Osteoarthritis http://www.nlm.nih.gov/medlineplus/ency/article/000423.

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Alternative names
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Hypertrophic osteoarthritis; Osteoarthrosis; Degenerative joint disease; DJD; OA; Arthritis osteoarthritis Definition
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Osteoarthritis is the most common joint disorder. The chronic disease causes the cushioning (cartilage) between the bone joints to wear away, leading to pain and stiffness. It can also cause new pieces of bone, called bone spurs, to grow around the joints. Causes, incidence, and risk factors
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Most of the time, the cause of osteoarthritis (OA) is unknown. It is primarily a disease due to aging. However, metabolic, genetic, chemical, and mechanical factors can play a role in its development. Symptoms of osteoarthritis usually appear in middle age and is present in almost everyone by the age of 70. Before the age of 55 it occurs equally in both sexes. However, after 55 it is more common in women. The cartilage of the affected joint becomes rough and wears down (degenerates). As the disease gets worse, the cartilage disappears and the bone rubs on bone. Bony spurs usually develop around the joint. OA is classified as primary or secondary. Primary OA occurs without any type of injury or identifiable cause. Secondary OA is osteroarthritis due to another disease or underlying condition. The most common causes of secondary OA are metabolic conditions, such as acromegaly, problems with anatomy (for example, being bow-legged), injury, or inflammatory disorders like septic arthritis. Symptoms
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gradual and subtle onset of deep aching joint pain o worse after exercise or weight bearing o often relieved by rest joint swelling limited movement morning stiffness grating of the joint with motion joint pain in rainy weather

Note: There may be no symptoms. Signs and tests

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A physical exam can show limited range of motion, grating of a joint with motion, joint swelling, and tenderness. An x-ray of affected joints will show loss of the joint space, and in advanced cases, wearing down of the ends of the bone and bone spurs. Treatment
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The goals of treatment are to relieve pain, maintain or improve joint mobility, increase the strength of the joints, and minimize the disabling affects of the disease. The specific treatment depends upon the affected joints. MEDICATIONS The most common type of medication used to treat osteoarthritis are nonsteroidal, antiinflammatory drugs (NSAIDs). They are common pain relievers that reduce pain and swelling. Types include aspirin, ibuprofen (Motrin, Advil, Nuprin), and naproxen (Aleve, Naprosyn, Naprelan, Anaprox). Although NSAIDs work well, long-term use can cause stomach problems, such as ulcers and bleeding. In April 2005, the FDA asked drug manufacturers of NSAIDs to include a warning label on their product that alerts users of an increased risk for cardiovascular events and gastrointestinal bleeding Other medications used to treat OA include: COX-2 inhibitors (coxibs). Coxibs block an inflammation-promoting enzyme called COX2. This class of drugs was initially believed to work as well as traditional NSAIDs, but with fewer stomach problems. However, numerous reports of heart attacks and stroke have prompted the FDA to re-evaluate the risks and benefits of the COX-2s. Rofecoxib (Vioxx) and valdecoxib (Bextra) have been withdrawn from the U.S. market following reports of heart attacks in some patients taking the drugs. Celecoxib (Celebrex) was still available at the time of this report, but labeled with strong warnings and a recommendation that it be prescribed at the lowest possible dose for the shortest duration possible. Patients should ask their doctor whether the drug is appropriate and safe for them. Steroids. These medications are injected directly into the joint. They may also be used to reduce inflammation and pain. Supplements. Many people are helped by over-the-counter remedies like glucosamine and chondroitin sulfate. There is some evidence that these supplements are helpful in controlling pain, although they do not appear to grow new cartilage. Artificial joint fluid (Synvisc, Hyalgan). These medications can be injected into the knee, They may temporary relief pain for up to six months.

LIFESTYLE CHANGES Exercise helps maintain joint and overall mobility. Ask your health care provider to recommend an appropriate home exercise routine. Water exercises, such as swimming, are especially helpful. Heat and cold treatments, protection of the joints, the use of self-help devices and rest are all recommended. Good nutrition and careful weight control are also important. Weight loss for overweight individuals will reduce the strain placed on the knee and ankle joints.

PHYSICAL THERAPY Physical therapy can be useful to improve muscle strength and the motion at stiff joints. Therapists have many techniques for treating osteoarthritis. If therapy does not make you feel better after 3-6 weeks, then it will likely will not work at all. SURGERY Surgery to replace or repair damaged joints may be needed in severe, debilitating cases. Surgical options include: Arthroplasty (total or partial replacement of the deteriorated joint with an artificial joint -see knee arthroplasty, hip arthroplasty ) Arthroscopic surgery to trim torn and damaged cartilage and wash out the joint Osteotomy (change in the alignment of a bone to relieve stress on the bone or joint) Arthrodesis (surgical fusion of bones, usually in the spine)
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Support Groups

For additional information and support, see arthritis resources. Expectations (prognosis)
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Movement may become very limited. Treatment generally improves function. OA is the leading cause of disability in industrialized nations. Complications
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Decreased ability to walk Decreased ability to perform activities of daily living, such as personal hygiene, house chores, or cooking Adverse reactions to drugs used for treatment Surgical complications
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Calling your health care provider

Call your health care provider if you have symptoms of osteoarthritis. Prevention
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Weight loss can reduce the risk of developing knee osteoarthritis in overweight women.

Osteoarthritis

Osteoarthritis is a chronic disease of the joint cartilage and bone, often thought to result from "wear and tear" on a joint, although there are other causes such as congenital defects, trauma and metabolic disorders. Joints appear larger, are stiff and painful and usually feel worse the more they are used throughout the day. Update Date: 7/3/2004

Osteoarthritis

Osteoarthritis is associated with the aging process and can affect any joint. The cartilage of the affected joint is gradually worn down, eventually causing bone to rub against bone. Bony spurs develop on the unprotected bones causing pain and inflammation. This booklet is for people who have osteoarthritis, their families, and others interested in learning more about the disorder. The booklet describes osteoarthritis and its symptoms and contains information about diagnosis and treatment, as well as current research efforts supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and other components of the National Institutes of Health (NIH). It also discusses pain relief, exercise, and quality of life for people with osteoarthritis. If you have further questions after reading this booklet, you may wish to discuss them with your doctor.

What Is Osteoarthritis?
Osteoarthritis (AH-stee-oh-ar-THREYE-tis) is the most common type of arthritis, especially among older people. Sometimes it is called degenerative joint disease or osteoarthrosis. Osteoarthritis is a joint disease that mostly affects the cartilage (KAR-til-uj). Cartilage is the slippery tissue that covers the ends of bones in a joint. Healthy cartilage allows bones to glide over one another. It also absorbs energy from the shock of physical movement. In osteoarthritis, the surface layer of cartilage breaks down and wears away. This allows bones under the cartilage to rub together, causing pain, swelling, and loss of motion of the joint. Over time, the joint may lose its normal shape. Also, bone spurs--small growths called osteophytes--may grow on the edges of the joint. Bits of bone or cartilage can break off and float inside the joint space. This causes more pain and damage. People with osteoarthritis usually have joint pain and limited movement. Unlike some other forms of arthritis, osteoarthritis affects only joints and not internal organs. For example, rheumatoid arthritis--the second most common form of arthritis--affects other parts of the body besides the joints. It begins at a younger age than osteoarthritis, causes swelling and redness in joints, and may make people feel sick, tired, and (uncommonly) feverish.

