Postherpetic neuralgia

Definition

Postherpetic neuralgia (post-her-PET-ic noo-RAL-jah) is a painful condition affecting your nerve fibers and skin. Postherpetic neuralgia is a complication of shingles, a second outbreak of the varicella-zoster virus, which initially causes chickenpox.

During an initial infection of chickenpox, some of the virus remains in your body, lying dormant inside nerve cells. Years later, the virus may reactivate, causing shingles.

Once reactivated, the virus travels along nerve fibers, causing pain. When the virus reaches your skin, it produces a rash and blisters. A case of shingles (herpes zoster) usually heals within a month. But some people continue to feel pain long after the rash and blisters heal — a pain called postherpetic neuralgia. A variety of treatments for postherpetic neuralgia exist, although you may not experience complete relief from pain.

Symptoms

The symptoms of postherpetic neuralgia are generally limited to the area of your skin where the shingles outbreak first occurred. They may include:

• Sharp and jabbing, burning, or deep and aching pain
• Extreme sensitivity to touch and temperature change
• Itching and numbness
• Headaches

In rare cases, you might also experience muscle weakness or paralysis — if the nerves involved also control muscle movement.

Causes

Postherpetic neuralgia results when nerve fibers are damaged during an outbreak of shingles. Damaged nerves aren’t able to send messages from your skin to your brain as they normally do. Instead, the messages become confused and exaggerated, causing chronic, often excruciating pain that may persist for months — or even years — in the area where shingles first occurred.

This complication of shingles occurs much more frequently in older adults. About 50 percent of adults older than 60 experience postherpetic neuralgia after shingles, whereas only 10 percent of all people with shingles do.

When to seek medical advice

See a doctor at the first sign of shingles. Aggressively treating shingles early — within two days of developing the rash — may reduce the likelihood of developing postherpetic neuralgia or the length and severity of symptoms should it develop.

If you do develop postherpetic neuralgia, see your doctor right away. Finding an effective treatment to relieve the pain can sometimes be frustrating. You may have to work with your doctor and sometimes other specialists to try a variety of treatments before you find something that helps.

Treatments and drugs

Treatment for postherpetic neuralgia depends on the type of pain you experience. Possible options include:

• Antidepressants. Your doctor may prescribe antidepressants for postherpetic neuralgia, even if you’re not depressed. These drugs affect key brain chemicals, including serotonin and norepinephrine, which play a role in both depression and how your body interprets pain. Doctors typically prescribe antidepressants for postherpetic neuralgia in smaller doses than they do for depression.

  Drugs that inhibit the reuptake of norepinephrine and serotonin — including tricyclic antidepressants, such as amitriptyline, desipramine (Norpramin), nortriptyline (Pamelor) and duloxetine (Cymbalta) — may not eliminate the pain. However, they can make it more tolerable.

• Certain anticonvulsants. Medications for treatment of seizures also can lessen the pain associated with postherpetic neuralgia. These medications stabilize abnormal electrical activity in your nervous system caused by injured nerves. Doctors may prescribe gabapentin (Neurontin), pregabalin (Lyrica) or another anticonvulsant to help control burning and pain.
• Injected steroids. Corticosteroid medications injected into the area around the spinal cord may help relieve the persistent pain of postherpetic neuralgia. This treatment is usually reserved until after the pustular skin rash associated with shingles has gone away.
• Painkillers. Your doctor may prescribe painkillers such as tramadol (Ultram) or drugs containing oxycodone, either in short-acting formulations such as Percocet or in long-acting formulations such as OxyContin. However, these drugs are narcotics and can be addictive. Although this risk is generally low, discuss it with your doctor.
• Transcutaneous electrical nerve stimulation (TENS). This treatment involves the placement of electrodes over the painful area. The electrodes deliver tiny, painless electrical impulses to nearby nerve pathways. You turn the TENS unit on and off as needed to control pain. Exactly how the impulses relieve pain is uncertain. One theory is that the impulses stimulate production of endorphins, your body’s natural painkillers. This treatment doesn’t work for everyone.
• Spinal cord or peripheral nerve stimulation. These devices are similar to TENS, but are implanted underneath the skin. Like with TENS units, you can turn these units on and off as needed to control pain. Before the device is surgically implanted, doctors do a trial using a thin wire electrode. The trial is done to ensure that the stimulator will provide effective pain relief. The electrode is inserted through your skin into the epidural space over the spinal cord for a spinal cord stimulator or under your skin above a peripheral nerve in the case of a peripheral nerve stimulator. If a permanent stimulator is implanted, the stimulator’s pulse generator is placed under the skin, usually in the upper buttocks, but occasionally in other locations. Some areas, such as your chest, abdomen and some areas of your face, are less amenable to treatment using this method.
• Lidocaine skin patches. These are small, bandage-like patches that contain the topical, pain-relieving medication lidocaine. These patches can be cut to fit the affected area. You apply the patches, available by prescription, directly to painful skin to deliver temporary relief. Don’t use patches containing lidocaine on your face.

