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Review | DOI: https://doi.org/10.31579/2694-0248/099
Family Physician & Public Health Consultant, Bengaluru, India.
*Corresponding Author: Suresh Kishanrao, Family Physician & Public Health Consultant, Bengaluru, India.
Citation: Suresh Kishanrao, (2024), Diagnosis of Arthritis & Management Among Middle Aged & Elderly (MA&Es) in Primary Settings, J. Clinical Orthopedics and Trauma Care, 6(5); DOI:10.31579/2694-0248/099
Copyright: © 2024, Suresh Kishanrao. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 11 July 2024 | Accepted: 19 July 2024 | Published: 26 July 2024
Keywords: RMSK= Rheumatic &musculoskeletal diseases; RA= Rheumatoid arthritis; RF= Rheumatoid factor; OA= Osteoarthritis; joints deformity; NSAIDs & DMARDs; Knee replacement
Arthritis is a generic term that refers to an inflammation or degenerative change in a joint, leading to the swelling and tenderness of one or more joints. The common rheumatic diseases among middle aged and elderly individuals are soft tissue rheumatism, neck and back pain, fibromyalgia and unspecified joint pains and osteoarthritis. These diseases are most commonly prevalent among productive age between the 30 and 50 years and elderly, more often in females, in both rural and urban populations, and account for considerable disability in up to 1/5 of individuals leading to loss of livelihood and dependence on others for self-care. Knees, Feet, Hands, Hips, and the lower back are those joints where arthritis is most prevalent. Arthritis and allied bone and muscular conditions are among the most common of all disorders affecting people 65 years of age and over.
The primary health care providers are the gateway for helping arthritis patients worldwide especially in developing countries. In India and other developing countries Arthritis patients seek care from multiple providers after trying some or many home remedies. They include, traditional healers, trained basic graduates of all systems of Medicine, Orthopaedic, and Superspecialists for Robotic surgical interventions without any gatekeeping. It is estimated that 10-12 % of outpatient visits in the preceding fortnight and 5% of hospital admissions in in India during 2023 were due to Rheumatic and Musculoskeletal disease symptoms.
The main goals of arthritis treatments are to reduce symptoms and improve quality of life. However, primary care must involve inter-professionals (Biomarkers & Radio-diagnostics, physiotherapy) coordinated (IPC) care seeking pathways and proper referral system.
Materials and Methods: Treatments of arthritis vary depending on the type of arthritis. This article is based on authors recent involvement in 4 cases of arthritis management by Allopathic medicines, Ayurveda, Homeopathy and traditional therapies, and monitoring Robotic knee replacement, each giving satisfaction to the patients.
Outcomes: Author’s spouse aged 70 years, who was on NSAID for rheumatoid arthritis for 5 years switched over to Ayurvedic treatment in May 2024 and finds 50% relief from pain and stiffness in both knees in 6 weeks. A man of 65 years using homeopathy claims relief after 3 months and a lady of 50 years found relief in Cabbage leaf capping therapy. A lady of 67 years who was unable to stand for more than 10 minutes or walk more than 100 steps, after standard medical therapy for 3 years, underwent Robotic knee replacement and is moving around happily after 4 weeks of bilateral knee replacement surgery without any support. There is no fit-all therapeutic approach, and the author observed client satisfaction among all approaches to conclude that seeking care is determined by affordability and access to varieties of therapies
The most common types of arthritis cases seen by primary health care providers both in public and private sector are osteoarthritis and rheumatoid arthritis in adults. In Osteoarthritis cartilage the hard, slippery tissue covering the ends of bones at any joint breaks down. Rheumatoid arthritis is a disease in which the immune system attacks the joints, beginning with the lining of joints. Knees, Feet, Hands, Hips, & the lower back are the joints commonly affected. In adults, Gout, due to uric acid in blood is not uncommon. Occasionally general practitioners encounter cases of psoriasis or lupus [1].
Arthritis is a generic term that refers to an inflammation or degenerative change in a joint, leading to the swelling and tenderness of one or more joints. The common rheumatic diseases in the community are soft tissue rheumatism, neck and back pain, fibromyalgia and unspecified pains and osteoarthritis. These diseases most commonly affect persons between the third to the fifth decade of life, more often females, are prevalent in both rural and urban populations, and account for considerable disability in up to 1/5 of individuals leading to loss of livelihood and dependence on others even for self-care [1]. Arthritis and allied bone and muscular conditions are among the most common of all disorders affecting people 65 years of age and over. The main symptoms of arthritis are joint pain and stiffness, which typically worsen with age. The main goals of arthritis treatments are to reduce symptoms and improve quality of life, they vary depending on the type of arthritis, access to high tech interventions affordability, and affordability [2].
