Diagnosing Arthritis

"At the Hillel Yaffe Medical Center Rheumatology Clinic, I often encounter people between the ages of 35-45 who arrive complaining of stiff joints or intolerable pain in their wrists," said Dr. Nina Avshovitch, specialist in rheumatology and Director of Internal Medicine D at Hillel Yaffe Medical Center. I frequently hear, "I get up like this, and it passes as the day goes on," or "I've been to the orthopedist several times, and he prescribed anti-inflammatory drugs or pain-killers, but they didn't really help." 

Their stories are the same. They have been suffering for years from joint pain. Initially just a little, now much more. They are sent to orthopedists, neurologists and pain specialists. Some regularly take narcotic pain killers or prednisone (better known as "hormones" or "steroids") that cause side effects such as drowsiness and constipation, increased blood sugar levels, hypertension and weight gain, but do not alleviate their daily pain. Some even end up in the emergency room, because they are suffering from intolerable pain and real functional difficulties. 

"48-year-old M was hospitalized in our department for pain in her wrists, hips, knees and ankles, pain from which she has been suffering from for a year and a half," said Dr. Avshovitch. "The pain forced her to stop working and made it difficult for her to take care of her children. When the medical anamnesis (history of treatment, drugs, etc.) was taken, M stated that she had been tested several times by specialists: a neurologist, orthopedist and pain specialist and that she had been treated with particularly strong pain-killers that triggered side effects but that did not alleviate her pain, which only got worse. Blood tests, physical examinations and simple imaging tests resulted in a diagnosis of rheumatoid arthritis (RA), and M began treatment with the right drugs. Several days later, M reported that she has absolutely no pain for the first time in eighteen months."

What is rheumatoid arthritis?
"Rheumatoid arthritis is a common disease that affects about 1% of the general population, with women being affected three times as frequently as men. The disease is typical among people between the ages of 35-45, although it can appear at any age. Furthermore, the disease frequently has already manifested itself at an early age in the form of mild symptoms that worsen over time."

"Typical symptoms of rheumatoid arthritis include a multiple joint, largely symmetrical inflammation, with the small joints of the fingers and legs being most affected. The majority of patients develop inflammation in other joints such as shoulders, joints, hips, knees and ankles.

"The process is characterized by pain accompanied by local fever, swelling and redness – all of which the patient experiences throughout the day. The pain, however, tends to peak in the middle of the night. When morning arrives, significant stiffening appears in the joints. Failure to diagnose and treat the inflammation in time might result in irreversible changes in the joints in the form of limited joint movement. The patient is sentenced to living in perpetual pain that cannot be alleviated by even the strongest pain-killers."

Why is rheumatoid arthritis difficult to diagnose?  
"Patients who come to the clinic and are seen in our department have generally gone through quite a bit before they get to us." Between 5-10 patients every day at the clinic. Failure to diagnose is not only due to physicians' lack of knowledge, but mainly due to the gradual progression of the disease, which might 'mock' the patient and the doctor. Also realize that an orthopedist's lack of knowledge of internal medicine might also impede diagnosis. The start of the disease is characterized by stiff joints in the small joints of the hand in the morning –people are unable to bend their hands or make a fist, use buttons, etc. The stiffness passes as the affected joints move during the day.

"In some cases, the disease can begin with the large joints such as shoulders and ankles. Later, pain, swelling and local fever in the joints might appear – the person is unable to lift a shoulder, lay on the shoulder, suffer from pain in the knees, groin pain, wrist pain, etc.

"Because this type of pain is automatically suspected as being nerve or orthopedic in origin, these people find themselves being examined by orthopedists and neurologists. They might even be sent to undergo unnecessary surgery. Some patients even go to a pain specialist and begin taking strong pain-killers."

How is RA diagnosed?
"In order to make a diagnosis," said Dr. Avshovitch, "a rheumatology test must be administered by a doctor experienced in joint tests. Additionally, the history of the disease and patient complaints of pain is critical. All of this, along with simple blood tests and a targeted physical examination, are needed to make an accurate diagnosis."

"The material importance in the diagnosis, and definitely for an early diagnosis, is prevention of joint destruction that is typical of the early stages of the disease, and is responsible for exacerbation of pain. In addition, rheumatoid arthritis affects normal function of other organs, including cardiovascular organs. Research published in March 2011 in Annals of the Rheumatic Diseases found that patients with rheumatoid arthritis faced greater risk of damage to the blood vessels in the heart, similar in severity to that experienced by diabetes patients. In other words, early treatment can not only prevent joint damage, but can also prevent development of heart disease attributed to chronic inflammatory diseases in the body."

Dr. Avshovitch stressed, "It should be noted that after diagnosis, drugs are given to significantly alleviate pain and halt the progression of the disease, but the bell cannot be unrung. In other words, damage already caused to the joints cannot be repaired following administration of the suitable drugs."

In conclusion, rheumatoid arthritis is a chronic disease. Patients suffering from rheumatoid arthritis require drug treatment to prevent future joint damage and to maintain normal health and good quality of life. As previously stated above, diagnosis time is critical. Family physicians and orthopedists must become aware of symptoms, as they can refer the patients for an appropriate diagnosis. This is also true for cases in which the symptoms are mild and nay 'evade' the doctor's notice.