In some cases, treatment of postherpetic neuralgia brings complete pain relief. But most people still experience some pain, and a few don’t get any relief. Although some people must live with postherpetic neuralgia the rest of their lives, most people can expect the condition to gradually disappear during the first three months. For about 10 percent to 20 percent of people with postherpetic neuralgia, the pain may persist for a year or more.

Prevention

Two vaccines may help prevent shingles and subsequent postherpetic neuralgia — the chickenpox (varicella) vaccine and the shingles (varicella-zoster) vaccine.

If you haven’t had chickenpox: Chickenpox vaccine
The varicella virus vaccine (Varivax) has become a routine childhood immunization to prevent chickenpox. It’s also recommended for older kids and adults who’ve never had chickenpox.

Though the chickenpox vaccine doesn’t guarantee you won’t get chickenpox or shingles, it can reduce your chances of complications and reduce the severity of the disease.

If you’ve already had chickenpox: Shingles vaccine
The varicella-zoster vaccine (Zostavax) can help prevent shingles in adults age 60 and older who’ve had chickenpox. Like the chickenpox vaccine, the shingles vaccine doesn’t guarantee you won’t get shingles. But this live attenuated virus vaccine will likely reduce the course and severity of the disease and reduce your risk of postherpetic neuralgia. One study found the vaccine reduced the number of cases of postherpetic neuralgia by two-thirds.

The shingles vaccine is given as a single injection, usually in the upper arm. It’s only used as a prevention strategy, however. It’s not intended to treat people who already have the disease. Common side effects include redness, pain and swelling at the needle site, itching and headache.

This shingles vaccine isn’t recommended if you:

• Have ever had a life-threatening allergic reaction to gelatin, the antibiotic neomycin or any other component of the shingles vaccine
• Have a weakened immune system from HIV/AIDS or another disease that affects your immune system
• Are receiving medical treatments such as steroids, radiation and chemotherapy
• Have a history of bone marrow or lymphatic cancer
• Have active, untreated tuberculosis

If you are mildly ill, such as with a cold, it’s OK to get the vaccine. However, if you’re moderately or severely ill, wait until you feel better before getting the vaccine.

Lifestyle and home remedies

After talking with your doctor, you may find the following over-the-counter medications ease the pain of postherpetic neuralgia:

• Capsaicin. This cream, made from the seeds of hot chili peppers, may relieve pain from postherpetic neuralgia. Capsaicin (Capzasin-P, Zostrix) can cause a burning sensation and irritate your skin, but these side effects usually disappear over time. Capsaicin cream can be very irritating if rubbed on unaffected parts of your body, such as in your eyes. Follow the application instructions carefully, including wearing gloves for application and washing your hands thoroughly after applying.
• Topical analgesics and anesthetics. Aspirin mixed into an absorbing cream or nonprescription-strength lidocaine cream may reduce skin hypersensitivity. Don’t apply cream containing lidocaine to your face. Your doctor may also recommend using a cream containing other medications.

Arthritis is inflammation of one or more of your joints, such as one or both knees or wrists, or a part of your spinal column. The two most common types of arthritis are osteoarthritis and rheumatoid arthritis. Joint pain and stiffness are the main symptoms of arthritis.

Less common types of arthritis may be associated with conditions that also affect other parts of your body. For example, lupus can affect the kidneys and lungs, in addition to joints, while psoriasis is primarily a skin disease that sometimes also affects joints.

