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What's New in Arthritis Treatment

Online Health Chat with Dr. Michael Schaefer

May 8, 2012

Introduction

The two most common forms of arthritis, osteoarthritis and rheumatoid arthritis, both cause joint pain and limit movement. Osteoarthritis results from wear-and-tear of the cartilage cushioning the joints, typically after an injury or with advancing age. Also called degenerative joint disease, osteoarthritis (OA) usually develops over years and is often found in patients who have had a knee infection or injury and those who are overweight. Symptoms of OA include pain, stiffness, tenderness, a limited range of motion and a grating sensation when you move the affected joint. The pain is usually worse after activity.

Rheumatoid arthritis (RA) can affect joints on both sides of the body (i.e. both knees, both hands and/or wrists). In RA, the cells from your body attack your own tissue. While in most people symptoms develop gradually over years, they can appear rapidly. RA affects three to five times more women than men and often presents between the ages of 20 and 50.

Learn what’s new in the treatment of arthritis, tips to avoid surgery and what’s best for you.

Michael Schaefer, MD is a physiatrist within the Arthritis and Musculoskeletal Center. He is also the Director of Musculoskeletal Physical Medicine & Rehabilitation. His specialty interests are musculoskeletal medicine, joint pain, ultrasound-guided and fluoroscopic guided injections, viscosupplement injections and sports medicine. After graduating medical school at the Ohio State University, he went on to complete his residency in physical medicine and rehabilitation and a fellowship in physiatric sports medicine at Mayo Clinic in Rochester, Minnesota.

To make an appointment with Dr. Michael Schaefer or any of the other specialists in our Arthritis and Musculoskeletal Center at Cleveland Clinic, please call 216.445.3330 or call toll-free at 800.223.2273, ext. 53330. You can also visit us online at www.clevelandclinic.org/arthritis.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialist Dr. Michael Schaeffer. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.


Psoriatic Arthritis

macee61: Is there anything new in the treatment of psoriatic arthritis? I currently only have it in my hands, but I am concerned about the the pain and twisting of the joints.

Dr__Schaefer: Yes, there are new medications for psoriatic arthritis which modify the immune system. You should see a rheumatologist who specializes in this condition to learn more about them.

macee61: I have psoriatic arthritis, but no insurance to cover the cost of the biologics. Are there any studies currently being conducted? If so, how would I go about applying?

Dr__Schaefer: The Cleveland Clinic is not doing any research studies, but we are keeping a patient registry to follow patients over a long period of time. I'd suggest looking at the Arthritis Foundation's website or searching online for other clinical studies.


Viscosupplementation

Renegade: What can be done non-surgically for arthritis in the hip joint area, specifically in the groin area?

Dr__Schaefer: I recommend injections with cortisone or joint fluid (viscosupplement), although the viscosupplements are not FDA approved. There is good research to support their use. I do them in my practice with ultrasound guidance. As always, weight loss, use of a cane, and physical therapy are most important!

Renegade: Will insurance cover these treatments since they are not FDA approved?

Dr__Schaefer: Not usually, but most insurance companies have a method to seek prior authorization or appeal denials.

Renegade: Are the viscosupplements the same as Synvisc® used in knee joints?

Dr__Schaefer: Yes, there are 5 different brands available in the U.S. All have been proven to be effective. Synvisc® is the only product with a one-time injection; most of the others require 3 injections.

Renegade: You say you do these injections with ultrasound in your practice. What is time period these will last, and do they deteriorate the joint?

Dr__Schaefer: It depends what is injected--most commonly it is a corticosteroid (cortisone-type medicine). Over-use of this medicine can cause joint damage, but injections can usually be repeated every 3 months (and they usually last 2 to 3 months). The viscosupplements (joint fluid) injections are also given with ultrasound guidance. They do not damage the joints, but usually are too expensive to repeat more than once every 6 months. Corticosteroids also are more effective for inflammatory arthritis or bursitis.


Knee Issues

boomer46: When do you think stem cell therapy will be available for knee joint treatment?

Dr__Schaefer: I'm not familiar with stem cell treatments for knee arthritis, but there is good work being done on cartilage transplantation.

boomer46: Would you briefly describe knee cartilage transplantation?

Dr__Schaefer: This is done with two different techniques. In Mosaicplasty, cartilage plugs are harvested from a different (non-weight bearing) portion of the joint and transplanted to the affected area. In the other technique (chondrocyte transplant), cartilage cells are harvested and then grown in a laboratory to be implanted at a later date. Mosaicplasty is more common due to expense.

play_ball: I’m 75 years old; I fell many times on ice, cement, etc., when I was young. About 5 years ago I got arthritis in my right knee cap only; I took 5 shots of medicine that didn’t work. Now I take cortisone shots 3 to 4 months a year. I have been told that to correct my problem I must have a complete knee replacement. Is this true?

