Rheumatoid arthritis is an autoimmune disease that causes inflammation of the joints and surrounding tissues. It results in swollen, warm, tender joints and stiffness, especially in the mornings. Over time it can cause bone erosion and joint deformity. While it most commonly affects small joints in the hands and feet, it can also affect other joints like knees, ankles, elbows, hips and shoulders on both sides of the body. In some cases, rheumatoid arthritis can also damage other body systems outside of the joints like skin, eyes, lungs, heart and blood vessels. New medications have improved treatment but severe rheumatoid arthritis can still cause physical disabilities.

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NAME: SUMBUL
FATHER NAME: MALIK ZULFIQAR ALI
SEAT NO.: MP-18264011
PROGRAM NAME: M.PHIL. 2nd
semister
PRESENTATION TOPIC: ARTHRITIS
SUBMITTED TO MAM RIZWANA GHAFFAR

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INDEX:
S NO. TOPIC PAGE
NO.
1. ARTHRITIS………………………………………………… 3
a. Osteoarthritis………………………………................ 4-8
b. Rheumatoid arthritis………………………………… 9-15
c. Psoriatic arthritis…………………………………….. 15-19
d. Ankylosing spondylitis……………………………… 20-23
e. Gout………………………………………………… 24-28
f. Juvenile idiopathic arthritis…………………………. 29-33
2. PREVALENCE RATE OF ARTHRITIS…………………… 34

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ARTHRITIS:
Arthritis is an inflammation of the joints. It can affect one joint or multiple joints.
There are more than 100 different types of arthritis, with different causes and
treatment methods. The most common types of arthritis are
i. Osteoarthritis (OA)
ii. Rheumatoid arthritis
iii. Psoriatic arthritis
iv. Gout
v. Ankylosing spondylitis
vi. Juvenile idiopathic arthritis.
Figure showing joint having Osteoarthritis and Types of arthritis
Rheumatoid arthritis.

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1. OSTEOARTHRITIS:
Osteoarthritis is the most common form of arthritis, affecting millions of people
worldwide. It occurs when the protective cartilage that cushions the ends of your
bones wears down over time.
Although osteoarthritis can damage any joint, the disorder most commonly affects
joints in your hands, knees, hips and spine.
Osteoarthritis symptoms can usually be managed, although the damage to joints can't
be reversed. Staying active, maintaining a healthy weight and some treatments might
slow progression of the disease and help improve pain and joint function.
Osteoarthritis of the spine Osteoarthritis of the hip
Symptoms:
Osteoarthritis symptoms often develop slowly and worsen over time. Signs and
symptoms of osteoarthritis include:
 Pain. Affected joints might hurt during or after movement.
 Stiffness. Joint stiffness might be most noticeable upon awakening or after
being inactive.
 Tenderness. Your joint might feel tender when you apply light pressure to or
near it.
 Loss of flexibility. You might not be able to move your joint through its full
range of motion.
 Grating sensation. You might feel a grating sensation when you use the joint,
and you might hear popping or crackling.

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 Bone spurs. These extra bits of bone, which feel like hard lumps, can form
around the affected joint.
 Swelling. This might be caused by soft tissue inflammation around the joint.
Causes:
Osteoarthritis occurs when the cartilage that cushions the ends of bones in your joints
gradually deteriorates. Cartilage is a firm, slippery tissue that enables nearly
frictionless joint motion. Eventually, if the cartilage wears down completely, bone
will rub on bone.
Osteoarthritis has often been referred to as a "wear and tear" disease. But besides the
breakdown of cartilage, osteoarthritis affects the entire joint. It causes changes in the
bone and deterioration of the connective tissues that hold the joint together and attach
muscle to bone. It also causes inflammation of the joint lining.
Risk factors:
Factors that can increase your risk of osteoarthritis include:
 Older age. The risk of osteoarthritis increases with age.
 Sex. Women are more likely to develop osteoarthritis, though it isn't clear
why.
 Obesity. Carrying extra body weight contributes to osteoarthritis in several
ways, and the more you weigh, the greater your risk. Increased weight adds
stress to weight-bearing joints, such as your hips and knees. Also, fat tissue
produces proteins that can cause harmful inflammation in and around your
joints.
 Joint injuries. Injuries, such as those that occur when playing sports or from
an accident, can increase the risk of osteoarthritis. Even injuries that occurred
many years ago and seemingly healed can increase your risk of osteoarthritis.
 Repeated stress on the joint. If your job or a sport you play places repetitive
stress on a joint, that joint might eventually develop osteoarthritis.
 Genetics. Some people inherit a tendency to develop osteoarthritis.
 Bone deformities. Some people are born with malformed joints or defective
cartilage.
 Certain metabolic diseases. These include diabetes and a condition in which
your body has too much iron (hemochromatosis).

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Complications:
Osteoarthritis is a degenerative disease that worsens over time, often resulting in
chronic pain. Joint pain and stiffness can become severe enough to make daily tasks
difficult.
Depression and sleep disturbances can result from the pain and disability of
osteoarthritis.
Diagnosis:
During the physical exam, your doctor will check your affected joint for tenderness,
swelling, redness and flexibility.
Imaging tests
To get pictures of the affected joint, your doctor might recommend:
 X-rays. Cartilage doesn't show up on X-ray images, but cartilage loss is
revealed by a narrowing of the space between the bones in your joint. An X-
ray can also show bone spurs around a joint.
 Magnetic resonance imaging (MRI). An MRI uses radio waves and a strong
magnetic field to produce detailed images of bone and soft tissues, including
cartilage. An MRI isn't commonly needed to diagnose osteoarthritis but can
help provide more information in complex cases.
Lab tests
Analyzing your blood or joint fluid can help confirm the diagnosis.
 Blood tests. Although there's no blood test for osteoarthritis, certain tests can
help rule out other causes of joint pain, such as rheumatoid arthritis.
 Joint fluid analysis. Your doctor might use a needle to draw fluid from an
affected joint. The fluid is then tested for inflammation and to determine
whether your pain is caused by gout or an infection rather than osteoarthritis.
Treatment:
Osteoarthritis can't be reversed, but treatments can reduce pain and help you move
better.

