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Managing Arthritis Pain When Surgery is not an Option

Online Health Chat with Ellen King, MD and Rochelle Rosian, MD

November 5, 2012

Introduction

Arthritis affects 50 percent of people over the age of 65 years old, and 22 percent of all adults over the age of 18 years old. Handling the painful joint inflammation associated with arthritis can be a struggle for many sufferers. Knowing how to effectively manage arthritis pain can make a significant difference in your life. Learning which type you have and getting the right diagnosis is the important first step in determining how you treat it.

Although osteoarthritis (OA) and rheumatoid arthritis (RA) are two of the most widely known forms, arthritis is a term used to describe over 100 rheumatic diseases and conditions affecting the joints, according to the Centers for Disease Control and Prevention (CDC). Osteoarthritis (OA) and rheumatoid arthritis (RA) both cause joint pain and limit movement. OA results from wear-and-tear of the cartilage cushioning the joints, typically after injury or with advancing age. RA is classified as an autoimmune disease.

Treatment for joint pain differs widely, depending on the type. The right diagnosis and early treatment can arrest joint damage and return you to your previous level of activity. The wrong treatment—or avoiding treatment—may mean joint deterioration, poor function and compromised mobility.
The causes, symptoms and risk factors of arthritis may differ and can affect people at any age. Various therapies to treat arthritis include medication, physical therapy, exercise, joint injections, orthotic braces, assistive devices or pain psychotherapy services.

For More Information

On Cleveland Clinic
Cleveland Clinic Pain Management specialists are among the most experienced in the world, treating more than 10,000 new patients each year. Our board-certified physicians are dedicated to the goal of helping people with chronic pain return to a normal, productive lifestyle. Using the latest in diagnostic technology, paired with medical and interventional therapeutics, they will work with you to identify the source of your pain, eliminate or reduce the pain and teach you to manage it.

Our multidisciplinary team of healthcare professionals develops customized care plans for each patient, using the latest equipment and innovative procedures to diagnose pain and determine the safest and most effective pain management possible. We are committed to providing state-of-the-art service closer to home, caring for patients at Cleveland Clinic's main campus and over 20 northeast Ohio locations.

Cleveland Clinic's Orthopaedic & Rheumatologic Institute offers expert diagnosis, treatment and rehabilitation for adults and children with bone, joint or connective tissue disorders. The Department of Rheumatic and Immunologic Diseases at Cleveland Clinic, which treats rheumatoid arthritis and other diseases, is ranked second in the nation by U.S.News & World Report, and is top ranked in Ohio.

The Orthopaedic & Rheumatologic Institute launched its first multidisciplinary clinic combining the expertise of nonoperative orthopaedists and rheumatologists in one location at Cleveland Clinic’s Arthritis & Musculoskeletal Center. This center offers a convenient and integrated approach for the evaluation of patients with joint pain due to arthritis and associated musculoskeletal problems.

Our evaluation and treatment center brings together experts so the cause of your joint pain can be quickly and appropriately diagnosed. Cleveland Clinic doctors have a specific interest in joint pain problems and can work efficiently within a multidisciplinary team to provide you with the highest level of care so you can return to your usual level of activity.

Cleveland Clinic’s Arthritis & Musculoskeletal Center team includes rheumatologists, nonoperative orthopaedic physicians, musculoskeletal radiologists, physical and occupational therapists, brace technicians and musculoskeletal patient educators.

On Your Health
MyChart®: Your Personal Health Connection, is a secure, online health management tool that connects Cleveland Clinic patients with their personalized health information. All you need is access to a computer. For more information about MyChart®, call toll-free at 866.915.3383 or send an email to: mychartsupport@ccf.org

A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® website. To request a remote second opinion, visit eclevelandclinic.org/myConsult


For Appointments

To make an appointment with Dr. Ellen King or any of the other specialists in our Department of Pain Management at Cleveland Clinic, please call 216.444.PAIN(7246) or 800.392.3353. You can also visit us online at clevelandclinic.org/painmanagement.

