A Clinician’s Guide to Arthritis

Introduction

A diagnosis of arthritis can feel unnerving and confusing to patients.

There are so many kinds of arthritis. Your patients may wonder, “what does each one mean?”

In this blog, we will compare and contrast some of the most common forms of arthritis; Osteoarthritis, Rheumatoid Arthritis, and Spondyloarthritis, including their causes, symptoms, and management.

You will find an easy-to-read table at the end of this piece summarizing the key points for each of the conditions discussed throughout. Additionally, much of the information in this blog is also available for subscribers to share with their patients directly in the form of an education tool on the Embodia Education Library, which is apart of Embodia for Home Exercise Programs (HEP).

What is Arthritis?

Arthritis literally means inflammation of a joint, but it can be due to various causes or disease processes depending on the type of arthritis.

Osteoarthritis (OA) is the degeneration of an individual joint due to the cartilage being unable to repair itself. This leads to the destruction of the cartilage, thickening of the bone underneath, and development of bone spurs and cysts, all resulting in a joint surface that is not smooth.

Rheumatoid arthritis (RA) is a chronic, systemic (whole-body) inflammatory condition that targets the synovial capsule that surrounds many joints, but it can also affect other parts of the body since it is systemic inflammation. RA is an autoimmune disease, which means that the body creates antibodies that attack its own healthy tissues, rather than foreign invaders, as antibodies typically should.

Spondyloarthritis, similar to RA, is also a chronic, systemic inflammatory process, however, it targets different joints than RA. Since spondyloarthritis involves systemic inflammation, like RA, various parts of the body can be affected. Spondyloarthritis is actually an umbrella term for a few kinds of related arthritis, the most common one being Ankylosing Spondylitis which affects the vertebrae and sacroiliac joint, leading to the fusing of the spine. Other kinds of spondyloarthritis include Peripheral Spondyloarthritis which affects joints other than the spine, Psoriatic Arthritis, and Reactive Arthritis which are arthritis combined with skin conditions e.g. psoriasis and Enteropathic / Irritable Bowel Disease Associated Spondyloarthritis which is arthritis combined with Irritable Bowel Disease. Someone may have one or multiple types of spondyloarthritis together. 

Arthritis Risk Factors

Osteoarthritis

Females and older individuals have a higher risk of developing OA, as do individuals who have sustained previous injuries to joints or have poor skeletal alignment. Additionally, obesity increases the risk of developing OA both in non-weight-bearing joints, as well as weight-bearing joints, where it may also exacerbate symptoms due to the increased loads. 

Rheumatoid Arthritis

In contrast to OA, the main risk factors for RA include HLA-DR4 and HLA-DR1 genes and poorly understood environmental exposures (e.g. asbestos, smoking). Further, RA is typically diagnosed younger than OA, between the ages of 40-50. However, similar to OA, RA is more common in females than males and obesity is a risk factor.

Spondyloarthritis

Similar to RA, a large risk factor for Spondyloarthritis is the HLA-B27 gene. In contrast to RA and OA, Spondyloarthritis is typically diagnosed in younger populations, before the age of 30, and it is more common in males compared to females.

It is important to note that not everyone with the HLA gene variations mentioned above will develop RA or Spondyloarthritis, but many people with RA or Spondyloarthritis have these gene variations.

Symptoms of Arthritis

Osteoarthritis

Typically, OA results in pain in the affected joint that worsens as the day goes on, with more activity. There may be mild swelling, a cracking/grating/grinding sensation when moving the joint, and it may feel like the joint is going to buckle. The joint may feel stiff in the morning, but this should subside within 30 minutes. Weight-bearing joints that undergo excessive loading are more susceptible to OA. These joints include knees, hips, shoulders and joints of the spine. If there was a history of trauma to a particular joint, that joint would be susceptible to OA as well. Since OA affects individual joints, a joint may be affected on one side of the body, but not on the other.

Rheumatoid Arthritis

Joints affected by RA will be painful, tender, warm, red, and swollen. RA differs from OA in that pain is worse without activity, therefore it is more prominent in the morning after resting all night. Furthermore, morning stiffness typically persists longer than in OA, lasting more than 30 minutes, sometimes even hours. Commonly affected joints are the small joints in the hands and feet, as well as the wrists, hips, knees, ankles, elbows and shoulders. Unique to RA, the DIP joints (distal interphalangeal joint) of the hands are typically not affected. RA presents itself symmetrically across the body in synovial joints, affecting the same joints on each side.

Spondyloarthritis

Spondyloarthritis, specifically the most common kind, Ankylosing Spondylitis, results in pain and loss of movement in the lumbar spine and sacroiliac region. Similar to RA, the pain is worse after rest, leading many to wake up with back pain during the second half of the night. 

Complications of Arthritis

In addition to symptoms that directly relate to arthritis, there are additional complications that can be a result of the various disease processes. 

Osteoarthritis

OA can lead to muscle weakness near the joint because of disuse, and this can further exacerbate arthritis because weak muscles do not support the joint well. Bone spurs that occur in later stages of OA can compress blood vessels or nerves, leading to weakness or sensation changes.

Rheumatoid Arthritis

Since RA is a systemic condition, it can have effects all over the body, including rheumatoid nodules (lumps under the skin); Sjogren’s disease involving dry mouth, eyes, and skin; various heart and lung conditions; peripheral neuropathy; vasculitis (inflammation of blood vessels); loss of muscle mass and fatigue. However, with medical advances and better management of RA, many of these effects are less prevalent than before.