Symptoms

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

• Pain
• Stiffness
• Swelling
• Redness
• Decreased range of motion

Some types of arthritis are accompanied by signs and symptoms involving other parts of your body. These symptoms may include:

• Fever
• Fatigue
• Rash
• Weight loss
• Breathing problems
• Dry eyes and mouth
• Night sweats

Causes

The pain associated with arthritis is caused by joint damage. Joints are made up of the following parts:

• Cartilage. A hard, but slick, coating on the ends of bones, cartilage allows bones of the joint to slide smoothly over each other.
• Joint capsule. This tough membrane encloses all the joint parts.
• Synovium. This thin membrane lines the joint capsule and secretes synovial fluid, which lubricates the joint.

How arthritis damages joints
The two main types of arthritis damage joints in different ways.

• Osteoarthritis. In osteoarthritis, wear-and-tear damage to cartilage 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 joints and inflames the synovium, causing swelling, redness and pain. The disease can eventually destroy cartilage and bone within the joint.

Risk factors

Risk factors for arthritis include:

• 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. While your genes don’t actually cause arthritis, they can make you more susceptible to environmental factors that may trigger arthritis.
• Age. The risk of many types of arthritis — including osteoarthritis, rheumatoid arthritis and gout — increases with age.
• Sex. Women are more likely than are men to develop rheumatoid arthritis, while most of the people who have gout 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 take care of 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

While you might first discuss your symptoms with your family doctor, he or she may refer you to a rheumatologist — a doctor who specializes in the treatment of arthritis and other inflammatory conditions — for further evaluation.

What you can do
Because appointments can be brief, plan ahead and write a list that includes:

• Detailed descriptions of your symptoms, including when they started and if anything makes them better or worse
• 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
During 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.

Tests and diagnosis

Depending on the type of arthritis suspected, your doctor may suggest some of the following tests.

Laboratory 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
• Joint fluid

To obtain a sample of your joint fluid, your doctor will cleanse and numb your skin, and then insert a needle into your joint space to withdraw some fluid.

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 are often used to track progression of the disease.
• Magnetic resonance imaging (MRI). Combining radio waves with a strong magnetic field, MRI can visualize soft tissues such as cartilage, tendons and ligaments as well as bone.

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

Arthritis 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.

Medications
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) and narcotics like oxycodone (Percocet) and hydrocodone (Vicodin).
• Counterirritants. Some varieties of creams and ointments contain a substance such as 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.
• Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs reduce both pain and inflammation. Over-the-counter NSAIDs include aspirin, ibuprofen and naproxen. 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.
• 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 suppress the immune system. Examples include TNF blockers such as 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 more-conservative measures don’t help, your doctor may suggest surgery, such as:

• Synovium removal (synovectomy). Rheumatoid arthritis causes the joint capsule’s lining, called the synovium, to swell — particularly in the wrists, hands and fingers. Removing the synovium may slow joint deterioration.
• 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 or water aerobics is often a good choice 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

Many people use alternative remedies for arthritis, but there is little reliable evidence to support the use of many of these products. Some alternative remedies appear to reduce the symptoms of some types of arthritis but not others. The most promising alternative remedies for arthritis include:

• Glucosamine. Although study results have been mixed, many experts now recommend this nutritional supplement as a first-line treatment for osteoarthritis.
• 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.
• 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.

Coping and support

The pain and disability associated with arthritis can be frustrating and depressing. In many cases, it may help to talk about your feelings with people who are facing the same problems.

Prevention

While there is no proven way to prevent arthritis, maintaining a healthy weight and exercising regularly may help reduce your risk.

People who have gout should avoid:

• Alcohol
• Organ meats, such as liver and kidney
• Sardines
• Anchovies
• Gravy

Osteoarthritis

Definition

Osteoarthritis, sometimes called degenerative joint disease or osteoarthrosis, is the most common form of arthritis. Osteoarthritis occurs when cartilage in your joints wears down over time.

Osteoarthritis can affect any joint in your body, though it most commonly affects joints in your hands, hips, knees and spine. Osteoarthritis typically affects just one joint, though in some cases, such as with finger arthritis, several joints can be affected.

Osteoarthritis gradually worsens with time, and no cure exists. But osteoarthritis treatments can relieve pain and help you remain active. Taking steps to actively manage your osteoarthritis may help you gain control over your osteoarthritis pain.

