Make no bones about arthritis therapy

Tyrone M. Reyes, M.D.

If you are in your 60s, it’s a good bet that you have osteoarthritis. If you are in your 80s, it’s a sure thing. In fact, if you take an x-ray of the hips or knees of people over age 50, you’ll probably see signs of arthritis in many of them. But some people with severe damage can be as frisky as those decades younger, while others with only modestly damaged joints call the pain and disability unbearable. “Arthritis affects everyone differently,” says Peter Juni, MD, an expert on joint disease at the University of Berne in Switzerland. “How you experience it depends on not just the joint damage but your emotional health, weight, pain tolerance, activities, and willingness to participate in your own care, among other things,” he says. Research suggests that some doctors may downplay joint pain that’s not confirmed by x-rays, while others may recommend invasive procedures if they see severe joint damage. But since arthritis pain and disability are so subjective, only you — upon consultation with your physician — can decide how aggressively to treat it. As my former professors in medical school used to tell us, “Treat the patient, not the x-rays!”

Your preferences and responses to treatment count strongly for other reasons as well. For one thing, people respond very differently to the various options, especially alternative ones, depending partly on whether they expect the treatments to work and are willing to follow the necessary steps. Moreover, all arthritis medications pose health risks, especially to the gut, heart, liver, and kidneys. So you need to choose drugs based on your vulnerability to those risks vs. your need for relief. Similarly, deciding to delay surgery for joint replacement until you can’t bear the pain, or instead to have it sooner as some other experts now recommend, depends on whether you’d rather put up with the arthritis or the operation and the often intensive physical therapy treatments that follow.

“Effective arthritis care usually means mixing and matching from the various options until you find the combination that works best for you,” Dr. Juni says. Today’s article will hopefully help you do just that.

First Step: Limit The Damage

Effective osteoarthritis treatment starts by addressing the many factors that help determine whether the joint damage translates into significant pain and disability. For example, try to lose any excess weight, since it increases stress on damaged joint. In addition, the following steps can help ease the strain from routine tasks like walking, sitting, and sleeping:

• Wear low-heeled shoes that provide firm support.

• Avoid sitting in low or armless chairs, since getting up from them can be difficult, and don’t carry heavy objects for long distances.

• Keep warm; the cold can stiffen joints.

• Don’t sit or stand in one position for extended periods.

• Try not to lie on your affected hips while sleeping. Whichever side you sleep on, place a pillow between your legs to keep your legs aligned. For knee pain, lay a pillow lengthwise under your leg, centered beneath the joint, to elevate it.

• When possible, avoid walking up or down stairs or hills, or on uneven surfaces.

• Talk to your doctor about using a joint brace, special shoe insoles, or a cane during certain activities or exercises.

While people with arthritis should limit the stress on their joints, regular activity is crucial. The following guidelines can help ensure safe, effective exercises:

• Avoid high-impact activities, such as running, or vigorous, twist-and-turn sports, such as singles tennis.

• Do at least some weight-bearing exercise, which eases pain and improves function, possibly by squeezing fluid into the spongy cartilage. Any relatively gentle activity — walking, tai-chi, biking, even ballroom dancing — will do.

• Try swimming or water aerobics if you have severe arthritis. It doesn’t let your joints bear much weight.

• Stretch regularly to keep muscles loose.

• Try applying heat before exercise and cold afterward to see if that helps.

• Or, ask your physician for a referral to a rehab doctor to learn exercises that strengthen the muscles supporting the damaged joints.

Alternative Therapies

Research has identified several alternative treatments that may help at least some people with arthritis and are almost certainly safe for most. Other evidence suggests that people get more relief from alternative therapies that they trust. If you want to try nontraditional methods, here are the main options:

• Acupuncture. A recent review of clinical trials concluded that acupuncture treatments relieved knee arthritis at least somewhat for up to a year.

• Capsaicin. Over-the-counter creams or gels that contain capsaicin (Zostrix and generic), derived from the pepper plant, seem to provide some relief.

• Glucosamine and chondroitin. These nutritional supplements supposedly prevent cartilage from breaking down. Scientific results had been mixed with European studies showing better results than those in the United States. In a survey published in 2005, however, 2,000 people who tried the combination, found that it eased arthritis symptoms at least as effectively as over-the-counter drugs.

Drug benefits vs. Risks

Expert guidelines recommend that most people who have arthritis should start with acetaminophen (Tylenol and generic), since it’s generally the safest. If that’s not adequate, they should then try an over-the counter nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen (Advil and generic), and, if necessary, higher-dose prescription versions of those drugs, such as naproxen (Naprosyn), which may pose less heart risk than other NSAIDs and appears less likely to undermine aspirin’s cardiac benefits. But there are many exceptions, depending on how susceptible you are to side effects and whether the recommended drugs give adequate relief. Talk to your doctor about which drug is most effective and safest for you.

Invasive Procedures

Various injections and surgical procedures can often help if drugs and lifestyle changes don’t. But they also have drawbacks that you must balance against your need for relief.

• Injections. Shots of anti-inflammatory steroids and possibly the joint lubricant hyaluronic acid (Hyalgan, Synvisc, and others) seem to relieve knee arthritis symptoms in many patients. But the benefits of the steroid shots dwindle after about a month, requiring further injections. Hyaluronic acid, which requires weekly injections (three to five weeks), may provide longer relief, though the benefit is modest and the supporting evidence weak. And it’s not clear whether repeatedly undergoing either of those treatments is safe and effective.

• Joint replacement. You should consider discussing joint replacement with an orthopedic surgeon if:

• Medications no longer relieve the pain or produce unacceptable side effects.

• The pain makes it hard to sleep.

• You have trouble with your routine actions, such as getting out of a chair or off the toilet, climbing stairs, or bathing.

• The pain prevents everyday activities, such as visiting friends, shopping, traveling, or doing low-impact exercises.

Doctors have traditionally recommended delaying joint replacement as long as possible to avoid a second operation if the first artificial joint wears out, typically about 15 years. But recent improvements in implant design and materials have made that less of a concern. Other pieces of evidence, including a survey in the US in 2006, which included about 1,000 people who had the operation, suggest that waiting until damage is severe makes surgery harder and full recovery less likely. And earlier intervention may allow your surgeon to perform a less invasive surgery, which allows for faster recovery, lesser post-operative pain, and better functional outcome.

But even in the best of cases, joint replacement is expensive, recovery takes weeks, and it requires extensive physical therapy. And five to 15 percent of those in the survey, all of whom had total joint replacement, said they developed complications, including infection, muscle weakness or contracture, and unequal leg lengths. If you opt for joint replacement, look for a surgeon with good experience in this type of surgery, and arrange for someone to care for you during the first week or two after surgery.

Post-operative rehabilitation is very important. Indeed, the desire to stay put after undergoing major surgery, such as total joint replacement, is understandable but unfortunate. The 2006 survey found the patients who said they “completely” complied with exercises and physical therapy treatments were less likely to need long-term pain medication, had fewer recovery complications, and walked sooner on their own.

In arthritis therapy, as in the treatment of other medical conditions, your personal preference and decision play a key role in choosing the best treatments for you.

Source: Philippine Star