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Medications:
Medications that can help relieve osteoarthritis symptoms, primarily pain, include:
 Acetaminophen. Acetaminophen (Tylenol, others) has been shown to help
some people with osteoarthritis who have mild to moderate pain. Taking more
than the recommended dose of acetaminophen can cause liver damage.
 Nonsteroidal anti-inflammatory drugs (NSAIDs). Over-the-counter
NSAIDs, such as ibuprofen (Advil, Motrin IB, others) and naproxen sodium
(Aleve, others), taken at the recommended doses, typically relieve
osteoarthritis pain. Stronger NSAIDs are available by prescription.
NSAIDs can cause stomach upset, cardiovascular problems, bleeding
problems, and liver and kidney damage. NSAIDs as gels, applied to the skin
over the affected joint, have fewer side effects and may relieve pain just as
well.
 Duloxetine (Cymbalta). Normally used as an antidepressant, this medication
is also approved to treat chronic pain, including osteoarthritis pain.
Surgical and other procedure:
Knee osteotomy

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Artificial hip Knee comparisons
If conservative treatments don't help, you may want to consider procedures such as:
 Cortisone injections. Injections of corticosteroid medications may relieve
pain in your joint. During this procedure your doctor numbs the area around
your joint, then places a needle into the space within your joint and injects
medication. The number of cortisone injections you can receive each year is
generally limited to three or four injections, because the medication can
worsen joint damage over time.
 Lubrication injections. Injections of hyaluronic acid may offer pain relief by
providing some cushioning in your knee, though some research suggests these
injections offer no more relief than a placebo. Hyaluronic acid is similar to a
component normally found in your joint fluid.
 Realigning bones. If osteoarthritis has damaged one side of your knee more
than the other, an osteotomy might be helpful. In a knee osteotomy, a surgeon
cuts across the bone either above or below the knee, and then removes or adds
a wedge of bone. This shifts your body weight away from the worn-out part
of your knee.
 Joint replacement. In joint replacement surgery (arthroplasty), your surgeon
removes your damaged joint surfaces and replaces them with plastic and metal
parts. Surgical risks include infections and blood clots. Artificial joints can
wear out or come loose and may need to eventually be replaced.

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2. RHEUMATOID ARTHRITIS:
Rheumatoid arthritis in finger
Rheumatoid arthritis is a chronic inflammatory disorder that can affect
more than just your joints. In some people, the condition can damage a wide variety
of body systems, including the skin, eyes, lungs, heart and blood vessels.
An autoimmune disorder, rheumatoid arthritis occurs when your immune system
mistakenly attacks your own body's tissues.
Unlike the wear-and-tear damage of osteoarthritis, rheumatoid arthritis affects the
lining of your joints, causing a painful swelling that can eventually result in bone
erosion and joint deformity.
The inflammation associated with rheumatoid arthritis is what can damage other
parts of the body as well. While new types of medications have improved treatment
options dramatically, severe rheumatoid arthritis can still cause physical disabilities.
Symptoms:
Signs and symptoms of rheumatoid arthritis may include:
 Tender, warm, swollen joints
 Joint stiffness that is usually worse in the mornings and after inactivity
 Fatigue, fever and loss of appetite
Early rheumatoid arthritis tends to affect your smaller joints first — particularly the
joints that attach your fingers to your hands and your toes to your feet.

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As the disease progresses, symptoms often spread to the wrists, knees, ankles,
elbows, hips and shoulders. In most cases, symptoms occur in the same joints on
both sides of your body.
About 40 percent of the people who have rheumatoid arthritis also experience signs
and symptoms that don't involve the joints. Rheumatoid arthritis can affect many
non-joint structures, including:
 Skin
 Eyes
 Lungs
 Heart
 Kidneys
 Salivary glands
 Nerve tissue
 Bone marrow
 Blood vessels
Rheumatoid arthritis signs and symptoms may vary in severity and may even come
and go. Periods of increased disease activity, called flares, alternate with periods of
relative remission — when the swelling and pain fade or disappear. Over time,
rheumatoid arthritis can cause joints to deform and shift out of place.
Causes:
Joint showing both healthy and affected joints
Rheumatoid arthritis occurs when your immune system attacks the synovium — the
lining of the membranes that surround your joints. The resulting inflammation
thickens the synovium, which can eventually destroy the cartilage and bone within

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the joint. The tendons and ligaments that hold the joint together weaken and stretch.
Gradually, the joint loses its shape and alignment.
Doctors don't know what starts this process, although a genetic component appears
likely. While your genes don't actually cause rheumatoid arthritis, they can make
you more susceptible to environmental factors — such as infection with certain
viruses and bacteria — that may trigger the disease.
Risk factors:
Factors that may increase your risk of rheumatoid arthritis include:
 Your sex. Women are more likely than men to develop rheumatoid arthritis.
 Age. Rheumatoid arthritis can occur at any age, but it most commonly begins
in middle age.
 Family history. If a member of your family has rheumatoid arthritis, you may
have an increased risk of the disease.
 Smoking. Cigarette smoking increases your risk of developing rheumatoid
arthritis, particularly if you have a genetic predisposition for developing the
disease. Smoking also appears to be associated with greater disease severity.
 Environmental exposures. Although poorly understood, some exposures
such as asbestos or silica may increase the risk of developing rheumatoid
arthritis. Emergency workers exposed to dust from the collapse of the World
Trade Center are at higher risk of autoimmune diseases such as rheumatoid
arthritis.
 Obesity. People — especially women age 55 and younger — who are
overweight or obese appear to be at a somewhat higher risk of developing
rheumatoid arthritis.
Complications:
Rheumatoid arthritis increases your risk of developing:
 Osteoporosis. Rheumatoid arthritis itself, along with some medications used
for treating rheumatoid arthritis, can increase your risk of osteoporosis — a
condition that weakens your bones and makes them more prone to fracture.
 Rheumatoid nodules. These firm bumps of tissue most commonly form
around pressure points, such as the elbows. However, these nodules can form
anywhere in the body, including the lungs.

