Introduction:

Arthritis is the inflammation of a joint which causes pain, swelling and stiffness of the joint. The causes may be due to autoimmune mechanism, infection, degenerative changes, or genetic defect

The common types of arthritis are:

• Osteoarthritis (OA)
• Rheumatoid Arthritis
• Infectious arthritis
• Polymyalgia rheumatica

Signs and Symptoms

• Joint pain (arms, wrists, fingers, ankle, knees, hips, lower spine) especially during and after activity
• Swelling of the joint and in OA there are firm swellings around the joint margins
• Stiffness of the joint
• Tenderness around the joint margins
• Deformities
• Crepitus on movement in OA
• Muscle wasting (Quadriceps for knee OA)
• Restricted joint mobility with functional limitations and handicap
  • difficulty with certain tasks,
  • pain worse at the extremes of movement

Risk Factors (OA)

• Advancing age
• Obesity:
  • in bilateral knee OA
• Heredity:
  • especially generalized OA
• Hyper mobility
• Major joint injury:
  • fracture
  • meniscal tear
  • circulate ligament damage
• Occupational:
  • knee OA in manual worker
  • hip OA in farmers

Management

• The management of OA involves a multidisciplinary approach with the aim to relieve symptoms and improve joint function.
• It involves non-pharmacological and pharmacological therapy.
• In certain cases, surgery is indicated.

Patient education

• Patients with OA should be informed of their diagnosis and the nature of the disease and its progression discussed.
• Patients who have an understanding of the disease and its natural history cope better and report less pain.
• The most important goal is to instill a positive attitude.

Weight reduction

• Overweight patients should aim to lose weight.
• Weight loss decreases pain substantially in those with knee OA.
• Losing 5 kg of weight reduces the force on the knee by 15 – 30 kg with each step.

Physiotherapy

• Physiotherapy should be started as soon as possible to improve joint mobility, increase muscle strength, reduce pain and prevent further disability.
• All patients should participate in an exercise programmed to mobilize the joints and strengthen the surrounding muscles.

Exercise Programme

• Exercise programme should be individualized.
• A combination of exercises including range of movement (ROM), strengthening and low impact aerobic exercises are appropriate.

There are 2 types of exercise programme:

• Range of motion exercises and strengthening exercises

• Isometric exercises are recommended initially, followed by progressive resistance exercises and a combination of open and closed chain exercises. These exercises should be done daily.

• Aerobic programme
  • Aerobic exercises that can be recommended include walking for 30 minutes 3 times per week, biking, swimming, aerobic dance and hydrotherapy.

Joint Protection

Assisted Walking Device.

• In hip and knee OA, the proper use of a walking stick in the contra-lateral hand reduces forces through these joints by as much as 50%.
• Canes should be of correct height.
• The top of the cane handle should reach the patient’s wrist when the patient is standing with the arms at the side.
• Shoes with good shock-absorbing properties are recommended.

Knee Brace

• The use of a knee brace has been shown to lessen the load in the degenerative knee

Patellar taping

• Medial patella taping in patello-femoral OA followed by quadriceps exercises has been shown to reduce pain and improve function.

Pain Relief Modalities

• Thermal Modalities
  • Thermal modalities may be beneficial in decreasing pain, increasing flexibility and reducing swelling.
  • Some thermotherapy modalities used are hot packs, shortwave diathermy and ultrasound.
  • Heat therapy is not recommended for acutely inflamed joints.
• Transcutaneous Electrical Nerve Stimulation (TENS)
  • TENS has significant benefit in pain relief if treatment duration is more than 4 weeks.
  • Both high frequency and strong burst mode TENS have shown benefit

Occupational Therapy

• Occupational therapy helps correct and minimizes the dysfunction in lifestyle by improving function through the use of adaptive equipment.

Indications for Splinting

• Splints are used to improve function, correct position or deformity and reduce pain.

Examples: Protective carpo-metacarpal splint and knee extension splint.

• Footwear modification
  • Useful shoe modifications include heel raise, medial arch support and lateral weight shift, lateral arch support and medial weight shift as well as metatarsal arch support.
• Stress Management
  • Pain is often combined with muscle spasm and other signs of stress.
  • Relaxation activities and structured relaxation techniques can help decrease pain which can be taught by the occupational therapist.
• The patient may need to reschedule activities to accommodate pain peaks.

