Osteoarthritis

Definition

Osteoarthritis causes cartilage — the hard, slippery tissue that covers the ends of bones where they form a joint — to break down. Rheumatoid arthritis is an autoimmune disorder that first targets the lining of joints (synovium).Arthritis is inflammation of one or more of your joints. The main symptoms of arthritis are joint pain and stiffness, which typically worsen with age. The most common types of arthritis are osteoarthritis and rheumatoid arthritis.

Uric acid crystals, infections or underlying disease, such as psoriasis or lupus, can cause other types of arthritis.

Treatments vary depending on the type of arthritis. The main goals of arthritis treatments are to reduce symptoms and improve quality of life.

Symptoms

PainThe most common signs and symptoms of arthritis involve the joints. Depending on the type of arthritis you have, your signs and symptoms may include:

• Stiffness
• Swelling
• Redness
• Decreased range of motion

Causes

OsteoarthritisThe two main types of arthritis — osteoarthritis and rheumatoid arthritis — damage joints in different ways.

The most common type of arthritis, osteoarthritis involves wear-and-tear damage to your joint's cartilage — the hard, slick coating on the ends of bones. Enough damage can result in bone grinding directly on bone, which causes pain and restricted movement. This wear and tear can occur over many years, or it can be hastened by a joint injury or infection.

Rheumatoid arthritis

In rheumatoid arthritis, the body's immune system attacks the lining of the joint capsule, a tough membrane that encloses all the joint parts. This lining, known as the synovial membrane, becomes inflamed and swollen. The disease process can eventually destroy cartilage and bone within the joint.

Risk factors

Family history. Some types of arthritis run in families, so you may be more likely to develop arthritis if your parents or siblings have the disorder. Your genes can make you more susceptible to environmental factors that may trigger arthritis.Risk factors for arthritis include:

• Age. The risk of many types of arthritis — including osteoarthritis, rheumatoid arthritis and gout — increases with age.
• Your sex. Women are more likely than are men to develop rheumatoid arthritis, while most of the people who have gout, another type of arthritis, are men.
• Previous joint injury. People who have injured a joint, perhaps while playing a sport, are more likely to eventually develop arthritis in that joint.
• Obesity. Carrying excess pounds puts stress on joints, particularly your knees, hips and spine. Obese people have a higher risk of developing arthritis.

Complications

Severe arthritis, particularly if it affects your hands or arms, can make it difficult for you to do daily tasks. Arthritis of weight-bearing joints can keep you from walking comfortably or sitting up straight. In some cases, joints may become twisted and deformed.

Preparing for your appointment

What you can doWhile you might first discuss your symptoms with your family doctor, he or she may refer you to a doctor who specializes in the treatment of joint problems (rheumatologist) for further evaluation.

Before your appointment, make a list that includes:

• Detailed descriptions of your symptoms
• Information about medical problems you've had in the past
• Information about the medical problems of your parents or siblings
• All the medications and dietary supplements you take
• Questions you want to ask the doctor

What to expect from your doctor

Your doctor may ask some of the following questions:

• When did your symptoms start?
• Does activity make the pain better or worse?
• What joints are painful?
• Do you have a family history of joint pain?

Tests and diagnosis

Laboratory testsDuring the physical exam, your doctor will check your joints for swelling, redness and warmth. He or she will also want to see how well you can move your joints. Depending on the type of arthritis suspected, your doctor may suggest some of the following tests.

The analysis of different types of body fluids can help pinpoint the type of arthritis you may have. Fluids commonly analyzed include blood, urine and joint fluid. To obtain a sample of your joint fluid, your doctor will cleanse and numb the area before inserting a needle in your joint space to withdraw some fluid (aspiration).

Imaging

These types of tests can detect problems within your joint that may be causing your symptoms. Examples include:

• X-rays. Using low levels of radiation to visualize bone, X-rays can show cartilage loss, bone damage and bone spurs. X-rays may not reveal early arthritic damage, but they are often used to track progression of the disease.
• Computerized tomography (CT). CT scanners take X-rays from many different angles and combine the information to create cross-sectional views of internal structures. CTs can visualize both bone and the surrounding soft tissues.
• Magnetic resonance imaging (MRI). Combining radio waves with a strong magnetic field, MRI can produce more-detailed cross-sectional images of soft tissues such as cartilage, tendons and ligaments.
• Ultrasound. This technology uses high-frequency sound waves to image soft tissues, cartilage and fluid-containing structures such as bursae. Ultrasound also is used to guide needle placement for joint aspirations and injections.

