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Arthritis Pain / Joint Pain

Joints form the connections between bones. They provide support and help you move. Any damage to the joints from disease or injury can interfere with your movement and cause a lot of pain. Joint pain is extremely common. About one-third of adults report having joint pain within the past 30 days. 
Knee pain is the most common complaint, followed by shoulder and hip pain, but joint pain can affect any part of your body, from your ankles to your shoulders. As you get older, painful joints become increasingly more common. Joint pain can range from mildly irritating to debilitating. It may go away after a few weeks (acute), or last for several weeks or months (chronic). Even short-term pain and swelling in the joints can affect your quality of life. Many different conditions can lead to painful joints, including Arthritis, bursitis, strains, sprains, and other injuries. Among these Arthritis is most common causes.
 Arthritis is a non-specific term for inflammation of joint. Inflammation is the body’s first reaction to injury. When the joint is inflamed due to some internal of external injury it is called arthritis. In the case of joint inflammation (or arthritis) the following changes occur: In response to injury, nonspecific immune system is activated (immune system is the body’s defense system.) It may be activated by injured tissue debris in or around the joint. Sometimes the immune system is wrongly activated without any injury. When immune system is activated, there is increased blood flow drawing different blood cells like WBC etc. in/around the joints. Meanwhile, a redistribution of arteriolar flow produces stasis and hypoxia at the site of injury. The resultant localized infiltration of tissues by leukocytes, plasma proteins, and fluid causes the red, swollen, and painful lesions characteristic of inflammation. Inflammation serves several practical purposes. The influx of leukocytes facilitates the process of phagocytosis, by which damaged cells and other particulate matter are removed from the site of injury. Pain and tenderness serve to remind the sufferer to guard and protect the damaged part, so that the process of repair may be completed without interruption. Inflammation of a joint may be the outcome of an isolated injury, or it may be a cumulative process that occurs in response to one or more of the following conditions below. Some of the recognized causes of inflammatory lesions are,

