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Osteoarthritis

National Institutes of HealthNational Institute of Arthritis and

Musculoskeletal and Skin Diseases

This booklet is not copyrighted. Readers are encour-aged to duplicate and distribute as many copies asneeded.

Additional copies of this booklet are available fromthe National Institute of Arthritis and Musculoskeletaland Skin Diseases, NIAMS/National Institutes ofHealth, 1 AMS Circle, Bethesda, MD 208923675,and on the NIAMS Web site at www.niams.nih.gov/hi.

Table of Contents

What Is Osteoarthritis? ................................................... 1Who Has Osteoarthritis? ................................................. 2How Does Osteoarthritis Affect People? .............................. 2Osteoarthritis Basics: The Joint and Its Parts ......................... 5How Do You Know if You Have Osteoarthritis? ............................. 7How Do Doctors Diagnose Osteoarthritis? .................... 9How Is Osteoarthritis Treated? ........................................ 11Be a Winner! Practice Self-Care and Keep a

Good-Health Attitude ................................................ 21Current Research ........................................................... 25Hope for the Future ....................................................... 32Additional Resources .................................................... 32

Illustrations

What Areas Does Osteoarthritis Affect?....................................... 3A Healthy Joint ...................................................................... 6A Joint With Severe Osteoarthritis .............................................. 6Exercises for Osteoarthritis............................................ 24

Information Boxes

Cartilage: The Key to Healthy Joints ......................................... 7The Warning Signs of Osteoarthritis ........................................... 8On the Move: Fighting Osteoarthritis

With Exercise ................................................................ 13Questions To Ask Your Doctor or Pharmacist

About Medicines ...................................................... 16Treatment Approaches to Osteoarthritis...................................... 18Health Professionals Who Treat Osteoarthritis ...................... 19Self-Management Programs Do Help ........................... 21Enjoy a Good-Health Attitude.................................... 22

1Osteoarthritis

This booklet is for people who have osteoarthritis, theirfamilies, and others interested in learning more about thedisorder. The booklet describes osteoarthritis and its symp-toms and contains information about diagnosis and treat-ment, as well as current research efforts supported by theNational Institute of Arthritis and Musculoskeletal and SkinDiseases (NIAMS) and other components of the NationalInstitutes 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?

O steoarthritis (AH-stee-oh-ar-THREYE-tis) is the mostcommon type of arthritis, especially among olderpeople. Sometimes it is called degenerative joint diseaseor osteoarthrosis.

Osteoarthritis is a joint disease that mostly affects thecartilage (KAR-til-uj). Cartilage is the slippery tissue thatcovers the ends of bones in a joint. Healthy cartilageallows bones to glide over one another. It also absorbsenergy from the shock of physical movement. In osteo-arthritis, the surface layer of cartilage breaks down andwears away. This allows bones under the cartilage to rubtogether, causing pain, swelling, and loss of motion ofthe joint. Over time, the joint may lose its normal shape.Also, bone spurssmall growths called osteophytesmay grow on the edges of the joint. Bits of bone or carti-lage can break off and float inside the joint space. Thiscauses more pain and damage.

2People with osteoarthritis usually have joint pain andlimited movement. Unlike some other forms of arthritis,osteoarthritis affects only joints and not internal organs.For example, rheumatoid arthritisthe second mostcommon form of arthritisaffects other parts of thebody besides the joints. It begins at a younger age thanosteoarthritis, causes swelling and redness in joints, andmay make people feel sick, tired, and (uncommonly)feverish.

Who Has Osteoarthritis?

O steoarthritis is one of the most frequent causes ofphysical disability among adults. More than 20million people in the United States have the disease.By 2030, 20 percent of Americansabout 70 millionpeoplewill have passed their 65th birthday and willbe at risk for osteoarthritis. Some younger people getosteoarthritis from joint injuries, but osteoarthritis mostoften occurs in older people. In fact, more than half of thepopulation age 65 or older would show x-ray evidence of osteoarthritis in at least one joint. Both men andwomen have the disease. Before age 45, more men thanwomen have osteoarthritis, whereas after age 45, it ismore common in women.

How Does Osteoarthritis Affect People?

O steoarthritis affects each person differently. In somepeople, it progresses quickly; in others, the symptomsare more serious. Scientists do not know yet what causesthe disease, but they suspect a combination of factors,including being overweight, the aging process, jointinjury, and stresses on the joints from certain jobs andsports activities.

3What Areas Does Osteoarthritis Affect?

Osteoarthritis most often occurs at the ends of the fingers, thumbs,neck, lower back, knees, and hips.

4Osteoarthritis hurts people in more than their joints: theirfinances 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 andfamily joys and responsibilities.

Despite these challenges, most people with osteoarthritiscan lead active and productive lives. They succeed byusing osteoarthritis treatment strategies, such as thefollowing:

Pain relief medications

Rest and exercise

Patient education and support programs

Learning self-care and having a good-healthattitude.

