Rheumatoid Arthritis

By Gennaro Polverino, M.D.
Family Medicine Physician

There are several types of arthritis. Many of them put patients at risk for falls. This happens because the progression of arthritic disease located in places such as a hip joint or knee joint can lead to loss of joint integrity and eventually a loss of function. The loss of function isn’t limited to damage over years thereby affected only the elderly. In some instances, arthritis can progress quite rapidly causing disability and risk of falls even in the young. As you will see below the specific diagnosis of an arthritis can be complicated.

In general terms, arthritis is classified as either inflammatory or noninflammatory.  Some of the most common inflammatory arthritides include gout, rheumatoid arthritis (RA,) septic arthritis, Reiter’s syndrome, spondyloarthropathy, and systemic lupus erythromatosis (SLE.) As one would assume, certain arthritides are more likely to occur in certain age groups. One exception to this generalization is septic arthritis. (Korn, p. 670.) Septic arthritis is an infection of a joint that can occur at any age.

In general, inflammatory arthritides present as redness, pain, and or swelling of one or more joints. There may also be accompanying fatigue or fever.

When a patient presents with a joint pain complaint, the diagnosis isn't always clear. Some arthritides may have symptoms of pain that can peak within hours. Others may take a few days to months. Although these characteristics could suggest a specific type of arthritis, they’re by no means diagnostic. In other words, some arthritis presentations can mimic others thereby making a diagnosis difficult. (Hubscher, p. 49.)

For example, rheumatoid arthritis, an autoimmune disease, usually presents as a slow onset of inflammation of the small joints of the hands and feet. There may also be an accompanying generalized fatigue. (Cush, Kavanaugh, and Stein, p. 323.) However, other times rheumatoid arthritis can present as a sudden onset involving multiple joints (polyarthritis.) The latter presentation is most likely to occur in the elderly. (Hubscher, p. 49)

Those with a history of the skin condition called psoriasis can also develop a polyarthritis. As a result, these patients may present similarly to those with rheumatoid arthritis when in fact they may have psoriatic arthritis. (Cush, Kavanaugh, and Stein, p. 307.)

Unlike OA which is classified as a noninflammatory arthritis, RA initially tends to affect the metacarpophalangeal (MCP) joints of the hands, the wrists, or proximal interphalangeal (PIP) joints. (The MCP joints are the joints where the fingers meet the rest of the hand. The PIP joints are located between MCP joint of each finger and the distal-most joint of the finger.) However, other joints can also be affected.

A common location for OA to first appear is at the base of the thumb. Unlike RA which is an inflammatory arthritis, OA tends to affect the distal interphalangeal joints of the hands. (Altman & Lozada p.506-507.) These joints are the most distal two joints of digits two through five where the thumb is considered digit one.

Since the arthritis presentation history doesn’t always allow the physician to make an immediate specific diagnosis, why not just order a test?
 

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Some tests can be helpful. One such test is joint aspiration. This involves a physician using a needle to enter the inflamed joint space and aspirate fluid for microscopic and chemical study. If the swollen joint appears to have only minimal fluid on exam, sometimes a radiologic technique can be implemented. One such technique is using ultrasound to help guide a needle into a joint space in order to increase the chances of obtaining a sufficient amount of joint fluid for study.

In the case of an infected joint, an analysis of the fluid after aspiration can point to bacteria or other infectious agents. In the case of gout, diagnostic monosodium urate crystals can be visualized during microscopic examination.

Monosodium urate crystals form in a joint when the blood has too much uric acid. The monosodium urate crystals form when certain white blood cells react to the uric acid resulting in the formation of the monosodium urate crystals. These crystals then deposit into a joint. (Cush, Kavanaugh, and Stein, p.188.) The joint that’s initially most often affected is the metatarsophalangeal joint of the great toe. (Cush, Kavanaugh, and Stein, p.190.) This joint is located at the base of the big toe. However, gout can involve other joints as well.
Understandably, patients sometimes feel frustrated when a diagnosis can’t be immediately made. They may ask, “Can’t you just do a blood test?” Unfortunately blood tests, in contrast to direct joint aspiration, can be less sensitive or specific.

