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Better joints without surgery

These steps can help you reduce arthritis pain and stay mobile

Consumer Reports on Health: January 2013

Americans are wearing out their joints. Knee replacement is now among the most common major surgeries, up 162 percent in the last two decades, according to an analysis of Medicare data published in September 2012 in the Journal of the American Medical Asso­ciation. The increase is partly due to the population growth of aging baby boomers. It also reflects rising rates of obesity and the fact that a more active group of people is unwilling to live with the pain and disability of osteoarthritis.

Surgery to replace joints is a good option if your condition has become disabling (see "The surgery decision: New tools make it easier"). But it's possible to delay or prevent the need for surgery, even if you already have symptoms.

Following is a roundup of evidence-based approaches that can help protect your joints and minimize the painful symptoms of arthritis.

Achieve a healthy weight

"Obesity is one of the most important modifiable factors contributing to the need for joint replacements," says Joseph D. Zuckerman, M.D., chairman of the department of orthopaedic surgery at the NYU Langone Medical Center in New York City. Being overweight increases the stress on your joints and might even hasten the breakdown of cartilage. Obesity can also have systemic effects that are not well understood. Research suggests that it even increases the risk of developing arthritis in joints that don’t bear weight, such as those in the hand.

Excess weight makes it more likely that mild osteoarthritis will eventually become severe. For example, among people ages 60 to 64 with early osteoarthritis, 63 percent of those who are obese will develop debilitating disease within 10 years, compared with 37 percent of those who aren’t obese, according to estimates based on the 2008 U.S. Census and other government data.

Fortunately, even modest weight loss—as little as 5 percent of your body weight—has been shown to reduce the risk of arthritis later. Research suggests that losing weight reduces pain in people who already have the disease.

Stay active

Because osteoarthritis can arise from the overuse of joints or from sports injuries, some people who have the condition worry that exercise will make it worse. In fact, the opposite may be true. Limited evidence suggests that routine physical activity is linked to healthier cartilage in the knees, according to a 2011 review of 28 studies. "Even if you already have evidence of arthritis, regular moderate activity is important to alleviate symptoms and slow the pro­gression of the disease," says Lynn Millar, Ph.D., P.T., a professor of physical therapy at Winston-Salem State Univer­sity in North Carolina. People have a higher likelihood of ending up disabled from arthritis if they're sedentary.

Along with regular aerobic exercise, aim for two to three sessions a week of strengthening activities using weights, resistance bands, or your body weight (such as push-ups and squats). The exercises are important to build the muscles that support the knees and other joints. And incorporate stretching or other flexibility training into your daily activities. Take breaks while working at your desk to extend your legs, stretch your hands, and roll your shoulders.

Treat injuries promptly

Left untreated, injuries such as a small tear in the knee cartilage or a shoulder tendon can set in motion a wear-and-tear process that leads to joint deterioration. See a doctor for any injury that causes severe pain or swelling, or minor pain that doesn’t resolve after a week or so.

Perhaps more important, take steps to minimize the risk of injury in the first place. Choose the proper equipment for your activity. For example, don't wear running shoes, which are designed to keep your weight from shifting sideways, to play tennis. Strive for a balance in your choice of activities and in how often you do them; it’s better to do shorter sessions throughout the week than try to catch up with a marathon session on the weekend. And listen to your body. "No pain, no gain does not apply to arthritis patients," says Zuckerman, a former runner who switched to elliptical training when the repetitive impact on his knees began to hurt.

Consider nondrug steps

Finding effective ways to alleviate pain, swelling, and stiffness is critical to staying active. Many people find that one or more of these nondrug measures can reduce the need for pain medication:

  • Acupuncture. Real acupuncture pro-vided modest benefits over a sham procedure in relieving chronic pain, including pain due to osteoarthritis, according to a review of 29 clinical trials involving nearly 18,000 patients published in the Oct. 22, 2012, Annals of Internal Medicine.
  • Heat and cold. Moist heating pads, a warm, damp towel, or a warm bath or shower can help relax and soothe stiff joints. Ice packs can help with acute pain and swelling.
  • Massage. Although there's not a lot of scientific evidence on the effectiveness of massage in treating osteoarthritis, the deep-tissue variety got high marks in a 2010 survey of Consumer Reports online readers who had tried it. Half of them rated it very helpful.
  • Mechanical aids. A cane, crutch, or walker can take a load off painful hips and knees. Over-the-counter knee braces that slip on or fasten with Velcro may also decrease symptoms, and they're often a better option than custom leg braces, which can be bulky and expensive, Zuckerman says.

