Living a Healthy Life with Chronic Conditions

CHAPTER 17

Managing Chronic Arthritis and Osteoporosis

LITERALLY, THE WORD ARTHRITIS MEANS “inflammation of a joint.” However, as the word has come to be used, arthritis commonly refers to virtually any kind of damage to a joint. Although most forms of arthritis cannot be cured, you can learn to reduce pain, maintain mobility, and use medications to manage symptoms or slow the progression of the disease.

The most common form of chronic arthritis is osteoarthritis. It is the arthritis that generally affects us as we age, causing knobby fingers, swollen knees, or back pain. Osteoarthritis is not caused by inflammation, although sometimes it may result in inflammation of a joint. The cause of osteoarthritis is not precisely known but involves deterioration or a wearing away of the cartilage that cushions the ends of bone together with degeneration of bones, ligaments, and tendons associated with the joint.

Many other kinds of chronic arthritis are due to inflammation. The most common forms are those caused by rheumatic diseases such as rheumatoid arthritis, metabolic diseases such as gout, and psoriasis. With these diseases, the lining of the joint becomes inflamed and swollen and also secretes extra fluid. As a result, the joint becomes swollen, warm, red, tender, and painful to move. If present for a time, inflammatory arthritis can also result in destruction of cartilage and bone. Such destruction can ultimately lead to deformity. The cause of the inflammation associated with these diseases is not precisely known, but with respect to gout, it is clearly related to the formation of uric acid crystals in the joint fluid, and in the case of rheumatic diseases, it is thought to be due to a form of autoimmunity (an immune or allergic reaction of the body against itself).

Most arthritic diseases do not affect only the joints. Joints are crossed by tendons from nearby muscles that move the joints and by ligaments that stabilize the joints. When the joint lining is inflamed or the joint is swollen or deformed, those tendons, ligaments, and muscles can be affected. They may become inflamed, swollen, stretched, displaced, thinned out, or even broken. Also, in many places where tendons or muscles move over each other or over bones, there are lubricated surfaces to make the movement easy. These surfaces are called bursas. With arthritis, they too may become inflamed or swollen, causing bursitis. Thus arthritis of any kind does not simply affect the joint. It can affect all of the structures in the area around the joint.

Consequences of Arthritis

The irritation, inflammation, swelling, or joint deformity of arthritis can cause pain. The pain may be present all the time or only sometimes, as when moving the joint. Of all the symptoms of arthritis, pain is the most common.

Arthritis can also limit movement. The limitation may be due to pain, to swelling that prevents normal bending, to deformity of the joint or tendons, or to weakness in nearby muscles.

In addition, arthritis can cause problems in areas distant from the joint. For example, if arthritis affects the joints of one leg, that leg may be favored during walking or other motion. The person’s posture is altered, and an extra burden is placed on other muscles and joints. Abnormal posture or extra burdens can create pain on the other side of the body or in areas distant from the site of the arthritis.

Stiffness of joints and muscles may also occur, particularly after periods of rest such as sleeping and sitting. The stiffness makes it difficult to move. However, if you are able to get going, or if you can get heat to the affected joint and muscles (hot pad or hot shower), the stiffness may lessen or disappear. For most people, the stiffness lasts only a short while; for others it can last all day.

Another common consequence of arthritis is fatigue. Here again, the precise cause is not known. Inflammation itself causes fatigue. So does chronic pain, and so does the effort of movement when joints and muscles don’t work right. In addition, fatigue can be caused by the worries and fears that often accompany arthritis. Whatever its cause or combination of causes, fatigue is an issue most arthritis patients must confront.

Depression may also accompany chronic arthritis. People with chronic arthritis often have trouble doing what they need or want to do. This can make them feel helpless, angry, and withdrawn, which may lead to depression. Depression can make other symptoms such as pain, fatigue, and disability seem worse. It can reduce an individual’s work or social functioning. It can damage family relationships, as well as the capacity for independent living. Usually the depression is the situational type, meaning that it comes from the difficulties caused by the arthritis and is not a mental illness. Often it improves when the arthritis improves, but it can also be helped through self-management practices (see Chapter 2), managing pain and depression (see Chapter 4), and by the use of antidepressant medication.