5Osteoarthritis Basics: The Joint and Its Parts

M ost jointsthe place where two moving bones cometogetherare designed to allow smooth movementbetween the bones and to absorb shock from movementslike walking or repetitive movements. The joint is madeup of:

Cartilage: a hard but slipperycoating on the end of eachbone. Cartilage, which breaksdown and wears away inosteoarthritis, is describedin more detail in the box onpage 7.

Joint capsule: a tough mem-brane sac that holds all thebones and other joint partstogether.

Synovium (sin-O-vee-um): athin membrane inside the jointcapsule.

Synovial fluid: a fluid thatlubricates the joint and keepsthe cartilage smooth and healthy.

Ligaments, tendons, and muscles: tissues thatkeep the bones stable and allow the joint to bendand move. Ligaments are tough, cord-like tissuesthat connect one bone to another. Tendons aretough, fibrous cords that connect muscles tobones. Muscles are bundles of specialized cellsthat contract to produce movement when stimu-lated by nerves.

Osteoarthritis

hurts people in

more than their

joints: their

finances and

lifestyles also

are affected.

6Worn-away cartilage

Synovial membrane

Synovial fluidCartilagefragments

in fluid

Bone

Muscles

Tendons

Bone spurs

Posterior cruciate ligament

Anterior cruciate ligament

Medial collateral ligament

Lateral collateral ligament

With osteoarthritis, the cartilage becomes worn away. Spurs growout from the edge of the bone, and synovial fluid increases. Altogeth-er, the joint feels stiff and sore.

Cartilage

Joint capsuleMedial collateral ligament

Synovial fluidLateral collateral ligament

Bone

Posterior cruciate ligament

Anterior cruciate ligament

MusclesTendons

Synovial membrane

A Healthy Joint

In a healthy joint, the ends of bones are encased in smooth cartilage.Together, they are protected by a joint capsule lined with a synovialmembrane that produces synovial fluid. The capsule and fluid protectthe cartilage, muscles, and connective tissues.

A Joint With Severe Osteoarthritis

7How Do You Know if You Have Osteoarthritis?

U sually, osteoarthritis comes on slowly. Early in thedisease, joints may ache after physical work or exer-cise. Osteoarthritis can occur in any joint. Most often itoccurs at the hands, knees, hips, or spine.

Hands: Osteoarthritis of the fingers is one type ofosteoarthritis that seems to have some hereditary charac-teristics; that is, it runs in families. More women thanmen have it, and they develop it especially after meno-pause. In osteoarthritis, small, bony knobs appear on the

Cartilage: The Key to Healthy Joints

Cartilage is 65 to 80 percent water. Three othercomponents 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 combi-nation of proteins and sugars. Strands of proteo-glycans and collagen weave together and form amesh-like tissue. This allows cartilage to flexand absorb physical shock.

Chondrocytes (KAHN-druh-sytz): cells that arefound all through the cartilage. They mainly helpcartilage stay healthy and grow. Sometimes,however, they release substances called enzymesthat destroy collagen and other proteins.Researchers are trying to learn more aboutchondrocytes.

8end joints of the fingers. They are called Heberdens(HEB-err-denz) nodes. Similar knobs, called Bouchards(boo-SHARDZ) nodes, can appear on the middle jointsof the fingers. Fingers can become enlarged and gnarled,and they may ache or be stiff and numb. The base of thethumb joint also is commonly affected by osteoarthritis.Osteoarthritis of the hands can be helped by medications,splints, or heat treatment.

Knees: The knees are the bodys primary weight-bearingjoints. For this reason, they are among the joints mostcommonly 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. Medica-tions, weight loss, exercise, and walking aids can reduce

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, suchas rheumatoid arthritis.

Pain? Not always. In fact, only a third of peoplewhose x rays show evidence of osteoarthritisreport pain or other symptoms.

9pain and disability. In severe cases, knee replacementsurgery may be helpful.

Hips: Osteoarthritis in the hip can cause pain, stiffness,and severe disability. People may feel the pain in theirhips, or in their groin, inner thigh, buttocks, or knees.Walking aids, such as canes or walkers, can reduce stresson the hip. Osteoarthritis in the hip may limit moving andbending. This can make daily activities such as dressingand foot care a challenge. Walking aids, medication, andexercise can help relieve pain and improve motion. Thedoctor may recommend hip replacement if the pain issevere and not relieved by other methods.

Spine: Stiffness and pain in the neck or in the lower backcan result from osteoarthritis of the spine. Weakness ornumbness of the arms or legs also can result. Some peo-ple feel better when they sleep on a firm mattress or situsing back support pillows. Others find it helps to useheat treatments or to follow an exercise program thatstrengthens the back and abdominal muscles. In severecases, the doctor may suggest surgery to reduce pain andhelp restore function.

How Do Doctors Diagnose Osteoarthritis?

N o single test can diagnose osteoarthritis. Most doctorsuse a combination of the following methods to diag-nose the disease and rule out other conditions:

Clinical history: The doctor begins by asking the patientto describe the symptoms, and when and how the condi-tion started. Good doctor-patient communication isimportant. The doctor can give a better assessment if thepatient gives a good description of pain, stiffness, andjoint function, and how they have changed over time.

