Published: Oct. 17, 2006
Updated: July 13, 2010
Arthritis is the leading cause of disability in America, affecting about 40 million adults. Osteoarthritis -- the age-related degeneration of cartilage tissues that cushion joints -- is the most prevalent form of the disease, affecting up to 70 percent of people in their 60s and 70s.
In addition, more than two million Americans -- mostly women -- have rheumatoid arthritis, a complex autoimmune disease in which the body’s defense systems attack healthy joint tissue, causing inflammation and subsequent joint damage.
In contrast to the painkillers and sedentary lifestyle that were typically recommended a generation ago, the key message for people with arthritis today is early, aggressive treatment and energetic self-help. New, more effective drugs for both types of arthritis are available. Weight control, exercise, and psychological approaches can play a key role in relieving pain and restoring function.
In the near future, novel diagnostic techniques may be used to identify arthritis earlier and thus treat it more effectively. Scientists are also investigating high-tech strategies to protect or rebuild cartilage cells that may one day prevent arthritis altogether. As a leading site of arthritis care and research, Duke is playing a key role in all of these efforts.
A generation ago, doctors had little to offer people with arthritis besides painkillers, and sufferers were often sent to bed to “save their joints.” Osteoarthritis -- the gradual wearing down of the cartilage that cushions the joints -- was viewed as an inevitable part of growing older. Rheumatoid arthritis -- in which the joints' cushioning cartilage is attacked by the body's own immune system -- was considered a chronic disease that always led to disability.
But today, arthritis care has dramatically changed. Instead of rest and resignation, the new message is action and early, aggressive treatment. New and highly effective drugs are available; more are on the horizon. Exercise, once taboo, is now encouraged as one of the best ways to relieve pain and restore function. And psychological interventions and relaxation techniques can enhance the quality of life for people with arthritis and possibly even slow the disease process.
“We now have a more comprehensive view of arthritis that offers numerous opportunities to take action," says Duke rheumatologist Virginia Byers Kraus, MD, PhD. “With the self-care practices and medical treatments available now, there’s a lot we can do to help people feel better and lead productive, vigorous lives.”
Arthritis -- the term literally means joint inflammation -- actually refers to more than 100 different diseases that affect the joint and surrounding tissues, such as muscles and bones. Arthritis affects approximately 15 percent of the total U.S. population and is projected to strike more than 59 million by 2020.
Osteoarthritis (OA) is the most prevalent form of the disease, affecting up to 70 percent of people in their 60s and 70s. Sometimes called “degenerative” arthritis, OA gradually erodes the cartilage that cushions joints, causing microfractures in bone, stretching of surrounding tendons, joint inflammation, and associated pain and swelling. Rather than being an inevitable part of growing older, OA results from a combination of environmental factors, including trauma, occupation, and lifestyle, as well as hereditary traits that make an individual more susceptible to developing it.
A major problem with current treatment of OA is that, all too often, by the time the condition is diagnosed, irreversible damage has occurred. “Cartilage is invisible on x-ray, so OA is only visible with x-rays late in the disease process," says Kraus. Other imaging techniques such as MRI and ultrasound have the potential to detect disease earlier, but are not yet commonly used in clinical practice. “We need better tools so we can intervene at earlier stages,” Kraus says, “and prevent joint destruction.”
A promising new tool for diagnosis of OA is a thermal scanner sensitive enough to detect temperature differences of a tenth of a degree Fahrenheit. In a recent study of 91 people with clinical hand osteoarthritis, Kraus found that the finger joints are warmer than average -- a sign of inflammation -- in the first stage of osteoarthritis. In the future, she says, checking for changes in joint temperature could help evaluate the effectiveness of osteoarthritis treatments.
Obesity has long been recognized as a major risk factor for OA, “but the reason was thought to be purely mechanical -- that overloading the joints with excess weight wears them down,” says Farshid Guilak, PhD, director of orthopedic research. “Yet surprisingly, if that excess weight is muscle, not fat, it doesn’t carry the same risk of OA.”
Unraveling the link between obesity and arthritis plays a central role in Guilak's current research, a 10-year, $12-million study funded by the NIAMS (National Institute of Arthritis and Musculoskeletal and Skin Diseases). Emerging evidence indicates that obesity is a mild inflammatory condition linked to a number of diseases, he notes: “What we now think is that, in addition to the mechanical load obesity imposes on joints, fat cells put the body in a heightened state of inflammation, which may encourage the development of OA." Among the team's laboratory studies are attempts to build cartilage from fat cells outside the body, which could be used to replace damaged cartilage.