Fibromyalgia is a condition that sometimes accompanies chronic arthritis but usually exists alone. Though not inflammatory, it creates muscle tenderness and joint pain similar to that of chronic inflammatory arthritis. The cause is not yet known. Anti-inflammatory treatment does not usually help. However, much of the self-management therapy used by patients with chronic arthritis is beneficial for people with fibromyalgia.

Although arthritis can have very damaging effects, much can be done to offset or eliminate these effects. The remainder of this chapter will describe aspects of appropriate management and lead you to helpful self-management techniques described in detail elsewhere in this book.

Prognosis: What Does the Future Hold?

Most chronic arthritic diseases, if left untreated, would have different outcomes for different people. Some people would progress more or less steadily, with increasing disability. Others would experience disease that waxed and waned over many years, possibly getting slowly worse but maybe not. Some individuals might even have the disease or symptoms disappear spontaneously. With modern treatment, most patients can be helped to reduce the limitations from their arthritis, and in some the progression can be slowed or stopped.

There is no real cure for any of the forms of chronic arthritis. As just noted, for some fortunate people, the arthritis will subside partly or completely on its own. Medical treatment can usually suppress the inflammation and the symptoms but must often be continued for long time periods. Proper self-management can greatly enhance improvement and the prevention of disability. This depends largely on the participation of the person with arthritis and sometimes the person’s family. Therefore, a prognosis—what the future holds—cannot be predicted accurately for any individual. It depends partly on medical treatment, partly on the individual’s own self-management efforts, and partly on good fortune.

Because there is no cure for chronic arthritis, medical treatment is aimed at preventing or controlling inflammation, swelling, and pain and improving physical function. The medications commonly used either help pain or reduce inflammation and swelling, or do both. When inflammation is reduced, pain usually declines and function increases.

It is important to realize that most people with chronic arthritis can lead normal or nearly normal lives. Proper use of medications and self-management practices make this possible. Thus one should not abandon major life plans. Rather, one should adjust them to accommodate treatment needs and remember that treatment plans can often be modified to meet the particular needs or wishes of the person with chronic arthritis.

Common Types of Arthritis and Their Treatment

As noted earlier, arthritis can be the result of either loss of cartilage or bone in a joint or inflammation of a joint. Treatment depends on the type.

Osteoarthritis

Osteoarthritis is a result of degenerative changes in the cartilage and bones in joints. Cartilage cushions the ends of bones and allows them to move smoothly over one another. Because of this degeneration, the bone surfaces become rough and painful when in motion. The roughness may also irritate the joint lining (the synovium), causing it to produce more than normal amounts of joint fluid. The extra fluid results in swelling. Occasionally, small pieces of damaged cartilage will break off, float in the fluid, catch on a moving surface, and increase pain. Also, bone ends may grow small spurs (called osteophytes) that create, for instance, knobs on fingers and heel spurs. Although osteoarthritis can affect any joint, it most commonly affects the hands, knees, hips, shoulders, and spine. In general, its presence increases as we age.

The cause of osteoarthritis is not known, and there is no specific medical treatment to prevent or arrest the degenerative changes. Treatment is therefore aimed at maintaining joint function and reducing pain.

With osteoarthritis, the saying “use it or lose it” is particularly true. Unless the affected joints are used, they will slowly lose mobility, and the surrounding muscles and tendons will weaken. Fortunately, exercise will not make the osteoarthritis worse, and as movement improves with exercise and surrounding tissues strengthen, pain often declines. Thus exercise is the centerpiece of treatment. Use of exercise is discussed later in this chapter and Chapters 7 and 8 of this book.

Because osteoarthritis damages joint cartilage, an exercise program also protects cartilage. Cartilage needs joint motion and some weight bearing to stay healthy. In much the same way that a sponge soaks up and squeezes out water, joint cartilage soaks up nutrients and fluid and gets rid of waste products by being squeezed when you move the joint. If the joint is not moved regularly, cartilage deteriorates.

