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Arthritis is a condition that all healthcare providers must
understand so that their patients can be educated about options
in pain management and treatment.

Anna* has pain from osteoarthritis - and she knows what to expect. She knows that her knees will ache when she climbs the stairs later in the day. She knows that she will have hip pain when she sits for a long time at the movies tonight. She knows that she will be stiff when she climbs out of bed tomorrow morning. And at 65 years of age, Anna jokes with her friends about their aging bodies and their inability to move as well as they once did.
But Anna does not know everything about arthritis pain. Anna and her friends, like more than half of Americans with arthritis, think there is little that can be done to help them. "That is a common misconception," says Eileen Lydon, RN, MA, ANP, adult nurse practitioner in Rheumatology at the Hospital for Joint Diseases and the Peter D. Seligman Center for Advanced Therapeutics in NYC. "People often just accept arthritis and the pain that goes with it as part of the aging process." There are some important facts to know about this potentially debilitating - but treatable - condition.
Look at the Whole Picture
Arthritis is actually a term that includes 100 different diseases that affect the musculoskeletal system and the joints. "Osteoarthritis is certainly the most common form, with 60% of women over the age of 65 affected, but there are many other types of arthritis that cause pain, stiffness, inflammation, and damage to the joints," says Lydon. Arthritis is often looked at as a condition of old age, but there are 300,000 children affected, and some forms can start in infancy.1 Many forms of arthritis are limited in scope and can improve without specific treatment. These limited forms of arthritis include tendonitis and bursitis, which affect the soft tissues around the joint, and osteoarthritis, which can affect a single joint.
"Rheumatoid arthritis is an example of a more systemic and disabling condition that affects the entire body," says Lydon. Some forms of generalized arthritis, such as fibromyalgia, cause muscle and soft tissue discomfort without swelling or inflammation. Other systemic conditions that cause inflammation that affects the entire body include gout, ankylosing spondylitis, and rheumatoid arthritis. Systemic lupus erythematosus, which causes damage to joints and other connective tissue, and scleroderma, the disease that causes a thickening and hardening of connective tissue, are both serious, life-threatening, forms of arthritis.
Osteoarthritis - Part of the Arthritis Family
In a healthy joint, cartilage serves as the cushion between the bones. Osteoarthritis occurs when there is a breakdown of articular cartilage in the joints followed by an inflammation of the lining of the joint. In Anna's case, the osteoarthritis resulted from the aging process in combination with the extra weight she gained over the last 10 years. "The primary predisposition for osteoarthritis is when a person is overweight, because the weight puts greater pressure on the hip and knee joints." Just taking a step puts two to three times the body weight on the hips and knees, meaning that a person weighing 150 pounds is putting 450 pounds of pressure on those joints. "Other factors that predispose a person to osteoarthritis may include age, previous injury, occupation, or recreation that caused repeated stress to the joint, anatomical abnormalities, and a lack of strength in the muscles supporting the joints," Lydon says.
Diagnosis of osteoarthritis is based on -
· History of pain, stiffness, tenderness, or inflammation
· Physical exam that reveals deformities or an asymmetrical joint
· X-ray that shows cartilage loss indicated by a narrowing of the joint, bone damage, or bone spurs
Blood tests can rule out other medical conditions. "Sometimes the healthcare provider may pick it up on an x-ray," Lydon says. "Or the patient may have been coping with a major debilitation for a long time before he or she comes for help. Typically the patient comes to the healthcare provider with a complaint of pain, an inability to get up and down the stairs, or a report of stiffness in the morning."
First Step - Pain Management
No matter what the cause, when it comes to osteoarthritis, pain management is always one of the first treatment goals. Pain from arthritis can be caused by inflammation and damage to joint tissues and exacerbated by fatigue and depression. "We want to be able to relieve the pain first," says Lydon. "Then we can work on reducing the stress on the affected joints, restoring the joint alignment, and strengthening the muscles." The ultimate goals are to keep the patient moving, exercising, and using the joint correctly, so pain management is essential to patient care.
"The first line of pain management in osteoarthritis includes over-the-counter analgesics, such as acetaminophen (Tylenol®), and nonsteroidal anti-inflammatory drugs (NSAIDS)," Lydon says. "Prescription pain medications may include Cox-2 inhibitors such as celecoxib (Celebrex®) and rofecoxib (Vioxx®). With the NSAIDS we have to be careful about the risk of GI distress or bleeding, and with the Cox-2 inhibitors we must watch for other side effects, including hypertension and renal insufficiency."
Lydon says that some patients have also had some success with topical pain relief creams, such as capsaicin and lidoderm patches. "Steroid injections reduce inflammation, and a hyaluronic acid injection into the joint improves the viscosity and elasticity of the synovial fluid," she adds.
At the Peter D. Seligman Center for Advanced Therapeutics, Lydon participates in research studies that include ways to prevent, detect, diagnose, and control different types of arthritis and autoimmune diseases. One aspect of the research includes clinical trials for new medications and new ways to prescribe well-known medications. "We just finished a trial with a new topical cream," Lydon says. "Now we are starting trials on a new Cox-2 inhibitor and a trial where we will give 3,900mg of acetaminophen (Tylenol®) a day to treat osteoarthritis. Funding for some of the studies comes from the National Institutes of Health (NIH) and local and national chapters of the Arthritis Foundation.
There are other ways to relieve the stiffness and pain of osteoarthritis aside from medication. "Losing weight is often the first step for many patients, along with movement and exercise, which strengthen the muscles supporting the joint and help absorb the pressure," says Lydon. Walking and swimming programs are therapeutic, and losing 10 pounds can take about 30 pounds of pressure off the knees.
Lydon says that it is important to be aware of and treat the underlying diseases, such as depression or Parkinson's disease, which influence mobility and the ability to exercise. Assistive devices, including handrails, grips, raised toilets, a cane, and orthotics that can help with foot and knee alignment, may help relieve pain and promote more activity. Some over-the-counter dietary supplements, such as glucosamine, have been shown in early clinical trials to slow the progression of osteoarthritis at half the cost of drugs used in the control group.2
When All Else Fails - Surgery
There are times when medication, exercise, and other treatments do not work. Sometimes the joint is so painful that the patient avoids using it. The supporting muscles become weaker - and the problem gets worse. "There are times when surgery is the best alternative," says Lydon. "Surgery may include osteotomy, arthroscopy, or total joint replacement." Knee osteotomy surgically repositions the joint, realigning the mechanical axis of the limb away from the diseased area. This procedure allows the knee to glide freely and carry weight evenly on a more normal compartment.
Some studies question the usefulness of arthroscopic knee surgery. In a study at Baylor University, published in the July 11, 2002, issue of the New England Journal of Medicine, researchers showed that patients with osteoarthritis of the knee who underwent placebo arthroscopic surgery were just as likely to report pain relief as those who received the real procedure. The researchers say that these results challenge the usefulness of one of the most common surgical procedures performed for osteoarthritis of the knee. Total joint replacement for the hip or knee is considered if other treatment options do not relieve the pain or disability.
Anna received treatment for her osteoarthritis through a regimen of exercise, weight loss, and over-the-counter analgesics, greatly improving her quality of life. Instead of limiting her activities because of the pain, Anna found that regular exercise and strength training gave her a new level of mobility.
Even a mild case of arthritis can interfere with a person's activities of daily living. Arthritis is a condition that all healthcare providers must understand so that their patients can be educated about options in pain management and treatment. "And when we consider our aging patient population, most of us in healthcare will be caring for patients with arthritis," says Lydon.