Who Has Osteoarthritis?

Osteoarthritis is one of the most frequent causes of physical disability among adults. More than 20 million people in the United States have the disease. By 2030, 20 percent of Americans--about 70 million people--will have passed their 65th birthday and will be at risk for osteoarthritis. Some younger people get osteoarthritis from joint injuries, but osteoarthritis most often occurs in older people. In fact, more than half of the population age 65 or older would show x-ray evidence of osteoarthritis in at least one joint. Both men and women have the disease. Before age 45, more men than women have osteoarthritis, whereas after age 45, it is more common in women.

How Does Osteoarthritis Affect People?

Osteoarthritis affects each person differently. In some people, it progresses quickly; in others, the symptoms are more serious. Scientists do not know yet what causes the disease, but they suspect a combination of factors, including being overweight, the aging process, joint injury, and stresses on the joints from certain jobs and sports activities. What Areas Does Osteoarthritis Affect?

Osteoarthritis most often occurs at the ends of the fingers, thumbs, neck, lower back, knees, and hips. Osteoarthritis hurts people in more than their joints: their finances and lifestyles also are affected. Financial effects include The cost of treatment Wages lost because of disability.

Lifestyle effects include Depression Anxiety Feelings of helplessness Limitations on daily activities Job limitations Trouble participating in everyday personal and family joys and responsibilities.

Despite these challenges, most people with osteoarthritis can lead active and productive lives. They succeed by using osteoarthritis treatment strategies, such as the following: Pain relief medications Rest and exercise Patient education and support programs Learning self-care and having a "good-health attitude."

Osteoarthritis Basics: The Joint and Its Parts

Most joints--the place where two moving bones come together--are designed to allow smooth movement between the bones and to absorb shock from movements like walking or repetitive movements. The joint is made up of: Cartilage: a hard but slippery coating on the end of each bone. Cartilage, which breaks down and wears away in osteoarthritis, is described in more detail below. Joint capsule: a tough membrane sac that holds all the bones and other joint parts together. Synovium (sin-O-vee-um): a thin membrane inside the joint capsule. Synovial fluid: a fluid that lubricates the joint and keeps the cartilage smooth and healthy. Ligaments, tendons, and muscles: tissues that keep the bones stable and allow the joint to bend and move. Ligaments are tough, cord-like tissues that connect one bone to another. Tendons are tough, fibrous cords that connect muscles to bones. Muscles are bundles of specialized cells that contract to produce movement when stimulated by nerves.

How Do You Know if You Have Osteoarthritis?

Usually, osteoarthritis comes on slowly. Early in the disease, joints may ache after physical work or exercise. Osteoarthritis can occur in any joint. Most often it occurs at the hands, knees, hips, or spine. Hands: Osteoarthritis of the fingers is one type of osteoarthritis that seems to have some hereditary characteristics; that is, it runs in families. More women than men have it, and they develop it especially after menopause. In osteoarthritis, small, bony knobs appear on the end joints of the fingers. They are called Heberden's (HEB-err-denz) nodes. Similar knobs, called Bouchard's (boo-SHARDZ) nodes, can appear on the middle joints of the fingers. Fingers can become enlarged and gnarled, and they may ache or be stiff and numb. The base of the thumb joint also is commonly affected by osteoarthritis. Osteoarthritis of the hands can be helped by medications, splints, or heat treatment. Cartilage: The Key to Healthy Joints Cartilage is 65 to 80 percent water. Three other components make up the rest of cartilage tissue: collagen, proteoglycans, and chondrocytes. Collagen (KAHL-uh-jen): a fibrous protein. Collagen is also the building block of skin, tendon, bone, and other connective tissues. Proteoglycans (PRO-tee-uh-GLY-kanz): a combination of proteins and sugars. Strands of proteoglycans and collagen weave together and form a mesh-like tissue. This allows cartilage to flex and absorb physical shock. Chondrocytes (KAHN-druh-sytz): cells that are found all through the cartilage. They mainly help cartilage stay healthy and grow. Sometimes, however, they release substances called enzymes that destroy collagen and other proteins. Researchers are trying to learn more about chondrocytes.

Knees: The knees are the body's primary weight-bearing joints. For this reason, they are among the joints most commonly affected by osteoarthritis. They may be stiff, swollen, and painful, making it hard to walk, climb, and get in and out of chairs and bathtubs. If not treated, osteoarthritis in the knees can lead to disability. Medications, weight loss, exercise, and walking aids can reduce pain and disability. In severe cases, knee replacement surgery may be helpful. Hips: Osteoarthritis in the hip can cause pain, stiffness, and severe disability. People may feel the pain in their hips, or in their groin, inner thigh, buttocks, or knees. Walking aids, such as canes or walkers, can reduce stress on the hip. Osteoarthritis in the hip may limit moving and bending. This can make daily activities such as dressing and foot care a challenge. Walking aids, medication, and exercise can help relieve pain and improve motion. The doctor may recommend hip replacement if the pain is severe and not relieved by other methods. Spine: Stiffness and pain in the neck or in the lower back can result from osteoarthritis of the spine. Weakness or numbness of the arms or legs also can result. Some people feel better when they sleep on a firm mattress or sit using back support pillows. Others find it helps to use heat treatments or to follow an exercise program that strengthens the back and abdominal muscles. In severe cases, the doctor may suggest surgery to reduce pain and help restore function.

The Warning Signs of Osteoarthritis Steady or intermittent pain in a joint Stiffness in a joint after getting out of bed or sitting for a long time Swelling or tenderness in one or more joints A crunching feeling or the sound of bone rubbing on bone Hot, red, or tender? Probably not osteoarthritis. Check with your doctor about other causes, such as rheumatoid arthritis. Pain? Not always. In fact, only a third of people whose x rays show evidence of osteoarthritis report pain or other symptoms.

How Do Doctors Diagnose Osteoarthritis?

No single test can diagnose osteoarthritis. Most doctors use a combination of the following methods to diagnose the disease and rule out other conditions: Clinical history: The doctor begins by asking the patient to describe the symptoms, and when and how the condition started. Good doctor-patient communication is important. The doctor can give a better assessment if the patient gives a good description of pain, stiffness, and joint function, and how they have changed over time. It also is important for the doctor to know how the condition affects the patient's work and daily life. Finally, the doctor also needs to know about other medical conditions and whether the patient is taking any medicines. Physical examination: The doctor will check the patient's general health, including checking reflexes and muscle strength. Joints bothering the patient will be examined. The doctor will also observe the patient's ability to walk, bend, and carry out activities of daily living. X rays: Doctors take x rays to see how much joint damage has been done. X rays of the affected joint can show such things as cartilage loss, bone damage, and bone spurs. But there often is a big difference between the severity of osteoarthritis as shown by the x ray and the degree of pain and disability felt by the patient. Also, x rays may not show early osteoarthritis damage, before much cartilage loss has taken place. Other tests: The doctor may order blood tests to rule out other causes of symptoms. Another common test is called joint aspiration, which involves drawing fluid from the joint for examination. It usually is not difficult to tell if a patient has osteoarthritis. It is more difficult to tell if the disease is causing the patient's symptoms. Osteoarthritis is so common--especially in older people--that symptoms seemingly caused by the disease actually may be due to other medical conditions. The doctor will try to find out what is causing the symptoms by ruling out other disorders and identifying conditions that may make the symptoms worse. The severity of symptoms in osteoarthritis is influenced greatly by the patient's attitude, anxiety, depression, and daily activity level.