For instance, attempting a gout diagnosis by checking for elevated uric acid in the blood can be miss the diagnosis. Up to 40% of patients who suffer a gout attack can have normal levels of uric acid in their blood. (Cush, Kavanaugh, and Stein, p.191.)

What about a blood test for rheumatoid arthritis? Here too blood tests may be misleading. One test is called the rheumatoid factor test. If one were to test the general population, this test would be positive in 4-5% of people while the reality is that only 1% will actually have the disease. Systemic lupus erythromatosis, another autoimmune disease, has similar outcomes with even a lower percentage of people actually having the disease. In the case of SLE, only 0.04% would have the disease. (Cush & Lipsky, p. 1982.)

As mentioned above, some arthritides are classified as noninflammatory arthritis. As previously mentioned, one such noninflammatory arthritis is called Osteoarthritis (OA.) For a discussion on OA, please refer to the separate article on OA.

As illustrated above, the specific diagnosis for arthritis may not be obvious and may require, at least at first, frequent visits with a physician. If you go to your doctor because you are suffering from joint pain, follow your doctor’s recommendations for testing and follow-up. This may be a time-consuming task for you but nonetheless essential to properly diagnosing your illness, treating your pain, and preventing future loss of function. Simply using over the counter agents without the advice of your doctor may temporarily help with the pain but could result in further complications from the over the counter agents themselves. In addition, self-treatment may result in unnecessary loss of joint function and disability from inadequate treatment of the disease process.

That said, what are the treatments for the arthritides? These are many therapeutic approaches. Some may include medical, surgical (such as joint replacement,) and joint injection therapy or any combination thereof. Medical treatment in the case of rheumatoid arthritis can include prescription medications that have been shown to actually slow the progression of the disease. In the case of OA, joint injection therapy is commonly employed.

If you suffer from joint pain, over the counter agents may help. However, they may be inadequate or inappropriate depending on your specific diagnosis and other coexisting conditions. If you suffer from joint pain, see your doctor for a thorough workup, diagnosis, and treatment plan. In some cases you may be referred to a rheumatologist who is a specialist in the musculoskeletal system and many other diseases that affect multiple body systems.

About the author: Dr. Polverino is board certified in Family Medicine. He is a practicing physician living in Colorado and does freelance writing. He has not endorsed any products.

References:

Korn JH, Approach to the Patient with Rheumatic Disease. In: Andreoli TE, Carpenter
CCJ, Griggs RC, & Loscalzo J, eds. Cecil Essentials of Medicine 5th ed. Chapter 78, Philadelphia: W.B. Saunders, 2001: p. 670

Hubscher O, Pattern Recognition in Arthritis. In: Hochberg MC, Silman AJ, Smolen JS,
& Weinblatt ME, eds. Practical Rheumatology 3rd ed. Chapter 4, Philadelphia: Mosby, 2004: p. 49.

Cush JJ, Kavanaugh AC, and Stein CM, Rheumatology: Diagnosis
and Therapeutics 2nd ed. Philadephia: Lippincott, Williams & Wilkins, 2005: pp. 188, 190, 191, 307, 323.

Altman RD and Lozada CJ, Clinical Features. In: Hochberg MC, Silman AJ, et. al., eds.,
Practical Rheumatology, 3rd ed. Chapter 39, Philadelphia: Mosby, 2004: pp. 506-507.

Cush JJ & Lipsky PE, Disorders of the Joints. In: Braunwald E., Fauci, et. al., eds.,
Harrison’s Principles of Internal Medicine, 15th ed. Chapter 320, New York: McGraw-Hill, 2001: p.1982
 

 


- What could happen to an elderly person if he or she has a fall?

Falls in the elderly in are the leading cause injury-related visits to emergency departments. Many fractures could result from a fall including, but not limited to, the hip, pelvis, and shoulder. Trauma could be caused by a fall.

The fear of falling again will could result which could be a potentially debilitating consequence. This constant fear could cause decreased socialization, decreased mobility, and a depressed mood because they lose their independence. They eventually must rely on others to take care of them.