Conventional Treatments
Conventional medicines do not cure nor do they bring lasting relief; but they do give instant pain relief, and often this is necessary. Pain can actually do more harm to the body than the cause of the pain; therefore, short-term use may be essential. Understanding the various types of drugs and the effects they have is vital in the process of taking charge of your own health.
Painkillers come in the forms of prescription or non-prescription drugs, narcotic and non-narcotic medications, and steroidal and non-steroidal analgesics. Simple analgesics include aspirin, while narcotic forms include codeine and morphine. Non-steroidal anti-inflammatories (NSAIDs) include ibuprofen and aspirin. Many brand name painkillers combine aspirin with another non-narcotic drug, as caffeine, or with a mild narcotic drug, as codeine, to produce a compound painkiller. Care must be taken not to mix brands, which can produce an overdose; and they must not be taken with alcohol either. Another danger is overusing the joint when the pain has been eliminated. Pain is nature's way of telling the body that something is wrong in that area. When the warning is masked, more damage can result.
Cortecosteroids wreak havoc with the body's nutritional status, decreasing the absorption of vitamin D and speeding up the excretion of zinc, potassium, and vitamin C. The following are some of the more popular medications prescribed for the relief of arthritic pain.
Acetaminophen is an analgesic and antipyretic, which means it relieves pain and lowers fevers. It is often used instead of aspirin, and is sold under such trade names as Tylenol, Datril, and Liquiprin. As an arthritis treatment, Acetaminophen is used if there is pain but no inflammation, as is often the case with OA. When taken over a long period of time, acetaminophen can cause a significant decrease in liver function and can harm the kidneys -- which is the cause of thousands of cases of kidney failure in the US alone each year. However, this risk is reduced if it is taken for short periods of time with food.
Aspirin (acetylsalicylic acid) is a common drug originally derived from willow bark. It is used to relieve pain and reduce fevers, but it has fallen into disfavour over recent years because of its suspected association with the subsequent development of Reye's Syndrome after being taken during a viral infection. It was specifically prescribed for rheumatic and arthritic disorders; but now, other alternatives are used more often. Taking high doses of aspirin will cause a decrease in vitamin C absorption, plus an increased loss of iron and a reduction in folic acid in the blood. It will also prolong bleeding time.
Corticosteroids (steroids for short) are hormones. Some are produced naturally in the body while others are manufactured synthetically. Those used in the treatment of arthritis are derived from, or are synthetic variants of, the natural corticosteroid hormones formed in the outer part of the adrenal glands. When present in large quantities, they not only reduce inflammation, but they suppress immune responses, a desired effect for such autoimmune disorders as rheumatoid arthritis and other types of rheumatic diseases. Conventional doctors are more likely to prescribe an anti-inflammatory drug early in the disease. They believe that as soon as the inflammation is suppressed, joints will not deteriorate and should improve, and patients will also suffer fewer side effects if they are treated sooner rather than later. Rheumatologists are convinced that accurate diagnosis and appropriate intervention with drugs and physiotherapy in the early stage of the disease is crucial because the longer the inflammation lasts, the more damage that is caused. However, it must be stressed that drugs may reduce inflammation, but they only mask symptoms and do nothing to reduce joint deterioration. It is recommended that no more than three steroid shots per year be taken as they can cause potentially dangerous side effects that affect the central nervous system, endocrine system, acardiovascular system, and the eyes.
DMARDs (disease-modifying antirheumatic drugs) play a key role in the treatment of RA, as well as such other types of rheumatic diseases as ankylosing spondylitis or psoriasis-linked arthritis. DMARDs lower disease activity and inflammation, thereby reducing pain, swelling, and stiffness of joints. They are often effective in cases where anti-inflammatory drugs are not. However, they have potentially more damaging side effects than NSAIDs. They are also slow acting, taking weeks or even months before full benefit is felt. Because they are not analgesics, they have to be taken in conjunction with them, thus magnifying the risk potential.