To make an appointment with Dr. Rochelle Rosian or any of our specialists in our Department of Rheumatology at Cleveland Clinic, please call 216.444.5632 or 800.223.2773 ext. 45632. You can also visit us online at clevelandclinic.org/rheum.


About the Speakers

Cleveland Clinic Department of Pain Management physician Ellen King, MD is board-certified in anesthesiology and pain management. Dr. King completed her fellowship at the Hospital of The University of Pennsylvania, in Philadelphia. She also received acupuncture training at Helms Medical Institute, in Berkeley, Calif. Dr. King completed her medical residency at Beth Israel Deaconess Medical Center, in Boston, and Harvard Medical School, in Cambridge, Mass. She completed her internship at Metrowest Medical Center, in Framingham, Mass., and graduated from medical school at University of Iowa College of Medicine, in Iowa City, Iowa.

Dr. King sees patients at Cleveland Clinic main campus and Twinsburg Family Health and Surgery Center.
Her specialty interests include interventional pain management, complex regional pain syndrome (CRPS), neuropathic pain, spinal cord stimulation, chronic back and neck pain, phantom limb pain, arthritis, musculoskeletal pain and cancer pain.

Cleveland Clinic rheumatologist Rochelle Rosian, MD, is the Director of Regional Rheumatology. Dr. Rosian is currently seeing patients at Solon Family Health Center and at Beachwood Family Health and Surgery Center. Dr. Rosian completed her rheumatology fellowship at Cleveland Clinic after finishing her internal medicine residency at Allegheny General Hospital—Suburban Campus in Pittsburgh. She graduated from Northeastern Ohio Universities College of Medicine, in Rootstown, Oh. Dr. Rosian is board-certified in internal medicine and internal medicine – rheumatology.

Her specialty interests include general rheumatology, osteoarthritis, psoriatic arthritis, rheumatoid arthritis, lupus, and connective tissue disease.


Let’s Chat About Arthritis: Treatment and Pain Management Options

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic experts Dr. Ellen King and Dr. Rochelle Rosian. We are thrilled to have them here today to discuss Arthritis: Treatment and Pain Management Options. Let’s begin with some of your questions.


Inflammatory Arthritis and hs-CRP (High-sensitivity C-reactive Protein)

miamimama: Can arthritis cause a high hs-CRP (high-sensitivity c-reactive protein) reading? If so, how does one find out definitively whether cardiovascular disease or arthritis is causing the high reading? My hs-CRP is 10.39. My LDL (low-density lipoprotein) is 114, and my HDL (high-density lipoprotein) is 68. My triglycerides are 118 and my cholesterol is 200.
Dr_Rosian: The hs CRP reading does show inflammation that is system wide. Certain forms of arthritis, like rheumatoid and lupus, that are inflammatory can elevate the test significantly. Osteoarthritis generally does not lead to an increase in inflammatory markers.

 

Gel Phenomenon

calli3: Why do I have so much pain after sitting in the car or driving? I can hardly walk when I get out.
Dr_Rosian: What you are describing is called the gel phenomenon. It is the sensation of the ligaments and tendons that are surrounding the joints getting stiff from inactivity. Blood needs to move back around in those tissues. Also, knees that have loss of cartilage from osteoarthritis can be stiff after prolonged sitting. This is likely due to the joint fluid being less lubricating than it is in a healthy joint. Gel phenomenon lasts typically less than 15 minutes in wear-and-tear forms of arthritis. If the stiffness or gel phenomenon is longer than that, you may need to see a rheumatologist to be sure there is no inflammatory component to your arthritis.

