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Many people with locomotor problems will need more than one type of treatment – for example, drugs combined with physiotherapy and a programme of exercise to rehabilitate joints and soft tissues. Brief details of treatments for specific conditions are given in the preceding chapters. This section covers the treatments that may be used for arthritis and soft-tissue rheumatism in general.
Analgesics, or pain-killers, and non-steroidal anti-inflammatory drugs are the most important drugs in the treatment of arthritis and rheumatism. They are especially useful when the underlying cause of the symptoms cannot be cured.
Examples of analgesics (often called ‘simple analgesics’ to distinguish them from anti-inflammatory drugs, which also act as pain-killers) are paracetamol, codeine, co-dydramol and dihydrocodeine. Paracetamol and codeine, and combinations of the two, are available over the counter under different trade names but the others are prescription-only drugs.
All of these medications, except paracetamol, can cause drowsiness and constipation. Co-proxamol is a simple analgesic which was widely used until recently. Now we know that it can be very dangerous in overdose, so it has been withdrawn. Simple analgesics relieve pain but they do not have any anti-inflammatory action so they have little effect on stiffness and swelling.
Non-steroidal anti-inflammatory drugs (NSAIDs – pronounced ‘en-seds’) can often be very helpful when simple analgesics fail to relieve symptoms. They are so named because they reduce inflammation, which steroids also do, but they are completely different from steroids in the way that they work and in their potential side effects. NSAIDs are particularly effective in combating the stiffness and swelling that are caused by inflammation, as well as the pain.
The oldest anti-inflammatory drug is aspirin.
Unfortunately, it needs to be given in large doses for it to have an anti-inflammatory effect (as distinct from a pain-killing effect) and in large doses it has a high risk of side effects, especially on the stomach. It has been superseded by more modern drugs with fewer side effects, such as ibuprofen, diclofenac and naproxen.
Guidelines for using simple analgesics
• Start with paracetamol, which is the simplest, safest and cheapest analgesic, and which, if taken properly, is very effective.
• Always follow the instructions on the packaging and never exceed the recommended dose – all drugs are dangerous if you take too many, including paracetamol.
• If you have constant or frequent pain, take painkillers regularly throughout the day, rather than waiting until the pain becomes really troublesome.
• If you have a lot of pain at night, take your painkillers half an hour before bed-time.
• If you are planning a shopping trip or some other activity that you know will worsen your pain, take your pain-killers half an hour before you set off.
• If you find that the pain-killers that you are taking are not strong enough or you are taking them continuously, consult your doctor as there may be better pain-relieving strategies which could reduce your need for analgesics. Keep a record of how long each packet or bottle lasts you so that your doctor knows how many you’ve been taking.
REMEMBER: Many proprietary cold and flu treatments contain paracetamol, and there is a risk of an accidental overdose if you are already taking paracetamol regularly for pain relief.
NSAIDs and the stomach
Why do NSAIDs cause stomach irritation? All NSAIDs work by blocking the production of prostaglandins in the tissues. Prostaglandins are chemicals released by cells at the site of an injury or damage caused by disease. They increase the flow of blood to the inflamed area, making it red and hot, and cause the blood vessels to become ‘leaky’, making the area swollen. Unfortunately, blocking prostaglandin production has negative as well as positive effects. This is because other types of prostaglandins, not involved in disease, play an important part in protecting the stomach lining from being damaged by its own digestive juices and acid. Unfortunately, NSAIDs block all prostaglandins, including the stomach protectors. This is why side effects such as indigestion, ulcers and bleeding from the stomach wall can all occur in people who take NSAIDs.
Newer NSAIDs (known as selective COX-2 or cyclooxygenase 2 inhibitors), such as celecoxib (Celebrex), etoricoxib (Arcoxia) and lumiracoxib (Prexige), appear to act in a specific way and their blocking effect is concentrated on the inflammatory prostaglandins rather than the protective ones (they reduce prostaglandin production at sites of pain and inflammation without affecting production in the stomach). In theory, these drugs look promising but it is not yet clear what their long-term side effects might be.
