Arthritis refers to inflammatory diseases that occur in the joints and surrounding tissues of the body and can be divided into dozens of types. There are more than 100 million patients with arthritis in China and the number is increasing. Clinical manifestations include redness, swelling, heat, pain, dysfunction and deformity of the joints, which in severe cases lead to joint disability and affect the quality of life of patients.
Main symptoms: pain, swelling, dysfunction
Main causes: inflammation, autoimmune reaction, infection, metabolic disorders, trauma, degenerative disease
Causes: The etiology of arthritis is complex and is mainly related to inflammation, autoimmune reaction, infection, metabolic disorders, trauma, and degenerative disease. The etiology, clinical manifestations, treatment and regression of arthritis vary from one arthritis to another.
Note: Arthritis is one of the most common manifestations of rheumatic disease, but the presence of arthritis does not necessarily mean rheumatic disease, and patients with rheumatic disease do not necessarily present with arthritis.
Disease Classification
Common clinical arthritis includes the following: rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, gouty arthritis, reactive arthritis, infectious arthritis, traumatic arthritis, psoriatic arthritis, enteropathic arthritis, and joint manifestations of other systemic diseases including systemic lupus erythematosus, tumors, and hematologic diseases.
Clinical manifestations
1, pain: is the most important manifestation of arthritis.
2, swelling: swelling is a common manifestation of joint inflammation and does not necessarily correlate with the degree of joint pain.
3, dysfunction: joint pain and inflammation-induced edema of the peri-articular tissues, resulting in limited joint movement. Patients with chronic arthritis may experience permanent joint function loss due to long-term joint movement restriction.
In addition, acute infectious arthritis may also present with joint redness and swelling.
Differential diagnosis
It is important to differentiate arthritis because of the wide variety of arthritis, the complexity of the causes, and the different principles of treatment.
Rheumatoid arthritis: This disease is one of the most common types of chronic arthritis. It is associated with genetics, bacterial and viral infections, and environmental factors including smoking. It can occur at any age, but is more common in women between the ages of 40 and 60. The small joints of the hands (finger joints and wrists) are most commonly involved and show bilateral involvement. Patients also have morning stiffness lasting more than one hour and limited joint movement. In severe cases, systemic organ involvement may occur. Anti-cyclic citrullinated peptide antibodies are specific to the patient. The vast majority of patients are positive for rheumatoid factor, but there is no absolute correlation between the level of rheumatoid factor and the activity of the disease.
2, osteoarthritis: also known as degenerative joint disease, osteoarthropathy, commonly known as osteophytes. The prevalence of osteoarthritis is closely related to age and obesity; the prevalence of osteoarthritis in people under 45 years old is only 2%, while the prevalence in people over 65 years old is as high as 68%. In short, all people suffer from osteoarthritis to varying degrees by the time they reach old age. All joints can be involved. However, when the small joints of both hands are involved, it is mostly the distal interphalangeal joints of both hands. Bony prominence of the distal interphalangeal joints is seen clinically. Morning stiffness may also occur, but it lasts less than half an hour. The rheumatoid factor in the blood of these patients is often negative.
Gouty arthritis: This disease is associated with excessive production and/or reduced excretion of uric acid in the body. Excessive local deposition of uric acid in the joints causes arthritis. Its onset is very rapid, often triggered by overeating or stress, and manifests as red, swollen and hot joint pain. Single joint involvement is common, with the most common site of onset being the bony prominence next to the big toe. Acute gouty arthritis also resolves rapidly, either without treatment or after one to two weeks of medication, but is prone to recurrence. Chronic gouty arthritis can have no significant interval, but is characterized by recurrent episodes of arthritis.
4, ankylosing spondylitis: young men are more frequent, there is a clear tendency of family onset. It mainly involves the spine, sacroiliac joints, but also peripheral joint involvement. The spine may become stiff when the lesion is severe, with restricted movement of the cervical, lumbar and thoracic vertebrae and a “hunchback”, which seriously affects the patient’s daily life. 90% of patients are HLA-B27 positive, while rheumatoid factor negative.
5.Psoriatic arthritis: also known as psoriatic arthritis. Patients are often accompanied by the skin manifestations of psoriasis. Psoriatic arthritis joint involvement is partially similar to rheumatoid arthritis, so it may be confused with rheumatoid arthritis. However, when the small joints of both hands are involved, they are mostly in the interphalangeal joints at the ends of the fingers. However, sacroiliac joint and spine involvement is rare in rheumatoid arthritis. Some patients may not have skin lesions at the time of arthritis, and these patients may be misdiagnosed. The patient’s serum is negative for rheumatoid factor.
