suffering from Athritis?
Types of Arthritis
Facts about Arthritis
What is osteoarthritis? What are the causes?
Osteoarthritis (OA) is the most common form of arthritis, affecting over 20 million people in the United States alone. By the age of 50, most people have some signs of osteoarthritis. Before age 45, osteoarthritis is more common in men. After age 55, osteoarthritis is more common in women.
Osteoarthritis is also known as degenerative osteoarthritis. It is caused by a degeneration of the cartilage in joints. Cartilage is a remarkable substance. It glides on itself smoother than ice on ice, providing for smooth seemless motion of the joints. At the same time, cartilage is able to function as a shock-absorber between the joints. As with any shock-absorber, repetitive use year after year takes its toll, causing the cartilage to become irritated, inflamed, and ultimately degenerated. When cartilage degenerates, its cushioning and lubricating effects are diminished and friction is created between bones. In severe cases of osteoarthritis, the cartilage is essentially gone and bones grate directly on bone. As the cartilage degenerates, irritation, inflammation, pain, and loss of range of motion occurs within the joint itself. The patient experiences this as pain and stiffness. In response, to bone rubbing on bone, new bony outgrowths called bone spurs may develop in and around the joint. These bony outgrowths can be an additional cause of irritation and inflammation (and thus further pain) to the joint and surrounding soft tissues.
The joints that are most commonly affected by osteoarthritis are the hands, wrists, feet, and major weight-bearing joints such as the hips, knees, and spine. These joints bear the brunt of repetitive trauma throughout oneís life and are therefore subject to the most stresses on the cartilage.
Most cases of osteoarthritis are caused by daily mechanical stresses from wear and tear. The ex-football player who develops arthritis in his lower back and knees. The ex-pitcher who develops arthritis in his shoulder. The ex-ballerina who develops arthritis in her hips. These are excellent examples and are termed primary osteoarthritis. However, some cases of osteoarthritis are caused by an identifiable inciting cause. These cases of osteoarthritis are termed secondary osteoarthritis. Conditions that result in secondary osteoarthritis include obesity (the increased weight places increased stresses on the joints), a history of trauma or surgery to a joint, history of joint infection, bone disease, gout, pseudogout, diabetes, and congenital joint abnormalities.
How is osteoarthritis diagnosed?
There is no blood test, radiograph, physical exam test, biopsy or other medical test that can in and of itself diagnose osteoarthritis. Instead, your physician must listen to your story, take some tests, and ultimately put your whole picture together to determine if you have osteoarthritis and, more importantly, if it is the cause of your pain and/or stiffness. The most important part of the diagnosis of osteoarthritis is the history that you give your doctor about your symptoms. Unlike other forms of arthritis, osteoarthritis does not cause systemic illness such as fever, fatigue, and weight loss. The most common symptom of osteoarthritis is joint pain that is worse after prolonged activity. Often, people with osteoarthritis will also complain of pain and stiffness in the morning or after prolong inactivity (watching a movie or taking a nap). This pain and stiffness will typically get better after 10-30 minutes. Once the joints are ďwarmed-upĒ the pain and stiffness tend to resolve. However, after performing an activity such as walking, hiking, playing tennis, or using the affected joint for a prolonged period (playing the piano in hand osteoarthritis), the joint will become painful and stiff. In severe osteoarthritis, the joint may be painful even at rest.
Your doctor may take blood tests to exclude other potential causes of your joint pain. An arthrocentesis may also be performed. This is a test in which a needle is inserted into the affected joint and the joint fluid is aspirated. This fluid is then analyzed in a laboratory to also exclude other causes of joint pain including gout, pseudogout, infection, as well as other causes. Most commonly a radiograph (x-ray) may be taken of the affected joint. Common findings on x-ray evaluation indicative of osteoarthritis include joint space narrowing and bone spur formation, and subchondral cysts. An x-ray is very good at showing bones but is not able to visualize cartilage. However, it is important to realize that many people over the age of 50 will have evidence of osteoarthritis on x-ray even if they donít have any symptoms. Furthermore, the degree of osteoarthritis on x-ray does not necessarily correlate with the severity of symptoms that the person may be experiencing. Some people will have very osteoarthritic appearing x-rays but be pain free. The x-rays provide important clues to your diagnosis. But they are just clues. It is very important for your health care provider to always treat you and not just your x-ray.
Other tests that your doctor may consider, depending on your symptoms, include a bone scan to help rule out other potential causes of your pain such as cancer or bone infection (osteomyelitis).