  1. Inflammatory Arthritis (Rheumatoid Arthritis,Spodyloarthropathies)
  2. Osteoarthritis or Degenerative joint disease (primary or secondary)
  3. Connective tissue disease (acquired)
  4. Non-articular rheumatism (tendonitis,bursitis)
  5. Arthritis due to infection
  6. Traumatic or neurogenic disorder
  7. Neoplasm
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Rheumatoid Arthritis
Rheumatoid arthritis (RA) is a chronic autoimmune and inflammatory disease that causes pain, swelling, and stiffness in the joints. RA affects the hands and feet joints on both sides of the body, distinguishing it from other forms of arthritis. It leads to bone erosion and joint deformity. The disease may also affect many other body systems, such as skin, lungs, eyes, nerves, heart, and blood vessels.
Causes Of Rheumatoid Arthritis In rheumatoid arthritis, the body’s natural defense system confuses healthy cells of joint lining with abnormal body cells and attacks them. It is usually the inflammation associated with RA that damages joints and other areas associated. The exact cause of this disease is not known, although genetics appears to play a role. People with certain genes are more likely to have rheumatoid arthritis after a particular viral or bacterial infection. Other risk factors include being a woman, middle or old age, family history, smoking, and obesity.
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Interventions
  • Platelet Rich Plasma Injection–PRP therapy involves injecting platelets from the patient’s own blood to rebuild a damaged tendon or cartilage. It has been successful in not only relieving the pain, but also in jumpstarting the healing process. The patient’s blood is drawn and placed in a centrifuge for 15 minutes to separate out the platelets. The platelet-rich plasma is then injected into the damaged portion of the tendon or cartilage.
  • Prolotherapy and Prolozone Therapy.Injection of tissue proliferates (like ozone, dextrose, etc.) inside the joint and around the joint reduces pain, inflammation and strengthens ligaments. It is also claimed that they promote cartilage growth.
  • Visco-supplementation– High molecular weight hyaluronic acid resembling synovial fluid is very helpful particularly in early osteoarthritis .
  • Intra-articular injections– Patients with severe pain, joint effusions, and local signs of inflammation benefit from intraarticular analgesics (pain killers).. Some patients will require about 2 to 3 injections in a year, to using aseptic precautions. Sometimes mild flare-ups are possible in joint inflammation following intraarticular injections. Repeated injections are not recommended for the fear of damaging the cartilage of weight-bearing joints.
  • Radio-Frequency Procedure– Radio frequency ablation of nerves affecting the aafected joint is an option when other option fails and patient don’t want surgery.
  1. Other Non Interventional Therapies
  • Basic Electrotherapies like TENS, Ultrasound Therapy, IFT, Infra red therapy etc.
  • Advanced Electrotherapies like Low Level Laser Therapy, Radial Shock Wave Therapy, Pulsed Electromagnetic Field Therapy etc.
  • Dry Needling
  • Accupuncture
  • Non Invasive Pulsed Radio Frequency Therapy
  1. Surgery
  • Surgical options like osteotomy, arthroplasty, and joint replacement are considered in patients having very severe symptoms and once the medical line of treatment and interventions have failed. But surgical options should be delayed as much because the total joint arthroplasty might last between 10-20 years. Patients will have to modify his/her lifestyle to a certain extent because of the ergonomics of the replaced joint.
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Gout
Gout is metabolic cause of arthritis which arises from mismanagement of some protein metabolism. Gout is a common and complex form of arthritis that can affect anyone. It’s characterized by sudden, severe attacks of pain, swelling, redness and tenderness in one or more joints, most often in the big toe. An attack of gout can occur suddenly, often waking you up in the middle of the night with the sensation that your big toe is on fire. Gout symptoms may come and go, but there are ways to manage symptoms and prevent flares.
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Causes
Gout occurs when urate crystals accumulate in your joint, causing the inflammation and intense pain of a gout attack. The human body makes uric acid during the breakdown of proteins called purines found in certain food and drinks. This normal byproduct goes through the kidneys and exits the body when you urinate. Purines are also found in certain foods, including red meat and organ meats, such as liver. Purine-rich seafood includes anchovies, sardines, mussels, scallops, trout and tuna. Alcoholic beverages, especially beer, and drinks sweetened with fruit sugar (fructose) promote higher levels of uric acid. Sometimes the body produces too much uric acid. Or the kidneys can’t do a good job handling it. When the body has high levels of uric acid, or hyperuricemia, uric acid crystals can concentrate in the joints. The sharp, needle-like crystals cause gout. However, many people with higher uric acid levels never get gout.
Risk factors
Factors that increase the uric acid level in your body include:
  • Diet. Eating a diet rich in red meat and shellfish and drinking beverages sweetened with fruit sugar (fructose) increase levels of uric acid, which increase your risk of gout. Alcohol consumption, especially of beer, also increases the risk of gout.
  • Weight. If you’re overweight, your body produces more uric acid and your kidneys have a more difficult time eliminating uric acid.
  • Medical conditions. Certain diseases and conditions increase your risk of gout. These include untreated high blood pressure and chronic conditions such as diabetes, obesity, metabolic syndrome, and heart and kidney diseases.
  • Certain medications. Low-dose aspirin and some medications used to control hypertension — including thiazide diuretics, angiotensin-converting enzyme (ACE) inhibitors and beta blockers — also can increase uric acid levels.
  • Family history of gout. If other members of your family have had gout, you’re more likely to develop the disease.
  • Age and sex. Gout occurs more often in men, primarily because women tend to have lower uric acid levels. After menopause, however, women’s uric acid levels approach those of men. Men are also more likely to develop gout earlier — usually between the ages of 30 and 50 — whereas women generally develop signs and symptoms after menopause.
