ARTHRITIS PAIN: TREATMENT OF OSTEOARTHRITIS

Osteoarthritis cannot be cured but it can be treated. A rheumatologist can design a treatment program to help manage the condition. Beginning treatment as early as possible can help reduce long-term damage to the joints and bones. The goal of treatment is to reduce pain and stiffness, allow for greater movement, and slow the progression of the disease. A combination of several of the following treatments usually works best. It can take time to find the most effective combination. Work with your doctor to develop the treatment plan that will be most helpful for you.

Weight Loss

Weight loss and exercise are usually the first treatments recommended for osteoarthritis. Losing weight can help relieve the pressure and strain on your joints, thereby reducing the damage to tissues inside the joint. Weight loss can also help reduce pain and stiffness in the affected joints, especially the joints in the hips, knees, back and feet. Avoiding weight gain as you get older or losing excess weight can help prevent osteoarthritis or reduce your symptoms.

Exercise

Regular exercise can be very effective for relieving the pain and stiffness of osteoarthritis and may help slow the progression of the disease. Exercise also helps you reach or maintain a healthy weight, which reduces stress on your joints. Pick an exercise program that works for you and fits your lifestyle and physical abilities. Doctors generally recommend a combination of stretching exercises, mild strengthening exercises (such as lifting weights), and low-impact aerobic exercises (such as swimming, walking or bicycling).

Physical and Occupational Therapy

Your doctor may recommend that you work with a physical therapist to prevent or reduce joint stiffness. A physical therapist will help you improve the range of motion in your affected joints and strengthen the muscles around the joints to give the joints support. He or she can also provide splints, canes, crutches, walkers, and other mobility aids if you need them.

An occupational therapist will help you learn new ways to perform everyday activities such as bathing, dressing, walking and climbing stairs. You will learn to move in ways that reduce discomfort and put less strain on your joints. An occupational therapist can help you make changes in your home or office that will enable you to get around and perform routine tasks more easily and safely.

Hot and Cold Treatments

Applying heat or cold directly to the affected joints can temporarily relieve pain, stiffness and occasional swelling. Finding the most effective treatment for you may require trial and error. Do not apply either heat or cold for longer than 20 minutes at a time, and allow your skin to return to normal temperature between applications. Do not use pain-relieving creams or rub your skin when using hot or cold treatments; you could injure your skin and not realize it because your sensation of pain is reduced.

Heat is usually used to relax muscles and warm them up before exercising. Heat up your sore joints with a heating pad or hot pack or by sitting in a hot tub or heated pool. Many people who have osteoarthritis find that a hot shower in the morning is all they need to loosen their stiff joints.

Applying cold can be helpful for short-term pain relief. Cooling a sore joint reduces pain by numbing the area. Never apply ice or cold packs directly to your skin — wrap them in a towel first. Use cold treatments carefully; the lack of feeling may cause you to overuse the sore joint.

Medication

Because of the potential side effects of many drugs that are used for treating osteoarthritis, medication is usually recommended only after other treatments such as weight loss and exercise have been tried and have not been effective. Arthritis medications generally are used to reduce pain and tenderness in the joints. No drugs are available that can stop the progression of the disease or cure it.

Many medications that are used to relieve osteoarthritis pain are available over the counter; some of the stronger ones are available only by prescription. All drugs used to treat osteoarthritis can cause side effects. If you are taking a medication for arthritis, tell your doctor immediately if you have any unusual symptoms. You may not have any problems until after you have been taking the medication regularly for a long time.

Topical Medications
Creams, rubs, or sprays can be applied to the skin over a sore muscle or joint to temporarily relieve pain. Creams containing capsaicin (a substance found in hot peppers) reduce pain by blocking the ability of the nerve endings around the joint to send pain messages to the brain. Many of these medications are available over the counter. (Do not touch your eyes, nose or genitals after applying capsaicin cream.)

Pain Relievers
Drugs containing acetaminophen are usually prescribed for osteoarthritis because they don't cause stomach irritation like some other pain relievers such as aspirin. Acetaminophen is most effective when it is used regularly. However, acetaminophen does not relieve inflammation, and you should not take it regularly if you consume three or more alcoholic beverages a day because the combination can damage the liver.

Nonsteroidal Anti-inflammatory Drugs
Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, naproxen and ketoprofen are often used to relieve the pain and inflammation of osteoarthritis. Many NSAIDs are available over the counter, but stronger ones require a doctor's prescription.

Prescription NSAIDs such as celecoxib (in a class called cox-2 inhibitors) can be effective pain relievers for people with arthritis but have been linked with serious blood vessel and gastrointestinal problems. Before taking celecoxib (or any other NSAID) regularly for your arthritis pain, discuss the risks and benefits with your doctor. If you decide to use an NSAID, your doctor will probably prescribe the lowest effective dose for the shortest time possible to help relieve your symptoms.

Corticosteroids
Corticosteroids are sometimes given in injections to reduce the inflammation and pain of severe osteoarthritis. A doctor injects the corticosteroid directly into the affected joint. Because corticosteroids can cause serious side effects, such as damage to bones and cartilage, the injections are given no more than a few times a year.

Glucosamine and Chondroitin Sulfate
A combination of the over-the-counter supplements glucosamine and chondroitin sulfates may help relieve osteoarthritis pain and increase mobility. These supplements seem to work together to strengthen cartilage.

