in case of rheumatoid arthritis-pelvis-in ankolysing spondylitis (look for sacroilitis), Knee joints - in case of Knee osteoarthritis- are advised. Changes in these X-rays, which are often specific to arthritis, can help in diagnosis.

In addition to investigations directed in making diagnosis, physicians will order tests to survey the intactness of other systems and also to look for any other associated chronic diseases. This helps the treating doctor to understand whether the disease in question has affected any other system. He will be able to decide  about  the probable safer medicine, which he can prescribe to patients. For instance, if patient had a liver problem, drugs, which produce adverse reaction on liver, are to be completely avoided.

The investigations done in the beginning serve as a baseline values. A few of the investigations are repeated during follow-up, at specified intervals, to estimate the improvement rate and detect adverse reaction at the earliest. Hence, investigations that are well planned may appear extensive but  are required to help the treating doctor in management of the disease.

The investigation reports, the complaints put forward by you, and the observation made by the physician are analyzed to arrive at a diagnosis. . From the above information, the doctor can plan the appropriate therapy. While using disease-modifying drugs in arthritis, regular investigation once in 1-3 months are recommended. These investigations assisst in reducing  the incidences of adverse reactions, especially serious ones, by forewarning the treating physician. It has been seen  in certain defaulting patents the incidence of adverse reactions are increased. Defaulting such protocols which are devised after scientific scrutiny is not worth a risk.  Following them carefully from either end, improve the safety of these medications.

Food and Arthritis

The question that lingers in any arthritis patient is: "Did any of my food habits cause my disease?" It is a fact that good food, good habits, good physical exercise, a good mind, and a good environment help  in  reducing the ailments. But how much these factors are responsible in causing and sustaining arthritis is a matter that is still under scientific scrutiny.

A few nutritional factors are known to influence arthritis. An excess of purine, in a patient suffering from gout, will precipitate an attack. Foods such as red meat, wine, and a few purine rich foods are directly responsible for gout attacks. Similarly a deficiency of vitamin C in childhood causes laxity in joints and can produce pain. Vitamin D and calcium deficiencies can produce pain and muscular weakness, which may resemble arthritis. But a major types of arthritis are not influenced by food.

Patients allergic to food substances and develop arthritis and pain is a well-described and documented phenomenon. But such conditions are rare. The prevalent idea  in the public domain regarding food and arthritis is worth discussing briefly.  Myths or ideas with reference to food and arthritis are often generalized  for example, the concept that a few food items are arthrogenic (often called "vayu" foodstuffs). Surprisingly, the list of food items is not uniform amongst the patients as well between the communities.  The observed  inconsistencies are without any specific ideas and are not explainable with cultural practice. The myth that- food produce arthritis, is universal. The most commonly listed foodstuffs are potato, brinjal (egg plant), tamarind, sour foods, broad beans (Indian variety), non-vegetarian diet (exception of fish and eggs), and curds. Other food items include milk, milk products and pulses. There is adequate scientific scrutiny regarding the possible role of food in arthritis and quite a few are still ongoing. So far no clear facts have emerged. There are some studies, which have shown that fasting intermittently along with a vegetarian diet reduces the rheumatoid arthritis activity but observations from other groups are not consistent. A change in dietary habits alone will not help.

Some have observed from their experiences, that whenever they ingest specific food preparations, the pain exacerbates. But scientific evidences are lacking for such exacerbation of arthritis with these foods. Quiet often, psychological anticipation, what we called somatic preoccupation, could result in such worsening of pain. In such situations, if it is just one or two food items, it is worthwhile to avoid them.

The strict adherence to diet is a must in gouty arthritis and in renal disease. and in presence of definite allergic diathesis. In gluten-associated inflammatory bowel disease, a gluten-free diet has role in production of disease. With a few of the above exceptions, the role of diet in arthritis is controversial.

Treating Arthritis – Cure or Relief, What is needed?

There is prevailing confusion amongst physician, patients and their family members, especialy with reference to management of arthritis. The patient's anticipations, what is achievable in management of arthritis need little clarity between treating physician and patients. The fact that all arthritis are chronic and disabling is an incorrect generalized statement.   Some of the arthritis are short lived and may need no continuation of medicine eg. Post viral arthritis, reactive arthritis (as discussed in earlier chapters). These are the situations where one may describe that arthritis is cured. But medical book describes it as spontaneous remission or cure. This is a sincere scientific admission of the fact that disease has regressed on it's own, by the very nature of the disease.  But there are  arthritis, which persist and produce persistent  discomfort with agonizing pain resulting indeformities towards the end. Patient needs to understand and appreciate these facts. Cure, in the medical sense, is a state of health achieved from a state of disease, where there is no relapse or recurrence of disease or its causative agents. In brief cure is a state where the disease process is totally stopped. This cure is an idealistic end point to any disease. But there are several diseases where we cannot achieve this end point. These diseases are often designated as chronic disease. The list is long and includes diseases like Diabetes mellitus, hypertension (High Blood Pressure), deficiency disorders of hormones like hypothyroidism, etc., and coronary heart disease. Rheumatoid arthritis, ankylosing spondylitis, etc., are the contenders to this list. This arthritis has several similarities and also differences when compared to other chronic diseases like hypertension and diabetes. Before going further, readers have to understand that all arthritis are not chronic conditions (refer to previous pages). Good examples of a chronic arthritis condition are rheumatoid arthritis, osteoarthritis, ankylosing spondylitis and related arthritis. (For details on each, readers should refer to corresponding booklets).

Arthritis, in contrast to hypertension and diabetes, is a painful condition. Swelling, limitation of movement and disfiguring that occurs when the disease is active contributes much to apprehension. All humans  long for a pain free, smooth mobility – without a need for additional support. Panic grips everyone's mind when mobility is threatened. The agonizing pain reminds patients with arthritis at every instance. This makes life more miserable and problematic. 