How is osteoarthritis treated?
There are many methods of symptom reduction, and possibly even disease modification for osteoarthritis.
Weight reduction: If you are overweight or obese, weight reduction is very important. Increased weight puts continual stress on your joints. If overweight patients decrease their weight, they often notice a marked improvement in symptoms.
Avoiding painful activities: It is also important to eliminate or reduce activities that cause excessive pain. In osteoarthritis, pain is a good guide as to what you should and should not be doing. If you jog every morning and jogging causes a great deal of pain, it is important to limit that activity. Try doing the offending activity fewer times per week and replacing it with other less painful activities. Topical sprays and other pain relieving modalities may help decrease the pain and allow you to participate in more activities.
Diet: There are specific, anti-inflammatory diets that may be very helpful in decreasing the symptoms of arthritis. Basic principles of the diet include eating more fruits and vegetables and consuming more omega-3 fatty acids (e.g. small, cold water fish, green leafy vegetables) and less omega-6 fatty acids (e.g. red meat).
Rest: Resting the painful joint or joints for very short periods of time, using ice or heat, allows the inflammation a chance to quiet down.
Exercise: While rest and avoidance of painful activities is important, it is also very important that you do not become inactive. Exercise is excellent not just for your osteoarthritis but for your health in general. Most forms of exercise do not aggravate osteoarthritic symptoms when performed at moderate intensity levels. Swimming and other aquatic exercises is a terrific way to exercise. When you are in the water, the effect of gravity on your joints is counterbalanced and your joints do not undergo the same stresses as they do on land. Cycling, running on an elliptical machine, and other non-impact activities are particularly well-suited for people with osteoarthritis. The elliptical machine or other weight-bearing exercise is especially beneficial because it will help to build bone mass and fight osteoporosis. Be sure to consult with your individual doctor for an exercise regimen that is right for you.
Ergonomic aids: People with osteoarthritis are at increased risk for developing daily pains. Therefore, it is that much more important to focus on body biomechanics at home and at work. Simple things like a properly adjusted chair and work station are very helpful. A back support made of memory foam, or other adjustable back support such as one with air support can also be helpful to provide support that contours your lower back. See the article on pain relief for further details.
Beds: Spending a third of your life in your bed, you can understand how important it is to sleep on a bed that properly contours to your back and provides you with the needed support in the curves of your spine without putting too much pressure on your hips and shoulders. www.beds.org is an organization started by physicians to objectively evaluate beds to determine if they properly support a personís back.
Supportive Devices: For some people, a supportive device such as a cane, walker, splint, or brace may be helpful. People with hip osteoarthritis often use a cane to help unload stress from the hip joint. In this case, the cane should be used in the hand opposite the painful hip (e.g. cane in right hand for left hip pain). If indicated, your doctor and/or physical therapist will fit you for a cane and instruct you on how to use it.
Physical therapy: It is important to stretch and strengthen your core muscles in your trunk and spine as well as the muscles surrounding the painful joint or joints. By strengthening your core muscles, you improve your posture, use your body more efficiently, and ultimately decrease unnecessary load on your individual joints. In a similar manner, strengthening the muscles around the painful joint(s) takes the load off the joint(s). Stretching and keeping limber is likewise important because contracted, tight, or stiff muscles pull unnecessarily on your joints causing increased wear and tear.
Occupational therapy; Occupational therapists are particularly suited to help with hand splints and other splints and exercises to help with activities of daily living.
Modalities: Your physician, chiropractor, physical therapist, and/or occupational therapist may use modalities as part of their treatment for you. These include ultrasound, heat, ice, electrical stimulation, and massage. Heat and/or ice may be helpful for you to use at home before and after activities. Certain heating pads are available that you can fit over your hands and feet. Some patients find these particularly useful. If you are considering a heating pad, you may consider getting one with herbal aromatherapy built in as many patients find this very soothing. If you have impaired sensation from a peripheral neuropathy or other cause, only use heating and cooling pads under a doctorís supervision.
Topical Analgesics: The advantage of a topical analgesic is that it is not systemically absorbed in the same way as an oral medication, and thus they tend to have far fewer side effects. Topical sprays may be optimal as they tend to be less messy and more pleasant to use without sacrificing the important analgesic properties. See the article on Pain Relief for further discussion in this regard.
