Agony In the Bones
Arthritis is crippling more people, but there are nine key ways to beat the pain
It is a timeworn sign of old age and frailty. Yet arthritis often strikes the young. "At night, I just cried and cried because my feet hurt so much," says 11-year-old Leona West of Springfield, Ill. And it hits the strong. "It was like having a dentist drilling into my knees," says Rich Kase, 52, of Cuyahoga Falls, Ohio, an insurance broker, former college football player, and self-described jock. "I was up to 12 ibuprofen a day. I had a terrible time walking. I had to walk down hills backwards."
This disease of the body also has a terrible impact on the mind. "I got very depressed. I couldn't sleep. When pain is constant like that, it changes your personality. And it affected everyone around me," says Nora Baldner, 41, of Quincy, Ill., who had arthritis in both hips. "I'd pour evaporated milk on my kids' cereal because I didn't want to walk to the back of the supermarket where the real milk was."
Joint problems are now hurting and crippling 43 million Americans, and they're more costly than cancer or diabetes. The most common form, osteoarthritis, affects about 21 million. Rheumatoid arthritis, another common type, hits slightly more than 2 million. (There are 95 or so other forms, often affecting fewer people.) And the numbers are going up steadily. By 2025, the total is expected to top 60 million, as an obese population pounds more heavily on its joints and an active generation of baby boomers grinds them down.
What's worse, these people will be fighting the disease without medicines that had become staples of treatment: The drugs Vioxx and Bextra have just been yanked off the market because they appear to raise the risk of heart disease, and that same shadow of fear has been cast over remaining drugs like Celebrex and even ibuprofen--a medicine that had already worried doctors because heavy use can cause bleeding in the stomach.
Yet instead of being crushed, doctors and patients say there is now more hope for beating the disease than ever before. "Arthritis has always been looked at as the minor aches of getting old, and there's nothing you can do about it. None of that is true," says rheumatologist Roland Moskowitz, codirector of an arthritis research program at the University Hospitals of Cleveland. "We're seeing it in younger people. But you can arrest the disease, and you can manage the pain."
In osteoarthritis, doctors have recently learned how a program of exercise and simple braces can make major improvements in misaligned joints. The remaining anti-inflammatory drugs, it turns out, can be used to great advantage--especially when combined with medication that protects the stomach. And there have been tremendous strides in joint replacement surgery. For rheumatoid arthritis, there's a lot of excitement about new medicines known as biologic response modifiers, which can hit the disease hard and fast and either slow it down or stop it altogether. Says rheumatologist John Klippel, president of the Arthritis Foundation: "We have a huge amount of optimism. In the next decade, I think we're going to change the course of this disease."
Two diseases. To understand those changes, it helps to know that rheumatoid arthritis (RA) and osteoarthritis (OA) affect joints in two different ways. RA is an autoimmune disease, in which the body turns on itself and attacks the tissues lining the ends of bones, causing serious inflammation. It's a bodywide ailment. OA, by contrast, is often confined to one joint and occurs when the cartilage breaks down, causing the bones to rub together. Disease seriousness is rated by degree of pain--using a 1-to-10 scale or similar measure--and loss of movement, as well as the impact on daily activities. X-rays can also determine the amount of deterioration in the joint.
For both conditions, treatment starts with the simplest and least risky interventions and progresses to more intense medicine that is specialized for each illness. "We use everything we can," says Joe Couri, a rheumatologist in Peoria, Ill.--an OA patient himself, currently recovering from shoulder surgery. "I did anti-inflammatory drugs for a while and then cortisone shots. The challenge is finding the right combination for the right person. Sometimes it takes months, or even years, but eventually we get there." The approaches Couri and other doctors call on fall into nine general categories.
1. TOPICAL TREATMENT
Some arthritis remedies go on the skin, not into the body. The most common include heat and cold. This can be as simple as a hot water bottle or a bag of frozen peas. Cold, says Klippel, keeps inflammation down, while heat increases blood flow and loosens up a stiff joint. Some rheumatologists feel that heat can actually increase inflammation, so if your knee is red and swollen, stay away from the heating pads and use ice or those pea bags. Ultimately, it's an individual choice.
A skin patch containing 5 percent lidocaine, a topical anesthetic, cut OA pain, according to a study published this year. Creams are also common remedies. Celecaine, a cream made of natural oils, improved pain and function better than a placebo did in several scientific trials.
Doctors are a lot more skeptical about two folk remedies: magnets and copper bracelets. While some studies have shown that magnets of certain strengths may relieve a little pain, Roy Altman, a rheumatologist at the medical school of the University of California-Los Angeles, concludes: "If you're going to try them, don't spend too much money." As for a copper bracelet, you're best not spending anything at all.
