3.1 Degenerative joint disease
Osteoarthritis
Osteoarthritis is characterized by joint pain after loading, stiffness of the joint and restriction of movement. If the cause of OA is not obvious, one speaks of primary or idiopathic OA. The condition can also arise from a distinct cause (infection or trauma) and is then defined as secondary OA. Joint injuries are a risk factor for OA, but most cases of OA occur without any specific history of injury. Obesity is also a risk factor for knee OA and, to a lesser extent, for hip and hand OA. Osteoarthritis is diagnosed on the history and clinical examination and is confirmed by X-rays showing the loss of cartilage and other associated radiographic abnormalities. It is a slowly progressive disease. Disease-modifying treatment is not yet available.
Osteoarthritis is a leading cause of disability in older adults. Globally, as of 2010, approximately 250 million people had OA of the knee (3.6% of the world population). Hip OA affects about 0.85% of the population. In 2005, 26.9 million US adults were estimated to have OA (OARSI White Book – 2016). As of 2004, OA globally causes moderate to severe disability in 43.4 million people. Together, knee and hip OA rank globally for disability as 11th of 291 disease conditions assessed (Cross et al 2014).
A Swedish registry data study counted the proportion of people aged 45 years and older with any form of physician-diagnosed OA (knee, hip, hand, or other locations except the spine), and found the result to be 26·6%. In the Dutch population the prevalence of physician-diagnosed OA (hip, knee, hand, or feet) is projected to increase from 7% in 2011, to 12% in 2040. The prevalence is generally highest around the age of 75 years (prevalence of 4–5% for hand OA, 6% for hip OA, and 16–17% for knee OA). The coming decades will witness an increase in the prevalence of OA, making it become one of the most frequent diseases. Knee OA is ranked 15th in Western Europe for year’s life lost due to disability (IHM 2015). (Figure ).
Ranking of conditions on basis of Years of life disabled (YLD).
Pain is the predominant symptom in OA and is a major driver of clinical decision making and health costs. With pain-modifying treatment the majority of patients can be managed well, but when this is unsuccessful and the patient is significantly disabled, joint replacement may be a good option. Joint replacement surgery is a clinically appropriate and cost-effective treatment for end-stage OA of the knee and hip. The prevention of OA is in its infancy, but joint injury, obesity and impaired muscle function are modifiable risk factors amenable to primary and secondary prevention strategies, including lifestyle change (reduction of body weight and increased exercise, such as walking and riding a bike) (Roos and Arden 2016).
3.2 Inflammatory joint disease
a- Rheumatoid arthritis
Rheumatoid arthritis (RA) is a chronic autoimmune disease that causes pain, stiffness and swelling in multiple joints, especially the hands. The disease may also affect other organ systems of the body. The cause of RA is still not clear. It is believed to involve a combination of genetic and environmental factors. The incidence of RA is 20–300 per 100000 subjects per year, whilst that of the juvenile form of RA is 20–50 per 100000 subjects per year (WHO TRS 919). The prevalence of RA in most industrialized countries varies between 0.3% and 1%.
The goals of treatment of RA are to reduce pain, decrease inflammation and improve a person’s overall functioning. This may be facilitated by balancing rest and exercise, the use of splints and braces, or the use of assistive devices. Pain medications and steroids are frequently used to reduce symptoms. Disease-modifying antirheumatic drugs (DMARDs), such as hydroxychloroquine and methotrexate, may be used to try to slow progression of disease. Biological DMARDs may be used when disease does not respond to other treatments. Biological DMARD agents used to treat rheumatoid arthritis include: tumor necrosis factor alpha (TNFα) blockers such as infliximab; interleukin 1 blockers such as anakinra, monoclonal antibodies against B cells such as rituximab, and tocilizumab, and T-cell co-stimulation blockers such as abatacept.
However, these drugs may be more likely to cause adverse effects and are rather expensive. Surgery to repair, replace, or fuse joints may help patients with significant damage in a joint with severe symptoms. Over recent years the need for surgery has decreased because of effective and early drug treatment of RA.
b- Juvenile arthritis
Arthritis and other rheumatic conditions are relatively uncommon in children. Juvenile (disease onset before age 16 years) idiopathic arthritis (JIA) is the most common, chronic rheumatic disease of childhood, affecting approximately one per 1000 children. JIA is an autoimmune, noninfective, inflammatory joint disease. It is differs significantly from the RA commonly seen in adults.