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 Dry eyes and mouth. People who have rheumatoid arthritis are much more
likely to experience Sjogren's syndrome, a disorder that decreases the amount
of moisture in your eyes and mouth.
 Infections. The disease itself and many of the medications used to combat
rheumatoid arthritis can impair the immune system, leading to increased
infections.
 Abnormal body composition. The proportion of fat to lean mass is often
higher in people who have rheumatoid arthritis, even in people who have a
normal body mass index (BMI).
 Carpal tunnel syndrome. If rheumatoid arthritis affects your wrists, the
inflammation can compress the nerve that serves most of your hand and
fingers.
 Heart problems. Rheumatoid arthritis can increase your risk of hardened and
blocked arteries, as well as inflammation of the sac that encloses your heart.
 Lung disease. People with rheumatoid arthritis have an increased risk of
inflammation and scarring of the lung tissues, which can lead to progressive
shortness of breath.
 Lymphoma. Rheumatoid arthritis increases the risk of lymphoma, a group of
blood cancers that develop in the lymph system.
Diagnosis:
Rheumatoid arthritis can be difficult to diagnose in its early stages because the early
signs and symptoms mimic those of many other diseases. There is no one blood test
or physical finding to confirm the diagnosis.
During the physical exam, your doctor will check your joints for swelling, redness
and warmth. He or she may also check your reflexes and muscle strength.
Blood tests
People with rheumatoid arthritis often have an elevated erythrocyte sedimentation
rate (ESR, or sed. rate) or C-reactive protein (CRP), which may indicate the presence
of an inflammatory process in the body. Other common blood tests look for
rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP) antibodies.
Imaging tests
Your doctor may recommend X-rays to help track the progression of rheumatoid
arthritis in your joints over time. MRI and ultrasound tests can help your doctor
judge the severity of the disease in your body.

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Treatment:
There is no cure for rheumatoid arthritis. But clinical studies indicate that remission
of symptoms is more likely when treatment begins early with medications known as
disease-modifying ant rheumatic drugs (DMARDs).
Medications
The types of medications recommended by your doctor will depend on the severity
of your symptoms and how long you've had rheumatoid arthritis.
 NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain
and reduce inflammation. Over-the-counter NSAIDs include ibuprofen
(Advil, Motrin IB) and naproxen sodium (Aleve). Stronger NSAIDs are
available by prescription. Side effects may include stomach irritation, heart
problems and kidney damage.
 Steroids. Corticosteroid medications, such as prednisone, reduce
inflammation and pain and slow joint damage. Side effects may include
thinning of bones, weight gain and diabetes. Doctors often prescribe a
corticosteroid to relieve acute symptoms, with the goal of gradually tapering
off the medication.
 Disease-modifying anti rheumatic drugs (DMARDs). These drugs can
slow the progression of rheumatoid arthritis and save the joints and other
tissues from permanent damage. Common DMARDs include methotrexate
(Trexall, Otrexup, others), leflunomide (Arava), hydroxychloroquine
(Plaquenil) and sulfasalazine (Azulfidine).
Side effects vary but may include liver damage, bone marrow suppression and
severe lung infections.
 Biologic agents. Also known as biologic response modifiers, this newer class
of DMARDs includes abatacept (Orencia), adalimumab (Humira), anakinra
(Kineret), baricitinib (Olumiant), certolizumab (Cimzia), etanercept (Enbrel),
golimumab (Simponi), infliximab (Remicade), rituximab (Rituxan),
sarilumab (Kevzara), tocilizumab (Actemra) and tofacitinib (Xeljanz).
These drugs can target parts of the immune system that trigger inflammation
that causes joint and tissue damage. These types of drugs also increase the risk
of infections. In people with rheumatoid arthritis, higher doses of tofacitinib
can increase the risk of blood clots in the lungs. Biologic DMARDs are

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usually most effective when paired with a nonbiologic DMARD, such as
methotrexate.
Therapy
Your doctor may send you to a physical or occupational therapist who can teach you
exercises to help keep your joints flexible. The therapist may also suggest new ways
to do daily tasks, which will be easier on your joints. For example, you may want to
pick up an object using your forearms.
Assistive devices can make it easier to avoid stressing your painful joints. For
instance, a kitchen knife equipped with a hand grip helps protect your finger and
wrist joints. Certain tools, such as buttonhooks, can make it easier to get dressed.
Catalogs and medical supply stores are good places to look for ideas.
Surgery
If medications fail to prevent or slow joint damage, you and your doctor may
consider surgery to repair damaged joints. Surgery may help restore your ability to
use your joint. It can also reduce pain and improve function.
Rheumatoid arthritis surgery may involve one or more of the following procedures:
 Synovectomy. Surgery to remove the inflamed lining of the joint (synovium)
can be performed on knees, elbows, wrists, fingers and hips.
 Tendon repair. Inflammation and joint damage may cause tendons around
your joint to loosen or rupture. Your surgeon may be able to repair the tendons
around your joint.
 Joint fusion. Surgically fusing a joint may be recommended to stabilize or
realign a joint and for pain relief when a joint replacement isn't an option.
 Total joint replacement. During joint replacement surgery, your surgeon
removes the damaged parts of your joint and inserts a prosthesis made of metal
and plastic.

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Synovectomy of knee
Surgery carries a risk of bleeding, infection and pain. Discuss the benefits and risks
with your doctor.
3. PSORIATIC ARTHRITIS:
This condition occurs when patients have inflammation of not just the joints, but the
skin as well. Patients with psoriatic arthritis have patches of red or white areas of
inflamed skin, usually around the elbows, knees, and scalp. The specific symptoms
of this condition can vary greatly from person to person. For example, some people
will have just a couple of joints affected, whereas others may experience pain in
joints all over the body. The exact cause of psoriatic arthritis is believed to be an
autoimmune problem that causes the body to mistakenly attack healthy joints,
resulting in inflammation and pain.
Severe psoriatic arthritis of both feet and ankles. Note the changes to the nails.