To help with osteoarthritic pain, the best medications are acetaminophen (Tylenol) and aspirin. Drugs such as ibuprofen (Motrin) and naproxen (Aleve), along with aspirin, are known as nonsteroidal anti-inflammatory drugs, or NSAIDs. When there is no inflammation involved in the arthritis, as is commonly the case with osteoarthritis, the anti-inflammatory activity of these drugs is not important. The benefit from these anti-inflammatory medications comes from their pain-reducing effect, which is similar to that of aspirin. Therefore, aspirin or acetaminophen (Tylenol) is usually as effective as the NSAIDs.

Heat to the joint and pain-controlling measures such as relaxation and cognitive distraction can be very helpful (see Chapter 5). Heat before exercise often makes the exercise easier. For pain at night in hands, feet, or knees, gloves, socks, and a sleeve over the knees can greatly improve sleep.

When swelling from irritation or mild inflammation is present, draining and injection of the joint with a corticosteroid medication often corrects the problem, sometimes with lasting benefit.

If the disease progresses to deformity, discomfort, and weakness that make normal living impossible, surgical joint replacement is available. Artificial joints commonly function like normal joints and permit recovery of lost strength in muscles and tendons.

Two additional therapies for osteoarthritis have been introduced. Both are intended to improve damaged cartilage or substitute for it. One is glucosamine, taken daily in pill form. The other is hyaluronan, injected into the joint as a lubricant. Studies suggest that glucosamine diminishes symptoms from osteoarthritis in the short term with potency similar to low doses of aspirin. However, the studies are not definitive, and long-term outcomes have not been established. Fortunately, glucosamine appears to have no significant adverse effects. Use of hyaluronan is more complicated because it requires injections into the joint and is also expensive. But as of this writing, both methods of treatment appear not to be of certain benefit to people with osteoarthritis, and they have no theoretical or practical value in other forms of arthritis.

Chronic Inflammatory Arthritis

The rheumatic diseases (rheumatoid arthritis, lupus erythematosus, and others), psoriasis, and gout are the commonest forms of chronic inflammatory arthritis. Inflammatory arthritis can also occur in association with inflammatory diseases of the intestines or liver. It may appear with infections such as Lyme disease or streptococcal and virus illnesses. In those settings, it will sometimes clear with antibiotic treatment or with time, but sometimes it will become chronic.

The most commonly used medications for chronic inflammatory arthritis, with the exception of gout, fall into the following categories:

Nonsteroidal anti-inflammatory drugs (NSAIDs). As noted earlier, these drugs have both pain-reducing and anti-inflammatory effects. They are usually the first drugs used to treat arthritis because they are often helpful and tend to have the least severe side effects. Representatives of this group include aspirin, ibuprofen (Motrin), naproxen (Naprosin, Aleve), sulindac (Clinoril), and diclofenac (Voltaren). Acetaminophen (Tylenol), though not an NSAID, is also used to reduce pain, but it has no anti-inflammatory effect. Most of the NSAIDs can damage the stomach and intestines, but this can be minimized by always taking the medications in the middle of a meal. This sounds simple, but many people don’t follow this advice all the time.

A few years ago, three new NSAIDs became available: celecoxib (Celebrex), rofecoxib (Vioxx), and valdecoxib (Bextra). They were designed to have anti-arthritic abilities similar to other NSAIDs but to be less damaging to the stomach and intestines. However, Vioxx and Bextra have been withdrawn from sale or restricted in use because over time they can cause heart and blood vessel disease. Celebrex remains available.

“Disease-modifying” drugs. The drugs in this category are all anti-inflammatory drugs, more powerful than the NSAIDs but also potentially more toxic. The term “disease-modifying” implies slower progression or reversal of inflammatory arthritis, but healing from these drugs usually does not occur. Members of this group are gold (Myochrysine), methotrexate (Rheumatrex), sulfasalazine (Azulfidine), hydroxychloroquine (Plaquenil), and leflunomide (Arava). They are usually used in inflammatory arthritis if NSAIDs fail. They are not used for osteoarthritis.

