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 65or 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
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
Its 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.
Its 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 dont 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.
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
Hopkins Arthritis Center
From The Johns Hopkins Medical Letter:
Health After 50, March 2001.