Diagnosing and treating arthritis
How will arthritis be diagnosed?
A consultation will likely begin with a medical review which will cover the following areas:
- Your symptoms: How long ago did you notice symptoms? How would you describe the level of pain or discomfort? Are there specific times you have noticed symptoms of stiffness? How long does stiffness typically last? Are your symptoms constant or do they come and go? Have you tried anything that has either alleviated your symptoms or worsened them?
- Health check – current, recent or past: This is to assess any previous, current or recently experienced health conditions, such as high blood pressure or diabetes, you may have been evaluated for or diagnosed with. Your doctor may ask whether you have been unwell recently, travelled abroad or experienced any joint injuries. He or she may also ask whether you have or have been evaluated for an autoimmune condition. Other questions which may come up include:
- Are you in the habit of playing contact sports?
- Does the nature of your job require long hours of sitting, standing, or other repetitive motion, such as kneeling or climbing stairs?
- Do you use any medications (prescription or over-the-counter) to treat any existing conditions?
- Do you use or take any supplements (including herbal products)?
A doctor will also assess some of your habits, which may include smoking (if applicable), exercise routines (what you do and how often you participate in activity), sleeping patterns and nutrition (or lack of a healthy diet). He or she may also ask questions relating to any possible mental health problems such as anxiety or depression, or whether you are currently stressed.
- Assess family history: Also part of the discussion is a quick assessment for any signs of autoimmune conditions or rheumatic disease in your family line. Your doctor may ask relevant questions regarding your parents, siblings, aunts and uncles or even grandparents.
Once notes have been made during the medical review, a doctor will wish to conduct a physical examination. This part of the evaluation is ‘hands-on’ and is necessary in order to assess, in detail, any visible signs of joint tenderness, redness (inflammation), swelling or stiffness.
A doctor can physically assess which fingers, for instance, are affected. He or she will want to determine if there is a particular pattern of symptoms by assessing all joints. Is there a symptomatic pattern which is symmetrical (i.e. the same joint is affected on both sides, such as the ankles)? He or she may also note a count of affected joints in the body.
The doctor will also need to assess signs of warmth, swelling, tenderness and fluid build-up (near the affected joint areas). A doctor may also gently prod specific areas to assess the level of tenderness and how far away from affected joints this symptom is being experienced. Joints may also be moved to assess your range of motion during the evaluation.
The doctor will also assess and note a temperature reading, check for swollen lymph nodes (glands), assess the eyes, blood pressure, and throat, as well as conduct a reflex check.
Are there any tests involved?
To determine the best course of action, a doctor will need to have a clearer idea as to which variation of arthritis you have. It is also possible to have more than one variation of arthritis at the same time. For treatment to prove beneficial, the type/s of arthritis in the body (or associated conditions) will need to be determined through a series of tests.
The medical review discussion and physical exam will likely give your doctor distinctive clues to work with, ensuring that appropriate tests are done to either rule out or conclusively determine the root cause of symptoms. In this way, a conclusive diagnosis will likely be made.
Tests that are commonly used to make a diagnosis are:
- Laboratory analysis tests: Your doctor may request a few different body fluid samples for testing in the laboratory. These tests can help to pinpoint a specific form of the condition and through analysis, determine the cause of inflammation and pain. Fluid samples will include those of blood (taken through a vein in the arm), joint fluid (taken using a sterilised needle in an affected joint – known as aspiration) and urine (provided in a small, sealed cup for urinalysis). Blood samples will be analysed for signs of inflammation, Rheumatoid factors (proteins that attack healthy tissues in the body), the presence of antibodies (anti-CCP antibody and antinuclear antibody or ANA), HLA antigens for HLA B27 analysis (check for the presence of human leukocyte antigen B27 or HLA-B27 protein in white blood cells), as well as check that general systems (such as liver and kidney function – C-reactive protein, and a complete blood count) are in working order. A doctor may also assess your erythrocyte sedimentation rate (ESR) – the rate at which red blood cells sediment during an hour-long period of time, a synovial fluid analysis, blood culture, and uric acid measurement in the blood or urine. Joint aspiration will be used to assess your cell count, perform a gram stain and culture and examine the formation of crystals under a microscope.
- Imaging tests: These give your doctor a view of the inside of the body and can help to detect problem areas, such as the joints. A doctor will wish to assess any possible structural changes in the joints, as well as check for signs of joint erosion, soft tissue tears, inflammation, cartilage loss, and the presence of any loose fragments of tissue. A doctor will also be looking for location of fluid build-up and how much is present in the affected areas. Tests which are useful for making a diagnosis are X-rays (low levels of radiation can help to create clear images of bone, and show any cartilage loss, damage or bone spurs, as well as monitor progression of the condition), a computerised tomography (CT) scan (cross-sectional views of bone and cartilage structures, as well as surrounding soft tissues), a magnetic resonance imaging (MRI) scan (a highly detailed cross-sectional visual of structures, such as ligaments, tendons, and cartilage) and an ultrasound scan (high-frequency sound waves which create visuals of fluid-containing structures, soft tissues and cartilage, as well as guide joint aspiration tests or the accurate administering of injections).