How Is Osteoarthritis Treated?

Most successful treatment programs involve a combination of treatments tailored to the patient's needs, lifestyle, and health. Osteoarthritis treatment has four general goals: Improve joint care through rest and exercise.

Maintain an acceptable body weight. Control pain with medicine and other measures. Achieve a healthy lifestyle. Treatment Approaches to Osteoarthritis Exercise Weight control Rest and joint care Pain relief techniques Medicines Alternative therapies Surgery

Osteoarthritis treatment plans often include ways to manage pain and improve function. Such plans can involve exercise, rest and joint care, pain relief, weight control, medicines, surgery, and nontraditional treatment approaches. Exercise: Research shows that exercise is one of the best treatments for osteoarthritis. Exercise can improve mood and outlook, decrease pain, increase flexibility, improve the heart and blood flow, maintain weight, and promote general physical fitness. Exercise is also inexpensive and, if done correctly, has few negative side effects. The amount and form of exercise will depend on which joints are involved, how stable the joints are, and whether a joint replacement has already been done. (See Be a Winner! Practice Self-Care and Keep a "Good-Health Attitude." ) On the Move: Fighting Osteoarthritis With Exercise You can use exercises to keep strong and limber, extend your range of movement, and reduce your weight.Some different types of exercise include the following: Strength exercises: These can be performed with exercise bands, inexpensive devices that add resistance. Aerobic activities: These keep your lungs and circulation systems in shape. Range of motion activities: These keep your joints limber. Agility exercises: These can help you maintain daily living skills. Neck and back strength exercises: These can help you keep your spine strong and limber. Ask your doctor or physical therapist what exercises are best for you. Ask for guidelines on exercising when a joint is sore or if swelling is present. Also, check if you should (1) use pain-relieving drugs, such as analgesics or antiinflammatories (also called NSAIDs), to make exercising easier, or (2) use ice afterwards. Rest and joint care: Treatment plans include regularly scheduled rest. Patients must learn to recognize the body's signals, and know when to stop or slow down, which prevents pain caused by overexertion. Some patients find that relaxation techniques, stress reduction, and biofeedback help. Some use canes and splints to protect joints and take pressure off them. Splints or braces provide extra support for weakened joints. They also keep the joint in proper position during sleep or activity. Splints should be used only for limited periods because joints and muscles need to be

exercised to prevent stiffness and weakness. An occupational therapist or a doctor can help the patient get a properly fitting splint. Nondrug pain relief: People with osteoarthritis may find nondrug ways to relieve pain. Warm towels, hot packs, or a warm bath or shower to apply moist heat to the joint can relieve pain and stiffness. In some cases, cold packs (a bag of ice or frozen vegetables wrapped in a towel can relieve pain or numb the sore area. (Check with a doctor or physical therapist to find out if heat or cold is the best treatment.) Water therapy in a heated pool or whirlpool also may relieve pain and stiffness. For osteoarthritis in the knee, patients may wear insoles or cushioned shoes to redistribute weight and reduce joint stress. Weight control: Osteoarthritis patients who are overweight or obese need to lose weight. Weight loss can reduce stress on weight-bearing joints and limit further injury. A dietitian can help patients develop healthy eating habits. A healthy diet and regular exercise help reduce weight. Medicines: Doctors prescribe medicines to eliminate or reduce pain and to improve functioning. Doctors consider a number of factors when choosing medicines for their patients with osteoarthritis. Two important factors are the intensity of the pain and the potential side effects of the medicine. Patients must use medicines carefully and tell their doctors about any changes that occur. The following types of medicines are commonly used in treating osteoarthritis: Acetaminophen: Acetaminophen is a pain reliever (for example, Tylenol*) that does not reduce swelling. Acetaminophen does not irritate the stomach and is less likely than nonsteroidal anti-inflammatory drugs (NSAIDs) to cause long-term side effects. Research has shown that acetaminophen relieves pain as effectively as NSAIDs for many patients with osteoarthritis. Warning: People with liver disease, people who drink alcohol heavily, and those taking blood- thinning medicines or NSAIDs should use acetaminophen with caution. * Note: Brand names included in this booklet are provided as examples only. Their inclusion does not mean they are endorsed by the National Institutes of Health or any other Government agency. Also, if a certain brand name is not mentioned, this does not mean or imply that the product is unsatisfactory. NSAIDs (nonsteroidal anti-inflammatory drugs): Many NSAIDs are used to treat osteoarthritis. Patients can buy some over the counter (for example, aspirin, Advil, Motrin IB, Aleve, ketoprofen). Others require a prescription. All NSAIDs work similarly: they fight inflammation and relieve pain. However, each NSAID is a different chemical, and each has a slightly different effect on the body. Side effects: NSAIDs can cause stomach irritation or, less often, they can affect kidney function. The longer a person uses NSAIDs, the more likely he or she is to have side effects, ranging from mild to serious. Many other drugs cannot be taken when a patient is being treated with NSAIDs because NSAIDs alter the way the body uses or eliminates these other drugs. Check with your health care provider or pharmacist before you take NSAIDs in addition to another medication. Also, NSAIDs sometimes are associated with serious gastrointestinal problems, including ulcers, bleeding, and perforation of the stomach or intestine. People over age 65 and those with any history of ulcers or gastrointestinal bleeding should use NSAIDs with caution. COX-2 inhibitors: Several new NSAIDsvaldecoxib (Bextra) and celecoxib (Celebrex) from a class of drugs known as COX-2 inhibitors are now being used to treat

osteoarthritis. These medicines reduce inflammation similarly to traditional NSAIDs, but they cause fewer gastrointestinal side effects. However, these medications occasionally are associated with harmful reactions ranging from mild to severe. (See Current Research.) Other medications: Doctors may prescribe several other medicines for osteoarthritis, including the following: Topical pain-relieving creams, rubs, and sprays (for example, capsaicin cream), which are applied directly to the skin. Mild narcotic painkillers, which--although very effective--may be addictive and are not commonly used. Corticosteroids, powerful anti-inflammatory hormones made naturally in the body or manmade for use as medicine. Corticosteroids may be injected into the affected joints to temporarily relieve pain. This is a short-term measure, generally not recommended for more than two or three treatments per year. Oral corticosteroids should not be used to treat osteoarthritis. Hyaluronic acid, a medicine for joint injection, used to treat osteoarthritis of the knee. This substance is a normal component of the joint, involved in joint lubrication and nutrition. Questions To Ask Your Doctor or Pharmacist About Medicines How often should I take this medicine? Should I take this medicine with food or between meals? What side effects can I expect? Should I take this medicine with the other prescription medicines I take? Should I take this medicine with the over-the-counter medicines I take?