Several COX-2 inhibitors have been withdrawn because they have been associated with an increased risk of heart attacks and strokes. As a result of these concerns, the Committee on Safety of Medicines advises that COX-2 inhibitors should not be taken by people who have heart disease or vascular disease (diseases of blood vessels or ‘hardening of the arteries’).
However, it has become clear that COX-2 inhibitors have fewer gastrointestinal effects than NSAIDs, in particular the incidence of life-threatening ulcer complications such as bleeding and perforation.
At present this group of drugs is likely to be prescribed for you only if you develop gastric problems while on NSAIDs or have had ulcers in the past and if you do not have heart disease or vascular disease.
As a rule, NSAIDs offer most benefit to people with a form of inflammatory arthritis, such as rheumatoid arthritis, or who have developed an acute inflammation, such as gout. People with osteoarthritis and the soft-tissue problems described in the preceding chapter should begin with simple analgesics, which have fewer side effects, and change to an NSAID, for the shortest possible time, only if the analgesic does not work.
Steroids are produced naturally by the body. There are many different types and they act in many different ways. Many steroids can now be manufactured in the form of tablets and injections, and they are prescribed by doctors to treat a variety of conditions.
People often get worried when their doctor says that they need steroids. They have heard a lot about side effects and also about the abuse of steroids by certain sportsmen and body-builders. But the steroids used in arthritis are quite different from the ones abused in sports. The steroids used to treat arthritis are powerful anti-inflammatory drugs and they are very effective in controlling swelling, stiffness and pain. There is even some evidence from research that, in certain circumstances, they can reduce the damage done to joints by rheumatoid arthritis.
Guidelines for using anti-inflammatory drugs (NSAIDs)
• Ibuprofen is the most widely available NSAID with the fewest side effects, so, unless your doctor advises otherwise, start with ibuprofen.
• Ibuprofen is available over the counter in a number of branded formulas but the unbranded or ‘generic’ version is cheaper and just as effective.
• If an NSAID reduces stiffness and swelling but you still have some pain, then also taking a simple analgesic, such as paracetamol, can be helpful. It is quite safe to do this as the two drugs work in different ways and do not interact.
• All NSAIDs must be taken with food and never on an empty stomach and, if you get a stomach upset, you must stop taking them. This is because they can irritate the lining of the stomach, causing indigestion and even ulcers and bleeding. All NSAIDs have this side effect to some extent, although only a minority of people who take them suffer from it.
• If you are elderly or if you have had an ulcer in the past, you are more susceptible to stomach irritation. You should consult your doctor before you take an NSAID. You may be given a combination treatment of an NSAID together with a drug to protect the stomach.
• If you have asthma, you need to be aware that occasionally aspirin and other NSAIDs may bring on an attack.
• Some NSAIDs are also available in the form of a gel that is massaged into the painful area. This can help pain that arises from the tissues near the surface of the skin, but is of little help in the pain of arthritis because the joints are too deep for the drug to penetrate to them.
Steroids can be taken in a variety of ways:
• In high doses for short periods to treat a flare in conditions such as systemic lupus erythematosus. The steroids may be given by mouth or, in severe cases, in hospital by direct injection into a vein.
• By single injection into the buttock muscle. This method is often used in people with rheumatoid arthritis who have just started taking drugs to control the arthritis long term. The steroid injection can tide them over while their drugs take effect – usually several weeks.
• In lower doses taken by mouth over the long term to keep inflammation under control in conditions such as polymyalgia rheumatica.
• Injected directly into a problem area such as an inflamed joint, tendon sheath or other soft tissue.
Possible side effects of steroids
Like all drugs, steroids can have side effects. But despite the long list of side effects, steroids are powerful, effective drugs which are invaluable if used wisely. For example, when polymyalgia sufferers start taking steroids, they feel that they have been given a new lease of life.
The possible side effects of long-term steroids
• Weight gain caused by an increase in appetite and retention of fluid.
• Raised blood pressure.
• Increased risk of developing diabetes and poor control of blood sugar levels in people who already have diabetes.
