Baltimore,MD--3/15/02--The American Pain Society (APS),the leading United States professional organization devoted to pain management,today released its new clinical guideline for treating acute and chronic pain associated with arthritis,a chronic disease that affects one in six Americans.

 

Among the major recommendations in the APS Arthritis Pain Management guidelines are:

 

1) All treatment for arthritis should begin with a comprehensive assessment of pain and function.

 

2) For mild arthritis pain,acetaminophen is the drug of choice for its mild side effects,over-the-counter-availability and low cost.

 

3) For moderate to severe pain from both osteoarthritis and rheumatiod arthritis, COX-2 non-steriodal anti-inflammatory drugs (NSAIDs),such as Celebrex and Vioxx,are the drugs of choice for their pain-relieving potency and absence of gastrointestinal side effects.

 

Use of non-selective NSAIDs should only be considered if the patient is non-reponsive to acetaminophen and COX-2 drugs and is not at risk for NSAID-induced GI side effects. Due to the high cost of the COX-2 agents,some patients might benefit from taking non-specific NSAIDs and a medication to moderate GI distress.

 

4) Opiod medications, such as oxycodone and morphine,are recommended for treating severe arthritis for which COX-2 drugs and non-specific NSAIDs do not provide substantial relief (there will be objections from the established medical community,no doubt) --ACR does not recommend indiscriminate use of narcotic medication.

 

5) Unless there are medical contraindications,most people with arthritis, including the obese and elderly,should be referred for surgical treatment when drug therapy is ineffective and functional imparity is severely impaired to prevent minimal physical activity. It is advised that surgery be recommended before the onset of severe deformity and advanced muscular deterioration.

 

In addition to specific treatment options,the APS Guideline specifies that arthritis patients should maintain an ideal body weight and adhere to a balanced diet. Adults should lose weight if their BMI is greater than 30 and follow a weight-management program.

 

Also,referrals should be made for physical therapy/or occupational therapy to evaluate and reduce impairements in range of motion,strength,flexibility and endurance. DMARDs therapy which will ensure control of the disease will also result in less pain.

 

Since arthritis is a chronic and progressive disease,clinicians must be sure that regular exercise or physical therapy are important components of  a comprehensive management program. 

 

The X-ray findings of cartilage calcification is common,but in most cases it means nothing. It's found with increasing frequency with advancing age. On rare occasion it's found in someone under 50,it may be linked to an underlying disorder-most often hyperoarathyroidism ( abnormally high activity of the parathyroid gland ) or hemochromatosis ( a disease charachterized by abnormal iron stores in the body ) Chondrocalcinosis can not be inherited. Osteoarthritis theory suggests OA is a inherited disease,unlike what we are talking about.

 

CC is without symptoms in the majority of patients with the X-ray abnormality. Symptomatic CC-the peak decade for symptoms is 65 to 75 can take two forms  The "pseudo-gout" CC may be suspected as a cause of an acutely swollen joint in an older person if an x-ray shows evidence of chondrolcalcinosis. Joint infection,or even Gout are valid possibilities. Diagnostic certainty requires that the joint be aspirated and the synovial fluid examined for crystals and bacteria. There is no blood tes to detec this condition.

 

Chronic pain due to chondrocalcinosis may be mistakenly be labeled "osteoarthritis' because many of the shared features-the pain and crepitus ( frinding-sensations or sounds ) with use,a tendency to involve joints like knees and hips,and the appearance of later x-rays (which,because of advanced deterioration,may no longer show the telltale cartilage calcification)

 

CC may be one of the most important causes of OA. Its presence should be suspected when X-ray changes like those of OA are seen in joints that are rarily ffected by OA-shoulders,elbows,wrists and the knuckles at the base of the long index fingers,or when there is prolonged morning stiffness or too much joint warmth and swelling. Such evidence of inflmmation can be so impressive that rheumatoid arthritis is often diagnosed.

 

Chronic arthritis due to CC is usually only slowly  progressive,so most peope cope with it well in the long run. Knee and hips,though,often eventually become so troublesome that surgery is necessary, Overall, when compared to patients with osteoarthritis,people with this form of CC do much better.