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Symptoms:
Psoriatic arthritis can affect joints on just one side or on both sides of your body.
The signs and symptoms of psoriatic arthritis often resemble those of rheumatoid
arthritis. Both diseases cause joints to become painful, swollen and warm to the
touch.
However, psoriatic arthritis is more likely to also cause:
 Swollen fingers and toes. Psoriatic arthritis can cause a painful, sausage-like
swelling of your fingers and toes. You may also develop swelling and
deformities in your hands and feet before having significant joint symptoms.
 Foot pain. Psoriatic arthritis can also cause pain at the points where tendons
and ligaments attach to your bones — especially at the back of your heel
(Achilles tendinitis) or in the sole of your foot (plantar fasciitis).
 Lower back pain. Some people develop a condition called spondylitis as a
result of psoriatic arthritis. Spondylitis mainly causes inflammation of the
joints between the vertebrae of your spine and in the joints between your spine
and pelvis (sacroiliitis).
Causes:
Psoriatic arthritis occurs when your body's immune system begins to attack healthy
cells and tissue. The abnormal immune response causes inflammation in your joints
as well as overproduction of skin cells.
It's not entirely clear why the immune system attacks healthy tissue, but it seems
likely that both genetic and environmental factors play a role. Many people with
psoriatic arthritis have a family history of either psoriasis or psoriatic arthritis.
Researchers have discovered certain genetic markers that appear to be associated
with psoriatic arthritis.
Physical trauma or something in the environment — such as a viral or bacterial
infection — may trigger psoriatic arthritis in people with an inherited tendency.
Risk factors:
Several factors can increase your risk of psoriatic arthritis, including:

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 Psoriasis. Having psoriasis is the single greatest risk factor for developing
psoriatic arthritis. People who have pitted, deformed nails are especially likely
to develop psoriatic arthritis.
 Your family history. Many people with psoriatic arthritis have a parent or a
sibling with the disease.
 Your age. Although anyone can develop psoriatic arthritis, it occurs most
often in adults between the ages of 30 and 50.
Complications:
A small percentage of people with psoriatic arthritis develop arthritis mutilans — a
severe, painful and disabling form of the disease. Over time, arthritis mutilans
destroys the small bones in the hands, especially the fingers, leading to permanent
deformity and disability.
People who have psoriatic arthritis sometimes also develop eye problems such as
pinkeye (conjunctivitis) or uveitis, which can cause painful, reddened eyes and
blurred vision. They are also at higher risk of cardiovascular disease.
Diagnosis:
Imaging tests
 X-rays. Plain X-rays can help pinpoint changes in the joints that occur in
psoriatic arthritis but not in other arthritic conditions.
 Magnetic resonance imaging (MRI). MRI uses radio waves and a strong
magnetic field to produce very detailed images of both hard and soft tissues
in your body. This type of imaging test may be used to check for problems
with the tendons and ligaments in your feet and lower back.
MRI of the fingers in psoriatic arthritis

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Laboratory tests
 Rheumatoid factor (RF). RF is an antibody that's often present in the blood
of people with rheumatoid arthritis, but it's not usually in the blood of people
with psoriatic arthritis. For that reason, this test can help your doctor
distinguish between the two conditions.
 Joint fluid test. Using a needle, your doctor can remove a small sample of
fluid from one of your affected joints — often the knee. Uric acid crystals in
your joint fluid may indicate that you have gout rather than psoriatic arthritis.
Treatment:
No cure exists for psoriatic arthritis, so treatment focuses on controlling
inflammation in your affected joints to prevent joint pain and disability.
Medications
Drugs used to treat psoriatic arthritis include:
 NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain
and reduce inflammation. Over-the-counter NSAIDs include ibuprofen
(Advil, Motrin IB, others) and naproxen sodium (Aleve). Stronger NSAIDs
are available by prescription.
Side effects may include stomach irritation, heart problems, and liver and
kidney damage.
 Disease-modifying anti rheumatic drugs (DMARDs). These drugs can
slow the progression of psoriatic arthritis and save the joints and other tissues
from permanent damage.
Common DMARDs include methotrexate (Trexall, Otrexup, others),
leflunomide (Arava) and sulfasalazine (Azulfidine). Side effects vary but may
include liver damage, bone marrow suppression and severe lung infections.
 Immunosuppressants. These medications act to tame your immune system,
which is out of control in psoriatic arthritis.
Examples include azathioprine (Imuran, Azasan) and cyclosporine (Gengraf,
Neoral, Sandimmune). These medications can increase your susceptibility to
infection.

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 Biologic agents. Also known as biologic response modifiers, this newer class
of DMARDs includes abatacept (Orencia), adalimumab (Humira),
certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi),
infliximab (Remicade), ixekizumab (Taltz), secukinumab (Cosentyx),
tofacitinib (Xeljanz) and ustekinumab (Stelara).
These medications target specific parts of the immune system that trigger
inflammation and lead to joint damage. These drugs can increase the risk of
infections. Higher doses of tofacitinib can increase the risk of blood clots in
the lungs. Biologic agents can be used alone or combined with DMARDs,
such as methotrexate.
 Newer oral medication. Apremilast (Otezla) decreases the activity of an
enzyme in the body that controls the activity of inflammation within cells.
Potential side effects include diarrhea, nausea and headaches.
Surgical and other procedures
 Steroid injections. This type of medication reduces inflammation quickly and
is sometimes injected into an affected joint.
 Joint replacement surgery. Joints that have been severely damaged by
psoriatic arthritis can be replaced with artificial prostheses made of metal and
plastic.