Arthroscopy

In some cases, your doctor may look for damage in your joint by inserting a small, flexible tube — called an arthroscope — through an incision near your joint. The arthroscope transmits images from inside the joint to a video screen.

Treatments and drugs

MedicationsArthritis treatment focuses on relieving symptoms and improving joint function. You may need to try several different treatments, or combinations of treatments, before you determine what works best for you.

The medications used to treat arthritis vary depending on the type of arthritis. Commonly used arthritis medications include:

• Analgesics. These types of medications help reduce pain, but have no effect on inflammation. Examples include acetaminophen (Tylenol, others), tramadol (Ultram, others) and narcotics containing oxycodone (Percocet, Oxycontin, others) or hydrocodone (Vicodin, Lortab, others).
• Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs reduce both pain and inflammation. Over-the-counter NSAIDs include ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve). Some types of NSAIDs are available only by prescription. Oral NSAIDs can cause stomach irritation, and some may increase your risk of heart attack or stroke. Some NSAIDs are also available as creams or gels, which can be rubbed on joints.
• Counterirritants. Some varieties of creams and ointments contain menthol or capsaicin, the ingredient that makes hot peppers spicy. Rubbing these preparations on the skin over your aching joint may interfere with the transmission of pain signals from the joint itself.
• Disease-modifying antirheumatic drugs (DMARDs). Often used to treat rheumatoid arthritis, DMARDs slow or stop your immune system from attacking your joints. Examples include methotrexate (Trexall) and hydroxychloroquine (Plaquenil).
• Biologics. Typically used in conjunction with DMARDs, biologic response modifiers are genetically engineered drugs that target various protein molecules that are involved in the immune response. Examples include etanercept (Enbrel) and infliximab (Remicade).
• Corticosteroids. This class of drug, which includes prednisone and cortisone, reduces inflammation and suppresses the immune system. Corticosteroids can be taken orally or be injected directly into the painful joint.

Therapy

Physical therapy can be helpful for some types of arthritis. Exercises can improve range of motion and strengthen the muscles surrounding joints. In some cases, splints or braces may be warranted.

Surgery

If conservative measures don't help, your doctor may suggest surgery, such as:

• Joint replacement. This procedure removes your damaged joint and replaces it with an artificial one. Joints most commonly replaced are hips and knees.
• Joint fusion. This procedure is more often used for smaller joints, such as those in the wrist, ankle and fingers. It removes the ends of the two bones in the joint and then locks those ends together until they heal into one rigid unit.

Lifestyle and home remedies

• Weight loss. If you're obese, losing weight will reduce the stress on your weight-bearing joints. This may increase your mobility and limit future joint injury.
• Exercise. Regular exercise can help keep your joints flexible. Swimming and water aerobics may be good choices because the buoyancy of the water reduces stress on weight-bearing joints.
• Heat and cold. Heating pads or ice packs may help relieve arthritis pain.
• Assistive devices. Using canes, walkers, raised toilet seats and other assistive devices can help protect your joints and improve your ability to perform daily tasks

Alternative medicine

Acupuncture. This therapy uses fine needles inserted at specific points on the skin to reduce many types of pain, including that caused by some types of arthritis.Many people use alternative remedies for arthritis, but there is little reliable evidence to support the use of many of these products. The most promising alternative remedies for arthritis include:

• Glucosamine. Although study results have been mixed, it now appears that glucosamine works no better than placebo. However, glucosamine and the placebo both relieved arthritis pain better than taking nothing, particularly in people who have moderate to severe pain.
• Transcutaneous electrical nerve stimulation (TENS). Using a small device that produces mild electrical pulses, TENS therapy stimulates nerves near the aching joint and may interfere with the transmission of pain signals to the brain.
• Yoga or tai chi. The slow, stretching movements associated with yoga and tai chi may help improve joint flexibility and range of motion in people with some types of arthritis.
• Massage. Light stroking and kneading of muscles may increase blood flow and warm affected joints, temporarily relieving pain. Make sure your massage therapist knows which joints are affected by arthritis.

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Osteoporosis

Osteoporosis is a condition that weakens bones, making them fragile and more likely to break.

It's a fairly common condition that affects around three million people in the UK. More than 300,000 people receive hospital treatment for fragility fractures (fractures that occur from standing height or less) every year as a result of osteoporosis.

Wrist fractures, hip fractures and fractures of the vertebrae (bones in the spine) are the most common type of breaks that affect people with osteoporosis. However, they can also occur in other bones, such as in the arm, ribs or pelvis.

