Osteoarthritis, rheumatoid arthritis, or just normal aging? Knowing the difference can affect patient care and quality of living. Join experts discussing the real science behind the common degenerative disease, arthritis. Find out what you can do to help prevent it, and learn about promising treatments on the horizon.
What is arthritis?
Arthritis literally means "joint inflammation." There are actually more than one hundred forms of arthritis, but osteoarthritis (sometimes called degenerative joint disease or osteoarthrosis) is the most common. Most often, it affects older people, though it can strike younger people as well. It's usually caused by the normal wear and tear of time, though, especially in younger people, it can also be caused by injury or trauma to the joint. Other causes are obesity, repeatedly stressing a joint (usually because of a job or certain sports), and genetic defects.
What is osteoarthritis?
Osteoarthritis generally affects cartilage. Cartilage is the hard but slippery tissue on the end of bones, where they meet to make a joint. It allows the bones to move smoothly against each other. Osteoarthritis is the breakdown of this cartilage tissue. With less cartilage, the bones are less protected, and when they move, they rub against each other. This causes pain and swelling and makes the movement less smooth. After a while, it can cause the joint's shape to change, make small deposits of bone (called osteophytes or bone spurs) grow on the edges of the joint, or make small bits of cartilage or bone break off and float in the joint, causing more pain.
The disease affects people in a variety of ways. Usually, the joints at the ends of the fingers (closest to the nail), thumbs, neck, lower back, knees, and hips are most affected by it. In some people, it progresses slowly, or causes mild discomfort that doesn't interfere with daily living. In others, it progresses rapidly, or causes greater pain, stiffness, and disability, which can limit activities at work and home. These problems can, in turn, lead to depression, anxiety, and other psychological issues.
What is rheumatoid arthritis?
Rheumatoid arthritis is the second most common form of arthritis. It usually strikes at a younger age than osteoarthritis. It's caused by the body's own immune system attacking the tissues of the joints, which creates pain, inflammation, swelling, and redness in joints. After a while, it can make the joint's shape change and cause joint damage; it can even make people feel tired, ill, and unusually feverish.
- Osteoarthritis (sometimes called degenerative joint disease or osteoarthrosis) is the most common form of arthritis. It affects about 12.1% of the U.S. population age 25 and older, nearly 21 million people.
- Osteoarthritis is caused by the breakdown of the cartilage that normally covers the ends of bones and allows them to move smoothly against each other. With less cartilage protecting them, the bones rub against each other, causing pain, stiffness, swelling, and other problems.
- Osteoarthritis is diagnosed through a physical exam and various imaging techniques (such as X-rays). Because it is so common among older people, doctors need to be sure that it is causing the symptoms rather than another condition.
- There are many effective treatments for arthritis, ranging from exercise, weight control, non-drug pain relief techniques, drugs, and alternative (non-traditional) therapies such as acupuncture, to joint replacement surgery.
- Joint replacement (arthroplasty) is a surgical procedure in which diseased or damaged parts of a joint are removed and replaced with new artificial implants.
- Most artificial joints and implant components are made out of some combination of specialty metals and plastics. Your surgeon will suggest the one most appropriate for you, depending on your age, weight, bone strength, activity level, and the joint being replaced.
- Joint replacement surgery is a very effective treatment. But it is a very invasive operation that requires a lot of preparation and a long and intense recuperation.
- Because of the seriousness of joint replacement surgery, choose a surgeon carefully and do a lot of research before making the choice.
Ask Your Doctor
This list of questions has been adapted from information provided by the National Institutes of Health and the Arthritis Foundation. It is a good starting point for discussion with your doctor; however, it is not a comprehensive list.
- I want to start an exercise program and I have osteoarthritis. What should I do?
- I want to lose weight. What diet appropriate for me?
- Will non-drug pain relief treatments work for me? Which ones do you recommend? Why?
- What other treatments do you recommend? Why?