2. SUPPLEMENTS
One popular supplement, called glucosamine-chondroitin, really seems to work. A review in the Journal of the American Medical Association concluded that the compound has a modest beneficial effect and is safe. Glucosamine is supposed to help cartilage form, and chondroitin is supposed to prevent it from breaking down. There are lots of preparations on the market, however, and one lab analysis found that not all of them contain as much of these substances as they claim. Chondroitin was the ingredient most likely to come up short--in one case, only 18 percent of the claimed 500 mg. Some brands that did meet their label claims included CosaminDS and Puritan's Pride.
3. STRENGTH AND BALANCE
One of the more dramatic recent discoveries about OA is that it can be driven by "malalignment" of the bones, says rheumatologist David Felson of Boston University. In the legs, this shows up as being either knock-kneed or bowlegged. "If you are malaligned you get worse; if you are neutral you don't," Felson says. If the upper and lower legs are bent out at the knee, for instance, the inner side of the joint will be closer together. That makes cartilage damage more likely, and erosion of cartilage brings the bones even closer, producing a vicious cycle of more erosion.
The way out of this trap is to balance the joint, usually by strengthening the muscles and tendons that support it. A brace can also hold the joint in a neutral position. Because of this, doctors are recognizing that managing arthritis often can be done by physical therapy rather than drugs. "It's not the caboose; it's the engine. Too often we tend to pick up the newest prescription with the hopes that will be it," says Kenneth Brandt, a rheumatologist at the Indiana University School of Medicine. The first goal is stretching to improve the range of motion, says Brenda Greene, a physical therapist at Emory University. Then comes strengthening the surrounding muscles, and then a plan for aerobic exercise to increase overall fitness and control weight. "I'm bicycling, I'm swimming, I'm on the elliptical trainer--if you'd told me I'd be doing all that two months ago, I'd have said you were crazy," says Shlomo Twersky, 63, who had both knees replaced earlier this year.
Physical therapists or orthopedists may also recommend other simple changes. "I tell most of [my patients with arthritis] to move into sneakers," says Altman.
4. EXERCISE
Outside the physical therapist's office, you can't use arthritis as an excuse for staying on the sofa. Exercise, in fact, should be part of your routine. Strength and flexibility exercises help keep your joints supported and allow you to reach the full range of motion, and aerobic exercise helps keep off the weight that can exacerbate arthritis. Even weight loss of 7 or 8 pounds helps cut the strain.
The much-maligned sport of running can help. If you're used to your daily runner's high, there is no reason to stop solely out of fear that in 10 years or so you will wear out your knees. There's no link between running and developing arthritis, says Cedric Bryant, chief exercise physiologist with the American Council on Exercise. The only connection is to sudden trauma, which occurs in contact sports and other activities. Torn cartilage or ligaments make it more likely that you'll get arthritis further down the road.
If you begin developing arthritis, it's probably time to switch to something less pounding. "Your knee is like a tire--there's only so much life to the tread," says Jason Snibbe, an orthopedic surgeon at the Beverly Hills Orthopedic Group. Bryant suggests looking for low-impact alternatives, like an elliptical trainer or activities in the water, like swimming or pool running. Cycling is also great, especially on a recumbent bike, which strains the knees less. Studies have shown that to lose weight, you need 60 to 90 minutes of aerobic activity six days a week, but even walking 30 minutes a day is a good start. In addition to cardiovascular exercise, weights help build up the muscles, and activities like yoga and tai chi are great for improving flexibility, he says.
If you're just starting an exercise routine, don't hesitate to talk with a physical therapist or doctor about any new aches and pains. "One of the first things we do is differentiate between normal pain at the beginning of an exercise program and arthritis," says Greene. If the pain is in the muscles and fades in 24 to 48 hours, it's probably old-fashioned muscle soreness. If the joint is inflamed--swollen and feels warm to the touch--and stays that way for a long time, it's most likely linked to arthritis.
5. ANTI-INFLAMMATORY DRUGS
Drugstore shelves are filled with different brands of aspirin, ibuprofen (such as Motrin or Advil), and naproxen (such as Aleve). And behind the prescription counter, there used to be a host of more specialized drugs like Vioxx, Bextra, and Celebrex. They not only killed pain but blocked inflammation, a special boon for arthritis patients. Then, last fall, the roof caved in. Vioxx, it turned out, was raising the risk of heart attacks. The manufacturer, with nudging from the Food and Drug Administration, pulled it. This February, Bextra also got the hook, leaving only Celebrex and the over-the-counter drugs--and a lot of scared arthritis patients. Susan Silbiger, a retired schoolteacher from Aurora, Ohio, who has OA, says: "I was on Vioxx for a while, but my blood pressure went up. So then I switched to Bextra. Then all the news reports came out about those heart problems. It was all a little scary. I just stopped as soon as I heard." Now she gets by with a few over-the-counter pills. "I'm a lot more cautious now. My big problem is in my thumb, probably from playing too much golf. I still play. But I take an Aleve, I don't grip the club quite so tightly, and I'm ready to go."