  • Recent surgery or trauma. Experiencing recent surgery or trauma can sometimes trigger a gout attack. In some people, receiving a vaccination can trigger a gout flare.
Clinical Features
The clinical features of gout almost always occur suddenly, and often at night. They include:
  • Intense joint pain. Gout usually affects the big toe, but it can occur in any joint. Other commonly affected joints include the ankles, knees, elbows, wrists and fingers. The pain is likely to be most severe within the first four to 12 hours after it begins.
  • Lingering discomfort. After the most severe pain subsides, some joint discomfort may last from a few days to a few weeks. Later attacks are likely to last longer and affect more joints.
  • Inflammation and redness. The affected joint or joints become swollen, tender, warm and red.
  • Limited range of motion. As gout progresses, you may not be able to move your joints normally.
Complications
People with gout can develop more-severe conditions, such as:
  • Recurrent gout. Some people may never experience gout signs and symptoms again. Others may experience gout several times each year. Medications may help prevent gout attacks in people with recurrent gout. If left untreated, gout can cause erosion and destruction of a joint.
  • Advanced gout. Untreated gout may cause deposits of urate crystals to form under the skin in nodules called tophi (TOE-fie). Tophi can develop in several areas, such as your fingers, hands, feet, elbows or Achilles tendons along the backs of your ankles. Tophi usually aren’t painful, but they can become swollen and tender during gout attacks.
  • Kidney stones. Urate crystals may collect in the urinary tracts of people with gout, causing kidney stones. Medications can help reduce the risk of kidney stones.
Diagnosis
Diagnosis is based mainly on the results of
  • Medical history
  • Clinical features
  • Physical exam,
    • Blood tests
A blood test for the uric acid helps in diagnosis
  • Medical imaging- X ray, USG, CT Scan, MRI or affected joint
  • Aspiration: Aspiration of fluid from joint is most specific test for Gout. Aspirated fluid may have uric acid crystals (confirming gout) or a different problem (such as bacteria with infection or other type of crystal).
Management
Gout’s management consist of different phases.
  • Acute Phase: Treatment for flares consists of nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, steroids, and the anti-inflammatory drug colchicine.
  • Prevent future flares.Making changes to your diet and lifestyle, such as losing weight, limiting alcohol, eating less purine-rich food (like red meat or organ meat), may help prevent future attacks. Changing or stopping medications associated with hyperuricemia (like diuretics) may also help.
  • Prevent tophi and kidney stonesfrom forming as a result of chronic high levels of uric acid. Tophi are hard, uric acid deposits under the skin. For people with frequent acute flares or chronic gout, preventive therapy to lower uric acid levels in the blood using drugs like allopurinol, febuxostat, and pegloticase is recommended.
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Types Of Spondyloarthropathies
  • Ankylosing Spondylitis: Ankylosing Spondylitis is a specific type of spondyloarthropathy where there is ankylosis or fusion of the spine joints. Typically affects young men ages 15-30. Women can be affected but much less than men (3:1 men:women). Affects about 1 in 1000 . In women it is usually untypical AS may present as neck and breast pain without the IBP inflammatory low back pain. As the disease progresses all the spine joints are fixed with calcifications of ligaments around the spine and gradually the patient is unable to move the spine, unable to turn the head, unable to touch the chest with the chin. It is a severe and debilitating form of SPA. In this disease, chronic inflammation causes pain and stiffness in the joints and spine. In severe cases, spinal vertebrae may fuse (hence the name ankylosis), giving rise to rigid spine and abnormal posture. The disease can also cause fever, fatigue, and inflammation of the eyes or bowel. In rare cases, it can involve the heart and lungs as well.
  • Reactive Arthritis: Formerly known as Reiter’s syndrome, it develops 2 to 4 weeks after an infection of the urinary tract or digestive system. It tends to cause inflammation of the lower joints, eyes, and urinary tract but may also lead to the inflammation of the spinal joints.
  • Psoriatic Arthritis: It develops in the 30s or 40s, and affects men and women equally. It is seen in associated with the skin condition psoriasis and develops after its symptoms have appeared already. The disease affects the pelvis and the back, major joints of the body, and fingers and toes. It may cause neck pain as well.
  • Enteropathic Arthritis: It is associated with inflammatory bowel diseases, i.e., ulcerative colitis and Crohn’s disease. It causes pain in the spine and peripheral joints and may also cause bloody diarrhea and abdominal pain.
  • Juvenile Spondyloarthropathy: It is not a specific disease but a group of conditions that develop in children at or before the age of 16 but may last throughout adulthood. It affects the lower extremities such as the pelvis, hips, ankles, and knees and causes pain.
  • Undifferentiated Spondyloarthropathy: Its symptoms are not as specific as other diseases of this group. It causes pain in the lower back and heels. Sometimes, it develops into a more identifiable disease such as ankylosing spondylitis.
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Clinical Feature
  • The immune cells attack the joint lining leading to inflammation and periods of flare or exacerbations. It is during these periods that most of the clinical signs and symptoms appear. The symptoms in RA are as follows
    • Joint Pain
    • Redness, tenderness, and swelling in joints of both sides of the body
    • Joint stiffness usually in the morning, after some activity or sitting still for sometime
    • Loss of function, mobility, or joint deformities
    • Low-grade fever
    • Loss of appetite
    • Lack of energy
    RA affects the smaller joints of the hand and feet first and then progresses to the hips, knees, ankles, elbows, and wrists. More than one-third of the people with RA may experience symptoms of areas other than joints. These areas can be skin, heart, lungs, eyes, kidneys, nerves, and blood vessels. RA complications include osteoporosis, infections, dry mouth and eyes, and heart or lung problems.