In India Arthritis patients try all household remedies like oil application, massage, kneecaps etc and then seek care from multiple providers – untrained, trained and specialists without any gatekeeping. However, the primary health centres or private family doctors are the first point of care for maximum patients due to accessibility and affordability. It is estimated that 10-12 % of outpatient visits in the preceding fortnight and 5% of hospital admissions in 2023 were due to RMSK symptoms [2].
The primary health care providers are the gateway for keeping arthritis patients. Hence, there as an urgent need to make available interprofessional (Radiologist, Laboratory Services physiotherapy providers, and proper referral system) coordinated RA trained providers at primary health centre is essential. More specialists and follow-up care are needed at all First Referral units (Taluka Hospitals and Community Health Centres) to prevent complication among RA patients. Community-based national healthcare programs to manage RMSK diseases at the community level are urgently needed. There also remains an unmet need to train more doctors to diagnose and manage rheumatic diseases at the primary, secondary and tertiary levels of care.
This article is based on authors recent involvement in 5 cases of arthritis management by different therapies, each giving satisfaction to the patients. The choice of the treatment depended upon type of arthritis, affordability and possibilities of achieving the main goals of reducing symptoms and improve the quality of life.
Short Review of 4 cases:
1.Satisfaction of moving from Standard Disease-modifying antirheumatic drugs (DMARDs) to Ayurvedic Therapy:
Author’s spouse aged 70 years, who was on DMARDs for rheumatoid arthritis for 5 years between 2018 and 2023. Every time she dis-continued the pain used to recur. Since January 2024 she tried using Kneecaps throughout the day and apply TRP (containing Linseed oil, Diclofenac, Methyl Salicylate and Menthol) Gel overnight. In May 2024 hearing a client satisfaction incidence from her friend about a Ayurvedic treatment she consulted switched over to Ayurvedic treatment. The therapy consisted of
Having followed the instructions, for 6 weeks now the patient feels 40% relief in stiffness in the joint and pain while walking. In a recent visit last to Goa she was able to walk in the sand of a beach. Her walking and climbing few steps were comfortable even without the kneecaps, inferring the benefit of therapy.
Sridhar Joshi a male aged 68 years, with RA of both knees, seeing the satisfaction by our first case consulted the same Ayurvedic Physician. His therapy included i) Sandhi Sudha Tablet (once a day in the afternoon after meals) ii) he was to consume Rasyana Kwath Churna boiled in water in the morning and iii) Tab Anuloma half tablet in the night for constipation. He is reporting a 20% relief in knee pain.
Based on a research report [6], I tried the cabbage leaf therapy with little modification. I had asked 2 of my patients (First case Right knee only and Second case both knees both from poor families) in May 2024 to try wrap the affected joints with cold cabbage leaf overnight. The changes were measured by the patients themselves using OKS score over 4 weeks’ time. The OKS score improved from 15 to 28 in first case and from 20 to 35 in the second case.
A 45-year-old married woman visited me, a private practitioner in 2019 with complaints of pain, stiffness, and decreased range of movements in right shoulder joint, right wrist joint, both knee joints, right jaw, both ankles, and swelling in both legs. Additional symptoms and conditions included headache, gastritis, and constipation. Symptoms began with moderate to severe pain associated with swelling, stiffness in multiple joints especially over small joints. Pain and swelling started on the second left toe and left leg. Then she applied ice and after one month swelling started on left feet and her doctor prescribed i) Use of Kneecap and Tab Ibuprofen 400 mg daily in the night which she took for 2 week and the stopped. Two weeks later again pain started on right jaw, both knee joints, both ankle joints, and swelling on both legs associated with walking difficulty. When she cam to me it was her third allopathic consultation after trying local applicant gels. My examination showed clear involvement of multiple joints, and I put her on triple therapy of three medications – methotrexate (30 mg daily once), Iwata (500mg sulfasalazine) in the night, and Hydroxychloroquine Hcqs (200 Mg hydroxychloroquine sulphate) in the night to target arthritis symptoms effectively. After about 6 weeks of treatment her pain reduced to negligible level, and she can do her daily routines with maintenance dose of Remtrex (15mg- Methotrexate) daily once in the night. Orthopaedic surgeon advised Left Knee replacement due to damage, but the patient is yet to make up her mind & mobilize resources.
4.A Case of effective Homeo-therapy:
A 50-year-old married woman from a middle socio-economic status family reported to the outpatient department of government homoeopathic medical college and hospital, Bengaluru on 28th September 2023 with complaints of pain, swelling and stiffness in multiple joints since 1 to 2 years. She had developed pain gradually, swelling and stiffness of joints in upper extremities later in all the joints. Exciting cause could not be elicited. At the time of reporting, she complained of pain in bilateral metacarpophalangeal joints, wrist joints, elbow joints, shoulder joints, knee joints, ankle joints, but had become severe for last 2 months. The pain was les in the night, and early mornings, slowly increased after routine movements and standing for long time. She had used NSAIDs after consulting an Allopathic doctor. The pain was relieved if she took the tablets but recurred within a week after stopping them. Investigations revealed a high RH Factor.
