Bone of contention

Arthritis may involve one joint (monoarthritis), a few joints (oligoarthritis), or many joints (poly-arthritis). It may be the main feature of a disease or a secondary feature of a systemic illness, for example, inflammatory bowel disease.

Arthritis may lead to deformity or destruction of involved joints. This often results in impairment of function, both in terms of activities of daily living and ability to perform your occupation.

Some forms of arthritis are unremitting (chronic continuous disease) and lead to permanent disability, while others may be associated with periods of relatively unimpaired function interspersed with debilitating flare-ups. Sometimes only one acute episode occurs with subsequent remission.

There are over 100 types of arthritis, but the most common are osteoarthritis and rheumatoid arthritis.

Osteoarthritis

This is the most common type of arthritis, especially among older people. It is sometimes called degenerative joint disease or osteoathrosis. The most common areas affected are the hands, knees, hips and spine.

Osteoathritis is a disease that mainly affects cartilage ' the tissue that covers the ends of bones in a joint. Healthy cartilage allows bones to glide over one another. It also absorbs energy from the shock of physical movement. In osteoarthritis, the surface layer of cartilage breaks down and wears away. This allows bones under the cartilage to rub together, causing pain, swelling and loss of motion of the joint. Over time, the joint may lose its normal shape.

Also, bone spurs ' small growths called osteophytes ' may grow on the edges of the joint. Bits of bone or cartilage can break off and float inside the joint space, causing more pain and damage.

Osteoarthritis sufferers usually have joint pain and limited movement. Unlike some other forms of arthritis, osteoarthritis only affects joints, and not internal organs.

Osteoarthritis is one of the most frequent causes of physical disability among adults. Some younger people get osteoarthritis from a joint injury, but osteoarthritis most often occurs in older people. In fact, by age 65, more than half the population has x-ray evidence of osteoarthritis in at least one joint. Since the number of older people is increasing, so is the number of people with osteoarthritis. Both men and women have the disease. Before age 45, more men have it, while after age 45 osteoarthritis is more common in women.

There are no abnormal blood tests in osteoarthritis, although they are carried out to exclude other rheumatological diseases. X-ray changes are characteristic, with loss of articular cartilage, narrowing of the joint space, sclerosis of the sub-articular cartilage, small subchondral cysts in the bones and osteophytes (bony outgrowths adjacent to the joint).

Some of the complications associated with osteoarthritis are depression, functional limitation, deformed joints, falls in old people and spinal cord compression.

Most cases can be treated and maintained at a normal level of function with weight reduction, simple analgesics, anti-inflammatory drugs, and physiotherapy to improve joint mobility. Maintenance of muscular tone and strength may help to compensate for instability or deformity. Occasionally, intra-articular steroid injections may be used.

More severe involvement may necessitate surgery, including total hip or knee replacement.

The prognosis of osteoarthritis is variable. There is poor correlation between x-ray appearance, clinical findings and symptoms and even those with marked knee joint deformity may have good mobility albeit at reduced pace.

Furthermore, the pain varies from day to day and may disappear spontaneously.

Rheumatoid arthritis

Rheumatoid arthritis is an inflammatory disease that causes pain, swelling, stiffness, and loss of function in the joints. It has several features that make it different from other kinds of arthritis. For example, rheumatoid arthritis generally occurs in a symmetrical pattern. This means if one knee or hand is involved, the other one is as well. The disease often affects the wrist joints and the finger joints closest to the hand. Extra-articular manifestations may occur in virtually any organ including the heart, lungs, nerves, eyes and blood vessels.

In over 50% of cases, systemic symptoms appear first. These include malaise, anorexia, weakness and aches and pains. These symptoms may continue for months before typical arthritis begins. Rheumatoid nodules will also occur in about a quarter of patients and may be found in a variety of sites. Rheumatoid factor is an antibody which is positive in two-thirds of patients with the disease. Therefore if someone has a positive rheumatoid factor it may assist in diagnosis, but is not a certain factor that will always be present.

Another feature of rheumatoid arthritis is that it varies a lot from person to person. For some people, it lasts only a few months or a year or two and goes away without causing any noticeable damage. Other people have mild or moderate disease, with periods of worsening symptoms, called flare-ups, and periods in which they feel better, called remissions. Others have a severe form of the disease that is active most of the time, lasts for many years, and leads to serious joint damage and disability.