Other tests (where applicable) may include:
- Electrocardiogram (ECG)
- Thyroid function test
- Synovial biopsy
- Schirmer’s test (assess tear production)
- Tear test
- Slit lamp eye examination
- A salivary gland biopsy
Diagnosing arthritis may be a comprehensive process, which can sometimes be fairly straightforward. If the process shows up other associated conditions or problems, a diagnosis may be a little more complex.
A diagnosis will largely be based on the apparent pattern of symptoms, test findings and the distribution or number of affected joints in the body.
Of the many forms of arthritis, osteoarthritis and rheumatoid arthritis are typically the most common of the lot. A doctor will look for key features, such as a distinctive inflammatory cause, which will point him or her in the right direction for testing and diagnosis. Even if it isn’t clear, after a thorough evaluation, a doctor will carefully assess what is known and advise appropriate means of reducing inflammation to try and avoid as much potential further damage (which can sometimes be irreversible) as possible. The earlier a diagnosis is made and treatment implemented, the better.
Treatments and medications
Many doctors and specialists strongly recommend early treatment that prescribes an aggressive regimen. ‘Early treatment’ refers to a ‘window of opportunity’ during the initial two years following symptom onset.
In the case of RA, in particular, aggressive treatment during this period could prevent disease progression which is evident in the erosion of the joints that takes place. Not all doctors pay much attention to this ‘window of opportunity’ and rather take the stance that anyone diagnosed with a form of arthritis must be appropriately treated as soon as possible, no matter how far advanced a condition is. The earlier, the better applies to all.
Early treatment is especially important for those at higher risk of developing another, more serious medical condition. If this is of particular concern, treatment may be aggressive and constant monitoring will likely be required.
The primary aim of treatment is to gain control over symptoms of pain and discomfort, both medically and with lifestyle adjustments, in order to prevent potentially irreversible joint damage, or possible risk of developing a more destructive medical condition.
Treatment will also focus on improving joint function and mobility. Often, combination treatment methods work best to accomplish substantial improvements.
In the mix of options are:
- Medications: When it comes to pain and inflammation management, a doctor may prescribe or recommend the following types of medications – analgesics, such as Tramadol (Ultram) (these will alleviate pain, not inflammation), nonsteroidal anti-inflammatory medications or NSAIDS, such as ibuprofen taken orally or rubbed on affected areas as a cream or gel, or applied as a patch (these alleviate pain and inflammation), or menthol / capsaicin creams (these counterirritants can help to alleviate the transmission of pain signals to the joints). Other medication options include DMARD (disease-modifying antirheumatic) medications (used to treat RA by suppressing the immune system so as to prevent it from attacking the joints), biologic response modifiers (often used in combination with DMARDs, these target protein molecules which play a role in immune response) and corticosteroids (these alleviate inflammation and suppresses the immune system). All medications will need to be used according to the recommended dosage so as to avoid potentially harmful side-effects. It is a good idea to discuss all over-the-counter medications with your doctor before use to ensure that possible interactions will not cause harmful effects to the treatment of your condition.
- Physical (or occupational) therapy: An important (ongoing) part of treatment, physical therapy involves a series of recommended exercises which are aimed at strengthening muscles surrounding affected joints to improve mobility and body strength. Where necessary, physical therapy may also involve splints, joint adhesive aids or braces. For the most part, physical therapy will involve warm water therapy sessions (exercises performed in a warm water pool), a tailored daily exercise programme and occupational therapy (how to manage fatigue, prevent joint damage during daily activity and practical advice for home care and overall lifestyle).
- Surgery: Knee and hip replacements are an option if damage is extensive. Joint fusions are also a possibility, especially if damage is severe in the wrists, ankles and fingertips (smaller joints). This procedure focuses on locking bones together until they ‘fuse’ or grow together to form one, as opposed to replacing them with an artificial joint (as is done in a replacement procedure). Joint repair is another option, whereby the joint surfaces can be realigned or smoothed in an effort to alleviate pain and promote better mobility.
Some relief may be achieved through some alternative treatment means. Not all are medically approved, but those that may provide some relief without causing any major harm include:
- Glucosamine (this is an amino sugar supplement but the use of this should still be discussed with your doctor)
- Yoga and tai chi