6. Reactive arthritis: The onset is rapid, often preceded by a history of intestinal or urinary tract infection. The large peripheral joints (especially the lower extremities) are asymmetrically involved. Sacroiliac joints and the spine may also be involved. Extra-articular manifestations may include ophthalmitis, urethritis, and phimosis. More than 80% of patients are HLA-B27 positive and rheumatoid factor negative.
7. Enteropathic arthritis: Patients with ulcerative colitis may have combined arthritis. The joint symptoms are mild and often have other extra-intestinal manifestations including ophthalmia, rash, etc.
8, infectious arthritis: associated with bacterial infection. Common pathogens include Staphylococcus aureus, S. pneumoniae, S. meningitidis, gonococcus, streptococcus, and Mycobacterium tuberculosis. The pathogenesis includes direct bacterial infection and the release of toxins or metabolites by bacteria during the infection process, including subacute bacterial endocarditis and arthritis after scarlet fever. Arthritis due to direct bacterial infection is characterized by red, swollen, and painful joints and joint dysfunction. The weight-bearing joints of the lower extremities are asymmetrically involved. Large joint involvement is common, such as hip and knee joints. The joint cavity puncture fluid often shows purulent changes. Bacteria may be found on smear or culture. Arthritis with Mycobacterium tuberculosis infection occurs in young adults with evidence of tuberculosis at other sites including the lungs or lymph nodes. There may be erythema nodosum and a negative serum rheumatoid factor. A tuberculin test is positive. Arthritis due to bacterial metabolites or toxins can heal spontaneously in 1-2 weeks, with wandering joint symptoms.
9, traumatic arthritis: related to joint trauma. After joint trauma, it is necessary to pay attention to whether the injury is combined with fracture, ligament rupture or partial tear, cartilage rupture or partial tear and whether there is blood and fluid accumulation in the joint.
10, autoimmune diseases involving joints: autoimmune diseases such as systemic lupus erythematosus, dry syndrome, scleroderma and tumors often appear in the process of occurrence and development of arthritis. This type of arthritis is mostly non-erosive, and some of the arthritis may resolve after the primary disease is controlled. There is no residual joint dysfunction.
Disease treatment
1.Diet regulation
Different types of arthritis patients have different dietary principles. There is no conclusive evidence to confirm that there is an inevitable link between nutritional deficiency and arthritis, but nutritional deficiency may lead to aggravation of arthritis, while overnutrition and obesity may trigger or aggravate arthritis such as gouty arthritis and osteoarthritis. Patients with rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis often show signs of malnutrition such as anemia and wasting due to the systemic inflammatory response. Other infectious arthritis can also be due to acute inflammation resulting in body depletion, which is detrimental to the recovery of arthritis. Patients with the above-mentioned conditions should replenish their daily nutrient requirements as much as possible and give gastrointestinal nutrition if necessary to improve the body’s ability to resist disease. In contrast to the above, patients with osteoarthritis and gout are mostly overweight, especially those with gout, who often have metabolic disorders such as hyperglycemia, hypertension and hyperlipidemia, and excessive blood uric acid levels induce and aggravate arthritis. Therefore, patients with osteoarthritis, hyperuricemia and gouty arthritis should control their diet and reduce their body weight to reduce the burden on their joints. Patients with hyperuricemia and gout are advised to reduce the intake of high-purine foods such as animal offal and aquatic products, eat more alkaline foods such as rape, cabbage, carrots and melons, and strictly limit alcohol consumption, mainly white wine and beer. There is no evidence to prove that red wine can trigger gout, on the contrary, drinking moderate amounts of red wine may be conducive to lowering uric acid, while drinking tea, coffee and milk may also help to lower uric acid.