- How well has this option worked for others?
- Where can I find clinical drug trials I can participate in?
- What are the potential benefits of this treatment?
- What medicines/drugs should I take?
- How often should I take this medicine?
- Should I take this medicine with food or between meals?
- What side effects might occur?
- I'm experiencing some side effects from my medication. Is that normal?
- Should I take this medicine with the other prescription medicines I take? Will it interact with them?
- Will this medicine interact with over-the-counter medicines I take?
- Is this medication safe considering other medical conditions I have?
- How much or how little medicine I should be taking? What's my correct dosage?
- I want to try an alternative treatment. What's safe and effective?
General questions about joint replacement
- What are the most common causes of severe joint problems that can lead to the need for joint replacement?
- What conditions or symptoms must exist before a doctor will recommend such a procedure?
- Arthroplasty is a major invasive procedure. How disruptive is it to a person?
- What does joint replacement surgery involve? Describe the process.
- What is an artificial joint made of? How does it work?
- How does an artificial joint "interface" with a person's flesh and bone?
- How long do artificial joints last? Will I need another arthroplasty at some point?
- What are the success rates for arthroplasty?
- What are the possible complications, and how common are they?
- Are there reasonable, effective alternatives to arthroplasty?
- What about new research and findings? Are there any less invasive but equally effective remedies "right around the corner" that I might want to hold out for?
- What can a person do to put off severe joint problems or relieve their symptoms?
If joint replacement becomes a likely course of treatment for you
- Specifically, why is this procedure being recommended? What alternatives were considered and why were they rejected?
- What benefits should I anticipate in terms of pain relief, improvements in mobility, etc., and to what degree?
- What percentage of arthroplasty patients have seen these improvements, and for how long?
- What are the risks associated with arthroplasty? Do my circumstances suggest I face any particular issues or risks?
- Is there a long-term "down side" to this procedure? Will I lose certain abilities?
- What type of joint "hardware" is being recommended for me, and why?
- What can I expect immediately after surgery?
- How long will it take for me to recover, and what will I have to do?
- What role will medication play in my recovery, and what kinds will I have to take?
- What kinds of exercise and physical therapy will I have to do "post-implant"?
- Should I make any changes around my home to accommodate my recovery?
- What specific roles do my personal doctor and my orthopaedist play?
- What should I expect if I decide not to have the surgery at this time?
- If I want a second opinion, whom can I consult?
Key Point 1
Arthritis is a huge problem in the U.S. It is expensive and many people suffer with it. In fact, osteoarthritis is the leading cause of disability in this country.
According to the National Institutes of Health, osteoarthritis affects about 12.1% of the U.S. population age 25 and older. That's nearly twenty-one million people. It strikes both men and women. Before age 45, men are more likely to get it; after that age, women are more likely to get it.
Although younger people can have the disease, it is most often a condition of older people. As the leading cause of disability in older people, it is responsible for an estimated 86.2 billion dollars annually in medical care and indirect expenses. That number will only grow in time. By 2030, twenty percent of the U.S. population - about 72 million people - will be over 65 and at high risk for the disease.
The symptoms of osteoarthritis include:
- Pain and/or stiffness in a joint brought on by using the joint, or conversely after not using the joint for a long time, or a change in weather
- A noise created by bone rubbing against bone, a crunching feeling, or feeling less flexible when using the joint
- Bony lumps on finger and thumb joints
The disease is generally diagnosed by:
- Physical exam and clinical history. The doctor will examine the patient's joints, reflexes, muscle strength, and general health, and ask the patient to describe the symptoms, other health issues, medications being taken, etc.