Electrical Therapy involves two main types used to stimulate tissue in an area affected by arthritis: TENS or TNS (transcutaneous electrical nerve stimulation) and ultrasonic therapy. TENS is commonly used throughout the world for the relief of chronic pain. It works by electrically stimulating nerve fibers in the skin which helps to block or suppress pain messages to the brain. TENS units are about the size of small portable radios and have controls for the frequency and amplitude of the current used. The current is passed into the skin through reusable rubber or self-adhesive electrodes. Some units have large rotary control knobs designed for people with arthritis in the hands. The electrodes are placed on the skin in the affected area, and a low-voltage current is passed through them. The amplitude is then gradually increased and the frequency varied until it becomes noticably painful. The level is adjusted to just below that point. Each treatment may last from twenty minutes to two hours and requires three to five sessions before the pain is reduced. About 60% of those trying the treatment find relief from their pain. Some find that relief is short-lived, while others have relief lasting from several hours to several days or weeks before another treatment. TENS should not be used during pregnancy or by those fitted with a pacemaker. Ultrasonic therapy is a form of massage that depends on sound waves to cause gentle, rapid vibrations, and slight localized heating into the tissues to bring pain relief. As the waves pass through, different frequencies are absorbed by different tissues. For example, skin, fat, muscle, and bone all vary in their rate of absorption.
NSAIDs (nonsteroidal anti-inflammatory drugs) are the drugs most often prescribed for arthritis and come under such names as aspirin, Advil, Aleve, Excedrin-IB, and Motrin. NSAIDs are also used as an alternative to such corticosteroids as cortisone and prednisone. Although they are great at reducing pain and inflammation, corticosteroids do have some nasty side effects. Because of this, NSAIDs were developed. The first was aspirin, developed from willow tree bark. Others, like Indocin and Ibuprofen followed in the 1960s. Today, there are more than 100 different NSAIDs on the market.
NSAIDs are either short-acting (less than six hours of relief) or long-acting (bringing 10 hours or more of relief). Short-acting medications are rapidly absorbed into the body, acting quickly on symptoms. They are also rapidly eliminated from the body, which helps prevent toxic reactions. The down-side is that this also means more is taken. Long-acting medications are taken once and then forgotten for the rest of the day. However, this also means they stay in the body longer, increasing the risk of accumulated toxicity. This is why they are not usually prescribed for those with kidney problems or for the elderly.
NSAIDs reduce inflammation in the joint linings, thereby reducing swelling and relieving pain and stiffness. This is accomplished by blocking the production of prostaglandins (hormone-like substances that cause the pain responses in the body). Prostaglandins, however, have other duties, including playing a role in the regulation of blood pressure, blood coagulation, kidney regulation, and the secretion of gastric acids. Anything that interferes with the" bad" actions of the prostaglandins will also hamper "good" ones. That is why taking high doses of NSAIDs, or taking them over a long period of time can interfere with vital bodily activities and will trigger such side effects as: nausea, cramps, indigestion, diarrhea, constipation, sensitivity to sunlight, nervousness, drowsiness, headaches, ulcers or stomach bleeding, sore throats or fevers (which may be an early sign of bone marrow disorders associated with taking phenylbutazone), swelling of fingers, hands, feet and weight gain (which may be signs of heart or kidney disorders), anyaphylaxis (a potentially deadly allergic reaction), and high blood pressure.
Long term use can damage the stomach. Buffering the drug with an antacid is not effective in reducing this risk. Older adults, smokers, and those who consume alcohol are most at risk for stomach damage in the form of ulcers or gastrointestinal bleeding. NSAIDs also increase the risk of elevated blood pressure, especially in those already having a problem with hypertension, dizziness, ringing in the ears, headaches, skin rashes, and depression.
There is also growing evidence that NSAIDs may inhibit the synthesis of proteoglycans (those important molecules that attract water to cartilage). Therefore, the medications that are normally used to treat OA to block the pain, may actually decrease the action of proteoglycans. When used for short-term relief from pain and inflammation, NSAIDs can be helpful, but continually using them instead of seeking alternate relief can be dangerous to the rest of the body, as well as the joints in question. To make matters worse, some studies are now indicating that NSAIDs not only do not delay the progression of OA, but they may actually hasten it.
NSAIDs can be taken in conjuction with glucosamine and chondroitin sulfates for a week or two in the beginning, but then should be tapered off. To minimize side effects of NSAIDs, take with food and drink plenty of filtered water.