2. Avoid environmental factors that trigger the development of arthritis
The relationship between arthritis and the environment, especially infection, cannot be ignored. The strep arthritis, reactive arthritis, and infectious arthritis are all directly related to infection. Pathogenic bacterial infections may also be one of the predisposing factors for autoimmune diseases such as rheumatoid arthritis and systemic lupus erythematosus. Streptococcus is one of the main pathogens that cause arthritis. Other microorganisms that may be associated with the development of arthritis include EBV, cytomegalovirus (CMV), B19, Mycobacterium dysenteriae, Klebsiella, Mycobacterium tuberculosis, and some mycoplasmas and chlamydia. A humid environment helps certain pathogenic bacteria to grow and has a relationship with the development of arthritis. Therefore, you should pay attention to hygiene, keep your living room well ventilated and airy, prevent moisture, keep warm, avoid the spread of pathogenic bacteria, especially streptococcus, strengthen physical exercise, improve the ability to resist disease, and prevent it before it happens.
In recent years, smoking has been found to be significantly associated with the development of rheumatoid arthritis. Smokers are significantly more likely to develop rheumatoid arthritis, and smoking can affect the outcome of rheumatoid arthritis patients. Therefore, smoking cessation is one of the preventive measures for rheumatoid arthritis.
In addition, other environmental factors such as ultraviolet light, exposure to certain chemicals may lead to abnormal immune response in some susceptible people, resulting in the occurrence of different arthritis.
3. Patient education, spiritual and psychological regulation
The stability of the immune system is correlated with emotions. Many patients clinically have developed autoimmune disease manifestations after experiencing adverse life events. Therefore, maintaining an optimistic and stable state of mind is beneficial to the prevention of rheumatic diseases. It is significant for the treatment of arthritis that patients are instructed to maintain an optimistic mood, eliminate depressive states and fight the disease with a positive attitude.
4.Functional exercise and lifestyle adjustment
Long-term joint lesions can lead to limited joint movement and muscle atrophy, functional exercise is an important method to restore and maintain joint function. Functional exercise should pay attention to the timing, type and intensity of exercise. During the acute phase of joint swelling, joint movement should be limited, the affected limb should be elevated to reduce edema, and if necessary, bed rest should be provided until the joint swelling and pain improve. After the swelling and pain improve, flexion, extension and rotation of the joint should be performed without increasing pain to increase joint mobility. Arthritis of weight-bearing joints such as knee arthritis and hip arthritis require avoidance of weight-bearing exercises. The types of joint exercises vary. Patients with knee arthritis can choose exercises such as swimming and walking, avoiding excessive walking and stairs; patients with lumbar and neck arthritis can choose rotational activities for local joints, avoiding long-term ambulation and head tilting; for patients with ankylosing spondylitis, swimming is the best total body exercise. For patients with small hand arthritis, they can choose to knit, braid, knead play-doh, cut paper, calligraphy, typing, gardening, etc. to move their small joints. No matter what kind of exercise you choose, you should start with a small amount and progress gradually, so as not to cause joint pain after exercise, otherwise you need to adjust the exercise intensity and reduce the exercise time. In hospitals that have the conditions, the above functional exercises can be carried out under the guidance of rheumatologists and rehabilitation specialists. In addition, patients should pay attention to lifestyle adjustments, such as ankylosing spondylitis patients need to stand upright when standing, sleep more on hard beds, maintain supine position to avoid flexion contracture, low pillows, once the upper thoracic and cervical spine involvement should stop using pillows. And patients with knee arthritis should avoid wearing high heels.
5.Physical therapy
Physical therapy mainly includes the following: direct current therapy and drug ion introduction, low frequency pulse electrotherapy, medium frequency current therapy, high frequency electrotherapy, magnetic field therapy, ultrasound therapy, acupuncture, light therapy that is infrared, ultraviolet light, cold therapy. On the basis of drug therapy, according to the location and nature of joint involvement, appropriate physical therapy can better relieve joint symptoms and promote functional recovery. In acute arthritis, the use of ultraviolet radiation can reduce joint inflammation, and in the subacute and chronic stages, warm therapy is the main treatment.