Oral Supplementation: Certain supplements have been found to be very effective for treating osteoarthritis. Glucosamine and chondroitin sulfate have evidence to support their use in the treatment of the symptoms of osteoarthritis. MSM may also be helpful. Fish oil supplements and tart cherry supplements may also be beneficial. These supplements may interfere with medications you are already taking. Check with your physician to discuss which supplement may be right for you.
Oral medications: You should always check with your physician before starting any medication. Even mild pain relievers such as acetaminophen (Tylenol) can be dangerous in people with liver conditions and other medical problems. However, in general, acetaminophen is well tolerated in low dosages and is effective for certain people with mild to moderate symptoms of osteoarthritis.
Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuopren and naproxen also may reduce pain and inflammation. The problem with these medications is that they may cause stomach problems, increase blood pressure, and cause kidney problems. Meloxicam (Mobic) is an NSAID that requires a doctorís prescription and may be useful for the pain caused by osteoarthritis.
Recently, Cox-2 inhibitors have received a lot of attention. Cox‑2 inhibitors are similar to NSAIDs but are designed to reduce stomach side effects. Cox-2 inhibitors require a doctorís prescription. Examples of Cox-2 inhibitors include Celebrex, Vioxx, and Bextra. First, these medications received attention because they seemed to reduce pain better than NSAIDs without many of the potential side effects of NSAIDs. Next, these medications received media attention because they were feared to cause even more side effects. Vioxx and Bextra have since been pulled from the market and Celebrex remains under increased scrutiny. The true picture of benefit-to-side effect ratio may be more complicated and will be discussed in another section. As with any medication, consult your doctor before starting Cox-2 inhibitors.
Tramadol (Ultram) is another medication that can be used for the pain of osteoarthritis. Tramadol is a prescription medication that is also packaged in a combination form with acetaminophen. This combination pill is called Ultracet. Ultram and Ultracet are generally well tolerated and can be used for mild-severe pain. A benefit of Ultram and Ultracet over narcotics is that they donít have as much sedating qualities as narcotics. Also, Ultram and Ultracet do not carry the same addictive qualities as do narcotics. All medications, without exception, have some potential side effects and you should consult your doctor before starting them.
Cortisone is a potent anti-inflammatory agent but oral cortisone is generally not used for treating the pain and inflammation of osteoarthritis.
Because of the side effects of oral medications, topical sprays and oral supplements with generally well tolerated supplements such as glucosamine, chondroitin, tart cherries, MSM, and fish oils may be preferable. Talk to your physician for individual recommendations.
Injections: For people with knee and/or hip pain from osteoarthritis, there are two types of injections that your doctor may offer you. Both injections involve your doctor placing a needle, under sterile conditions, into the affected joint. A corticosteroid injection introduces the steroid directly to the site of inflammation. Steroids are powerful anti-inflammatory medications. Because steroids cannot be repeatedly injected more than 3-4 times per year, these injections are reserved for moderate-severe pain. Another injection procedure is an injection series of hyaluronic acid (e.g. Synvisc, OrthoVisc, Euflexxa, Hyalgan). Hyaluronic acid is a fluid substance that bathes the joint and keeps it well lubricated. It can be injected into the affected knee, hip, or shoulder. Currently, it is typically only injected into the knee in most clinics. However, academic institutions are experimenting with the injection for hip and shoulder osteoarthritis as well. When it is injected into the hip or shoulder it is generally injected under x-ray or ultrasound guidance. Many patients receive good pain relief with these injections. However, the relief is temporary and the injections will generally need to be repeated periodically. As with any injection procedure, there is always a small risk of bleeding and infection. For this reason, it is important that your doctor use sterile technique and that you have an open discussion with your doctor about the potential risks and benefits.
Surgery: When symptoms of osteoarthritis become severe and interfere with your activities of daily living, it may be reasonable to consider surgical intervention. The ability of surgery to effectively treat an osteoarthritic joint depends to a great extent on which joint is involved. Hips and knees that suffer from severe osteoarthritis may respond well to surgical replacement of the affected joint. Total hip replacement and total knee replacement surgery are becoming more common and the techniques and replacements continue to improve. However, surgical intervention always comes with risks and conservative treatments should be exhausted before surgery is pursued. The sooner that conservative intervention is begun, the better. Donít wait for your symptoms to get severe before making an appointment and going to see your doctor to discuss how you can treat your more mild symptoms before they become severe. Discuss with your doctor if a surgical intervention is appropriate for you.
Author: Grant Cooper, M.D., Department of Physical Medicine and Rehabilitation, New York-Presbyterian Hospital, The University Hospital of Columbia and Cornell, New York City, NY