10

It also is important for the doctor to know how the condi-tion affects the patients work and daily life. Finally, thedoctor also needs to know about other medical conditionsand whether the patient is taking any medicines.

Physical examination: The doctor will check the patientsgeneral health, including checking reflexes and musclestrength. Joints bothering the patient will be examined.

The doctor will also observe thepatients ability to walk, bend, andcarry out activities of daily living.

X rays: Doctors take x rays to seehow much joint damage has beendone. X rays of the affected joint canshow such things as cartilage loss,bone damage, and bone spurs. Butthere often is a big difference betweenthe severity of osteoarthritis as shownby the x ray and the degree of painand disability felt by the patient. Also,x rays may not show early osteoarthri-tis damage, before much cartilage losshas taken place.

Other tests: The doctor may orderblood tests to rule out other causes ofsymptoms. Another common test iscalled joint aspiration, which involvesdrawing fluid from the joint forexamination.

It usually is not difficult to tell if a patient has osteo-arthritis. It is more difficult to tell if the disease is causingthe patients symptoms. Osteoarthritis is so commonespecially in older peoplethat symptoms seemingly

It usually is not

difficult to tell if a

patient has

osteoarthritis. It

is more difficult

to tell if the dis-

ease is causing

the patients

symptoms.

caused by the disease actually may be due to other med-ical conditions. The doctor will try to find out what iscausing the symptoms by ruling out other disorders andidentifying conditions that may make the symptomsworse. The severity of symptoms in osteoarthritis isinfluenced greatly by the patients attitude, anxiety,depression, and daily activity level.

How Is Osteoarthritis Treated?

M ost successful treatment programs involve a combi-nation of treatments tailored to the patients needs,lifestyle, and health. Osteoarthritis treatment has fourgeneral goals:

Improve joint care through rest and exercise. Maintain an acceptable body weight.

Control pain with medicine and other measures.

Achieve a healthy lifestyle.

Osteoarthritis treatment plans often include ways to man-age pain and improve function. Such plans can involveexercise, rest and joint care, pain relief, weight control,medicines, surgery, and nontraditional treatmentapproaches.

Exercise: Research shows that exercise is one of the besttreatments for osteoarthritis. Exercise can improve moodand outlook, decrease pain, increase flexibility, improvethe heart and blood flow, maintain weight, and promotegeneral physical fitness. Exercise is also inexpensiveand, if done correctly, has few negative side effects. Theamount and form of exercise will depend on which joints

11

are involved, how stable the joints are, and whether ajoint replacement has already been done. (See Be aWinner! Practice Self-Care and Keep a Good-HealthAttitude, page 21.) Rest and joint care: Treatment plans include regularlyscheduled rest. Patients must learn to recognize the

bodys signals, and know when to stopor slow down, which prevents paincaused by overexertion. Some patientsfind that relaxation techniques, stressreduction, and biofeedback help.Some use canes and splints to protectjoints and take pressure off them.Splints or braces provide extra supportfor weakened joints. They also keepthe joint in proper position duringsleep or activity. Splints should beused only for limited periods becausejoints and muscles need to be exer-cised to prevent stiffness and weak-ness. An occupational therapist ora doctor can help the patient get aproperly fitting splint.

Nondrug pain relief: People with osteoarthritis may findnondrug ways to relieve pain. Warm towels, hot packs, ora warm bath or shower to apply moist heat to the jointcan relieve pain and stiffness. In some cases, cold packs(a bag of ice or frozen vegetables wrapped in a towel) canrelieve pain or numb the sore area. (Check with a doctoror physical therapist to find out if heat or cold is the besttreatment.) Water therapy in a heated pool or whirlpoolalso may relieve pain and stiffness. For osteoarthritis inthe knee, patients may wear insoles or cushioned shoesto redistribute weight and reduce joint stress.

12

Patients must

learn to recognize

the bodys

signals, and know

when to stop or

slow down.

Weight control: Osteoarthritis patients who are overweightor obese need to lose weight. Weight loss can reduce stresson weight-bearing joints and limit further injury. A dieti-tian can help patients develop healthy eating habits. Ahealthy diet and regular exercise help reduce weight.

On the Move: Fighting OsteoarthritisWith Exercise

You can use exercises to keep strong and limber,extend your range of movement, and reduce yourweight. (See examples, page 24.) Some differenttypes of exercise include the following: Strength exercises: These can be performed withexercise bands, inexpensive devices that addresistance. Aerobic activities: These keep your lungs andcirculation systems in shape. Range of motion activities: These keep your jointslimber. Agility exercises: These can help you maintaindaily living skills. Neck and back strength exercises: These can helpyou keep your spine strong and limber. Ask your doctor or physical therapist what exercisesare best for you. Ask for guidelines on exercisingwhen a joint is sore or if swelling is present. Also,check if you should (1) use pain-relieving drugs,such as analgesics or anti-inflammatories (alsocalled NSAIDs), to make exercising easier, or(2) use ice afterwards.

