Johns Hopkins Health Alerts - Arthritis

New Drugs Offer Hope to Gout Sufferers

Mon, 15 Sep 2008 06:00:00 CDT

Gout is one of the most painful yet treatable forms of arthritis. Today, it's estimated that two to five million Americans have gout, with most men suffering a first attack between 40 and 50 years of age. Women develop it later, in the years following menopause.

For people who develop gout, approximately 10% inherit enzyme deficiencies that cause the overproduction of uric acid. More commonly, however, gout is associated with a variety of factors that negatively impact the kidneys, including aging, elevated cholesterol, obesity, diabetes, and high blood pressure.

For the first gout attack, a high dosage of a nonsteroidal anti-inflammatory drug (NSAID; 600 mg of ibuprofen three to four times daily or 25–50 mg of indomethacin three to four times daily) is often chosen as a first-line therapy because of its quick onset of action, its ability to relieve the pain and swelling of acute gout, and its good tolerability. Treatment is stopped when gout symptoms resolve. Many patients will have a long duration – sometimes even years – between their first and second attacks of gout.

The numbers are imprecise, but experts believe there are anywhere from 25,000–100,000 treatment-failure gout patients in the United States. These patients have no alternative therapeutic options for their gout other than symptomatic relief. For these patients with chronic active gout, three new medications may soon offer relief.

Rilonacept (IL-1 Trap), an injectable drug now in Phase II trials -- Rilonacept works by preventing interleukin-1 (IL-1) from attaching to cell-surface receptors and creating a flare in disease. Interleukin-1 is a protein secreted by many cells in the body; secreted in excess, IL-1 can trigger disease activity in gout.

Febuxostat -- Febuxostat -- recently approved in the European Union (as Adenuric) and currently awaiting FDA approval -- may prove to be a new alternative for long-term management. This is especially good news for the nearly 20% of people with gout who have bad reactions to allopurinol (Zyloprim) and for those with kidney impairment that prevents them from using the drug.

Pegloticase (Puricase ) -- An injectable drug designed for people who have failed traditional gout therapy Puricase is currently awaiting FDA approval. Puricase is made from a pig enzyme called uricase. All mammals except humans and primates produce the uricase enzyme, which breaks down uric acid, leaving very low levels in the blood circulation. Uricase converts uric acid to the more water-soluble metabolite allantoin, which can be readily excreted.

The Challenge of Driving With Arthritis

Mon, 25 Aug 2008 06:00:00 CDT

The pain and stiffness of arthritis can make it a challenge to drive a car. Knowing what types of features to look for when purchasing a new car is important. In addition, adaptive devices and car modifications after the car purchase can make driving with arthritis safer and more enjoyable. Here's some practical advice from Johns Hopkins.

If you are ready to buy a new car, keep some arthritis-friendly features in mind. These will be more or less important, depending on which joints give you the most trouble. Here are some car features to consider:

Keyless entry

Running boards and assist handles on sport utility vehicles and vans

Adjustable steering wheel (up and down and telescoping)

Fully adjustable seats (height, distance from pedals, tilt, and lumbar support)

Adjustable pedals

Padded steering wheel

Easy-to-grasp controls within easy reach

Dashboard-mounted and pushbutton ignition switch

Seat belts that are easy to reach, lock, and release

Cruise control

Easy-to-use door handles

Easy-to-adjust mirrors and sun visors

Easy-to-access trunk or rear door

Shorter turning radius for ease in maneuvering

Seat type is often a personal preference in a car. A bench seat, for example, allows more room to adjust your position for comfort than does a bucket seat. Leather seats make it easier to slide in and out of the car. Some people prefer high seats to reduce the need to bend when entering and exiting the car; others find it easier to slip into lower seats.

If you are significantly disabled, it’s important to consult a specialist in driver rehabilitation before you shop for a car. The specialist will assess your abilities and disabilities and offer advice about the types of modifications that may be helpful.

The available modifications include a left-side accelerator and brake pedal or hand controls if you are unable to use your right leg. Other devices include special mirrors, extended gearshift levers, and reduced-effort steering wheels.

Finally, don’t be afraid to discuss your driving difficulties with your physician or to seek the services of a rehabilitation specialist. Some people fear that admitting their physical limitations behind the wheel will ultimately cost them their driver’s license. However, if you are otherwise fit to drive, having the right car with some adaptations should allow you to continue driving and, most important, to continue driving safely.

For more information, contact: Association for Driver Rehabilitation Specialists 711 South Vienna Street Ruston, LA 71270 (800) 290-2344 www.aded.net

Advice for Fibromyalgia Sufferers

Mon, 04 Aug 2008 06:00:00 CDT

Fibromyalgia is famously difficult to diagnose and to treat. Now data suggest that acupuncture can relieve some of fibromyalgia's uncomfortable symptoms – very good news for everyone affected by this often-debilitating condition.

Fibromyalgia is a syndrome characterized by widespread muscle pain, fatigue, and the presence of what are called “tender points” -- 18 specific sites on the body that are exceptionally sensitive to pressure. Fibromyalgia is not a type of arthritis because it doesn’t cause inflammation or damage the joints. But it is included under the broad umbrella of rheumatic disorders, health conditions that affect the joints or soft tissues and cause chronic pain.

In addition to chronic muscle pain, tenderness, and fatigue, fibromyalgia symptoms may include sleep problems, morning stiffness, headaches, cognitive and memory problems ("ibro fog”), irritable bowel syndrome, painful menstrual periods, restless legs syndrome, numbness or tingling in the extremities, and temperature sensitivity.

What can you do to relieve your fibromyalgia discomfort? A study reported in the Mayo Clinic Proceedings (Volume 81, page 749 ) indicates that acupuncture may relieve some of the most bothersome and debilitating symptoms of fibromyalgia.

In a randomized, controlled trial, researchers assigned 50 fibromyalgia patients to receive either true acupuncture or sham (simulated) acupuncture. The patients all met the American College of Rheumatology’s diagnostic criteria for fibromyalgia. Each of them had already tried conservative treatments.

Participants’ symptoms were assessed with the Fibromyalgia Impact Questionnaire (FIQ) and the Multidimensional Pain Inventory at the outset of the study, again immediately after the treatment, and at one month and seven months after treatment.

The findings: The study results showed significant improvements among patients in the true acupuncture group compared with those who had received the sham procedure. The greatest benefits were seen in FIQ total scores at one month (42.2 in the sham group vs. 34.8 in the true acupuncture group).

Acupuncture relieved fibromyalgia-related pain, but its greatest benefits were in reducing fatigue and anxiety. The treatment appeared to have no effect on the patients’ activity levels or physical functioning. The researchers reported that the acupuncture treatments were well tolerated and had few adverse effects.

The Estrogen-Osteoarthritis Connection

Mon, 12 May 2008 06:00:00 CDT

Why do so many middle-aged women develop osteoarthritis? Scientists believe that declining estrogen levels may play a role.

Osteoarthritis is often called a wear-and-tear disease because it develops in joints after many years of use. Aging increases the risk of developing osteoarthritis, but it's not the sole cause. Scientists aren't sure exactly what causes the condition, but several factors play a role in its development. These include genetic predisposition, obesity, prior joint injuries, wear and tear on the joints due to repeated overuse or sports-related activities, muscle weakness, and nerve injury.

Now a study reported in the journal Arthritis and Rheumatism (Volume 54, page 2481) suggests that low estrogen levels are linked to osteoarthritis of the knee in middle-aged women.

Following up on findings from animal studies, researchers from the University of Michigan measured the estrogen levels of more than 800 premenopausal and perimenopausal women. Based on these results, they ranked the study participants into three groups according to their estrogen levels. The women had yearly x-rays of both knees and answered questions about knee pain, their general health, and various lifestyle factors.

After taking into account osteoarthritis risk factors such as body mass index, the researchers found that women with the lowest estrogen levels were nearly twice as likely to develop osteoarthritis over the next three years as were those with higher levels.

These findings may help explain why signs of osteoarthritis tend to appear when women are in their 40s, a time of fluctuating or declining estrogen levels. The relationship between estrogen and osteoarthritis isn’t clear. However, the hormone is believed to interfere with arachidonic acid, a substance in the body that is associated with pain and inflammation. The researchers suggest that a better understanding of estrogen’s apparent protective effect on the knee may lead to new approaches to osteoarthritis management.

Acetaminophen or NSAID for Arthritis Pain Relief?

Mon, 02 Jun 2008 06:00:00 CDT

If you have osteoarthritis, what's your best first line of defense against painful joints? Dr. Clifton O. Bingham III, Director of the Johns Hopkins Rheumatology Clinics, offers advice.

Q. Which pain medication has the best risk-to-benefit ratio for osteoarthritis?

Dr. Bingham: Overall, acetaminophen (Tylenol) is the safest, which is why it stands at the top of treatment recommendations for patients with osteoarthritis. As a first treatment, acetaminophen has been shown in some studies to be just as effective as most NSAIDs and is less likely to cause side effects such as stomach irritation. It’s also inexpensive.