Most medicines used to treat osteoarthritis have side effects, so it is important for people to learn about the medicines they take. Even nonprescription drugs should be checked. Several groups of patients are at high risk for side effects from NSAIDs, such as people with a history of peptic ulcers or digestive tract bleeding, people taking oral corticosteroids or anticoagulants (blood thinners), smokers, and people who consume alcohol. Some patients may be able to help reduce side effects by taking some medicines with food. Others should avoid stomach irritants such as alcohol, tobacco, and caffeine. Some patients try to protect their stomachs by taking other medicines that coat the stomach or block stomach acids. These measures help, but they are not always completely effective. Surgery: For many people, surgery helps relieve the pain and disability of osteoarthritis. Surgery may be performed to Remove loose pieces of bone and cartilage from the joint if they are causing mechanical symptoms of buckling or locking Resurface (smooth out) bones Reposition bones Replace joints.

Surgeons may replace affected joints with artificial joints called prostheses. These joints can be made from metal alloys, high-density plastic, and ceramic material. They can be joined to bone surfaces by special cements. Artificial joints can last 10 to 15 years or longer. About 10 percent of artificial joints may need revision. Surgeons choose the design and components of prostheses according to their patient's weight, sex, age, activity level, and other medical conditions. The decision to use surgery depends on several things. Both the surgeon and the patient consider the patient's level of disability, the intensity of pain, the interference with the patient's lifestyle, the patient's age, and occupation. Currently, more than 80 percent of osteoarthritis surgery cases involve replacing the hip or knee joint. After surgery and rehabilitation, the patient usually feels less pain and swelling, and can move more easily. Nontraditional Approaches: Among the alternative therapies used to treat osteoarthritis are the following: Acupuncture: Some people have found pain relief using acupuncture (the use of fine needles inserted at specific points on the skin). Preliminary research shows that acupuncture may be a useful component in an osteoarthritis treatment plan for some patients. (See Current Research.) Folk remedies: Some patients seek alternative therapies for their pain and disability. Some of these alternative therapies have included wearing copper bracelets, drinking herbal teas, and taking mud baths. While these practices are not harmful, some can be expensive. They also cause delays in seeking medical treatment. To date, no scientific research shows these approaches to be helpful in treating osteoarthritis. Nutritional supplements: Nutrients such as glucosamine and chondroitin sulfate have been reported to improve the symptoms of people with osteoarthritis, as have certain vitamins. Additional studies are being carried out to further evaluate these claims. (See Current Research.) Health Professionals Who Treat Osteoarthritis Many types of health professionals care for people with osteoarthritis: Primary care physicians. Doctors who treat patients before they are referred to other specialists in the health care system. Rheumatologists. Medical doctors who specialize in treating arthritis and related conditions that affect joints, muscles, and bones. Orthopaedists. Doctors who specialize in treatment of and surgery for bone and joint diseases. Physical therapists. Health professionals who work with patients to improve joint function. Occupational therapists. Health professionals who teach ways to protect joints, minimize pain, and conserve energy. Dietitians. Health professionals who teach ways to use a good diet to improve health and maintain a healthy weight. Nurse educators. Nurses who specialize in helping patients understand their overall condition and implement their treatment plans. Physiatrists (rehabilitation specialists). Doctors who help patients make the most of their physical potential. Licensed acupuncture therapists. Health professionals who reduce pain and improve physical functioning by inserting fine needles into the skin at various points on the body.

Psychologists. Health professionals who help patients cope with difficulties in the home and workplace resulting from their medical conditions. Social workers. Professionals who assist patients with social challenges caused by disability, unemployment, financial hardships, home health care, and other needs resulting from their medical conditions.

Be a Winner! Practice Self-Care and Keep a "Good-Health Attitude"

People with osteoarthritis can enjoy good health despite having the disease. How? By learning self-care skills and developing a "good-health attitude." Self-care is central to successfully managing the pain and disability of osteoarthritis. People have a much better chance of having a rewarding lifestyle when they educate themselves about the disease and take part in their own care. Working actively with a team of health care providers enables people with the disease to minimize pain, share in decisionmaking about treatment, and feel a sense of control over their lives. Research shows that people with osteoarthritis who take part in their own care report less pain and make fewer doctor visits. They also enjoy a better quality of life. Self-Management Programs Do Help People with osteoarthritis find that self-management programs help them Understand the disease Reduce pain while remaining active Cope physically, emotionally, and mentally Have greater control over the disease Build confidence in their ability to live an active, independent life.

Self-Help and Education Programs: Three kinds of programs help people learn about osteoarthritis, learn self-care, and improve their good-health attitude. These programs include Patient education programs Arthritis self-management programs Arthritis support groups.

These programs teach people about osteoarthritis, its treatments, exercise and relaxation, patient and health care provider communication, and problem solving. Research has shown that these programs have clear and long-lasting benefits. Exercise: Regular physical activity plays a key role in self-care and wellness. Two types of exercise are important in osteoarthritis management. The first type, therapeutic exercises, keep joints working as well as possible. The other type, aerobic conditioning exercises, improve strength and fitness, and control weight. Patients should be realistic when they start exercising. They should learn how to exercise correctly, because exercising incorrectly can cause problems.

Most people with osteoarthritis exercise best when their pain is least severe. Start with an adequate warmup and begin exercising slowly. Resting frequently ensures a good workout. It also reduces the risk of injury. A physical therapist can evaluate how a patient's muscles are working. This information helps the therapist develop a safe, personalized exercise program to increase strength and flexibility. Many people enjoy sports or other activities in their exercise program. Good activities include swimming and aquatic exercise, walking, running, biking, cross-country skiing, and using exercise machines and exercise videotapes. People with osteoarthritis should check with their doctor or physical therapist before starting an exercise program. Health care providers will suggest what exercises are best for you, how to warm up safely, and when to avoid exercising a joint affected by arthritis. Pain medications and applying ice after exercising may make exercising easier. Exercises for Osteoarthritis

People with osteoarthritis should do different kinds of exercise for different benefits to the body. Body, Mind, Spirit: Making the most of good health requires careful attention to the body, mind, and spirit. People with osteoarthritis must plan and develop daily routines that maximize their quality of life and minimize disability. They also need to evaluate these routines periodically to make sure they are working well.

Good health also requires a positive attitude. People must decide to make the most of things when faced with the challenges of osteoarthritis. This attitude--a good-health mindset--doesn't just happen. It takes work, every day. And with the right attitude, you will achieve it. Enjoy a "Good-Health Attitude" Focus on your abilities instead of disabilities. Focus on your strengths instead of weaknesses. Break down activities into small tasks that you can manage. Incorporate fitness and nutrition into daily routines. Develop methods to minimize and manage stress. Balance rest with activity. Develop a support system of family, friends, and health professionals.