13

14

Medicines: Doctors prescribe medicines to eliminate orreduce pain and to improve functioning. Doctors considera number of factors when choosing medicines for theirpatients with osteoarthritis. Two important factors are theintensity of the pain and the potential side effects of themedicine. Patients must use medicines carefully and telltheir doctors about any changes that occur.

The following types of medicines are commonly used intreating osteoarthritis:

Acetaminophen: Acetaminophen is a pain reliever(for example, Tylenol*) that does not reduceswelling. Acetaminophen does not irritate thestomach and is less likely than nonsteroidal anti-inflammatory drugs (NSAIDs) to cause long-termside effects. Research has shown that aceta-minophen relieves pain as effectively as NSAIDsfor many patients with osteoarthritis.

Warning: People with liver disease, people whodrink alcohol heavily, and those taking blood-thinning medicines or NSAIDs should use aceta-minophen with caution.

NSAIDs (nonsteroidal anti-inflammatory drugs):Many NSAIDs are used to treat osteoarthritis.Patients can buy some over the counter (for exam-ple, aspirin, Advil, Motrin IB, Aleve, ketoprofen).Others require a prescription. All NSAIDs worksimilarly: they fight inflammation and relievepain. However, each NSAID is a different chemi-

* Note: Brand names included in this booklet are provided as examples only.Their inclusion does not mean they are endorsed by the National Institutesof Health or any other Government agency. Also, if a certain brand name isnot mentioned, this does not mean or imply that the product is unsatisfactory.

15

cal, and each has a slightly dif-ferent effect on the body.

Side effects: NSAIDs cancause stomach irritation or,less often, they can affect kid-ney function. The longer a per-son uses NSAIDs, the morelikely he or she is to have sideeffects, ranging from mild toserious. Many other drugs can-not be taken when a patient isbeing treated with NSAIDsbecause NSAIDs alter the waythe body uses or eliminatesthese other drugs. Check withyour health care provider orpharmacist before you takeNSAIDs in addition to anothermedication. Also, NSAIDssometimes are associated withserious gastrointestinal problems, includingulcers, bleeding, and perforation of the stomach orintestine. People over age 65 and those with anyhistory of ulcers or gastrointestinal bleedingshould use NSAIDs with caution.

COX-2 inhibitors: Several new NSAIDsvaldecoxib (Bextra), celecoxib (Celebrex), androfecoxib (Vioxx)from a class of drugs knownas COX-2 inhibitors are now being used to treatosteoarthritis. These medicines reduce inflam-mation similarly to traditional NSAIDs, but theycause fewer gastrointestinal side effects. However,these medications occasionally are associated with

Check with your

health care

provider or

pharmacist

before you take

NSAIDs in addition

to another

medication.

16

harmful reactions ranging from mild to severe.(See Current Research, page 25.)

Other medications: Doctors may prescribe severalother medicines for osteoarthritis, including thefollowing:

Topical pain-relieving creams, rubs, and sprays(for example, capsaicin cream), which are applieddirectly to the skin.

Mild narcotic painkillers, whichalthough veryeffectivemay be addictive and are not common-ly used.

Corticosteroids, powerful anti-inflammatory hor-mones made naturally in the body or manmade foruse as medicine. Corticosteroids may be injected

Questions To Ask Your Doctor orPharmacist 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 pre-

scription medicines I take? Should I take this medicine with the over-the-

counter medicines I take?

17

into the affected joints to temporarily relieve pain.This is a short-term measure, generally not recom-mended for more than two or three treatments peryear. Oral corticosteroids should not be used totreat osteoarthritis.

Hyaluronic acid, a medicinefor joint injection, used to treatosteoarthritis of the knee. Thissubstance is a normal compo-nent of the joint, involved injoint lubrication and nutrition.

Most medicines used to treat osteo-arthritis have side effects, so it isimportant for people to learn aboutthe medicines they take. Even nonpre-scription drugs should be checked.Several groups of patients are at highrisk for side effects from NSAIDs,such as people with a history of pepticulcers or digestive tract bleeding, peo-ple taking oral corticosteroids or anti-coagulants (blood thinners), smokers,and people who consume alcohol.Some patients may be able to helpreduce side effects by taking somemedicines with food. Others shouldavoid stomach irritants such as alco-hol, tobacco, and caffeine. Some patients try to protecttheir stomachs by taking other medicines that coat thestomach or block stomach acids. These measures help,but they are not always completely effective.

Most medicines

used to treat

osteoarthritis

have side effects,

so it is important

for people to

learn about the

medicines they

take.

Surgery: For many people, surgery helps relieve thepain and disability of osteoarthritis. Surgery may beperformed to

Remove loose pieces of bone and cartilage fromthe joint if they are causing mechanical symptomsof buckling or locking

Resurface (smooth out) bones Reposition bones Replace joints.

Surgeons may replace affected joints with artificial jointscalled prostheses. These joints can be made from metalalloys, high-density plastic, and ceramic material. Theycan be joined to bone surfaces by special cements. Artifi-cial joints can last 10 to 15 years or longer. About 10 per-cent of artificial joints may need revision. Surgeonschoose the design and components of prostheses accord-ing to their patients weight, sex, age, activity level, andother medical conditions.