c- Spondyloarthropathies
Spondyloarthropathies are a cluster of overlapping and interrelated chronic inflammatory rheumatic disorders, in which joint disease also affects the vertebral column. Examples include ankylosing spondylitis, reactive arthritis, psoriatic arthritis, enteropathic arthritis (associated with ulcerative colitis or Crohn’s disease) and juvenile spondylarthritis. They have an increased incidence of HLA-B27, as well as being negative for rheumatoid factor and antinucleic antibodies.
d- Gout and other crystal arthropathies
Gout is a disease caused by an excess uric acid in the body. Urate crystals are deposited in some joints leading to an inflammatory reaction. Gout most often affects the joint of the great toe and is characterized by recurrent attacks of painful, red, tender, warm, and swollen joints. It is more common in men, in whom it is the most common cause of inflammatory arthritis and affects almost as many subjects as RA. Gout occurs frequently in patients with metabolic syndromes (patients who also have diabetes, hypertension, and obesity).
Other crystal arthropathies can be caused by deposits of calcium pyrophosphate dihydrate (CPPD) crystals in the joints and have symptoms similar to gout. CPPD deposition disease is less common than gout, although radiographic chondrocalcinosis is common in older adults.
e- Fibromyalgia
Fibromyalgia is a syndrome of widespread musculoskeletal pain and tenderness. The diagnosis is difficult to make with certainty.
Other symptoms are fatigue, sleep, memory and mood issues. Symptoms often begin after physical trauma, surgery, an infection or significant psychological stress. In other cases, symptoms gradually accumulate over time with no single triggering event. Women are more likely to develop fibromyalgia than are men. Many people who have fibromyalgia also have tension headaches, temporomandibular joint (TMJ) disorders, irritable bowel syndrome, anxiety and depression. There is no known specific cure for fibromyalgia. Exercise, relaxation and stress-reduction measures may help.
f- Systemic lupus erythematosus
Systemic lupus erythematosus (SLE) is an autoimmune disease in which the body’s immune system turns upon its host and may attack many body systems, especially the skin, kidneys, and joints. Symptoms vary between people but may be severe. Common symptoms include painful and swollen joints, fever, chest pain, hair loss, mouth ulcers, swollen lymph nodes, feeling tired and a red rash, which is most commonly seen on the face. There are periods of illness and periods of remission, during which there are few symptoms. The cause of SLE is not clear. There is no known cure for SLE.
Treatments may include NSAIDs, corticosteroids, immunosuppressants, hydroxychloroquine and methotrexate. SLE significantly increases the risk of cardiovascular disease, this being the most common cause of death. The incidence of SLE varies between countries, from 20 to 70 per 100000.
g- Systemic sclerosis
Systemic sclerosis, or scleroderma, is an autoimmune disease that primarily affects the skin but can affect any organ system. It is characterized by diffuse fibrosis and vascular abnormalities affecting the skin, joints, and internal organs. Specific treatments are difficult to identify, and the emphasis is often on the treatment of complications.
h- Primary Sjögren’s Syndrome
Primary Sjögren’s Syndrome is a syndrome of dry eyes, dry mouth, and arthritis. Secondary Sjogrens syndrome can occur in association with other rheumatologic diseases such as RA and lupus. Sjögren’s syndrome can affect various exocrine glands or other organs. Treatment is usually symptomatic.
i- Polymyalgia rheumatica and giant cell (temporal) arteritis
Polymyalgia rheumatica (PMR) is a syndrome of rapid onset of aching and stiffness, usually in the neck, shoulders, upper arms, and hips, in older adults. It responds to treatment with anti-inflammatory medications (e.g., corticosteroids). Most people with PMR wake up in the morning with muscle pains. Giant cell arteritis (GCA), which often occurs with PMR, is a type of vasculitis that affects medium-size arteries and results in headache, vision loss, and other symptoms.
j- Soft tissue disorders (excluding back pain)
These are a variety of problems of the tendons, bursae, muscles, ligaments and fascia that cause pain and dysfunction. The prevalence of soft tissue disorders is difficult to determine due to the variety of conditions included.
k- Tendinopathy
Tendinopathy is a type of tendon disorder that can cause pain, swelling, and impaired function. The pain is related to movement. Frequent locations are the shoulder (rotator cuff tendinitis, biceps tendinitis), elbow (tennis elbow, golfer’s elbow), wrist, hip, knee (jumper’s knee, popliteus tendinopathy), and ankle (Achilles tendinitis). It may be rendered symptomatic by an injury or repetitive activity. Treatment may include rest, NSAIDs, splinting, and physiotherapy. Tendinopathy occurs relatively frequently. Older people are more commonly affected.