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4. ANKYLOSING SPONDYLITIS:
Figure showing healthy and ankylosing spondylitis
Ankylosing spondylitis is an inflammatory disease that, over time, can cause some
of the small bones in your spine (vertebrae) to fuse. This fusing makes the spine less
flexible and can result in a hunched-forward posture. If ribs are affected, it can be
difficult to breathe deeply.
Ankylosing spondylitis affects men more often than women. Signs and symptoms
typically begin in early adulthood. Inflammation also can occur in other parts of your
body — most commonly, your eyes.
There is no cure for ankylosing spondylitis, but treatments can lessen your symptoms
and possibly slow progression of the disease.
Spinal cord showing stages of ankylosing spondylitis

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Symptoms:
Early signs and symptoms of ankylosing spondylitis might include pain and stiffness
in your lower back and hips, especially in the morning and after periods of inactivity.
Neck pain and fatigue also are common. Over time, symptoms might worsen,
improve or stop at irregular intervals.
The area’s most commonly affected are:
 The joint between the base of your spine and your pelvis
 The vertebrae in your lower back
 The places where your tendons and ligaments attach to bones, mainly in your
spine, but sometimes along the back of your heel
 The cartilage between your breastbone and ribs
 Your hip and shoulder joints
Causes:
Ankylosing spondylitis has no known specific cause, though genetic factors seem to
be involved. In particular, people who have a gene called HLA-B27 are at a greatly
increased risk of developing ankylosing spondylitis. However, only some people
with the gene develop the condition.
Risk factors:
 Your sex. Men are more likely to develop ankylosing spondylitis than are
women.
 Your age. Onset generally occurs in late adolescence or early adulthood.
 Your heredity. Most people who have ankylosing spondylitis have the HLA-
B27 gene. But many people who have this gene never develop ankylosing
spondylitis.
Complications:
In severe ankylosing spondylitis, new bone forms as part of the body's attempt to
heal. This new bone gradually bridges the gap between vertebrae and eventually
fuses sections of vertebrae. Those parts of your spine become stiff and inflexible.
Fusion can also stiffen your rib cage, restricting your lung capacity and function.
Other complications might include:

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 Eye inflammation (uveitis). One of the most common complications of
ankylosing spondylitis, uveitis can cause rapid-onset eye pain, sensitivity to
light and blurred vision. See your doctor right away if you develop these
symptoms.
 Compression fractures. Some people's bones thin during the early stages of
ankylosing spondylitis. Weakened vertebrae can crumble, increasing the
severity of your stooped posture. Vertebral fractures can put pressure on and
possibly injure the spinal cord and the nerves that pass through the spine.
 Heart problems. Ankylosing spondylitis can cause problems with your aorta,
the largest artery in your body. The inflamed aorta can enlarge to the point
that it distorts the shape of the aortic valve in the heart, which impairs its
function.
Diagnosis:
During the physical exam, your doctor might ask you to bend in different directions
to test the range of motion in your spine. He or she might try to reproduce your pain
by pressing on specific portions of your pelvis or by moving your legs into a
particular position. Also, your doctor might ask you to take a deep breath to see if
you have difficulty expanding your chest.
Imaging tests
X-rays allow your doctor to check for changes in your joints and bones, though the
visible signs of ankylosing spondylitis might not be evident early in the disease.
An MRI uses radio waves and a strong magnetic field to provide more-detailed
images of bones and soft tissues. MRI scans can reveal evidence of ankylosing
spondylitis earlier in the disease process, but are much more expensive.
Lab tests
There are no specific lab tests to identify ankylosing spondylitis. Certain blood tests
can check for markers of inflammation, but inflammation can be caused by many
different health problems.
Your blood can be tested for the HLA-B27 gene. But most people who have that
gene don't have ankylosing spondylitis and you can have the disease without having
the gene

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Treatment:
The goal of treatment is to relieve your pain and stiffness and prevent or delay
complications and spinal deformity. Ankylosing spondylitis treatment is most
successful before the disease causes irreversible damage to your joints.
Medications
Nonsteroidal anti-inflammatory drugs (NSAIDs) — such as naproxen (Naprosyn)
and indomethacin (Indocin, Tivorbex) — are the medications doctors most
commonly used to treat ankylosing spondylitis. They can relieve your inflammation,
pain and stiffness. However, these medications might cause gastrointestinal
bleeding.
If NSAIDs aren't helpful, your doctor might suggest starting a biologic medication,
such as a tumor necrosis factor (TNF) blocker or an interleukin-17 (IL-17) inhibitor.
TNF blockers target a cell protein that causes inflammation in the body. IL-17 plays
a role in the body's defense against infection and also has a role in inflammation.
TNF blockers help reduce pain, stiffness, and tender or swollen joints. They are
administered by injecting the medication under the skin or through an intravenous
line.
The five TNF blockers approved by the Food and Drug Administration (FDA) to
treat ankylosing spondylitis are:
 Adalimumab (Humira)
 Certolizumab pegol (Cimzia)
 Etanercept (Enbrel)
 Golimumab (Simponi)
 Infliximab (Remicade)
IL-17 inhibitors approved by the FDA to treat ankylosing spondylitis include
secukinumab (Cosentyx) and ixekizumab (Taltz).
TNF blockers and IL-17 inhibitors can reactivate untreated tuberculosis and make
you more prone to infection.
If you're unable to take TNF blockers or IL-17 inhibitors because of other health
conditions, your doctor may recommend the Janus kinase inhibitor tofacitinib
(Xeljanz). This drug has been approved for psoriatic arthritis and rheumatoid

24. 24
arthritis. Research is being done on its effectiveness for people with ankylosing
spondylitis.
4. GOUT:
Gout is a common and complex form of arthritis that can affect anyone. It's
characterized by sudden, severe attacks of pain, swelling, redness and tenderness in
the joints, often the joint at the base of the big toe.
An attack of gout can occur suddenly, often waking you up in the middle of the night
with the sensation that your big toe is on fire. The affected joint is hot, swollen and
so tender that even the weight of the sheet on it may seem intolerable.
Gout symptoms may come and go, but there are ways to manage symptoms and
prevent flares.
Figure 1 showing X-ray of normal foot and figure 2 showing gout condition
Symptoms:
The signs and symptoms of gout almost always occur suddenly, and often at night.
They include:
 Intense joint pain. Gout usually affects the large joint of your big toe, but it
can occur in any joint. Other commonly affected joints include the ankles,
knees, elbows, wrists and fingers. The pain is likely to be most severe within
the first four to 12 hours after it begins.

