Transcription:
Osteoarthritis: Symptoms, Treatment & Prevention

Melanie Cole (Host): Osteoarthritis is the most common form of arthritis affecting millions of people around the world. My guest is Dr. Jeffery Rosenberg. He’s a Primary Care Sports Medicine physician at the Summit Medical Group. Welcome to the show, Dr. Rosenberg. Tell us a little about osteoarthritis and, really, what it is. Give us a working definition so that people understand where it affects the most and how they got it.

Dr. Jeffery Rosenberg (Guest): Thank you very much for having me. I appreciate the opportunity to talk to you. Osteoarthritis is a degenerative process of the joints. What happens is that as we age, the cartilage, which is a spongy cushion-like substance at the edge of each bone, starts to wear away. Because the cartilage wears away, the bone starts to feel a lot more mechanical stress, and that mechanical stress is the actual symptoms that you feel in your joints. It’s often described as an achy, throbby, toothache pain, which is usually worse after a significant inactivity [and benefits rest]. Osteoarthritis is typically most bothersome in the large joints of the body, so that would include the knees or the hips, although you can get osteoarthritis in any joint of your body. We see it most often in people as they age, so starting anywhere from the ages of 40s and on up, you can start to have arthritis symptoms. You’ll be more likely to be affected by it if you had a prior orthopedic injury or any significant orthopedic surgery, including having an ACL replacement or other meniscal surgeries when you were younger, injuries from your high school or college ages, or any significant overusage from activities or sports. All of these events can start a degenerative process, which will still be worsened, and eventually, you would develop osteoarthritis symptoms from that.

Melanie: So you say it will gradually worsen. It’s something that comes with age and/or previous surgery or injury, and a lot of people experience osteoarthritis, Dr. Rosenberg, in their hands. So, what can we do about it? What’s your first line of defense when somebody in their 40s comes to you? Their knuckles are a little more swollen; their knees are starting to bother them. All these things start to signal that we’re getting older. What is the first line of defense?

Dr. Rosenberg: Well, I think the first line of defense for most people is to understand the process. So we spend a lot of time educating people about the nature of their osteoarthritis, what may have caused them. And then we often would talk about what to do about the future. In spite of the fact that people would think, “Well, if my joints hurt, I should stop moving them,” one of the mainstays of treatment for arthritis in any joint, whether it’s big or little, is to make sure that you do continue some form of physical activity. As the joint breaks down more, it tends to get very stiff, and that stiffness can then involve more of a tightening of the capsules or the ligaments around the joints, and that can then develop more pain and stiffness. So I do encourage people to do what are called range-of-motion exercises, which basically tries to allow them to straighten and completely then flex whatever the joint may be. We also want the muscles around the joints to be strong. So if it’s for the knees or hips or shoulders, even using some very light weights to help strengthen the muscles can be very important.

Melanie: Okay. So you want the range-of-motion exercises. You want movement, contrary to what people have thought before. And what about for the pain? Do you like anti-inflammatories? Do you like Tylenol, which is really just a painkiller, not so much of an anti-inflammatory? So what do you think? Because there’s so many things on the market now it’s dizzying.

Dr. Rosenberg: Yes, it sure is. I love when people come in and they say they’ve had Tylenol arthritis formula, and Motrin arthritis formula and aspirin arthritis formula. And all those are the normal versions of those medicines with the name arthritis added to them. Really, the number one and the safest thing to take is Acetaminophen, which is the generic name for Tylenol. We prefer Tylenol because it is generally safer for most of patients, and it will take the edge off for the pain. Next one would be the anti-inflammatory medicines, which can go by the names of Ibuprofen or Motrin or Advil or Aleve. Those are the over-the-counter versions of that. They also can help with swelling, if there’s significant swelling in the joints, and can be useful for pain as well. But the side effect profile of those medications is much worse. There’s more interactions with other medicines. And for people who have kidney disease or high blood pressure, you need to be careful with the amount of anti-inflammatories that you take. I actually find topical treatments, so either the over-the-counter treatments like Aspercreme or Bengay can be very helpful just to allow you to help loosen up the joints. There are prescription topical anti-inflammatories, which can be used to support people who don't  the oral ones. Those go by the name of Voltaren gel, and that’s a prescription anti-inflammatory. It’s especially good for hand arthritis because basically, you rub it into the joints, and after it absorbs, it gives pain relief for six to eight hours.