There are usually no warnings you've developed osteoporosis and it's often only diagnosed when a bone is fractured after even minor falls.

Symptoms of osteoporosis 

Osteoporosis develops slowly over several years.

There are often no warning signs or symptoms until a minor fall or a sudden impact causes a bone fracture.

Healthy bones should be able to withstand a fall from standing height, so a bone that breaks in these circumstances is known as a fragility fracture.

The most common injuries in people with osteoporosis are:

• wrist fractures
• hip fractures 
• fractures of the spinal bones (vertebrae)

Sometimes a cough or sneeze can cause a rib fracture or the partial collapse of one of the bones of the spine.

In older people, a fractured bone can be serious and result in long-term disability. For example, a hip fracture may lead to long-term mobility problems.

Although a fracture is the first sign of osteoporosis, some older people develop the characteristic stooping (bent forward). It happens when the bones in the spine have fractured, making it difficult to support the weight of the body.

Is osteoporosis painful?

Osteoporosis isn't usually painful until it causes a fracture.

Although not always painful, spinal fractures are the most common cause of long-term (chronic) pain associated with osteoporosis.

What causes osteoporosis?

During childhood, bones grow and repair very quickly, but this process slows as you get older.

Bones stop growing in length between the ages of 16 and 18, but continue to increase in density until you're in your late 20s.

You gradually start to lose bone density from about 35 years of age. Women lose bone rapidly in the first few years after themenopause (when monthly periods stop and the ovaries stop producing an egg).

Losing bone is a normal part of the ageing process, but for some people it can lead to osteoporosis and an increased risk of fractures.

Other factors that increase your risk of developing osteoporosis include:

• inflammatory conditions, such as rheumatoid arthritis, Crohn's disease and chronic obstructive pulmonary disorder (COPD)
• conditions that affect the hormone-producing glands, such as an overactive thyroid gland (hyperthyroidism) or an overactive parathyroid gland (hyperparathyroidism)
• a family history of osteoporosis, particularly history of a hip fracture in a parent  
• long-term use of certain medications that affect bone strength or hormone levels, such as oral prednisolone
• malabsorption problems
• heavy drinking and smoking

Causes of osteoporosis 

Osteoporosis causes bones to become less dense and more fragile. Some people are more at risk than others.

Bones are at their thickest and strongest in your early adult life and their density increases until your late 20s. But you gradually start losing bone density from around the age of 35.

This happens to everyone, but some people develop osteoporosis and lose bone density much faster than normal. This means they are at greater risk of a fracture.

Risk groups

Osteoporosis can affect men and women. It's more common in older people, but it can also affect younger people.

Women

Women are more at risk of developing osteoporosis than men because the hormone changes that occur in the menopause directly affect bone density.

The female hormone oestrogen is essential for healthy bones. After themenopause (when monthly periods stop), oestrogen levels fall. This can lead to a rapid decrease in bone density.

Women are at even greater risk of developing osteoporosis if they have:

• an early menopause (before 45 years of age)
• a hysterectomy (removal of the womb) before the age of 45, particularly when the ovaries are also removed
• absent periods for more than six months as a result of overexercising or too much dieting

Men

In most cases, the cause of osteoporosis in men is unknown. However, there's a link to the male hormone testosterone, which helps keep the bones healthy.

Men continue producing testosterone into old age, but the risk of osteoporosis is increased in men with low levels of testosterone.

In around half of men, the exact cause of low testosterone levels is unknown, but known causes include:

• the use of certain medications, such as oral glucocorticoids
• alcohol misuse
• hypogonadism (a condition that causes abnormally low testosterone levels)

Risk factors

Many hormones in the body can affect the process of bone turnover. If you have a condition of the hormone-producing glands, you may have a higher risk of developing osteoporosis.

Hormone-related conditions that can trigger osteoporosis include:

• hyperthyroidism (overactive thyroid gland)
• disorders of the adrenal glands, such as Cushing's syndrome
• reduced amounts of sex hormones (oestrogen and testosterone)
• disorders of the pituitary gland
• hyperparathyroidism (overactivity of the parathyroid glands)

Other risk factors

Other factors thought to increase the risk of osteoporosis and broken bones include:

• a family history of osteoporosis
• a parental history of hip fracture 
• a body mass index (BMI) of 19 or less
• long-term use of high-dose oral corticosteroids (widely used for conditions such as arthritis and asthma), which can affect bone strength
• having an eating disorder, such as anorexia or bulimia
• heavy drinking and smoking
• rheumatoid arthritis 
• malabsorption problems, as experienced in coeliac diseaseand Crohn's disease
• some medications used to treat breast cancer and prostate cancer which affect hormone levels
• long periods of inactivity, such as long-term bed rest

Diagnosing osteoporosis

If your doctor suspects you have osteoporosis, they can make an assessment using an online programme, such as FRAX or Q-Fracture. They may also refer you for a scan to measure your bone mineral density.