Spondyloarthritis

Similar to RA, spondyloarthritis is a systemic condition and therefore can have effects throughout the body, including enthesitis (inflammation of the insertion of tendons/ligaments into bone), sausage fingers known as dactylitis, uveitis (painful red eye), heart and lung conditions, osteoporosis, spinal fractures, weight loss, and fatigue. Additionally, spondyloarthritis may co-occur with irritable bowel disease and skin conditions such as psoriasis. As with RA, the more serious complications are rare.

Medical Management of Arthritis

Osteoarthritis

The most common pharmacological management for OA is a class of drugs known as non-steroidal anti-inflammatories (NSAIDs). However, your patient should only use these in consultation with a physician/pharmacist as long term use can lead to gastrointestinal problems. Another option is Glucocorticoid injections into the painful joint, but there is controversy regarding this treatment. If the disease progresses to a point that it greatly impacts your patient’s day-to-day function and all other treatments have failed, surgical intervention may be an option.

Rheumatoid Arthritis

NSAIDs can also be helpful in managing symptoms of RA, but they do not prevent disease progression. Therefore, upon diagnosis of RA, a class of drugs known as disease-modifying antirheumatic drugs (DMARDs) are typically prescribed. If these drugs do not manage your patient’s condition effectively, then a class of drugs known as Biologic Agents may be prescribed. As many of the above drugs take time to have an effect, glucocorticoids may be prescribed temporarily to manage your patient’s symptoms until DMARDs or Biologic Agents take effect. However, glucocorticoids can have significant side effects and therefore are prescribed only at low doses and for short periods of time.

Spondyloarthritis

Similar to OA and RA, NSAIDs are used to manage symptoms of spondyloarthritis. However, if NSAIDs do not succeed in managing your patient’s condition effectively, Biologic Agents may be prescribed sooner than in RA, as DMARDs are often not effective at treating Spondyloarthritis. Similar to RA, glucocorticoids may be prescribed temporarily to manage your patient’s symptoms until other drugs take effect.

Physiotherapy Management of Arthritis

Osteoarthritis

Although it seems counterintuitive because more activity usually results in more pain for individuals with OA, therapeutic exercise is actually a vital part of the management of this disease. Different stages of OA will allow for different amounts of movement. In each stage, it is important for your patient to stay as active as possible. This will maintain strength in the surrounding muscles to support the affected joint(s) and it will also help lubricate the joint(s) to slow the progression of OA. As the disease progresses, modifications can be made to ensure that your patient can still exercise. This could include reducing weight-bearing activities which may cause flare-ups and move to cycling or aquatic-based activities. These aerobic exercises are helpful in weight management to reduce the load placed on your patient’s joint(s) during day-to-day weight-bearing activities. Rehab practitioners that subscribe to Embodia have access to 1200+ exercises through the Embodia Exercise Library that can be used to build an appropriate home exercise program for the patient’s therapeutic exercise needs.

Rheumatoid Arthritis

Therapeutic exercise is also a large component of RA management. It can help improve joint mobility and strength, cardiovascular health, pain, psychological well-being, and fatigue. Fatigue is a common symptom of RA, which can decrease your patient’s ability to perform their daily tasks and result in decreased quality of life. Again, although it may seem counterintuitive, exercise has been shown to reduce fatigue. Exercise can improve strength and cardiovascular fitness, making daily tasks easier, and leaving your patient with more energy for other activities. 

It is important to be aware that it may take time to get your patient on board with an exercise routine. Research has shown that while individuals living with RA recognize the benefit of exercise on their fatigue and quality of life, they also acknowledge they had to come to that realization through their own experience.5 

Because of the nature of the disease progression and its ability to cause joint deformity, joint protection makes up a key part of managing RA. You can help your patient protect their joints through strengthening surrounding muscles, teaching safe movement strategies, and recommending splints and other assistive devices that can support the affected joints. 

Spondyloarthritis

Similar to OA and RA, therapeutic exercise is a large component of physiotherapy management of Spondyloarthritis. Therapeutic exercise for spondyloarthritis will help to address stiffness, breathing capacity, cardiovascular health, sleep quality, fatigue, and overall fitness and function. 

Therapeutic exercise also helps to reduce pain by activating the body’s natural endogenous opioids, (e.g. endorphins), and by teaching the nervous system that movement is not harmful but rather healthy and safe. As Ankylosing Spondylitis progresses, the spine may begin to fuse. To ensure the spine fuses in a position which will enable maximal daily function, physiotherapy management should also focus on optimizing postural alignment.

Conclusion

We hope this helped to clarify some of the similarities and differences between different types of arthritis. The table below summarizes the key points from this blog. If you would like to learn more about the various kinds of arthritis and improve your skills for assessing and treating patients with these conditions, check out Embodia’s multiple continuing education courses from experts on these topics. 

Summary Table 

*See definitions in the Complications of Arthritis section above.

References

1. https://www.ncbi.nlm.nih.gov/books/NBK482326/
2. https://www150.statcan.gc.ca/n1/pub/82-003-x/2014009/article/14087-eng.htm
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5920070/
4. https://www.ncbi.nlm.nih.gov/books/NBK459356/
5. Feldthusen C, Mannerkorpi K. (2019). Factors of importance for reducing fatigue in persons with rheumatoid arthritis: a qualitative interview study. BMJ Open 9(5). doi: 10.1136/bmjopen-2018-028719

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Blog Writers: Bella Levi, MScPT Student; Debra Posluns, MScPT Student; Linnea Thacker, MScPT Student