- Imaging. Various imaging techniques provide pictures of the joints that can reveal worn or thinning cartilage, bone roughness, worn knee joints, and other signs of osteoarthritis. Techniques include:
- X rays
- Arthography: images taken after a dye has been injected into the joint to provide greater contrast (for better quality images)
- CT scan (computerized tomography, popularly known as a "CAT scan"): a sophisticated imaging system that creates a series of very detailed, cross-sectional images of organs and tissues. Unlike an x-ray, which images bones, computed tomography can produce an image that shows organs, bones, and blood vessels
- MRI (magnetic resonance imaging): an imaging technique that produces detailed cross-sectional pictures ("slices") of internal organs and body parts like the CT scan. However, the MRI scan provides superior contrast resolution
- Other tests, such as:
- Blood tests to rule out other conditions that might cause the symptoms
- Joint aspiration (drawing fluid from a joint for lab analysis)
Osteoarthritis is not difficult to diagnose. But because it is so common among older people, doctors want to make sure that symptoms are really caused by it, and not by another condition.
Key Point 2
There are many effective treatments for arthritis. You don't have to live with arthritic pain.
Most treatment programs combine several forms of treatment tailored to meet the individual's specific needs.
Always good for general health, exercise can help osteoarthritis sufferers by decreasing pain, increasing flexibility, controlling weight, and improving mood and outlook. Even the simplest exercises, such as walking (outside or on a treadmill), walking in water, or stretching, can be very beneficial. Yoga is especially helpful. You need to speak to your doctor or physical therapist to design an exercise program specifically for you. A variety of exercises can be included, such as:
- Muscle strengthening exercises
- Range-of-motion exercises (to keep joints limber)
- Agility exercises (to help you handle daily activities)
Obesity increases the stress on joints and therefore increases the pain and other symptoms of osteoarthritis. You need to speak to your own doctor to design a diet program specifically for you.
Relieving joint stress
People with osteoarthritis learn when they need to sit or rest to reduce the stress on their joints. Some people use canes or other devices (such as splints and braces) for extra support.
Non-drug pain relief
Besides medications (which are discussed below), there are many non-drug pain relieving methods, including:
- Heat and cold: Applying heat, cold, or a combination of both directly onto the painful joint can reduce the pain significantly. Work with your doctor or physical therapist to discover which is best for you.
- Heat can be applied by using a heating pad, hot or warm towel, hot bath or shower.
- Cold can be applied by using ice packs (or even bags of ice or frozen vegetables wrapped in a towel).
- Transcutaneous electrical nerve stimulation (TENS): This technique involves a small electronic device that applies mild electric pulses to the nerve endings in the painful area.
- Massage: Many people find massage an effective pain reducer, but the massage therapist must tailor the massage to each person's specific condition.
- Relaxation and stress reduction techniques: Techniques such as meditation and biofeedback may help reduce pain.
Many drugs, both prescription and non-prescription (over-the-counter or OTC), are available to treat osteoarthritis. You need to work with your doctor to find which one(s) are right for you. Drugs to treat osteoarthritis include:
- Topical creams, rubs, and sprays. These are pain relievers that are applied directly to the skin over painful joints. Most are over-the-counter preparations.
- Acetaminophen (generic form of Tylenol and other brands). This OTC drug is a pain-reliever but not an anti-inflammatory.
- NSAIDs (nonsteroidal anti-inflammatory drugs). These are both pain-relievers and anti-inflammatories. Many are available by prescription; others are OTC. Prolonged use of NSAIDs can cause stomach irritation and has been associated with serious gastrointestinal problems, including ulcers, bleeding, perforation of the stomach or intestine, and kidney function, and may increase the chance of heart attack or stroke. That's why you should consult with your doctor even when taking over-the-counter NSAIDs. To reduce the risk of side effects from NSAIDs, take them with food and avoid other stomach irritants such as alcohol, tobacco, and caffeine. Your doctor may also suggest taking a drug that coats the stomach or blocks stomach acids along with the NSAID.
- COX-2 inhibitors. These are a sub-class of NSAIDs. They have been very effective in relieving pain and inflammation and do not seem to have the side effect of irritating the stomach. However, they have been associated with an increased risk of heart attack and stroke and may cause or increase high blood pressure. Celecoxib (generic form of Celebrex) is one well-known COX-2 inhibitor.