Current Research
The leading role in osteoarthritis research is played by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), within the National Institutes of Health (NIH). The NIAMS funds many researchers across the United States to study osteoarthritis. It has established a Specialized Center of Research devoted to osteoarthritis. Also, many researchers study arthritis at NIAMS Multipurpose Arthritis and Musculoskeletal Diseases Centers and Multidisciplinary Clinical Research Centers. These centers conduct basic, laboratory, and clinical research aimed at understanding the causes, treatment options, and prevention of arthritis and musculoskeletal diseases. Center researchers also study epidemiology, health services, and professional, patient, and public education. The NIAMS also supports multidisciplinary clinical research centers that expand clinical studies for diseases like osteoarthritis. For years, scientists thought that osteoarthritis was simply a disease of "wear and tear" that occurred in joints as people got older. In the last decade, however, research has shown that there is more to the disorder than aging alone. The production, maintenance, and breakdown of cartilage, as well as bone changes in osteoarthritis, are now seen as a series or cascade of events. Many researchers are trying to discover where in that cascade of events things go wrong. By understanding what goes wrong, they hope to find new ways to prevent or treat osteoarthritis. Some key areas of research are described below. Animal Models: Animals help researchers understand how diseases work and why they occur. Animal models help researchers learn many things about osteoarthritis, such as what happens to cartilage, how treatment strategies might work, and what might prevent the disease. Animal models also help scientists study osteoarthritis in very early stages before it causes detectable joint damage. Diagnostic Tools: Some scientists want to find ways to detect osteoarthritis at earlier stages so that they can treat it earlier. They seek specific abnormalities in the blood, joint fluid, or urine of people with the disease. Other scientists use new technologies to analyze the differences between the cartilage from different joints. For example, many people have osteoarthritis in the knees or hips, but few have it in the ankles. Can ankle cartilage be different? Does it age differently? Answering these questions will help us understand the disease better. Genetics Studies: Researchers suspect that inheritance plays a role in 25 to 30 percent of osteoarthritis cases. Researchers have found that genetics may play a role in approximately 40 to 65 percent of hand and knee osteoarthritis cases. They suspect inheritance might play a role in

other types of osteoarthritis, as well. Scientists have identified a mutation (a gene defect) affecting collagen, an important part of cartilage, in patients with an inherited kind of osteoarthritis that starts at an early age. The mutation weakens collagen protein, which may break or tear more easily under stress. Scientists are looking for other gene mutations in osteoarthritis. Recently, researchers found that the daughters of women who have knee osteoarthritis have a significant increase in cartilage breakdown, thus making them more susceptible to disease. In the future, a test to determine who carries the genetic defect (or defects) could help people reduce their risk for osteoarthritis with lifestyle adjustments. Tissue Engineering: This technology involves removing cells from a healthy part of the body and placing them in an area of diseased or damaged tissue in order to improve certain body functions. Currently, it is used to treat small traumatic injuries or defects in cartilage, and, if successful, could eventually help treat osteoarthritis. Researchers at the NIAMS are exploring three types of tissue engineering. The two most common methods being studied today include cartilage cell replacement and stem cell transplantation. The third method is gene therapy. Cartilage cell replacement: In this procedure, researchers remove cartilage cells from the patient's own joint and then clone or grow new cells using tissue culture and other laboratory techniques. They then inject the newly grown cells into the patient's joint. Patients with cartilage cell replacement have fewer symptoms of osteoarthritis. Actual cartilage repair is limited, however. Stem cell transplantation: Stem cells are primitive cells that can transform into other kinds of cells, such as muscle or bone cells. They usually are taken from bone marrow. In the future, researchers hope to insert stem cells into cartilage, where the cells will make new cartilage. If successful, this process could be used to repair damaged cartilage and avoid the need for surgical joint replacements with metal or plastics. Gene therapy: Scientists are working to genetically engineer cells that would inhibit the body chemicals, called enzymes, that may help break down cartilage and cause joint damage. In gene therapy, cells are removed from the body, genetically changed, and then injected back into the affected joint. They live in the joint and protect it from damaging enzymes.

Comprehensive Treatment Strategies: Effective treatment for osteoarthritis takes more than medicine or surgery. Getting help from a variety of care professionals often can improve patient treatment and self-care. (See Health Professionals Who Treat Osteoarthritis.) Research shows that adding patient education and social support is a low-cost, effective way to decrease pain and reduce the amount of medicine used. Exercise plays a key part in comprehensive treatment. Researchers are studying exercise in greater detail and finding out just how to use it in treating or preventing osteoarthritis. For example, several scientists have studied knee osteoarthritis and exercise. Their results included the following: Strengthening the thigh muscle (quadriceps) can relieve symptoms of knee osteoarthritis and prevent more damage. Walking can result in better functioning, and the more you walk, the farther you will be able to walk. People with knee osteoarthritis who were active in an exercise program feel less pain. They also function better.

Research has shown that losing extra weight can help people who already have osteoarthritis. Moreover, overweight or obese people who do not have osteoarthritis may reduce their risk of developing the disease by losing weight.

Using NSAIDs: Many people who have osteoarthritis have persistent pain despite taking simple pain relievers such as acetaminophen. Some of these patients take NSAIDs instead. Health care providers are concerned about long-term NSAID use because it can lead to an upset stomach, heartburn, nausea, and more dangerous side effects, such as ulcers. Scientists are working to design and test new, safer NSAIDs. One example currently available is a class of selective NSAIDs called COX-2 inhibitors. Traditional NSAIDs prevent inflammation by blocking two related enzymes in the body called COX-1 and COX-2. The gastrointestinal side effects associated with traditional NSAIDs seems to be associated mainly with blocking the COX1 enzyme, which helps protect the stomach lining. The new selective COX-2 inhibitors, however, primarily block the COX-2 enzyme, which helps control inflammation in the body. As a result, COX-2 inhibitors reduce pain and inflammation but are less likely than traditional NSAIDs to cause gastrointestinal ulcers and bleeding. However, research shows that some COX-2 inhibitors may not protect against heart disease as well as traditional NSAIDs, so check with your doctor if you have concerns. Drugs to Prevent Joint Damage: No treatment actually prevents osteoarthritis or reverses or blocks the disease process once it begins. Present treatments just relieve the symptoms. Researchers are looking for drugs that would prevent, slow down, or reverse joint damage. One experimental antibiotic drug, doxycycline, may stop certain enzymes from damaging cartilage. The drug has shown some promise in clinical studies, but more studies are needed. Researchers also are studying growth factors and other natural chemical messengers. These potential medicines may be able to stimulate cartilage growth or repair. Acupuncture: During an acupuncture treatment, a licensed acupuncture therapist inserts very fine needles into the skin at various points on the body. Scientists think the needles stimulate the release of natural, pain-relieving chemicals produced by the brain or the nervous system. Researchers are studying acupuncture treatment of patients who have knee osteoarthritis. Early findings suggest that traditional Chinese acupuncture is effective for some patients as an additional therapy for osteoarthritis, reducing pain and improving function. Nutritional Supplements: Nutritional supplements are often reported as helpful in treating osteoarthritis. Such reports should be viewed with caution, however, since very few studies have carefully evaluated the role of nutritional supplements in osteoarthritis. Glucosamine and chondroitin sulfate: Both of these nutrients are found in small quantities in food and are components of normal cartilage. Scientific studies on these two nutritional supplements have not yet shown that they affect the disease. They may relieve symptoms and reduce joint damage in some patients, however. The National Center for Complementary and Alternative Medicine at the NIH is supporting a clinical trial to test whether glucosamine, chondroitin sulfate, or the two nutrients in combination reduce pain and improve function. Patients using this therapy should do so only under the supervision of their doctor, as part of an overall treatment program with exercise, relaxation, and pain relief. Vitamins D, C, E, and beta carotene: The progression of osteoarthritis may be slower in people who take higher levels of vitamin D, C, E, or beta carotene. More studies are needed to confirm these reports.

