Arthritis therapy: You decide

Your preferences play a key role in choosing the best treatments

Take an X-ray of the hips or knees of most people over age 50 and you'll probably see signs of arthritis. But some people with severe damage can be as frisky as those decades younger, while others with only modestly damaged joints call the pain and disability unbearable.

"Arthritis affects everyone differently," says Peter Juni, M.D., an expert on the condition at the University of Berne in Switzerland. "How you experience it depends on not just the joint damage but your emotional health, weight, pain tolerance, activities, and willingness to participate in your own care, among other things," he says.

Research suggests that some doctors may downplay joint pain that's not confirmed by X-rays, while others may recommend invasive procedures if they see severe joint damage. But since arthritis pain and disability are so subjective, only you can decide how aggressively to treat it.

Your preferences and responses to treatment count strongly for other reasons as well. For one thing, no treatment stands out as clearly superior overall. And people respond very differently to the various options, especially alternative ones, depending partly on whether they expect the treatments to work and are willing to follow the necessary steps.

Moreover, all arthritis medications pose health risks, especially to the gut, heart, liver, and kidneys. So you need to choose drugs based on your vulnerability to those risks vs. your need for relief. Similarly, deciding to delay surgery for joint replacement until you can't bear the pain or to have it sooner, as some experts now recommend, depends on whether you'd rather put up with the arthritis or the operation and the often substantial postoperative pain and physical therapy.

"Effective arthritis care usually means mixing and matching from the various options until you find the combination that works best for you," Juni says. Our report will help you do just that.

First steps: Limit the damage

Injuries and the wear and tear of repeated movements can erode the cartilage between the joints, causing the adjoining bones to rub together. That's osteoarthritis. (Rheumatoid arthritis, a far less common but more serious disorder, stems from a misguided immune reaction, and treatment requires careful supervision by a rheumatologist.)

Effective osteoarthritis treatment starts by addressing the many factors that help determine whether the joint damage translates into significant pain and disability. For example, try to lose any excess weight, since it increases stress on damaged joints. If you feel hopeless or distressed about your arthritis, consider seeing a cognitive-behavioral therapist, since negative thoughts and behaviors involving the disease can needlessly limit your activity and intensify the pain. Relaxation techniques, including meditation, biofeedback, or even listening to calming music, may also help.

In addition, the following steps can help ease the strain from routine tasks like walking, sitting, and sleeping:

• Wear low-heeled shoes that provide firm support, or, if practical, go barefoot.
• Avoid sitting in low or armless chairs, since getting up from them can be difficult, and don't carry heavy objects for long distances.
• Keep warm; cold can stiffen the joints.
• Don't sit or stand in one position for extended periods.
• Try not to lie on your affected hip while sleeping. Whichever side you lie on, place a pillow between your legs to keep your hips aligned. For knee pain, lay a pillow lengthwise under your leg, centered beneath the joint, to elevate it.
• When possible, avoid walking up or down hills or stairs or on uneven surfaces.
• Talk with your doctor about using a knee brace or, for either hip or knee pain, special shoe insoles.

While people with arthritis should limit the stress on their joints, regular activity is crucial. These guidelines can help ensure safe, effective exercise:

• Avoid high-impact activities, such as running, or vigorous, twist-and-turn sports, such as singles tennis.
• Do at least some weight-bearing exercise, which eases pain and improves function, possibly by squeezing fluid into the spongy cartilage. Any relatively gentle activity-walking, tai-chi, biking, even ballroom dancing-will do. Moderate activities like doubles tennis or step aerobics are probably OK if they don't cause significant pain.
• Try swimming or water aerobics if you have severe arthritis that doesn't let your joints bear much weight.
• Ask your doctor for a referral to a physical therapist to learn exercises that strengthen the muscles supporting the damaged joints.
• Stretch regularly to keep muscles loose.
• Consider using trekking poles while hiking for extra support.
• Try applying heat before exercise and cold afterward-or the reverse-to see if that helps.
• Check whether a local health club or gym offers special classes for people with arthritis.