Dr__Schaefer: Probably. For patellofemoral (kneecap) arthritis, total knee replacement is almost always necessary--usually because it co-exists with arthritis in rest of the joint.

trl354: For arthritis/loss of cartilage in knee, how often and how long can a person get injections?

Dr__Schaefer: As I mentioned earlier, there are 5 different brands available in the U.S. All have been proven effective. Synvisc is the only one with a one-time injection; most of the others require 3 injections.

joem: What do you recommend for knee pain at night?

Dr__Schaefer: This really depends on the diagnosis. For osteoarthritis, pre-medication with a long-acting medicine is helpful. I usually recommended naproxen (Aleve®) or extended-release acetaminophen (Tylenol® 8-hour). I suggest getting a diagnosis first, however!


Back/Spine Issues

angel: Should I buy a certain kind of bed mattress and pillows to help with back pain? I have rheumatoid arthritis.

Dr__Schaefer: I recommend a firm mattress, usually with a soft top-cover (for comfort). I've treated two mattress salesmen with low back pain who have both recommended the name-brand mattresses. I suggest trying a friend or family member's bed for a few nights to "test-drive" the mattress. Get a money-back guarantee!

angel: Please explain arthritis of the spine; is it serious or just age-related?

Dr__Schaefer: Most spine arthritis is age-related. Specifically known as facet joint osteoarthritis, it is usually mild and manageable with exercise and medications.


Hip Issues

still_going: My left leg is ½ inch longer due to a total hip replacement Will I have to have a right hip replacement to correct this problem? The right side hurts always due to the leg difference.

Dr__Schaefer: I recommend trying a heel lift (or a lift built into the whole sole of the shoe). Usually we use a lift about 1/2 the size of the discrepancy. I like the "Adjust-A-Lift" heel insert (available over the counter or online), as you can choose how much lift to add. Hip replacement is not recommended unless there is significant arthritis in the hip.

kpn34: Is there a best exercise for hip pain?

Dr__Schaefer: I'd consult with a physical therapist. In most hip conditions, the hip abductors (gluteals) get weak, so they should be strengthened.

Zee: I have been advised to consider a hip replacement but also have some pain in the other hip and back area. Will physical therapy do any damage?

Dr__Schaefer: Physical therapy is always worth a try, but many of my patients have exacerbations of pain from hip arthritis. Core/abdominal exercises are important for both conditions, but be wary of anything that puts stress through the hip joint, especially in a weight-bearing position.


Treatments

macee61: Do you believe glucosamine and/or chondroitin supplements are of any benefit to arthritis sufferers?

Dr__Schaefer: Yes. Many large (composite) studies have failed to show a benefit, but some well-done individual research shows a benefit for both substances. I think they work better for mild-to-moderate arthritis, but they take 1 to 2 months to take effect. Most studies are done with "glucosamine sulfate" and "chondroitin sulfate.” Glucosamine hydrochloride has not been studied as much and should probably be combined with chondroitin sulfate.

jgray127: What is the current state of biologic treatments, or other treatments that are on the horizon? Because of my low immune system, I'm wary of going on a biologic.

Dr__Schaefer: There are a number of new ones on the horizon. It often comes down to a risk-benefit analysis and long discussion with your rheumatologist. With close monitoring, they are usually safe (relative to the risk of the disease).

jodi890: Is acupuncture successful in treating arthritis? Does acupuncture help RA in wrists?

Dr__Schaefer: There are a few studies showing short-term pain relief for knee arthritis, but I'm not sure about the wrist. Acupuncture is safe and worth trying. It is offered at the Cleveland Clinic in a few different sites!

gloved: How long can a patient tolerate methotrexate if it is helpful? Once the liver becomes affected, will other treatments also harm the liver? Will eating certain foods stop the progression of RA?

Dr__Schaefer: Methotrexate can be tolerated for a number of years. Patients can often return to treatment after a brief “drug holiday.” I am not aware of dietary measures that can stop RA. I would defer this to a rheumatologist.

for_me: How long can one be on a regimen of ibuprofen? What pain medication do you recommend?

Dr__Schaefer: Ibuprofen may cause stomach ulcers. It should be limited to as brief a time as possible. However, many patients take ibuprofen for many years without side effects. I often recommend combining low-dose ibuprofen with acetaminophen. I also recommend taking a medication to protect the stomach lining, such as omeprazole, if long-term ibuprofen treatment is needed.

dog_days: What can be done if you were told you have arthritis of the neck?