Hyaluronic Acid: Injecting this substance into the knee joint provides long-term pain relief for some people with osteoarthritis. Hyaluronic acid is a natural component of cartilage and joint fluid. It lubricates and absorbs shock in the joint. The Food and Drug Administration (FDA) approved this therapy for patients with osteoarthritis of the knee who do not get relief from exercise, physical therapy, or simple analgesics. Researchers are presently studying the benefits of using hyaluronic acid to treat osteoarthritis.

Estrogen: In studies of older women, scientists found a lower risk of osteoarthritis in women who had used oral estrogens for hormone replacement therapy. The researchers suspect having low levels of estrogen could increase the risk of developing osteoarthritis. Additional studies are needed to answer this question.

Hope for the Future

Research is opening up new avenues of treatment for people with osteoarthritis. A balanced, comprehensive approach is still the key to staying active and healthy with the disease. People with osteoarthritis should combine exercise, relaxation education, social support, and medicines in their treatment strategies. Meanwhile, as scientists unravel the complexities of the disease, new treatments and prevention methods should appear. They will improve the quality of life for people with osteoarthritis and their families.

Osteoarthritis (Degenerative Arthritis)

Medical Author: William C. Shiel Jr., MD, FACP, FACR What is osteoarthritis? What causes osteoarthritis? What are symptoms of osteoarthritis? How is osteoarthritis diagnosed? How is osteoarthritis treated? "If I have minimal or no symptoms with early signs of osteoarthritis, what should I do?" What does the future hold for osteoarthritis? Osteoarthritis At A Glance What is osteoarthritis? Osteoarthritis is a type of arthritis that is caused by the breakdown and eventual loss of the cartilage of one or more joints. Cartilage is a protein substance that serves as a "cushion" between the bones of the joints. Osteoarthritis is also known as degenerative arthritis. Among the over 100 different types of arthritis conditions, osteoarthritis is the most common, affecting over 20 million people in the United States. Osteoarthritis occurs more frequently as we age. Before age 45, osteoarthritis occurs more frequently in males. After age 55 years, it occurs more frequently in females. In the United States, all races appear equally affected. A higher incidence of osteoarthritis exists in the Japanese population, while South African blacks, East Indians and Southern Chinese have lower rates. Osteoarthritis commonly affects the hands, feet, spine, and large weight-bearing joints, such as the hips and knees. Most cases of osteoarthritis have no known cause and are referred to as primary osteoarthritis. When the cause of the osteoarthritis is known, the condition is referred to as secondary osteoarthritis. What causes osteoarthritis? Primary osteoarthritis is mostly related to aging. With aging, the water content of the cartilage increases and the protein makeup of cartilage degenerates. Repetitive use of the joints over the years irritates and inflames the cartilage, causing joint pain and swelling. Eventually, cartilage begins to degenerate by flaking or forming tiny crevasses. In advanced cases, there is a total loss of the cartilage cushion between the bones of the joints. Loss of cartilage cushion causes friction between the bones, leading to pain and limitation of joint mobility. Inflammation of the cartilage can also stimulate new bone outgrowths (spurs) to form around the joints. Osteoarthritis

occasionally can be found in multiple members of the same family, implying an heredity (genetic) basis for this condition.

Secondary osteoarthritis is caused by another disease or condition. Conditions that can lead to secondary osteoarthritis include obesity, repeated trauma or surgery to the joint structures, abnormal joints at birth (congenital abnormalities), gout, diabetes, and other hormone disorders. Obesity causes osteoarthritis by increasing the mechanical stress on the cartilage. In fact, next to aging, obesity is the most powerful risk factor for osteoarthritis of the knees. The early development of osteoarthritis of the knees among weight lifters is believed to be in part due to their high body weight. Repeated trauma to joint tissues (ligaments, bones and cartilage) is believed to lead to early osteoarthritis of the knees in soccer players. Interestingly, recent studies have not found an increased risk of osteoarthritis in long-distance runners. Crystal deposits in the cartilage can cause cartilage degeneration, and osteoarthritis. Uric acid crystals cause arthritis in gout, while calcium pyrophosphate crystals cause arthritis in pseudogout. Some people are born with abnormally formed joints (congenital abnormalities) that are vulnerable to mechanical wear, causing early degeneration and loss of joint cartilage. Osteoarthritis of the hip joints is commonly related to design abnormalities of these joints that had been present since birth. Hormone disturbances, such as diabetes and growth hormone disorders, are also associated with early cartilage wear and secondary osteoarthritis. What are symptoms of osteoarthritis? Osteoarthritis is a disease of the joints. Unlike many other forms of arthritis that are systemic illnesses, such as rheumatoid arthritis and systemic lupus, osteoarthritis does not affect other organs of the body. The most common symptom of osteoarthritis is pain in the affected joint(s) after repetitive use. Joint pain is usually worse later in the day. There can be swelling, warmth, and creaking of the affected joints. Pain and stiffness of the joints can also occur after long

periods of inactivity, for example, sitting in a theater. In severe osteoarthritis, complete loss of cartilage cushion causes friction between bones, causing pain at rest or pain with limited motion. Symptoms of osteoarthritis vary greatly from patient to patient. Some patients can be debilitated by their symptoms. On the other hand, others may have remarkably few symptoms in spite of dramatic degeneration of the joints apparent on x-rays. Symptoms also can be intermittent. It is not unusual for patients with osteoarthritis of the hands and knees to have years of pain-free intervals between symptoms. Osteoarthritis of the knees is often associated with obesity or a history of repeated injury and/or joint surgery. Progressive cartilage degeneration of the knee joints can lead to deformity and outward curvature of the knees referred to as "bow legged." Patients with osteoarthritis of the weight bearing joints (like the knees) can develop a limp. The limping can worsen as more cartilage degenerates. In some patients, the pain, limping, and joint dysfunction may not respond to medications or other conservative measures. Therefore, severe osteoarthritis of the knees is one of the most common reasons for total knee replacement surgical procedures in the United States. Osteoarthritis of the spine causes pain in the neck or low back. Bony spurs that form along the arthritic spine can irritate spinal nerves, causing severe pain, numbness, and tingling of the affected parts of the body. Osteoarthritis causes the formation of hard bony enlargements of the small joints of the fingers. Classic bony enlargement of the small joint at the end of the fingers is called a Heberden's node, named after a very famous British doctor. The bony deformity is a result of the bone spurs from the osteoarthritis in that joint. Another common bony knob (node) occurs at the middle joint of the fingers in many patients with osteoarthritis and is called a Bouchard's node. Dr. Bouchard was a famous French doctor who also studied arthritis patients in the late 1800s. The Heberden's and Bouchard's nodes may not be painful, but they are often associated with limitation of motion of the joint. The characteristic appearances of these finger nodes can be helpful in diagnosing osteoarthritis. Osteoarthritis of the joint at the base of the big toes leads to the formation of a bunion. Osteoarthritis of the fingers and the toes may have a genetic basis, and can be found in numerous women members of some families.