Symptoms

Osteoarthritis symptoms often develop slowly and worsen over time. Signs and symptoms of osteoarthritis include:

• Pain in a joint during or after use, or after a period of inactivity
• Tenderness in the joint when you apply light pressure
• Stiffness in a joint, that may be most noticeable when you wake up in the morning or after a period of inactivity
• Loss of flexibility may make it difficult to use the joint
• Grating sensation when you use the joint
• Bone spurs, which appear as hard lumps, may form around the affected joint
• Swelling in some cases

Osteoarthritis symptoms most commonly affect the hands, hips, knees and spine. Unless you’ve been injured or placed unusual stress on a joint, it’s uncommon for osteoarthritis symptoms to affect your jaw, shoulder, elbows, wrists or ankles.

Causes

Osteoarthritis occurs when the cartilage that cushions the ends of bones in your joints deteriorates over time. The smooth surface of the cartilage becomes rough, causing irritation. Eventually, if the cartilage wears down completely, you may be left with bone rubbing on bone — causing the ends of your bones to become damaged and your joints to become painful.

It isn’t clear what causes osteoarthritis in most cases. Researchers suspect that it’s a combination of factors, including being overweight, the aging process, joint injury or stress, heredity, and muscle weakness.

Risk factors

Factors that increase your risk of osteoarthritis include:

• Older age. Osteoarthritis typically occurs in older adults. People under 40 rarely experience osteoarthritis.
• Sex. Women are more likely to develop osteoarthritis, though it isn’t clear why.
• Bone deformities. Some people are born with malformed joints or defective cartilage, which can increase the risk of osteoarthritis.
• Joint injuries. Injuries, such as those that occur when playing sports or from an accident, may increase the risk of osteoarthritis.
• Obesity. Carrying more body weight places more stress on your weight-bearing joints, such as your knees. But obesity has also been linked to an increased risk of osteoarthritis in the hands, as well.
• Other diseases that affect the bones and joints. Bone and joint diseases that increase the risk of osteoarthritis include gout, rheumatoid arthritis, Paget’s disease of bone and septic arthritis.

When to seek medical advice

If you have swelling or stiffness in your joints that lasts for more than two weeks, make an appointment with your doctor.

If you’re already taking medication for osteoarthritis, contact your doctor if you’re experiencing side effects from arthritis medications. Tell your doctor if you experience side effects such as nausea, abdominal discomfort, black or tarry stools, constipation, or drowsiness.

Tests and diagnosis

If your doctor suspects you have osteoarthritis, he or she will examine your affected joint and ask you questions about your joint pain. To better understand the cause of your pain, he or she may also recommend:

• X-rays. X-ray images of your affected joint may reveal a narrowing space within a joint, which indicates that the cartilage is breaking down. An X-ray may also show bone spurs around a joint.
• Blood tests. Blood tests may help rule out other causes of joint pain, such as rheumatoid arthritis.
• Joint fluid analysis. Your doctor may use a long needle to draw fluid out of the affected joint. Examining and testing the fluid around your joint can determine if your pain is caused by gout or an infection.
• Examining the joint with a tiny camera (arthroscopy). In some cases, your doctor may recommend arthroscopy to see inside your joint in order to determine the cause of your pain. During arthroscopy, small incisions are made around your joint and a tiny camera is inserted to see inside your joint. Your doctor watches a video screen to look for abnormalities within your joint.

Complications

Osteoarthritis is a degenerative disease that worsens over time. As many as a third of people with osteoarthritis will eventually experience significant disability. Joint pain and stiffness may become severe enough to make getting through the day difficult, if not impossible. Some people are no longer able to work. When joint pain is this severe, doctors typically suggest joint replacement surgery. For those who aren’t able to undergo surgery, pain medications and assistive devices can make daily tasks more manageable.

