Arthrosis stage 1: what mistakes are made most often

Rheumatoid arthritis is a so-called systemic disease that affects the connective tissue of the body, which entails a lot of negative consequences. Small joints are severely affected, they are destroyed, change their size and shape. About 1% of people worldwide suffer from this disease.

The difficulty is that no one yet knows the exact causes of the disease. There are only a set of factors that contribute to the development of the disease, and therefore it cannot be avoided. The disease itself leads to the loss of a person’s ability to work and greatly reduces the quality of his life.

Rheumatoid arthritis is diagnosed on average at 30-35 years of age, then the disease gradually develops and by old age has the greatest impact on a person’s life. Women suffer from this disease 3 times more often than men.

Possible causes of the problem

The medical community assumes that the development of the disease is influenced by many factors, and not just one. Possible causes of rheumatoid arthritis include:

• genetic predisposition. The point is that at the genetic level a person has a tendency to various disorders in the development of immunity;
• some infectious agents. There are several “candidates” here, but the researchers of this problem have not yet fully decided;
• a set of triggers: hypothermia, hyperinsolation, intoxication, bacterial infections, taking certain medications. This group also includes thyroid disorders and even stress.

There is information that breastfeeding for two years is a factor that reduces the risk of developing the disease (on average by half).

Prevention of arthritis

To prevent the development of arthritis and new relapses, it is recommended to adhere to the following rules:

• limit the load on your knees during work or sports, giving preference to workouts that do not load the knee joints;
• Gradually reduce excess weight;
• avoid prolonged static voltage, hypothermia and overload;
• treat injuries, sprains, ligament ruptures and infectious and inflammatory diseases in a timely manner;
• Warm up before each workout using walking and stretching exercises for the muscles of the anterior and posterior thighs.

Up to contents

The information in this article is for reference only and does not replace professional advice from a doctor. To make a diagnosis and prescribe treatment, consult a qualified specialist.

Symptoms

Symptoms of rheumatoid arthritis include:

• stiffness in the morning. That is, when waking up and for an hour after sleep, a person cannot move actively, in his usual mode - it can be difficult to perform even simple actions, for example, rearranging a pillow or blanket;
• joint pain, which can recur at varying intervals. If you palpate the joints, the pain intensifies. As the disease progresses, reduced joint mobility appears. The temperature of the skin in the fold area may be higher than in other areas of the skin;
• presence of rheumatoid nodules. Dense subcutaneous formations are palpated in the joint area;
• general poor health. It can manifest itself as a decrease in appetite, causeless weight loss, and a constant feeling of fatigue.

With an aggressive course of the disease and a long period of illness, other internal organs may be damaged, which is not so common.

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Treatment of post-traumatic arthritis

The process of treating post-traumatic arthritis involves a combination of a number of methods, including:

• pharmacological;
• physiotherapy;
• non-medicinal.

Timely initiation of treatment allows for remission to be achieved.

Properly structured treatment of post-traumatic arthritis provides the opportunity to:

• preventing the progression of pathology;
• pain relief and inflammation reduction;
• the ability to maintain joint mobility;
• maintaining the same standard of living.

The course, its duration and the list of additional, supportive therapy are determined exclusively by the attending physician, on an individual basis, taking into account the degree of development of the pathological process, the age and state of health of the patient.

Physiotherapy

Physiotherapeutic treatment is an effective method of restoring the functional capabilities of the human body for various types of diseases and pathologies.

The most effective are:

Drugs used in the treatment of post-traumatic arthritis

Drug treatment involves the implementation of several stages:

• removal of acute inflammatory process;
• the appointment of maintenance therapy, which involves the regeneration of articular tissues and the normalization of metabolic processes.

In the treatment of joint injury, NSAIDs (non-steroidal anti-inflammatory drugs) are used, one of the most effective of which is Artradol.

. Drugs in this group play a critical role in the success of treatment.

