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http://www.nytimes.com/2002/08/06/health/06BROD.html

First Step in Treating Arthritis: Keep Moving

By JANE E. BRODY

hese are boom times for companies that make products that aim to treat osteoarthritis, the leading cause of disability in the United States. This wear-and-tear disease is keeping many specialists busy, as well, including physical therapists, movement specialists, acupuncturists and surgeons who operate on arthritic joints.

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Advice on how best to treat arthritis is now coming from so many different quarters that it often causes more confusion than clarity.

But there is one point of agreement. The wrong way to respond to the pain and stiffness of arthritis is to stop moving. A neighbor of mine did just that, and within a year he was living in a wheelchair and had to be carried up and down stairs.

Regular moderate exercise is critical to retaining mobility of arthritic joints, and exercise to build the strength of supporting muscles is the best way to reduce the painful stress and the disease progression.

A Hierarchy of Therapies

Long before surgery on arthritic joints becomes an issue, a host of nondrug, drug and herbal remedies can often relieve the pain and disability. Only after these have been given a fair trial, and only if arthritis is far advanced and interferes with normal activities, is it time to consider surgery, the more drastic remedy.

First and foremost, for arthritis in a weight-bearing joint like the knee or hip, it is crucial to achieve and maintain a normal body weight through diet and low-impact exercise. The force on the knee with each foot strike is two to three times as great as the body weight, so weight loss of just 11 pounds takes 22 to 33 pounds off the knee.

Other helpful measures for reducing knee pain include avoiding stressful activities like prolonged standing, kneeling, squatting and stair climbing. Going down stairs is often more painful than going up.

Braces that unload stress on the knee are also helpful, as is a walking stick, used in the hand opposite that of the affected knee or hip. Shock-absorbing shoes, heel wedges, periodic applications of ice packs insulated by cloth, and moist heat on the affected joint are useful as well.

Most people with arthritis can benefit from sessions with physical therapists who can demonstrate and teach muscle-building and stretching exercises to restore mobility.

Acupuncture may also help, though the results of a government-sponsored, well-designed study of its effectiveness are not yet available.

The Remedies

Although it is tempting to ask doctors to prescribe the latest and most expensive prescription drug to hit the market, a more reasonable approach starts with less glamorous low-cost over-the-counter options.

The first and safest drug to try is acetaminophen, sold as tablets or capsules and now available in long-acting extra-strength versions for people with arthritis.

Next come the low-potency nonsteroidal anti-inflammatory drugs, aspirin, ibuprofen and naproxen.

But these and other more potent nonsteroidal drugs like indomethacin and etodolac can cause bleeding, bruising and gastric ulcers and are best taken in enteric-coated versions on a full stomach along with a drug like misoprostol (Cytotec), a histamine blocker like Tagamet or Zantac or a proton-pump inhibitor (like Prilosec or Prevacid) to protect the stomach lining.

Another nonsteroidal anti-inflammatory drug, meloxicam (Mobic), has been shown in some studies to be less likely than other drugs in this class to cause gastric ulcers and susceptibility to bleeding and bruising.

There are also topical agents like methylsalicylate or capsaicin, a hot pepper derivative; menthol; oil of wintergreen; camphor; and eucalyptus oil that can mask arthritic pain, but only in the area where they are applied.

Topical ibuprofen and naproxen are available over the counter in Europe. Topical agents have the advantage of causing no bodywide side effects, though some can cause rashes and blisters on sensitive skin.

The newest drugs to capture the attention of people with arthritis are the cox-2 inhibitors, celecoxib (Celebrex) and rofecoxib (Vioxx). Although no more effective than nonsteroidal anti-inflammatory drugs, they have a lower risk of gastrointestinal side effects, although they may slow the healing of existing gastric ulcers.

These are not yet available in generic versions and are thus very expensive. Furthermore, none of the cox-2 inhibitors have been used long enough on a chronic basis to be certain of their long-term safety.

Keep in mind, too, that all drugs can interact with other medications. Be sure to tell your doctor about every drug you take, including low-dose aspirin, as well as any chronic condition you may have, like liver or kidney disease. Also, be sure to follow the doctor's instructions about having periodic blood tests while taking arthritis medications.

Those needing more potent pain relief may benefit from narcotic-containing analgesics like acetaminophen with codeine or oxycodone, which are associated with side effects like dizziness, drowsiness and constipation and may cause dependence over time.

So-called dietary supplements offer another option that may be taken alone or along with other arthritis drugs. Most popular among them are glucosamine and chondroitin sulfate, often sold in combination tablets or capsules with instructions to take three a day.

Other than a possibility of somewhat loose stools in the first few weeks of therapy, they have no known side effects. Several clinical studies, not always pristinely conducted, have indicated that glucosamine alone or the two in combination can relieve arthritic discomfort and may delay or halt its progression.

The National Institutes of Health is conducting a proper study of their effectiveness.

Some evidence also supports another dietary supplement, SAM-e, for arthritis pain, as well as mild depression. For arthritis, 200 to 400 milligrams of SAM-e are taken three times a day. With all supplements, do not expect noticeable pain relief for three or four weeks.

Dietary supplements can be quite costly and are not covered by medical insurance. Neither are their quality and potency regulated by the Food and Drug Administration. So bargain hunting may be a bad idea. It is best to choose products made by reputable companies like Nutramax and Schiff.

When oral or topical remedies are not enough to control arthritic pain, an injection of cortisone into the affected joint can bring short-term relief, for weeks or months. Because cortisone can cause further joint deterioration, the injections can be used just three or four times a year.

Another option is a series of injections of hyaluronate (Synvisc and Hyalgan), intended to replace the lubricating fluid in the knee joint. The medication can relieve pain for most sufferers for six months or longer. The therapy is expensive and may not be covered by insurance, so check first.

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