Dear Doctor Column, May 23, 2005

Pain of Osteoarthritis Can Be Managed

Question:

I've been having pain in my thumb and wrist intermittently for about a year. Recently, the base of my thumb became swollen, and the pain got so bad I went to the doctor. After taking X-rays, he told me I have osteoarthritis. He gave me an injection of cortisone in the joint, which has helped. I would appreciate some information about osteoarthritis and what I can expect as I get older. My mother was diagnosed with osteoarthritis in her hands a few years ago, but I'm only 38 years old.

Answer:

Osteoarthritis — also known as degenerative joint disease — is the most common type arthritis and one of the most frequent causes of physical disability among adults, especially among older people. More than 20 million Americans have the disease; more than half the population aged 65 years and older show X-ray evidence of osteoarthritis in at least one joint.

Osteoarthritis occurs when cartilage that cushions the gliding surfaces of bones that make up a joint gradually deteriorates. The surface of the normally smooth cartilage becomes rough and pitted. Cartilage loses much of its water content, and thus loses its cushioning effect, which changes the way a joint handles stresses put upon it. The changes in stress across a joint can cause formation of new bony deposits called "spurs", or osteophytes, which are seen on X-rays of the joints. All these changes can cause pain, especially when the joint is moved.

Unlike other types of arthritis, such as rheumatoid arthritis, osteoarthritis is not systemic — that is, it does not spread into internal organs, but instead concentrates in one or several joints where gradual deterioration occurs.

Osteoarthritis most commonly strikes joints of the feet, knees, hips, spine, and fingers (the base of the thumb is a common site), although it can affect any joint. Symptoms begin gradually with aching pain in one or more joints, stiffness, and loss of mobility. Stiffness is usually worse after sitting or lying for a while. Inflammation and swelling may or may not be present.

As you note, pain can ebb and flow, with bad spells followed by periods of relative relief. Pain often worsens after extensive use of a joint; some people develop constant pain, even when a joint is at rest.

Researchers now think osteoarthritis is linked to several factors including heredity, obesity, and joint injury. As in your situation, heredity is clearly involved in some cases. Being overweight is one of the main risk factors for osteoarthritis and damages "weight-bearing" joints, such as the knees and hips, and those in the lower spine. Athletes are more prone to developing osteoarthritis in joints damaged by trauma, such as football knee injuries.

Treatment Approaches to Osteoarthritis

Osteoarthritis itself is not life-threatening but can be quite painful and even disabling. Treatment plans include ways to manage pain and improve function, including exercise, rest and joint care, pain relief, weight control, surgery, and nontraditional treatment approaches, such as acupuncture.

Over-the-counter pain relief medication, such as aspirin, ibuprofen, and naproxen — also known as NSAIDs (nonsteroidal anti-inflammatory drugs) — usually helps control pain and stiffness. However, NSAIDs can irritate the stomach and less often, damage the kidneys or small intestine. NSAIDs should be taken on a full stomach or along with over-the-counter proton- pump inhibitors, such as Prilosec, or H-2 receptor blockers, such as Tagamet, Pepcid, Zantac, or others, to decrease the risk of irritation.

NSAIDs sometimes are associated with serious gastrointestinal problems, including ulcers and bleeding. COX-2 inhibitors (Celebrex or Bextra) are sometimes prescribed for osteoarthritis patients who suffer gastrointestinal side effects of NSAIDs. COX-2 inhibitors provide the same pain-killing effects as aspirin and other NSAIDs but with less chance of causing ulcers and bleeding. However, recent studies suggest some COX-2 selective drugs increase risk of heart attacks and strokes, especially when used at higher doses. After those reports, the company that made Vioxx decided to take it off the market. Data are still being analyzed and evaluated by physicians, public advocacy groups, and the Food and Drug Administration (FDA), the federal agency that oversees drug approval and safety in the U.S. Recently, an advisory group to the FDA recommended COX-2 NSAIDs remain available for patients, with stronger warnings about the cardiovascular risks on the labels. Unless you have stomach problems, it is best to try older NSAIDs first.

Acetaminophen (Tylenol) is another effective pain reliever, which does not irritate the stomach or increase cardiovascular disease risk. While it does relieve pain, it does not reduce inflammation. Also, for people who regularly drink alcohol, acetaminophen can damage the liver.

Other treatments prescribed for osteoarthritis, include:

• Topical pain-relieving creams, rubs, and sprays for example, Capsaicin-P cream, or Aspercreme and Ben Gay (which contain salicylate, a chemical similar to aspirin) applied to the skin.
• Hyaluronic acid, a medicine for joint injection, used to treat osteoarthritis of the knee. This substance is a normal component of the joint, involved in joint lubrication and nutrition.
• Corticosteroids, powerful anti-inflammatory hormones made naturally in the body or manufactured for use as medicine. Corticosteroids may be injected into the affected joints to temporarily relieve pain. This is a short-term measure, generally not recommended for more than two or three treatments per year.
• Studies are underway to determine if dietary supplements chondroitin sulfate and glucosamine may help.

People with osteoarthritis may find other measures help, such as warm towels, hot packs, or a warm bath or shower. Some people find cold packs (a bag of ice or frozen vegetables wrapped in a towel) relieves pain better than heat. Water therapy in a heated pool or whirlpool also may relieve pain and stiffness and allow for non-weight-bearing exercises in the water. For osteoarthritis in the knee, insoles in shoes or cushioned shoes can help redistribute weight and reduce joint stress. In the hand, splinting can reduce joint wear and tear and increase comfort.

Your doctor can refer you to a physical therapist for instructions about exercises to increase muscle strength, relieve pressure on joints, and help preserve as much flexibility and range of motion in affected joints as possible.

Joint replacement surgery significantly improves comfort and function in knee and hip joints, in particular. Before deciding on surgery, both surgeon and patient must consider level of disability, intensity of pain, interference with the lifestyle, and the patient's age and occupation. Currently, more than 80% of osteoarthritis surgery cases involve replacing the hip or knee joint. After surgery and rehabilitation, the patient generally feels less pain and can move more easily.

Although osteoarthritis cannot be cured, it can be managed. For more information, visit the following Web sites: Arthritis Foundation, www.arthritis.org; National Institute of Arthritis and Musculoskeletal and Skin Diseases, www.nih.gov/niams; and the American College of Rheumatology, www.rheumatology.org.