Q. What dosage of acetaminophen do you recommend for effective osteoarthritis pain relief?

Dr. Bingham: Acetaminophen can effectively treat pain and provide enough relief so that many people with osteoarthritis can engage in more physical activity. As with every pain medication for osteoarthritis, we’ve learned that the lowest effective dose is the best dose. That's because increasing doses of any drug, including acetaminophen, are associated not only with increased pain relief but also an increased risk of side effects, which may tilt the risk-to-benefit ratio toward the riskier side.

The maximum recommended daily dosage of acetaminophen is 4,000 mg, generally taken as 1,000 mg four times a day, or as extended release or arthritis strength (1,300 mg three times a day). When taken regularly, dosages above that amount can cause dangerous side effects. Acetaminophen may be harmful for people who have liver disease or who drink large amounts of alcohol. To decrease risk of liver damage, you should not consume alcoholic beverages while taking this medication.

Acetaminophen may also be dangerous if you are taking the blood-thinning drug warfarin (Coumadin). Some research indicates that, in rare cases, heavy daily use of acetaminophen may increase the risk of kidney damage.

Important note: If you take acetaminophen for osteoarthritis, it's important to recognize that other over-the-counter preparations such as cold medicines or multi-symptom relievers often also contain acetaminophen. Therefore, if you combine the two, it's possible to get a cumulative dosage that exceeds recommended safety levels.

Q. If acetaminophen doesn't work, what are the risks and benefits of switching to traditional NSAIDs?

Dr. Bingham: Aspirin, the original NSAID, is an effective and inexpensive treatment for osteoarthritis pain, but high doses have significant side effects on the stomach. You can consider other over-the-counter NSAIDs such as ibuprofen (Advil and others), naproxyn (Aleve and others), and ketaprofen (Orudis KT).

NSAIDs work primarily as pain relievers, but also decrease inflammation, which may be present in over 30% of individuals with osteoarthritis. How osteoarthritis symptoms respond to a specific NSAID varies greatly from person to person. As a result, finding the right drug largely depends on trial and error. On average, it can take at least two weeks of treatment with a drug to know if a particular drug is effective.

As with all medications, there are risks as well as benefits, even with over the counter medications. Acetaminophen is safe for many people, but speak with your doctor about which pain reliever is right for your arthritis given your personal health history, such as a history of high blood pressure.

The Cartilage Connection

Mon, 14 Jul 2008 06:00:00 CDT

In this excerpt from a recent issue of the Johns Hopkins Arthritis Bulletin, Associate Professor Lynne C. Jones, Ph.D. talks about the importance of cartilage in the development of osteoarthritis.

In my experience here at Johns Hopkins, most patients have little awareness of cartilage until something goes wrong with it. And even then, they often have a limited understanding of what cartilage is and does, what can be done to protect joints from further damage, and what treatment options are available to help reduce pain and restore mobility. In many ways, that’s perfectly understandable. </>

Compared with most other body tissues and organs, cartilage is "out of sight and out of mind." Like a shock absorber in a car, it doesn't announce its presence until it becomes damaged and affects your ability to navigate the highways of everyday life.

Cartilage is an essential component of healthy joints. You may have experienced the pain and loss of mobility that occur when cartilage is damaged, either by a traumatic injury or by diseases such as osteoarthritis and rheumatoid arthritis. If so, you're not alone. Approximately 900,000 cartilage injuries occur each year in the United States and an estimated 20 million Americans are affected by osteoarthritis, most commonly in the knee.

Here are my answers to some the most common cartilage-related questions asked by patients.

Q. What is cartilage?

Dr. Jones: Cartilage is a translucent, connective soft tissue that's found in many areas of the body, including the joints, rib cage, spine, ear, nose, voice box, and bronchial tubes. This semitransparent substance is called hyaline cartilage, a name that derives from the Greek word hyalos, which means glass.

In normal joints, hyaline cartilage is a firm, rubbery material that covers and protects the ends of bones. Its primary components are water and two types of proteins—type II collagen and proteoglycans -- that together form a gel-like matrix that allows it to change shape when compressed. Cartilage also contains specialized cells called chondrocytes, which produce collagen, proteoglycans, and enzymes that help maintain healthy cartilage.

Q. Is aging inevitably associated with cartilage degeneration?

Dr. Jones: There are age-related cartilage changes. And yes, it seems that osteoarthritis is an age-related disease. That said, it still doesn’t mean that the changes due to aging are necessarily the changes that automatically lead to osteoarthritis. After age 60, a majority of men and women show some evidence of joint-space narrowing on X-rays (a sign of cartilage loss), but most of them have no osteoarthritis symptoms. Their cartilage is still fully functional.

Gender-Specific Knee Implants Offer Women a Choice

Mon, 21 Apr 2008 06:00:00 CDT

Now women facing knee replacement surgery can choose an implant designed to fit the narrower shape of their knees and offer greater flexibility and comfort.

According to Consumer Reports, more than 600,000 people in the United States have hip or knee replacement surgery each year, 70% of them because of osteoarthritis. A 2006 survey showed that even though recovery can be long and sometimes painful, 82% of people who had this kind of surgery were very or completely satisfied with the results.

Women account for nearly two-thirds of the knee-replacement procedures performed each year. These artificial knees have functioned well for both men and women. The anatomy of a woman’s knee, however, does differ in some ways from a man’s. Called the Gender Solutions High-Flex Knee, a women-specific knee implant addresses these differences.

Women’s knees are narrower from side to side and are shaped more like a trapezoid than a rectangle (the shape of a man’s knee). The bone in the front of a woman’s knee also is less prominent than a man’s. As a result, according to the manufacturer (Zimmer, Inc.), a conventional artificial knee may feel bulky to a woman. In addition, the angle between the pelvis and the knee is different in men and women. This can affect the way the usual artificial kneecap tracks over the end of the thighbone and may give a woman an unnatural feeling as it moves.

The Gender Solutions knee also has a high degree of flexion (up to 155 degrees), which may make movements like stair climbing easier. It’s important to note that this new knee is just one more option for women who need a knee implant. At this point, there is no actual scientific evidence that it is superior to other types of artificial knees when implanted in women. [This information was reported by the Food and Drug Administration, May 2006.]

The Good News About Exercise

Mon, 31 Mar 2008 06:00:00 CST

It may seem counterintuitive, but a recent study confirms that people with osteoarthritis can improve mobility and enhance their quality of life with modest levels of exercise.

Although arthritis is a wear-and-tear condition, mild to moderate exercise will not damage your joints. In fact, carried out routinely and carefully, an exercise program can dramatically reduce the risk of osteoarthritis by strengthening the muscles that support weight-bearing joints. Of course, exercise will also help with weight loss, which in itself will reduce your risk of arthritis.

And what if you already have osteoarthritis? A study reported in the journal Arthritis and Rheumatism (Volume 53, page 879) indicates that even modest physical activity can preserve mobility in people already diagnosed with arthritis.

For many people with arthritis, the idea of starting an exercise program can be intimidating. But the study has found that even small amounts of physical activity can help preserve mobility and the ability to carry out daily tasks.

The researchers analyzed data from the Health and Retirement Study (HRS). The HRS has monitored the health status of more than 3,500 men and women with arthritis who were ages 53–63 in 1994. Participants were categorized into three groups according to how well their physical activity level met national recommendations: Recommended group (30 minutes per day of moderate activity or 20 minutes of vigorous activity), insufficient group (some exercise but not the recommended amount), and inactive group (no regular activity).

The good news: Compared with inactivity, physical activity at the recommended -- and even at insufficient -- levels was equally protective against functional decline or disability. Both reduced the risk by about 40%. Functional ability refers to successful performance of daily tasks such as walking a short distance, climbing stairs, bathing, and preparing meals. Study participants who engaged in the most physical activity actually achieved modest improvements in their functional status over the several years of the study.

Honey, Vinegar, Water, and Cherry Juice for Osteoarthritis

Mon, 18 Feb 2008 06:00:00 CST

Is there any credible evidence that cherry juice or a drink mixture of honey, vinegar, and water relieves symptoms of osteoarthritis? Johns Hopkins specialists answer readers’ questions in this excerpt from a recent issue of the Arthritis Bulletin.

Arthritis question 1

Q. My cousin, who has osteoarthritis in her hip, swears that drinking a daily mixture of equal parts honey, vinegar, and water has alleviated her arthritis pain. Though I have never been one for folk remedies, I’m assuming that there is some logic operating behind this one. As for the honey and water, I suspect that they are simply a delivery system that makes vinegar palatable. Is my cousin’s honey-vinegar-water concoction just a homemade placebo? Kansas City, MO

A. Human physiology is quite complex, so it’s difficult to ascertain and analyze which properties of a given food or drug actually have a desired effect in a given target tissue. The body cannot be viewed as a container in which everything we ingest is evenly distributed to all tissues. The trip from mouth to joint involves many modifications, and few substances ever get to the joint in the same form as they entered the mouth. Moreover, pain modification in osteoarthritis is just as likely to happen at the level of pain perception (in other words, in the brain) as in the joint itself. To my knowledge, there have never been any studies evaluating the use of this honey, vinegar, and water mixture for the treatment of osteoarthritis or rheumatoid arthritis.