The decision to use surgery depends on several things.Both the surgeon and the patient consider the patientslevel of disability, the intensity of pain, the interference

18

Exercise Weight control Rest and joint care Pain relief techniques

Medicines Alternative therapies Surgery

Treatment Approaches to Osteoarthritis

19

Health Professionals Who Treat Osteoarthritis

Many types of health professionals care for people withosteoarthritis: Primary care physicians. Doctors who treat patients

before they are referred to other specialists in the healthcare system.

Rheumatologists. Medical doctors who specialize intreating arthritis and related conditions that affect joints,muscles, and bones.

Orthopaedists. Doctors who specialize in treatment ofand surgery for bone and joint diseases.

Physical therapists. Health professionals who work withpatients to improve joint function.

Occupational therapists. Health professionals whoteach ways to protect joints, minimize pain, and conserveenergy.

Dietitians. Health professionals who teach ways to usea good diet to improve health and maintain a healthyweight.

Nurse educators. Nurses who specialize in helpingpatients understand their overall condition and imple-ment their treatment plans.

Physiatrists (rehabilitation specialists). Doctors whohelp patients make the most of their physical potential.

Licensed acupuncture therapists. Health professionalswho reduce pain and improve physical functioning byinserting fine needles into the skin at various points onthe body.

Psychologists. Health professionals who help patientscope with difficulties in the home and workplace result-ing from their medical conditions.

Social workers. Professionals who assist patients withsocial challenges caused by disability, unemployment,financial hardships, home health care, and other needsresulting from their medical conditions.

with the patients lifestyle, the patients age, and occupa-tion. Currently, more than 80 percent of osteoarthritissurgery cases involve replacing the hip or knee joint.After surgery and rehabilitation, the patient usually feelsless pain and swelling, and can move more easily.

Nontraditional Approaches: Among the alternative thera-pies used to treat osteoarthritis are the following:

Acupuncture: Some people have found pain reliefusing acupuncture (the use of fine needles insertedat specific points on the skin). Preliminaryresearch shows that acupuncture may be a usefulcomponent in an osteoarthritis treatment plan forsome patients. (See Current Research, page 25.)

Folk remedies: Some patients seek alternativetherapies for their pain and disability. Some ofthese alternative therapies have included wearingcopper bracelets, drinking herbal teas, and takingmud baths. While these practices are not harmful,some can be expensive. They also cause delays inseeking medical treatment. To date, no scientificresearch shows these approaches to be helpful intreating osteoarthritis.

Nutritional supplements: Nutrients such asglucosamine and chondroitin sulfate have beenreported to improve the symptoms of people withosteoarthritis, as have certain vitamins. Additionalstudies are being carried out to further evaluatethese claims. (See Current Research, page 25.)

20

21

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

P eople with osteoarthritis can enjoy good healthdespite having the disease. How? By learning self-care skills and developing a good-health attitude.

Self-care is central to successfully managing the painand disability of osteoarthritis. People have a muchbetter chance of having a rewarding lifestyle when theyeducate themselves about the disease and take part intheir own care. Working actively with a team of healthcare providers enables people with the disease to mini-mize pain, share in decisionmaking about treatment, andfeel a sense of control over their lives. Research showsthat people with osteoarthritis who take part in their owncare report less pain and make fewer doctor visits. Theyalso enjoy a better quality of life.

Self-Management Programs Do Help

People with osteoarthritis find that self-manage-ment 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.

22

Self-Help and Education Programs: Three kinds of pro-grams help people learn about osteoarthritis, learn self-care, and improve their good-health attitude. Theseprograms include

Patient education programs

Arthritis self-management programs

Arthritis support groups.

These programs teach people about osteoarthritis, itstreatments, exercise and relaxation, patient and healthcare provider communication, and problem solving.Research has shown that these programs have clear andlong-lasting benefits.

Exercise: Regular physical activity plays a key role inself-care and wellness. Two types of exercise are impor-

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.

23

tant in osteoarthritis management. The first type, thera-peutic exercises, keep joints working as well as possible.The other type, aerobic conditioning exercises, improvestrength and fitness, and control weight. Patients shouldbe realistic when they start exercising. They should learnhow to exercise correctly, because exercising incorrectlycan cause problems.

Most people with osteoarthritis exer-cise best when their pain is leastsevere. Start with an adequate warmupand begin exercising slowly. Restingfrequently ensures a good workout.It also reduces the risk of injury. Aphysical therapist can evaluate howa patients muscles are working. Thisinformation helps the therapist devel-op a safe, personalized exercise pro-gram to increase strength andflexibility.

Many people enjoy sports or otheractivities in their exercise program.Good activities include swimming and aquatic exercise,walking, running, biking, cross-country skiing, and usingexercise machines and exercise videotapes.