Alternative therapies

Research has identified several alternative treatments that may help at least some people with arthritis and are almost certainly safe for most. Other evidence suggests that people get more relief from alternative therapies that they trust. If you want to try nontraditional methods, here are the main options:

• Acupuncture. A recent review of clinical trials that pitted real acupuncture against sham treatment concluded that the therapy relieved knee arthritis at least somewhat for up to a year.
• Capsaicin. Over-the-counter creams or gels that contain capsaicin (Zostrix and generic), derived from the pepper plant, seem to provide some relief, though they may work better for the hand, wrist, or knee than the hip, where the joint is farther below the skin.
• Glucosamine and chondroitin. Scientific support for these nutritional supplements, which supposedly prevent cartilage from breaking down, has weakened considerably in the past two years. Still, a Consumer Reports survey published in 2005, which included some 2,000 people who tried the combination, found that it eased arthritis symptoms at least as effectively as over-the-counter drugs. If you decide to try the pills, keep a daily record of your symptoms and stop taking the supplements after three months if you see no improvement.
• Massage. Two-thirds of the 313 readers in our 2005 survey who tried deep-tissue massage for osteoarthritis said it helped at least somewhat, and 35 percent said it helped a lot-substantially higher numbers than for either over-the-counter drugs or supplements.

Drug benefits vs. risks

Two years ago Pfizer stopped advertising its pain reliever celecoxib (Celebrex) amid growing concerns that it increased the risk of heart attack and stroke. Now the company has resumed those ads, which suggest that the drug is as safe for the heart as other prescription pain drugs.

But expert guidelines and our medical consultants say there are over-the-counter and probably prescription pain relievers that pose less heart risk than celecoxib. They recommend that most people who have arthritis start with acetaminophen (Tylenol and generic), since it's generally the safest. If that's not adequate, they should then try an over-the-counter nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen (Advil and generic) or naproxen (Aleve and generic), and, if necessary, higher-dose prescription versions of those drugs because they're cheaper and, at least in naproxen's case, probably safer. But there are many exceptions, depending on how susceptible you are to side effects and whether the recommended drugs give adequate relief.

The guidelines also recommend taking those drugs in low doses for short periods to minimize the risks. But that approach doesn't relieve pain sufficiently in many cases. If you need higher doses or prolonged treatment, here's how to reduce the chance of adverse effects:

• Talk with your doctor about which drug is safest for you.
• Try the nondrug measures described above, which may help you decrease medication doses.
• Periodically reduce your dosage to see whether you can get by with less.
• See your doctor if you experience any gastrointestinal symptoms. If you take medication most days, get blood tests every few months for anemia (a sign of stomach bleeding) and liver or kidney problems. And control any coronary risk factors, especially hypertension, which can be worsened by NSAIDs.

Invasive treatments

Various injections or surgical procedures can often help if drugs and lifestyle changes don't. But they each have substantial drawbacks that you must balance against your need for relief.

• Injections. Shots of anti-inflammatory steroids and possibly the joint lubricant hyaluronic acid (Hyalgan, Orthovisc) seem to relieve knee-arthritis symptoms in most patients and may ease hip pain, too. But the benefits of the steroid shots dwindle after about a month, requiring further injections. Hyaluronic acid, which requires weekly injections, may provide longer relief, though the benefit is modest and the supporting evidence weak. Both therapies can cause infection or nerve damage in rare cases. And it's not clear whether repeatedly undergoing either of those treatments is safe and effective.
• Osteotomy. Removing a small wedge of bone can ease pain if the knee or hip arthritis stems from poor joint alignment. While simpler than joint replacement, osteotomy usually requires general anesthesia, a two- to four-day hospital stay, and several months of wearing a brace and doing physical therapy.
• Joint replacement. Doctors have traditionally recommended delaying joint replacement as long as possible to avoid a second operation if the first artificial joint wears out, typically after about 15 years. But recent improvements in implant design and materials have made that less of a concern. Other evidence, including results of a Consumer Reports survey published in 2006, which included about 1,000 people who had the operation, suggest that waiting until the damage is severe makes surgery harder and full recovery less likely. And early intervention may allow your surgeon to perform a slightly easier operation in which only part of the joint is replaced.

But even in the best cases, recovery is often long and painful, and requires extensive physical therapy. And some 5 to 15 percent of those in our survey, all of whom had total joint replacement, said they developed complications, including infection, muscle weakness or contraction, and unequal leg lengths. If you opt for joint replacement, look for a surgeon who performs at least 50 of the operations per year, and arrange for someone to care for you during the first week or two after surgery.

This article first appeared in the July 2007 issue of Consumer Reports on Health.