Arthritis question 2

Q. My wife reads the popular health literature religiously and is now on a cherry juice kick. We start every day not with orange juice (our breakfast drink for the past thirty years) but with a cherry juice concentrate that she buys at the local health food store.

We both have arthritis. I have arthritis my left knee and both hips. Harriet has arthritis in her neck and upper back. She insists that we drink the juice to fight off the arthritis pain. I happen to like the taste of it, but I have my doubts about its pain-relieving effects. Have you heard of any studies of cherry juice, or do you know of people who have benefited from it? Princeton, NJ

A. The pigments in the skins of cherries, blackberries, grapes, and other dark-colored fruits contain compounds known as anthocyanins. Some studies have demonstrated in vitro (test-tube) activity of these compounds as antioxidants and weak anti-inflammatories, with some studies suggesting that they may inhibit prostaglandins in animals. To our knowledge, no controlled clinical trials of these compounds in humans with arthritis have been published in the peer-reviewed medical literature. Still, I’d encourage you to include a variety of dark-colored fruits (and vegetables) in your diet simply because they offer other, proven health benefits in the form of vitamins, minerals, and fiber.

Relieving Pain of Rheumatoid Arthritis with Acupuncture

Tue, 18 Mar 2008 06:00:00 CST

Chinese researchers believe that acupuncture can reduce joint tenderness in people with rheumatoid arthritis. Should you try it? Johns Hopkins offers bottom-line advice.

Rheumatoid arthritis, the most common form of inflammatory arthritis, dramatically limits movement and function as well as causing damage to cartilage and bone. For the 60 million individuals around the world (1% of the population) with rheumatoid arthritis, the inflammation causes pain, stiffness, swelling, and damage to a variety of joints.

Even though researchers have questioned the utility of acupuncture over the years, acupuncture is a potentially viable adjunctive therapy for arthritis pain, and it is rapidly gaining favor in the western world.

When an acupuncturist inserts thin needles into a person’s skin at any of 2,000 carefully defined pressure points, Qi (pronounced chi, it means "life force”) is restored throughout the various meridians, or channels, within the human body. If Qi is at optimum flow, the body is harmonized with the universal forces of yin and yang (emblematic of balance), and the patient is pain-free and physically healthy.

What’s the evidence? At a meeting of the Association of Rheumatology Health Professionals, Lai-Shan Tam, M.D., Associate Professor, The Chinese University of Hong Kong, presented his randomized, placebo-controlled acupuncture study (the best kind of medical trial).

Dr. Tam and his colleagues randomly assigned 7 male and 29 female patients (58 years old, on average) with rheumatoid arthritis that was unresponsive to other therapies to one of three acupuncture/placebo groups. The first group of 12 subjects received electro-acupuncture, in which pulsating electrical currents are sent through the acupuncture needles to stimulate target areas. The second group of test subjects was given traditional acupuncture, while the remaining 12 patients received placebo needles.

At the end of the acupuncture sessions, the researchers noted that:

Those receiving electro-acupuncture had experienced a significant reduction in the number of tender joints and a measurable decrease in pain, stiffness, and swelling.

The traditional acupuncture group experienced benefits but at a diminished rate.

Those in the placebo group saw no change.

"The patient’s comfort is as important as relieving the disease itself,” says Dr. Tam, "so, while the results were not as positive as had been hoped, this does show that acupuncture, either electro- or traditional, when used in conjunction with disease modifying agents, may still provide beneficial pain relief for those with otherwise intractable rheumatoid arthritis.”

The bottom line: If you have rheumatoid arthritis, do not stop taking medications that actually treat the underlying causes of rheumatoid arthritis in favor of acupuncture. If you have rheumatoid arthritis (or osteoarthritis) and are thinking about acupuncture for pain relief, here are some important tips:

Make sure that your physician and acupuncturist is involved in planning the duration and specifics of your treatment.

Use acupuncture as an adjunctive therapy in addition to standard arthritis treatments -- not in lieu of them.

Be certain that your acupuncturist uses disposable needles as required by law.

To find a licensed practitioner in your area, visit the website of the American Association of Acupuncture and Oriental Medicine at http://www.aaaomonline.org.

Does Weather Affect Arthritis Pain?

Mon, 07 Jan 2008 06:00:00 CST

If you have arthritis, you may be among those people (and there are many) who feel that their arthritis pain is influenced by the weather -- specifically, that they experience more arthritis pain on cold, rainy days and less arthritis pain on warm, dry days. But research studies on whether climate really does affect arthritis pain have produced conflicting results.

What the Research on Arthritis Pain Shows
One study looked for a relationship between weather and arthritis pain in 151 people with osteoarthritis, rheumatoid arthritis, or fibromyalgia (a rheumatic disorder that causes joint pain) as well as 32 people without arthritis. All participants lived in Cordoba City, Argentina, which has a warm climate. Participants kept a journal for one year recording the presence and features of any pain, and these daily reports were matched with weather conditions such as temperature, barometric pressure, and relative humidity.

Patients in all three groups experienced more pain on days when the temperature was low, while people in the control group were unaffected by any of the weather conditions. In addition, patients with rheumatoid arthritis were affected by high humidity and high pressure; osteoarthritis patients by high humidity; and those with fibromyalgia by high pressure. However, the associations were not strong enough to allow pain to predict weather, or vice versa.

Another study looked at 154 people (average age 72) who lived in Florida and had osteoarthritis of the neck, hand, shoulder, knee, or foot. Participants reported their arthritis pain scores for up to two years, then researchers matched the scores with the daily temperature, barometric pressure, and precipitation status. No significant associations were found between any of the weather conditions and osteoarthritis pain at any site, except for a slight association between rising barometric pressure and hand pain in women.

A Mild Case for Warmer Weather
Although some evidence exists that people living in warmer, drier climates experience fewer episodes of arthritis pain, climate does not affect the course of the disease. At most, it may affect symptoms of arthritis pain.

One theory holds that a drop in air pressure (which often accompanies cold, rainy weather) allows tissues in the body to expand to fill the space, meaning that already inflamed tissue can swell even more and cause increased arthritis pain. Other possibilities: Pain thresholds drop in colder weather; cold, rainy days affect mood; and during colder weather people are less likely to be outside and get the exercise that normally helps keep arthritis pain in check.

So does this possible link between cold, rainy weather and arthritis pain mean that people with arthritis should you should move to a dry, warm climate like Arizona? Not necessarily, especially if it means leaving your family, friends, doctors, and support system behind. If you are thinking of moving, first spend a considerable amount of time in your new location to see if the weather affects your arthritis pain symptoms.

But bear in mind that no environment is arthritis-proof: Even though the people in these research studies live in warm climates, they still struggle with arthritis pain. Similarly, it’s possible to get relief from arthritis pain in any climate. For example, even if cold weather means you can’t spend time outdoors, you can still get valuable exercise in a gym or heated pool.>p>

Treating Symptoms of Fibromyalgia Without Medication

Mon, 17 Dec 2007 06:00:00 CST

In a recent issue of the Johns Hopkins Arthritis Bulletin, Dr. Kevin R. Fontaine, Assistant Professor of Medicine in the Division of Rheumatology at Johns Hopkins University, talked about non-pharmacological treatments for fibromyalgia. Here’s an excerpt.

Although fibromyalgia syndrome is not curable and has no blood tests to detect it, there are a variety of non-pharmacological treatments that can help relieve symptoms. Following are several questions I am frequently asked about complementary fibromyalgia treatments, and my answers.

Q. How important is it for a person with fibromyalgia to take a majority stake in their improvement?

A. People with fibromyalgia have to understand that, in most cases, they're not going to be able to take a pill that’s going to give them tremendous relief. Rather, it’s up to them to stretch, to exercise, to walk, to try to reduce stress in their lives, to seek counsel for anything that’s going to relieve stress or family issues. A willingness to be proactive and to learn ways to take better control over their symptoms is a critical factor in managing fibromyalgia.

Q. How is fibromyalgia treated?

A. Despite the lack of a definitive cause, fibromyalgia symptoms can be significantly improved with a multifaceted approach. There are two major goals:

Lessen pain and fatigue

Improve sleep

Much of the success of fibromyalgia treatment lies with the patient, and many people report feeling better simply because a diagnosis has been made. It is reassuring for people to know that the disorder is not deforming or life threatening, and that they will be able to take steps to help better control their symptoms.