She was put on Rhus Toxicodendron TID for 5days followed by MP 6x TID for 7days. A follow up after 2 weeks indicated a slight (20%) reduction in pain. Then she was asked to continue Rhus tox 200, BD for 3 days. Followed by PL 200, BD for 5days. after 2 months she was put on Pl 200, BD and by end of March 2024 she was fully recovered and continues to have no pain without any medication till end June 2024.
5.Robotic Knee Replacement:
Pushpa as 70-year-old lady had both knee joint pains since 2020, after the standard treatment with DMRDs, for3 years she consulted a local orthopaedic specialist. He diagnosed the case as ‘Osteoarthritis’ after an MRI and felt that the condition had not progressed extensively and was a suitable candidate for robotic knee surgery after ruling out contraindications like severe obesity, bowel obstruction, and an inability to tolerate general anaesthesia. On the advice of orthopaedician she underwent a bilateral knee replacement in tertiary care private hospital in first week of May 2024. She was ambulatory with support in the first week of the surgery and without support about 4 weeks and on 2 June she attended a social function to the surprise of all relatives. This intervention is not in the purview of primary Care Physician but then they have a larger role in referring appropriate cases
A major update to the GBD published in 2017 reported the prevalence of musculoskeletal complaints as 1,312,131.3 thousand, the annual incidence as 334,744.9 thousand and the disability-adjusted life years (DALYs) lost due to these diseases as 135,881.3 thousand years. DALYs due to musculoskeletal complaints have progressively increased over time, by 38.4% from 1990 to 2017. The major prevalent musculoskeletal disorders were low back pain followed by osteoarthritis (most commonly osteoarthritis of the knee), neck pain (288,718.6 thousand) and others (rheumatoid arthritis [RA], gout, other musculoskeletal disorders. The DALYs attributable to each of these diseases had also increased significantly between 1990 and 2017. In the GBD 2019, overall, contribution of low back pain and other musculoskeletal complaints to the DALYs increased from 1990 to 2019. Low back pain was a leading cause of disability upwards of 10 years of age, maximum at the age group of 25–49 years. Complaints other than low back pain, neck pain, RA, osteoarthritis and gout were a leading cause of disability between 25 and 74 years, maximum between the ages of 25–49 years, inferring musculoskeletal diseases contribute the maximum to disability during the most productive years of life [1].
Figure 1: The Prevalence of Different Rheumatic & Musculoskeletal Diseases in India - COPCORD Studies.
Note:
AS= Ankylosing spondylitis CTDs= connective tissue diseases. OA=osteoarthritis; RA= Rheumatoid arthritis; SLE= Systemic lupus erythematosus. SpA= Spondylarthritis; STR= Soft tissue rheumatism UIA= undifferentiated inflammatory arthritis.
COPCORD, Community Oriented Program for Control of Rheumatic Diseases [1]
A community-based survey of 2,535 eligible adults, 2,259 (89%) were surveyed, and 1,247 (55%) reported pain in the back or the extremities and were therefore referred to the specialist clinic. Out of 884 (71%) participants who attended the clinics, 615 (70%) reported pain in the extremities. The point prevalence of soft tissue rheumatism (STR) in the community was 28% (95% confidence interval, CI=26.1-29.8%) while that of arthritis was 12.2% (10.8-13.5). The point prevalence of rheumatoid arthritis was 0.4% (0.1-0.6). Both STR and arthritis were more common in women and in the elderly. This study inferred that soft tissue rheumatism was the commonest rheumatic disorder in the rural community, followed by arthritis. Inflammatory and infectious disorders were rare. Given the high prevalence of STR and arthritis, community health workers and physicians working in rural areas need to be trained, to improve the management of these conditions [3].
Types Of Arthritis [1,2, 4]:
Degenerative Or Mechanical Arthritis: An assortment of illnesses together referred to as degenerative or mechanical arthritis primarily entail harm to the cartilage that surrounds the ends of the bones. This kind of arthritis causes the cartilage with primary function of facilitating easy gliding and motion in the joints to weaken and roughen. The body starts remodelling the bone to restore stability to make up for cartilage loss and changes in joint function. Osteophytes- unwanted bone growths, form as a result or the joint develops a misalignment leading to osteoarthritis. Osteoarthritis may also develop because of joint injuries, such as a fracture, or joint inflammation.
