If self-help doesn’t work, surgery may be the answer, but there might also be new developments on the horizon.
Osteoarthritis (OA) is the most common form of arthritis, and affects millions of us in the all world. In OA, repeated micro-shocks, or more serious injury, wear away our joints’ smooth, slippery cartilage surfaces. Bones become roughened, extra lubricating fluid is produced, surrounding tissues stiffen, and muscles get out of condition as we use our joints awkwardly, or less than we should.
OA has a genetic link in around 50% of people; this form often targets fingers and knees. Women and people who are overweight are also more prone to OA; work and hobbies may affect joints, too.
Our joints become swollen and misshapen; pain is usually worse after using them, or in bed. But we feel stiff after resting or waking, and our joints may feel slightly warm (red-hot swelling is a sign of infection/inflammation – see your GP urgently). OA often affects the base of the thumb, and produces knobbly finger knuckles – Heberden’s nodes – as well as affecting hips, knees, neck, back and/or feet.
If you’re over 45, you may not need any tests unless you have unusual symptoms (see box, opposite) as your GP can normally diagnose OA by examining you.
The charity Arthritis Care says many people wait until their pain is unbearable before seeking help, but new guidance from NICE, the National Institute for Health and Care Excellence, recommends an early assessment and a holistic approach. Your GP will ask how your OA is affecting your life, work, mood, sleep, activities and lifestyle – and vice versa, for example, whether you’ve fallen. She’ll also balance this with your other medical problems, ask how you (and any carers) are coping, and ask what remedies you’ve already tried.
Exercise is vital for OA. It keeps you moving, improves fitness, strengthens muscles, helps to relieve pain and assists weight loss – which in turn reduces pain and slows joint deterioration. Your GP may refer you to a weight management programme or physiotherapist/rehabilitation programme, or advise cushioned shoes, insoles, joint supports/braces, or walking aids (a pole can relieve knee strain by 25% when hill walking). A hotwater bottle, warm bath, heated pad or TENS machine (produces a small electrical stimulus) can ease pain, too.
NICE no longer suggests using supplements such as glucosamine or chondroitin, hyaluronan injections or acupuncture, although some people find them helpful. It’s currently reviewing painkillers – ask your pharmacist’s advice and take them only when needed; your GP can prescribe stronger ones if necessary.
Steroid injections may help, too.
NICE also recommends an annual review with your GP, and referral for joint surgery if your symptoms have a substantial impact on your quality of life. It says you should be referred before you have severe or permanent pain or disability and that smoking, your weight or other medical conditions shouldn’t be a barrier (although they could affect the results of surgery).
Your GP and consultant can advise you on the benefits and risks of having/not having surgery, discuss your recovery and rehabilitation, and explain local ‘pathways’ for joint replacement. To help weigh up the options.
Scientists are hoping that drugs used to treat osteoporosis may be useful in treating not only osteoarthritis (OA) pain, but cartilage damage as well.
In particular, the focus is on bisphosphonates, which work against osteoporosis by inhibiting cells called osteoclasts that break down bone. Researchers believe they may work similarly for OA, by inhibiting the activity of osteoclasts in the bone beneath the cartilage in affected joints. In animal studies, bisphophonates have shown to reduce OA progression – as measured by the severity of cartilage damage and bony overgrowth – by as much as 30–40%.
Limited clinical research on humans suggests bisphosphonates – whether taken orally or injected – may indeed be helpful for both relieving pain and reducing cartilage damage in people with OA, but many questions remain. In an Italian study, the bisphosphonate drug clodronate was found to give greater improvement in pain level, self-reported OA severity, and need for painrelieving medication, compared with a placebo, however other studies have produced varying results, so scientists feel more research is needed to determine which patients could benefit most from bisphosphonate treatment.
On the possible beneficial effects on cartilage damage of osteoporosis drugs, researchers have assessed joint space narrowing – a sign of OA progression – and bone marrow lesions, which are predictive of more rapidly progressing OA. In one study it was found that treatment with bisphosphonates over a period of two to three years was associated with both a reduction of osteoarthritis pain and less joint space narrowing. Researchers compared the effects of a single infusion of bisphosphonates with placebo in 59 people with knee osteoarthritis and bone marrow lesions. They found that after six months, patients taking the bisphosphonates not only had reduced pain scores, but magnetic resonance imaging scans showed a reduction in the size of their bone marrow lesions.
And in a different study, 1,683 patients with knee OA were randomly selected to receive a different another anti-osteoporosis drug, strontium ranelate or a placebo. Researchers followed the participants over three years measuring joint damage pain, stiffness and physical function. They found that it was associated with decreases in joint damage, as measured by joint space narrowing, compared to a placebo.
Like bisphosphonates, strontium ranelate was effective in reducing pain and improving physical function, suggesting that osteoporosis drugs may indeed hold a role in the treatment of OA. However, further research is needed to determine if and what that role might be.
5 Tests You May Need
- Blood tests for inflammatory arthritis (such as rheumatoid and gout) or infection.
- X-rays (although arthritis symptoms may be worse than the X-rays suggest).
- A Magnetic Resonance scan looking for ligament and cartilage damage that could be surgically repaired.
- An arthroscopy – telescope examination inside the joint (using a general anaesthetic).
- Fine needle aspiration – to test fluid from joint for infection, gout and other conditions.