Working with pain specialist Francis Keefe, PhD, Guilak is also conducting clinical studies with overweight patients with OA of the knee to determine how lifestyle-based weight management and/or coping skills training affect OA symptoms. “Emerging evidence suggests that distraction and mood may influence whether or not a pain signal gets from your spinal cord to your brain," says Keefe. "By making it difficult for people to engage in basic activities, arthritis can result in feelings of helplessness, depression, and anxiety, further decreasing a person's ability to do everyday things."
To combat this vicious cycle, Keefe teaches arthritis patients ways to pace their activity, how to relax in the face of severe pain, and strategies for restructuring negative thinking. "By learning to manage pain, stress, and negative affect, both OA and RA patients may be able to slow the course of the disease," Keefe says. “It’s clear that patients do better with active coping rather than passive coping. The patient I’d worry about most is the one who is feeling helpless, resting in bed too much, relying more and more on medications, and depending on others.”
When people begin noticing morning stiffness in their joints, often around midlife, “Many just assume this is what it’s like to get older,” says David S. Pisetsky, MD, PhD, director of the Duke Arthritis Center. But for more than two million Americans -- mostly women -- their stiffness, swollen joints, and aching actually signal rheumatoid arthritis. By the time they finally see a physician and are diagnosed, a unique opportunity to slow or even stop the disease may have passed.
“The earlier you treat rheumatoid arthritis, the better the outcome,” Pisetsky says. “With early, aggressive therapy, we can actually arrest the disease in many people.”
This early assault represents a revolutionary approach to RA, a complex autoimmune disease in which the body’s defense systems attack healthy joint tissue, causing inflammation and subsequent joint damage. “We used to have a limited number of therapies, often with toxicity involved,” Pisetsky says, “so we parsed them out over time.”
Now, with a growing arsenal of better-tolerated treatments such as methotrexate (Rheumatrex, Trexall) and a class of drugs known as TNF Blockers, including infliximab (Remicade), the picture is changing. “For many patients, combinations of medications are more effective than single agents,” says Duke rheumatologist E. William St. Clair, MD. RA is one of several autoimmune disorders that will be examined as part of a recent $3.4-million federal grant to establish one of nine nationwide Autoimmunity Centers of Excellence at Duke, led by St. Clair.
Another form of arthritis, gout, is the subject of clinical trials by associate professor of medicine John Sundy, MD, PhD, who has led several studies to examine the effect of intravenous PEG-uricase (puricase) on patients who don't respond to or can't take allopurinol, the standard therapy. “This could be a promising new therapy for people with gout who currently have no other options," says Sundy.
These vigorous and varied efforts make it clear that Duke physicians and researchers aren't taking arthritis lying down. And if you have arthritis, neither should you. "Numerous self-care strategies can relieve pain and inflammation and improve function," says Kraus. So don't just wait for the miracle cure, such as Guilak's intriguing efforts to convert fat cells to cartilage: Take some simple self-help steps now. Your joints will thank you for it.
According to Kraus, positive thinking and a “can-do” approach can lead to significant improvements in arthritis. Co-author of the book The Everyday Arthritis Solution, Kraus offers the following tips.
Get moving. Water exercise and recumbent bicycling are particularly well-suited to people with arthritis, since they activate the body's large muscles while minimizing joint stress. If you've been sedentary, start by alternating one day of aerobic activity with a day of easy stretching, eventually progressing to exercising aerobically five to six days per week. If you have more than two hours of discomfort after exercise, cut back on the intensity or duration of your exercise next time.
Eat right and maintain a healthy weight. Proper nutrition, including eating at least five fruits and vegetables a day, may help relieve arthritis symptoms and prevent the disease from getting worse. A multivitamin and calcium supplement may also enhance joint health. Eat appropriate portions from a well-balanced diet to avoid excess pounds that can exacerbate arthritis. Ideally, keep your body mass index under 25.
Review your prescriptions with your doctor. In an era of uncertainty about pharmacologic treatments for arthritis -- with the popular pain medication rofecoxib (Vioxx) withdrawn several years ago due to concerns about increased cardiovascular risk, and experts still evaluating the risks and benefits of other drugs in its class -- it’s important to regularly review your prescription drug regimen with your physician.
The Arthritis Rehabilitation Program at the Duke Center for Living offers a specialized treatment plan, which may include aquatic exercise, such as the Arthritis Foundation aquatic class and land-based exercise. Medicare and insurance companies reimburse much of the cost. Call 919-660-6659.