In this Article

What is osteoarthritis? What causes osteoarthritis? What are symptoms of osteoarthritis? How is osteoarthritis diagnosed? How is osteoarthritis treated? "If I have minimal or no symptoms with early signs of osteoarthritis, what should I do?"

What does the future hold for osteoarthritis? Osteoarthritis At A Glance Osteoarthritis Center

Osteoarthritis (cont.)
How is osteoarthritis diagnosed? There is no blood test for the diagnosis of osteoarthritis. Blood tests are performed to exclude diseases that can cause secondary osteoarthritis, as well as to exclude other arthritis conditions that can mimic osteoarthritis. X-rays of the affected joints can suggest osteoarthritis. The common x-ray findings of osteoarthritis include loss of joint cartilage, narrowing of the joint space between adjacent bones, and bone spur formation. Simple x-ray testing can be very helpful to exclude other causes of pain in a particular joint as well as assist the decision-making as to when surgical intervention should be considered. Arthrocentesis is often performed in the doctor's office. During arthrocentesis, a sterile needle is used to remove joint fluid for analysis. Joint fluid analysis is useful in excluding gout, infection, and other causes of arthritis. Removal of joint fluid and injection of corticosteroids into the joints during arthrocentesis can help relieve pain, swelling, and inflammation. Arthroscopy is a surgical technique whereby a doctor inserts a viewing tube into the joint space. Abnormalities of and damage to the cartilage and ligaments can be detected and sometimes repaired through the arthroscope. If successful, patients can recover from the arthroscopic surgery much more quickly than from open joint surgery. Finally, a careful analysis of the location, duration, and character of the joint symptoms and the appearance of the joints helps the doctor in diagnosing osteoarthritis. Bony enlargement of the joints from spur formations is characteristic of osteoarthritis. Therefore, Heberden's nodes, Bouchard's nodes, and bunions of the feet can help the doctor make a diagnosis of osteoarthritis. How is osteoarthritis treated? Aside from weight reduction and avoiding activities that exert excessive stress on the joint cartilage, there is no specific treatment to halt cartilage degeneration or to repair damaged cartilage in osteoarthritis. The goal of treatment in osteoarthritis is to reduce joint pain and inflammation while improving and maintaining joint function. Some patients with osteoarthritis have minimal or no pain, and may not need treatment. Others may benefit from conservative measures such as rest, exercise, weight reduction, physical and occupational therapy, and mechanical support devices. These measures are particularly important when large, weightbearing joints are involved, such as the hips or knees. In fact, even modest weight reduction can

help to decrease symptoms of osteoarthritis of the large joints, such as the knees and hips. Medications are used to complement the physical measures described above. Medication may be used topically, taken orally, or injected into the joints to decrease joint inflammation and pain. When conservative measures fail to control pain and improve joint function, surgery can be considered. Resting sore joints decreases stress on the joints, and relieves pain and swelling. Patients are asked to simply decrease the intensity and/or frequency of the activities that consistently cause joint pain. Exercise usually does not aggravate osteoarthritis when performed at levels that do not cause joint pain. Exercise is helpful in osteoarthritis in several ways. First, it strengthens the muscular support around the joints. It also prevents the joints from "freezing up" and improves and maintains joint mobility. Finally, it helps with weight reduction and promotes endurance. Applying local heat before and cold packs after exercise can help relieve pain and inflammation. Swimming is particularly suited for patients with osteoarthritis because it allows patients to exercise with minimal impact stress to the joints. Other popular exercises include walking, stationary cycling, and light weight training. Physical therapists can provide support devices, such as splints, canes, walkers, and braces. These devices can be helpful in reducing stress on the joints. Occupational therapists can assess daily activities and determine additional devices that may help patients at work or home. Finger splints can support individual joints of the fingers. Paraffin wax dips, warm water soaks, and nighttime cotton gloves can help ease hand symptoms. Spine symptoms can improve with a neck collar, lumbar corset, or a firm mattress, depending on what areas are involved. In many patients with osteoarthritis, mild pain relievers such as aspirin and acetaminophen (Tylenol) may be sufficient treatment. Studies have shown that acetaminophen given in adequate doses can often be equally as effective as prescription anti-inflammatory medications in relieving pain in osteoarthritis of the knees. Since acetaminophen has fewer gastrointestinal side effects than NSAIDS, especially among the elderly patients, acetaminophen is generally the preferred initial drug given to patients with osteoarthritis. Medicine to relax muscles in spasm might also be given temporarily. Pain-relieving creams applied to the skin over the joints can provide relief of minor arthritis pain. Examples include capsaicin (Arthricare, Zostrix), salycin (Aspercreme), methyl salicylate (Bengay, Icy Hot), and menthol (Flexall). Nonsteroidal anti-inflammatory drugs (NSAIDs) are medications that are used to reduce pain and inflammation in the joints. Examples of NSAIDs include aspirin (Ecotrin), ibuprofen (Motrin), nabumetone (Relafen), and naproxen (Naprosyn). It is sometimes possible to use NSAIDs for a while and then discontinue them for periods of time without recurrent symptoms, thereby decreasing side effect risks. The most common side effects of NSAIDs involve gastrointestinal distress, such as stomach upset, cramping diarrhea, ulcer and even bleeding. The risk of these and other side effects increases in the elderly. Newer NSAIDs called Cox-2 Inhibitors have been designed that have less toxicity to the stomach and bowels. Because osteoarthritis symptoms vary and can be intermittent, these medicines might be given only when joint pains occur or prior to activities that have traditionally brought on symptoms. Recently, the food supplements glucosamine and chondroitin have been shown to relieve symptoms of pain and stiffness for some persons with osteoarthritis. These supplements are available in pharmacies and health food stores without a prescription, although there is no certainty about the purity of the products or the dose of the active ingredients because they are not monitored by the FDA. The National Institutes of Health is studying glucosamine and