Depending on the nature of the lesion, other groups of drugs may be prescribed, which usually include:

• painkillers;
• corticosteroids;
• chondroprotectors.

All prescribed medications can be available in various forms.

Therapeutic physical education (PT) as a method of complex treatment of post-traumatic arthritis

Therapeutic physical education (PT) is an effective component of drug treatment, the use of which is especially important during the remission stage.

Performing a set of exercises, developed in accordance with the existing symptomatic picture and the general health of the patient, helps maintain the motor activity of the joint, as well as strengthen the muscular system.

It is recommended to perform gymnastic exercises in various positions (sitting/lying/in water), under the supervision of a physical therapy instructor.

Surgical intervention

The presence of an advanced stage of development of the pathological process or the lack of effectiveness of drug and physiotherapeutic treatment may lead to the need for radical treatment methods

, among which is surgical intervention.

There are two types of operations:

• open;
• closed.

The surgical intervention is performed by a traumatologist-surgeon, after a carefully conducted comprehensive examination, mainly under general anesthesia.

Affected joints may undergo manipulations such as:

• joint replacement with an endoprosthesis;
• osteotomy (elimination of deformity);
• osteosynthesis (fixation of bone fragments) using screws, nails, knitting needles and other medical structures;
• plastic correction of the ligamentous apparatus.

The patient is discharged after surgery, as a rule, after the sutures are removed.

Forms of arthritis

The disease in its pure form assumes that only the joints are affected, without affecting other organs. If we are talking about a disease with systemic manifestations, then in this case autoimmune processes affect the heart, lungs, kidneys, nervous and other systems. The development of the disease is associated with the deposition of a pathological type of protein in the organs.

Diagnostics of rheumatoid arthritis and other additional diseases may reveal. It is sometimes combined with osteoarthritis and rheumatism.

There is also a so-called juvenile variant of the disease - this is a severe form of the disease that affects children and adolescents. It can also involve only joints or joints together with internal organs.

What is post-traumatic arthritis?

Arthritis

– this is a group of diseases involving damage to the joint of a degenerative-dystrophic type. Pathology can be an independent disease or a symptom of another.

Post-traumatic arthritis

– a type of arthritis that involves the development of degenerative-dystrophic processes against the background of a previous injury, in a situation where dysfunction of the damaged part of the body is observed.

Athletes and elderly people are considered to be particularly susceptible to the disease.

In the absence of timely diagnosis and necessary treatment, the pathology leads to irreversible disability of the patient.

Types of the disease depending on the course

Slowly progressive rheumatoid arthritis means that the disease develops over many years, gradually affecting the joints. The joints themselves do not suffer very much. This is where treatment helps and you can maintain a fairly comfortable standard of living.

The rapidly progressing type is characterized by frequent and severe exacerbations, joint damage is severe, treatment helps little. A person's quality of life deteriorates noticeably.

The simplest and easiest type for the patient is a disease without noticeable progression. You can live with it until you are very old without particularly suffering from symptoms.

Causes of post-traumatic arthritis

Before considering the symptoms of post-traumatic arthritis, it is important to understand the causes of its occurrence and development.

Key reason

post-traumatic arthritis - damage to joint tissues (muscle, connective, bone), as well as the vessels and nerves inside them. Cartilage tissue rarely suffers from injury, however, inflammatory foci located near it provoke an acceleration of its wear.

Damage to joint tissues can occur due to reasons such as:

• injuries received at home, at work or during sports training;
• damage received as a result of an accident and other unusual situations;
• surgeries and other medical events.

In addition, the causes of post-traumatic arthritis are not always serious injuries. Pathology can develop due to lack of treatment for even mild bruises.

Degrees of development

The extent to which the insufficiency of the musculoskeletal system manifests itself depends on the degree. There are 4 stages, including zero:

• zero. The patient takes care of himself independently, his life practically does not change;
• first. Due to joint problems, not all movements are available to the patient. Some professional activities are already excluded;
• second. At this stage, a person loses his professional ability to work;
• third. The most difficult degree assumes that the patient does not have the ability to independently care for himself even in everyday life one hundred percent.