This spring the FDA, after reviewing many studies of these nonsteroidal anti-inflammatory drugs, or NSAID s, as these drugs are collectively known, came to two basic conclusions. First, all of these drugs raised the risk of heart trouble. But, second, it remained unclear just how much that risk was increased. Some studies implied a little rise or even none at all, while other studies pointed to a big jump. So rather than banning ibuprofen, naproxen, and Celebrex, the agency opted for big warning labels and left it up to doctors and patients to sort things out.
The latest news is that lower doses of these drugs appear to be safer. That's according to a massive study of some 650,000 arthritis patients just announced at the Annual European Congress of Rheumatology in Vienna. Gurkirpal Singh, a gastroenterologist from Stanford University who conducted the study, says even at higher doses the increased risk was "modest." Basically, this means arthritis patients with high blood pressure or other heart disease risk factors should be watched carefully if they use these drugs for pain on a daily basis. Occasional use doesn't seem to be a problem.
The heart isn't the only concern with these drugs. There are well-documented worries about stomach ulcers, even with Celebrex, which is supposed to be easier on the stomach. So one thing that patients can do is add a drug called a proton-pump inhibitor, which protects the stomach. "You can use Nexium, or better yet the generic version of Prilosec, which is a lot cheaper and you get the same protection," says Moskowitz. "If I had to use naproxen, I'd feel a lot more comfortable adding one of these."
Still another way to manage serious inflammation is with steroids, either in pill form (prednisone) or as cortisone injections directly into the joint. RA patients are often put on prednisone, because it works throughout the body, but doctors don't like to use it for extended periods, because it has been linked to diabetes, high blood pressure, and osteoporosis. OA patients, who don't have a system-wide illness, can get the local injections. They relieve pain but don't stop the underlying cartilage degeneration; in fact, if repeated more than two or three times a year they can make it worse.
6. DISEASE-MODIFYING DRUGS
RA patients have other medication options, including newer drugs that block their immune systems from attacking their joints. Methotrexate, a mild immunosuppressant originally developed as a cancer drug, has become a valuable tool in the past decade. Now doctors have started combining this drug with others, like Enbrel or Remicade, which inhibit inflammatory immune system proteins. About 70 percent of patients given this combo soon after their diagnosis respond well, with big decreases in pain and big increases in their ability to function.
Methotrexate alone has made a huge difference for Cindy Morris, who was diagnosed with RA a year ago. The 37-year-old Peoria, Ill., woman had severe pain in her heels, ankles, and fingers. "But today it's unbelievable how good I feel. I forget I even have it," she says. "It's a lot different from what my mom has gone through." Morris's mother, Dorothy Maloney, 61, was diagnosed with RA a quarter century ago. "I started on coated aspirin, taking 10 pills a day, and it didn't help. Then ibuprofen, which was prescription back then." Today she has trouble walking because her toes have become all swollen and knobby--as have her fingers, making it difficult for her to hold a fork or zip up a dress. Maloney thinks her daughter will have a different future, and so do doctors.
7. OPIOID ANALGESICS
The demise of Vioxx has sent some patients, who have not gotten relief from NSAID s and who have intermittent, not constant, pain, to opioids like Darvocet and Ultram. For many, the pain is worse at night, and though drowsiness is an opioid side effect, that doesn't matter at bedtime. But doctors say patients are often scared to take these mild drugs, even though they've been in use for decades and have very good safety records. They are mostly afraid of addiction. Yet research has shown that addiction is more a function of personality than it is of the drugs, especially when they are used intermittently.
8. JOINT LUBRICATION
Because so many people now worry about taking oral medications, injections of substances called hyaluronans into the joint are growing in popularity. "It's like oil within your knee that lubricates it," says orthopedic surgeon Snibbe. It may also act as a chemical barrier, blocking cells involved in the inflammatory process. Injections are not for everyone, because not everyone gets relief. The best candidates have moderate, rather than severe, disease, with some cartilage damage but no bone-on-bone-crunching.
9. SURGERY AND REPLACEMENT
" I tell my patients, 'when you're sick and tired of the conservative stuff and it doesn't work, it's time to think about surgery,' " says rheumatologist Couri. For OA, one option is an osteotomy, in which a surgeon cuts away part of the bone to relieve pressure on damaged cartilage and shift weight to a healthier spot. People with RA have their own set of operations, including synovectomy, to remove inflamed tissue that surrounds the joint. Simply scraping and cleaning out the joint, or arthroscopic surgery, has been on the decline since a recent article in the New England Journal of Medicine showed a sham surgery relieved pain and improved function just as well.