• Increased susceptibility to infections.
• Increased risk of stomach ulcers and bleeding.
• Increased risk of developing osteoporosis.
• Thinning of the skin and slow healing of cuts and grazes.
Guidelines for taking long-term steroids
• Steroid treatment should always be prescribed and supervised by a doctor. Never adjust the dose except on the advice of a doctor.
• You will be given a blue card by the pharmacist when you start steroids. It carries the details of your steroid treatment and you should carry it with you at all times.
• If you are taken ill or injured, you must tell the doctor treating you that you take steroids and show him or her your blue card.
• Steroid tablets should be taken in the early morning, when the levels of natural steroids are at their peak. This causes less suppression of the adrenal glands.
• Instead of a dose every day, your doctor may suggest that you take double the dose on alternate days. This also can reduce the effect on the adrenal glands. Unfortunately, it is not always possible to do this as some people find that their symptoms are much worse on the non-steroid days.
• Once your condition has been controlled, if you need steroids long term, your doctor will reduce the dose to the lowest possible level to reduce the risk of side effects.
When steroids are taken as treatment, they suppress the body’s production of its own steroids, especially those made by the adrenal glands. These are small glands that sit on top of the kidneys and which produce steroids that control vital functions such as salt and water balance and blood pressure. If you stop taking steroids suddenly, you can become very ill because your adrenal glands need time to begin making their own steroids again. Therefore, steroids taken as treatment should always be tailed off gradually, to give the adrenal glands time to adjust.
Local steroid injections
If you have only one or two inflamed joints then steroids injected directly into the joints may be the best treatment. Many people with rheumatoid arthritis have repeated injections into their joints with great benefit. If the knee or the ankle is injected, it is safe to walk but you should rest the joint as much as possible for a day or two after the injection.
Steroid injections can also be given into painful and inflamed soft-tissue areas. This is a widely used and very effective form of treatment. Tennis elbow, tenosynovitis and carpal tunnel syndrome are often completely relieved by the injection of a small amount of steroid.
The injected steroid remains at the site of the injection and is slowly dispersed. Very little is absorbed into the rest of the body and so, in contrast to steroids taken by mouth, local steroid injections produce very few side effects. Occasionally, some people experience an increase in their pain for 24 hours but this settles as the steroid takes effect.
Local steroid injections carry a slight risk of wasting of the tissue and thinning of the skin at the injection site. This is seen as a small depression in the skin associated with loss of skin colour, which is more obvious in people with pigmented skin. The only disadvantage of this is cosmetic but for some people this is important so they should always be warned of the risk.
Disease-modifying anti-rheumatoid drugs (DMARDs)
These are sulfasalazine, methotrexate, azathioprine, leflunomide (Arava), gold salts, penicillamine and hydroxychloroquine, and the newer drugs etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira) and rituximab (MabThera).
They form a very important group of drugs but they are only ever used to treat widespread inflammatory arthritis, such as rheumatoid arthritis. They are not used in other forms of arthritis and musculoskeletal conditions so information about them is included in the chapter on rheumatoid arthritis rather than here.
Some people with chronic, painful conditions may develop depression, making the pain even harder to cope with. There are several antidepressant drugs that help to lift the mood and ease the pain. Interestingly, certain types of pain, such as neuralgia, are eased by antidepressants even in people who are not depressed.
These very useful drugs are not addictive and, although some of the older drugs may cause drowsiness, newer ones do not.
Many people with joint problems are referred to a physiotherapist for treatment. Physiotherapists are based in hospitals, some health centres and in private practices. Some are based in the community and can visit disabled people in their own homes. They are experts at maintaining the function of the locomotor system – that is, they will help you maintain strength and movement and reduce pain.
After a course of treatment, the physiotherapist may give you an exercise programme to do at home, to continue the benefit of your treatment. But physiotherapy cannot work miracles! It is important for you to keep your part of the bargain. Lose weight if you are overweight, perform your exercises regularly and take care to look after your joints.