Obviously, when combined with other diseases, the situation at each stage becomes significantly more complicated.

Severe variant of rheumatoid arthritis

The course of RA is highly variable. This is due to many reasons. The patient may be resistant to treatment or cannot tolerate it. Delay in prescribing therapy with disease-modifying anti-inflammatory drugs (DMARDs) also worsens the prognosis in RA. In addition, it is known that inflammation in the synovium can begin to develop long before the first clinical symptoms of the disease appear. It is known that serological tests such as rheumatoid factor (RF) and/or antibodies to cyclic citrullinated peptide (ACCP) are detected in the blood of patients with RA several years before the onset of arthritis (up to 10 years) [4] (Fig. 1).

A morphological study of the synovial membrane obtained from patients in the first months of the onset of arthritis showed that not everyone showed signs of acute rheumatoid inflammation; in some patients, clear signs of chronic synovitis were observed already in the first biopsy [5]. It was in these patients that a more torpid variant of RA was observed with a poor response to DMARD therapy. The severity of the condition of a patient with RA at each stage depends on the level of inflammatory activity, which determines the severity of joint pain, stiffness, and functional impairment. With adequate therapy and suppression of activity before the development of irreversible anatomical changes in the joints (destruction, deformation), the function of the joints is restored (Fig. 2). A severe variant of the course of the disease occurs with inadequate or ineffective therapy, and is determined by the degree of persistent loss of the patient’s functional ability not only for professional work, but also for self-care. Therefore, the earliest possible start of anti-inflammatory therapy is of fundamental importance in RA.

In the last decade, diagnostic criteria for the early stages of RA have been introduced into healthcare practice [6] for timely referral of the patient to a rheumatologist and early initiation of therapy. And the emergence of new ACR/EULAR classification criteria in 2010 made it possible to start treatment with DMARDs as early as possible [7]. It is ideal to start DMARD therapy immediately after the first symptoms of inflammation in the synovium appear: morning stiffness, joint pain and swelling, which is reflected in these criteria: the presence of polyarthritis involving small joints has the greatest weight. In practice, a patient with the onset of RA sometimes goes through a long path of consultations and diagnostic measures before meeting with a rheumatologist.

In addition, the onset of the disease may be clinically mild and the symptoms of the disease increase slowly, making it difficult to establish a diagnosis of RA. According to foreign authors [8] and our data [9], with the acute onset of RA, the long-term outcome of the disease is better than with a gradual onset of the disease. Probably, the acute onset of the disease forces the patient to quickly seek medical help, and the doctor in this case quickly determines the diagnosis and begins therapy. Our data indicate a better outcome of RA, assessed after 15 years of disease in terms of the degree of preservation of the function of the musculoskeletal system, the severity of destruction in the joints, the frequency of long-term remissions and patient survival, when DMARDs are prescribed in the first 6 months. from the onset of arthritis symptoms [10].

Delay in initiation of DMARDs results in poorer response to these drugs, as has been shown in controlled trials [11]. Methotrexate is considered the first-line drug; other DMARDs (leflunomide, sulfasalazine) are used at the beginning of treatment if methotrexate cannot be prescribed. DMARD therapy in many patients leads to suppression of the activity and progression of RA, especially when prescribed in the first months of the disease. But starting therapy in a very early period of the disease (1–2 months of illness) does not in all cases allow achieving a pronounced effect (clinical remission or maintaining low RA activity). First, the patient may not respond to DMARDs; secondly, in many patients, the effectiveness of DMARDs decreases after 1–2 years of therapy; in some patients, sequential changes in basic drugs occur due to symptoms of intolerance.

When sequentially prescribed DMARDs are ineffective and/or intolerable, a severe form of RA develops. The most significant parameters for determining the severity of RA are the severity of destructive changes in the joints and the degree of persistent loss of functional ability of the joints, up to the loss of the patient’s ability to self-care.