Then there's the big one: joint replacement. It's extremely popular both with patients and with doctors, and for good reason--it works. "It's one of the most successful operations in the history of medicine," says Lester Borden, head of adult reconstructive orthopedic surgery at the Cleveland Clinic. In recent years, implants have become much more durable and now may last for 30 years, and surgeons have figured out how to insert them using smaller incisions, reducing recovery time. But it's still not to be taken lightly.
Recovery can be painful and involve many days in the hospital or a rehab facility. But for Rich Kase, after 15 years of drugs and injections and smaller knee surgeries, "I wanted it. I wanted a new lease on life. I could only walk about 50 yards, the pain was constant, and my orthopedist said I had the joints of an 80-year-old." He was 50 at the time and opted for a double-knee replacement. "My surgeon said to do them both at the same time, because I'd only have to go through rehab and recovery once. And it's excruciating. It's tough surgery. I wouldn't want to do it twice. The next morning they made me get up and out of bed, and I'd say the pain was a 9 or a 10, even though I had a morphine drip in."
Road to rehab. Kase went home and had physical therapy there for three weeks, followed by three more weeks at the therapist's office. In a month he was back at work and soon after that, back on the golf course. "It's been phenomenal. I walk the course, going down hills the right way. I can go on vacation and bike 10 miles with no pain. I had to get my pants lengthened because I'm taller and straighter. I do, however, use the surgery as an excuse not to kneel in church."
Susan Thompson, a 72-year-old retired veterinarian in Sag Harbor, N.Y., says she is conservative by nature, which is why she is holding off on hip replacement for now. She's got osteoarthritis in that joint and rheumatoid arthritis elsewhere and is taking Enbrel and other medications to keep her pain in check. "They recommend surgery to me all the time, but the idea of the recuperation really throws me," she says. "You never know how long it will take, how long you'll be out of your home." She can still do housework and get around and is happy to wait until she absolutely needs surgery. "After all, it's not like I'm resuming a career in the dance," she says.
For RA patients, joint replacement can be even more complex. "Some of the patients with osteoarthritis are coming in here because they can't play golf or tennis. Rheumatoid arthritis patients are coming in because they can't get out of a wheelchair or walk," says Mark Figgie, chief of the surgical arthritis service at the Hospital for Special Surgery in New York City. Many are on immune-system-altering drugs that may need to be temporarily stopped before surgery. Their bones are softer, skin is more fragile, and they run a higher risk of infection. And since many joints can be affected, surgeons also have to strategize about which ones to fix first.
Patients need to take care of their new joints, since the life of the implant depends on how much wear it gets. "It's mileage dependent, like a part on your car," says David McAllister, an orthopedic surgeon at UCLA. Even with the new materials, patients under 50 may live long enough to need surgery to tinker with or replace the replacement at some point.
There are other treatments in the offing. An experimental trial with the tried and true (and cheap) antibiotic doxycycline indicates that it stops OA progression by blocking enzymes that help break down cartilage tissue. And earlier this month, researchers reported on the world's first gene therapy for arthritis, in which an anti-inflammatory gene was transplanted into the knuckles of RA patients. The gene was active, but doctors are going to have to conduct longer studies to see if it has a real-world benefit.
For now, arthritis patients are bringing available treatments together in a management program, including drugs, physical therapy, exercise, and surgery. Nora Baldner, the mother who couldn't walk to the back of a supermarket for milk, took glucosamine-chondroitin and had hip replacement operations five years ago. Today she rides her bike and feels pain free. "In the roulette wheel of medical problems," she says, "I think I came out pretty lucky."
BAD TO THE BONE
Joints, the place where two bones meet, are meant to move. The junction is lined by a thin membrane that releases a fluid, which serves as a lubricant. The end of each bone is covered by a cushion of slippery cartilage. Arthritis can damage any, or all, of these crucial parts.
[INSET]
HEALTHY KNEE JOINT
Patella
Cartilage
Membrane
Femur
Tibia
OSTEOARTHRITIS
This disease hits when the protective cartilage starts wearing away, often on one side of the joint. As the space in the joint narrows, more cartilage starts rubbing and eroding, even down to the bone. Knobs of the bone called spurs, start to grow. Bits of cartilage fill the area, irritating the membrane. All of this means the joint grinds painfully whenever it moves. Hips, knees and hands are most commonly affected.
[LABELS]
Cartilage roughens and cracks
Joint fluid
Spurs
Membrane
RHEUMATOID ARTHRITIS
This illness begins when the body's immune system turns on itself, attacking the membrane. It thickens, swelling into the joint, and starts to damage the cartilage. Immune cells also attack cartilage, bone, and surrounding muscles and tendons, and the whole area becomes painfully inflamed. Many joints are affected at once, particularly feet, fingers, knees, and elbows.
[Labels]
Erosion
Inflamed membrane
Sources: Roland Moskowitz, M.D., Arthritis Foundation
This story appears in the June 27, 2005 print edition of U.S. News & World Report.