A Little Creaky?

Achy joints? Creaky knees? If you are over 50, you may conclude that you have “a touch of arthritis.” Osteoarthritis, the most common kind of arthritis, affects an estimated 22 million Americans. For many, the condition will be painful at times but not debilitating. For some, though, arthritis brings severe limitations.

Osteoarthritis is a gradual breaking down of a joint. The cartilage, a rubbery covering over the ends of the bones, loses its elasticity. As the cartilage breaks down, changes occur in the bone as well. It thickens and fluid-filled cysts form under the cartilage. Bony growths called spurs may develop at the bone surface.

Healthy cartilage provides a smooth surface for joint motion and a cushion between the bones. Without healthy cartilage to smooth the motion — the stretching and flexing necessary to movement — there is pain.

The pain is usually mild in the early stages. Dr. Donald Caruso, of Dartmouth Hitchcock/Keene, says that most people self-medicate until the condition begins to interfere with daily life. Some mention it only when seeing the doctor for another problem and then it’s “By the way, my hip is bothering me. Guess I’m getting old.”

Age is a factor, says Dr. Caruso, especially when there has been a long work history in a physically stressful job. Repetitive motions over the years cause wearing of the joint. Upper joints — shoulders, arms, wrists and hands — are vulnerable. Also vulnerable are knees and hips, especially after years of squatting, lifting, bending and standing. The activities of the “weekend warrior” may also hasten the onset of arthritis.

Accidents can also predispose you to arthritis. Often the accident was years ago, but it left a vulnerability. A car accident may be forgotten until arthritis in the neck gives an unpleasant reminder.

The interventions for osteoarthritis are primarily for symptom relief. “We cannot stop the deterioration of the joint,” says Caruso. “But we can slow the process and, usually, reduce the pain.” There is no proven way to restore bone and cartilage. Many people (including some physicians) take glucosamine or chondroitin to nourish joint cartilage. Caruso allows that this is a possibility but does not prescribe the supplements because there is not yet evidence-based documentation of results.

What can one do? “Stay as active as you can,” says Dr. Caruso. “Working that arthritic joint helps it to retain elasticity.” Activity is essential to strengthen muscles around the joint, thereby easing stress on the joint. Your activity should include both stretching and weight-bearing exercise, essential to nourish the joint. The motion literally squeezes joint fluid in and out of the cartilage. If an activity causes pain to increase, change the activity, but keep moving. It is preferable to stay active, even if there is some pain. Physical and/or occupational therapists can recommend suitable activities.

Much of the pain of arthritis comes from inflammation of joint linings. There are several nonsteroidal anti-inflammatory agents, often called NSAIDS. Aspirin, ibuprofen (Motrin) and naproxen sodium (Aleve) are examples of over the counter nonsteroidal anti-inflammatory medications. Recent concerns about the risks of certain prescription NSAIDS left many people wondering what is safe and what isn’t.

There is a possibility of risk with any medication taken over long periods of time. Caruso believes, however, that there is little or no cardiovascular risk with time-limited use of anti-inflammatory medications. He says that the benefit of being able to get off the couch and exercise may outweigh the risk of the medication.

Both narcotic and non-narcotic analgesics may provide temporary pain relief but do not reduce inflammation. Non-narcotic pain relievers, such as Tylenol, may give relief from mild pain. Narcotic pain relievers (codeine, for example) may be prescribed to relieve moderate to severe pain.

Another treatment option is the injection of glucocorticoid, a substance related to cortisone. Because of possible side effects, this treatment is usually limited to three or four injections per year.

“At some point,” says Caruso, “a patient may need to consider joint replacement.”

When is it time? “When you can no longer do the things you need or want to do.” Joint replacement surgery has come a long way. A frequent response to joint replacement is “Why did I wait so long?”

A much smaller number of people, perhaps two million in this country, have rheumatoid arthritis. Though the two conditions share some symptoms, they are different in significant ways. Rheumatoid arthritis is a malfunction of the immune system and usually begins in the young to middle adult years. The immune system attacks the body’s own joints and other organs, causing joint damage and inflammation. Inflamed joints are swollen, red, painful and difficult to move.

Many of the treatments suggested for osteoarthritis can also reduce the symptoms of rheumatoid arthritis but do not change the underlying process. The good news is that there has been a major shift in the past 10 years, says Dr. John Schlegelmilch, rheumatologist and medical director at Dartmouth-Hitchcock in Keene. Treatment possibilities now include disease-modifying medications. These medications are an important part of treatment for almost all that have the disease. Such therapies can change the progression of rheumatoid arthritis, often preventing deformity and disability. Each patient’s course of treatment is individualized and must be carefully monitored by a rheumatologist.

As good as they are, none of the new drugs offers a cure for rheumatoid arthritis. Research is ongoing, to better understand the dysfunction of the immune system and to identify a possible infectious agent that triggers rheumatoid arthritis. NH