Hydrotherapy is physiotherapy performed in a warm swimming pool. It is very effective at relieving the discomfort of stiff, painful joints. The water supports the weight of your body and the warmth helps your muscles relax and your joints to move. A course of hydrotherapy can give prolonged benefit in conditions such as osteoarthritis of the hip and ankylosing spondylitis.
Many people with arthritis assume that the only thing a surgeon can do to help is to replace a damaged joint. This is probably the most common operation, but it is by no means the only form of surgical treatment available.
Your doctor may discuss the possibility of surgery with you if one or more joints have become so damaged, painful and stiff that you can no longer use them properly, despite taking pain-killers and regular exercise.
This is a form of ‘keyhole’ surgery usually performed under a general anaesthetic, but as a day case (that is, the patient is discharged from the hospital after the procedure, on the same day). It is used to diagnose and treat problems within a joint, most often injury to the knee. A thin tube passed through a small incision in the skin allows the surgeon to see into the joint. Other surgical instruments inserted through further small incisions allow the surgeon to perform small operations.
This operation removes inflamed synovium from within joints and around tendons in people with rheumatoid arthritis. Although it can help to relieve symptoms and may slow the progress of the disease, it is not a cure and the inflamed tissue often re-forms, sometimes quite quickly. For this reason, it is always used together with drug treatment.
Tendon and ligament surgery
Surgery can be performed to realign tendons or loosen tight tendon sheaths and even, in some cases, to repair broken tendons.
If one area of a joint surface is badly damaged but other parts are still in a relatively good condition, surgery to realign the bone may redirect the pressure away from the damaged area. Osteotomy is sometimes used in younger people with arthritis to postpone the need for joint replacement.
This is surgery to fuse a joint so that it can no longer move. It abolishes pain but the joint is left completely stiff. It is a very useful operation for severe arthritis affecting the feet, ankles, wrists and occasionally in the spine.
Arthroplasty or joint replacement
Artificial joints for hips and knees have been widely used for over 30 years and have a very high success rate. In certain cases, shoulders, elbows and finger joints can be replaced, although the surgery is technically more difficult. For more information on joint replacement, see the book Understanding Hip and Knee Arthritis Surgery in the Family Doctor series.
The two parts of a hip replacement are the metal femoral component (artificial upper thigh bone) and the plastic acetabular component (artificial hip socket). The combination of metal and plastic is very hard wearing.
The two parts of a knee replacement are the femoral component and the tibial component. Again, a combination of metal and plastic is used.
Many people who have arthritis or rheumatism feel that they gain benefit from complementary medicines and use them as well as their conventional medicines. This may be because orthodox treatment is unable to control their symptoms completely and also because they believe that complementary therapies are natural and safer.
Although there is some truth in this view, it is not the whole story and there are other factors that you should bear in mind before deciding whether to try the complementary approach.
In fact, it can be very difficult to make an objective assessment as to whether complementary methods and treatments are effective. Few have been scientifically tested, so there is little reliable evidence as to whether they actually work. The picture is complicated by the fact that the symptoms of arthritis may vary over time regardless of treatment, making it difficult to judge whether an improvement is the result of a particular treatment or simply part of the normal pattern of the disease.
Although many types of therapy are safe, you cannot always assume that this is so. In particular, you should be wary of herbal remedies imported from abroad and distributed by small-scale practitioners or shops. The quality of these products is not controlled and, in the past, some have been found to contain powerful drugs such as steroids or even poisonous heavy metals.
These are a traditional remedy for all kinds of aches and pains, but there is no real evidence that they are effective. However, they are unlikely to be harmful.
Glucosamine and chondroitin sulphate
These dietary supplements contain substances found naturally in the body which play a role in strengthening cartilage and help it to retain water. Some research has suggested that taking supplements may encourage damaged cartilage to repair itself, and even prevent cartilage damage in the first place, without causing side effects. Other research has shown no benefit. Some people find that the supplements help their pain but the ideal dose and formulation have not been identified, nor is it clear whether the effects will be long lasting.