There are seven diagnostic criteria used for rheumatoid arthritis from the American College of Rheumatology. These are:

• Morning stiffness for at least one hour.

• Arthritis of three or more joint areas including the proximal interphalangeal joints (small bones in the fingers and toes), wrist, elbow, knee and ankle.

• Swelling of at least one hand.

• Symmetric arthritis.

• Rheumatoid nodules.

• Positive rheumatoid factor.

• Characteristic x-ray changes.

In order for a diagnosis of rheumatoid arthritis to be made, four or more of these criteria must be met, with the first four being present for at least six weeks.

Treatment includes physiotherapy and occupational therapy. Aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs) are the standard drug therapy.

The current trend is to add disease modifying drugs (DMDs) early in the disease course, often in combination, to prevent joint damage. All drugs used for rheumatoid arthritis have adverse side effects. These include bone marrow suppression, proteinuria, retinopathy, gastrointestinal bleeding and renal impairment.

Surgery may also help relieve symptoms. Removal of overgrowth of synovium (synovectomy) can reduce progression. Sometimes fusion of the joint is necessary but, as with osteo-arthritis, joint replacement surgery is having a major impact, particularly for hips and knees.

There are numerous factors that have the potential to affect mortality in rheumatoid arthritis. These include progressive and often rapid damage to joints causing severe disability, vasculitis (inflammation of the blood vessels) and other extra articular involvement of the lungs, vascular system, heart, kidneys, blood, nervous system, liver and eyes. In addition, complications related to the treatment prescribed may also have implications. Finally, due to the pain and disability resulting from rheumatoid arthritis, it can be the cause of social and domestic complications leading to depression.

When underwriting an application where an individual has disclosed a history of arthritis, the type of arthritis they have is obviously a significant factor in type of evidence required. For osteoarthritis, a point of sale questionnaire is usually sufficient to assess the condition and make a decision. For rheumatoid arthritis, however, a GP's report along with an arthritis questionnaire to the GP, asking for full details of the disease and the current severity are usually required.

The severity of an individual's arthritis is key throughout the underwriting process, regardless of the benefit being underwritten. Examples of how a company may assess the degree of the disease are as follows:

Mild: Minimal joint pain, swelling and stiffness, no hospitalisation, no impairment of activities of daily living. Symptoms may be intermittent or continuous, but of low severity. Medications generally limited to aspirin or non-steroidal anti-inflammatory drugs (NSAIDs).

Moderate: More extensive joint involvement, rare hospitalisation, and minimal impairment of activities of daily living (ADLs). Symptoms are continuous with slow deterioration. Use of remittive medications is generally indicated.

Severe: Active, progressive disease with significant disability; frequent hospitalisation. Usually requires assistance with ADLs.

In addition, if the applicant is currently awaiting joint surgery, this may result in a temporary extra being applied during the first year of the contract, if the applicant is aged over 45. This is to cover the surgical mortality risk whereas all non-life benefits will be postponed until after the surgery has been performed and a full recovery has been made.

Life cover

Osteoarthritis:

Mild to moderate: Ordinary rates

Severe: A rating of +50% may apply

Rheumatoid arthritis:

Mild: Ordinary rates/+ 50%

Moderate: +75%

Severe: +150%

Critical illness

Osteoarthritis and Rheumatoid Arthritis

Mild: Ordinary rates

Moderate: +50%/+100%

Severe: Decline

When underwriting disability benefits the severity of the disease and the definition of disability that is being underwritten will determine the terms a provider can offer. In addition, the underwriter will need to consider the following questions in relation to the applicant's occupation:

• Is the occupation likely to aggravate the condition?

• Does any current deformity interfere with the applicant's ability to perform duties?

Examples for deferred 13 weeks on income protection/waiver of premium are:

Income protection/total and permanent disability and waiver of premium

Osteoarthritis:

Mild to moderate: +50/+75%

Severe: +100% or exclude

Rheumatoid arthritis

Present: Decline

If in remission for at least 12 months:

Mild to moderate: +50% to +150%

Severe: Exclude