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Back to the future

Published on 01 January 2011
Source: Arthritis Today

Canadian Red Cross hospital

In 2011 Arthritis Research UK celebrates its 75th anniversary. Jane Tadman looks back to 1936, the year the charity was founded, and at how, largely through its work, treatment of arthritis has changed beyond recognition.

When Arthritis Research UK’s forerunner, the Empire Rheumatism Council, was founded, Britain was another country. We still had an Empire, on which the sun had yet to set; and the word ‘arthritis’ was rarely used.

World War II was still a distant possibility, the nuclear bomb still unimaginable. King Edward VIII abdicated in that year, Gone with the Wind was still in the making, and the treatment of what was then commonly termed ‘rheumatism’ was just about untreatable. The term osteoarthritis as we now know it had yet to be coined.

If you were unlucky enough to develop rheumatoid arthritis in 1936 the probability was you would have been sent to bed and encouraged to stay there. You’d probably have ended up in a wheelchair, wracked with increasing pain. There were few, if any, effective painkillers, and no forms of joint replacement surgery. You may have been subjected to electric shocks or pumped full of high doses of gold, which caused toxic side-effects.

“It really was the dark ages in terms of treatment of arthritis, until the advent of steroids and the discovery of aspirin,” says Dr Madeleine Devey, former scientific secretary for the charity.

“My grandmother had rheumatoid arthritis and spent half her life in bed. She completely seized up. The treatment for people with ankylosing spondylitis was plaster beds and rigid corsets, and it wasn’t really until around 1970 that it was accepted that people with arthritis were better off keeping themselves as mobile and active as possible.”

Such then was the need for the Empire Rheumatism Council, set up by Dr Will Copeman (an eminent physician, elected a Fellow of the Royal College of Physicians in 1937) and other like-minded doctors, who knew only too well that a charity specifically dedicated to alleviating the suffering of such people was a health priority.

Their inaugural mission statement was unequivocal:

“Recognising that rheumatic disease in its various forms causes grave suffering and loss to humanity, and recognising that more knowledge regarding its origins and treatment is urgently needed, the Empire Rheumatism Council is hereby constituted with the aim of enrolling the forces of medical science throughout the British Empire for research into the causes of, and the means of most effectively fighting, this enemy of human well-being.”

The war intervened, and it took a while for the medical establishment to recognise the importance of research into the condition of rheumatism. But by the 1950s the charity was firmly established, setting up the UK’s first and world’s third Chair of Rheumatology at the University of Manchester in 1953, and the following year setting up what is now its renowned epidemiology unit, also in Manchester. Crucially, in 1950, the speciality of rheumatology was recognised by the Royal College of Physicians – a sign that musculoskeletal conditions as we know them today were being taken seriously by the medical profession.

The charity began to train doctors and medical students and to educate the public: its first booklet on rheumatoid arthritis was published in 1956; osteoarthritis followed two years later. Today there are more than 90. It started to fund hundreds of different research projects, investigating the entire spectrum of rheumatological conditions.

As a result of this, over the years there were numerous breakthroughs, although many drugs and treatments hailed widely at the time as miracle cures were later shown to have serious side-effects – steroids being the most obvious example. Although they enabled people crippled for years with rheumatoid arthritis to throw away their walking sticks, the high doses administered often led to osteoporosis – thinning of the bones.

From the 1950s and 60s, when aspirin became widely prescribed as a painkiller for people with rheumatoid and osteoarthritis, a spate of other tablets known as non-steroidal anti-inflammatory drugs (NSAIDs), were launched. Ibuprofen, naproxen and diclofenac, though not always effective, are predominantly safe and moderately effective in controlling the pain of arthritis. (However, the unacceptable side-effects of many NSAIDs, in particular the more recent COX-2 inhibitors, have meant that apart from paracetamol, there remains a huge gap in the market for a safe, effective painkiller to this day.)

On a more promising note, increasingly more effective disease-modifying drugs, such as methotrexate and sulfasalazine, became available for patients with rheumatoid arthritis in the 1970s, targeting the inflammatory process more effectively.