25. 25
 Lingering discomfort. After the most severe pain subsides, some joint
discomfort may last from a few days to a few weeks. Later attacks are likely
to last longer and affect more joints.
 Inflammation and redness. The affected joint or joints become swollen,
tender, warm and red.
 Limited range of motion. As gout progresses, you may not be able to move
your joints normally.
Causes:
Gout occurs when urate crystals accumulate in your joint, causing the inflammation
and intense pain of a gout attack. Urate crystals can form when you have high levels
of uric acid in your blood.
Your body produces uric acid when it breaks down purines — substances that are
found naturally in your body.
Purines are also found in certain foods, such as steak, organ meats and seafood. Other
foods also promote higher levels of uric acid, such as alcoholic beverages, especially
beer, and drinks sweetened with fruit sugar (fructose).
Normally, uric acid dissolves in your blood and passes through your kidneys into
your urine. But sometimes either your body produces too much uric acid or your
kidneys excrete too little uric acid. When this happens, uric acid can build up,
forming sharp, needlelike urate crystals in a joint or surrounding tissue that cause
pain, inflammation and swelling.
Risk factors:
You're more likely to develop gout if you have high levels of uric acid in your body.
Factors that increase the uric acid level in your body include:
 Diet. Eating a diet rich in meat and seafood and drinking beverages sweetened
with fruit sugar (fructose) increase levels of uric acid, which increase your
risk of gout. Alcohol consumption, especially of beer, also increases the risk
of gout.
 Obesity. If you're overweight, your body produces more uric acid and your
kidneys have a more difficult time eliminating uric acid.
 Medical conditions. Certain diseases and conditions increase your risk of
gout. These include untreated high blood pressure and chronic conditions such
as diabetes, metabolic syndrome, and heart and kidney diseases.

26. 26
 Certain medications. The use of thiazide diuretics — commonly used to treat
hypertension — and low-dose aspirin also can increase uric acid levels. So
can the use of anti-rejection drugs prescribed for people who have undergone
an organ transplant.
 Family history of gout. If other members of your family have had gout,
you're more likely to develop the disease.
 Age and sex. Gout occurs more often in men, primarily because women tend
to have lower uric acid levels. After menopause, however, women's uric acid
levels approach those of men. Men are also more likely to develop gout earlier
— usually between the ages of 30 and 50 — whereas women generally
develop signs and symptoms after menopause.
 Recent surgery or trauma. Experiencing recent surgery or trauma has been
associated with an increased risk of developing a gout attack.
Complications:
People with gout can develop more-severe conditions, such as:
 Recurrent gout. Some people may never experience gout signs and
symptoms again. Others may experience gout several times each year.
Medications may help prevent gout attacks in people with recurrent gout. If
left untreated, gout can cause erosion and destruction of a joint.
 Advanced gout. Untreated gout may cause deposits of urate crystals to form
under the skin in nodules called tophi (TOE-fie). Tophi can develop in several
areas such as your fingers, hands, feet, elbows or Achilles tendons along the
backs of your ankles. Tophi usually aren't painful, but they can become
swollen and tender during gout attacks.
 Kidney stones. Urate crystals may collect in the urinary tract of people with
gout, causing kidney stones. Medications can help reduce the risk of kidney
stones.
Diagnosis:
Tests to help diagnose gout may include:
 Joint fluid test. Your doctor may use a needle to draw fluid from your
affected joint. Urate crystals may be visible when the fluid is examined under
a microscope.
 Blood test. Your doctor may recommend a blood test to measure the levels of
uric acid and creatinine in your blood. Blood test results can be misleading,
though. Some people have high uric acid levels, but never experience gout.

27. 27
And some people have signs and symptoms of gout, but don't have unusual
levels of uric acid in their blood.
 X-ray imaging. Joint X-rays can be helpful to rule out other causes of joint
inflammation.
X-ray of knee
 Ultrasound. Musculoskeletal ultrasound can detect urate crystals in a joint or
in a tophus. This technique is more widely used in Europe than in the United
States.
 Dual energy CT scan. This type of imaging can detect the presence of urate
crystals in a joint, even when it is not acutely inflamed. This test is not used
routinely in clinical practice due to the expense and is not widely available.
Treatment:
Treatment for gout usually involves medications. What medications you and your
doctor choose will be based on your current health and your own preferences.
Gout medications can be used to treat acute attacks and prevent future attacks.
Medications can also reduce your risk of complications from gout, such as the
development of tophi from urate crystal deposits.
Medications to treat gout attacks
Drugs used to treat acute attacks and prevent future attacks include:
 Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs include over-
the-counter options such as ibuprofen (Advil, Motrin IB, others) and naproxen
sodium (Aleve), as well as more-powerful prescription NSAIDs such as
indomethacin (Indocin) or celecoxib (Celebrex).

28. 28
Your doctor may prescribe a higher dose to stop an acute attack, followed by
a lower daily dose to prevent future attacks.
NSAIDs carry risks of stomach pain, bleeding and ulcers.
 Colchicine. Your doctor may recommend colchicine (Colcrys, Mitigare), a
type of pain reliever that effectively reduces gout pain. The drug's
effectiveness may be offset, however, by side effects such as nausea, vomiting
and diarrhea, especially if taken in large doses.
After an acute gout attack resolves, your doctor may prescribe a low daily
dose of colchicine to prevent future attacks.
 Corticosteroids. Corticosteroid medications, such as the drug prednisone,
may control gout inflammation and pain. Corticosteroids may be in pill form,
or they can be injected into your joint.
Corticosteroids are generally used only in people with gout who can't take
either NSAIDs or colchicine. Side effects of corticosteroids may include
mood changes, increased blood sugar levels and elevated blood pressure
Surgery of gout

29. 29
5. JUVENILE IDIOPATHIC ARTHRITIS:
Figure showing a healthy and affected joint of a kid
Juvenile idiopathic arthritis, formerly known as juvenile rheumatoid arthritis, is the
most common type of arthritis in children under the age of 16.
Juvenile idiopathic arthritis can cause persistent joint pain, swelling and stiffness.
Some children may experience symptoms for only a few months, while others have
symptoms for the rest of their lives.
Some types of juvenile idiopathic arthritis can cause serious complications, such as
growth problems, joint damage and eye inflammation. Treatment focuses on
controlling pain and inflammation, improving function, and preventing joint
damage.
Symptoms:
The most common signs and symptoms of juvenile idiopathic arthritis are:
 Pain. While your child might not complain of joint pain, you may notice that
he or she limps — especially first thing in the morning or after a nap.
 Swelling. Joint swelling is common but is often first noticed in larger joints
such as the knee.
 Stiffness. You might notice that your child appears clumsier than usual,
particularly in the morning or after naps.

