It may begin as a slight morning stiffness. For the lucky person with arthritis, that’s as far as it goes. But for millions of others, arthritis can become a disabling, even crippling, disease. The Roman Emperor Diocletian exempted citizens with severe arthritis from paying taxes, no doubt realizing that the disease itself can be taxing. In Pakistan two to three per cent of the population is struck with rheumatoid arthritis and around 10 to 15 per cent have osteoporosis after the age of 50.
This chronic illness impacts a person’s entire lifestyle, work, family and recreation. “To improve the quality of life, drug treatment with education, social support and moderate forms of exercise is required,” says Dr Imran Haroon, a senior consultant physiotherapist.
Arthritis means joint inflammation. In a normal joint, where two bones meet, the ends are coated with cartilage, a smooth, slippery cushion that protects the bone and reduces friction during movement. A tough capsule lined with synovial membrane seals the joint and produces a lubricating fluid. Ligaments surround and support each joint, connecting the bones and preventing excessive movement. Muscles attach to bone by tendons on each side of a joint. Inflammation can affect any of these tissues.
Inflammation is a complex process that causes swelling, redness, warmth and pain. It’s the body’s natural response to injury and plays an important role in healing and fighting infection. Joint injury can be caused by trauma or by wear and tear of aging. But in many forms of arthritis, injury is caused by the uncontrolled inflammation of auto-immune disease in which the immune system attacks the body’s own tissues. In severe cases, all joint tissues, even a bone, can be damaged.
The general term arthritis includes over 100 kinds of rheumatic diseases, most of which last for life. Rheumatic diseases are those affecting joints, muscle and connective tissue which makes up or supports various structures of the body, including tendons, cartilage, blood vessels, and internal organs.
The most common type of arthritis is osteoarthritis. It begins when cartilage breaks down, sometimes eroding entirely to leave a bone-on-bone joint in extreme cases. Any joint can be affected, but the feet, knees, hips, and fingers are most commonly affected. It may appear in one or two joints and spread no further. Painful and knobby bone growths in the fingers are common, but usually not crippling.
“In osteoporosis there are medications which lessen the pain and inflammation but moreover a patient has to reduce his weight and exercise,” says says Dr Azra Arifali, rheumatologist, at the Aga Khan Hospital and Mideast Medical Centre. “All patients should go to a physiotherapist for a week or two and learn the exercises so that if the pain has begun they can minimize it by exercising. If the muscles and ligaments are strong they can hold on to the joints in a much better way than if the body has not exercized.”
In men, cervical spondylosis, or arthritis of the neck is quite common. Mohammed Athar, who works for the State Bank, suffered a backache six years ago. Through Magnetic Resonance Imaging (MRI) he was diagnosed with a cervical and lower back ache.”I have to be careful of my posture. When the pain occurs I need to rest and avoid bending over and go for physiotherapy,” he says. “Among women I see a majority of cases with knee arthritis. Women have a tendency of misusing their muscles and what they need to do is light exercises to tone their muscles. Secondly one should also take care of their weight,” says Dr Imran.
Mrs Shah has been nursing her osteoarthritis for nearly 10 years but a recent trip to the States aggravated her condition. “I went to America to visit my daughter. I visited a lot of places and got very little rest which aggravated my arthritis. When I came back my knee ached so much that I limped. I soon started physiotherapy, my medications were changed and I found relief. I was advised to diet, control my weight and go for regular walks. But often there are days when the pain reoccurs. I rest for sometime but avoid postponing my regular chores as this would make me very lethargic,” she says.
The disease though, is often mild but can get quite severe. “In some cases bones get deformed due to acute osteoarthritis. There are two kinds of surgical treatments. One is where an incision is made through an arthroscope to look into the joint, wash it, and take out any loose tissue. This is an expensive test and the treatment is temporary. The ultimate treatment in such severe cases is joint replacement. The artificial knee, which is replaced, is imported from America. The only inhibiting factor is the cost, which comes to around 300,000 rupees and there is minimum risk involved,” opines Dr Azra.
The second most common is rheumatoid arthritis. It can strike at any age, but usually appears between ages 20 and 50 (see box). The hands are most commonly affected but it can affect most joints of the body. Inflammation begins in the synovial lining and can spread to the entire joint. Highly variable and difficult to control, the disease can severely deform joints. Some become bedridden. Others continue to run marathons. “I love making chappatis and parathas,” says Safia, “but my arthritis has rendered my fingers incapable of swift movement. So there are days when I have to be careful. My msasi is a great help. I also often have mood swings. My husband is very supportive during the worst season i.e., winters when I have excruciating pain.”
“Today rheumatoid arthritis is called an auto-immune disease which affects the whole body. There are some systemic medicines, which are also called disease modifying drugs or D-mard. These medicines should be immediately administered for inflammatory arthritis, as they are not painkillers but suppress the disease and take it towards cure,” explains Dr Azra. A recent patient that came to Dr Azra was Rizwana, a bubbly woman of 36 with three children. She couldn’t walk for two to three years having developed rheumatoid arthritis in her hip and knee joints. Hip replacement surgery has helped her to start walking but she still has to undergo knee surgery. “Fortunately for Rizwana financing the operations was not a problem. What I would recommend to patients of arthritis is an early diagnosis so that medication can be administered with close monitoring as the dosage could have side affects. Once a rheumatologist examines a patient and outlines his treatment he can later have it followed up by his GP. Our aim is to make such patients functional people for their family and society at large.