Q. What role does physical activity play in fibromyalgia treatment?

A. Getting up and moving is the key to improving fibromyalgia. A lack of physical activity worsens fibromyalgia symptoms because unconditioned muscles are more sensitive to pain. Although activity and exercise may be the last thing people with fibromyalgia want to do when they feel achy and tired, studies have shown that fibromyalgia symptoms improve after six to eight weeks of moderate aerobic exercise. It’s thought that aerobic activities such as walking, swimming, and bicycling raise the pain threshold and increase pain tolerance, along with physical stamina.

At Johns Hopkins, we encourage our fibromyalgia patients to explore different ways to become active and find what works best for them. It is important not to overdo activity, however. Start slowly, with perhaps 5 to 10 minutes of brisk walking a day, for example. As you begin to feel better, gradually increase the time of the exercise session until you are up to 30 to 40 minutes of aerobic activity at least three times a week. People whose pain is exacerbated by the jarring movements of weight-bearing exercise (such as walking or jogging) may try swimming or riding a stationary bicycle instead.

Heat, Humidity, and Gout

Mon, 05 Nov 2007 06:00:00 CST

Recent research shows that adequate hydration is an important way to prevent dehydration and the onset of a gout attack.

Today, it’s estimated that 2 to 5 million Americans have gout, with most male victims suffering a first attack between 40 and 50 years of age. Women develop gout later, in the years following menopause.

Despite the longstanding belief, for most people, dietary indulgence is only one of several causes of gout. As with many diseases, one of the main problems is the underlying genetic condition that predisposes certain people to experience the accumulation of too much uric acid (hyperuricemia). Diet, however, does exert an influence for those predisposed to gout.

Researchers now believe that climatic factors such as heat and humidity that lead to dehydration can signal a future attack for gout sufferers.

Depleting the body of fluids through perspiration has long been considered a potential trigger for recurrent gout attacks. To test the suspected effects of humidity and temperature on the chances of recurrent gout attacks, researchers recruited 197 individuals who had experienced a gout attack within the past year. Participants were asked to log onto a study Web site when they experienced a gout attack and complete a questionnaire on the risk factors they had experienced the two days prior (known as the hazard period). They also were asked to complete the same questionnaire on experiences over a two-day control period.

Climatic data on temperature, barometric pressure, humidity, and precipitation for each participant’s ZIP code, obtained from the National Oceanic and Atmospheric Administration, was then compared between hazard period and control period. Adjustments were made for alcohol consumption, purine intake, and diuretic use. Study results indicated that:

High temperature and high humidity were strongly associated with increased risk of a recurrent gout attack.

Risk of recurrent gout attacks increased almost two-fold when the maximum daily temperature increased from 0–53° F to 87–105 ° F. A similar magnitude of increased risk also was found when the humidity increased from a dew point of 4–32°F to 64–77°F.

Barometric pressure and precipitation appeared to have no influence.

"Our data indicate that both high temperature and high humidity are associated with an increased risk of recurrent gout attacks,” explains Yuquing Zhang, D.Sc., Professor of Medicine and Epidemiology at Boston University School of Medicine in Boston and an investigator in the study. "Thus, when it’s hot and humid, those with gout should consider drinking more fluids to avoid potentially painful gout attacks.”

Rheumatoid Arthritis and Your Heart

Mon, 28 Jan 2008 06:00:00 CST

Johns Hopkins Health Alerts Arthritis Rheumatoid Arthritis and Your Heart

The inflammation that damages joints also takes a toll on the heart. Johns Hopkins doctors offer bottom line advice.

People with rheumatoid arthritis understandably focus on caring for their joints. But their most serious health risk involves their heart. Compared to the general population, rheumatoid arthritis patients have a significantly increased risk of heart attack and stroke and a shorter life expectancy. Here are some of the findings from recent studies:

Heart attacks are twice as common among women with rheumatoid arthritis as among those without the disease.

Atherosclerosis ("hardening of the arteries”) starts early and progresses more rapidly in people with rheumatoid arthritis.

Carotid artery blockages (a risk factor for stroke) are three times more common in people with rheumatoid arthritis than in people without the disease (44% vs. 15%).

Cardiovascular events, such as heart attack and stroke, occur about 10 years earlier in people with rheumatoid arthritis.

Mortality is higher among rheumatoid arthritis patients after a first heart attack.

Blood vessel damage is often already apparent at the time of rheumatoid arthritis diagnosis.

Heart attacks in rheumatoid arthritis patients are more likely to be silent or to occur without the typical symptoms, and they more often result in sudden cardiac death.

Congestive heart failure (weakening of the heart’s pumping ability) is more common among people with rheumatoid arthritis.

Researchers have identified several links between rheumatoid arthritis and cardiovascular disease. Inflammation is believed to be the most important of these. Cardiologists now understand that inflammation plays a crucial role in the onset of atherosclerosis. They believe that an injury to the inner lining of the arteries (the endothelium) triggers an immune response, sending immune system cells rushing to repair the damage.

But in chronic inflammatory states such as rheumatoid arthritis, the immune response doesn’t shut off after the injury heals. The accumulating immune system cells attract deposits of cholesterol, blood platelets, cellular debris, and calcium, which clump together to form plaque. As plaque deposits grow, they restrict blood flow through the artery. If the plaque ruptures, clots can break away and travel to the heart or brain, where they may cause a heart attack or a stroke.

Bottom line advice: What Can You Do? The relationship between rheumatoid arthritis and the heart is complex, and rheumatologists still have a great deal to learn about how to reduce the risk of cardiovascular disease among people who have rheumatoid arthritis. For now, it’s important to do everything possible to reduce the traditional risk factors for heart disease and stroke: smoking, obesity, a sedentary lifestyle, high blood pressure, high cholesterol, and diabetes.

Getting regular exercise and losing extra pounds (even a 5–10% weight reduction is beneficial) will help your joints as well as your heart. Monitor your blood pressure and have your cholesterol levels checked regularly. Also, ask your physician about the possibility of taking a low-dose aspirin each day to reduce your risk of cardiovascular disease. In addition, the cholesterol-lowering medications known as statins—atorvastatin (Lipitor) and others—not only help the heart, but also have modest beneficial effects on rheumatoid arthritis -related inflammation. If your doctor hasn’t already suggested one of these, you might ask about it.

Johns Hopkins Health Alerts Arthritis Rheumatoid Arthritis and Your Heart

Music Can Ease Your Pain

Mon, 15 Oct 2007 06:00:00 CDT

Johns Hopkins Health Alerts |

Arthritis | Music Can Ease Your Pain

Many people with arthritis rely on complementary medicine, products, and techniques -- in combination with conventional treatments -- to reduce pain. Now a new study shows that listening to soothing music really helps.

If you suffer with osteoarthritis you probably know that there are many effective medications available to relieve your pain. Oral medications are used most often, but some people find that injections into the affected joint or topical products applied to the skin surrounding a painful joint also help reduce pain. However, although pain relievers make you feel better, they can’t cure your osteoarthritis. Researchers have not yet identified any medications that can reverse or prevent worsening of the condition.

But did you know that music can help to ease your pain, too? New research documents the common sense idea that listening to music for an hour every day can reduce pain, depression, and other symptoms associated with chronic pain. In the study, the researchers assigned 60 people with chronic pain to one of three groups: music of their own choosing, music chosen by the researchers for its relaxing quality, or no intervention (the control group).

The study included people with long-term pain from osteoarthritis, rheumatoid arthritis, or back problems. Their chronic symptoms were rated at the outset by standard rating scales for pain, depression, disability, and feelings of power over their pain. Compared with the control group, the two music groups showed significant improvements in these measures (whether or not they had chosen the music). People in the two music groups reported between 12% and 21% less pain, as measured on two pain scales. The control group reported an increase in pain of 1–2%.

Assessment of the music groups also showed about 25% less depression, up to 18% less disability, and about 8% more sense of power over their pain than the control group. This study was reported in the Journal of Advanced Nursing (Volume 54, page 553).

Johns Hopkins Health Alerts |

Arthritis | Music Can Ease Your Pain

Delay Knee Replacement with Osteotomy

Mon, 24 Sep 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Arthritis | Delay Knee Replacement with Osteotomy

Improved alignment of the knee through osteotomy takes stress off damaged areas and can delay the need for joint replacement by about 10 years for people with osteoarthritis of the knee.

Osteoarthritis often damages the cartilage more on one side of the knee than on the other. When that happens, the leg bones become misaligned, which can put even more stress on the already damaged joint.

Osteotomy is a "bone-cutting” surgical procedure that shifts the individual’s body weight from the damaged area of the knee toward the healthy side. This relieves pain and allows the knee to function more normally -- and that can buy time for a person who would like to delay total knee replacement surgery.