- Tramadol (Ultram). This prescription pain reliever has stronger possible side effects than acetaminophen and NSAIDs, including the potential to cause addiction.
- Mild narcotic painkillers. These are fairly powerful pain relievers, such as codeine or hydrocodone, but they also have the potential to cause addiction.
- Corticosteroids. These anti-inflammatory hormones can be injected into the affected joints to relieve pain temporarily.
- Hyaluronic acid substitutes. Sometimes called viscosupplements, these drugs replace a normal component of the joint involved in joint lubrication and nutrition. They're given by injection and are used only for osteoarthritis of the knee.
- Antidepressants. Some antidepressants, such as amitriptyline and nortriptyline (Pamelor, Aventyl), can help reduce the pain of osteoarthritis. At the same time, they benefit those who have sleep disorders or become depressed because of the effect of osteoarthritis on their daily lives.
Among the non-traditional (complementary) treatments currently used for osteoarthritis are:
- Acupuncture. This process involves a licensed acupuncture therapist inserting very fine needles into specific points on the skin. It is often very effective in relieving pain.
- Nutritional supplements such as:
- The nutrients glucosamine and chondroitin sulfate. These are both components of cartilage and have been reputed to be effective pain relievers. A recent study cosponsored by two of the National Institutes of Health - the National Center for Complementary and Alternative Medicine (NCCAM) and the -National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) found that they did not relieve pain in all participants, but were of significant help to a smaller sub-group of them.
- Vitamins D, C, E, and beta carotene may slow the progress of osteoarthritis. NIAMS is sponsoring a clinical trial of Vitamin D to treat osteoarthritis. More studies are needed to confirm these reports.
- Other studies are investigating the active ingredients in green tea, which appear to have an anti-inflammatory effect and may also slow the breakdown of cartilage that leads to osteoarthritis.
Joint replacement surgery is discussed in Key Point 3.
Much of this information has been adapted from articles available at the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) where you'll find many more details about all these treatment methods. You can also read about current research into possible future treatment approaches, including:
- Tissue engineering (removing cells from a healthy part of the body and putting them where tissue is diseased or damaged)
- Cartilage cell replacement (removing cartilage cells from the patient's joint, cloning or growing new cells from them, and placing these new cells into the damaged area)
- Stem cell transplantation (using stem cells - primitive cells that can transform into other kinds of cells - to grow new cartilage cells)
- Gene therapy (genetically engineering cells that could prevent cartilage breakdown)
Key Point 3
When all else fails in treatment of osteoarthritis, tremendous progress has been made with effective joint replacement surgery.
Joint replacement (arthroplasty) is a surgical procedure in which diseased or damaged parts of a joint are removed and replaced with new artificial implants. Most artificial joints and implant components are made out of some combination of specialty metals and plastics. There are three main types of replacement parts used in joint replacement. Your surgeon will suggest the one most appropriate for you, depending on your age, weight, bone strength, activity level, and the joint being replaced. The types are:
- Cemented: The surgeon uses a bone "cement" or glue to hold the artificial parts in place and connect them to healthy bone. This surgery is recommended for older or less active people, because results are consistently good and recovery is relatively quick.
- Cementless (or non-cemented): Parts that come in contact with healthy bone are produced from a material and feature a design that encourages the bone to grow into and around them. This type of implant generally lasts longer. However, it requires healthy bones that will grow into the replacement joint, as well as a longer recovery time. Most people who receive cementless joint implants are younger or more active. Some newer designs are used for all ages.
- Hybrid: These are made up of both cemented and cementless components. The surgeon selects the parts after deciding what will work best, given the condition of the patient's joint and surrounding bone and tissue.
Doctor and patient together should weigh the advantages and disadvantages of each type. For example:
- Cement particles can break off the joint through use and movement, which can cause irritation.