People with osteoarthritis should check with their doctoror physical therapist before starting an exercise program.Health care providers will suggest what exercises are bestfor you, how to warm up safely, and when to avoid exer-cising a joint affected by arthritis. Pain medications andapplying ice after exercising may make exercising easier.

Body, Mind, Spirit: Making the most of good healthrequires careful attention to the body, mind, and spirit.

Regular physical

activity plays

a key role in

self-care and

wellness.

24

Exercises for Osteoarthritis

Strengthening

Aerobics/heart and lung health

Range of motion

People with osteoarthritis should do different kinds of exercisefor different benefits to the body.

25

People with osteoarthritis must planand develop daily routines that maxi-mize their quality of life and minimizedisability. They also need to evaluatethese routines periodically to makesure they are working well.

Good health also requires a positiveattitude. People must decide to makethe most of things when faced withthe challenges of osteoarthritis. Thisattitudea good-health mindsetdoesnt just happen. It takes work,every day. And with the right attitude,you will achieve it.

Current Research

T he leading role in osteoarthritis research is played bythe National Institute of Arthritis and Musculoskeletaland Skin Diseases (NIAMS), within the NationalInstitutes of Health (NIH). The NIAMS funds manyresearchers across the United States to study osteoarthri-tis. It has established a Specialized Center of Researchdevoted to osteoarthritis. Also, many researchers studyarthritis at NIAMS Multipurpose Arthritis and Musculo-skeletal Diseases Centers and Multidisciplinary ClinicalResearch Centers. These centers conduct basic, labora-tory, and clinical research aimed at understanding thecauses, treatment options, and prevention of arthritis andmusculoskeletal diseases. Center researchers also studyepidemiology, health services, and professional, patient,and public education. The NIAMS also supports multi-disciplinary clinical research centers that expand clinicalstudies for diseases like osteoarthritis.

Plan and develop

daily routines

that maximize

quality of life

and minimize

disability.

26

For years, scientists thought that osteoarthritis was simplya disease of wear and tear that occurred in joints aspeople got older. In the last decade, however, researchhas shown that there is more to the disorder than agingalone. The production, maintenance, and breakdownof cartilage, as well as bone changes in osteoarthritis,are now seen as a series or cascade of events. Manyresearchers are trying to discover where in that cascadeof events things go wrong. By understanding what goeswrong, they hope to find new ways to prevent or treatosteoarthritis. Some key areas of research are describedbelow.

Animal Models: Animals help researchers understandhow diseases work and why they occur. Animal modelshelp researchers learn many things about osteoarthritis,such as what happens to cartilage, how treatment strate-gies might work, and what might prevent the disease.Animal models also help scientists study osteoarthritis invery early stages before it causes detectable joint damage. Diagnostic Tools: Some scientists want to find ways todetect osteoarthritis at earlier stages so that they can treatit earlier. They seek specific abnormalities in the blood,joint fluid, or urine of people with the disease. Other sci-entists use new technologies to analyze the differencesbetween the cartilage from different joints. For example,many people have osteoarthritis in the knees or hips, butfew have it in the ankles. Can ankle cartilage be differ-ent? Does it age differently? Answering these questionswill help us understand the disease better.

Genetics Studies: Researchers suspect that inheritanceplays a role in 25 to 30 percent of osteoarthritis cases.Researchers have found that genetics may play a rolein approximately 40 to 65 percent of hand and knee

27

osteoarthritis cases. They suspect inheritance might playa role in other types of osteoarthritis, as well. Scientistshave identified a mutation (a gene defect) affecting col-lagen, an important part of cartilage, in patients with aninherited kind of osteoarthritis that starts at an early age.The mutation weakens collagen protein, which may breakor tear more easily under stress. Scientists are lookingfor other gene mutations in osteoarthritis. Recently,researchers found that the daughters of women who haveknee osteoarthritis have a significant increase in cartilagebreakdown, thus making them more susceptible to dis-ease. In the future, a test to determine who carries thegenetic defect (or defects) could help people reduce theirrisk for osteoarthritis with lifestyle adjustments. Tissue Engineering: This technology involves removingcells from a healthy part of the body and placing them inan area of diseased or damaged tissue in order to improvecertain body functions. Currently, it is used to treat smalltraumatic injuries or defects in cartilage, and, if success-ful, could eventually help treat osteoarthritis. Researchersat the NIAMS are exploring three types of tissue engi-neering. The two most common methods being studiedtoday include cartilage cell replacement and stem celltransplantation. The third method is gene therapy.

Cartilage cell replacement: In this procedure,researchers remove cartilage cells from thepatients own joint and then clone or grow newcells using tissue culture and other laboratorytechniques. They then inject the newly growncells into the patients joint. Patients with cartilagecell replacement have fewer symptoms of osteo-arthritis. Actual cartilage repair is limited,however.

28

Stem cell transplantation: Stem cells are primitivecells that can transform into other kinds of cells,such as muscle or bone cells. They usually aretaken from bone marrow. In the future, research-ers hope to insert stem cells into cartilage, wherethe cells will make new cartilage. If successful,this process could be used to repair damagedcartilage and avoid the need for surgical jointreplacements with metal or plastics.