In an osteotomy for knee osteoarthritis, the surgeon removes a wedge of bone from the healthy shinbone (tibia). If the cartilage damage is on the inner side of the knee, bone is removed from the outer part of the shinbone; for damage to the outer side of the knee, bone is removed from the inner shinbone. The bone is taken from an area below the healthy cartilage. This allows the knee joint to open more freely and redistributes the weight across the joint.

Performed under general or regional anesthesia, osteotomy takes about 60–90 minutes to complete. The surgeon makes a 4- to 5-inch incision from just below the kneecap to below the top of the shinbone, and uses guide wires anchored into the top of the shinbone to outline the triangular area to be cut. The wedge is removed with an oscillating saw, and the top of the shinbone is lowered to reposition the joint. The realigned joint is held in place with staples or internal plates, or it may be immobilized with a cast.

Rehabilitation begins almost immediately after surgery with passive-motion exercises to flex and stretch the knee and restore adequate range of motion. You will be fitted with a knee brace (unless your leg is put in a cast) and will be on crutches for at least six weeks.

Physical therapy usually begins at about six to eight weeks, after the bone has had a chance to heal. The therapist will teach you stretching exercises at first and then strengthening and light aerobic activities.

Is Osteotomy Right for You? Osteotomy may be a good option for people under age 60 who want to delay a total knee replacement. Delaying knee replacement makes sense, because artificial knees wear out over time, often necessitating a second replacement surgery. Osteotomy can delay the need for joint replacement by about 10 years. The procedure is appropriate only when damage to the joint is uneven and no significant inflammation is involved.

Johns Hopkins Health Alerts | Arthritis | Delay Knee Replacement with Osteotomy

Meditation Benefits Body and Mind

Mon, 03 Sep 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Arthritis | Meditation Benefits Body and Mind

Many arthritis sufferers are trying non-traditional complementary remedies, such as meditation, to help reduce pain and discomfort.

Arthritis pain and disability have both a physical and a psychological component. People who cope best with their disease have found ways to address all of the factors that influence their pain. Pain relievers and anti-inflammatory drugs remain the mainstay of medical treatment for most moderate to severe arthritis. But adding yoga and meditation can bring a new dimension to pain relief and may even reduce the amount of medication you need.

The basics of meditation are often taught along with yoga, or you can find separate classes at colleges, community centers, or as part of mental health or cardiac rehabilitation programs.

The Transcendental Meditation approach gained prominence in the 1960s. This is the practice of focusing attention on an object, a word, or your own breathing, as a way of suspending the stream of thoughts that normally occupy your mind.

Meditation or quieting the mind in this way for 20 - 30 minutes a day has positive effects on the body. These include reducing your heart rate, respiration rate, and blood pressure and bringing about a reduction in the damaging "fight-or-flight” response that can be triggered by physical or emotional stress.

Meditation allows you to achieve a state of profound calm commonly referred to as the relaxation response. Meditation has been shown to alter physical and emotional responses to stress and may reduce the psychological distress that often accompanies chronic illness. Results of various studies suggest that the regular practice of meditation can reduce arthritis pain as well as relieve anxiety, stress, and depression.

In a study reported in 2005 at an American College of Rheumatology meeting, rheumatoid arthritis patients were assigned to one of two groups. Half of the group took a class on Mindfulness- Based Stress Reduction (MBSR), a program that includes meditation, yoga, and other relaxation exercises. The rest of the group had no intervention.

After six months, patients who practiced MBSR experienced a 33% reduction in psychological distress, an 11% decrease in standard measures of disease activity such as the number of painful or swollen joints, and a 46% decrease in erythrocyte sedimentation rate (indicating a reduction in inflammation).

For more Alerts and Special Reports, please visit the Arthritis Topic page.

Johns Hopkins Health Alerts | Arthritis | Meditation Benefits Body and Mind

Going to Hip School

Mon, 23 Jul 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Arthritis | Going to Hip School

If you have hip or joint pain, a hip rehabilitation program can help reduce the pain and improve your quality of life.

The term “hip school” is popular in Great Britain and Europe. It refers to a formalized program of hip care that is usually conducted in groups. Some hip schools aim to help people to improve hip function so they can avoid hip replacement surgery. Other hip school programs prepare people for hip surgery or help them with post-surgery rehabilitation.

No matter what they are called, hip rehabilitation programs can help people achieve significant reductions in hip pain and disability. In a study reported in the journal Arthritis and Rheumatism, people with hip problems who attended a six-month hip school led by physical therapists had less pain, fewer limitations in their activities, and better health-related quality of life. They also had fewer sleep disturbances and greater physical mobility. These benefits lasted for at least six months after completion of the program.

If you have significant hip pain and disability, a hip rehabilitation program could help. Ask your doctor, who may give you a recommendation or referral. Local hospitals, orthopedic centers, and physical therapy groups also offer such programs.

If your hips are generally healthy but you are at risk for developing hip problems, a general program of hip-strengthening exercises is a good idea. Besides rheumatoid arthritis and osteoarthritis, risk factors for hip pain and disability include osteoporosis, previous hip injury, excess weight, and sitting for long periods each day.

If you already have mild hip discomfort, exercising in water is ideal. This doesn’t put extra stress on your joints and makes it easier to move your hip through its range of motion. Exercising against the resistance of water builds muscle strength and provides some aerobic conditioning. Many health clubs and community pools offer aquatic exercise classes. But be sure that the program is appropriate for people with arthritis. Your local chapter of The Arthritis Foundation may be able to direct you to programs geared specifically to arthritis.

Although water exercise is easiest on your joints, you also need to spend some time exercising on land. That’s because weight-bearing exercise improves balance, helps prevent osteoporosis, and is necessary to build and maintain strength in the muscles that support the hip (such as the quadriceps, gluteals, and hamstrings).

Walking is an ideal type of weight-bearing exercise. Try to walk on most days of the week. To improve and maintain flexibility, try some beginning yoga postures. Strength training also is important to build strong supporting muscles for your hips. Check with your physician first and get some instruction from a physical therapist or a personal trainer who is knowledgeable about arthritis.

For more Alerts and Special Reports, please visit the Arthritis Topic page.

Johns Hopkins Health Alerts | Arthritis | Going to Hip School

6 Tips to Prevent Bursitis

Thu, 05 Jul 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Arthritis | 6 Tips to Prevent Bursitis

Performing any movement repeatedly can irritate the bursa near the joint and cause bursitis.

Bursitis is caused by inflammation of one or more of the body's 150 small, fluid-filled sacs called bursae. Bursae cushion and lubricate areas where bones, muscles, and tendons move across one another. Like fibromyalgia, bursitis causes pain and stiffness in tissues around the joints, rather than in the joints themselves. People with arthritis are at risk of developing bursitis because of altered body alignment and movement. Improved body awareness and good mechanics will help prevent bursitis.

Bursitis is most common among people over age 40. This group is more likely to fit the profile of the "weekend warrior” -- a sedentary person who suddenly overexerts him or herself in an activity, often on the weekend or during vacation. Injury to the bursa is more likely if the muscles in the area are weak or tight. Too much tennis on Saturday or pushing yourself too hard when you first join a gym can set you up for bursitis if you aren’t properly conditioned. The solution is to ease into exercise, allow muscles and tendons to adapt gradually to the added stress, and warm up and cool down each time you engage in an activity.

Over time, people with arthritis may develop poor posture as they shift their body or alter their movements in an attempt to protect painful joints. A physical therapist can help you achieve better body alignment and restore normal body mechanics. In addition, following a personalized exercise program will strengthen muscles in vulnerable areas.

Here are some recommendations from the Arthritis Foundation on how to avoid bursitis:

Bursitis Tip 1 -- To protect your shoulders, take periodic breaks from activities such as vacuuming. Do push-ups and range-of-motion exercises to maintain your strength and flexibility.

Bursitis Tip 2 -- To protect your elbows, don’t clench your fists or grip tools or pens too tightly; use a forearm band (tennis elbow strap) while playing tennis (though true tennis elbow is actually a tendon problem).

Bursitis Tip 3 -- To protect your wrists and hands, purchase tools, utensils, pencils, and pens with large or foam-covered handles so you won’t have to grip so tightly.

Bursitis Tip 4 -- To protect your knees, do thigh strengthening exercises (straight-leg raises) to provide added support for your knees; when you have to sit for long periods, get up and walk around every 20–30 minutes; use kneepads for kneeling activities.

Bursitis Tip 5 -- To protect your hips, sit on cushioned chairs, get a shoe lift if your legs are different lengths, and bend your knees, not your back or hips, when picking up objects.

Bursitis Tip 6 -- To protect your ankles and feet, wear comfortable walking and jogging shoes that fit properly and provide good support; wear heel cups or shoe inserts if your doctor recommends them.

For more Alerts and Special Reports, please visit the Arthritis Topic page.

