By Evelyn O. Salido, MD, MS, FPCP, FPRA (ΜΣΦ 1987)
At 60, are you feeling that pain in your back or hear some creaking sounds from your joints when you move and worry that “age is catching up on you?” Or are you 40 years old and concerned that you will have arthritis like your dad, keeping him in severe pain for days at a time? When older adults feel pain in their limbs and back, it is often assumed to be due to arthritis and “normal” with ageing. Is this true?
Arthritis is not one disease.
There are many different kinds of arthritis that can occur in anyone at any age, even among children. Examples are gout, osteoarthritis, rheumatoid arthritis, infectious arthritis, psoriatic arthritis, and ankylosing spondylitis. Although all these manifests with pain and swelling of the joints, their causes differ and so do treatment.
Not all body aches are due to arthritis.
Some result from soft tissue rheumatism. Other pains arise from problems outside of the musculoskeletal system, like our blood vessels or nerves. Someone with a clogged artery that supplies blood to the leg can feel pain at the thigh, leg, or foot when walking. Dysfunction of nerves can cause pricking, shooting or burning pain at the limbs; these pains are not due to arthritis.
How do we know if pain in our limbs or back is, or is not, due to arthritis?
Two things to check: 1) Is pain present diffusely at the joint or at a localized area near or around it? 2) Is pain present on active motion (person does the motion) only or even during passive motion (person allows someone else to move the joint for him)? In an arthritic joint, there is pain at the whole joint when it is passively or actively moved or pressed. There may be swelling and increased warmth of the joint.
In soft tissue rheumatism, however, the painful spot is close to the joint or around it and there is tenderness at a localized spot near the joint (not on it). Pain may be marked during active motion, but it is markedly less or absent when somebody else moves the joint for him passively. Examples of soft tissue rheumatisms are muscle spasms, bursitis, shoulder tendonitis, “trigger finger,” and “tennis elbow.”
Why differentiate arthritis from soft tissue rheumatism? Because treatment significantly differs.
Most soft tissue rheumatisms result from major or minor repetitive trauma to the joint (e.g. lifting, pushing) that may arise from daily activities. Therefore, treatment usually involves rest, activity modification, and/ or topical or injectable anti-inflammatory medicines.
Arthritides result from many causes, have varying patterns of joint affectation, may or may not affect other organs of the body (heart, lungs, kidney), and have different treatments.
The two most common arthritides in the Philippines are gouty arthritis and osteoarthritis.
Gouty arthritis occurs after years of sustained high uric acid in the body and deposition of urate crystals in joints, ligaments, tendons, skin, kidneys, and other organs of the body. Deposition of these crystals can destroy the organ where these are deposited. There is severe pain and swelling of one or more joints that become more frequent through the years. Gout also causes irreversible kidney damage in at least 30% of Filipinos with the disease. In a study of 669 patients with gout in the University of the Philippines-Philippine General Hospital (UP-PGH), 15 percent had onset of gout before 30 years of age (average was at 25 years old). There is gout in another family member in about half of the patients. What is sad is that there is an average delay of 10 years prior to diagnosis and treatment and more than 30 percent of them already have poor kidney function.
What causes high body uric acid?
Most of the uric acid (70-80 percent) comes from our body’s dead cells. Our blood cells and those that line our gut have a limited life span and are degraded to uric acid. Humans do not have the enzyme to degrade uric acid and it needs to be excreted from our body through our urine or feces. Humans who have genetic defects in uric acid metabolism or other diseases that either increase production or reduce excretion of uric acid from the body eventually develop gout. The rest of the uric acid in our body (20-30%) comes from our diet.
How is gout treated?
The good news is that gout is a treatable disease. The pain and inflammation of gout easily responds to anti-inflammatory medicines, like colchicine or non-steroidal anti-inflammatory drugs (NSAIDs). Use of these medicines should be supervised by a physician. Treatment, however, does not end there. High uric acid levels must be controlled and this must be maintained for the rest of the patient’s life to avoid complications of the disease. High uric acid can go down very easily by maintaining the correct and safe medicines to dissolve the deposited urate crystals. These medicines reduce our body’s uric acid production or increase its elimination.
Avoidance of purine -rich food and beverages (red meat, internal organs, alcohol, soda, drinks with high fructose corn syrup) is helpful but is not sufficient to reduce high levels of uric acid without medicines. Other helpful practices to reduce uric acid are adequate water intake, sufficient physical activity to maintain close to ideal body weight, and control of other diseases like obesity, hypertension, diabetes, high blood cholesterol.
Treatment should aim for a blood uric acid level less than 6 mg/deciliter or 0.36 mmol/liter. Since the effect of uric acid lowering medicine lasts for only a day, it is important to keep taking the medicine daily. Generally, these are safe for long-term use. However, it is still best for these to be taken in consultation with, and close supervision by, a doctor who is well-informed on gout treatment.
