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MAJOR REVIEW REVEALS THAT OSTEOARTHRITIS IS A
COMPLEX DISEASE WITH NEW SOLUTIONS
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MAJOR REVIEW REVEALS THAT OSTEOARTHRITIS IS A
COMPLEX DISEASE WITH NEW SOLUTIONS
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| A multidisciplinary group of scientists has declared that
osteoarthritis (OA), the most common form of arthritis, is
"surprisingly complex," but has outlined a number of new
approaches to its understanding, prevention and treatment.
Their report, a review by 28 researchers at 17 academic and
government institutions, cites over 250 published articles
and is presented in two parts in the "Annals of Internal
Medicine".
The effort was led by David T. Felson, M.D., M.P.H., of
Boston University, and Reva C. Lawrence, M.P.H., of the
National Institute of Arthritis and Musculoskeletal and
Skin Diseases (NIAMS), a part of the National Institutes of
Health (NIH).
The disease, says the review, can result from an inherited
predisposition to OA combined with a joint injury. Regular
runners have almost no additional risk of OA, but football
and soccer players and baseball pitchers are at increased
risk. A healthy lifestyle helps -- exercise can lessen
disability if OA has developed. Strengthening the thigh
muscles reduces risk of OA of the knee, as can losing
weight. For people who have the disease, a combination of
treatment approaches, including new medications and patient
education, is effective.
"I am delighted that we have been able to publish this
comprehensive, two-part review arising from our 1999
conference 'Stepping Away from OA,' " says Stephen I. Katz,
M.D., Ph.D., director of the NIAMS. "OA is a major public
health problem, affecting some 20 million people in this
country."
The review points out that in the United States about 6
percent of adults over 30 have OA of the knee and about 3
percent have OA of the hip. The disease is responsible for
more trouble walking and stair climbing than any other
disease, and it is the most common indication for total
joint replacement of the hip and knee. Before age 50 the
prevalence of OA in most joints is higher in men than
women. After this age, more women are affected by OA of
the hand, foot and knee. The occurrence of the disease
increases with age, rising 2- to 10-fold in people from 30
to 65 years of age.
In osteoarthritis, there is focused, progressive loss of
cartilage, the slippery material that cushions the ends of
bones, along with changes in the bone below the cartilage
leading to bony overgrowth. The tissue lining of the joint
can become inflamed, the ligaments looser, and associated
muscles weak, with resulting pain when the joint is used.
The review covers risk factors, such as being overweight
and joint injury from specific sports, and treatments
ranging from established and new medications, exercise, and
patient education to surgery when other treatments do not
work. It also discusses new areas of research, such as
easily measured disease indicators known as biomarkers, as
well as engineering of new cartilage. Specific findings
are given on the attached backgrounder.
"This review shows that arthritis research is a vibrant
area, yielding new means of preventing the disease and
slowing its progression, as well as new and effective
combinations of drug and behavioral treatments," says Dr.
Katz, NIAMS director. "People with osteoarthritis and
those at risk for the disease should be encouraged that
there is much that they and their doctors can do about it."
The mission of the NIAMS is to support research into the
causes, treatment and prevention of arthritis and
musculoskeletal and skin diseases, the training of basic
and clinical scientists to carry out this research and the
dissemination of information on research progress in these
diseases. For more information about NIAMS, call our
information clearinghouse at 1-877-22-NIAMS or visit the
NIAMS Web site at http://www.nih.gov/niams.
-------------------------------
REFERENCES:
The two-part review appears as:
--Felson DT, Lawrence RC, Dieppe PA, et al. Osteoarthritis:
New Insights. Part 1: The Disease and Its Risk Factors.
"Ann Internal Med 2000";133(8):635-646
--Felson DT, Lawrence RC, Hochberg MC, et al.
Osteoarthritis: New Insights. Part 2: Treatment Approaches.
"Ann Internal Med 2000";133(9):726-737
The development of the review was coordinated and funded by
the NIAMS and was based on a July 1999 conference at NIH
initiated, organized and funded by the Institute.
Conference cosponsors were the NIH Office of Disease
Prevention, NIH National Center for Complementary and
Alternative Medicine, NIH Office of Research on Women's
Health, NIH Office of Behavioral and Social Sciences
Research, NIH National Center for Medical Rehabilitation
Research, National Institute of Child Health and Human
Development, Centers for Disease Control and Prevention,
Arthritis Foundation and American Academy of Orthopaedic
Surgeons.
To interview Dr. Felson, contact Rebecca Sullivan, Boston
University, at (617) 638-8491. For Ms. Lawrence, contact
Connie Raab, NIAMS, at (301) 496-8190 or
RaabC@mail.nih.gov.
-------------------------------
BACKGROUNDER
FINDINGS FROM THE TWO-PART NIAMS "ANNALS OF INTERNAL
MEDICINE" ARTICLE: "OSTEOARTHRITIS: NEW INSIGHTS"
RISK FACTORS AND DISEASE PREVENTION:
Serious joint injury can lead to osteoarthritis (OA), but
more often the disease results from a combination of
systemic and joint-related factors. OA is strongly
genetically determined, with genetic factors accounting for
about half of OA in the hands and hips and a smaller
percentage of OA of the knees. However, several steps can
be taken to prevent or delay onset of OA.