Melanie: And so you mentioned Voltaren gel. Now, what about the anti-inflammatories that are prescription? Because I mean, some people, it gets so bad they take a narcotic pain reliever. But again, that doesn't reduce the inflammation, can be addictive. So what about Voltaren Celebrex? All of these ones on the market?

Dr. Rosenberg: Well, the prescription anti-inflammatories can be helpful again for folks who don't get enough pain relief with the over-the-counter anti-inflammatory. They are stronger. But again, I worry about side effects and drug interactions for many patients. Certainly, as you get up into your 60s and 70s, your risk of developing ulcers or kidney problems in response to taking prescription anti-inflammatories does go up. So I do try to get patients away from them, although for some folks, that’s all that they use. Celebrex is very helpful, but again, high doses for long periods of time has been shown to cause heart problems. There are some patients where narcotics are all that are left that work for them, and certainly, I would do that at times. That typically is folks who are older and have problem that are not as amenable to surgical treatments or other kinds of treatment because we do risk side effects and addiction from narcotic medications. But there are patients who need them. And unfortunately, if that’s the only thing that works for them, I’ll certainly prescribe it.

Melanie: Now, what about cortisone shots? Dr. Rosenberg, some people, they get those as often as they’re allowed.

Dr. Rosenberg: Yes. I do use a lot of injections for osteoarthritis. I use two different kinds of shots, one are corticosteroid injections or cortisone shots, as you just mentioned. They can be very helpful at getting rid of acute pain, especially in the setting of somebody who has a very swollen joint. So the story I’ll often have is somebody who’s had some mild pain in their knees. They know they have osteoarthritis, but they spent the night dancing at a wedding, or they bumped or twisted their knee, and then the next day their knee is very swollen and painful. That’s a great time to go into the physician. I’ll aspirate the fluid out of the joint using ultrasound to help guide the needle into where the fluid is, and then we’ll give cortisone shots back into the joint. They provide great immediate relief of pain and will typically last anywhere from two to three months. Once the cortisone wears off after about three months, many times patients’ pain will come back. So it’s a very good treatment for severe pain, but unfortunately, it’s very short-lasting. I also like to use what are called viscous supplementation injections. There are several of them on the market, but they are all -- let’s go to hyaluronic acid injections. The idea of these injections is that this medication helps to induce healthier, more physiological fluid within the joints. Normally, in addition to the cartilage and the meniscus, which is the cushion inside of the joint, the fluid itself within the joint does provide cushioning to support the bones. As we have arthritis, that fluid does not work as well, so they use injection to help to induce a healthier, more normal or natural fluid cushioning substances. They last for anywhere from six months to a year, depending on the patient, and they’re either one or three shots depending on which drug company you go with. But I use those as second line treatments for people who need more relief than just cortisone or just one cortisone shot a year.

Melanie: So when does it come down, Dr. Rosenberg, to joint replacement and/or surgery?

Dr. Rosenberg: Well, that is often a question of -- what I often ask patients is are they really miserable and can they continue to be functional in spite of their pain? And when they get to the point where they’re not able to take care of themselves or their family members, that certainly is an important time when they’re truly not able to sleep at night or nothing they can do seems to relieve the pain, that’s when surgical intervention is most useful. A knee replacement, yes, is a big operation, but it does provide almost complete improvement of the joint pain in patients once they’ve recovered from the surgery and they rehab themselves. And so, if the knee is the thing that limits their ability to exercise every day or to be happy and functional as a retired person, then I think that’s a great time to get the surgery done when none of the easier treatments or injections or prescription medicines really help anymore. That’s when you go to get your joint replaced.

Melanie: And what do you like people to do at home? Ice,  movement, exercise? Just 30 seconds, give us your best advice.

Dr. Rosenberg: In general, like I said, if you feel stiff in the morning, heat and some Tylenol is great to loosen things up. You want to keep the joints moving. You want to try to exert them as much as you can. Non-weight bearing exercises such as the bicycle or a pool are a great way keep your joints moving in spite of some pain, and just basically try to keep moving. And when you have enough problems that you need to do more, then make sure you come in and see a physician.

Melanie: Thank you so much, Dr. Jeffery Rosenberg. You’re listening to Summit Medical Group Radio. For more information, you can go to summitmedicalgroup.com. This is Melanie Cole, thanks for listening.