Johns Hopkins Health Alerts | Arthritis | 6 Tips to Prevent Bursitis

Hip Resurfacing -- A New Tool for Osteoarthritis

Mon, 21 May 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Arthritis | Hip Resurfacing -- A New Tool for Osteoarthritis

In a recent issue of The Johns Hopkins Arthritis Bulletin, Joan M. Bathon, M.D., director of the Johns Hopkins Arthritis Center, talked about the promise of hip resurfacing for patients suffering with the pain and disability of arthritis. Because many of our Arthritis Health Alerts subscribers have asked us about this still-experimental procedure, we include an excerpt of Dr. Bathon’s article for your information.

For those of you who don’t know about hip resurfacing, here’s how it differs from total hip replacement: Instead of removing the top of the thighbone and placing a metal stem into the femur to anchor a replacement for the femoral head, the surgeon sands down ("resurfaces”) the hip’s roughened and damaged ball-and-socket, inserts a metal cup into the hip socket, and then places a metal cap on top of a small stem that is inserted into the thighbone.

Since the implant closely matches the size of a patient’s natural femoral head, and is substantially larger than the femoral head of a traditional artificial hip, the patient may attain greater flexibility and range of motion with greater stability and less likelihood of dislocation (the ball slipping out of the cup) in the months and years following surgery.

Hip resurfacing allows the surgeon to preserve more of the patient’s natural bone structure and stability than is possible with minimally invasive hip replacement. With the femoral head and neck preserved, as well as bone from the femur, it is still possible to have a total hip replacement or some other newer technology or procedure in the future, if necessary.

At the third annual Medical Innovation Summit held at The Cleveland Clinic Foundation last year, Sir Christopher O’Donnell, the CEO of Smith & Nephew, the English medical device company that makes the Birmingham Hip Resurfacing system, was asked why hip resurfacing was so popular in Europe but had failed to be adopted in the U.S. as a viable option for people with hip arthritis.

"There were three problems when hip resurfacing was initially tried in the U.S. in the 1970s,” admitted Sir Christopher. (Hip resurfacing was tested in the U.S. three decades ago, but the outcomes were very poor.) "The initial designs were not as well developed as they are today, nor was the surgical technique. In some hospitals, the method of entering the implant wasn’t well developed and the patient selection wasn’t as strict as it should have been.” Sir Christopher noted that the ideal candidate for hip resurfacing would be under age 60, because the procedure requires that the patient’s bones still be strong.

The FDA has recently approved the Birmingham Hip Resurfacing system. It remains to be seen, though, how hip resurfacing will compare with total hip arthroplasty, which is the standard approach in the United States, and how rapidly U.S. surgeons will adopt the procedure.

"Long term results are not available for hip resurfacing procedures,” said Simon Mears, M.D., when contacted by The Johns Hopkins Arthritis Bulletin. Dr. Mears, an assistant professor of orthopedic surgery at Johns Hopkins and chief of total joint arthroplasty and trauma at the Johns Hopkins Bayview Medical Center, believes that hip resurfacing does present a risk of fracture of the femoral neck. Current reported results have shown higher failure rates for hip resurfacing than for contemporary total hip arthroplasty.

For more Alerts and Special Reports, please visit the Arthritis Topic page.

Johns Hopkins Health Alerts | Arthritis | Hip Resurfacing -- A New Tool for Osteoarthritis

The Good News on Osteoarthritis and Weight Loss

Mon, 19 Mar 2007 15:08:50 CST

Johns Hopkins Health Alerts | Arthritis | Osteoarthritis and Weight Loss

If you’re overweight and have osteoarthritis, you may wonder: How much weight do I have to lose before I see any benefits? Here’s the answer and it’s encouraging.

At Johns Hopkins we recently completed a five-year study that demonstrates that even small amounts of weight loss can result in significant improvements in osteoarthritis symptoms and functioning. We placed about 40 overweight and obese adults (average age 58) with knee osteoarthritis on a four-month program of lifestyle change. At the beginning of the study, participants with osteoarthritis experienced pain in one or both knees more than 50 percent of the time, causing difficulty in daily activities such as driving, climbing stairs, and getting in and out of bed.

The lifestyle changes we recommended for these osteoarthritis patients included moderate adjustments in both diet and daily exercise. The dietary changes emphasized principles of healthy eating (plenty of whole grains, fruits and vegetables) while limiting amounts of high calorie or nutritionally empty foods. The women were asked to eat between 1,400 to 1,600 calories a day; men were asked to stay within a range of 1,600 to 1,800 calories.

We also asked the study participants with osteoarthritis to gradually increase the number of steps they walked each day. They started at around 3,500 steps a day and gradually built up over the course of four months to around 10,000 steps a day, which was accumulated over the course of the day (10,000 steps is the equivalent of four to five miles, depending on stride length).

We were looking for a modest amount of weight loss. The average person with osteoarthritis in the program lost only about 15 pounds. However, with this modest weight loss, we saw significant improvements, both in the amount of osteoarthritis pain our subjects experienced and in their ability to function. Their reductions in pain averaged 41%; their improvements in functioning averaged over 50%. Again, that was from a weight loss of only 15 pounds. That degree of improvement exceeds the benefit we typically see in people who use even the strongest prescription anti-inflammatory medications.

We consider that degree of benefit from a relatively minor weight loss to be very encouraging news. Some of these people with osteoarthritis may still be heavy enough to be defined as obese, and yet they experienced impressive benefits. The anecdotal evidence from the trial was also very impressive. A number of osteoarthritis patients in the study were people who love to garden, but they’d essentially stopped gardening because it was just too painful and too difficult. After the weight loss, these osteoarthritis patients resumed gardening and they were thrilled. Did that mean they never had pain? No, it didn’t. After a day of gardening, they did experience some pain. However, their baseline level of pain was much lower, and they seemed much more able to tolerate the pain that they had in the past. I think, in part, this is because they felt so much better. They were recovering some of their zest for life.

Johns Hopkins Health Alerts | Arthritis | Osteoarthritis and Weight Loss

The Approaching Storm in American Health Care

Mon, 09 Apr 2007 06:00:00 CDT

Johns Hopkins Health Alerts Arthritis Arthritis, Aging and Obesity

Susan Bartlett, Ph.D., Associate Professor of Medicine, Division of Rheumatology, Johns Hopkins University, explains how arthritis, aging, and obesity are combining to create a “perfect” storm for American Health Care.

If you read Sebastian Junger’s Perfect Storm or saw the Hollywood adaptation, you will probably recall the scene in which a weatherman stares in horror at the radar charts on his computer screen. He watches as three massive weather systems converge toward a point at which they will all collide with unprecedented force. The perfect storm is gathering.

Today, another sort of perfect storm -- I call it this because three forces are gathering into one -- is gaining momentum in American health care. The three factors that are converging with potentially unprecedented impact are:

Arthritis. According to the Arthritis Foundation, in 1985 there were 35 million Americans with arthritis or chronic joint symptoms. By 1998, that number had increased to 43 million, and it jumped to 66 million in 2005. Nearly one in three adults now have arthritis. Women are particularly at risk for arthritis: Arthritis affects about twice as many women as men. Arthritis is now the leading cause of disability among older women in the United States and the second most common cause of disability among older men. The Arthritis Foundation estimates that the various forms of the disease cost the U.S. economy more than $86 billion annually.

Age. Nearly 77 million Americans were born between 1946 and 1964, the years of the postwar baby boom. And that massive bulge in the American population is just hitting prime time as far as arthritis is concerned. More than 32 million boomers are now over age 50; by 2011, the leading edge of the boomer population will be turning 65, at which point any medical issues they have will exert a major influence on the American health care system.

Obesity. A huge percentage of the boomer population is overweight or obese. Researchers from the Beth Israel Deaconess Medical Center and the Harvard School of Medicine compared the rates of obesity among baby boomers with the rates of obesity in the previous generation (those born between 1926 and 1945). Up to 32% of the boomers were obese by age 44, whereas in the previous generation fewer than 18% were obese at that age. In other words, boomers are spending more years of their lives obese, so the excess weight has a longer period during which to exert its destructive effects, which include the development of arthritis. It’s no secret that obesity has already reached epidemic proportions in the United States: Almost 65% of the U.S. population is currently overweight or obese.

When taken together, these numbers clearly indicate that arthritis will be one of the most important public health challenges we face in the next 20 years. However, there is reason for hope, not only for people who have arthritis, but also for people who struggle with their weight. Arthritis and obesity are indeed linked, but important progress is being made in research on both fronts, with reason to be hopeful about the future.

One thing in particular we have learned: The combined impact of aging, obesity, and arthritis is neither inevitable nor unbeatable. People with arthritis who manage to lose even modest amounts of weight can enjoy major reductions in pain, major increases in mobility, and the enhanced quality of life that results from these changes.

Johns Hopkins Health Alerts Arthritis Arthritis, Aging and Obesity

Arthritis and Exercise

Mon, 11 Jun 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Arthritis | Arthritis and Exercise

What’s the most dangerous type of exercise for a person with arthritis? Answer: None at all. And the surprising fact is that more than a third of adults with arthritis don’t exercise. If you’re one of them, you’ll want to read this helpful advice from Dr. Susan Bartlett.

