Get the Upper Hand
Innovative treatments spell relief for many arthritis sufferers.
By Jennifer O. Bryant

TRUE OR FALSE?

Arthritis is an inevitable side effect of aging, the result of years of wear and tear on your bones and joints.

FALSE. Although some forms of arthritis are related to aging, many people progress happily into their later years without ever reporting problems with stiff, creaky joints. Experts no longer believe that "wear and tear" causes arthritis - and, in fact, have reversed their recommendations regarding exercise. Additionally, research shows some forms of arthritis aren't age-related at all and may have more to do with genetics or even environmental factors.

As the following six pages show, medical science has made great progress in pinpointing the causes and mechanisms of arthritis and developing new treatments that have eased the symptoms of millions of sufferers. In addition, ongoing research holds exciting promise for future treatment - and perhaps even prevention.

Arthritis is a catchall term that encompasses more than 100 ailments affecting the joints and the tissues around the joints. The word itself means joint inflammation (arthr = joint; itis = inflammation), although some forms of arthritis don't actually produce inflammation at all, and other forms affect other parts of the body besides the joints and related structures. Two forms of arthritis most commonly affect people in their 40s and older: osteoarthritis (OA) and inflammatory arthritis, two very different diseases.

Osteoarthritis. OA is the big daddy of the disease. "There are 70 million arthritis sufferers in the [United States], and half of those have OA," says Dr. John H. Klippel, medical director of the Arthritis Foundation in Atlanta. "OA generally begins in the 40s, and it is related to aging."

The places where the bones of your joints meet are cushioned by a tough, spongy material called cartilage. The entire joint is surrounded by a joint lining called the synovial membrane, which produces a lubricating fluid that helps keep the joint structures moving smoothly.

Erosion to the cartilage can result in pain and stiffness in the affected joints - most commonly the hips and knees, although the neck, lower back, and fingers also can be affected. In addition to loss of joint cartilage, OA also can cause bone changes that lead to tender swelling, often in the end joints of the fingers.

Strong muscles, tendons, and ligaments support your joints and keep the structures aligned properly. Unfortunately, OA can set off a vicious cycle: Your joints hurt, so you limit their range of motion in an attempt to ease the pain. You may not feel like exercising because you're in pain or fear the exertion will further harm your sore joints. The result is underused muscles that no longer can move through their full range of motion and lose the mass and strength needed to support your joints properly - exacerbating the very condition you want to relieve.

"The stability of a joint is very important," says Klippel. Even people without arthritis lose muscle mass as they age, he says, and this loss can lead to OA. For instance, "The quadriceps [the large muscles at the front of the thigh] stabilize the knees. Aging can lead to instability of the joint and therefore osteoarthritis in the knees," he says.

"Obesity is a big risk factor for osteoarthritis of the knees, hands, and wrists," adds Dr. Kevin Fontaine, a behavioral rheumatologist at Johns Hopkins University's Department of Medicine in Baltimore. Fontaine has studied the effects of obesity and weight loss on arthritis and is researching ways to encourage arthritis sufferers to become more physically active.

It's fairly obvious how excess pounds can stress the weight-bearing knee joints - which absorb as much as three to six times your own body weight when you run or engage in other activities in which you're momentarily airborne - but the hands and wrists? Fontaine says researchers believe fatty tissue may affect "growth factor," a family of hormones or biological factors the body uses to regulate the growth, maturation, and reproduction of blood cells.

Inflammatory arthritis. Although inflammatory arthritis is 10 times less common than OA, Klippel says it wreaks havoc on the sufferer's body. A few common forms of inflammatory arthritis are rheumatoid arthritis (RA), psoriatic arthritis, and ankylosing spondylitis.

RA is characterized by chronic inflammation of the synovial membranes, which produces swelling, pain, stiffness, and heat. In severe cases, cartilage and bone erode, and joints become permanently deformed and damaged. RA's telltale inflammation is caused when immune cells - the body's infection fighters - amass in the synovial membrane, causing it to become irritated and thickened. The cells of the synovial membrane release proteins called cytokines (Klippel calls them "messengers of the immune system"), which attack the joint, destroying ligaments, tendons, cartilage, and bone. Because RA is a case of the body's immune system turned against itself, it is classified as an autoimmune disorder. As with most other autoimmune problems, researchers don't yet fully understand what triggers the immune system to attack itself, although genetics plays a role.

RA has other significant differences from OA. RA sufferers are younger at the onset - typically, between the ages of 20 and 50. RA usually affects the joints of the hands, wrists, ankles, and feet, although other joints can be involved.

Psoriatic arthritis usually occurs in the hands and feet and is associated with psoriasis, a common skin ailment. Ankylosing spondylitis involves the spinal joints and affiliated structures and can cause back, shoulder, and neck pain.

Thanks to breakthroughs in medical research and a number of innovations - from simple to high-tech - many OA and inflammatory-arthritis sufferers are leading more comfortable and pain-free lives than ever before. Recently developed treatments have helped millions of people with arthritis "get their lives back," as Klippel puts it.

Improved pain medication. Many OA sufferers still reach for their bottles of aspirin, ibuprofen, or naproxen to help relieve pain and inflammation. These drugs, known as nonsteroidal anti-inflammatory drugs (NSAIDs), and acetaminophen can offer relief when used sparingly, but long-term use can have undesirable side effects, among them ulcers and gastrointestinal problems.

In 1999, the U.S. Food and Drug Administration (FDA) approved the first of a new breed of prescription pain medications known as COX-2 inhibitors (Celebrex and Vioxx are two widely advertised brand names). These substances have been shown to be as effective at reducing pain as traditional NSAIDs but without the gastrointestinal side effects caused by the long-term use of NSAIDs.

