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An Action Plan for Relieving Joint Pain

Osteoarthritis (OA), a disease characterized by degeneration of the cartilage that lines the joints, affects half of adults over age 65—or more than 20 million Americans. Sufferers typically experience joint pain, stiffness, and sometimes swelling. Symptoms can be so severe that it is difficult to walk, open a jar, comb hair, or perform a host of other ordinary daily activities. For the last few decades, therapeutic options have been limited to acetaminophen (Tylenol) or aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs). Recent advances have been so outstanding, however, that the American College of Rheumatology has issued new guidelines after just five years. Here is a distillation of the recommendations.

Try This at Home

Studies conducted over the last several years consistently show that exercise is one of the best remedies for OA. The guidelines highlight the importance of exercise as a way to maintain strength and flexibility, as well as to control pain. Toning muscles around an arthritic joint helps stabilize it. Range-of-motion exercises reduce stiffness and increase flexibility, while standard aerobic activities improve blood flow and reduce joint stress by controlling weight. Exercise also improves mental outlook, an important aspect of dealing with any chronic disorder.

In one study of older people who were mildly disabled by knee OA, exercise regimens that involved muscle strengthening or aerobics lessened pain and disability for more than a year. The magnitude of the improvement was directly related to how well participants stuck with their programs. Other research shows that using exercise to boost muscle strength, mobility, and coordination reduces the number of times OA sufferers need to visit the doctor.

Knowing when to rest joints is as important as knowing when to use them because overuse can lead to additional injury. In general, it's normal to be slightly sore the day after a workout. Soreness that lingers longer is an indication that you may be overdoing it. For those with significant pain, devices to rest or protect the joints may be helpful. Canes or braces reduce the pressure on the lower joints. Corrective footwear can be particularly useful for people with arthritic knees. Special shoes absorb shock; shoe inserts correct improper foot-knee alignment and improve stability. Heel wedges can lessen symptoms and delay or eliminate the need for knee replacement surgery in some patients by reducing the lateral thrust on the knee.

Other Self-Care Measures

Over the counter (OTC) analgesics are helpful for occasional mild to moderate aches and pains. Acetaminophen is generally preferred because it is less likely to cause stomach irritation than NSAIDs (aspirin, ibuprofen, ketoprofen, and naproxen). Unlike NSAIDs, however, acetaminophen does not have significant anti-inflammatory properties. Therefore, if swelling is present, NSAIDs may be the better option.

Hot and cold treatments can also ease pain and stiffness and may lessen the need for medication. Heat treatments are appropriate when inflammation is not evident. If inflammation is present, ice may be more effective. But hot and cold applications should not last more than 20 minutes at a time and should be stopped if the skin becomes overly red. Some people like to alternate hot and cold applications. In any case, be sure to put a towel between your skin and whatever hot or cold source you are using.

Topical creams, rubs, and sprays (such as capsaicin cream or methyl salicylate) can be applied directly to the skin for pain relief. Capsaicin cream can be particularly effective for knee pain. Keep in mind, however, that topical remedies must usually be applied a few times a day in order to obtain pain relief.

Research has shown that self-help programs, particularly the curriculum offered by the National Arthritis Foundation (NAF), can supplement a doctor's advice and improve the effectiveness of self-care measures. NAF classes are offered through local chapters and led by people with OA who have been specially trained to share practical tips about managing the disorder. A study in the Archives of Internal Medicine found that those who attend the NAF classes report significantly less pain and save nearly $300 per person in doctor visits over four years.

How a Doctor Can Help

It’s important for anyone with arthritis to consult a doctor before starting an exercise program or purchasing a protective device. A doctor can establish a safe level of exercise tailored to individual health needs and provide a referral to someone who can explain what exercises may be most beneficial and how to perform them correctly. Assistive devices and braces must also be chosen carefully and used properly since a poor fit or overuse can lead to injury.

It’s also important to consult a doctor if you are taking OTC analgesics more frequently than recommended on the product label, in order to avoid the possibility of stomach, kidney, or liver damage. Higher dose, prescription NSAID therapy is the next step. Although higher dosages and frequent use of these medications can cause gastrointestinal and kidney problems, they can be used safely with careful monitoring. Monitoring is especially important in people over age 60, who are four times more likely than younger adults to experience gastrointestinal bleeding or ulceration when taking NSAIDs. Adding a proton pump inhibitor-such as lansoprazole (Prevacid) or omeprazole (Prilosec), which are ordinarily prescribed for heartburn-can minimize the likelihood of gastrointestinal problems. NSAIDs can also interact with many common medications, including anticoagulants, corticosteroids, diuretics, and angiotensin converting enzyme (ACE) inhibitors.

The COX-2 inhibitors celecoxib (Celebrex) and rofecoxib (Vioxx) are alternatives for those who do not obtain adequate relief from NSAIDs or who cannot take them because of gastrointestinal bleeding problems. However, they should be used with caution in people with kidney disease, high blood pressure, and congestive heart failure. COX-2 inhibitors have been linked to a handful of deaths and to gastrointestinal bleeding episodes. In most cases, however, victims were taking other medications or had illnesses that could have precipitated these problems.

Opioids, such as tramadol (Ultram) or codeine, may be an option for those who do not respond to NSAIDs or COX-2 inhibitors. However, opioids are associated with side effects such as constipation, nausea, and drowsiness, as well as the possibility of dependence. Using the lowest effective dose and frequent monitoring can reduce the risk of these problems. Tramadol is less likely to cause dependency or side effects than codeine. Combining opioid therapy with acetaminophen or NSAIDs may be more effective than taking either type of medication alone.

When Pain Persists

Injections of a glucocorticoid (a type of steroid) or hyaluronic acid (a natural component of joints) can be particularly beneficial for OA-associated knee inflammation. Glucocorticoid injections relieve pain for about three weeks and can be given once every three months. The relief from hyaluronic acid injections can last up to a year. The procedure is appropriate for people who don’t obtain adequate relief from exercise, physical therapy, or analgesics.

When other therapies for hip and knee OA have been exhausted, surgery may be an option for those with persistent pain and limited movement. There are two options: arthroscopy (joint repair using endoscopic techniques) and arthroplasty (total joint replacement). Performed on an outpatient basis, arthroscopy involves making two or three small incisions around the joint and removing bits of bone and damaged cartilage floating within the joint. Arthroplasty is a major operation that requires one or more larger incisions and a longer recovery period. It is reserved for patients with severe pain, deformity, or instability.

Alternative Therapies

The two most promising supplements for OA are glucosamine and chondroitin, which are often sold together. Glucosamine is a compound derived from the shells of crustaceans; chondroitin is a component of connective tissue extracted from cow tracheas. They have been used by veterinarians for many years in animals with OA. Both are being investigated for humans in large-scale multicenter trials supported by the National Institutes of Health (NIH). Results are expected within the next several years. Acupuncture, a Chinese therapy that involves the insertion of fine needles into specific points on the skin, is also being investigated in NIH-supported research. Findings may be available within the next one to two years.

For More Information
National Arthritis Foundation
Johns Hopkins Arthritis Center

From The Johns Hopkins Medical Letter: Health After 50, March 2001.



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