- Revision surgery is usually more difficult with a cemented joint.
- Cementless joints can take three months or more to heal and stabilize.
- The process of natural bone growth can cause pain for a number of months after surgery.
Implants can wear out or become loose with time. Historically these types of problems might occur after 10 to 15 years. Newer hip implants may now last much longer, but the long-term function of new implants is less clear. Collectively, over 90 percent of replacement joints are fully functional after 25 years. But, for younger patients and/or active, whose artificial joints tend to get more wear and tear, revision surgery might be needed.
People who undergo arthroplasty can expect dramatic pain relief and improved ability to function normally. But there is a cost. Joint replacement is a very invasive operation. It requires a lot of preparation and a long and somewhat intense recuperation. There are a lot of things the patient can do before and after surgery to make everyday tasks easier and speed their recovery
- Research the most experienced surgeons and the best hospitals for joint replacement surgery in as wide a geographic area as is reasonable for you. You can evaluate a provider's competence by looking at:
- Whether they participate in continuing medical education
- Quality reports
- How they are viewed by former patients, peers and staff
- How they monitor and improve their quality of care
- Request and read information written for patients from the doctor and support agencies to make sure you understand the risks as well as the rewards
- If you have any factors that would increase your risk factors (such as being overweight or a smoker), work with your doctor to correct them
- Ask your doctor for pre-surgical exercises
- Enlist someone to help around the house for a couple of weeks after you get home from the hospital
- Set up a "recovery station" at home where you'll spend most of your time, complete with TV remote, radio, telephone, medicine, tissues, waste basket, water pitcher and glass
- Arrange your house so you can get around easily, and place everyday items at arm level so you don't have to bend or stretch
- Stock up on kitchen staples, fill the cupboard with easy-to-make foods like canned soup, and prepare and freeze meals in advance
- Arrange for transportation to and from follow-up appointments and for things like errands
- Take your medicines regularly, exactly as prescribed, and take your physical therapy seriously; both will be integral parts of your recovery
- Follow all doctor instructions related to diet, movement, and other critical matters
- Wear an apron with pockets to carry essentials around with you
- Use a long-handled "reacher" to turn on lights or grab things that are beyond your reach
- Be active when you're supposed to be active (during physical therapy) and rest when you're supposed to rest
- Be committed to your rehabilitation program
Rehabilitation from joint replacement surgery is an ongoing, life-long process. The initial rehabilitation may take as long as a year for full recovery. During that time, you must follow your doctor's prescribed rehabilitation program. It may include:
- Early rehabilitation includes gentle, range of motion (stretching) exercises to restore movement and strength to the joint and to promote blood flow for healing. Preexisting conditions such as hip weakness, osteoporosis, and the condition of other joints determine what and how much a patient can do.
- Long term rehabilitation will include more low-impact strengthening exercise, such as walking, swimming, golfing (with spikeless shoes), and bicycling
- Avoid jarring or repetitive activities which overload the joint, such as jogging, jumping, and horseback riding
- Avoid exercise that could result in excessive joint flexion such as racquet sports and contact sports (football, baseball)
- Infection prevention. You'll take antibiotics whenever there's the possibility of a bacterial infection. Infections elsewhere in the body should also be treated to prevent seeding of infection into the joint.
- Diet. You'll continue to watch your weight to avoid putting more stress on the joint and moderate your alcohol use to avoid potential falls.
Doctors follow patients with joint replacements according to a definite protocol. This includes a review at least at the end of the first year and every two to three years thereafter for life. These follow-ups help diagnose any problems that may arise.
You can find more information about joint replacement surgery at an earlier episode of Second Opinion: Second Opinion, Joint Replacement, Episode 207.
Conduct an off-site search for Osteoarthritis information from MedlinePlus. These up-to-date search results are based on search terms specific to Second Opinion Key Points.