This type of scan is known as a DEXA (DXA) scan. It's a short, painless procedure and your bone mineral density can then be used to assess your fracture risk.

Diagnosing osteoporosis 

Osteoporosis is often diagnosed after weakened bones have led to a fracture.

If you're at risk of developing osteoporosis, your GP may refer you for a bone mineral density scan, known as a dual energy X-ray absorptiometry (DEXA, or DXA) scan.

Normal X-rays are a useful way of identifying fractures, but they aren't a reliable method of measuring bone density.

DEXA (DXA) scan

A DEXA scan can be used to help diagnose osteoporosis. It's a quick, safe and painless procedure that usually takes about five minutes, depending on the part of the body being scanned.

The scan measures your bone mineral density and compares it to the bone mineral density of a healthy young adult and someone who's the same age and sex as you.

The difference between the density of your bones and that of a healthy young adult is calculated as a standard deviation (SD) and is called a T score.

Standard deviation is a measure of variability based on an average or expected value. A T score of:

• above -1 SD is normal 
• between -1 and -2.5 SD is defined as decreased bone mineral density compared with peak bone mass
• below -2.5 is defined as osteoporosis

Although a bone density scan can help diagnose osteoporosis, your bone mineral density result isn't the only factor that determines your risk of fracturing a bone.

Your age, sex and any previous injuries will need to be taken into consideration before deciding whether you need treatment for osteoporosis.

Your doctor can help you take positive steps to improve your bone health. If you need treatment, they can also suggest the safest and most effective treatment plan for you. 

Treating osteoporosis

Treatment for osteoporosis is based on treating and preventing fractures and using medication to strengthen bones.

The decision about what treatment you have – if any – will depend on your risk of fracture. This will be based on a number of factors, such as your age and the results of your DXA scan.

Treating osteoporosis 

Treating osteoporosis involves treating and preventing fractures and using medication to strengthen bones.

Preventing falls and fractures

The Department of Health's National Service Framework (NSF) for Older People provides doctors and other healthcare professionals with guidance about caring for older people.

An important objective for health services across England is to try to prevent falls and fractures. This is of particular concern for people who've been diagnosed with osteoporosis and those with risk factors for osteoporosis.

The key messages for older people and their family and carers are:

• falls are a risk as you get older, but aren't inevitable – there are measures you can take to prevent falls or reduce the harm that might be caused by falling
• staying active and healthy – for example, through exercise and diet – is likely to keep you independent and reduce your risk of falling
• if you're unsteady on your feet or fall, speak to your GP so possiblecauses of falls, such as poor eyesight, certain medications, and poor muscle strength and balance, can be identified and treated

Treatment overview

Although a diagnosis of osteoporosis is based on the results of your bone mineral density scan (DEXA or DXA scan), the decision about what treatment you need – if any – will also be based on a number of other factors. These include your:

• age
• sex
• risk of fracture
• previous injury history

If you've been diagnosed with osteoporosis because you've had a fracture, you should still receive treatment to try to reduce your risk of further fractures.

You may not need or want to take medication to treat osteoporosis. However, you should ensure that you're maintaining sufficient levels of calcium and vitamin D. To achieve this, your healthcare team will ask you about your current diet and may recommend making changes or taking supplements.

NICE recommendations

The National Institute for Health and Care Excellence (NICE) has made some recommendations about who should be treated with medication for osteoporosis.

A number of factors are taken into consideration before deciding which medication to use. These include your:

• age
• bone mineral density (measured by your T score)
• risk factors for fracture

NICE has summarised its guidance for two groups of people:

• postmenopausal women with osteoporosis who haven't had a fracture (primary prevention)
• postmenopausal women with osteoporosis who've had a fracture (secondary prevention)

Preventing osteoporosis

If you're at risk of developing osteoporosis, you should take steps to help keep your bones healthy. This may include:

• taking regular exercise
• healthy eating, including foods rich in calcium and vitamin D
• making lifestyle changes, such as giving up smoking and reducing your alcohol consumption

Preventing osteoporosis 

Your genes are responsible for determining your height and the strength of your skeleton, but lifestyle factors such as diet and exercise influence how healthy your bones are.