Susan Bartlett, Ph.D., Assistant Professor of Medicine, Division of Rheumatology at Johns Hopkins University, lectures frequently about physical activity, weight issues, and arthritis. Dr. Bartlett provided an in-depth report on Arthritis and Exercise in the Fall 2006 issue of the Arthritis Bulletin. As Dr. Bartlett notes, the best thing exercise does is help reduce joint pain and the attendant joint stiffness, enhance flexibility and endurance, and build strong muscles around your joint.

While beginning an exercise program often seems like a major undertaking for many people with arthritis, you can do it if you start slowly and maintain consistency. Here’s some practical advice from Dr. Bartlett.

Q. How much should people with arthritis exercise?

A. Don’t be a weekend athlete: It just doesn’t work. Exercising only once a week is not productive. Fitness can be achieved and maintained if your exercise is regular, rhythmic, and continuous. Current public health guidelines recommend that all adults accumulate at least 30 minutes of moderate intensity physical activity most days of the week.

Anyone can find the time to exercise even on a busy day. Exercise periods of 30 minutes, six times a week, add up to a mere three hours out of the 168 hours in the week. You can, for example, ride your stationary exercise bike while watching the news on TV; go for a walk before breakfast or during lunch; walk or swim after work; or lift weights to your favorite music before dinner.

To be effective, then, exercise should be done on a regular basis. Often, however, you may find yourself away from home, or stuck at the office, and so start to feel guilty when you miss your regular bouts of physical activity. However, there is a delicate balance between a firm commitment to exercise and a rigid compulsion about keeping to a predetermined workout schedule. By developing a flexible, healthy attitude about your exercise program -- making it part of your life, not your entire life -- your enthusiasm for being physically active will always remain high. Remember, brisk walking is a safe and effective form of exercise that can be done almost anywhere.

Q. How can you fit physical activity into your busy schedule?

A. The average American watches four hours of TV daily! That suggests that finding time to exercise is a matter of establishing priorities. Let’s take a closer look at the time element and see how it actually breaks down for most people. Of the 168 hours in a week, you spend an average of 40 to 50 hours working and 50 or so sleeping. Simple math leave you with 68 “free” hours.

Make a commitment and set aside at least three of those free hours for physical activity during the week. Make becoming more physically active your number one priority and let those three hours be a gift to yourself each and every week. Personal workouts can be difficult to schedule, but they’re imperative. Scheduling exercise time into your week helps turn these “appointments” into a habit. Just like making your bed, brushing your teeth, and combing your hair in the morning, exercise can become a regular part of your day. Moreover, for many it becomes one of the more enjoyable times of time day.

If you or someone you love has arthritis, you’ll want the latest advice and research available. The Johns Hopkins Arthritis Bulletin is a unique source of arthritis information. Interested? Click here to find out more.

Johns Hopkins Health Alerts | Arthritis | Arthritis and Exercise

New Research on Hip and Knee Osteoarthritis

Tue, 19 Sep 2006 14:31:55 CDT

Johns Hopkins Health Alerts | Arthritis | New Research on Hip and Knee Osteoarthritis

Osteoarthritis Update #1: Statin Use Linked to Increased Risk of Developing Hip Osteoarthritis

Many older people who take statin drugs (such as atorvastatin [Lipitor]) to lower their cholesterol levels have osteoarthritis or are at risk for developing it. A recent study in the Journal of Rheumatology shows that elderly women who take statins may have a small increase in their risk of developing hip osteoarthritis (OA), but statin use does not worsen progression of existing hip osteoarthritis.

A total of 5,678 white women aged 65 years and older had x-rays of the pelvis taken at the start of the study (baseline) and again an average of eight years later. X-ray evidence of hip osteoarthritis was found in 745 women (936 hips) at baseline. X-rays in the remaining 4,933 women (9,318 hips) showed no hip osteoarthritis. Overall, 7% of participants took statins during the sixth and/or the eighth year of the study.

In the group who did not have evidence of hip osteoarthritis at baseline, statin users had almost twice the risk of developing severe osteoarthritis of the hip but only a small increase in the risk of less severe osteoarthritis, compared to similar women who didn't take statins. In contrast, statin users with evidence of hip osteoarthritis at baseline showed a moderately decreased risk of osteoarthritis progression. The study shows that in elderly white women who don't have osteoarthritis of the hip, statin use may increase the risk of developing it.

Osteoarthritis Update #2: Use of Prescribed Exercises Decreases Disability in Knee Osteoarthritis

A study reported in the journal Arthritis and Rheumatism shows that people with knee osteoarthritis who exercised for as long as 18 months had less disability and were able to walk much greater distances than people who dropped out of the program.

A group of 156 overweight and obese older adults (age 60 and older) with knee osteoarthritis were randomly assigned to an 18-month program of exercise for 60 minutes a day, three days a week, or the same exercise regimen plus weight loss. During the first six months, all patients were required to exercise at a supervised facility. At 7–18 months, they could continue at the facility or exercise at home, keeping daily exercise logs.

Researchers determined which participants had low, intermediate, or high exercise adherence. After six months, people with the highest adherence showed the greatest improvement in the distance they could walk in six minutes and on an index of osteoarthritis-related pain and disability. At the 18-month point, 69 people in the exercise-only group and 65 in the exercise plus diet group were still following the exercise program to some degree and maintained improvements in walking performance. The study shows that adherence to prescribed exercise regimens can produce significant improvements in physical function and disability in overweight and obese people with knee osteoarthritis.

Johns Hopkins Health Alerts | Arthritis | New Research on Hip and Knee Osteoarthritis

Could Your Pain and Stiffness Be Caused By Ankylosing Spondylitis?

Tue, 19 Dec 2006 06:00:00 CST

Johns Hopkins Health Alerts | Arthritis | Ankylosing Spondylitis

Ankylosing spondylitis can be hard to diagnose because early symptoms mimic other arthritic conditions.

Ankylosing spondylitis is a systemic rheumatic disease characterized by inflammation of the spine and the sacroiliac joints. These joints are located in the lower back where the sacrum (the bone directly above the tailbone of your back) meets the iliac bones (bones on either side of the upper buttocks). Inflammation in these areas (spondylitis) causes pain and stiffness in and around the spine. Eventually, this can lead to a complete fusion of the vertebrae, a process referred to as ankylosis, which in turn leads to loss of spinal mobility. In addition to harming the spine, ankylosing spondylitis can inflame and injure joints in other parts of the body. Ankylosing spondylitis can also damage organs such as the heart and kidneys.

Ankylosing spondylitis is believed to be genetically inherited. The majority of people with this condition (nearly 90%) are born with a gene known as HLA-B27. Not everyone with the HLA-B27 gene gets ankylosing spondylitis, however: 7% of the U.S. population have the HLA-B27 gene, but only 1% of the population actually has ankylosing spondylitis. Researchers believe other conditions, perhaps environmental, are necessary for ankylosing spondylitis to become expressed.

The symptoms of ankylosing spondylitis are caused by inflammation of the spine, joints, and other organs. Symptoms include pain and stiffness in the lower back and the rest of the spine, upper buttocks, and neck. The pain and stiffness usually progress gradually over a matter of months, although onset can be rapid and intense. The pain and stiffness of ankylosing spondylitis are often worse in the morning or after periods of inactivity. These symptoms are sometimes relieved by motion, applied heat, or a warm shower. Other areas of the body affected by inflammation include the kidneys, heart, lungs, and eyes.

In advanced stages, for example, ankylosing spondylitis can lead to deposits of a substance called amyloid in the kidneys, which can cause kidney failure. Dialysis is sometimes needed to clear the kidneys. Rarely, people with ankylosing spondylitis develop scarring of the heart’s electrical system, which causes an abnormally slow heart rate. This requires correction with implantation of a pacemaker.

Johns Hopkins Health Alerts | Arthritis | Ankylosing Spondylitis

Why Do Some People Get Rheumatoid Arthritis?

Fri, 05 Jan 2007 06:00:00 CST

Johns Hopkins Health Alerts | Arthritis | Causes of Rheumatoid Arthritis

Several factors may increase your risk of developing rheumatoid arthritis, but for now the true cause of rheumatoid arthritis remains a mystery.

Rheumatoid arthritis affects approximately 2.1 million Americans. Unlike osteoarthritis, which occurs equally in both sexes, more than three times as many women as men have rheumatoid arthritis. Osteoarthritis usually begins late in life; rheumatoid arthritis often begins between ages 30 and 50, though it can develop at any age.

The major distinguishing characteristic of rheumatoid arthritis is that it is a chronic, systemic (affecting the whole body), inflammatory autoimmune disease. What does this mean? In an autoimmune disease, something triggers the body to mount an immune system attack against itself, much the way the immune system normally attacks harmful bacteria and viruses. In rheumatoid arthritis, the primary target of this attack is the synovial membrane that lines joints in every part of the body.