--Weight loss can reduce the risk of OA. In one major
study cited by the review, people who lost 11 pounds cut
their risk in half.
--Weakness of the quadriceps muscle (in front of the thigh)
is common in patients with OA. It is clear that
strengthening the quadriceps can help: a relatively small
increase in strength (20 percent for men and 25 percent for
women) can lead to a 20-30 percent decrease in risk of OA.
--There is low or no additional risk of OA from regular,
moderate running. However, sports that involve high-
intensity, acute, direct joint impact from contact with
other players, playing surfaces or equipment do have an
increased risk of OA; football is an example. Sports that
involve both repetitive joint impact and twisting also have
an increase risk of OA; examples are soccer and baseball
pitching. The authors suggest that individual counseling,
rule changes, changes in equipment and playing surfaces,
and training can help reduce injuries. Early diagnosis and
treatment of and complete rehabilitation from joint
injuries can decrease risk of subsequent OA.
--High intakes of vitamin C are associated with lower rates
of OA on X-ray and less knee pain from OA. High levels of
vitamin D protect against new and progressive OA.
--Much of the OA in men is attributable to occupational
activities, particularly jobs requiring kneeling or
squatting, along with heavy lifting.
--In the future, research may enable doctors to use
biomarkers to help identify people at risk for OA and
people with OA at risk for disease progression. These
biomarkers could also help doctors assess the effectiveness
of treatments. OA biomarkers are substances in joint
fluid, blood or urine that indicate changes in bone or
cartilage.
TREATMENT:
Once OA develops, certain factors put a patient at risk for
disability. These include pain, depression, muscle
weakness and poor aerobic capacity. Although the expert
group said that OA cannot be cured, there are new
medications available, and recent studies have shown the
potential of treatments that range from new medications to
complementary medicine, patient education approaches,
exercise and surgery. These approaches are often combined.
MEDICATIONS
--Acetaminophen can help mild or moderate joint pain in OA.
--The next drugs of choice are tramadol and nonsteroidal
anti-inflammatory drugs (NSAIDs).
--The use of NSAIDs is often associated with problems in
the gastrointestinal (GI) tract and kidney problems. For
people who experience these problems, the review suggests
use of either a combination of an NSAID and a drug that
protects the GI system or newer agents known as COX-2
inhibitors. These new agents act against inflammation but
with much less effect on the GI system. The federal Food
and Drug Administration recently approved two such drugs,
celecoxib and rofecoxib.
--Opioid painkillers can also be used in patients with OA,
as can creams containing painkillers applied to the skin
(for example, capsaicin cream).
NONDRUG APPROACHES, INCLUDING EXERCISE AND PATIENT
EDUCATION
--Glucosamine and chondroitin sulfate have received
tremendous popular attention, and a recent meta-analysis of
15 studies cited by the review shows they may have some
positive effects on OA. However, the review authors call
for high-quality independent studies to evaluate the
efficacy of these compounds. They cite an NIH study
underway that is expected to yield results in 2004.
--Exercise is important in people with OA. The review says
that deconditioned muscle, inadequate motion, and joint
stiffness make the signs and symptoms of OA worse. It
recommends well-designed exercise programs that include
training for strength and endurance. Exercise can help
patients regain or maintain motion and flexibility through
low-intensity, controlled movements that don't increase
pain.
--Shock-absorbing footwear and other devices can help OA of
the knee. Two papers cited suggest that heel wedges in the
shoes are an alternative to knee replacements in certain
cases of OA of the knee.
--Research on the efficacy of acupuncture in OA thus far is
inconclusive but promising. A large NIH study of this
approach is underway that should be completed in June 2001.
--Behavioral interventions are safe and effective in the
treatment of OA. Interventions include telephone, mail-
delivered and group self-management programs, which are
more effective than just providing information. In fact,
the review called patient education "the cornerstone" of
osteoarthritis treatment. One group patient education
program developed with NIAMS support at Stanford University
and now taught nationwide by the Arthritis Foundation as
the Arthritis Self-Management Program has been shown to
reduce pain, doctor's visits, and depression in patients
with arthritis as long as 4 years later.
SURGERY (AFTER NONSURGICAL TREATMENTS FAIL)
--Removal of bone or joint tissue can relieve symptoms.
--Joint fusion can also relieve pain, and is most often
done in the spine and in the small joints of the hands and
feet.
--Total joint replacement, according to the review, is the
greatest advance in OA treatment in the past century. It
can reduce pain and disability and restore patients to
near-normal function. To help replacements last longer,
intense research is focusing on more wear- and corrosion-
resistant materials as well as how the tissue around the
replacements responds.
--Replacement of damaged cartilage shows promise, with
three types available: use of one's own cartilage, use of
donor cartilage, and tissue engineering of cartilage
progenitor cells. Development of the latter is still in
its infancy.
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