Treatments and drugs

Initial treatment options for mild osteoarthritis
For mild osteoarthritis pain that is bothersome, but not enough to have a great impact on your daily activities, your doctor may recommend that you:

• Rest. If you’re experiencing pain or inflammation in your joint, rest it for 12 to 24 hours. Find activities that don’t require you to use your joint repetitively. Try taking a 10-minute break every hour.
• Exercise. With your doctor’s approval, get regular exercise when you feel up to it. Stick to gentle exercises, such as walking, biking or swimming. Exercise can increase your endurance and strengthen the muscles around your joint, making your joint more stable. Avoid exercising tender, injured or swollen joints. If you feel new joint pain, stop. New pain that lasts more than two hours after you exercise probably means you’ve overdone it.
• Lose weight. Being overweight or obese increases the stress on your weight-bearing joints, such as your knees and your hips. Even a small amount of weight loss can relieve some pressure and reduce your pain. Aim to lose 1 or 2 pounds a week, at most. Talk to your doctor about healthy ways to lose weight. Most people combine changes in their diet with increased exercise.
• Use heat and cold to manage pain. Both heat and cold can relieve pain in your joint. Heat also relieves stiffness and cold can relieve muscle spasms. Soothe your painful joint with heat using a heating pad, hot water bottle or warm bath. Heat should be warm, not hot. Apply heat for 20 minutes several times a day. Cool the pain in your joint with cold treatments, such as with ice packs. You can use cold treatments several times a day, but don’t use cold treatments if you have poor circulation or numbness.
• Work with a physical therapist. Ask your doctor for a referral to a physical therapist. The physical therapist can work with you to create an individualized exercise plan that will strengthen the muscles around your joint, increase your range of motion in your joint and reduce your pain.
• Find ways to avoid stressing your joints. Find ways to go about your day without stressing your joints. An occupational therapist can help you discover ways to do everyday tasks or do your job without putting extra stress on your already painful joint. For instance, a toothbrush with a large grip could make brushing your teeth easier if you have finger osteoarthritis. A special seat in your shower could help relieve the pain of standing if you have knee osteoarthritis.
• Apply over-the-counter pain creams. Creams and gels available at the drugstore may provide temporary relief from osteoarthritis pain. Some creams numb the pain by creating a hot or cool sensation. Other creams contain medications, such as aspirin-like compounds, that are absorbed into your skin. Read the label so you know what you’re using. Pain creams work best on joints that are close the surface of your skin, such as your knees and fingers.
• Try braces or shoe inserts. Consider trying special splints, braces, shoe inserts or other medical devices that can help reduce your pain. These devices can immobilize or support your joint to help you keep pressure off it.
• Take a chronic pain class. The Arthritis Foundation and some medical centers have classes for people with osteoarthritis or chronic pain. Ask your doctor about classes in your area or check with the Arthritis Foundation. These classes teach skills that help you manage your osteoarthritis pain. And you’ll meet other people with osteoarthritis and learn their tips for reducing joint pain or coping with your pain.

Treatment options for moderate osteoarthritis
Osteoarthritis pain that persists despite initial treatment may require medications in addition to initial treatment options. Don’t assume that taking a medication is all you need. In order to get the most from your treatment, continue exercising when possible and resting when you need to. If you’re overweight, continue working to lose weight.

Medications that may be useful for moderate arthritis include:

• Acetaminophen. Acetaminophen (Tylenol, others) can relieve pain, but doesn’t reduce inflammation. It has been shown to be effective for people with osteoarthritis who have mild to moderate pain. Taking more than the recommended dosage of acetaminophen can cause liver damage, especially if you consume three or more alcoholic drinks a day. Ask your doctor for guidance on limiting or abstaining from alcohol if you take acetaminophen regularly. Acetaminophen can also affect other medications you may be taking, so be sure to inform your doctor if you’re taking it.
• NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain and reduce inflammation. Over-the-counter NSAIDs include ibuprofen (Advil, Motrin, others) and naproxen sodium (Aleve). Stronger versions of these NSAIDs and others are available by prescription. NSAIDs have risks of side effects that increase when used at high dosages for long-term treatment. Side effects may include ringing in your ears, gastric ulcers, cardiovascular problems, gastrointestinal bleeding, and liver and kidney damage. Consuming alcohol or taking corticosteroids while using NSAIDs also increases your risk of gastrointestinal bleeding.
• Tramadol. Tramadol (Ultram) is a centrally acting analgesic that’s available by prescription. Tramadol has no anti-inflammatory effect, but can provide effective pain relief with fewer side effects – such as stomach ulcers and bleeding – than those of NSAIDs. However, tramadol may cause nausea and constipation. It’s generally used for short-term treatment of acute flare-ups. Your doctor may recommend using tramadol in combination with acetaminophen to increase pain relief.