Dietary supplements. Talk to a few arthritis sufferers, and chances are you'll hear about "nutraceuticals," herbs, and other substances that advocates swear provide relief. Many of these substances have not been shown to be effective in clinical studies, and some can be downright harmful if misused.

Two supplements that do come with some proof, however, are glucosamine and chondroitin sulfate. Both substances occur naturally in cartilage. The body uses glucosamine to help build and repair cartilage, and chondroitin sulfate helps keep cartilage sound and elastic.

According to Klippel, there have been "reasonably convincing studies that glucosamine limits pain and can even limit joint damage." The studies of glucosamine were limited to people with OA in their knees, so there is no conclusive evidence that it helps people with OA in other joints or has any preventive qualities. The effects of chondroitin sulfate have not been studied as thoroughly, although many people take it along with glucosamine and believe the two taken together produce maximum effectiveness.

"The management of osteoarthritis isn't simple," Klippel stresses. "Everyone is different. Ask your doctor to develop an individualized treatment regimen for you."

All of these treatments may have serious side effects, even those that are "all natural." Dietary glucosamine is derived from shellfish, and chondroitin sulfate comes from cattle trachea, so the possibility of allergic reactions exists. Klippel advises you check with your doctor before taking any medication or dietary supplement.

Surgery. Joint replacement, especially of the hip and knee, is "one of the single most important advances in arthritis treatment," says Klippel. The procedure, which is performed on nearly half a million Americans each year, can produce a stunning transformation, allowing a person crippled by arthritis to walk and move without pain, seemingly overnight. And that's no exaggeration: "The surgery has become almost routine," says Klippel. "You're usually home within a couple of days."

Still, joint-replacement surgery is generally considered a last resort, used in advanced OA cases that have failed to respond to noninvasive treatment. As in all surgeries, some degree of risk is involved. And, although newer artificial joints may last longer than older models (25 years as compared to 10 or 15), depending on the age of the patient, additional surgery may be needed down the road to replace the worn-out artificial joint.

Biologic agents. For inflammatory arthritis sufferers, these proteins, which were introduced in 1999 and are manufactured in living cells, inhibit the cytokines that cause the inflammation and damage that are the hallmarks of this type of arthritis. There are three FDA-approved biologic agents (sold under the brand names Remicade, Enbrel, and Kineret), which inhibit different types of cytokines.

Biologic agents must be administered via injection or intravenous infusion because the body degrades the proteins if they are taken orally, says Klippel. They usually are given daily or weekly.

Many researchers are studying the roles genetics plays in the various forms of arthritis, and the field holds many exciting possibilities for future treatment or even prevention.

"It is not yet known what role genetics plays in osteoarthritis," says Klippel. "Genetics is probably not as strongly related to osteoarthritis as it is to inflammatory arthritis because osteoarthritis is so common."

However, genetics may have a lot to do with OA treatment in the future. According to Klippel, genetic testing may be used to screen patients for their risk of developing arthritis. A subset of the genetics field, called "pharmacogenomics," may help doctors determine whether patients will respond to a given medication and whether they will suffer any side effects.

A second promising field is biotechnology, which Klippel terms "building on science." "Biotechnology could become important for the treatment of osteoarthritis as well as for inflammatory arthritis," he says. Researchers are exploring "tissue engineering," the cultivation and use of healthy cartilage to overgrow damaged cartilage. Someday a patient may be "seeded" with new cartilage that literally rejuvenates the joint. "It could eventually replace joint-replacement surgery," he says.

Many other factors are being studied. "We still fundamentally don't understand what causes arthritis," Klippel says. Medical researchers are studying the role of infectious agents, diet, stress, and other possible contributing factors. Sensible weight loss, a balanced diet, and a doctor-approved exercise program can relieve many symptoms.

"The American College of Rheumatology recommends weight loss" for overweight arthritis sufferers, says Fontaine. In a 1998 study, OA patients reported less pain and stiffness while on a program of regular exercise - either aerobic exercise (treadmill walking) or strength training on machines. Both forms of exercise appeared to be equally effective.

"The problem is that people tend to stop exercising when they're no longer participants in a study," says Fontaine. "My question is: How do we help people to maintain their activity?" In his current research, Fontaine explains, "I'm trying to apply the Lifestyle Activity Model, which has shown that the accumulation of moderate activity throughout the day - from parking your car farther from the store entrance to taking the stairs instead of the elevator - can be as beneficial as the traditional ‘20 minutes a day, three times a week' exercise model. This is especially important for arthritis patients because 20 minutes of continuous exercise for them can produce pain."

"It's important for people with arthritis to stay as active as possible," Fontaine adds. "Every little bit helps and can have effects that go beyond [relief from] arthritis," such as decreased blood pressure and reduced cholesterol levels. "Exercise and weight loss don't replace conventional medical care. You need both."

A final area of study poses intriguing questions for researchers: the mind-body connection. "Attitude has a lot to do with it," says Klippel. "If you were to take a random group of people walking down the street and x-ray their knees, many would show signs of osteoarthritis, yet very few would complain of pain. This raises the question: How do individuals perceive pain? Why does one person become totally disabled by arthritis while another ignores it?"

Although medical research has unlocked some of the mysteries pertaining to the causes and treatments of arthritis, many puzzles remain. Those who suffer from one of its many forms can take heart at the number of breakthroughs that have been achieved recently. Imagine what the next few years may bring!