30. 30
 Fever, swollen lymph nodes and rash. In some cases, high fever, swollen
lymph nodes or a rash on the trunk may occur — which is usually worse in
the evenings.
Juvenile idiopathic arthritis can affect one joint or many. There are several different
subtypes of juvenile idiopathic arthritis, but the main ones are systemic, oligo
articular and poly articular. Which type your child has depends on symptoms, the
number of joints affected, and if a fever and rashes are prominent features.
Like other forms of arthritis, juvenile idiopathic arthritis is characterized by times
when symptoms flare up and times when symptoms disappear.
Causes:
Juvenile idiopathic arthritis occurs when the body's immune system attacks its own
cells and tissues. It's not known why this happens, but both heredity and environment
seem to play a role. Certain gene mutations may make a person more susceptible to
environmental factors — such as viruses — that may trigger the disease.
Complications:
Several serious complications can result from juvenile idiopathic arthritis. But
keeping a careful watch on your child's condition and seeking appropriate medical
attention can greatly reduce the risk of these complications:
 Eye problems. Some forms can cause eye inflammation (uveitis). If this
condition is left untreated, it may result in cataracts, glaucoma and even
blindness.
Eye inflammation frequently occurs without symptoms, so it's important for
children with this condition to be examined regularly by an ophthalmologist.
 Growth problems. Juvenile idiopathic arthritis can interfere with your child's
growth and bone development. Some medications used for treatment, mainly
corticosteroids, also can inhibit growth.
Diagnosis:
Diagnosis of juvenile idiopathic arthritis can be difficult because joint pain can be
caused by many different types of problems. No single test can confirm a diagnosis,

31. 31
but tests can help rule out some other conditions that produce similar signs and
symptoms.
Blood tests:
Some of the most common blood tests for suspected cases include:
 Erythrocyte sedimentation rate (ESR). The sedimentation rate is the speed
at which your red blood cells settle to the bottom of a tube of blood. An
elevated rate can indicate inflammation. Measuring the ESR is primarily used
to determine the degree of inflammation.
 C-reactive protein. This blood test also measures levels of general
inflammation in the body but on a different scale than the ESR.
 Anti-nuclear antibody. Anti-nuclear antibodies are proteins commonly
produced by the immune systems of people with certain autoimmune diseases,
including arthritis. They are a marker for an increased chance of eye
inflammation.
 Rheumatoid factor. This antibody is occasionally found in the blood of
children who have juvenile idiopathic arthritis.
 Cyclic citrullinated peptide (CCP). Like the rheumatoid factor, the CCP is
another antibody that may be found in the blood of children with juvenile
idiopathic arthritis.
In many children with juvenile idiopathic arthritis, no significant abnormality will
be found in these blood tests.
Imaging scans:
X-rays or magnetic resonance imaging (MRI) may be taken to exclude other
conditions, such as fractures, tumors, infection or congenital defects.
Imaging may also be used from time to time after the diagnosis to monitor bone
development and to detect joint damage.
Treatment:
Treatment for juvenile idiopathic arthritis focuses on helping your child maintain a
normal level of physical and social activity. To accomplish this, doctors may use a

32. 32
combination of strategies to relieve pain and swelling, maintain full movement and
strength, and prevent complications.
Medications:
The medications used to help children with juvenile idiopathic arthritis are chosen
to decrease pain, improve function and minimize potential joint damage.
Typical medications include:
 Nonsteroidal anti-inflammatory drugs (NSAIDs). These medications, such
as ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve), reduce
pain and swelling. Side effects include stomach upset and liver problems.
 Disease-modifying anti rheumatic drugs (DMARDs). Doctors use these
medications when NSAIDs alone fail to relieve symptoms of joint pain and
swelling or if there is a high risk of damage in the future.
DMARDs may be taken in combination with NSAIDs and are used to slow
the progress of juvenile idiopathic arthritis. The most commonly used
DMARD for children is methotrexate. Side effects of methotrexate may
include nausea and liver problems.
 Biologic agents. Also known as biologic response modifiers, this newer class
of drugs includes tumor necrosis factor (TNF) blockers, such as etanercept
(Enbrel) and adalimumab. These medications can help reduce systemic
inflammation and prevent joint damage.
Other biologic agents work to suppress the immune system, including
abatacept (Orencia), rituximab (Rituxan), anakinra (Kineret) and tocilizumab
(Actemra).
 Corticosteroids. Medications such as prednisone may be used to control
symptoms until another medication takes effect. They are also used to treat
inflammation when it is not in the joints, such as inflammation of the sac
around the heart (pericarditis).
These drugs can interfere with normal growth and increase susceptibility to
infection, so they generally should be used for the shortest possible duration.

33. 33
Therapies:
Your doctor may recommend that your child work with a physical therapist to help
keep joints flexible and maintain range of motion and muscle tone.
A physical therapist or an occupational therapist may make additional
recommendations regarding the best exercise and protective equipment for your
child.
A physical or occupational therapist may also recommend that your child make use
of joint supports or splints to help protect joints and keep them in a good functional
position.
Surgery:
In very severe cases, surgery may be needed to improve the position of a joint.