Treatment options for severe osteoarthritis
If you’ve tried other treatments but are still experiencing severe pain and disability, you and your doctor can discuss other treatments including:

• Stronger painkillers. Prescription pain pills, such as codeine and propoxyphene (Darvon), may provide relief from more severe osteoarthritis pain. These stronger medications carry a risk of dependence, though that risk is thought to be small in people who have severe pain. Side effects may include nausea, constipation and sleepiness.
• Cortisone shots. Injections of corticosteroid medications may relieve pain in your joint. During this procedure your doctor numbs the area around your joint and then inserts a needle into the space within your joint and injects medication. It isn’t clear how or why corticosteroid injections work in people with osteoarthritis. Your doctor may limit the number of injections you can have each year, since too many corticosteroid injections may cause joint damage.
• Visco-supplementation. Injections of hyaluronic acid derivatives (Hyalgan, Synvisc) may offer pain relief by providing some cushioning in your knee. These treatments are made of rooster combs and are similar to a component normally found in your joint fluid. Visco-supplementation is only approved for knee osteoarthritis, though researchers are studying its use in other joints. Injections are typically given weekly over several weeks. Pain relief may last for a few months. Possible risks include infection, swelling and joint pain. People who are sensitive to birds, feathers or eggs shouldn’t undergo visco-supplementation treatments.

Surgery for osteoarthritis
Surgery is generally reserved for severe osteoarthritis that isn’t relieved by other treatments. You may consider surgery if your osteoarthritis makes it very difficult to go about your daily tasks. Surgical treatments include:

• Joint replacement. In joint replacement surgery (arthroplasty), your surgeon removes your damaged joint surfaces and replaces them with plastic and metal devices called prostheses. The hip and knee joints are the most commonly replaced joints. But today implants can replace your shoulder, elbow, finger or ankle joints. How long your new joint will last depends on how you use it. Some knee and hip joints can last 20 years. Joint replacement surgery can help you resume an active, pain-free lifestyle. In smaller hand joints, it can also improve appearance and comfort and may improve your joint’s mobility. Joint replacement surgery carries a small risk of infection and bleeding. Artificial joints can wear or come loose, and may need to eventually be replaced.
• Cleaning up the area around the joint (debridement). Your surgeon may recommend removing loose pieces of cartilage and bone from around your joint to relieve your pain. Debridement is most useful if you’re experiencing a locking sensation from a torn cartilage or loose debris in your knee joint. Debridement is typically done arthroscopically, meaning only small incisions are made in your body. A tiny video camera is inserted through the incision to allow your surgeon to see inside your joint. The surgeon uses special surgical tools to clean out any debris pieces from your joint.
• Realigning bones. Surgery to realign bones may relieve pain. These types of procedures are typically used when joint replacement surgery isn’t an option, such as in younger people with osteoarthritis. During a procedure called an osteotomy, the surgeon cuts across the bone either above or below the knee to realign the leg. Osteotomy can reduce knee pain by transferring the force of the joint away from the worn-out part of the knee.
• Fusing bones. Surgeons also can permanently fuse bones in a joint (arthrodesis) to increase stability and reduce pain. The fused joint, such as an ankle, can then bear weight without pain, but has no flexibility. Arthrodesis may be an option if you experience severe pain in your joint, but can’t undergo joint replacement surgery.

Lifestyle and home remedies

• Eat a healthy diet. A healthy diet emphasizing fruit, vegetables and whole grains can help you control your weight and maintain your overall health, allowing you to deal better with your arthritis. However, there’s no special diet effective for treating arthritis. It hasn’t been proved that eating any particular food will make your joint pain or inflammation better or worse.
• Take your medications as recommended. By taking medications regularly instead of waiting for pain to build, you will lessen the overall intensity of your discomfort.
• Use assistive devices. Assistive devices can make it easier to go about your day without stressing your painful joint. A cane may take weight off your knee or hip as you walk. Gripping and grabbing tools may make it easier to work in the kitchen if you have osteoarthritis in your fingers. Your doctor or occupational therapist may have ideas about what sorts of assistive devices may be helpful to you. Catalogs and medical supply stores may also be places to look for ideas.
• Avoid grasping actions that strain your finger joints. For example, instead of a clutch-style purse, select one with a shoulder strap. Use hot water to loosen a jar lid and pressure from your palm to open it, or use a jar opener. Don’t twist or use your joints forcefully.
• Spread the weight of an object over several joints. Use both hands, for example, to lift a heavy pan. Try using a walking stick or cane.
• Maintain good posture. Poor posture causes uneven weight distribution and may strain ligaments and muscles. The easiest way to improve your posture is by walking. The faster you walk, the harder your muscles must work to keep you upright. Some people find that swimming also helps improve their posture.
• Use your strongest muscles and favor large joints. Don’t push open a heavy glass door. Lean into it. To pick up an object, bend your knees and squat while keeping your back straight.
• Choose appropriate footwear. Wearing comfortable cushioned shoes that properly support your weight is especially important if you have arthritis in your weight-bearing joints or back.