The exact cause of rheumatoid arthritis is still unknown, but researchers have identified some factors that may increase your risk of developing the disease.

The Role of Genetics and Rheumatoid Arthritis
Rheumatoid arthritis can run in a family. But even if you have rheumatoid arthritis, your children’s risk of developing it is not greatly increased. Researchers have identified a specific genetic marker called HLA-DR4, which is found in more than two thirds of white men and women who have rheumatoid arthritis. However, about 20% of people without rheumatoid arthritis have the same genetic marker. So having the marker increases your risk of rheumatoid arthritis but does not mean that you’ll inevitably develop the disease.

The Role of Infection and Rheumatoid Arthritis.
Several types of arthritis occur as a result of infections. You’re probably familiar with Lyme disease, which is the result of a bite from an infected deer tick. The bacterium the tick transmits first causes a rash, fever, and neck stiffness. Weeks later, victims may develop severe joint inflammation (Lyme arthritis) that can last for months, or even for a lifetime. Some researchers think that in people who are genetically susceptible to rheumatoid arthritis, exposure to certain bacteria or viruses can trigger the abnormal immune response that causes the disease.

Environmental Factors and Rheumatoid Arthritis.
Several studies have found that heavy smokers are more likely to develop rheumatoid arthritis than nonsmokers. Other studies suggest that drinking coffee might also increase the risk of rheumatoid arthritis and that drinking tea might decrease the risk. However, a 2003 review of data from more than 80,000 women studied for nearly 20 years concluded that neither beverage affects rheumatoid arthritis risk.

Johns Hopkins Health Alerts | Arthritis | Causes of Rheumatoid Arthritis

Advance Planning for Hip or Knee Replacement Surgery Makes for Smoother Sailing

Thu, 19 Oct 2006 06:00:00 CDT

Johns Hopkins Health Alerts | Arthritis | Planning for Hip or Knee Replacement Surgery

Considering hip or knee replacement surgery? Here’s practical advice from Johns Hopkins doctors.

Because hip or knee replacement surgery is rarely an emergency, you have plenty of time to set your house in order before you go to the hospital. That includes arranging your home so that it will be rehab-friendly when you return home, taking care of important paperwork, and lining up neighbors and friends to help.

Hip or knee replacement surgery: Financial Concerns

The weeks before hip or knee replacement surgery are a good time to pay upcoming bills and review your health insurance coverage to avoid any unpleasant surprises later on. This includes inquiring about or verifying coverage issues such as:

Need for a second opinion on your hip or knee replacement surgery.
Hospital and health care providers’ status as “in-network” or “preferred.”
Deductibles for hospital services.
Limits on length of stay.
Coverage for hospital rehabilitation services.
After-care services for your hip or knee replacement surgery, such as physical or occupational therapy. (Ask whether the therapists must be from an approved list and how many visits or sessions are covered.)
Equipment such as wheelchairs, walkers, and crutches, and whether they must be obtained from approved vendors.
Home health care coverage, what type, and for how long.
Coverage of follow-up visits with your physician.

Hip or knee replacement surgery: Health Issues

Ask your doctor to explain the hip or knee replacement procedure, the type of device being implanted, and what you should expect in terms of rehabilitation (pain management, time on crutches or a walker, length of physical therapy, type of home assistance required, time off from work, restricted activities, and time until you can resume full activities). Your doctor or hospital may have printed material on the procedure, or you can request information from organizations such as The Arthritis Foundation.

Hip or knee replacement surgery: Home Improvements

Take a look at the rooms in your house to identify potential problem areas. To increase safety and convenience:

Remove throw rugs and small items from the floor. Tape down electrical cords. Rearrange furniture to create wide pathways to accommodate a walker or crutches.
Set up a bedroom downstairs.
Place kitchenware and other frequently used items within arm’s reach. Buy a long-handled grabbing device.
Consider installing handrails and grab bars in the bathroom and shower. A shower bench and elevated toilet seat are also helpful.
Place a sturdy high-backed chair with arms in the room where you will spend most of your time.
Set up a recovery center. Place a table and wastebasket near your chair. Include a phone, T.V. remote control, tissues, medications, water pitcher and glass, and reading material. Use a carpenter’s apron or shoulder bag to carry items around the house.
Make or buy frozen casseroles, soups, and other easy-to-prepare foods.

Above all, don’t hesitate to ask friends and neighbors for help with groceries, transportation, or other tasks. With your new hip or knee, you’ll be able to return the favor down the road.

Johns Hopkins Health Alerts | Arthritis | Planning for Hip or Knee Replacement Surgery

Q & A on Hip Replacement Surgery

Fri, 17 Nov 2006 06:00:00 CST

Johns Hopkins Health Alerts | Arthritis | Q & A on Hip Replacement Surgery

Considering hip replacement surgery, but not sure when the time is right? Frank Frassica, M.D., chairman of the department of orthopedic surgery at Johns Hopkins, offers advice.

Q. When should a damaged hip be replaced?

A. I have been an orthopedic surgeon for 20 years, and in my experience, the people who are least satisfied with hip replacement surgery are those who had the surgery too early. They were unsuitable hip replacement candidates because their pain and debilitation levels were too low to justify surgery. After the hip replacement, they still have some pain from the surgery, which leaves them not only uncomfortable and unhappy, but also angry.

I regularly tell people to delay arthroplasty of the hip for as long as possible. How long is long? People who can walk one to two miles, but can’t walk five miles, are not good candidates for hip replacement. If you can still walk one to two miles, meet the demands of your job, go to the mall, and buy groceries, then it is too early to have hip replacement.

On the other side of the coin, if you cannot walk one to two miles, can’t shop or enjoy activities with your spouse and children as you used to, if physical therapy sessions have not helped, and if you have so much pain that you need a narcotic, then it’s probably time to have your hip replaced. When you’re ready to admit that the pain and disability are disrupting your life, make an appointment to consult with an orthopedic surgeon.

Once the decision is made, you need to have realistic expectations. When physically active people tell me they want a hip replaced so they can go back to competitive tennis, or take up aggressive downhill skiing or jogging, I make it clear that there will be serious problems down the road. I can almost guarantee that if they try those activities with their new hips, the artificial joint will eventually loosen, wear out, or fracture.

Total hip replacement will provide complete or nearly complete pain relief to almost all patients. Moreover, those patients with stiff hips before hip replacement surgery should be able to return to nearly normal hip motion. However, there are still some unsolved problems in the total hip replacement procedure. For example, the materials we use for hip replacements don’t last forever, although depending on the patient’s age and activity level, a hip replacement can last for 15 to 20 years or even longer before it has to be revised (replaced).

Johns Hopkins Health Alerts | Arthritis | Q & A on Hip Replacement Surgery

The Benefits of Weight Loss for Osteoarthritis

Mon, 26 Feb 2007 06:00:00 CST

Johns Hopkins Health Alerts | Arthritis |

Benefits of Weight Loss for Osteoarthritis

Experts agree: weight loss should be a first choice therapy for knee osteoarthritis.

If you suffer from chronic pain due to knee osteoarthritis, a study in the journal Osteoarthritis and Cartilage offers hope. The study shows that for obese people who already have knee osteoarthritis, a rapid loss of 10% of their weight can quickly and dramatically improve their physical function.

Eighty people with knee osteoarthritis (average age 62) who were overweight or obese (body mass index 28–35 or more) participated in an eight-week dietary weight loss program. Half of the participants had six meals a day of nutrition powder dissolved in water that met all requirements for daily intake of protein, fat, and fiber. The other participants (control group) followed an eight-week regular, high-energy, high-protein diet of regular food. Both groups received nutrition recommendations from the same dietitian, and the low-energy diet group attended motivational sessions with the dietitian each week.

People in the low-energy diet group lost an average of 11% of their body weight and 2% of their body fat vs. a 4% weight loss in the control group. For people in both groups, a weight loss of 10% produced an average 28% decrease in functional disability related to knee osteoarthritis.

The study shows that a brief eight-week diet program can produce a 10% weight loss that significantly improves physical function in overweight and obese patients with knee osteoarthritis. The authors suggest that weight loss should be a first choice therapy for knee osteoarthritis.

This finding is confirmed by a study from The Arthritis, Diet, and Activity Promotion Trial (ADAPT), which focused on osteoarthritis patients over age 60 who were overweight. It also found that a combination of “modest” weight loss plus moderate exercise provided the greatest improvement in knee pain and mobility.

Other research has shown that people who have osteoarthritis in one knee can reduce the chance of it occurring in the other knee if they lose weight. So if you haven’t been successful in your weight-loss efforts, consult a nutritionist for help in changing your eating habits.

Johns Hopkins Health Alerts | Arthritis |

Benefits of Weight Loss for Osteoarthritis