Arthritis

We all have mornings when we wake up a bit stiff. We all know the achy feeling that comes from working too hard in the garden, sitting too long at the computer or sleeping in an awkward position, And from time to time we have all suffered pain because we’ve lifted a heavy object in a slightly wrong way. Even a particularly ferocious sneeze can cause a twinge of discomfort. But arthritis goes far beyond these occasional aches or pains.

The condition that we commonly refer to as arthritis includes a number of diseases that result in inflammation, pain and stiffness, primarily in the joints and connective tissues. Connective tissues are the supporting structures for joints, such as muscles, cartilage, ligaments and tendons. In many cases, these diseases affect other parts of the body as well. Arthritic disorders may be able chronic, but some such as gout, are intermittent. The conditions that are truly inflammatory (that is with actual joint inflammation present) cause warmth and swelling, whereas others are degenerative in which cartilage lining the joint wears out and the amount of inflammation is minor.

How the joint works. The ends of bones meet at the joint where they are cushioned by cartilage, a layer of smooth tissue. Around many of the larger joints such as the knee, hip and shoulder there is a pad-like sac or cavity called the bursa which is lined with cells similar to those lining the joint. In addition to acting as a buffer to reduce friction between the muscle, tendon tissue and bone, the inner lining produces a fluid, synovial fluid, that keeps the joints lubricated and provides nutrients. Ligaments connect and support bones to keep them in proper alignment whereas tendons connect muscles to bones. Joints move when a muscle on the one side of a joint contracts and pulls on the tendons that attach to a bone on the other side of the joint.

How arthritis affects the joints. The word arthritis means joint inflammation. Inflammation, a natural part of the body’s response to injury and infection, is a complex process that produces swelling, pain, warmth and redness. But inflammation is not only a response to injury, it may perpetuate injury as well. Significant problems arise when inflammation is persistent, intense or recurrent or spreads to other areas of the body.

Joints and the surrounding areas become inflamed for a number of reasons including trauma, disease, infection or merely wear and tear, which naturally occurs over time. Many forms of arthritis are thought to result from the uncontrolled inflammation of an autoimmune disease in which the body’s defense mechanism malfunctions and attacks its own tissues. At other times the joint area becomes inflamed and tender for no apparent reason.

When joints become arthritic, swelling causes stiffness, rigidity and tissue damage. Pain which is the body’s signal that something is wrong occurs as the joint is moved to the brink of its own limits. As mobility decreases the muscles surrounding the joint also weaken allowing for further injury to the joint. Over time, the cartilage breaks down, the bone erodes, and the joints become misshapen. It is this process regardless of the source, that may develop in the worst forms of arthritis.

There are more than 100 different types of arthritis and each has its own characteristic symptoms and its own course. In addition, the way in which the disease progresses varies from individual to individual. If you suffer from an arthritic condition you will most likely experience pain and limited movement at the involved sites. In chronic forms of arthritis there may be times when the disease is active (flares) and times when it is inactive (remission). Depending on the specific condition and how severe it is arthritis can interfere with even the most ordinary activities such as walking, dressing or bathing. In the most inflammatory types of arthritis such as rheumatoid arthritis pain and stiffness are more severe in the morning or on certain days. Sometimes symptoms disappear completely for considerable stretches of time only to flare up again later.

Diagnosing arthritis. Inmost cases, arthritis is diagnosed after an individual contacts with his or her health care professional because pain is significant and has begun to interfere with daily life. If you have that kind of pain your physician will ask you to describe the feeling because he severity and quality of the pain is helpful in figuring out the cause. Is it a throbbing, achy, burning or stabbing sensation? Is it constant or occasionally intense? Do certain activities make the pain worse? Is it worse in the morning or at night? In some cases your doctor may ask you to record your daily experiences in a pain diary.

Your health care professional will review your current symptoms as well as your past medical history, family history, and medication use. A thorough medical examination will follow. The doctor may order blood and urine tests and in select cases X-rays and possibly imaging procedures such as a computed tomography (CT) or magnetic resonance imaging (MRI) may be recommended.

Once arthritis has been detected a treatment plan can be developed to suit you and your lifestyle. With early diagnosis most arthritic conditioned can be managed sufficiently to minimize both the pain and the disruption to your daily life. In many instances early diagnosis and treatment can also work to curtail the actual damage that the condition can cause.

The pain associated with arthritis stems from a number of sources. When, for example, the tissue that lines the joints (synovial membrane), tendons or ligaments swells, you may feel aches and discomfort right at the joint. Muscle strain and fatigue frequently follows as well adding to the intensity and duration of pain. If there is joint damage over time, even the most ordinary activities – getting out of bed in the morning, taking a bath, holding a pencil – can cause pain.

At the same time the level of pain and discomfort that people find tolerable varies from person to person, from situation to situation. Each person’s threshold for pain is different. In addition it is not uncommon for an individual who lives with chronic pain or the possibility of intense, intermittent pain, to experience anxiety and reactive depression as a result. Emotional stress and distress can intensify the sensation of pain.

Recognizing the typical types of pain, the location and the accompanying features helps clarify whether arthritis is present. Once diagnosis is established, the type of arthritis may help direct treatment and provide an idea of what to expect. It should be noted, however, that the specific type of arthritis cannot always be diagnosed early in the course of illness. In addition, many types of arthritis are treated similarly so a specific diagnosis is not always as helpful as it might seem.