 

CMC Arthritis

nyst: I suspect I am developing CMC (carpometacarpal) joint arthritis. The base of both thumbs and index finger are extremely tender to painful, depending on my activity. Repetitive motions with needlepoint and using the computer aggravate it. Pain is experienced with opening jars, doors, etc. I am also allergic to NSAIDs (nonsteroidal anti-inflammatory drugs). Should I initially try splints that I can purchase at a drugstore? Rest is difficult with my job.
Dr_Rosian: The thumb and fingers can often be aggravated by our activity, either work or hobby related. Remember it is important to ‘use it of lose it’" though, and you should continue to do these activities. Heat, in the form of warm water or a paraffin bath, can be a great way to warm up the hands. Ice can be beneficial with the sharp pain. Using splints that protect the thumb, a thumb spica splint, can be very helpful as well. Over-the-counter medications like acetaminophen or rubs can help. Occupational therapy and injections or surgery might be options down the road.

 

Pain of Rheumatoid Arthritis and Gout

Tike: I have rheumatoid arthritis (RA) and gout in my finger joints and wrists, with a lot of soreness and swelling in the joints as well as stiffness. Do you have any suggestions that would help this? I am under the care of a physician at an arthritis center in Columbus.
Dr_Rosian: In order to minimize stiffness and pain and swelling it is important to treat your underlying conditions of RA and gout aggressively. There are many medications available and, if you do not feel adequate relief, you may to need adjust your disease-modifying medications as best you can with your physician. Ask for medications to help with pain as well.

 

Treatment for Back Arthritis

candyc: What do you recommend for pain relief for arthritis in the back?
Dr_King: Pain due to arthritis in the back can be treated by many different modalities. It is important to engage in a comprehensive pain management program that includes conservative management with medications and physical therapy, as well as more advanced treatment options such as injections into the joints of the back.

 

Arthritis Pain Relief

happyg: I have arthritis in the shoulder, hip and knee. What do you recommend for pain relief? Does one pain relief medication work the same on arthritis, no matter what the location, or do you recommend different types of pain relievers depending on where the arthritis is?
Dr_King: Anti-inflammatory medications are beneficial for the treatment of pain due to osteoarthritis. Usually, if a medication works for arthritic pain in a particular joint, it should work for arthritic pain in another joint, unless there is another source of pain in a given joint.

great_danes: For the  treatment of arthritis pain, what does a pain management consultation consist of? What are some of the treatments recommended?
Dr_King: During your initial consultation, a thorough history will be taken with regard to your pain complaint. You will be examined by the physician to evaluate the areas where you have pain. Depending on what is found on the physical examination, and how it relates to your symptoms, a treatment plan will be designed specifically for you. Treatments can range from medications alone to medications along other modalities including a TENS (transcutaneous electrical nerve stimulation) unit, over-the-counter preparations, physical therapy and injection therapy.

 

Pain Control for Polymyalgia Rheumatica

grkbfd: With diabetes mellitus without complications and polymyalgia rheumatica (PMR), where do I start for pain control?
Dr_Rosian: Pain control with any form of underlying arthritis requires that you treat the underlying form of arthritis. In your case, steroids, which are typically the treatment of choice for PMR, are not great to use in patients with diabetes. But there are other options you can discuss with your physician. You might want to ask about Tylenol® for pain control while waiting for other medications to work.

 

Topical Preparations for Pain Relief

of_course: Is there an over-the-counter gel that is as good as Voltaren®?
Dr_Rosian: Over-the-counter rubs tend to be either liniments, like Icy Hot® or Biofreeze®, that have menthol or wintergreen to increase blood flow to the area where they are applied. There are also capsaicin rubs that are derived from hot pepper and block substance P at the nerve endings. Other over-the-counter rubs include Aspercreme® which has some anti- inflammatory properties. There are no NSAID (nonsteroidal anti-inflammatory drug) over-the-counter rubs at this time.

 

Orthotics: Braces vs. Canes

marni: I am female, and I’m not eligible for a replacement surgery. I use a cane. Can I lose the cane if I wear a brace?
Dr_King: If you are referring to your knee or ankle, a brace can be fitted to help with support, which may allow you to walk without a cane. However, if you utilize the cane for stability and balance, you may need to continue to use it even when wearing a brace.

 

Exercises for Arthritis and Diabetes

Ritesh: My mother who is 62 years old suffers from diabetes and arthritis. What are the exercises that she could do to control both?
Dr_King: In general, diet and exercise are beneficial for helping to create better control of diabetes. Aquatic therapy tends to be gentler on the body for people with arthritis or other painful conditions.