Drug Therapy

Types of Pharmacological Therapy

• Oral therapy
• Intra-articular Injection
• Topical therapy
• Others

Oral therapy

Prescribing in the elderly

• The renal and liver function decreases as one age.
• It is, therefore important to be cautious in taking drugs commonly used for the symptomatic relief of arthritis in the elderly patient.
• Paracetamol is comparable in strength to low or high dose of ibuprofen in symptomatic control of pain and should be used in preference to Non-Steroidal Anti-Inflammatory Drugs (NSAIDs).
• COX-2 inhibitors are as effective as NSAIDs with less gastritis side effect. Of late there are reports of cardiac safety in these agents
• NSAIDs should be used with caution, as there is an increased likelihood of gastritis, decrease renal function, development of swelling of lower limbs and precipitate of heart failure in susceptible individuals.
• Tramadol can lead to constipation and confusion in the elderly patient if not taken carefully.

Intraarticular Therapy

This mode of therapy should be performed only by a practitioner trained in the procedure.

The drugs used for the intra articular injection are:

• Glucocorticoids
• Hyaluronan

Topical Therapy

• Topical NSAIDs,
• Methylsalicylate liniment (LMS)
• Capsaicin
• NSAID-containing medicated plasters are useful options in the treatment of Arthritis.

Others

• Glucosamine
  • Glucosamine soleplate has been shown to be useful in relieving pain and improving function in patients with mild to moderate OA.
  • It may stop joint space narrowing and modify disease progression .

Surgical Options

• If medical therapy fail i.e. pain still persists, then surgical options are considered.

Parameters useful in selecting the best surgical option are:

• Survivorship associated with a given procedure
• Complications of the procedure

Before deciding the best surgical option for a patient, important factors to consider are;

• The patient’s age
• The joints affected
• The timing of the surgery
• The expertise available

Surgical options include:

• Arthroscopic debridement
• Ligamentous reconstruction
• Osteotomy
• Unicompartmental arthroplasty
• Total joint arthroplasty
• Arthrodesis
  • Total joint arthroplasty is by far the best option in the older age groups (above 60 years).

Arthroscopic debridement

• This method provides transient relief of symptoms in mild-to-moderate knee osteoarthritis but does not alter the arthritic process.
• Patients must be warned about the potential complications and the possibility of a need for subsequent reconstructive surgery.

Ligamentous reconstruction of the knee joint

• The goals of this procedure are to provide pain relief, and restoration of joint stability.
• The patients must be counseled that this is a salvage procedure.

Osteotomy

• The goal of osteotomy is to provide pain relief and functional improvement.
• Osteotomy has also been used in the hip to alleviate symptoms and delay definitive surgery.

Unicompartmental arthroplasty

• Traditionally, this surgical option is for patients with unicompartmental arthritis of the knee who are more than sixty years of age and have a sedentary lifestyle.
• Patients with mild to moderate angular deformity and no filamentous laxity of the knee joint may benefit.
• The technique is demanding and good results have been reported only in centers of excellence.

Total joint arthroplasty

• Total joint arthroplasty is the mainstay of surgical treatment for osteoarthritis of the knee, hip and humeral joints.
• Most patients have complete pain relief and near-normal function following successful surgery.
• Total joint replacement has limited durability beyond 15 years and durability depends largely on the level of physical activity.

Arthrodesis

• Arthrodesis has been shown to effectively alleviate pain and is most commonly performed in the spine, and in small joints of the wrists, hands and feet.
• In the knee and hip it serves only as a salvage therapy.

PRIMARY PREVENTION

• Primary prevention is theoretically possible if all the risk factors are modified.
• Many of these risk factors are of particular importance in weight-bearing joints.
• Maintain ideal body weight, weight reduction in the obese and health education pertaining to joint protection techniques (including avoidance of trauma to the joints) are recommended as measures for primary prevention.
• An important aspect of primary prevention is to identify those individuals at risk.

Last Review	:	26 April 2012
Writer	:	Dr. Lee Fatt Soon
	:	Dr. Mohmad bin Salleh
	:	Dr. Mohd Faudzi bin Abdullah
Reviewed	:	Dr. A. Khalek bin Abd. Rahman