Gene therapy: Scientists are working to geneti-cally engineer cells that would inhibit the bodychemicals, called enzymes, that may help breakdown cartilage and cause joint damage. In genetherapy, cells are removed from the body, geneti-cally changed, and then injected back into theaffected joint. They live in the joint and protectit from damaging enzymes.

Comprehensive Treatment Strategies: Effective treatmentfor osteoarthritis takes more than medicine or surgery.Getting help from a variety of care professionals oftencan improve patient treatment and self-care. (See HealthProfessionals Who Treat Osteoarthritis, page 19.)Research shows that adding patient education andsocial support is a low-cost, effective way to decreasepain and reduce the amount of medicine used.

Exercise plays a key part in comprehensive treatment.Researchers are studying exercise in greater detail andfinding out just how to use it in treating or preventingosteoarthritis. For example, several scientists have stud-ied knee osteoarthritis and exercise. Their results includedthe following:

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Strengthening the thigh muscle (quadriceps) canrelieve symptoms of knee osteoarthritis and pre-vent more damage.

Walking can result in better functioning, and themore you walk, the farther you will be able towalk.

People with knee osteoarthritis who were activein an exercise program feel less pain. They alsofunction better.

Research has shown that losing extra weight can helppeople who already have osteoarthritis. Moreover, over-weight or obese people who do not have osteoarthritismay reduce their risk of developing the disease by losingweight.

Using NSAIDs: Many people who have osteoarthritishave persistent pain despite taking simple pain relieverssuch as acetaminophen. Some of these patients takeNSAIDs instead. Health care providers are concernedabout long-term NSAID use because it can lead to anupset stomach, heartburn, nausea, and more dangerousside effects, such as ulcers.

Scientists are working to design and test new, saferNSAIDs. One example currently available is a class ofselective NSAIDs called COX-2 inhibitors. TraditionalNSAIDs prevent inflammation by blocking two relatedenzymes in the body called COX-1 and COX-2. Thegastrointestinal side effects associated with traditionalNSAIDs seems to be associated mainly with blockingthe COX-1 enzyme, which helps protect the stomachlining. 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 inhibitorsreduce pain and inflammation but are less likely thantraditional NSAIDs to cause gastrointestinal ulcers andbleeding. However, research shows that some COX-2inhibitors may not protect against heart disease as wellas traditional NSAIDs, so check with your doctor if youhave concerns.

Drugs to Prevent Joint Damage: No treatment actuallyprevents osteoarthritis or reverses or blocks the diseaseprocess once it begins. Present treatments just relieve thesymptoms. Researchers are looking for drugs that wouldprevent, slow down, or reverse joint damage. One experi-mental antibiotic drug, doxycycline, may stop certainenzymes from damaging cartilage. The drug has shownsome promise in clinical studies, but more studies areneeded. Researchers also are studying growth factors andother natural chemical messengers. These potential medi-cines may be able to stimulate cartilage growth or repair.

Acupuncture: During an acupuncture treatment, alicensed acupuncture therapist inserts very fine needlesinto the skin at various points on the body. Scientiststhink the needles stimulate the release of natural, pain-relieving chemicals produced by the brain or the nervoussystem. Researchers are studying acupuncture treatmentof patients who have knee osteoarthritis. Early findingssuggest that traditional Chinese acupuncture is effectivefor some patients as an additional therapy for osteoarthri-tis, reducing pain and improving function.

Nutritional Supplements: Nutritional supplements areoften reported as helpful in treating osteoarthritis. Suchreports should be viewed with caution, however, sincevery few studies have carefully evaluated the role ofnutritional supplements in osteoarthritis.

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Glucosamine and chondroitin sulfate: Both ofthese nutrients are found in small quantities infood and are components of normal cartilage.Scientific studies on these two nutritional supple-ments have not yet shown that they affect thedisease. They may relieve symptoms and reducejoint damage in some patients, however. TheNational Center for Complementary and Alterna-tive Medicine at the NIH is supporting a clinicaltrial to test whether glucosamine, chondroitinsulfate, or the two nutrients in combination reducepain and improve function. Patients using thistherapy should do so only under the supervisionof their doctor, as part of an overall treatment pro-gram with exercise, relaxation, and pain relief.

Vitamins D, C, E, and beta carotene: The progres-sion of osteoarthritis may be slower in people whotake higher levels of vitamin D, C, E, or betacarotene. More studies are needed to confirmthese reports.

Hyaluronic Acid: Injecting this substance into the kneejoint provides long-term pain relief for some people withosteoarthritis. Hyaluronic acid is a natural component ofcartilage and joint fluid. It lubricates and absorbs shockin the joint. The Food and Drug Administration (FDA)approved this therapy for patients with osteoarthritis ofthe knee who do not get relief from exercise, physicaltherapy, or simple analgesics. Researchers are presentlystudying the benefits of using hyaluronic acid to treatosteoarthritis.