The management (treatment) of a disease as conceived in medical science has two different targets. The better target is to eliminate the disease or disease process completely: what is designated as a cure. On the other hand, in a disease, which cannot be eliminated completely for  variety of scientific reasons, the aim will be to reduce the impact of the disease on  short-term (i.e. day to day basis) or long-term (i.e. production of deformity and disability) basis. In the community, the majority has accepted few of the diseases to be managed to prevent like that. The best example is diabetes. In diabetes, oral drugs/insulin injections are prescribed with an intention to maintain a constant blood sugar, and reduce  problems like, excessive thirst, increased urinary frequency. More than the symptom control the major aim of treatment in diabetes is  is to reduce certain complications such as neuropathy, kidney damages, damages to the eyes. Etc. The situation is similar in high blood pressure conditions. But in arthritis, day-to-day problems are quiet prominent and may require high priority initially. The agonizing pain demands a lot of attention since it produces severe discomfort. The agonizing pain and  continued stress demands a quick, miraculous remedy, in contrast to other chronic diseases. In diabetes or hypertension, it is the laboratory parameters or the instrument readings (BP apparatus reading and blood sugar reading), which are alarming. In arthritis, the pain is a reminder of the existence of disease. In addition, vague concepts and perceptions about arthritis prevailing in society make it difficult to manage arthritis.

In  the management of any  chronic disease, the treating rheumatologist/ physician draw up his scheme to help  patients with arthritis. After appropriate evaluation, diagnosis and discussion with patient, the treatment in any arthritis is normally planned under three domains. It includes:

1.      Reducing pain and other symptoms.

2.      Reducing, and – if possible, eliminating the damages caused by the arthritis.

3.      Whenever possible to achieve a disease free state or least disease activity..

In  few  arthritis the disease activity may reduce completely and may require no drug. This state is called clinical remission. This is achieved in some typearthritis.

Reducing pain, Symptoms or Disease – What does Modern Care Target?

As a patient, his main concern is pain, swelling, limitation imposed on movement, and some additional features like fever, nodules, etc. There   important concerns forthe treating physician or rheumatologists. They are mainly the long-term effects the disease could produce (details below). For relief of the pain and swelling, several modalities-both drug and non-drug therapies –are used.

The Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), otherwise commonly called "pain killers", are the most commonly used drugs to reduce pain. There are a lot of myths surrounding these drugs. A few facts are worth mentioning (For detailed discussions please refer to "Am i taking safe pill?"). They are not just painkillers, they also reduce inflammation. They do interfere to some extent in the disease  process leading to the development of arthritis. The fact that NSAID produces kidney damage and gastric irritation (popularly called ‘gas'. Or heart burn), and ulcers, does not mean that all these complications  happens to everyone. These problems are reported only  in 15 to 20% of patients. The other 80-75% will not have any problems with the drug. The drug, if taken with appropriate consultation with a physician for arthritis, will produce fewer adverse reactions. The pain and restriction imposed by arthritis, when considered against the few adverse reactions of these drugs, the risk of these drugs are worthwhile. In addition to oral medications , local applications like creams or patches containing painkillers (NSAIDs), counter irritants, etc., will help in reducing pain. Physical measures like heat and cold, short-wave diathermy, ultrasonic massages and infrared heat are also used to reduce pain (refer to "Role of physiotherapy in arthritis").

In addition to pain relieving medications  depending upon the disease causing arthritis, disease-modifying drugs are used. For instance in moderate to severe RA, Methotrexate is used. Their usage has distinct advantage. They reduce inflammation and the need for NSAIDs (painkillers). More than just reducing pain and the need for reducing that, they reduce that amount of deformities and disabilities.

The reduction of disability and deformity is the most important focus in arthritis care. These are targets in the long run management of arthritis. In addition to drug therapy, physiotherapy, appropriate splinting, and occupational therapy will help the patients to reduce the deformities and disability.

Basically, the therapy aims at reliefs of symptoms, reduction of deformities and improving the quality of life and, wherever possible, to achieve  a permanent cure.

Lot's of research activities to reduce or alter the course of disease are underway. In addition, there are  research which are aiming to ameliorate the disease process permanently by altering the immune response.

Arthritis and Family

"Arthritis: is it seen in a family?" is a very perplexing question often faced by doctors from their patients. I say it is perplexing because its implication in a family and social background is far and wide and is much more than simple genetics.

No doubt, genes have a role to play in the development of arthritis. But they are not responsible.  Not all arthritis show genetic susceptibility. The familial occurrences  are strong in some arthritis and poor (weak) in others. There may be no familial tendency in some arthritis. Generalization of the fact that arthritis occur within family is not appropriate. Diseases like ankylosing spondylitis, reactive arthritis show a strong association with genetic inheritance. Rheumatoid arthritis and Systemic Lupus Erythematosus (SLE) have moderate to mild association with genetic inheritance. These are often confusing and cannot be applied using the simple principle of inheritance.

 The true fact is some arthritis occur in clusters with in a family. It means incidences are more with in family members compared to general population and  not all are affected unlike a Mandelian genetic disease.  In terms of  risk- a person developing  arthritis is higher if both parents are affected, when compared to a person who has none affected in his family. But this increase in   risk does not call for much concern, because one cannot be sure about developing disease. The risk, though higher than that of the normal population, is not substantial enough to cause a serious concern.

The confusion of altered risk may lead to conflicting interpretations even when it is not true. .The fact that arthritis can occur in an individual without a family history should be clear. The pattern of inheritance in a family more closely resembles that of diabetes and hypertension and  there is no need of greater concern.