Diagnosis of Rheumatoid Arthritis

Rheumatoid arthritis is diagnosed based on signs and symptoms, medical history, physical examination, and diagnostic tests.

Physical examination includes checking warmth, redness, tenderness, swelling, movement, deformity, reflexes, and strength of joints.

Many tests are performed to confirm the diagnosis of rheumatoid arthritis. These tests are:

  • Erythrocyte sedimentation rate or ESR tests. ESR is elevated during rheumatoid arthritis
  • C-reactive protein level test. The liver produces C-reactive proteins during inflammation
  • Rheumatoid factor test. Performed to check for the elevated levels of proteins called rheumatoid factor.
  • Anti-cyclic citrullinated peptide test. Usually, patients with RA have this antibody in their blood.

Imaging tests like X-rays, MRI, and ultrasound are also performed to judge disease severity.

Treatments of Rheumatoid Arthritis

The disease has no cure, and the treatment focuses on managing the symptoms. Early diagnosis — within six months — is crucial for treatment to reduce joint damage and improve quality of life. Prognosis is much worse among patients with a positive rheumatoid factor or Anti-cyclic citrullinated peptide test. The disease is not fatal. Although, in some patients, the life expectancy may shorten by up to 10 years due to RA complications.

1) Non pharmacological Treatment

It is extremely crucial for management of RA

  • Diet – Certain food can triggers acute flares. Those are Red meat, sugar and refined flour, fried foods, processed foods, gluten, alcohol etc. Avoiding these food helps in a great manner. One the other hand certain foods helps in RA , those are Fatty fish, Fruits and veggies, Whole grains, Peas and beans, Nuts, Olive oil.
  • Physical Therapies – A therapist can teach a person exercises to keep their joints flexible. They can suggest new and effective ways of doing daily tasks that are easier on joints. They may advise the use of assistive devices such as a cane to avoid stressing the joints.

Biofeedback and cognitive behavioral therapy

2) Pharmacological Treatment

Fortunately, clinical studies report disease remission in patients who adhere to the treatment. Depending on disease severity, the following drugs may be recommended:

  • NSAIDs (Non-steroidal anti-inflammatory drugs) such as ibuprofen, naproxen, or aspirin are available over the counter and reduce pain and inflammation in the joints temporarily.
  • Corticosteroids like prednisone reduce joint pain and inflammation quickly and slow joint damage. Their side effects make their use very limited.
  • DMARDs (disease-modifying anti-rheumatic drugs) like methotrexate slow the progression of rheumatoid arthritis and save joints from damage. If conventional DMARDs are not effective, targeted synthetic DMARDs may be used in place.
  • Biologic DMARDs are a newer generation of disease-modifying anti-rheumatic drugs that reduce inflammation without suppressing the immune system. They are used in patients who do not respond to conventional DMARDs. These are costly, but best treatment of Rheumatoid Arthritis particularly when other medicines are not that effective.

Nutraceutical supplements like Omega 3 fatty acid, Collegen Type 2, curcumin, boswelia, pre-probiotics may help in reducing inflammations.

3) Surgical Treatment

If medications and therapies don’t work, surgeries may become necessary to repair damaged joints. Surgery may involve the following procedures:

  • Synovectomy to remove inflamed joint lining
  • Tendon repair of loose or ruptured tendons
  • Joint fusion to stabilize or realign a joint when joint
  • Total Joint replacement as the last resort
4) Interventional Management

Ultrasonography-guided intraarticular steroid injection is one of the very important treatments for Rheumatoid arthritis.