 

A feature that distinguishes CC from gout is that crystal formation occurs only in cartilage, CC pyrophosphate,which is a common product of cell metabloism,seems to come mostly from cartilage cells. Why it conbines with calcium to form CPPD is unknow,but there may be different reasons for different patients. In most.the phenomenon is linked to aging. In other,truma is a factor e.g.,CC very often ocurs in the remaining cartilage after surgical removal of a torn knee cartilage.. The excessive weight load borne by the cartilage that remains seems to be the problem. In some cases,high levels of calcium (hyperparathyroidism) or iron (hemochromatosis )-somehow favors the formation of CPPD crystals.

 

 

OA USUALLY has very little to do with inflammation (synovitis has been detected in some OA patients of the hands). It usually,isn't even a single disease. The best definition is that osteoarthritis is what happens when joint cartilage fails.

 

Though OA can be found in any joint,it seems to affect primarily four regions-the knees,hips,hands and spine.

 

Osteoarthritis of the knee is one of the most common forms of OA. It occurs in about 10 % of people over 65,and in about 2 % of adults.

 

A few knee OA involves mostly the lateral compartment (outer half ),giving the patient knock-knees. This happens in about a quarter of patients with knee OA.

 

Other parts of the knee are more commonly affected: the medial compartment (inner half ) and the patellofemoral space (between the kneecap or patella and the end of the thighbone or femur ). Some have OA in more than one compartment of the knee. When the inner half of the knee is affected,the resulting deformity is bow leg.

 

When OA occurs behind the kneecap (patellofemoral OA ) there is often much more muscle weakness,pain and disability than with other kinds.

 

Knee surgery has advanced leaps and bounds in recent years.

 

Another type of patient develops knee OA. These patients are much younger and have had some sort of knee injury and often knee surgery. Only one side is affected in OA.

 

Nodal osteoarthritis of the hands is very common. Many will show local inflammation when the swelling first develops. Warmth and marked tenderness usually settle down after several months,leaving the knuckles characteristically boney and lumpy. Individual knuckles may be affected at different times.

 

The lumpiness is due to new bone being laid down as the margins of the joint. When this lumpiness affects the end (DIP) joints,it's called Heberden's nodes. Bouchard's nodes affect the middle (PIP ) joints,sometimes referred to as knobs. Only very rarely are the MCP joints involved,and when they are,there may be another kind of arthritis involved.

 

OA may also occur at the base of the thumb,where it pivots on the wrist ( the thumb CMC,or carpometacarpal joint. This isn't clearly linked to either DIP or knee OA,and it tends to be worse in the non-dominant hand. (on the left on a right-handed person ).

 

Nodal OA may be quite uncomfortable at times (and without symptoms in others). It may make the fingers look bent,and may make gripping difficult It does not,cause the kind of disability that is associated with finger involvvement in other kinds of arthritis. People with nodal OA,like those with obesity,are more likely to have OA of the knee.

 

OA of the hip is common and the hip joint is the only one involved in this kind of OA. In a few rare cases there's an obvious cause,such as bith abnormality. Hip OA can occur at any age,but most common in people in ther 60s and 70s. Some cases are like knee OA,and go on for a long time with minor symptoms before surgery is necessary. A very few,less than 5 % heal on their own. But most patients are ready for surgery within a few years.

 

A few patients have what doctors call,"referred pain". They feel most of the pain in the thigh and knee area,and not where it belongs-in the froin. Most patients who complain of  hip pain.or pain in on the outside of the upper thigh or in the buttock,while,pain in these areas may be associated with hip problems,it's usually caused by something else.

 

Spinal OA is so common that its difficult to consider as a disease. Rather,like gray hair,it's something to be expected as we age, The disks between the vertebrae lose some of their water content,shrink and become less bouncy. Most lose an inch in height.

 

The facet joints at the back of the vertebrae,which stabilizes the spine while still allowing movement,are pushed together. New bone grows in places where mechanical stress is high. Most of the time,we are not aware this process is going on.

 

 Sometimes,there is local irritation and we experience pain,the supporting muscles go into spasm to keep movement to a minimum,more pain and a doctor visit results. Only very rarely is there a serious problem like nerve pressure,and more rarely surgery is indicated.