6.Medication
Rheumatoid arthritis treatment drugs mainly include non-steroidal anti-inflammatory drugs, glucocorticoids, slow-acting anti-rheumatic drugs, botanical drugs, biological agents, etc. NSAIDs are the first-line anti-rheumatic drugs, which can rapidly relieve joint symptoms but cannot stop disease progression, and need to be combined with other drugs as appropriate. gs is the strongest anti-inflammatory drug, and if used correctly, can rapidly relieve inflammation and control the disease, but cannot be abused, and is suitable for the presence of extra-articular manifestations, transitional treatment and local application. 2010 Chinese Journal of Rheumatology Rheumatoid Arthritis Treatment The guidelines suggest that the principles for the use of Gs in rheumatoid arthritis are short-term, low-dose, combined vitamin D3 and calcium, and joint cavity injections. For patients with rheumatoid arthritis, early, combined, individualized regimens of DMARDs can provide early control of lesions, significantly slow disease progression, and improve prognosis. Such drugs include methotrexate, salazosulfapyridine, leflunomide, hydroxychloroquine sulfate? etc. However, DMARDs are poor in relieving pain and take some time to take effect, so the acute phase of arthritis should be combined with NSAIDs or Gs. Group A Group B hemolytic streptococcal infection can cause arthritic manifestations of rheumatic fever, and the use of penicillin in the acute phase is the most effective drug to control streptococcal infection. long-term use of long-acting antibiotics in patients with acute rheumatic fever to prevent the occurrence of distant rheumatic heart disease, adults Prevention must not be shorter than 5 years and maintained in children until at least 18 years of age. Tuberculous arthritis and fungal arthritis require a combination of these treatments on top of active and effective anti-tuberculosis or antifungal drugs, but antiviral therapy is not required for viral arthritis. Reactive arthritis is also associated with microbial infections, but the disease is self-limiting in most patients and resolves within 3-5 months, with some patients having a disease duration of up to 1 year, and opinions are divided as to whether anti-infective therapy is needed. Botanicals can assist in the treatment of arthritis, but there are no studies to confirm their definitive efficacy in delaying bone destruction. The advent of biologics is a boon to patients with rheumatic disease-related arthritis and may significantly improve patient prognosis. However, their use needs to be carefully screened for indications and contraindications, weighing the pros and cons.
Treatment of ankylosing spondylitis is also based on NSAIDs and DMARDs (SASP, MTX), with biologic agents, especially tumor necrosis factor (TNF)-α antagonists, being the most effective, especially for patients with medial joint involvement who do not respond well to DMARDs.
In addition to symptomatic pain relief (acetaminophen, NSAIDs), topical hyaluronic acid can be applied to the joint in the treatment of osteoarthritis. Glucosamine analogues are used in the treatment of osteoarthritis to slow down disease progression and are recommended for long-term application.
Treatment of gouty arthritis includes anti-inflammatory and analgesic (NSAIDs are preferred) in the acute phase, and uric acid-lowering therapy in the remission phase. Specific drugs should be selected according to the patient’s renal function and the presence or absence of kidney stones. Uric acid-lowering drugs mainly include those that inhibit uric acid production (allopurinol) and those that promote uric acid excretion (benzbromarone). The latter is usually preferred.
7.Immunotherapy and biological therapy
These treatments are aimed at the main aspects of arthritis development and progression, such as target molecular therapy for cytokines, plasma replacement, immune purification, immune reconstitution, mesenchymal stem cell transplantation, etc. They are mainly used for patients with other treatments that are ineffective, rapidly progressing and refractory severe arthritis, mainly rheumatoid arthritis.
8.Surgical treatment
Surgical treatment mainly includes joint cavity puncture, synovectomy, joint replacement, joint orthopedics, and joint fusion. Not every patient needs arthrocentesis, and clinical indications should be strictly controlled. Arthritis that has been diagnosed but persists in individual joints can be treated with joint cavity aspiration and intra-articular injection if the joint function is affected. The drugs often used for joint cavity injection are glucocorticoids, methotrexate and hyaluronic acid. The first two are mostly used in rheumatoid arthritis. There is no limit to the frequency of intra-articular hormone injections into the same joint, but if the effect is poor after 1-2 injections, the injections should not be continued. Hyaluronic acid is preferred for patients with osteoarthritis. Avoid excessive joint movement after joint cavity injection to avoid local swelling caused by drug exudation.
Synovectomy is indicated when the diagnosis cannot be confirmed by clinical, imaging and laboratory examinations, and when there is no significant improvement in drug treatment for six months. Before surgery, however, patients need adequate mental and psychological preparation and preoperative medication preparation. Joint orthopedics and joint replacement are used for patients with joint deformities and severe functional limitations. Joint fusion can artificially cause bony ankylosis of the joint to reduce pain, terminate the lesion, or provide joint stability.
In summary, the causes of arthritis vary and so does the treatment. Proper diagnosis of different arthritis is a prerequisite for treatment. Treatment should be comprehensive, taking into account the etiology, duration and individual differences of the patient, in order to achieve the best possible treatment. The prognosis varies depending on the cause of the disease.