In many types of arthritis, the course of the disease is unpredictable. Most chronic diseases involve periods when the symptoms are active and troublesome (flares) and periods when symptoms are negligible (remissions). This unpredictable and variable course can complicate both diagnosis and treatment.

Low back pain. What to do when so much is unknown. If you are one of the millions of people unfortunate enough to suffer from low back pain you may have received advice from your primary care doctor, your family, your friends or others experiencing similar symptoms. Few will suggest the same remedy, but remarkably all of their suggestions may be right. Because there is no single approach that will reliably help everyone numerous treatments (including no treatment at all) may provide relief.

How can this be? The answer reveals a well-kept secret about low back pain: for most people the cause is not known. However, there are many things about low back pain that are well known:

Low back pain is common. About 80 percent of the population will have low back pain at least once in the lifetime. Low back pain is not an inevitable result of aging, strenuous work or injury. It often develops for no apparent reason. Most low back pain is not associated with a dangerous or serious cause. There are reliable ways to detect the rarer and more serious causes. Most patients are not helped much by X-rays, computed tomography (CT) or magnetic resonance imaging (MRI). There is no single best treatment for low back pain. The goal of treatment should be to strike an acceptable balance between pain relief and the possible side effects of treatment, that balance is different for different patients.

Causes. Despite decades of research on thousands of people with thecondition, despite detailed anatomic pictures with CT scans and MRI, and despite major advances in the scientific understanding of disease mechanisms, the cause of pain in most cases remains uncertain. Moreover, many experts – for example, those at “back clinics” and specialty centers – will disagree about why your back hurts.

For the majority of patients with low back pain the cause is not serious. The pain is variable in its onset, quality, location and course. It may be: acute (sudden in onset) or chronic (lasting many weeks, months or years; centered on one or both sides of the lower back or radiating into one or both legs; sharp or dull, burning or aching; improved or worsened by different positions.

The sudden onset of pain increases the likelihood that the cause is a muscle spasm or bulging (herniated) disk. A patient who has pain on one side spreading into the buttock and back of the leg is often considered to have sciatica because the pain follows the path of the sciatic nerve, a common cause of this problem is a bulging disk.

If low back pain moves into both legs and worsens when you stand, spinal stenosis may be considered. In spinal stenosis the lower part of the spinal cord is compressed by a disk, ligaments, degenerative bone changes or some combination of these. Other common causes include back strain, muscle spasm and osteoarthritis (degenerative joint disease), but the symptoms that are associated with these disorders are much more variable. In older patients slippage of one vertebra on another (spondylolisthesis) and compression fractures (often related to osteoporosis) are important to consider after more serious causes have been excluded.

In many cases even when a common cause is suspected the diagnosis is generally difficult or impossible to prove. Even an abnormal MRI that reveals a bulging disk may not explain low back pain. Many patients perhaps one-third or more of the population have abnormalities on the MRI even when they have no pain and patients thought to have a disk problem based on their history and physical examination often have normal findings or irrelevant abnormalities on MRI. Among older individuals abnormalities on MRI are even more common.

Fortunately, among patients with low back pain dangerous causes are very uncommon representing only 1 percent or fewer of cases. These serious causes include infection, a tumor, vascular disease and fracture.

The red flags that alert your health care provider that one of these may be at play are advances age, weight loss, fever, past cancer, trauma, immune system problems, difficulty with bowel or bladder control, or vascular disease elsewhere in the body. The combination of past and current problems along with the physical examination will generally help guide which people with low back pain should be treated without further tests and which people should be evaluated further.

Treatment. If you or somebody close to you has low back pain what should be done? Common treatments include: rest, pain relievers, anti-inflammatory medicines, muscle relaxants, exercise. Other conservative treatments – those that avoid surgery or other invasive procedures – may include physical therapy, massage, chiropractic treatment and acupuncture.

Only when low back pain persists or worsens or when a doctor suspects a more serious cause should a patient consider elaborate testing and more aggressive treatments such as injections or surgery.

The role of imaging tests. When willa doctor recommend X-rays or MRI? A doctor will suggest imaging tests if he or she believes that the results are likely to lead to a change in your treatment or your outcome (how much pain you have, how good your function is, or even how long you live). Despite the development of guidelines by experts in the evaluation and management of low back pain, the approach continues to vary greatly among health care providers.

For example, one study found that a patient who sees a neurologist, rheumatologist andorthopedic surgeon with the same back complaints would receive dramatically different recommendations regarding which diagnostic tests to order, each specialist would tend to order tests that detect diseases in his or her field of expertise. Even when a disk problem is suspected and confirmed by MRI this test is probably unnecessary if no change in treatment or outcome follows.

Conclusion. Low back pain continues to e a big problem. it is common, its cause is frequently uncertain and the available treatments are not uniformly effective. Until we know more about why only some people have low back and which treatments are reliably effective, the answers you get about your back pain will depend largely on whom you ask. The good news is that most of the time low back pain improves, function returns to normal and the overall outcome is excellent regardless of the diagnosis offered or treatments provided.