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The Difference between Rheumatoid Arthritis and Osteoarthritis
organized and transcribed by pollinikrys

The term arthritis refers to over 100 joint, muscle, or cartilage disease. The two most common forms of arthritis, rheumatoid arthritis (RA) and osteoarthritis (OA), are major causes of work disability in the US, which we also should pay attention to here in Taiwan under such sultry and humid weather. Can you know how different they are?

OK, before knowing the differences in between, we should define the joint, in which arthritis could develop. A joint is formed at the junction of two bones. Joints help smooth movement and absorb weight and force. Movement at a joint occurs when muscles contract and pull on tendons around the joints. A capsule surrounds the joint. Surrounding ligaments, tendons, and muscles add support and stability to the joint. Synovial fluid surrounds a moveable joint and provides lubrication the joint, allowing smooth movements. Cartilage covers the articular end of the bone, providing a cushion for the bone. Since cartilage has no blood or nerves, it cannot heal or repair itself. It receives its nourishment from the synovial fluid. (Swann, 2007; Harvard Medical School, 2006)

Then what is arthritis? Arthritis (from Greek arthro-, joint + -itis, inflammation; plural: arthritides) is a group of conditions involving damage to the joints of the body such as lupus, gout, and other inflammations at joint areas. The major complaint by individuals who have arthritis is pain. Pain is often a constant and daily feature of the disease. The pain may be localized to the back, neck, hip, knee or feet. The pain from arthritis occurs due to inflammation that occurs around the joint, damage to the joint from disease, daily wear and tear of joint, muscle strains caused by forceful movements against stiff, painful joints and fatigue. The most important factor in treatment is to understand the disorder and find ways to overcome the obstacles which prevent physical exercise. (Healthline; WebMD)

Now let’s take a look at the pathology of RA, but before that we should know first what rheumatism is. Rheumatism is any of a variety of disorders marked by inflammation, degeneration, or metabolic derangement of the connective tissue structures, especially the joints and related structures, and attended by pain, stiffness, or limitation of motion, which can result in repeated attacks of arthritis without fever and without causing irreversible joint changes. However, the term "rheumatism" is still used in colloquial speech and historical contexts, but is no longer frequently used in medical or technical literature; it would be fair to say that there is no longer any recognized disorder simply called "rheumatism." (Dorland’s)

The pathology of RA:
1. Pathophysiology:
In contrast to OA, RA is the most common reversible disability in the world. It is a problem of inflammation, rather mechanical problem as OA. It is an autoimmune disease that attacks the synovial fluid and also a systemic disease that can affect other organs such as lungs, heart, and blood vessels. It affects women 5 times than men. RA is characterized by an uncontrolled synovial inflammation that causes bone erosion, destruction of cartilage, and loss of joint integrity. Left untreated, RA can cause permanent joint damage, decrease in quality of life, and disability.
2. Causes: Unknown. Suggested causes include genetics, viruses, and bacteria. There seems to be relationships between climates, older age, smoking, female gender, silicate exposure. Take of oral contraceptives, increased Vitamin D intake and tea may decrease the risk of RA. Since RA is a systemic disease, several complications such as anemia, cancer, pericarditis (心包炎), vasculitis (血管炎), and lung nodules may occur.
3. Sings and Symptoms: Swollen, warm, tender joints on both sides of the body. Onset is sudden as opposed to a gradual onset as seen in OA. ‘Gelling’ (stiffness after rest) is also more pronounced in RA than OA. Patients may experience loss of appetite, afternoon fatigue, anemia, low-grade fever, and weight loss.
4. Diagnosis: A history and physical examination is a key component in the diagnosis of RA. X-rays reveal a gradual and symmetrical loss of cartilage from the joints, which will thus be narrowed. Ultra-sonography (超音波) is better to find out or predict the erosion of cartilage than conventional radiography. Anti-cyclic citrullinated peptide antibodies (抗環瓜氨酸抗體) identify the destructiveness of RA before the onset of clinical disease. However, it can not confirm RA effectively for RA can present in other autoimmune or infectious disorders. A complete blood count may indicate anemia and an elevated platelet count. An elevated erythrocyte sedimentation rate (ESR; 紅血球沉降速率) as well as C-reactive protein (CRP; C反應蛋白) is indicated of inflammation. Magnetic resonance imaging (MRI; 磁共振造影) can detect synovitis (滑膜炎) and hyaline cartilage changes.
5. Treatment: Goals of the therapies include controlling inflammation, preventing joint destruction, and pain management.
Medications for RA include NSAIDS (非類固醇抗發炎劑), low-dose oral or intra-articular glucocorticosteroids (醣質腎上腺荷爾蒙), disease-modifying anti-rheumatoid drugs (DMARDs; primary treatment for RA, during 3 to 12 weeks for onset of action; 疾病修飾抗風濕藥), such as gold (rarely used currently), methotrexate (苯丁酸氮芥) in the 1980s, hydroxychloroquine (氯奎寧) (Plaquenil), leflunomide (目前尚無中文譯名) (Arava). Evidence demonstrates that combinations of DMARDs are more effective than single-drug therapy. A Cochrane review (實證醫學資料庫) states that adalimumab (復邁) (Humira) with methotrexate is more affective than alone. In addition, there are biologic response modifiers (BRMs; 生物製劑), such as etanercept (Enbrel), infliximab (Remicade), and adalimumab (Humira), which interfere with the activity of cytokines (細胞激素), such as tumor necrosis (惡性腫瘤) factor, resulting in the decrease of inflammation. As antagonist is an interlukin-6 (白細胞介素6), Rituximab (目前尚無中文譯名) (Rituxan). Besides, RA patients should incorporate physical therapy, weight reduction, proper nutrition, aquatics, and cognitive-behavioral therapies into their daily routine. A surgery may be needed when considering pain, function, and deformity.