chondroitin in the treatment of osteoarthritis and this research will clarify many issues regarding dosing, safety, and effectiveness of these products for osteoarthritis. Patients taking bloodthinners should be careful taking chondroitin as it can increase the blood-thinning and cause excessive bleeding. Fish oil supplements have been shown to have some anti-inflammation properties and increasing the dietary fish intake and/or fish oil capsules (omega 3 capsules) can sometimes reduce inflammation of arthritis. While oral cortisone is generally not used in treating osteoarthritis, when injected directly into the inflamed joints, it can rapidly decrease pain and restore function. Since repetitive cortisone injections can be harmful to the tissue and bones, they are reserved for patients with more pronounced symptoms. For persisting pain of severe osteoarthritis of the knee that does not respond to weight reduction, exercise or medications, a series of injections of hyaluronic acid (Synvisc, Hyalgan) into the joint can sometimes be helpful, especially if surgery is not being considered. These products seem to work by temporarily restoring the thickness of the joint fluid, allowing better joint lubrication and impact capability, and perhaps by directly affecting pain receptors. Surgery is generally reserved for those patients with osteoarthritis that is particularly severe and unresponsive to the conservative treatments. Arthroscopy, discussed above, can be helpful when cartilage tears are suspected. Osteotomy is a bone removal procedure that can help realign some of the deformity in selected patients, usually those with knee disease. In some cases, severely degenerated joints are best treated by fusion (arthrodesis) or replacement with an artificial joint (arthroplasty). Total hip and total knee replacements are now commonly performed in community hospitals throughout the United States. These can bring dramatic pain relief and improved function. For further information on joint surgeries, please read the Arthroscopy, Total Knee Replacement, and Total Hip Replacement articles. If I have minimal or no symptoms with early signs of osteoarthritis, what should I do?" The ideal steps to take should lead to a proper diagnosis and an optimal long-term treatment plan. While many steps are discussed here, the plan must be customized for each person affected by osteoarthritis, depending on the joints affected and the severity of symptoms. An opinion regarding the cause or the type of the arthritis can usually be adequately obtained by consulting a general family doctor. It is often unnecessary to see an arthritis specialist (rheumatologist), like myself, for this purpose. However, if the diagnosis or treatment plan is unclear, a rheumatologist might be consulted. When I determine that a patient has a classic node formation from osteoarthritis (Heberden's node), I may make the diagnosis solely based upon the examination, without the need for any additional tests, such as blood or X-ray testing. Sometimes, testing can be helpful to better understand the degree and character of the osteoarthritis affecting a certain joint. It can also be helpful for monitoring and to exclude other conditions. Treatment may not be necessary for osteoarthritis of the hands with minimal or no symptoms. When symptoms are troubling and persist, however, treatment might include pain and antiinflammatory medications, with or without food supplements, such as glucosamine and/or chondroitin. Furthermore, heat/cold applications and topical pain creams can be helpful. As a first step, I recommend that patients go ahead and try the over-the-counter food supplements, glucosamine and chondroitin. Each of these supplements has been independently shown, by studies presented at the national arthritis meeting in 1999, to relieve the pain and stiffness of some (but not all) patients with osteoarthritis. These supplements are available in

pharmacies and health food stores without a prescription. If patients do not benefit after a twomonth trial, I tell them that they may discontinue these supplements. The manufacturers sometimes make claims that these supplements "rebuild" cartilage. This claim has not been adequately verified by scientific studies to date. Researchers found that glucosamine (in a radioactive form that could be identified in tissues) fed to Beagle dogs by mouth was detectable in the cartilage of their joints. I spoke with the author of this study, who interpreted the results to imply that glucosamine supplements taken by mouth actually can reach the cartilage of the joints. Perhaps, in future studies, glucosamine will be shown to not only provide some relief of symptoms (already reported in some patients), but also be shown to protect the joints affected by osteoarthritis. In fact, investigators at the National Institutes of Health are currently looking into whether or not taking glucosamine or chondroitin could actually improve or protect the quality of the cartilage in joints affected by osteoarthritis. For another type of dietary supplementation, it should be noted that fish oils have been shown to have some anti-inflammation properties. Moreover, increasing the dietary fish intake and/or fish oil capsules (omega 3 capsules) can sometimes reduce the inflammation of arthritis. Obesity has long been known to be a risk factor for osteoarthritis of the knee. I recommend weight reduction for patients with early signs of osteoarthritis of the hands who are overweight, because they are at a risk for also developing osteoarthritis of their knees. As described above, even modest weight reduction can be helpful. Pain medications that are available over-the-counter, such as acetaminophen (Tylenol) can be very helpful in relieving the pain symptoms of mild osteoarthritis and I recommend these as the first medication treatment. Studies have shown that acetaminophen, given in adequate doses, can often be equally as effective as prescription anti-inflammatory medications in relieving pain in osteoarthritis of the knees. Since acetaminophen has fewer gastrointestinal side effects than nonsteroidal antiinflammatory drugs (NSAIDS), especially in elderly patients, acetaminophen is generally the preferred initial drug given to patients with osteoarthritis. If symptoms persist, then I recommend trials of over-the-counter antiinflammatory drugs, such as ibuprofen (Advil, Motrin IB, Nuprin), ketoprofen (Orudis), and naproxen (Aleve). Many patients do best when they take these medications along with their glucosamine and chondroitin. Some patients get significant relief of pain symptoms by dipping their hands in hot wax (paraffin) dips in the morning. Hot wax can often be obtained at local pharmacies or medical supplies stores. It can be prepared in a crockpot and be reused after it hardens as a warm covering over the hands by peeling off and replacing it into the melted wax. Warm water soaks and nighttime cotton gloves (to keep the hands warm during sleep) can also help ease hand symptoms. Gentle range of motion exercising regularly can help to preserve function of the joints. These exercises are easiest to perform after early morning hand warming. Pain-relieving creams that are applied to the skin over the joints can provide relief of daytime minor arthritis pain. Examples include capsaicin (Arthricare, Zostrix), salycin (Aspercreme), methyl salicylate (Bengay, Icy Hot), and menthol (Flexall). For additional relief of mild symptoms, local ice application can sometimes be helpful, especially towards the end of the day. Occupational therapists can assess daily activities and determine which additional techniques may help patients at work or home. Finally, when arthritis symptoms persist, it is best to seek the advice of a doctor who can properly guide the optimal management for each individual patient. Many other prescription medications are available for the treatment of osteoarthritis for patients with chronic, annoying symptoms. And, if you are concerned that osteoarthritis could be associated with injury to internal organsdon't be. This disease does not cause internal organ damage or blood test abnormalities.

In addition to the steps described above, you should pay attention to joint problems elsewhere in your body if you develop early signs and symptoms of osteoarthritis of the hands.

What does the future hold for osteoarthritis? In the future, medications may be available which protect the cartilage from the deteriorating consequences of osteoarthritis. New treatments, including an antiinflammatory lotion, diclofenac (Pennsaid) are being studied for the relief of the pain of osteoarthritis. Recently, surgical innovation has led to a technique for the repair of isolated splits of cartilage (fissures) of the knee. In this procedure, a patient's own cartilage is actually grown in the laboratory, then inserted into the fissure area and sealed over with a "patch" of the patient's own bone covering the tissue. While this is not a procedure for the cartilage damage of osteoarthritis, it does open the door for future cartilage research. These and other developing areas hold promise for new approaches to an old problem. Investigators at the National Institutes of Health are currently looking into whether or not taking glucosamine or chondroitin could actually improve or protect the quality of the cartilage in joints affected by osteoarthritis. Research scientists have found that doxycycline, a tetracycline drug, has been shown to slow the progression of cartilage degeneration in the knees of patients with osteoarthritis. More studies are needed to determined the significance of this early, but interesting, work.

Osteoarthritis At A Glance
Osteoarthritis is a joint inflammation that results from cartilage degeneration. Osteoarthritis can be caused by aging, heredity, and injury from trauma or disease. The most common symptom of osteoarthritis is pain in the affected joint(s) after repetitive use. There is no blood test for the diagnosis of osteoarthritis. The goal of treatment in osteoarthritis is to reduce joint pain and inflammation while improving and maintaining joint function.