Occupational Therapy is a form that teaches people how to live a normal life by using certain modifications and aides to assist in functional living. This differs from Physical Therapy in that this form directly applies therapeutic measures to the body.
Surgery is the last resort after all other treatments have failed. In some cases, the arthritic joint may have to be completely replaced, while in others, a less drastic procedure may be undertaken. Some of these less drastic procedures include the following:
- Arthrodesis is an operation in which a joint is cut out altogether and the cut ends of the bones that used to meet in the joint are fused together. The is a drastic, but effective, method for removing severe pain in a joint affected by arthritis. Although it removes all diseased tissue, it also severely limits movement. In times past, arthrodesis was the method of choice for rheumatoid arthritis and osteoarthritis. The technique was first used to treat cases of tuberculosis which affected joints and made them stiff and sore. The disease itself sometimes caused the joint to fuse and the pain to disappear, so the surgeons adopted it as a means for artificial replacements.
- Debridement comes from the French word meaning "tidying up" referring to the removal of dead or damaged tissues from an area. In arthritic cases, it is used when the load-bearing surfaces and the lining of the joint have become so worn or damaged that small portions fall away and cause havoc in the joint by producing swelling and inflammation. In 95% of the arthritic debridement cases, it is the knee that is affected. The majority of the debridements today are performed with an arthroscope. Anything that is seen to be rough or uneven is trimmed back, using a surgical power tool. Sometimes, it is the bone or cartilage that needs to be smoothed down. The upside of the surgery is that convalescence is relatively short, but the downside is that the effects do not last very long. It is usually performed on people in their forties or early fifties who are moving toward joint replacement. It may postpone the need for replacement by as much as eighteen months to two years, but the symptoms of joint damage will usually return. Each time another debridement takes place, the period of relief is shorter.
- Osteotomy literally means "cutting a bone" so that it can be put back in a different position. It is usually performed by an orthopedic surgeon when the joint involving the bone is not in the right position. This procedure is sometimes necessary in the hip, often in the knee, frequently in the foot, but rarely in other joints. Osteotomy is also performed after a fracture when bones have not healed in the right position or on birth defects involving bones lying in the wrong place. The average duration of relief from arthritic symptoms after the operation is about seven to ten years, after which the need for a complete joint replacement becomes necessary.
- Prosthesis or joint replacement is just what the term says. The entire diseased joint is removed, and a synthetic joint is put back in. This type of surgery is very common for hips and knees. Completely replacing a joint dates from 1891 when German surgeons experimented with an ivory ball-and-socket hip joint fixed to bone with nickel-plated screws. Today, there are a number of types of artificial joints. The most common reason that a joint deteriorates enough to consider a replacement is osteoarthritis, but it is also used in cases of rheumatoid arthritis. The standard hip joint replacement takes the form of a metallic ball (usually made of a chromium or titanium metal alloy) with a long spike attached to one end. The socket on the pelvis, in which the ball naturally rotates, is replaced by a socket made of extremely high density polyethylene plastic. Under general anesthetic, incisions are made and surrounding muscles are either pushed away or cut. The joint must then be dislocated. The natural bone ball at the top of the femur, for example, is removed and a shaft is driven deep into the femur to take the metal spike. The socket in the pelvis is enlarged to accept the new artificial socket. A special type of cement is used to hold both the spike and the socket in place. After the ball is positioned in the socket, any muscle and tendon repair work necessary is performed and the incisions are closed. It used to be that these replacements were only necessary on aging joints that also developed arthritic problems. Today however, younger people are requiring them in greater numbers. This means that a second replacement will likely be necessary down the road. The problem is that the second replacements are never as good as the first.
- Synovectomy is the surgical removal of the synovium, the thin membrane that lines the normally fluid-filled joint capsule and the cavity where the ends of two bones meet to form a joint. The operation is usually performed to treat cases of severely disabling rheumatoid arthritis that have failed to respond to other forms of treatment. By removing the diseased synovium, progression of the disorder often ceases. The procedure may be performed under general anesthetic when the joint is opened and the abnormal tissue cut away and removed. Increasingly, however, it is done using "keyhole" techniques in which the synovium is removed through a small hole, using a special instrument (arthroscope) the size and width of a pencil.