Research led down many new avenues and treatment has changed beyond what someone diagnosed in 1936 could have imagined. From the 1960s onwards it started to become known that it is neither simply a wear and tear condition, nor an inevitable part of the ageing process, but that there was a genetic component to osteoarthritis as well as environmental factors such as obesity and sports injuries.

Along the way, rheumatic fever was all but wiped out, gout can now be controlled and lupus – once almost certainly fatal – is now treatable in most cases. Ever since Sir John Charnley’s first-ever hip replacement was performed in 1962, joint replacement surgery has become hugely successful in reducing pain and increasing mobility, with 140,000 hip and knee replacements carried out every year in the UK.

Self-help messages to patients with osteoarthritis – encouraging them to lose weight, exercise more, avoid stress and keep positive – have done much to alleviate the sense of doom once sparked off by a diagnosis of arthritis. The concept of the stiff upper lip and suffering in silence has gone, to be replaced by a plethora of support groups.

From the 1970s onwards, scientists unravelled the mysteries of the immune system, and realised that rheumatoid arthritis and other inflammatory forms of the disease were caused by the body’s immune system attacking itself. This spawned the use of methotrexate and other drugs to dampen down the immune system.

Arthritis Research UK’s flagship research centre, the Kennedy Institute, which opened in 1967, was responsible for the charity’s biggest-ever success, as researchers found out more and more about how the immune system worked. Scientists Tiny Maini and Marc Feldmann won plaudits and honours galore, including knighthoods, for their “bench to bedside” research into the activities of a disease-causing molecule called tumour necrosis factor (TNF) that led to a whole new class of drugs called anti-TNF therapy, transforming the lives of people with rheumatoid and other types of inflammatory arthritis over the past decade.

More drugs are following on from this discovery, and the aim of developing much more targeted and tailored treatment aimed at providing “individualised medicine” is looking ever more likely. Many academics are on the record as saying it’s a hugely exciting time to be involved in arthritis research in 2011, and that Arthritis Research UK is leading the field in many areas. Medical director Professor Alan Silman has initiated numerous projects since his appointment in 2007, including new centres of excellence, several exciting clinical trials are asking very practical patient-orientated questions, and big genome screens are under way to find the genes that cause osteoarthritis, lupus and ankylosing spondylitis. New and exciting imaging techniques such as MRI and ultrasound, for example, have transformed our knowledge of what happens in arthritic joints.

Dr David Gould and Yuti Chernajovsky

As treatment changed, so did the charity’s name. In 1964 it became the Arthritis and Rheumatism Council, which remained until 1998 when it was re-named the Arthritis Research Campaign. In 2010 under the new moniker Arthritis Research UK, complete with new logo and new sense of direction, it was decided to extend the remit to campaigning and lobbying the Department of Health to take arthritis more seriously, and ultimately to make it an official government health priority.

At the same time, new chief executive Dr Liam O’Toole announced that the time was ripe to take the charity to the next level: to raise its profile and that of arthritis and musculoskeletal conditions, to dramatically increase income and to spend more money on research that had a direct patient benefit. The charity has also published ten ambitious goals aimed at improving patients’ lives by 2020.

In 2011 Professor Silman is preparing a new five-year research strategy, which encompasses the charity’s goals in a number of important areas, including keeping more people active and free from pain, harnessing the potential of stem cells, reducing the economic impact of arthritis, and developing new treatments. Seventy-five years on, so much has been achieved, but there is still so much more to do – and the charity is up to the challenge.

• Arthritis Today will report more fully on the new research strategy in the April edition.

Some major milestones:

Empire Rheumatism Council founded, later to become Arthritis Research UK

First British trial into the use of cortisone (steroids) in rheumatoid arthritis

First hip replacement performed

The first central bank of DNA material pioneered

We established obesity as a major risk factor for developing osteoarthritis of the knee

Licensing of the first anti-TNF therapy for rheumatoid arthritis

Early experimental work to develop tissue engineering techniques to regenerate areas of damaged cartilage

Our pioneering arcOGEN genome screening programme established to find out which genes cause osteoarthritis

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