By Prof Theresa Rossouw
Despite affecting approximately one-third of the global population, arthritis is probably one of the least recognised and understood areas of medicine.
There are many reasons for this. Arthritis, meaning ‘inflammation of the joints’, is caused by more than 100 different conditions; many of them are still poorly defined and difficult to diagnose and differentiate from one another.
Also, painful joints are often seen as a normal part of ageing, discouraging timely diagnosis and treatment.
What is arthritis?
Arthritis has been around as long as human existence and has even been described as being present in dinosaurs. There are many different causes, such as trauma, infection, auto-immunity – when the body attacks its own tissue – as well as ‘wear-and-tear’.
The end result is damage to the cartilage, which protects the end surfaces of bones where they meet at the joints, leading to friction, pain, swelling, and stiffness of the joint.
Left untreated, the joint becomes less flexible and causes muscle strain, which impairs mobility.
Arthritis types
There are six main types of arthritis. The most common is osteoarthritis, often referred to as “wear-and-tear” arthritis, which is caused by degeneration of the cartilage, most commonly at the hip and knee.
It is estimated that ±30% of the general and ±83% of the older (65 years) population in South Africa have osteoarthritis. Men are more likely to develop osteoarthritis at an early age (55 years). Women have a higher risk when they are older and are especially more likely to develop osteoarthritis of the knee.
The second most common arthritis is rheumatoid arthritis. For reasons that are still poorly understood, the immune system in some people attacks the joints.
It usually presents with pain and swelling of the smaller joints, such as the hands and feet, in a symmetrical fashion. But it is a systemic disease that can affect many organs, such as the heart, lungs, and kidneys.
Up to 14 million people around the world and ±2.5% of South Africans have rheumatoid arthritis.
Women are 3-6 times more likely to develop this disease, and smoking is a known risk factor. Because of its variable presentation, there is often a long delay in referral to a specialist. Untreated or inadequately treated, rheumatoid arthritis results in severe joint damage and significant functional impairment.
Psoriatic arthritis is a form of arthritis affecting people with psoriasis, a skin disorder that presents with red patches covered with a silvery scale, most commonly on the knees, elbows, and scalp.
It can also affect the nails, causing “pitting” – small (1mm) cavities in the nails. Importantly, a person need not have the skin condition to develop psoriatic arthritis.
It is estimated that up to 3% of the global population has psoriatic arthritis, and one study in South Africa found that 4.4% of the city-dwelling population had the disease.
It usually starts with pain, stiffness, and swelling of the small joints of the hands and feet but can also affect the larger joints and the spine.
Severe tiredness and morning stiffness are common features of this disease. Gout is caused by dysfunction of uric acid metabolism, which leads to the deposition of uric acid crystals in the joint, resulting in inflammation.
It affects about 42 million people around the world and ±4% of the North American population. It is becoming more common in Africa, with approximately 0.7% of South Africans affected.
Called by Hippocrates the ‘unwalkable disease’, it often presents acutely with a red, swollen and very painful big toe or foot, often precipitated by purine-rich foods or alcohol.
Many people do not realise that arthritis can also affect children. The term ‘juvenile arthritis’ is used to refer to a range of arthritis conditions affecting children and adolescents below the age of 16 years.
It is estimated that about one in every 1,000 children will develop some form of chronic arthritis during childhood. Juvenile idiopathic arthritis is the most common form and, as the name indicates, has an unknown cause (idiopathic = arising spontaneously or from an obscure or unknown cause).
Ankylosing spondylitis is an arthritis that usually first affects the spine, where it causes inflammation and progressively limits movement of the spine and chest wall.
It is not clear how common it is, but one study from rural South Africa only found it in ±0.10% of the population studied. It is more common in males and tends to start in early adulthood.
Living with arthritis
Arthritis exacts a heavy toll on those living with it. As many as 88% of people report that arthritis affects their quality of life, with 58% reporting a moderate to severe impact on their lives.
More than half have moderate to severe pain. It is, therefore, not surprising that arthritis is currently the leading cause of disability in the United States.
Arthritis tends to get worse with age, and nearly 50% of people older than 65 years have arthritis. Arthritis also comes with a host of other co-morbidities. For instance, people with osteoarthritis are ±25% more likely to develop heart disease than those without osteoarthritis.
The good news is that only 2/100,000 people will die from arthritis every year. While there is no cure for arthritis at this time, it can be controlled with appropriate treatment.
Management strategies revolve around reducing pain, preventing or delaying disability, and improving quality of life.
The first step is getting to the correct diagnosis as soon as possible. Since the symptoms and signs of many of the different forms of arthritis overlap, they can be difficult to distinguish from one another.
An accurate diagnosis is, however, a prerequisite for effective treatment. Arthritis is generally diagnosed by means of a physical examination, blood tests, and X-rays or scans.
The blood tests look for antibodies that help distinguish autoimmune arthritis from degenerative arthritis.
Blood tests are also used to identify specific genetic markers that have been associated with certain forms of arthritis and to investigate the health of other organs that might be affected by the disease.
Once the diagnosis has been made, the treating doctor will start a treatment regimen consisting of some of the following: pain medication, anti-inflammatory medication, steroids, and disease-specific medication, called disease-modifying antirheumatic drugs (DMARDs) and biological medicines that target different proteins in the blood.
It is not possible to predict who will respond to which therapy, so these therapies are often tried in a sequential manner.
Since many of these treatments suppress the immune system, it is important to ensure that all vaccinations (e.g., influenza, pneumococcus, Covid-19) are up to date.
General tricks and tips
Fortunately, there are also lots one can do to improve one’s situation. The CDC recommends five main strategies:
Learn new self-management skills
This can help one feel more in control, manage pain better, reduce stress, boost one’s mood, and improve communication with healthcare providers. It also teaches one to plan and execute valued activities, such as spending time with loved ones.
Be physically active
This can reduce pain as well as improve function, mood, and quality of life. Additional benefits include improved sleep, bone, and brain health, weight control, and reduction in the risk of heart disease.
It is recommended that adults should be physically active at a moderate intensity for 150 minutes a week. Remember that some physical activity is better than no activity!
Talk to your doctor
Early and effective treatment is critical for optimal management. It is also important to attend regular appointments and follow one’s treatment plan.
Manage your weight
Getting to and maintaining a healthy weight is very important for people living with arthritis. For people who are overweight, losing weight reduces stress on the joints. Roughly speaking, an optimal weight is a body mass index (BMI) between 20 and 25. BMI is calculated as follows: weight (kg)/(height (m)) 2 .
Protect your joints
Joint injuries can cause or worsen arthritis, so it is important to choose activities that are low-impact and have a low risk of injury, such as walking, cycling, dancing, and swimming. Avoid activities that involve repetitive movement or place a lot of stress on the joints.
Finally, remember that you are in for the long haul. Rest when you need to; laugh when you can; never forget to be thankful, and always be kind to yourself.
Prof Theresa Rossouw, Department of Immunology, University of Pretoria, President: South African Immunology Society