In recent years, evidence has emerged indicating that earlier use of “disease-modifying” agents slows the progression of the disease. Because the NSAIDs do not achieve such slowing, most patients with rheumatoid arthritis now receive treatment with second-line agents early in the course of their disease. Such an early benefit from “disease-modifying” drugs may also be true for other forms of chronic inflammatory arthritis. Use of these medications should be discussed with a rheumatologist, a physician with special training in treating arthritis and associated diseases.

Corticosteroids. Corticosteroids are powerful anti-inflammatory drugs that also suppress immune function. Both effects are helpful with inflammatory arthritis, especially for rheumatic diseases in which the body’s immune system appears to play a role in causing the disease (autoimmune disease). Most corticosteroids in use are synthetic versions of a normal human hormone, cortisol, which is present in everybody. Corticosteroids are the most rapid-acting and effective of the anti-arthritic drugs but may cause serious adverse effects when used for long periods of time. Prednisone (Deltazone) is the most commonly used corticosteroid and is often given with another anti-inflammatory drug to get a faster response.

Cytotoxic drugs. These drugs, developed to treat cancer, also have anti-inflammatory and immunosuppressive effects. Examples include cyclophosphamide (Cytoxan), azathioprine (Imuran), cyclosporine (Neoral), mycophenolate (CellCept), and rituximab (Rituxan). These drugs can be quite toxic but also very effective. They are usually used only after other drugs have failed to control the problem. They are never used for osteoarthritis.

New biological agents. A biological material called tumor necrosis factor (TNF) plays an important role in the inflammation of rheumatoid arthritis. TNF is a product of cells involved in the inflammatory and immune responses and is a member of the cytokine family. Two methods of counteracting TNF have been developed. One treatment uses an antibody to TNF called infliximab (Remicade) or adalimumab (Humira). The other treatment method uses a soluble receptor obtained from cells to neutralize the TNF. This material is called etanercept (Enbrel). Remicade is given intravenously, whereas Humira and Enbrel are injected subcutaneously (under the skin). Antibodies to other cytokines have been developed and can sometimes be effective. The new biological therapies can be very helpful when other treatments fail. However, their effects may not last, they can occasionally cause serious infections, and they are expensive.

For gout, the main treatment goal is reducing the blood uric acid level with drugs such as allopurinol (Zyloprim), colchicine (Colcrys), probenecid (Benuryl), and the newer febuxostat (Uloric). For chronic gout arthritis, most of the drugs and other methods of management for chronic inflammatory arthritis are also used.

For inflammatory arthritis, drugs are frequently used in combination. The combinations are usually based on the individual’s response to particular drugs. Thus many combinations are used, sometimes including the biological agents. Although a certain combination may work best for a particular person, recent evidence indicates that no one combination is clearly superior to the others.

Some years ago, each type of inflammatory arthritis was treated with a particular group of drugs. Today, almost all of the drugs discussed here are used for any type of inflammatory arthritis. The choice of drugs depends on the person’s condition and responses; commonly, milder drugs are used first, and more powerful ones are used when milder ones fail. However, as mentioned earlier, stronger drugs are now often used earlier in rheumatoid arthritis in an effort to prevent joint destruction.

It is almost impossible to predict beforehand whether any of the drugs will be helpful. Therefore, the treatment of chronic arthritis with drugs is a trial-and-error process. For chronic inflammatory arthritis, only occasionally do drugs other than corticosteroids provide an immediate benefit. Usually many days or even weeks are necessary before the full effects of the drug are felt.

Problems can be caused by the toxic effects of the drugs. All drugs can cause harm as well as benefit. Sometimes a particular drug can be very helpful for the arthritis but also cause so much harm that it cannot be used. Again, it is impossible to predict which drugs will be harmful in an individual patient. With some of the drugs, toxic effects cannot be recognized by the individual, and so the individual must be monitored with blood counts, liver function studies, analyses of urine, or other tests. People starting on any drug treatment for chronic arthritis should make sure they understand the signs and symptoms of potential harm, including rash, upset stomach, or unusual thoughts, and notify the physician if such symptoms appear. Also, discuss with your doctor whether you need to have regular blood or urine tests to monitor for toxic effects of the medications.