A large number of randomized clinical trials (RCTs) were devoted to identifying the most effective therapeutic strategies in the treatment of patients with RA: treatment results were compared with sequential monotherapy of DMARDs, with their combination both at the onset of the disease (step-down strategy) and after adding 2- 3rd, 3rd drugs if the first drug is ineffective (step-up strategy). The latest EULAR 2013 recommendations [12] suggest the use of a combination of DMARDs at the onset of treatment, which is based on the results of several randomized open trials [13–15].

A comparative assessment of the effectiveness of monotherapy with methotrexate, sulfasalazine, antimalarial drugs, cyclosporine A, leflunomide and their combinations [16–23] did not show a clear advantage of combination therapy of DMARDs over their use as monotherapy. A number of studies have shown that after 6, 12 and 24 months. the clinical effect was more pronounced when using a combination of DMARDs (either with a “step-up” or “step-down” strategy) [19, 21, 24–28]; according to other authors [29, 30], there were no significant differences in the effect of monotherapy or combination of DMARDs on activity indicators. When the study period was extended (up to 5 years), no advantage was noted in the effect of the combination of DMARDs over monotherapy on the activity of RA [16, 28, 29]. Evaluation of radiological changes in joints after 1–2 years did not show any advantages of combination treatment in the MASCOT study [21], and the combination of cyclosporine A and methotrexate in 2 studies after 6 [31] and 12 [32] months. suppressed the progression of destruction to a greater extent than methotrexate monotherapy. In the FIN-RACo study, the change in Larsen score was significantly less when using a combination of DMARDs after 2 years [19], but after 5 years there were no significant differences between combination therapy and monotherapy [20]. It should be noted that the combination of DMARDs was more effective than monotherapy with different DMARDs only when methotrexate was used in the combination.

In addition, interesting data were obtained when assessing the effectiveness of double combinations of DMARDs with a triple combination: the effectiveness of methotrexate + sulfasalazine, methotrexate + hydroxychloroquine and a combination of all 3 drugs was compared [13]. According to the ACR effectiveness criteria, the triple combination was superior to the double combination, but only in the group of patients who had not previously received methotrexate. In the group of patients previously treated with methotrexate, the effect of the triple combination did not exceed the effect of combined use of methotrexate and hydroxychloroquine.

Very interesting are the data obtained as a result of the TICORA study [17, 33], which compared the results of 18-month treatment of 2 groups of RA patients: in the 1st group, treatment was carried out with strict monthly monitoring of changes in RA activity according to DAS (“tight” control ), and therapy was adjusted in accordance with the dynamics of DAS (“intensive” group). In group 2, treatment was carried out routinely without such strict control. By the end of the study, remission was achieved in 65% of patients in group 1 and only in 16% of patients in group 2. The increase in the number of erosions was less in group 1. Controlled treatment (“intensive” group) was accompanied by more frequent correction of therapeutic tactics (use of a combination of DMARDs, escalation of their dose, use of intra-articular injections of GC). The authors, when analyzing these results, concluded that control of treatment provides the best results, regardless of the choice of DMARDs.

The same conclusion was made by JM Albers et al. [34] when assessing the results of 4 different regimens of using DMARDs: strict control over the success of treatment ensures similar results of therapy with various DMARDs. When evaluating treatment with methotrexate in patients with early RA (disease duration <1 year) in the CAMERA study [22, 23], it was also concluded that strict monthly monitoring of the dynamics of disease activity (“tight” control) and timely correction of therapy can achieve significantly better results over 2-year follow-up period. Thus, in the intensive control group (n=76), the remission rate was 50%, and with the routine treatment (n=55) – 37% (p=0.03) [23]. These data coincide with our opinion, based on the results of a longer open study of the effectiveness of basic therapy in 240 patients: improvement in the outcome of RA (functional state of the joints, X-ray picture) depends not only on the timing of the start of treatment, but also on the degree of continuous monitoring of the progress of treatment [10]. Also, these data created the prerequisites for the development of a modern RA treatment strategy “Treat to target,” when the main goal of treatment is to achieve remission, and the alternative goal is to achieve low RA activity [35].