Regular exercise

Regular exercise is essential. Adults aged 19 to 64 should do at least 150 minutes (2 hours and 30 minutes) of moderate-intensity aerobic activity, such as cycling or fast walking, every week.

Weight-bearing exercise and resistance exercise are particularly important for improving bone density and helping to prevent osteoporosis.

As well as aerobic exercise, adults aged 19 to 64 should also do muscle-strengthening activities on two or more days a week by working all the major muscle groups, including the legs, hips, back, abdomen, chest, shoulders and arms.

If you've been diagnosed with osteoporosis, it's a good idea to talk to your GP or health specialist before starting a new exercise programme to make sure it's right for you.

Weight-bearing exercises

Weight-bearing exercises are exercises where your feet and legs support your weight. High-impact weight-bearing exercises, such asrunning, skipping, dancing, aerobics, and even jumping up and down on the spot, are all useful ways to strengthen your muscles, ligaments and joints.

When exercising, wear footwear that provides your ankles and feet with adequate support, such as trainers or walking boots.

Read more about choosing sports shoes and trainers.

People over the age of 60 can also benefit from regular weight-bearing exercise. This can include brisk walking, keep-fit classes or a game of tennis. Swimming and cycling aren't weight-bearing exercises, however.

Resistance exercises

Resistance exercises use muscle strength, where the action of the tendons pulling on the bones boosts bone strength. Examples include press-ups, weightlifting or using weight equipment at a gym.

If you've recently joined a gym or haven't been for a while, your gym will probably offer you an induction. This involves being shown how to use the equipment and having exercise techniques recommended to you.

Always ask an instructor for help if you're not sure how to use a piece of gym equipment or how to do a particular exercise.

Healthy eating

Eating a healthy balanced diet is recommended for everyone. It can help prevent many serious health conditions, including heart disease, diabetes and many forms of cancer, as well as osteoporosis.

Calcium is important for maintaining strong bones. Adults need 700mg a day, which you should be able to get from your daily diet. Calcium-rich foods include leafy green vegetables, dried fruit, tofu and yoghurt.

Vitamin D is also important for healthy bones and teeth because it helps your body absorb calcium. Vitamin D can be found in eggs, milkand oily fish.

However, most vitamin D is made in the skin in response to sunlight. Short exposure to sunlight without wearing sunscreen (10 minutes twice a day) throughout the summer should provide you with enough vitamin D for the whole year.

Certain groups of people may be at risk of not getting enough vitamin D. These include:

• people who are housebound or particularly frail
• people with a poor diet
• people who keep covered up in sunlight because they wear total sun block or adhere to a certain dress code
• women who are pregnant or breastfeeding

If you're at risk of not getting enough vitamin D through your diet or lifestyle, you can take a vitamin D supplement. For adults, 10 micrograms a day of vitamin D is recommended.

The recommended amount for children is 7 micrograms for babies under six months, and 8.5 micrograms for children aged six months to three years. Talk to your GP for more information.

Other factors

Other lifestyle factors that can help prevent osteoporosis include:

• quitting smoking – smoking is associated with an increased risk of osteoporosis
• limiting your alcohol intake – the recommended daily limit is 3-4 units of alcohol for men and 2-3 units for women; it's also important to avoid binge drinking

Get some sun!

Between May and September, sunlight triggers the production ofvitamin D, which helps your body absorb calcium.

This process helps strengthen teeth and bones, which in turn helps prevent conditions such as osteoporosis.

Living with osteoporosis

If you're diagnosed with osteoporosis, there are steps you can take to reduce your chances of a fall, such as removing hazards from your home and having regular sight tests and hearing tests.

To help you recover from a fracture, you can try using:

• hot and cold treatments such as warm baths and cold packs
• transcutaneous electrical nerve stimulation (TENS) – where a small battery-operated device is used to stimulate the nerves and reduce pain
• relaxation techniques

Speak to your GP or nurse if you're worried about living with a long-term condition. They may be able to answer any questions you have.

You may also find it helpful to talk to a trained counsellor or psychologist or other people with the condition.

The National Osteoporosis Society can put you in touch with local support groups, and they also have an online discussion forum.

At-risk groups

Osteoporosis often affects women, particularly after themenopause (when monthly periods stop). However, it can also sometimes affect men, younger women and children.

Other groups who are at risk of developing osteoporosis include:

• people who've been taking steroid medication for more than three months
• women who've had their ovaries removed
• people with a family history of osteoporosis
• people with an eating disorder, such as anorexia or bulimia 
• people who don't exercise regularly
• people who smoke or drink heavily

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