Inflammatory Arthritis: Patients with inflammatory arthritis experience inflammation that is not immediately obvious, like a typical process of inflammation, as a preventative measure against germs and viruses or as a reaction to wounds like burns. The damage caused by this sort of inflammation, results in discomfort, stiffness, and swelling, is counterproductive and harmful to the afflicted joints. Multiple joints may be affected by inflammatory arthritis, and the inflammation can harm both the bone under the skin and the joint’s surface. Rheumatoid arthritis, Ankylosing spondylitis, and Psoriatic arthritis are some examples of inflammatory arthritis in MA&E’s.
Chronic Connective Tissue Disease (CTD): Supporting, uniting, or dividing other bodily tissues and organs are the functions of connective tissues, like cartilage, tendons, and ligaments. Inflammation and joint discomfort are symptoms of CTD. In addition to the skin, muscles, lungs, and kidneys, inflammation may also develop in other tissues, such as the lungs and muscles. CTD examples include Lupus, or SLE (systemic Lupus Erythematosus), Systemic sclerosis (scleroderma), dermatomyositis and Sjogren’s cause sore joints, and other signs and symptoms of arthritis.
Infectious Arthritis: Inflammation in joints can occasionally cause by bacteria, viruses, or fungi. Some common organisms causing infective arthritis include Shigella and salmonella, transmitted through tainted or contaminated food, sexually transmitted illnesses - gonorrhoea and chlamydia (STDs), Hepatitis C, a blood-to-blood infection that can be contracted via receiving blood transfusions or using shared needles. If the infection is not treated, arthritis may turn chronic and result in irreparable damage to the joints.
Metabolic Arthritis: When the body breaks down purine-containing compounds, urate is produced as a chemical. Most Uric acid dissolves in the blood and is carried to the kidneys, urine is produced and leaves the body. Some people have high amounts of uric acid because either their bodies naturally make more than required, or because their kidneys cannot remove the uric acid rapidly enough. A buildup of uric acid results in the formation of needle-like crystals in the joint, which can cause rapid spikes in their level of acute joint pain or a gout attack. If the amounts of uric acid are not lowered, Gout can either develop into a chronic condition or occur in episodes. The big toe and hands are typical joints that are affected, along with a few other smaller joints.
Septic Arthritis (SA): An infection, either bacterial or fungal, can cause septic arthritis, most often Hip and knee joints are impacted. It normally affects 2–6 people out of a Lakh. A joint may become infected with a microbe directly through an injury or surgery, or it may become infected when bacteria or other disease-causing germs travel to a joint through the blood. Most cases of acute septic arthritis are brought on by bacteria like Streptococcus, Staphylococcus, or Neisseria gonorrhoeae. Chronic septic arthritis is brought on by microbes like Candida albicans and Mycobacterium tuberculosis. Getting septic arthritis is increased in Joint injury or illness currently present, inserts for artificial joints, Infections somewhere else in the body, Bacterial presence in the blood, Chronic sickness or illness such as diabetes, RA, HIV, and sickle cell disease, Drug usage by injection or intravenous (IV), Medicines that lower immune function, recently injured joint or arthroscopy or other surgery on a joint, old age. SA’s ability to quickly destroy joints makes it a rheumatologic emergency. It could be fatal.
Osteoporosis: A position statement from the Indian Society of Bone and Mineral Research reported that about 20% of women older than 50 years (8% to 62%) have osteoporosis. In males older than 50 years, the prevalence of osteoporosis ranges from 8.5% to 24.6%. A study of 792 males and 808 females (post-menopausal) older than 50 years from urban New Delhi reported osteoporosis in 35.1% (24.6% males, 42.5
Arthritis is a common ailment with rare chance of getting cured completely. Its management calls for actions at Individual, Primary Crae Physicians, Specialists and the State at large.
Individual Actions: i) Self-care: Lose weight, 10-15% in 3 months, ii) Switch from high-impact activities- running, to low-impact ones-walking or swimming; iii) Avoid movements of lunges & squats, that worsen the condition iv) Painful arthritis discourages exercising, but, being active helps reduce & prevent pain, as regular exercise improves muscular power, movement and joint mobility. v) Apply ice or heat for pain or take NSAIDs in consultation with PCP.
Primary Care Physicians: i) Take a detailed history, do a thorough physical examination, use Scanning or MRI & Diagnose AEAP ii) Use a simple tool called Oxford Knee Score, to assess the initial condition, guide the therapy course and to monitor the progress iii) Refer the case urgently if beyond your resources to manage iv) Encourage your patients to stretch often, to help decrease the stiffness in the joints v) Remind the patient to use their strongest joints first and encourage them to sit in chairs with arms so they can push up when rising. Ensure the patient maintains a good balance between rest and activities
State/Governments: i) Train more Doctors, Physiotherapists, Nurses, CHOs and other Para-medicals to diagnose & manage rheumatic diseases at the primary, secondary and tertiary levels of care ii) Launch Community-based national health care programs to manage RMSK diseases at the community level (H&W Centres, PHCs, CHCs & Taluka Hospitals)
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