Where Gain Means Less Pain
Holistic pain management for osteoarthritis
By Jin Paul De Guzman
 Three hundred fifty-five million people all over the world suffer from any one of the over 200 kinds of arthritis, and nearly all of them complain primarily of one thing-pain. Pain, whether owing to inflammation, the damage to the bone or joint, or the emotional difficulty of dealing with the condition, should always be taken seriously. As Dr. Cenon Cruz, considered as the country's father of pain medicine, said to MEDICAL OBSERVER last year: "Pain is a separate entity…it is a disease in itself."
Osteoarthritis is one of the most common forms of arthritis, and although most of those who suffer from the disease are elderly, this does not mean that one could not suffer from the disease at a younger age. It also doesn't mean that all ageing people go through the disease-one may grow to be 100 years and keep the integrity of his bones and joints. Ageing, although considered as the strongest risk factor, is just one of the conditions that may lead to the development of arthritis. There are also biochemical, enzymatic, and anatomical reasons that trigger the emergence of the disease.
Degeneration
Normally, an ageing joint can perform its roles, such as movement and weight-bearing. There are, of course, limitations resulting from a number of factors-the decrease in cell density of the bone, decrease in tensile strength owing to the deterioration of the collagen network, and the aggregation of proteoglycans, among others. The atrophy of the muscle tissues surrounding the joint may also contribute to these limitations.
Osteoarthritis starts with an abnormality in the cells that synthesize collagen and proteoglycans, the major components of cartilage. This leads to the abnormal growth of the cartilage-it becomes thin, and develops cracks and cavities. Osteophytes also develop, interfering with joint function. There are also changes in the structures surrounding the joint-the joint capsule thickens, there's hypertrophy in the synovial tissues, etc. Thus, the joint becomes difficult-and painful-to use.
Osteoarthritis may also result from several secondary causes. Among these are Paget's disease, injury, and overuse. Obesity is also considered a risk factor.
Sometimes the patient doesn't immediately feel the symptoms despite these changes. Since the symptoms develop gradually, one may feel pain or stiffness in a few joints first-the fingers, the toes, the neck, the lower back, the hips, or the knees. As the damage worsens, pain becomes even more apparent, and the joints become difficult to move, if at all. Because of the abnormal growth in the cartilage and the changes in the surrounding structures, the joints enlarge and become gnarled. The ligaments surrounding the knees get stretched, or there is increased congruence of the femoral head and acetabulum. No matter which joint is affected, some of the results are pretty much the same-moving the affected joint feels like it is about to crack, and if it feels like it's cracking, can pain be far behind?
Relief
Dr. Sandra Navarra, rheumatology consultant at the University of Santo Tomas Hospital, stresses five points in the management of arthritis, regardless of type or severity-maximize functional independence, minimize joint damage, optimize treatment of pain and inflammation, provide access to care at reasonable cost, and enhance the quality of life.
These are the general principles on which arthritis management strategies should be based, although she stresses the importance of individualized treatment. She explains: "Even if [a patient has] the same kind of diagnosis as other individuals, the severity of the arthritis can be for one over the other. Even if the severity is the same among these individuals, their response to the treatment regimen or medication may be for one versus the other."
Two important features comprise the management strategy for arthritis-pharmacologic and nonpharmacologic, which Dr. Navarra says is just as important as the pharmacologic component. The pharmacologic component consists mainly of the use of pain medication. The use of nonsteroidal antiinflammatory drugs may also be necessary in some conditions-"There is also some inflammation, but not as bad as in other forms of arthritis," she stresses. Most of the time, NSAIDs may be the only drugs the patient needs. Although the use of traditional NSAIDs may bring about gastropathy and occasionally brings about renal and hepatic side effects, newer drugs such as the COX-2 inhibitors have significantly lower potential for gastrointestinal damage. In some situations, like in sudden and painful swelling, corticosteroids may be used.
Dr. Reynaldo Rey-Matias, who chairs the Department of Rehabilitation Medicine of the East Avenue Medical Center, says that there are some considerations in the elderly who suffer from bone and joint pain. "Physicians must consider the age-related changes in the pharmacokinetics of the medication they give the elderly," he says. Speaking in a symposium sponsored by the Pain Society of the Philippines, Dr. Rey-Matias explained that among the elderly, body water and body mass are considerably lower, while body fat is higher. This, he says, affect the volume of distribution of the drugs.
He adds that doctors should be extra careful in prescribing medication to the elderly. "We must have complete and accurate information about the patient's drug history, we need to carefully titrate the drug dosage and use smaller dosage if possible, and we need to discontinue unnecessary medication that can produce interactions and only lead to adverse reactions in the elderly," he says.
As for nonpharmacologic management strategies, they include the application of heat and cold treatments to soothe the pain. To protect the joints, Dr. Navarra stresses the importance of weight loss and exercise. For osteoarthritic patients who are also overweight or obese, she explains that losing weight will lessen the strain on the weight bearing joints. Some activities that could further strain the joints, particularly the knees and hips, are standing for long periods of time, carrying weights that are one-tenths of the patient's weight, kneeling, squatting, and the like. Support such as canes may also be used.
Exercise is an important feature in the nonpharmacologic portion of the treatment strategy. Muscle-strengthening exercises like stationary biking will help take away the pressure on the weight-bearing joints. However, some patients complain that they can't exercise because of the pain, which leads to muscle weakness, which in turn leads to further pressure on the weight-bearing joint, which leads to more pain. It then becomes "a vicious cycle," Dr. Navarra says.
When does surgical intervention become necessary? Dr. Navarra says, "It has a role in patients with long-standing osteoarthritis, where there's intractable pain that can no longer be alleviated by the usual pain medication and by nonpharmacologic therapy." Usually, surgery is resorted to when all other treatment options fail to bring relief.
Caregivers
Primary care physicians have an important role to play in the management of osteoarthritis, as well as the other rheumatic diseases. Dr. Navarra, who is also secretary-general of the Arthritis Care and Research Foundation of the Philippines, says that many rheumatic diseases can be diagnosed in the primary care setting. "Most arthritis patients do not need laboratory exams…you just get their clinical data and you have a diagnosis," she says.
Dr. Navarra is editor and project director of Approach to the Rheumatic Diseases for Primary Care Physicians, a joint project of the ACRFP and the Philippine Rheumatology Association launched in 2000. The project aims to further educate primary care physicians on the rheumatic diseases-this, Dr. Navarra says, does not mean to pass on all the responsibilities of the specialist to the primary care physician; instead it is meant to make the latter invaluable partners to the rheumatologists.
Some rheumatic diseases, especially the serious ones and those that need to be taken care of on a long-term basis, have to be referred to the specialist. "If you don't get a diagnosis, or if the patients don't get well, then they need to be referred," she stresses.
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