Coping and support

Medications and other treatments are key to managing pain and disability, but another major component to treatment is your own attitude. Your ability to cope despite pain and disability caused by osteoarthritis often determines how much of an impact osteoarthritis will have on your everyday life. Talk to your doctor if you’re feeling frustrated. He or she may have ideas about how to cope or refer you to someone who can help. In the meantime, try to:

• Keep a positive attitude. Make a plan with your doctor for managing your arthritis. This will help you feel that you’re in charge of your disease, rather than vice versa. Studies show that people who take control of their treatment and actively manage their arthritis experience less pain and function better.
• Practice relaxation techniques. Hypnosis, guided imagery, deep breathing and muscle relaxation can all be used to control pain.
• Know your limits. Rest when you’re tired. Arthritis can make you prone to fatigue and muscle weakness – a deep exhaustion that makes everything you do a great effort. A rest or short nap that doesn’t interfere with nighttime sleep may help.

Alternative medicine

People who aren’t helped by medications for osteoarthritis pain sometimes turn to complementary and alternative medicine practices for relief. Mainstream doctors are becoming more open to discussing these options with their patients. But, since few of these treatments have been extensively studied in clinical trials, it’s difficult to assess whether these treatments are helpful for osteoarthritis pain. In some cases, the risks of these treatments aren’t known.

If you’re interested in trying complementary and alternative medicine therapies for your osteoarthritis pain, discuss these treatments with your doctor first. He or she can help you weigh the benefits and risks and tell you if the treatments will interfere with your current osteoarthritis medications.

Some common complementary and alternative treatments that have shown some promise for osteoarthritis include:

• Acupuncture. During acupuncture, tiny needles are inserted into your skin at precise spots. Practitioners believe the needles free or redirect your body’s energy in order to relieve pain. Studies of acupuncture for knee osteoarthritis have been mixed. Most studies haven’t found a benefit, though some have found some short-term relief of pain. Acupuncture can be safe if you select a reputable practitioner — ask your doctor to suggest someone. Risks include infection, bruising and some pain where needles are inserted into your skin.
• Ginger. The ginger plant is best known for its use in cooking, but some research has found ginger extract may be helpful in reducing osteoarthritis pain. Limited studies have been conducted with ginger in people with osteoarthritis, and results have been mixed. Side effects of ginger supplements can include heartburn and diarrhea. Talk to your doctor before taking ginger supplements, since they can interfere with prescription medications such as warfarin (Coumadin).
• Glucosamine and chondroitin. Studies have been mixed on these nutritional supplements. Some have found benefits for people with osteoarthritis, while others haven’t. Tell your doctor if you’re considering taking these supplements. Don’t use glucosamine if you’re allergic to shellfish. Chondroitin sulfate may affect blood levels of warfarin if you’re taking that medication.
• Magnets. Some people believe placing magnets near your affected joint can relieve osteoarthritis pain. Some small studies have found magnets can provide temporary pain relief, though others haven’t found any benefit from magnets. It isn’t clear how magnet therapy might work. Still, a variety of magnetic products, such as bracelets, are available. Magnets appear to be safe.
• Tai chi and yoga. These movement therapies involve gentle exercises and stretches combined with deep breathing. Many people use these therapies to abate stress in their lives, though small studies have found that tai chi and yoga may reduce osteoarthritis pain. More study is needed to understand whether tai chi and yoga can relieve osteoarthritis pain. Talk to your doctor if you’d like to give tai chi or yoga a try. When led by a knowledgeable instructor, these therapies are safe. But don’t do any moves that cause pain in your joints.