Simplify drug treatment

Newer, heavily advertised name-brand drugs such as duloxetine (Cymbalta)—which is usually used to treat depression, but is also approved for treating chronic musculoskeletal osteoarthritis pain—often don't work better than basic pain relievers, but they cost more and can carry a greater risk of side effects. Zuckerman advises patients to instead start with a tried-and-true pain reliever, such as over-the-counter acetaminophen (Tylenol and generic). It's inexpensive and generally considered safe as long as you don't exceed the maximum dosage of 3,000 milligrams a day. For inflammation, try an over-the-counter nonsteroidal anti-inflam­ma­tory drug (NSAID), such as ibuprofen (Advil and generic) or naproxen (Aleve and generic).

You can also talk with your doctor about the topical version of the NSAID diclofenac (Pennsaid and Voltaren Gel). That prescription gel can be particularly effective for pain in smaller joints, such as ankles, elbows, fingers, and toes. And you'll avoid the risks associated with prescription oral pain drugs.

Finally, shots of anti-inflammatory steroids are an effective short-term remedy for moderate to severe pain and swelling in the knees and hips, especially during flare-ups. But you shouldn't get more than three or four shots a year, since more frequent injections might cause further joint damage.

Use supplements wisely

Despite mixed evidence and a lack of support from major health groups about the role of the supplements glucosamine and chondroitin in treating osteoarthritis, some people think they help. It's reasonable to try them if you want, Zuckerman says, but if you don't experience relief within three months there's no point in continuing to take them. Don’t use these supplements if you take the blood thinner warfarin (Coumadin and generic) because they may intensify the effect of the drug.

To avoid potential interactions, keep your doctor and pharmacist up-to-date on any supplements as well as over-the-counter medication you use. And keep in mind that supplements and other "natural" remedies can still cause drug-like side effects. In a recent study of 877 people who had suffered liver damage after taking drugs or supplements, researchers concluded that four cases were "highly likely" or "possibly" due to flavocoxid (Limbrel), a prescription plant derivative marketed as a "medical food" for managing osteoarthritis. Our consultants advise against using it.

Skip unproven treatments

In particular, the most recent data suggest that injections of hyaluronic acid (Synvisc) directly into a joint, known as viscosupplementation, isn't worth the risk. In a review of 89 clinical trials involving over 12,000 patients, published in August 2012, the authors concluded that viscosupplementation did little or nothing overall to relieve pain or increase function in people with knee osteoarthritis. But it did significantly increase the risk of serious side effects.

The surgery decision: New tools make it easier

For people whose osteoarthritis has progressed to the point that it prevents them from participating fully in life, joint-replacement surgery can be an excellent option to restore mobility. But it's not for everyone. To begin with, it's not meant to substitute for lifestyle changes. "We're still going to tell you to achieve a healthy weight and exercise as a way to protect the new joint," says Joseph D. Zuckerman, M.D., chair of the department of orthopaedic surgery at the NYU Langone Medical Center. Younger patients also need to consider the 10- to 20-year life span of artificial joints. And you must be prepared for the risks of major surgery, as well as a lengthy recovery period and substantial physical therapy.

Making a decision
Health-care researchers use what they call "decision aids" to help patients explore their options. These booklets, DVDs, or Web videos provide evidence-based information in plain language so that you can have an informed conversation with your doctor and reach a decision that takes into account your needs and preferences.

"Decision aids help you weigh risks and benefits and, with your provider's help, come to a conclusion about what treatment option is right for you," says David Arterburn, M.D., M.P.H., an associate investigator with Group Health Research Institute, the research arm of a nonprofit health-care system in Washington and Idaho.

Arterburn was the lead author of a study published in September 2012 that compared six-month outcomes for about 9,500 patients with knee or hip osteoarthritis before and after the providers introduced video and written decision aids. It found that the number of knee replacements dropped by 38 percent after patients started using the aids; hip replacements fell by 26 percent. And patient satisfaction increased, regardless of what treatment they chose.

Finding an aid
If your doctor doesn't provide decision aids, you can access the one used in the Group Health study, created by the company Health Dialog. For other aids, make sure the information comes from a reputable, impartial source—such as an academic research center or government agency—and not, say, a company that makes artificial joints, which probably has a vested interest in the outcome.

You should also discuss your decision with a provider other than your orthopaedic specialist, who may be more biased toward a surgical fix, Arterburn says. Your primary-care doctor is a good place to start.

More knee replacements—and more complications

The number of people having knee-replacement surgery for the first time has increased significantly in the last two decades, according to recent analysis of Medicare data. (Revision knee replacements are up, too.) And while hospital stays for the surgery are about half as long as they used to be, the 30-day readmission rate for complications has increased significantly for revision knee replacements.


   

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