The NICE (National Institute for Health and Clinical Excellence) is the organisation that assesses drugs and treatments for the National Health Service, and it does not recommend glucosamine and chondroitin sulphate as effective treatments.
Using complementary medicines
• Do as much research as you can into the training and experience of the therapist. Reputable ones are likely to be registered with a regulatory body that monitors practitioners. Be especially wary of anyone who promises you a cure.
• Tell your doctor if you are using other types of treatment. Occasionally there may be undesirable interactions between conventional and complementary medicines.
• As with any medicine, always read the instructions on the pack and do not exceed the recommended dose. It can be tempting to assume that ‘more is better’, but this is unlikely to be the case.
• Never stop taking conventional treatments without consulting your doctor, especially if you are taking steroids, as stopping them suddenly can be dangerous.
• Try to relate the cost of treatment to its effectiveness – if you see no improvement after a reasonable time, there is no point in wasting your money. One way of doing this is to keep a diary of your symptoms for a month or so before starting any complementary treatment, and continue for another month once you are using it. You can then use this information to see whether you feel that the therapy is making any difference.
Fish oils and evening primrose oil contain essential fatty acids (called ‘essential’ because the body cannot make them but must obtain them from food). There is now good scientific evidence that these oils can reduce inflammation in arthritis, although the effect is small. Cod liver oil contains essential fatty acids, together with vitamin D, which helps to absorb calcium. However, it also contains vitamin A and so should not be taken in large amounts as excess vitamin A can be dangerous.
This traditional Chinese therapy involves inserting fine needles into the skin at certain carefully defined points to liberate the flow of ‘ki’, sometimes called the ‘life force’. Modern research suggests that it may help to reduce pain by stimulating the body to produce natural pain-killing chemicals called ‘endorphins’. In China, acupuncture is used to treat a wide range of medical conditions and even to provide anaesthesia for surgical operations.
In the west, there is some scientific evidence that it helps certain types of musculoskeletal pain and many physiotherapy departments now use it in a limited way. If you consult a private practitioner, make sure that he or she is registered. In skilled hands, the procedure is very safe.
Homoeopathy was devised as a system of medicine in the late nineteenth century and homoeopathic remedies are widely used today. The principle of treatment is that ‘like cures like’: in other words, a homoeopath will choose remedies that, in larger amounts, would cause the symptoms being treated.
The actual choice of remedies will be based on your answers to extensive questioning about your history, symptoms and personality. The remedies are made from substances extracted from plants, minerals and animals, diluted many times.
Homoeopaths hold that, as the substances are diluted, they become more ‘potent’ and high-potency preparations are so dilute that they probably do not contain a single molecule of the original substance. Side effects and drug interactions are rare.
Osteopathy, chiropractic and Alexander technique
These are therapies with some similarities to physiotherapy, although they developed in very different ways. They are not usually available under the National Health Service but are widely available privately. They can be particularly effective for spinal problems.
Alexander technique can be helpful in correcting faulty posture. Practitioners teach how to use the body correctly and inhibit ingrained habits of poor posture and incorrect movement. Breathing techniques are also taught to aid movement.
Chiropractic is a variant of osteopathy. The two therapies are very similar and deal with biomechanical problems. They see pain and disability as arising from flaws in the function of the locomotor system. These flaws need not cause symptoms but may throw excessive strain on other parts of the locomotor system.
Many different types of drug are useful in the treatment of locomotor problems
Some people avoid drugs that could help them considerably because of misplaced fears – do not be afraid to take the drugs that your doctor recommends but, if you have concerns, do talk to your doctor about them
Complementary medicines and therapies can help the symptoms of arthritis and rheumatism
There is usually little scientific evidence that complementary medicines or therapies have a fundamental effect on diseases so, if they do not help your symptoms, they are best abandoned
Always consult registered complementary practitioners and buy medicines from reputable shops and pharmacies
Dr Terri Passenger is a Chartered Educational Psychologist working with children who have special educational needs. As a Senior Partner in a practice of educational psychologists, she splits her time between schools and the practice clinics in Harley Street and Nuffield Hospital, Cheltenham.