Estrogen: In studies of older women, scientists founda lower risk of osteoarthritis in women who had usedoral estrogens for hormone replacement therapy. The

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researchers suspect having low levels of estrogen couldincrease the risk of developing osteoarthritis. Additionalstudies are needed to answer this question.

Hope for the Future

R esearch is opening up new avenues of treatment forpeople with osteoarthritis. A balanced, comprehensiveapproach is still the key to staying active and healthy withthe disease. People with osteoarthritis should combineexercise, relaxation education, social support, and medi-cines in their treatment strategies. Meanwhile, as scientistsunravel the complexities of the disease, new treatmentsand prevention methods should appear. They will improvethe quality of life for people with osteoarthritis and theirfamilies.

Additional Resources

National Institute of Arthritis and Musculoskeletal andSkin Diseases National Institutes of Health1 AMS CircleBethesda, MD 208923675(301) 4954484 or (877) 22NIAMS (free of charge)TTY: (301) 5652966Fax: (301) 7186366niamsinfo@mail.nih.govwww.niams.nih.gov

NIAMS provides information about various forms ofarthritis and rheumatic diseases. It distributes patient andprofessional education materials and also refers people toother sources of information.

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American College of Rheumatology1800 Century Place, Suite 250Atlanta, GA 30345(404) 6333777Fax: (404) 6331870www.rheumatology.org

This association provides referrals to rheumatologists andphysical and occupational therapists who have experienceworking with people who have osteoarthritis. The organi-zation also provides educational materials and guidelines.

American Academy of Orthopaedic SurgeonsP.O. Box 2058Des Plaines, IL 60017(800) 824BONE (2663) (free of charge)www.aaos.org

The academy provides education and practice manage-ment services for orthopaedic surgeons and allied healthprofessionals. It also serves as an advocate for improvedpatient care and informs the public about the scienceof orthopaedics. The orthopaedists scope of practiceincludes disorders of the bodys bones, joints, ligaments,muscles, and tendons. For a single copy of an AAOSbrochure, send a self-addressed stamped envelope tothe address above or visit the AAOS Web site.

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Arthritis Foundation1330 West Peachtree StreetAtlanta, GA 30309Call your local chapter (listed in the telephone directory), or (800) 2837800 (free of charge)www.arthritis.org

The foundation is a major voluntary organization devotedto supporting research on arthritis and other rheumaticdiseases. The foundation publishes a free pamphlet onosteoarthritis and a magazine for members on arthritisand related conditions. It also provides up-to-date infor-mation on treatments, nutrition, alternative therapies, andself-management strategies. Chapters nationwide offerexercise programs, classes, support groups, physicianreferral services, and free literature.

Acknowledgments

The NIAMS gratefully acknowledges the assistance ofGayle Lester, Ph.D., Joan McGowan, Ph.D., JamesPanagis, M.D., Susana Serrate-Sztein, M.D., andBernadette Tyree, Ph.D., NIAMS, NIH; Kenneth D.Brandt, M.D., Indiana University School of Medicine,Indianapolis; Victor M. Goldberg, M.D., UniversityHospitals of Cleveland; Marc C. Hochberg, M.D.,M.P.H., University of Maryland, Baltimore; John Klippel,M.D., the Arthritis Foundation, Atlanta; and RolandMoskowitz, M.D., Case Western Reserve University,Cleveland, in preparation and review of this publication.Special thanks also go to the patients who reviewed thispublication and provided valuable input. Debbie Novakof Johnson, Bassin, and Shaw, Inc. wrote this booklet.

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About NIAMS and Its Clearinghouse:The mission of the National Institute of Arthritis andMusculoskeletal and Skin Diseases (NIAMS), a partof the National Institutes of Health (NIH), is to supportresearch into the causes, treatment, and prevention ofarthritis and musculoskeletal and skin diseases, thetraining of basic and clinical scientists to carry out thisresearch, and the dissemination of information onresearch progress in these diseases. The NationalInstitute of Arthritis and Musculoskeletal and SkinDiseases Information Clearinghouse is a public servicesponsored by the NIAMS that provides health informa-tion and information sources. Additional information canbe found on the NIAMS Web site at www.niams.nih.gov.

U.S. Department of Health andHuman ServicesPublic Health Service

National Institutes of Health

National Institute of Arthritis and Musculoskeletal and Skin Diseases

NIH Publication No. 024617July 2002

Table of ContentsWhat Is Osteoarthritis? Who Has Osteoarthritis? How Does Osteoarthritis Affe...Osteoarthritis Basics: The J...How Do You Know if You Have ...How Do Doctors Diagnose Oste...How Is Osteoarthritis Treate...Be a Winner! Practice Self-C...Current Research Hope for the Future Additional Resources

IllustrationsWhat Areas Does Osteoarthrit...A Healthy JointA Joint With Severe Osteoart...Exercises for Osteoarthritis

Info BoxesCartilage: The Key to Health...The Warning Signs of Osteoar...On the Move: Fighting Osteoa...Questions To Ask Your Doctor...Treatment Approaches to Oste...Health Professionals Who Tre...Self-Management Programs Do ...Enjoy a Good-Health Attitude