Nineteen year-old Brittany Ross from Millbury, Massachusetts, began suffering from severe juvenile arthritis
at the age of 16. Originally doctors thought she had rheumatoid arthritis, but eventually it was diagnosed as osteoarthritis. Recently, she underwent a left total hip replacement due to the major degeneration caused by the disease, and doctors say there are signs of arthritis in her right hip. Though she now gets around much easier and with much less pain, Brittany engages in physical therapy twice weekly, and will attend a local gym for swimming
and regular exercise, once released from medical care. Brittany is also considering yoga and dance class, which has been shown to improve symptoms of arthritis.
Nearly one in every 6 people in the United States, or almost 43 million people, has some form of arthritis. Almost 27 million of those people are women. The Centers for Disease Control and Prevention (CDC), says that by the year 2020, 60 million Americans will be affected by arthritis. Not only does arthritis create huge costs for patients and families, but the CDC reports that each year arthritis results in 750,000 hospitalizations, 44 million outpatient visits, and an estimated yearly medical care cost of $15 billion.
Robert Quinet, M.D., Section Head of Rheumatology at Ochsner Clinic Foundation in New Orleans, LA, says “there are at least 100 different types of arthritis. The most common is osteoarthritis.” Also included are rheumatoid arthritis, fibromyalgia, gout, and lupus. The most common symptoms are pain, aching, stiffness, and swelling in or around joints. Lupus and rheumatoid arthritis can affect more than one organ, and symptoms can become widespread.
Early diagnosis and treatment are keys to remaining active and maintaining quality of life. Dr. Quinet says early diagnosis helps distinguish among the many different types of arthritis, and treatment varies depending on the type. He goes on to say that the purpose of treatment is to prevent joint damage or deterioration, which eventually leads to loss of function and chronic pain. The earlier the treatment, the less likely there will be permanent damage to the joint, and loss of function.
Researchers are not clear on the causes of arthritis, though a few factors have been identified. Because twice as many women as men develop the disease, it is suspected that hormones may play a role in developing some rheumatic conditions, such as lupus. Dr. Quinet says that for rheumatoid arthritis “some predisposing genes do exist, but the disease is inherited as a susceptibility, instead of the disease itself, and that with lupus, there is genetic susceptibility in terms of the immune system.” For osteoarthritis, injury prevention measures and weight control can reduce the risk.
In January actress Donna Mills, best known for her role as Abby Cunningham on Knots Landing, joined the B.E.A.T. Arthritis (Boost Education of Arthritis Treatment) campaign, sponsored by Pharmacia Corporation and Pfizer Inc., in partnership with the National Women’s Health Resource Center (NWHRC), and local healthcare organizations and facilities across the nation. Ms. Mills is traveling to cities across the United States, and says, “as a woman’s advocate I encourage everyone, but especially women, to seek the information they want so that they can get the healthcare they need. Women so often think they just have to deal with pain, but this campaign is about letting women know that they don’t have to suffer in silence.” Ms. Mills uses Celebrex? (celecoxib capsules) to help control daily arthritis pain and inflammation, and remarked, “it has worked terrific for me, but women should see their doctor and find out what treatment will work best for them.” The Arthritis Foundation reports that arthritis and related diseases are the leading causes of women’s inability to perform daily activities, and that women with arthritis show higher percents of activity and work limitations than men with arthritis.
Traditional non-steroidal anti-inflammatory drugs (NSAIDS) relieve pain, but can cause gastrointestinal (GI) bleeding and ulcers. Cyclooxygenase-2 inhibitors (COX-2 inhibitors), a fairly new NSAID, relieve pain with less stomach irritation. The first COX-2 inhibitor, Celebrex? (celecoxib), was approved by the FDA in 1998 to treat rheumatoid arthritis. Vioxx? (refecoxib) was the second to receive approval in 1999 for the treatment of osteoarthritis.
Remicade? (infliximab) is the most recently approved COX-2 inhibitor to treat rheumatoid arthritis. It is a biologic response modifier (BRM) that binds to, and blocks the action of, a naturally occurring protein called tumor necrosis factor (TNF), which is believed to play a role in joint inflammation and damage. TNF levels are elevated in the synovial fluid of patients who have rheumatoid arthritis. The second BMF to be approved is Enbrel? (etanercept), which is taken twice weekly by injection. Enbrel decreases pain and morning stiffness, improves joint swelling and tenderness, and delays structural damage.
Arava? (leflunomide) is an oral treatment whose effects are similar to methotrexate, and slows the progression of rheumatoid arthritis. However, its label carries a warning for pregnant women and those planning to become pregnant, because it may cause birth defects.