But even with a competent approach to the treatment of patients with RA in accordance with the treatment strategy “Treat to achieve the goal” introduced in our country with classical DMARDs (early initiation of therapy and constant monitoring of the degree of suppression of activity and progression of the disease), a severe form of RA still develops. According to our data and literature data, in 15–25% of patients, sequentially prescribed DMARDs do not lead to a significant effect (good effect according to EULAR criteria or more than 50% improvement according to ACR criteria) or lead to adverse reactions and the need to discontinue DMARDs. The creation of genetically engineered biological drugs (GEBPs) has made it possible to significantly optimize the treatment of patients with RA.

Currently, 5 tumor necrosis factor-α (TNF-α) blockers are registered in the Russian Federation: infliximab, adalimumab, certolizumab pegol, golimumab, etanercept, the CD20-binding drug rituximab, an inhibitor of soluble membrane receptors for interleukin-6 - tocilizumab and abatacept. All of these drugs have demonstrated high efficacy in patients with insufficient response to DMARDs, including methotrexate. Treatment with rituximab is usually carried out when TNF-α inhibitors are ineffective, although the drug can be used as a first-line biological therapy for special indications (for example, living in a tuberculosis-endemic area), which is also noted in the latest EULAR recommendations (2013) [12]. The remaining GEBDs may be the first representatives of this group, prescribed in the absence of effect from DMARDs.

Taking into account the high cost of treatment with GEBD, the issue of selecting patients for GEBD therapy seems important. As was shown in the BEST study [13], if 2 sequentially prescribed classical DMARDs are ineffective, further use of other DMARDs does not lead to the development of an effect. Therefore, in many European countries and in Russia, one of the criteria for selecting patients for the prescription of a GB is the ineffectiveness of 2 DMARDs, one of which should be methotrexate. As an analysis of RCTs shows, starting therapy immediately with a combination of biologically active drugs and methotrexate has no advantages over sequentially increasing therapy if the effect of methotrexate is insufficient [36]. However, in the presence of unfavorable prognosis factors (high activity involving a large number of joints, high concentrations of RF and ACCP, progression of joint destruction), the issue of using a DMARD is discussed after the ineffectiveness of the first DMARD.

Classic DMARDs are capable of exerting a pronounced effect at the onset of RA and suppressing the radiological progression of destruction in a significant number of patients. In our practice, patients with an established diagnosis of RA are immediately prescribed methotrexate; if there are contraindications, the choice of DMARDs is discussed individually. The patient is then monitored monthly until there is a pronounced effect, with therapy correction carried out on an individual basis. During the first 3 months. treatment, it must be established whether there is an effect and what its severity is. Such control over the degree of suppression of activity allows for timely adjustment of therapy, if required. With 50% (or more) improvement, further during the first year of therapy, it is assessed whether there is suppression of the progression of erosive arthritis. Insufficient anti-inflammatory effect or the appearance of new erosions in the joints of the hands and feet, the development of destruction of large joints, and the persistence of extra-articular manifestations should lead to a change in therapy: increasing the dose of methotrexate or switching to its subcutaneous injections, changing DMARDs, a combination of DMARDs, or their combination with a GEBD. Involvement in symptomatic therapy, the desire to suppress disease activity with frequent intra-articular or IV administration of glucocorticoids in the absence of a sufficient and stable effect of DMARDs do not prevent the development of severe RA. These measures can only be an addition to the treatment of DMARDs, but not a substitute for it.

