by Dr. Gleen Anciro
Arthritis: is a common musculoskeletal condition that is classified into two groups, Rheumatoid arthritis (RA) and Osteoarthritis (OA).
These two different diseases have a common feature of joint pain, in our clinical settings, we have to critically identify the disease for reasons that our goals and treatment protocols are solely based on the right diagnosis of the disease.
Rheumatoid arthritis (RA) is a disruptive inflammatory condition that reduces the mortality of an individual. The main presenting symptom is joint pain, usually bilateral and commonly affecting the joints of the hands or joints of the feet. There is often total body weakness and early morning stiffness of the joints, the latter persisting for between 30 minutes and several hours. It is an inflammatory joint disease that is initiated by a defective immune response causing a ballistic immune attack on the synovial tissue that lines all moveable joints. The depletion of synovial tissue leads to flattening of the joint lining (pannus), which grows and extends, eroding Articular surfaces and ultimately the bone, eventually destroying the joint. Vital organs like lungs, heart and kidneys can be damaged as a manifestation of systemic effect of RA.
Osteoarthritis (OA) is the most common joint disease due to wear and tear. This leads to disintegration of Articular cartilage and alteration in subchondral bone. Osteophytes (bony spurs) and irregularity to ligaments are also present. These are by product of synovial joint damage, and the transformation or abnormal changes may lead to joint pain and stiffness. Classically, patients present with pain and stiffness in one joint and the most common sites are the knees, hands or hips. Also, the greatest risk factor for OA is age.
The pharmacological intervention of this two diseases varies at one point. Simple analgesia (ex: paracetamol) compound analgesia (ex: co-codamol 8/500 or 0/500), if needed. Use of NSAIDs (or Cox- inhibitors where indicated) with caution and is being prescribed at the lowest effective dose for the shortest period of time. Topical NSAIDs may be used for acute stage of pain relief in small joints. For those chronic cases, intra-Articular steroid injections can give immediate relief for a single affected joint. Hyaluronate injections can be applied to OA patients but not indicated for RA, although evidence of their advantages remains unclear (costs versus benefit). On the other hand, RA needs prompt and aggressive intervention to control its symptoms. The disease modifying antirheumatic drugs (DMARDs) are also frequently prescribed for its potential to reduce or prevent joint damage, preserve joint integrity and function. Given the slow onset of action of traditional DMARDs, low doses of glucocorticoids are often used as a bridge therapy to control symptoms until the DMARDs or biological agents become effective.
One of the most common prescribed drug under this class is methotrexate (MTX) which was originally designed as a chemotherapy drug (in high doses), in low-doses methotrexate is a safe and well tolerated drug in the treatment of certain autoimmune diseases. Its efficacy and safety, low-dose methotrexate is now considered first-line therapy for the treatment of rheumatoid arthritis. While patients who fail to achieve optimal disease control, combination of DMARDS is necessary like methotrexate with hydroxychloroquine and Sulfasalazine,which comes in low dosage and later gradually increase until the remission of the disease is stable.
Indeed, multiple studies and reviews showed that patients receiving methotrexate for RA in long term period had less pain, functioned better, had fewer swollen and tender joints, and had less disease activity overall as proven with the following study. The time duration of the study is 84 months open prospective trial at a single academic rheumatologycenter. The subjects are composed of twenty-six patients enrolled in taking MTX for RA. At 36 months ,therapy manifest positive transformation with lesser pain and function. At 84 months only 12 patients remained in the study for variety of unidentified reasons; the mean weekly dosage of MTX was 10.2 mg. A significant improvement was still noted at 84 months in the number of painful joints, number of swollen joints, joint pain index, joint swelling index, this was proven by the physician and patient global assessments. In the joint pain and swelling index it was observed at 50% increase in improvement in more than 80% of the patient included in the study. In conclusion, the effectiveness of MTX in the treatment of RA continues to be demonstrated in this study that last after 84 months of treatment.
Our role as therapists, is to provide basic care for pain, joint dysfunction that arise symptomatically. It also includes providing adequate advice on symptom control and treatment monitoring. Likewise, vigilance is required in relation to drug toxicities, immunosuppression and the risk of imminent infection or poor disease control. At the same time, the information about the condition, self-management and maintaining functional ability should be shared to members of the family who live with the patient. We should play an important part in helping individuals with OA and RA to manage their condition safely and effectively. It is also an immensely rewarding aspect for us therapists, if our patients can live independently and functional in their own dynamic environment.
Q: In general, arthritis undergoes inflammatory stage which exacerbates the patient’s condition. Do you think improper food category contributes to the inflammatory stage of arthritis?
A: Yes, the food that an individual eat can contribute or trigger the inflammation of an arthritic condition. With this statement given, food that is rich in anti-oxidants and vitamin c is a must in your diet for the development of cartilage. A lack of vit. c can weaken your cartilage and increase the symptoms of arthritis.
Doctor Gleen B. Anciro have been practicing for more than 15 years in the field of Physical therapy, mostly in an in depth out patient setting. I have seen and experienced patients from 10 to 92 years of age undergo a trauma or injury that can result to pain and limitation of function. As a physical therapist, I know how it can be overwhelming and can be a hurdle in our everyday task. As we live by our saying "LIVE FREE. PAIN FREE." I will give you an individualized approach of therapy that can help and guide you alleviate the pain and restore your normal function.
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