Viscosupplementation
Viscosupplementation is a nonsurgical procedure that is usually recommended for people with osteoarthritis who do not yet need surgery. In viscosupplementation, a doctor injects a sterile mixture of a synovial fluid substitute and saline solution into a joint (usually the knee joint) three times a day for two weeks. The synovial fluid substitute, which supplements the person's own synovial fluid, helps lubricate the joint and rejuvenate damaged cartilage. The procedure may have to be repeated.

Surgery

An orthopedic surgeon (a doctor who specializes in surgery on bones) can determine if surgery is necessary to relieve the pain from osteoarthritis and restore movement to a joint. Surgery is recommended only for severe, disabling osteoarthritis for which other treatments have been unsuccessful. (Most people who have osteoarthritis never need to have surgery.) If your doctor recommends surgery, get a second opinion from another doctor. Surgery may be done to prevent the joint from becoming deformed, to correct a deformity, to remove pieces of bone or cartilage from around the joint to allow greater movement, or to replace a damaged joint with an artificial one.

Arthroplasty
Artificial devices are available to replace almost any joint in the body. Arthroplasty, or joint replacement surgery, is most often done to repair hips and knees, but also is used to repair shoulders, elbows, fingers, ankles and toes. A successful joint replacement relieves pain and restores most of the joint's movement.

During joint replacement surgery, the surgeon first removes all the damaged bone from the joint. Artificial joint components made of metal and plastic are then cemented to the healthy bone that remains. The joint components are usually attached to the bone tissue with acrylic cement. For younger people who are more active or for older people who have strong bones, doctors sometimes use artificial joints that do not require cement to stay in place. These artificial joints are designed with spaces into which the person's own bone can grow, holding the artificial joint in place more naturally. By avoiding the use of cement, which can weaken over time, these types of artificial joints usually stay in place longer than those that are held in place with cement.

Recovery from joint replacement surgery depends on several factors, including a person's general health and level of activity before the surgery. For this reason, it is not a good idea to put off the surgery for long. The more active you are before your surgery, the faster your recovery is likely to be. Hip replacement and knee replacement surgery require more time for recovery than replacement of smaller joints, such as those in the fingers, wrists, toes, or ankles.

Although complications from joint replacement are rare, the new joint can become infected or slip out of place. For this reason, your doctor will ask you to come in regularly for checkups so that he or she can monitor your healing and recovery. To reduce the risk of blood clots, your doctor may prescribe anticlotting medication.

Joint replacement surgery is serious and will cause a short period of disability during recovery. Complete recovery can take from three to six months. Most people who have a hip or knee replaced will need physical therapy to help regain their mobility. A physical therapist will recommend special exercises to help you build up the muscles around your new artificial joint. Physical therapy starts in the hospital shortly after surgery and continues after you are home.

Hip Replacement
Hip replacement is a surgical procedure in which a damaged hip joint is removed and replaced with an artificial ball-and-socket joint made of metal and plastic. The procedure usually takes about two to three hours. You will be hospitalized for about a week after the surgery and will start physical therapy in the hospital. You will be encouraged to try to begin walking with support within a day or two after surgery. A physical therapist will teach you how to perform exercises to help strengthen the hip and teach you how to move the joint to avoid injuring your new hip.

At home, maintain a stretching and exercise program to help keep your new joint working properly. Full recovery can take up to six months, depending on your overall health, whether you have any complications (such as infection, blood clots, or joint dislocation), the success of your rehabilitation, and other factors. Hip replacements generally last from 15 to 20 years. Young and active people who have had hip replacements may eventually need to have surgery to repair or replace the artificial joint because of wear or loosening of the implant.

Arthrodesis
A surgical procedure called arthrodesis, or joint fusion, sometimes is used to correct severe joint problems caused by osteoarthritis. In this procedure, the surgeon makes the affected joint permanently immobile by using a bone graft and inserting metal screws, plates, and rods to hold the joint in place. Arthrodesis is performed only when the pain from osteoarthritis is so severe that immobilizing the joint is an improvement. This procedure is usually performed on smaller joints such as those in the fingers, toes, ankles or feet.

Osteotomy
Osteotomy is a surgical procedure most often performed on younger people who have a joint (usually a hip or knee) that has been unevenly damaged by osteoarthritis. The procedure is done to relieve stress on the cartilage and prevent further damage to the joint. During an osteotomy, the surgeon removes a small wedge of bone near the affected joint. Removing the piece of bone realigns the bone and improves the contact between the remaining, healthy areas of cartilage in the joint. In younger people, this procedure can delay joint replacement surgery for years.

Arthroscopy
Arthroscopy, or "scoping" a joint, is an outpatient procedure that is used to examine and sometimes repair joints. The procedure is performed most often on knees and shoulders but can be done on other joints including the hip. For arthroscopy, the doctor inserts a viewing tube (arthroscope) through a small incision into the fluid-filled space in the affected joint. Through the arthroscope the doctor can see any tissue damage and make necessary repairs. Although the repair may provide temporary relief of symptoms, it does not stop the progression of arthritis.

Cartilage Transplantation
Unlike bone, cartilage that is injured does not rejuvenate. Cartilage injuries commonly occur with ligament injuries. Damaged cartilage can increase friction in joints, sometimes leading to osteoarthritis. Cartilage transplantation uses live cells from donated cartilage. The donated cartilage must be transplanted within 72 hours. The graft is made of cartilage and bone (the person's bone heals into the donated bone supporting the cartilage).