Non-Surgical Treatments for Arthritis
Topic: Arthritis Treatment
By William Stillwell M.D.
The aging of the Baby Boomer Generation, the leading edge of which is now entering its sixties, brings with it a flood of degenerative diseases, including the various forms of arthritis. Because of the widespread pain and disability caused by arthritis, and the vast resources consumed in its treatment, arthritis is becoming a major health problem.
There are two main forms of arthritis--degenerative or osteoarthritis and inflammatory arthritis. OA is by far the more common disease, afflicting many of us as we age. Though commonly thought of as "wear and tear" arthritis, it's actually a much more complex biological problem, in which the protective coating of articular cartilage first loses water, then becomes soft, fragments and eventually erodes to expose the underlying bone. The "how" is well described, though the "why" is still unknown, save for cases where injury or trauma has caused cartilage damage. In response to this cartilage damage, the lining of the joint, the synovium, becomes secondarily inflamed, producing excessive joint fluid and joint swelling.
By contrast, inflammatory arthritis is a primary disease of the synovium. When this membrane becomes inflamed, it thickens and swells and produces destructive enzymes (erosive chemicals), which literally digest and ultimately destroy the articular cartilage, exposing the underlying bone. Another major difference from OA is that an inflammatory arthritis is a systemic disease, which affects the entire body, not only joints, but other connective tissues, as well. For this reason, they are often referred to as collagen diseases, named after the protein collagen from which the connective tissues are made.
There are a host of diseases classified as inflammatory arthritis, but the prototype for this group of diseases is Rheumatoid Arthritis. RA is theorized to be an autoimmune disease, that is, the body's own immune system erroneously behaves as though the body's own tissues are foreign and attacks them.
Though its cause is not known, it is likely there is a genetic predisposition to this disease, as it is more common in women and more common when a parent, or grandparent has had the disease.
If complete destruction of the articular cartilage has occurred within the joint, with broad surfaces of completely exposed, bare bone, nothing short of a total joint replacement will relieve pain, restore function and correct deformity. However, joint replacement is a major surgical procedure, with a number of potential risks. So it's best avoided until a joint is truly end stage and there is no other alternative. I believed that when I was actively performing those procedures, and I believe it now.
Fortunately, there are a number of other treatments and non-surgical methods from across the entire medical spectrum, including mainstream conventional, alternative and complimentary techniques. The object is to relieve pain, prevent or at least delay irreparable cartilage damage, and so avoid surgery, as long as possible. To this end, treatment goals are first, pain relief and then, restoration of function.
Pain is a result of chemical and mechanical stimulation of pain nerves within the subchondral bone and within the synovium and soft tissues around the joint. The cartilage itself has no nerves and can feel no pain. So to effect this, anti-inflammatory measures, combined with weight loss, behavior modification and analgesics help to relieve joint pain.
Actual weight reduction is helpful because for every pound of bodyweight lost, the force across the weightbearing joints (hip & knee) is reduced by three to four pounds. In addition, the use of a cane, crutches, or a walker can also lighten the load a joint carries, as well as providing stability. Appropriate bracing, with either custom or off-the-shelf braces can restore stability, optimal joint alignment and optimize distribution of joint forces. Well cushioned shoes are also effective as they absorb the shocks of walking. And avoiding those activities that subject the joints to increased joint forces and shocks, like running or jumping (eight to ten times bodyweight), will slow the degenerative process.
Anti-inflammatory measures are effective for both degenerative and inflammatory arthritis, because inflammation plays a role in producing pain in each. OTC NSAID's (Non-Steroidal Anti-Inflammatory Drugs) like Advil or Aleve can be effective, as can their prescription strength forms. These drugs, however, MUST be taken with FOOD or MILK, to protect the stomach from excess acidity, reflux, ulcer production or bleeding, which are well known side effects of these medications. This also applies to Aspirin, which should NOT be taken with NSAID's, as they both share the same side effects.
Tylenol (acetaminophen) CAN be taken, though, as it relieves pain (and reduces fever, like aspirin), but has NO anti-inflammatory effects, nor the side effects of NSAID's. Stronger analgesics, like Codeine, Darvon, Hydrocodone (Vicodin), Percocet (Oxycodone), etc. are narcotics and are only available by prescription, under a physician's supervision. Their main downside is the potential for addiction. There are some non-narcotic analgesics, like Ultram, but these too are prescription drugs.
A number of Disease Modifying Agents, like methotrexate are especially effective in controlling the inflamed synovium of inflammatory arthritis. These medications, and others like Ridaura, Humera, and Enbrel or some combinations of these may be effective, but require close monitoring by blood tests and the close supervision of a physician, preferably a rheumatologist (specialist in arthritic diseases).
Dietary measures to relieve pain include avoidance of red meat and other sources of arachadonic acid, which is a chemical precursor to prostaglandins (chemical mediators of pain). The use of Omega 3 Fatty Acids found in Fish Oil or Flax Seed Oil is also effective, due to its intrinsic anti-inflammatory properties. Vitamin E has anti-inflammatory properties, as well. Glucosamine sulfate, with or without Chondroitin sulfate has generated mixed reviews in a number of studies, in the US and Europe. But except for a tendency to elevate blood sugars in diabetics, it is harmless, may support articular cartilage and provide some pain relief. Various herbs, including ginger, turmeric, devil's claw, and enzymes like bromelain have known anti-inflammatory effects.
Topical measures include counter-irritants, like capsaician sprays and creams, derived from the oil of hot peppers, which can relieve pain. DMSO (Dimethyl Sulfoxone), a by-product of wood chips, has its own anti-inflammatory properties and in addition is a carrier molecukle--it can carry other substances through the skin to the tissues below, like steroids (hydrocortisone), or analgesics (morphine). Used by vetrinarians and athletic trainers with good effect for years, it is still not FDA approved for this purpose and must be used with caution.
Alternative methods include accupressure or accupuncture, chiropractic, physical therapy modalities (like ultrasound, diathermy, iontophoresis, cold laser, hydrotherapy, and massage therapy) and of course, strengthening and stretching exercises, for long term joint support and optimal function.
All these methods are effective for some people, but often work best in combination. The trick is to find that individualized combination that works for you. Getting your doctor involved early in that process is probably the best thing you can do. But regardless which methods you and your doctor choose, as you can see, although there is no cure for arthritis, there are many non-operative ways that you can relieve pain and maintain or restore function, while avoiding, or delaying surgery.
(c) 2008 W. Stillwell, MD
Dr. Bill is the on-line handle for William Thomas Stillwell, MD, FACS, FICS, FAAOS, FAANAOS, FAAPGS, board certified orthopaedic specialist, Chairman Emeritus, Department of Orthopaedic Surgery, St. Catherine of Siena Medical Center, Smithtown, NY and Associate Professor of Clinical Orthopaedic Surgery, SUNY at Stony Brook, NY; President & CEO of Dr. Bill's Clinic, Inc. and author of DR. BILL'S LITTLE GREEN BOOK FOR ELIMINATING KNEE PAIN, DR. BILL'S PAIN-FREE PROGRAM: EXERCISES TO PREVENT OR ELIMINATE KNEE PAIN and HOW TO AVOID KNEE SURGERY. For a FREE report: SECRETS TO RELIEVING KNEE PAIN, go to http://www.drbillsclinic.com/
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