Hair loss Treatment Center

PARTICIPANTS Stephen Smiles, MD New York University Medical Center Allan Gibofsky, MD, JD New York Presbyterian-Weill Cornell Hospital

Joining us to explore these questions is Dr. Allan Gibofsky. He's Professor of Medicine and Public Health at Cornell, and a rheumatologist at the Hospital for special surgery. Welcome.

And next to him is Dr. Stephen Smiles, Clinical Assistant Professor of Medicine at NYU. Thanks for being here.

Everybody has heard the word arthritis, but a lot of people probably don't know what it means. What does arthritis mean?

ALLAN GIBOFSKY, MD: In simplest terms, the word arthritis means inflammation of the joint. It comes from arthr, which means joint, and itis, which means inflammation. But the word arthritis is really like the word automobile. What makes, what model, what color, what options? There are over 100 different clinical conditions that we refer to as arthritis. As people understand arthritis, they use it to mean not just pain in the joints, but pain around the joints, as well as pain in the bones and muscles that may be nowhere near a joint. So when the lay public uses the term arthritis, they are frequently using it to refer to all of these conditions, rather than to just any one.

What that means is that the challenge to a physician like Dr. Smiles or myself is to be able to tease out exactly what kind of arthritis we're dealing with so that we can better individualize a therapy for that patient.

DAVID MARKS, MD: Dr. Smiles, what are some of the most common types of arthritis?

STEPHEN SMILES, MD: I believe that what we see most often common are two types of categories. One is the arthritis that we see related to the degeneration of joints.

DAVID MARKS, MD: What does that mean, degeneration? Explain what that means.

STEPHEN SMILES, MD: It is the localization of a process that is localized to the joint itself, rather than a system disease of the entire body that we see in disorders that are categorized under inflammatory joint disease like rheumatoid arthritis. So out of the two largest categories, we would see osteo arthritis, a localized degenerative process of the joint, rheumatoid arthritis, a generalized systemic disease with its major manifestation being a systemic joint disease

ALLAN GIBOFSKY, MD: Let me carry that one step further, as Steve has indicated. When we talk about degenerative disease, generally what we talk about is either normal use of an abnormal joint, or abnormal use of a normal joint. So, individuals who are basketball players and use their knees a lot develop the kind of arthritis in their knees that we would see in their grandparents. Their hands and the other parts of their body are fine.

Then we have those individuals who may have been born with a dislocation of the hip. There the joint is abnormal. When they are using an abnormal joint normally, they may develop an early form of degeneration.

DAVID MARKS, MD: So degeneration does not always mean when somebody is old.

ALLAN GIBOFSKY, MD: Oh, absolutely not. I think it's important for people to understand that arthritis is not a disease of old people. It's a disease that can be in your grandmother, but it's also a disease that can be in your grandchild. The different forms of arthritis can occur at different ages in different people.

DAVID MARKS, MD: There are some other maybe less common types of arthritis. Why don't you mention a couple of those. Like lupus. You can have arthritis also.

STEPHEN SMILES, MD: Well, lupus, known as systemic lupus areth amitosis (?), is a clinical entity of inflammation of many organ systems. One of them can be related to the joints themselves. You can have arthritis related to infections. In the region here in around New York, Lyme disease, which is a disease carried by a tick and is a bacteria, can lead to a chronic inflammatory joint disease. So we can see things that are related to diseases of unknown origin. We can see diseases that are related to infections, be it from viruses, be it from bacteria. We can also see other types of traumatic arthritises that people can develop, either through their occupation or through their avocation.

DAVID MARKS, MD: How does someone know if they have arthritis to begin with?

ALLAN GIBOFSKY, MD: Generally, the first sign of arthritis - the first symptom of arthritis, I should say - is pain. Pain in or around the joint, or pain in a bone, pain in a muscle, pain in a soft tissue structure like a ligament or a tendon. Generally, that's what people understand when they think they have arthritis. That's generally what causes them to seek attention for it. The problem is that unfortunately there is a culture, perhaps fostered in part by some advertising that we've seen in the past that arthritis is not a serious disease, that pain can be treated with simple aspirin. That's not always the case.

The kinds of conditions that cause arthritis often require much more treatment than what might be available over the counter. That's why it's important for people to have these kind of problems to see a physician early.

One last point I would make is that it's also important to understand that there are forms of arthritis diseases that cause symptoms other than arthritis. There are forms of other diseases that cause arthritis.

For example, people with bowel disease may have joint pain. People with joint pain may have problems with their eyes or problems with their heart. So it's very important to tease out or differentiate those conditions that can cause arthritis that are not of the joint, and those conditions that are arthritis causing things to happen outside the joint.

DAVID MARKS, MD: Give me an example of when a person should be concerned that their arthritis is caused by some systemic disease.

ALLAN GIBOFSKY, MD: I think that whenever someone has arthritis, they should be thinking not just of their joint, but of other things that could cause it as well.

Unfortunately, there can be a long time interval. Steve has seen many of these patients, as I have, of individuals who will present to with pain in the joint. As you watch them for a period of time, you come to realize that they are going to develop bowel disease, or they are going to develop a skin disease like psoriasis. Often, there can be a delay of up to a year between the time that patients will come in with the joint pain and when they have the other symptoms. So the mark of a good physician is to be able to identify when that's going to happen and to anticipate it. Steve, would you agree with that?