The unpredictability of benefits and harms from drug therapy creates uncertainty for both the patient and the physician. The best way to deal with this uncertainty is to ensure that you understand the treatment plan and the alternatives and that you have a clear way to communicate with the physician if the plan is not succeeding.

Sometimes, despite drug treatment, joints are damaged to the point where they no longer work effectively. Fortunately, modern surgical techniques allow for replacement of many types of joints, and replacement joints often function almost as well as natural joints. This is especially true for hips and knees. Modern surgery is efficient, and recovery is usually rapid.

Other Ways to Manage Chronic Arthritis

In addition to treatment with drugs or surgery, there are many other management approaches to achieve good results with chronic arthritis.

The goal of proper management is not just to avoid pain and reduce inflammation; it is to maintain the maximum possible use of affected joints. This involves maintaining the greatest motion of the joint and the greatest strength in muscles, tendons, and ligaments surrounding the joint. The key to this goal is exercise, which is an essential part of any good management program. The exercise should be regular, consistent, and as vigorous as possible. Exercise will not make the arthritis worse. In fact, failing to exercise can increase arthritis symptoms because of loss of joint mobility and physical deconditioning. Although exercise may increase pain temporarily, this is normal during joint and muscle reconditioning.

Maintaining good posture and normal motion of joints helps protect joints from deterioration, sustains mobility, and eases pain. The inactivity that results from long time periods spent sitting or lying down can worsen posture, reduce joint flexibility, and cause weakness even in the joints not affected by arthritis. Also after inactivity, especially sleeping, stiffness is common. It can be reduced by mild exercise in bed before arising or by a hot bath or shower. For some people, mild exercise before going to bed will reduce stiffness the next morning.

Appropriate exercise programs are described in Chapters 6, 7, and 8, and more specific recommendations for people with arthritis are found later in this chapter. It is wise to exercise as many joints as possible, including those without arthritis, in order to maintain general physical condition. However, chronic arthritis can affect the bones of the neck. Therefore, to prevent nerve damage, it is best to avoid extreme neck movements and strong pressure on the back of the neck or head. Because heat makes exercise easier, it is helpful to exercise when warm. Examples are exercise during or after a bath and, for hands and wrists, after washing dishes.

In addition to improving mobility, heat is also useful to reduce pain in joints and muscles, at least temporarily. When combined with rest, it can be very soothing. Alternatively, some people find cooling a warm joint with ice to be helpful. Cooling, however, does not increase mobility.

Control of fatigue is important. Rest periods between activities and restful sleep at night are essential for control (see Chapter 8 on sleeping better). When pain disturbs sleep at night, different types of beds (firm beds, foam beds, air beds) and the use of mild sleep medications can be of significant help. For some people with arthritis, low doses of antidepressive medication at bedtime will effectively control night pain and improve sleep.

Sometimes when joint function remains limited, use of assistive devices can be of benefit. Many types of devices are available (braces, canes, special shoes, grippers, reachers, walkers).

What you eat has little effect on most types of chronic arthritis, particularly osteoarthritis and rheumatoid arthritis. What you eat, however, is important for gout, where use of alcohol and eating certain meats can provoke attacks. People with gout should discuss this with their physicians. In rare cases, food allergies can cause attacks of arthritis. There is some evidence that eating oils from cold-water fish can help people with rheumatoid arthritis; however, the benefit is small. Of course, if you are overweight, losing weight can reduce the extra burden on joints, especially those that bear weight (hips, knees, feet). People with chronic arthritis should eat balanced, pleasurable meals and maintain a normal weight. Ways to do this are discussed in Chapters 11 and 12.

It is not surprising that sometimes in the struggle against arthritis, an individual becomes depressed. Usually this is a situational depression resulting from the consequences of chronic arthritis and not a mental illness. It is important to recognize the depression and to seek advice from health professionals. There are many ways to combat depression; the important thing is to know it is present and take steps to control it. (see Chapter 4).

Most people with chronic arthritis are able to lead productive, satisfying, and independent lives. The most important step in achieving this is to take an active part in managing your own arthritis. All of the components of management mentioned here either are the responsibility of the individual or are best done with the individual’s participation.

Osteoporosis

Osteoporosis is not arthritis but rather a condition that is usually a result of aging and affects the bones. In osteoporosis, bones lose calcium and become more brittle. Then they are more susceptible to fracture than normal.

Normal bone structure is maintained primarily by calcium and vitamin D intake and physical activity. In women, it is also maintained by estrogen, so after menopause, when estrogen production declines, osteoporosis increases. As we age and are less physically active, bone weakening becomes more likely. In addition, the risk of osteoporosis is increased by smoking and heavy drinking, by some endocrine diseases, and by long-term use of corticosteroids as medications. This last is especially important for patients with inflammatory arthritis who must often use corticosteroids for treatment.

Although osteoporosis can cause bone pain, it usually does not cause specific symptoms. Therefore, the diagnosis is made by bone imaging. Because X-rays can detect only advanced osteoporosis, the imaging is done with a DXA scan, which measures bone mineral density. Most physicians use the DXA scan for people who are at risk of osteoporosis; the result allows them to establish the diagnosis, determine its severity, and guide treatment.

The prevention and treatment of osteoporosis involve the dietary supplements and actions listed in the box on page 283. An appropriate intake of calcium and vitamin D is particularly important. If the osteoporosis does not respond to these steps or is severe, there are medications that strengthen bones, primarily estrogens and bisphosphonates, such as alendronate (Fosamax), ibandronate (Boniva), and risedronate (Actonel). If you cannot tolerate bisphosphonates or can’t take them for another medical reason, you may benefit from another class of medicines known as selective estrogen receptor modulators (SERMs) such as raloxifene (Evista). SERMs produce estrogen-like effects on bones and reduce the risk of vertebral fractures. They are less effective than bisphosphonates, but they can still be helpful. Use of these drugs should be discussed thoroughly with your physician; although they are generally safe, they can have adverse effects.

A mild form of osteoporosis called osteopenia can also be diagnosed by DXA scan. This can usually be managed by the supplements and actions in the box on page 283, and medications are unnecessary unless the osteopenia is progressing.

Exercising with Arthritis or Osteoporosis

Regular exercise is crucial to the management of all types of chronic arthritis and osteoporosis.

Osteoarthritis

Because osteoarthritis begins as primarily a problem with joint cartilage, an exercise program should include taking care of cartilage. Cartilage needs joint motion and some weight bearing to stay healthy. As noted earlier, in much the same way that a sponge soaks up and squeezes out water, joint cartilage soaks up nutrients and fluid and gets rid of waste products by being squeezed when you move the joint. If the joint is not moved regularly, cartilage deteriorates.

Any joint with osteoarthritis should be moved through its full range of motion several times daily to maintain flexibility and cartilage health. Judge your activity level so that pain is not increased. If hips and knees are involved, walking and standing should be limited to 2 to 4 hours at a time, followed by at least an hour off your feet to give the cartilage time to decompress. Using a cane on the opposite side of the painful hip or knee will reduce joint stress and often get you over a rough time. Good posture, strong muscles, and good endurance, as well as shoes that absorb the shocks of walking, are important ways to protect cartilage and reduce joint pain. Knee-strengthening exercises (Exercises 15, 18, and 19 in Chapter 7) performed daily can help reduce knee pain and protect the joint. Being overweight makes knee pain worse, and losing weight can reduce pain. Regular exercise is an important part of losing weight and keeping it off.

Chronic Inflammatory Arthritis

Exercise will not damage joints in chronic arthritis and is important for all types of chronic inflammatory arthritis. Its purposes are to maintain joint mobility, strengthen ligaments and tendons around the joint, and maintain or increase the strength of muscles that move the joint. Gentle flexibility exercises can also help with morning stiffness. When the joint is inflamed, mild exercise in all joint motions is good within the limits created by pain. When the inflammation is suppressed or eliminated by medication, full regular exercise is desirable. It should be done daily. Specific types of exercise are described in Chapter 7. They involve all the movements normal to the involved joint and should be done against increasing resistance (weights, elastic bands, compressible balls, spring structures). The goal is to achieve maximum function for the affected joints, and that is possible for most people.