Thus, to prevent loss of function in patients with RA, that is, to prevent the development of a severe form of the disease, the doctor must ensure the following:

• early administration of DMARDs to all patients with RA;
• provide patient education explaining the goals of therapy, the need for long-term (many months and many years) treatment, and monitoring drug tolerability;
• constant monitoring of the degree of suppression of activity and progression of the disease with an objective assessment of the quantitative severity of the articular syndrome and destructive changes in the joints, and the tolerability of therapy;
• if 2 sequentially prescribed DMARDs are ineffective, raise the question of the need to prescribe a GIBD.

To objectively monitor the activity of RA at each stage of treatment, the doctor must record the number of painful and swollen joints, the severity of pain as assessed by the patient, the general condition as assessed by the patient and the doctor using a visual analogue scale, as well as laboratory parameters (ESR and C-reactive protein) . Monitoring the success of therapy using the DAS28 composite index makes it possible to objectify the control of changes in RA activity.

Thus, the introduction of new classification criteria for RA, the presence of active DMARDs and an arsenal of physical therapy certainly creates the prerequisites for a significant improvement in the outcomes of RA and maintaining the quality of life of patients.

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Diagnostics

Different methods are used to diagnose rheumatoid arthritis:

• laboratory They involve immunological, biochemical studies and the study of a general blood test;
• instrumental. Joint puncture, radioisotope study, x-ray are common diagnostic options;
• biopsy. It also belongs to the instrumental ones, but is presented separately, since of all the listed solutions it is used most rarely.

Diagnosis begins with an appointment with a doctor and examination. To make an appointment, you must contact a rheumatologist.

What should I do?

Instead, you need to add dairy and fish dishes, buckwheat, beans, lentils, as well as products containing fiber and sulfur (flax seed, bran, onions, garlic) to the menu. They take an active part in the construction of cartilage and connective tissue.

Do your joints hurt? Eat less meat

4. Orthopedic shoes without prescription.

For arthrosis of the ankle, knee or hip, orthopedists often recommend wearing orthopedic insoles, or arch supports. They support the arch of the foot and reduce stress on the joints of the lower extremities. This is true provided the selection is correct. If insoles are chosen at random, they can cause harm.

Treatment in Moscow

For those forms where treatment of rheumatoid arthritis can give a good result, a whole range of different medications are used:

• anti-inflammatory non-steroidal drugs;
• basic drugs. They are made on the basis of several active components;
• hormonal substances. In this case, glucocorticoids are used in different forms: tablets, ointments, injections;
• biological agents: monoclonal antibodies, regulators of lymphocyte differentiation, etc.

In addition to the main treatment, patients are offered physiotherapeutic procedures and therapeutic exercises (only at the time of remission). Prevention of osteoporosis is mandatory. Also, rheumatoid arthritis, if it greatly reduces the quality of life, may require surgical correction of “complex” joints.

Degrees of post-traumatic arthritis

Like any other type of arthritis, the pathology has several degrees of development:

1st degree

– slight stiffness of movement, discomfort of the affected part of the body;

2nd degree

– narrowing of the joint space, formation of bone growths (osteophytes);

3rd degree

– proliferation of multiple osteophytes, complete absence of joint space.

Each degree of development of post-traumatic arthritis is characterized by a certain symptomatic picture, which makes it possible to accurately diagnose the degree of progression of the pathology and formulate the most effective plan for complex treatment of the patient.

Prevention of complications

If the symptoms of rheumatoid arthritis were identified at an early stage, then timely treatment in many situations can significantly slow down pathological processes and avoid complications. In addition to effective treatment, the following preventive measures should be added:

• maintaining a healthy lifestyle. Patients are also recommended a special diet;
• rejection of bad habits;
• regular physical activity without excessive stress;
• increased attention to the treatment of other diseases - even common colds.

Such prevention of rheumatoid arthritis gives a good chance that a person will be able to live his life in fairly comfortable conditions.

Possible complications of post-traumatic arthritis

Failure to consult a doctor in a timely manner, inaccurate diagnostic measures, as well as refusal or deviation from the prescribed treatment plan can cause the development of unwanted complications

, among which: