What you should know about osteoarthritis
September 19, 2006 | 12:00am
Arthritis is one of the leading causes of pain and disability in the Philippines, and osteoarthritis (OA) is far and away the most common type. In fact, the number of osteoarthritis cases is expected to virtually explode in the next 25 years as baby boomers start to develop this age-related disease, which will force them to limit their daily activities. It is estimated that the number of arthritis cases will rise by nearly 40 percent by 2030 and the disease will not be limited to the geriatric set then – one-third of the arthritis cases at that time will be people aged 45 to 64. And since the baby boomers are still very active and obesity is also an increasing problem worldwide, these two factors might well push the number beyond that prediction.
One other factor that might push the number of arthritis cases even higher: old sports injuries. Consider this: researchers have become increasingly concerned about young female athletes who injure a knee while playing soccer or basketball. A 2004 study published in the journal Arthritis & Rheumatism suggests that young women with such injuries are now developing an aggressive form of OA.
OA is a chronic disorder. It has never been cured, and there is no well-established way to slow its progression. But therapy can provide comfort and preserve function.
Lifestyle measures should be part of every treatment program. Patients who are overweight should reduce, and everyone with OA should eat a healthful, balanced diet and maintain good general health. Because mechanical stress increases the pain of OA, patients should avoid high-impact exercise and other activities that trigger pain.
Rest makes arthritic joints feel good, but in the long run, exercise is better. General aerobic conditioning is very important, and low-impact exercise is best. Swimming and other aquatic exercises provide cardiovascular conditioning and flexibility training without the stress of bearing weight. Walking, biking, elliptical trainers, and rowing machines are also desirable. Gentle stretching and yoga help by improving flexibility. Resistance exercises keep muscles strong, often taking pressure off joints. People with mild OA can get started on their own exercise program but patients with more serious OA (or other medical problems) should consult with a rehab doctor and should preferably be supervised by a physical therapist.
Many patients with OA feel better after applying heat or cold. A warm shower or bath can help loosen things up in the morning, and warm packs may also promote comfort. Applying cold packs to an acutely aching joint for 10 to 20 minutes can cut down on inflammation and pain, particularly after exercise.
There are ointments, sprays and liniments that produce warming or cooling and those containing anti-inflammatory medications. Capsaisin (Zostrix, ArthriCare) is an irritant derived from chili peppers that appears to provide relief by depleting a chemical that transmits pain from nerve endings. It causes a burning sensation and should be applied wearing gloves.
Until 1997, supplements were obscure preparations used in veterinary medicine. Then The Arthritic Cure burst on the scene, and glucosamine and chondroitin sulfate were in the big time. Doctors were skeptical of yet another unregulated dietary supplement with extravagant claims of medical benefit. But that skepticism didn’t stop them from investigating the products. In fact, glucosamine and chondroitin are among the few supplements that have been studied carefully, and the studies do suggest that while they are far from a cure, they can reduce the pain of OA, at least in some patients. (More on glucosamine and chondroitin in next week’s column). Other supplements have been advocated as treatments for OA. They include S-adenosyl-L-methionine (SAMe), ginger, dimethyl sulfoxide (DMSO), and cetyl myristoleate. At present, there are not enough reliable studies to permit an evaluation of the safety and efficacy of these products.
After decades of doubt and even division, doctors now recognize that acetaminophen (Tylenol and other brands) can often reduce the pain of OA. It’s an over-the-counter medication, but people with liver disease should check with their doctors. To be safe, people who take acetaminophen regularly should keep their alcohol intake low and should eat well.
If acetaminophen fails to relieve the pain, an anti-inflammatory medication is usually the next step. Two categories are available, the traditional nonsteroidal anti-inflammatory drugs (NSAIDs) and the newer, more controversial selective COX-2 inhibitors (coxibs). Examples of NSAIDs are aspirin, diclofenac (voltaren, cataflam), ibuprofen (Advil, Motrin), naproxen (Naprosyn, Aleve), piroxicam (Feldene) and others. An example of a relatively selective (target COX-2 more than COX-1) anti-inflammatory is meloxicam (Mobic). Two coxibs are available in the Philippines, celecoxib(Celebrex, Coxid) and etoricoxib (Arcoxia).
Pick the least expensive preparation that works for you and use the lowest dose that provides relief. Above all, be alert for side effects. Gastric irritation and intestinal bleeding are the most common worries; patients who are particularly vulnerable should ask their doctors about adding a proton pump inhibitor such as omeprazole (Losec), esomeprazole (Nexium), pantoprazole (Ulcepraz), and others.
Patients with high blood pressure or kidney disease require medical supervision and monitoring. In fact, it was the cardiovascular risks that led to the withdrawal of two popular coxibs, rofecoxib (Vioxx) and valdecoxib (Bextra).
Corticosteroids are the most powerful anti-inflammatory drugs. If needed, steroids can be injected directly to an inflamed joint, often combined with a local anesthetic. Clinical trials document substantial pain reduction, particularly for painful flares of knee OA, but the benefit wears off in weeks to months. Still, if a steroid injection seems to help, it can be repeated up to three or four times in the course of a year.
Hyaluronic acid is a natural constituent of cartilage and the joint capsule, providing lubrication and elasticity. The US FDA has approved injections of hyaluronic acid (Hyalgan, Synvisc) for OA of the knee. Depending on the preparation, the drug is injected once a week for three to five weeks. Unfortunately, the benefit is modest; and the pain returns after several weeks or months.