And the pathology of OA:
1. Pathophysiology:
Many consider OA as a disease from ‘wear and tear’. Aka degenerative joint disease, OA is characterized by a breakdown in cartilage. It is a chronic, progressive disease that produces a local tissue response, mechanical change, and failure of function. Cartilage is broken down faster than it can be replaced. OA follows the stages as: A. Cartilage loses its elasticity and becomes stiff due to injury or overuse/underuse. B. The underlying bone of the damaged cartilage thickens. Cysts can form under the bone. Spurs can develop at the end of the joints. C. Bits of bone or cartilage break off and float around the joint space. D. The synovium (滑膜) (lining of the joint) becomes inflamed. So the deterioration of the cartilage affects the structure of the joint so that it no longer functions smoothly. The end result is pain, stiffness, disability, and deformity.
2. Causes: Unknown. Possible factors include aging, obesity, joint injuries, race, gender, metabolic disorders, and genetics.
Primary factors may be aging and obesity. Every excess pound adds three pounds of pressure to the knees and six times the pressure on the hips! Besides, repetitive movement of joints can progress to OA. Of course, genetics also play a role. Caucasians suffer OA of hands more easily than Orientals. Women have higher incidence of OA in knees and hands. Wilson’s Disease, an inherited disease that causes copper to be deposited in various organs of the body, my be a risk factor for OA.
3. Sings and Symptoms: Joint soreness, gelling, pain, loss of joint function, inability to perform ADLs (Activities of Daily Living; 日常生活活動功能量表). Typically OA attacks the weight-bearing joints, such as hands, knees, hips, and spine asymmetrically.
4. Diagnosis: Professional help for confirmation of OA with clinical presentation and physical findings. Patients may experience crepitus (grating sound of two ends of broken bones rubbing together), swelling, enlargement of the joint, diminished range of motion, and nodules. X-ray may show narrowing of joint spaces, sclerosis (硬化), bone cysts (囊腫), and bone spurs.
5. Treatment: OA cannot be cured, but it can be managed; weight loss, aerobic exercises, flexibility routines, acupuncture, assistive devices, such as cushioned shoes, insoles, splints, modalities as heat/cold, water therapy, positioning, or cognitive-behavioral therapies like distraction and mental imagery, surgical procedures, such as arthroscopy to wash out debris or remove osteophytes (bone spurs), osteotomy (切骨手術), removal of damaged tissue, arthrodesis (關節固定術), fusion of bones, or, joint replacement.
Typical medication for pain management are: acetaminophen 2-3 grams per day for several weeks (Tylenol; 泰諾), nonsteroidal anti-inflammatory drugs (NSAIDs), tramadol (乙醯氨酚) (Ultram), or long-acting opioids (鴉片類止痛藥物), intra-articular injections of glucocorticosteroids no more than 3-5 times per year or other injections like hyaluronic acid (琉璃醣碳基酸).
Other therapies like oral glucosamine (葡萄糖胺) and chondroitin (軟骨素) (not with intake of anticoagulants (抗凝血劑), which may increase the anticoagulation!)
Capsaicin (辣椒素唐辛子) or methyl salicylate (水楊酸) creams rubbed over the joint can relieve pain, yet the effect can last for only several weeks.

Case Study One:
Mrs. Burns, 55, a retired schoolteacher, is with a chief complaint of pain in both knees for the past 10 years, crepitus, effusion, cartilage fibrillation, joint space narrowing, and osteophyte formation. Treatment consists of NSAIDs, opioids, arthroscopy, and steroid injections, which is obviously a patient of OA.

Case Study Two:
Ms. Knight, 40, admitted with right hip pain as well as both shoulders, elbows, knees, ankles. Swollen, tender, and warm joints indicate an inflammation and not a mechanical injury. She also displays systemic disease (iron deficiency anemia) and other autoimmune diseases. Treatment is DMARD (methotrexate). Therefore it is clearly indicted for RA.

So, RA and OA have many similar signs, symptoms, and treatments though the pathophysiology and causes are quite different. Yet the nurse care for both of these two types of arthritis will be the same. Focus will be on pain management, positioning, joint protection, and assistance with ADLs. (Academy of Med-Surgical Nurses) Most important of all, I hope there will be no chance for any of us to suffer such agonies like these.