STEPHEN SMILES, MD: I think that the process, once it becomes somewhat chronic, patients can have other signs and symptoms; loss of appetite, maybe fever, maybe loss of weight. Maybe some other part of their body, be it their chest or their abdomen is no longer functioning properly. In the context of them having joint discomfort, they should then seek out the attention of their physician, and wonder whether or not the presentation of the pain that could be in a swollen toe, because they've gone ahead and developed gout because of that toe, or the swelling over an elbow because of a plaque of psoriasis is something that they should then bring to their internist, and even to the possibility of seeing the rheumatologist.

ALLAN GIBOFSKY, MD: I would agree with everything that you said, but I would also argue for the earlier intervention, for the earlier approach to diagnosis and treatment. We know that unfortunately a number of people with arthritis don't come to see us until several months or even years into their process. You've seen the patient with low back pain due to a condition called ankylosing spondylitis who hasn't come to see you for 18 months to 2 years. Wouldn't it be nice if we knew about that at the beginning of symptoms so that maybe we could be more aggressive earlier on. But that's something that has to evolve over time.

STEPHEN SMILES, MD: I think that's definitely the case. If we try to get people to come earlier and earlier, I think the possibility of their care is going to be improved.

DAVID MARKS, MD: Before we talk about when people should see a doctor, who is at risk for arthritis? Is anybody at risk for arthritis?

ALLAN GIBOFSKY, MD: Everybody is at risk for arthritis, but there are different forms of arthritis. Some people are more at risk for some than for others. The older one gets, the more likely they are to have the degenerative form of arthritis from what I referred to earlier as the abnormal use of a normal joint. Then there are forms of arthritis, which Steve alluded to, which may occur as a result of infection. Those kinds of conditions may have a very definite genetic predisposition.

The long-winded answer to your question is that everyone is at risk at some time, and some people are at risk all the time. Again, our challenge is to identify what it is that is causing something to happen in the predisposed patient.

DAVID MARKS, MD: Let's talk about the advertisements for over the counter medications. Sometimes that's okay, but when should a person be concerned that they need to actually see a physician, that they can't self-medicate.

STEPHEN SMILES, MD: I think that once someone goes out, takes an over the counter medicine for what they believe is an ache and a pain, and in a relatively short period of time, be it a week, be it two weeks that they haven't had relief from having rest, an over the counter antiinflammatory and/or analgesic. If changing their mode of activity has not relieved them from their pains, I think at that time they should go and seek some attention by their physician.

DAVID MARKS, MD: Are there any specific symptoms that would make your more concerned for a patient?

ALLAN GIBOFSKY, MD: Absolutely. The word arthritis, as I said before, means joint inflammation. The more acute and dramatic the presentation of the joint inflammation, the more concerned I am. So were you to call me and say that your elbow aches, I would be concerned. Were you to call me and say that your elbow has blown up like a balloon. It's hot and tender, and you're running a fever of 105, I would be even more concerned because that would suggest to me an acute infection, rather than a chronic process of the joint.

STEPHEN SMILES, MD: And along with that, if you then presented with more than one joint...

DAVID MARKS, MD: At the same time?

STEPHEN SMILES, MD: At the same time. Joints of the upper and lower extremity at the same time. One would believe that we were dealing with something other than just a traumatic type of process. That should make someone concerned and bring them to their physician.

DAVID MARKS, MD: What about the weekend warrior out there? The 45-year-old guy who is going out and playing basketball on the weekends and hurts his knee. You hear people say all the time, "I know I'm going to end up with arthritis in this knee eventually." Is that something that they should be concerned about or look for to stem the development of arthritis?

STEPHEN SMILES, MD: I think the weekend warrior who goes out and has an acute injury should either be seen by a rheumatologist or an orthopedist. I think there are a number of injuries that could be dealt with quicker, so that if they need an intervention like a surgical procedure that they can have done for a torn cartilage or platelet, it could be a lot simpler, rather than taking pain killers, pushing through it and pushing on.

ALLAN GIBOFSKY, MD: Often, the weekend warrior really needs education. If the weekend warrior came in after the first episode, well then perhaps we could educate them on how to prevent the second. Only too often the weekend warrior comes in after the tenth episode, by which time there is chronic damage to the structures of the joint that he or she is complaining about. By then, the ante is up a little bit from where it could have been had we gotten involved earlier.

DAVID MARKS, MD: Is there a genetic component to arthritis?

ALLAN GIBOFSKY, MD: Yes there is. There is excellent data to suggest that certain forms of arthritis run in the family and can be determined from certain kinds of blood tests on blood groups. There is some early, elegant work that goes back to the late 1970s and early 80s, largely the work of Bob Winchester and his colleagues from the Rockefeller University, showing that rheumatoid arthritis has a strong genetic predisposition.

The arthritis that we referred to earlier as ankylosing spondylitis has a strong genetic predisposition. Rheumatic fever has a strong genetic predisposition. Lyme disease may have a genetic predisposition. The challenge though is that all of these genetic predispositions require an environmental trigger. We don't know what these triggers are yet, even though we're learning more and more about what kinds of things can interact in the genetically predisposed individual.

DAVID MARKS, MD: What are the three most common symptoms that a person should look for in arthritis?

STEPHEN SMILES, MD: The three most common symptoms would be pain in or around a joint, swelling in or around a joint, heat and redness in or around a joint.

DAVID MARKS, MD: Good. Well thank you very much, and thank you for joining our webcast. I'm Dr. David Marks. Goodbye.