Dr__Schaefer: Arthritis of the neck is usually manageable with over-the-counter medications, heat or ice, and activity modification. Posture is the most important factor related to activity. Physical therapy can sometimes reinforce good posture. If neck pain continues to be severe, injections into the arthritic joints are often helpful.


Arthritis With Other Diseases

Jebosley: I have lupus and rheumatoid arthritis. I tried working part time from home and couldn't do it. Do you think these conditions could cause disability? Some days I can do more; other days I can't do much of anything.

Dr__Schaefer: Yes, but before applying for disability you should be under maximal treatment. I would suggest consulting with another rheumatologist, preferably at a major medical center.

Jebosley: I have migratory joint pain and bursitis. I have RA and lupus. Why is it migratory? Everything I read says RA is usually symmetrical.

Dr__Schaefer: Yes, rheumatoid arthritis is usually symmetrical. I would suggest confirming the diagnosis with another rheumatologist. Lupus itself may also cause joint pains, or you may have osteoarthritis as well.

gone_fishing: How can you tell the difference between arthritis and bursitis in the shoulder or a combination of both?

Dr__Schaefer: In the shoulder, arthritis and bursitis often co-exist. Along with them, tendonitis also can co-exist. Arthritis pain will often improve after a few minutes of use, whereas bursitis/tendonitis may worsen. An MRI or ultrasound may help differentiate them. An ultrasound or X-ray (fluoroscopy) guided injection is the "gold standard" for diagnosis. Fortunately, the treatment is nearly the same for all of them and usually starts with physical therapy.

going_out: Shoulder arthritis: please speak to pain radiating down arm, especially large arm muscle.

Dr__Schaefer: Radiating pain is very common from shoulder arthritis--it is often misdiagnosed as a pinched nerve in the cervical spine. This more commonly comes from arthritis involving the ball and socket portion of the joint.

pptt56: How does the doctor determine if the pain is from arthritis or Sjogren’s syndrome?

Dr__Schaefer: Sjogren’s syndrome is often associated with joint pain. A rheumatologist should do laboratory studies, X-rays and a physical exam to differentiate, but it is often difficult to determine.

donald: Do you recommend Celebrex® (celecoxib) as an anti-inflammatory medication?

Dr__Schaefer: Yes, it is one of my favorite medications to prescribe, but you should check on insurance coverage.


Rheumatoid Arthritis

good_heavens: My 26-year-old daughter was diagnosed with RA last year. How often should she see her rheumatologist? What happens if she occasionally forgets her methotrexate?

Dr__Schaefer: This depends on how well her arthritis is controlled. It needs to be determined by her rheumatologist. Missing a few doses of methotrexate may predispose her to relapse.

long_time_coming: I have RA, am taking methotrexate, and my bones are fracturing; is this from the drug?

Dr__Schaefer: Probably not. The disease itself, or corticosteroids, are more likely to cause bone loss and fracture.

jgray127: I'm a 46-year-old male with RA. I also have Morton's neuroma in my right foot, which makes walking additionally painful. What are some ways to get exercise that don't involve using my foot?

Dr__Schaefer: I'd recommend getting treatment for the neuroma so you can walk more comfortably - cortisone injection, shoe inserts, or surgery all helpful. Meanwhile, you should try swimming. Bicycling may also be tolerable.

larry3: With severe RA, when do you determine that joint replacement will not help due to the aggressive RA progression?

Dr__Schaefer: Joint replacement is almost always possible in RA. If there is severe bony erosion or osteoporosis, it may be risky. The arthritis should be in maximal control by medical management prior to surgery. This is a difficult decision, best done jointly with your rheumatologist and surgeon.

gretag: Once you have bone erosion, can that damage be reversed?

Dr__Schaefer: Probably not, although the joints can fill small defects with scar tissue. Small erosions often do not cause pain once the disease is under control. Good luck!


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic specialist Dr. Michael Schaeffer is now over. Thank you, Dr. Schaeffer, for taking the time to talk with us.

Dr__Schaefer: Thank you all so much for your excellent questions! It has been a pleasure discussing arthritis with you. Please stay active! Your may find additional information on our website.

More Information

To make an appointment with Dr. Michael Schaefer or any of the other specialists in our Arthritis and Musculoskeletal Center at Cleveland Clinic, please call 216.445.3330 or call toll-free at 800.223.2273, ext. 53330. You can also visit us online at www.clevelandclinic.org/arthritis.

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