In most cases, surgical treatment is reserved for patients with marked OA who have failed to improve with conservative treatments, but in which surgery can provide important benefits. Several approaches are available. Arthroscopy was very popular for OA of the knee until a 2002 trial showed it was not beneficial. An osteotomy may help slow the progression of OA. Arthrodesis, or joint fusion, is usually reserved for the spine or small joints of the foot, hand and wrist; the operation reduces pain but impairs flexibility.
The most successful operation for advanced OA is arthroplasty, or total joint replacement. Artificial hip and knee joints were the first to be developed and new techniques and materials have made joint replacements highly successful, and they continue to improve (see illustration). It results in marked pain relief, greater functional improvement, and a much better quality of life for many patients.
OA is as old as humankind, and as people live longer it has become more and more troublesome. But new therapies hold real promise. Scientists have begun experimenting with cartilage grafts and transplants. New medications may be able to slow its progression and provide better relief. And artificial joints are getting better.
Still, we’d all do well to remember the basics: maintain a healthy body weight; get the right exercise, avoid joint injuries, and get good nutrition.
We cannot cure arthritis but with proper care and treatment, we can continue to live a comfortable and functional life for a long, long time.
One other factor that might push the number of arthritis cases even higher: old sports injuries. Consider this: researchers have become increasingly concerned about young female athletes who injure a knee while playing soccer or basketball. A 2004 study published in the journal Arthritis & Rheumatism suggests that young women with such injuries are now developing an aggressive form of OA.
Lifestyle measures should be part of every treatment program. Patients who are overweight should reduce, and everyone with OA should eat a healthful, balanced diet and maintain good general health. Because mechanical stress increases the pain of OA, patients should avoid high-impact exercise and other activities that trigger pain.
Rest makes arthritic joints feel good, but in the long run, exercise is better. General aerobic conditioning is very important, and low-impact exercise is best. Swimming and other aquatic exercises provide cardiovascular conditioning and flexibility training without the stress of bearing weight. Walking, biking, elliptical trainers, and rowing machines are also desirable. Gentle stretching and yoga help by improving flexibility. Resistance exercises keep muscles strong, often taking pressure off joints. People with mild OA can get started on their own exercise program but patients with more serious OA (or other medical problems) should consult with a rehab doctor and should preferably be supervised by a physical therapist.
Many patients with OA feel better after applying heat or cold. A warm shower or bath can help loosen things up in the morning, and warm packs may also promote comfort. Applying cold packs to an acutely aching joint for 10 to 20 minutes can cut down on inflammation and pain, particularly after exercise.
Until 1997, supplements were obscure preparations used in veterinary medicine. Then The Arthritic Cure burst on the scene, and glucosamine and chondroitin sulfate were in the big time. Doctors were skeptical of yet another unregulated dietary supplement with extravagant claims of medical benefit. But that skepticism didn’t stop them from investigating the products. In fact, glucosamine and chondroitin are among the few supplements that have been studied carefully, and the studies do suggest that while they are far from a cure, they can reduce the pain of OA, at least in some patients. (More on glucosamine and chondroitin in next week’s column). Other supplements have been advocated as treatments for OA. They include S-adenosyl-L-methionine (SAMe), ginger, dimethyl sulfoxide (DMSO), and cetyl myristoleate. At present, there are not enough reliable studies to permit an evaluation of the safety and efficacy of these products.
After decades of doubt and even division, doctors now recognize that acetaminophen (Tylenol and other brands) can often reduce the pain of OA. It’s an over-the-counter medication, but people with liver disease should check with their doctors. To be safe, people who take acetaminophen regularly should keep their alcohol intake low and should eat well.
If acetaminophen fails to relieve the pain, an anti-inflammatory medication is usually the next step. Two categories are available, the traditional nonsteroidal anti-inflammatory drugs (NSAIDs) and the newer, more controversial selective COX-2 inhibitors (coxibs). Examples of NSAIDs are aspirin, diclofenac (voltaren, cataflam), ibuprofen (Advil, Motrin), naproxen (Naprosyn, Aleve), piroxicam (Feldene) and others. An example of a relatively selective (target COX-2 more than COX-1) anti-inflammatory is meloxicam (Mobic). Two coxibs are available in the Philippines, celecoxib(Celebrex, Coxid) and etoricoxib (Arcoxia).
Pick the least expensive preparation that works for you and use the lowest dose that provides relief. Above all, be alert for side effects. Gastric irritation and intestinal bleeding are the most common worries; patients who are particularly vulnerable should ask their doctors about adding a proton pump inhibitor such as omeprazole (Losec), esomeprazole (Nexium), pantoprazole (Ulcepraz), and others.
Patients with high blood pressure or kidney disease require medical supervision and monitoring. In fact, it was the cardiovascular risks that led to the withdrawal of two popular coxibs, rofecoxib (Vioxx) and valdecoxib (Bextra).
Hyaluronic acid is a natural constituent of cartilage and the joint capsule, providing lubrication and elasticity. The US FDA has approved injections of hyaluronic acid (Hyalgan, Synvisc) for OA of the knee. Depending on the preparation, the drug is injected once a week for three to five weeks. Unfortunately, the benefit is modest; and the pain returns after several weeks or months.
The most successful operation for advanced OA is arthroplasty, or total joint replacement. Artificial hip and knee joints were the first to be developed and new techniques and materials have made joint replacements highly successful, and they continue to improve (see illustration). It results in marked pain relief, greater functional improvement, and a much better quality of life for many patients.
Still, we’d all do well to remember the basics: maintain a healthy body weight; get the right exercise, avoid joint injuries, and get good nutrition.
We cannot cure arthritis but with proper care and treatment, we can continue to live a comfortable and functional life for a long, long time.
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