 

Alternative and Adjunct Therapies and Supplements

Ritesh: How can my mother manage her arthritis pain better— with or without medication?
Dr_King: Water therapy is a good non-pharmacological treatment option to help with arthritic pain. Depending on the type of arthritis, over-the-counter anti-inflammatory medications are also good options.

libra27: I suffer with osteoarthritis, and nothing I takes works.  It makes me go into an anxiety attack even when I put those ointments on my knees. It goes through my body, and makes me short of breath. Is there anything that I can take without side effects? I am borderline diabetic, have high blood pressure and take thyroid pills. With the kind of work that I do I am on my feet all day, and that can get really painful.
Dr_Rosian: You are certainly in a position that many patients find themselves with other conditions that make treating pain difficult. No medications are free of side effects. You may try alternatives like bracing, heat and ice, as well as complimentary or alternative techniques like acupuncture or Reiki. Physical therapy and TENS (transcutaneous electrical nerve stimulation) units can be helpful as well.

hollyt65: Does acupuncture work?
Dr_King: Acupuncture has been shown to be effective for the treatment of arthritis pain. Success rates can vary depending on the severity of the disease and other medical problems that the patient has. Most patients will require several acupuncture treatments before any results can be seen.

soda_falls: Does taking calcium prevent the need for joint replacement? How much calcium should post-menopausal women take?
Dr_Rosian: Calcium is of course very important for bone health along with Vitamin D. In general, women should be getting 1200 mg to 1600 mg of calcium per day between their diet and supplements. Supplements should be either in the form of calcium carbonate or calcium citrate,. These supplements should be taken in divided doses throughout the day, as we can only absorb about 400 mg at a time. Take calcium with orange juice or meals to help with absorption. Avoid taking with caffeine, alcohol or when smoking since this interferes with absorption. Dietary forms are best, like milk, yogurt and cheese. Broccoli and kale can be good sources as well.

Please remember your Vitamin D, too. Levels of Vitamin D can be check by your physician. The daily recommendation is 800 IU daily. We live in Cleveland— where 1000 IU daily in the summer and 2000 IU daily in the winter are often needed!

rolling_stone: What natural supplements help with the pain?
Dr_King: Natural supplements are not FDA-regulated, and the quality of each batch cannot be guaranteed. However, if you take a natural supplement that works to help with your pain, you should contact your primary care physician to determine if the natural supplement is safe to take in consideration of your other medical problems and/or other medications.

ally: Does fish oil taken by mouth lubricate the joints?
Dr_Rosian: Omega 3 fish oil with DHA (docosahexaenoic acid) and EPA (eicosapentaenoic acid) is thought to be a mild anti-inflammatory and antioxidant at a dose of 1000 mg twice daily. Thereby, it is an option for treating arthritis pain and stiffness. As always, check with your physician to be sure there is not interaction with other medical conditions or treatments.

samp: If you have high inflammation, is there anything natural you can do to lower this?
Dr_Rosian: This is a great question, and it give me an opportunity to discuss diet and inflammation. We know that saturated fats like the ones found in red meat or other oils used for cooking can be pro-inflammatory. An anti-inflammatory diet includes lots of fruits and vegetables, fish and other lean meats, and omega 3 oils, as well as low dairy. In addition, omega 3 fish oil with DHA and EPA is thought to be a mild anti- inflammatory and antioxidant at a dose of 1000 mg twice daily. Thereby, it is an option for treating arthritis pain and stiffness. In addition making sure that there are no chronic infections, such as proper care of your teeth and gingiva will help lower inflammation. There is some thought that yogurt with live cultures or the use of probiotics helps the digestive track, too, to lower inflammation.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic experts Rochelle Rosian, MD and Ellen King, MD is now over. Thank you Dr. Rosian and Dr. King for taking your time to answer questions today about Arthritis: Treatment and Pain Management.


 

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