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Osteoarthritis: Painful Stride

Osteoarthritis is a slow, progressive disabling disease that is the most frequent cause of joint pain, especially in the elderly.  This relatively common disease affects about one in every 13 people, about 12 percent of people above 60 years of age experience pain due to osteoarthritis.

If you have advanced age, obesity, a history of significant injury to the knee, a congenital problem with a joint, a hormonal or metabolic disorder, or another form of inflammatory arthritis, you are more prone to developing osteoarthritis.  The disease also tends to run in families, especially in patients with osteoarthritis of the hand.  Work-related physical trauma or repetitive movements stressing the joints can also lead to osteoarthritis.

Osteoarthritis is characterized by pain upon an initial movement like rising from a seated position, or upon beginning to walk.  Patients often describe a crunching sensation or sound when using the affected joint.  There may also be swelling and warmth in the joints, though to a lesser degree than with other forms of inflammatory arthritis.  Patients often complain of gradual increase in pain and loss of function, and often end up unable to do activities of daily living.

Types of Osteoarthritis

Osteoarthritis most commonly involves the following joints: knees, hips, spine and fingers.  Knees and hips are commonly affected in osteoarthritis because they are weight-bearing joints.  Affected knees often cause pain on standing from a chair, on using stairs, or on kneeling.  Pain in the hip can cause pain and stiffness in your groin, inner thigh or knees.  This leads to difficulty crossing one’s legs, walking and bending.

Osteoarthritis of the spine can cause stiffness and pain in the neck or in the lower back, which on occasion may cause pain radiating down one side of the leg, or down the arm, due to an associated pinched nerve due to the changes in the joint and disc.  Hands with osteoarthritis may ache or be stiff and numb, especially for the first five to 10 minutes upon waking up.  The base of the thumb joint is commonly affected, as well as the middle joints and end joints of the fingers, which develop bony changes.  More women than men develop osteoarthritis of their fingers, often in their 30’s or early 40’s.

In patients with osteoarthritis, there is wear and tear with eventual loss of cartilage, a layer that covers the bony end of a joint.  Bony overgrowth called osteophytes and other changes in the surrounding bone also occurs.  These changes are often evident on physical exam, as well as on proper x-rays done on affected joints.  Most blood tests for joint inflammation are normal in patients with osteoarthritis.  Occasionally joint aspiration may also be necessary to help in diagnosis.

Diabetes mellitus is also common in a large number of patients with osteoarthritis, especially in elderly individuals, as well as in obese individuals.  Obesity is a very important risk factor for diabetes, and increases the risk for osteoarthritis by 300 percent. The presence of metabolic syndrome also increases the risk of developing osteoarthritis, regardless of age.

Treatment and Prevention
The cornerstone of treatment and prevention of osteoarthritis is non-pharmacologic. Any recreational activity or repetitive work-related activity, which can worsen the disease, should be avoided or modified to reduce stress on joints. Aids such as canes, walkers, and braces for weight-bearing joints are helpful. Shoe inserts and wedges also help reduce the pain due to malaligned knees due to osteoarthritis. Proper lighting and removal of rugs and small objects, which can cause falls, are important in symptomatic patients.

Since obesity is a major risk factor and puts undue stress on the joints of patients, weight loss is vital to relieving pain. Aerobic exercises such as brisk walking on soft surfaces, exercise bike or aquatic exercises for 20 to 30 minutes, five times a week help reduce weight. Specific isometric exercises also help strengthen muscles surrounding the affected joint.

Proper dieting reduces calories, and patients who have osteoarthritis and are also diabetic will have dual benefits from a low carbohydrate diet. On occasion, medications approved for weight loss can also help to achieve target weight.
Medication use for osteoarthritis is often necessary on a chronic basis, though the combination of different approaches often helps reduce the use of medication to an as-needed basis.

Paracetamol in moderate to large doses can relieve pain in osteoarthritis and is relatively safe, though dosing should be watched carefully in elderly patients who often clear the drug slower from the body. Non-steroidal Anti Inflammatory Drugs, or NSAIDs, and their newer forms, the COX-2 inhibitors have excellent results in reducing the pain of osteoarthritis.The older generation NSAIDs can occasionally increase stomach upset, ulcers, and decrease kidney flow. Recent issues regarding cardiovascular risk in patients with long-term use of certain COX-2 inhibitors have also arisen. Thus the use of as low a dose as possible, for as short duration as possible of these drugs is recommended.

Glucosamine, alone or in combination with Chondroitin sulfate or MSM, is a popular product for osteoarthritis. A few clinical studies suggest lack of worsening of joint space narrowing in osteoarthritis when glucosamine sulfate is taken. A large nationwide clinical study in the United States using glucosamine Hcl plus Chondroitin sulfate, on the other hand, did not show benefit in relieving symptoms of patients with mild osteoarthritis.

There also appears to be inconsistency in the actual amount of active substance in the different preparations flooding the market at this time. Preliminary evidence may suggest that intake of glucosamine preparations may increase insulin resistance, though other studies have shown no effect. Other pain relievers such as tramadol and similar drugs may be helpful in relieving osteoarthritis as well.

lnjectional therapies can also help patients with severe pain from osteoarthritis. Aspiration of excess joint fluid, and corticosteroid injections directly into the joint often help ease pain for up to four months. The injection of hyaluronic acid once a week for three to five weeks, can give even longer-term relief as well, lasting often up to one year.

Surgical options such as arthroscopy can be helpful, especially in patients with underlying injury or tears of ligaments surrounding the joint involved. In patients with pain despite all other measures and severe osteoarthritis on x-ray, total joint replacement for selected joint may be very helpful. Pre-operative assessment is vital to reduce medical complications during and after surgery.

In summary, osteoarthritis is a common disease, which often affects people with diabetes as well. The proper combination of non-pharmacologic measures and medications can help prevent and ease the pain and loss of function of patients with osteoarthritis.

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