In 1999 the Prosorba? column was approved by the FDA, the first non-drug alternative for patients with moderate to severe rheumatoid arthritis. It is a single-use medical device that contains material that binds antibodies and antigen-antibody complexes. The patient undergoes a two-hour process in the hospital in which a machine removes patient’s blood and separates the blood cells from the plasma. The plasma is passed thought the Prosorba column, recombines with the blood cells, and returned to the patient. The filtering process is believed to remove proteins that inadvertently attack joint cells, though its mechanism of action is not well understood. Side effects of this procedure include joint pain/swelling, fatigue, hypotension and anemia.
According to the Arthritis Foundation proper exercise on a regular basis is an extremely important part of a treatment program. Regular, moderate exercise is beneficial in decreasing fatigue, strengthening muscles and bones, increasing flexibility and stamina, and improving the general sense of well being. The National Institutes of Health (NIH) advises an exercise program should be based on which joints are involved, amount of inflammation, whether the joints are stable, and if a joint procedure has been performed. The main forms of exercise are:
Ã¢Â?Â¢Range of motion- moving the joint as far as it will comfortably go, then stretching a little more, which increases and maintains joint mobility, decreases pain, and improves joint function
Ã¢Â?Â¢Strengthening – using muscles without moving joints to help increase muscle strength, and stabilize weak joints.
Ã¢Â?Â¢Endurance – aerobic exercises, which include walking, swimming, and bicycling to strengthen the heart and lungs and increase stamina.
At the Ochnsner Clinic, water aerobics is preferred, because it has least amount of stress during exercise. Second is stationary bicycling or cross-training, which allow patients to exercise without full body weight on affected joints. Donna Mills’ primary exercise is tennis, but she also enjoys working out and dance.
Charles L. Christian, M.D., Professor of Medicine at the University of Florida in Gainesville, and Director of Rheumatology at Shands, Jacksonville, FL, advises that “patients are often confused about the indications for rest vs. exercise in the management of pain associated with arthritis; both play important roles. It is possible to minimize muscle weakness, promote normal alignment of joints, and combat general de-conditioning, with an exercise program that does not increase pain, or put unusual stress on joints.”
Nutritional Supplements and Diet
Glucosamine and chondroitin occur in the body naturally and are vital to normal cartilage formation. Claims have been made that in supplemental form, they rebuild joint tissues damaged by osteoarthritis and may halt the disease, but neither has been approved by the FDA. April Vallerand, PhD, RN, at Wayne State University College of Nursing in Detroit, MI, was on the American Pain Society committee that developed the pain guidelines for arthritis, which were published in March 2002. She states, “the guidelines recommend 1500 mg of oral glucosamine daily. Chondroitin is often combined with glucosamine and, in doses of 1200 mg. daily, has been shown to potentially decrease pain and inflammation. These agents are usually well tolerated, and worth trying for patients with arthritis pain.” Dr. Charles Christian says of these supplements, “though there are no long-range studies demonstrating change in rates of progression of osteoarthritis, they are almost unique in having no known potential for toxicity.”
Some evidence shows that Vitamin C & D slow progression of osteoarthritis. Topical ointments containing capsaicin, a component of hot peppers, are an effective analgesic when rubbed on arthritic joints. Per Dr. Quinet, proper diet, nutrition, and exercise are important in the treatment for arthritis, as well as maintaining ideal body weight. Women with arthritis need calcium supplements to help prevent the loss of bone that leads to osteoporosis. B vitamins may help reduce joint inflammation and pain, and vitamin E can help ease arthritic pain and leg cramps.
Women have found that meditation, yoga, relaxation, and even acupuncture, can help relieve the pain of arthritis. Dr. Christian does not recommend acupuncture, but does not object to his patients exploring their use, as long as “they avoid obvious commercial quacks.”
Herbs that may relieve inflammation and pain include ginger, boswellia (frankincense), turmeric and cat’s claw. Studies have show that eating cherries and drinking green tea can help reduce arthritis symptoms.
Prevention and Education
The CDC says that arthritis is the nation’s leading cause of disability. States throughout the country are targeting arthritis by taking action. The Florida Department of Health has recently launched the Florida Arthritis Prevention and Education Program to improve the quality of life, and decrease pain and disability of persons with arthritis.
Professor Vallerand emphasizes to her nursing students the importance of patient and family education in all areas. The students learn to advocate for better pain management, and to educate patients and caregivers.
Physical activity programs and self-management classes have been shown to reduce both the occurrence and progression of arthritis. As with all patients, women should play a major role in their own treatment decisions regarding arthritis. To accomplish this, it is extremely important to research the disease and keep up with the latest findings. Living with arthritis takes a physical and emotional toll, but there are ways to maintain an active lifestyle and independence, while decreasing pain and damage to joints.