34. 34
PREVALENCE RATE OF ARTHRITIS:
According to age group:
Prevalance rate of arthritis in age group
Prevalance rate of arthritis according to gender
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
18-44 YEARS 45-64 YEARS ABOVE 60 YEARS
Prevalance rate of arthrits in age group
WOMEN
58%
MEN
42%
Prevalance rate of arthritis in
gender
WOMEN MEN

35. 35
More than 22% of American adults (over 52.5 million people) have arthritis or
another rheumatic condition diagnosed by a doctor.2.9 million Hispanic adults and
4.6 million non-Hispanic Blacks report doctor-diagnosed arthritis. By 2030, the
number of people with arthritis (adults 18 years and older) is expected to rise to 67
million
THE PREVALENCE OF OSTEOARTHRITIS:
Osteoarthritis is a degenerative joint disease, which mainly affects the articular
cartilage. It is associated with ageing and will most likely affect the joints that have
been continually stressed throughout the years including the knees, hips, fingers, and
lower spine region.
 Osteoarthritis is already one of the ten most disabling diseases in developed
countries.
 Farming 1-9 years increases the risk of osteoarthritis 4.5 times; farming 10 or
more years increases the risk 9.3 times.
 Worldwide estimates are that 9.6% of men and 18.0% of women aged over 60
years have symptomatic osteoarthritis.
 80% of those with osteoarthritis will have limitations in movement, and 25%
cannot perform their major daily activities of life.
Prevalence rate of osteoarthritis according to gender
9.60%
18.00%
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
14.00%
16.00%
18.00%
20.00%
MEN WOMEN
Prevalance rate of osteoarthritis according
to gender

36. 36
THE PREVALENCE OF RHEUMATOID ARTHRITIS:
Rheumatoid Arthritis is a chronic systemic disease that affects the joints, connective
tissues, muscle, tendons, and fibrous tissue. It tends to strike during the most
productive years of adulthood, between the ages of 20 and 40, and is a chronic
disabling condition often causing pain and deformity.
 The prevalence varies between 0.3% and 1% and is more common in women
and in developed countries.
 Within 10 years on onset, at least 50% of patients in developed countries are
unable to hold down a full-time job.
THE PREVALENCE OF PSORIATIC ARTHRITIS:
 According to the IFPA, nearly 3 percent of the world’s population has some
form of psoriasis. That’s over 125 million people.
 The World Health Organization noted in 2016 that the reported prevalence of
psoriasis worldwide ranges between 0.09 percent and 11.43 percent, making
psoriasis a serious global problem. And out of which 7% to 42% of patient
with psoriaisis will develop arthritis.
THE PREVALENCE OF ANKYLOSING SPONDYLITIS:
According to recent study The mean AS prevalence per 10 000 (from 36 eligible
studies) was 23.8 in Europe, 16.7 in Asia, 31.9 in North America, 10.2 in Latin
America and 7.4 in Africa. Additional estimates, weighted by study size, were
calculated as 18.6, 18.0 and 12.2 for Europe, Asia and Latin America, respectively.
There were sufficient studies to estimate the number of cases in Europe and Asia,
calculated to be 1.30–1.56 million and 4.63–4.98 million, respectively.

37. 37
Prevalence rate of ankylosing spondylitis in different region
Prevalence of AS in Asia:
Within Asia, the prevalence of AS was reported by 15 studies, only 1 of which
was determined to be a hospital-based study. The remaining 14 studies reported AS
prevalence between 3.0 and 37.1 per 10 000 and individual study size ranged
between 2040 and 10 921(total study population 83 353). The mean prevalence of
AS within Asia was 16.7 per 10 000 (weighted mean 18.0 per 10 000). South Asian
countries provided the lowest prevalence estimates, between 3.0 and 24.3 per 10 000
(mean 8.5, weighted mean 7.8 per 10 000), whereas East Asian countries exhibited
varied prevalance from 11.0 to 37.1 per 10 000 (mean 25.5, weighted mean 26.4 per
10 000). Lastly, the only study from West Asia (Iran) reported an AS prevalence of
11.7 per 10 000, although it reported some variances due to ethnicity: 11.0 and 15.0
per 10 000 among Caucasians and Turks, respectively. As within Europe, Asian
studies based on a clinical diagnosis reported a lower prevalence (mean 13.3,
weighted mean 12.7 per 10 000) compared with those using either the New York or
modified New York criteria (mean 25.3, weighted mean 26.5 per 10 000). The only
hospital-based study within Asia reported the lowest AS prevalence of any study
found within this review (0.7 per 10 000).
Prevalence of AS in Asian countries based on population studies
*Prevalence and exact binomial CI.
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
AS
prevalance
per 10,000
23.80%
16.70%
31.90%
10.20%
7.40%
PREVALANCE RATE OF
ANKYLOSING SPONDYLITIS
Europe Asia North America Latin America Africa

38. 38
THE PREVALENCE OF GOUT GLOBALLY:
Gout prevalence: Gout is a common chronic crystal deposition disorder Recent
reports of the prevalence and incidence of gout vary widely according to the
population studied and methods employed but range from a prevalence of <1% to
6.8% and an incidence of 0.58–2.89 per 1,000 person-years. Gout is more prevalent
in men than in women, with increasing age, and in some ethnic groups. Despite rising
prevalence and incidence, suboptimal management of gout continues in many
countries. In addition, gout is the most common form of inflammatory arthritis.
Currently, gout affects about 1-10% of the world's population and is highly variable
across different countries. Today, the prevalence of gout is roughly 4% of the
population of the United States, Europe, and Southeast Asia.
PREVALANCE AND INCIDENCE RATE OF GOUT PER 1000 person per year
0%
1%
1%
2%
2%
3%
3%
4%
4%
5%
Gout per 1000 person - year
PREVALANCE RATE OF GOUT
Prevalance Incidence

39. 39
THE PREVALENCE OF JUVENILE IDIOPATHIC ARTHRITIS:
a. About 7/1000,00 newly diagnosed children with JIA per year.
b. Prevalence about 1/ 1000 children
REFERENCE:
World Health Organization reports www.who.int/
Global prevalence of ankylosing spondylitis
Linda E. Dean, Gareth T. Jones, Alan G. MacDonald, Christina Downham,
Roger D. Sturrock, Gary J. Macfarlane
Rheumatology, Volume 53, Issue 4, April 2014,