What is osteoarthritis?
Osteoarthritis is the long- term outcome from damage to the cartilage inside the joints. It often affects the hands, knees, and back. It develops over many years and can be silent at first. Eventually, there is pain for most days of the week, especially during movement of the joint. Pain is usually relieved by rest but long periods of rest may not also be good because the joints can become stiff. This stiffness is easily relieved by carefully moving the joints. There is minimal swelling for most affected joints but there can be enlargement of the bony parts of the joint, resulting in deformities. Other deformities can also result from changes in the shape and alignment of the bones due to thinning of the cartilage covering the ends of bones. Examples of these are knee varus (“sakang”) or valgus (“piki”).
What causes damage to the cartilage that results in osteoarthritis?
Some individuals are genetically predisposed to develop damage because their cartilage is not of “good quality” to begin with and can easily be damaged with daily normal use of the joints. Others develop osteoarthritis because of congenital abnormalities in their limbs. Consequently, the joints are poorly-aligned, unstable and prone to damage.
Some experience major trauma (for example, vehicular accident, fall from stairs, sports injuries) that damages the ligaments or other internal structures of the joint, resulting in inflammation and eventual instability.
Obesity, diabetes, and other kinds of arthritis, like gout, are diseases that increase the risk for osteoarthritis. However, ageing confers the highest risk to develop osteoarthritis. With ageing, muscles become weaker, ligaments can become lax, tendons easier to tear, and the fluid in the joints not as thick and viscous.
How is osteoarthritis treated?
The treatment targets in osteoarthritis are pain control and improvement in function. When the joint is severely damaged or deformed, it can be replaced surgically. Such surgical options are available and have high success rates for the knee and the hip but are usually done for those with refractory pain, with disabling deformities, and after careful consideration of all available medical and rehabilitative options.
For the majority of people with osteoarthritis, treatment consists of activity modification (i.e., avoidance of activities that can further damage the joint or cause pain), measures to improve joint stability, muscle strengthening, weight loss or use of walking aid, devices like sole wedges or arch support, and medicines to relieve pain.
Ideally, treatment is planned by a multidisciplinary team composed of a rheumatologist, physiatrist, orthopedic surgeon, physical therapist, occupational therapist, the patient and his/her family.
This talk of “damaged joints” may lead one to think that all hope for a good life is lost when diagnosed with osteoarthritis. Early recognition of disease, a well-planned treatment, and strict adherence to it can have very good outcomes of minimal or absence of pain and good joint function.
Moreover, correction of conditions that may lead to osteoarthritis, like obesity and congenital joint malalignment and proper joint protection during both simple and heavy daily activities and sports activities, can successfully prevent the disease even among genetically-predisposed individuals. Muscle strengthening through exercise is a positive step towards improving joint stability and prevention of osteoarthritis.
How does one keep that youthful stride at 60? Here are 7 tips:
1. Listen to your body. If there is pain, do not ignore it and assume that it is nothing. Consult an expert on joint diseases to correctly diagnose and properly treat the condition.
2. If you are diagnosed with arthritis, work with your doctor in keeping it under control to the best of your ability using a combination of means (medicine, rehabilitation, change in lifestyle) to control it.
3. Understand your disease. Secure information from reliable sources (your physician, arthritis foundations, associations of arthritis specialists). The better understanding you have of your disease, the better for its control.
4. Maintain a healthy and well-balanced diet. There are no food restrictions with most kinds of arthritis. For gout, remember to decrease intake of purine-rich food and drinks. For most people with gout, diet alone is not enough to maintain blood uric acid at optimal levels so a healthy diet with correct proportions of water, proteins, fats, and carbohydrates is encouraged.
5. Work towards maintaining your ideal weight (based on one’s height). This helps prevent or control gout, reduce pain of osteoarthritis and prevent its progression, and facilitates control of other kinds of arthritis, like rheumatoid or psoriatic arthritis.
6. Keep your muscles well-toned and strong. This is achieved through regular physical activities and appropriate exercises. Muscles that are not used become flabby and weak. Joints that are not moved become stiff. Move, exercise, and stretch! If you do not know how, learn from the experts around you.
7. Believe in yourself and your healing capacity. There is hope for comfort and strength for those who believe in its possibility.
Tee, KD, Hernadez AS, Magbitang ATD, Salido EO. Clinical profile of Filipino patients with young-onset gout. Section of Rheumatology UP-PGH files. 2014.
Firestein GS and Budd RC, editors. Kelley’s Textbook of rheumatology 9th Ed. Elsevier Saunders; 2013.