Life with Arthritis in Canada : A personal and public health challenge

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Chapter Two: Prevention and management

Table of Contents

• Introduction
• What we know about the risk factors of arthritis
  • Non-modifiable risk factors
    • Age
    • Sex
    • Hormones
    • Genetic-predisposition
  • Modifiable risk factors
    • Physical inactivity
    • Diet
    • Excess weight and obesity
    • Joint injury
    • Smoking
    • Occupation
    • Infections
• Reducing the impacts of arthritis
  • Education and awareness
  • Early symptom recognition, early detection and diagnosis
  • Self-management
  • Medication
    • Rehabilitation
    • Surgery
• Summary

"I have been persistent in trying to maintain my lifestyle despite the restrictions that deformities, pain and decreased strength/ grip have caused. Most people would probably be amazed that I manage to mountain bike, cross-country ski, swim and walk fairly aggressively, considering my condition. Although I am able to do these activities, I can't do them for as long (usually an hour to an hour and a half) on a daily basis, either because of pain or fatigue. I try to do some cardio activity every other day and on the off days do some weight training and exercises. I feel the benefits of the exercise outweigh the suffering that often occurs afterward. However, there have been lots of activities that I have had to give up."

— Person living with rheumatoid arthritis

Introduction

Arthritis is often mistaken as an inevitable part of aging— as a disease that affects only older individuals and for which there is no effective treatment or intervention. In reality, interventions can reduce the risk of developing certain types of arthritis, primarily osteoarthritis (OA) and gout, and improve the early detection and management of the disease, leading to improved health and quality of life of people living with arthritis.^{1 2 3 4 5}

This chapter provides information on risk factors for arthritis and on existing prevention and management strategies. Risk factors are characteristics that are associated with an increased risk of developing a particular disease or condition, or with the progression and severity of that disease. Risk factors associated with arthritis can be modifiable or non-modifiable. Table 2-1 presents a summary of the available literature on the risk factors associated with arthritis. Data on risk factors from the Canadian Community Health Survey (CCHS) 2007-2008 are also presented and show the distribution of arthritis-related risk factors in the Canadian population. The interventions aimed at reducing the risk of developing some types of arthritis and the ways to reduce the progression and negative impacts of all types of arthritis are also discussed.

Table 2-1: Summary of the evidence around risk factors for arthritis

Risk factor	Evidence	Level of evidence
Levels of evidence: • Accepted risk factor: Evidence from meta-analysis of randomised controlled trials; Evidence from at least one randomised controlled trial; Evidence from at least one controlled study without randomisation; Evidence from at least one other type of quasi-experimental study; Evidence from descriptive studies i.e., comparative studies, correlation studies and case-control studies • Under study: Evidence from expert committee reports or opinion, or clinical experience of respective authority or both; Inconsistent findings from research.
Non-modifiable
Age	Incidence and prevalence of arthritis increases with age. Arthritis can develop at any age.	Accepted risk factor
Sex	Women are disproportionably affected by all forms of arthritis except gout and ankylosing spondylitis (AS). Being a woman has been reported as a risk factor for poorer outcomes.	Accepted risk factor
Female hormones	Possible hormonal link for rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). Evidence of disease changes occurring around menopause and pregnancy, particularly in RA. Associated with disease progression.	Under study
Genetic predisposition	Specific genes associated with increased risk of arthritis. Specific genes associated with severity of RA.	Under study
Modifiable
Overweight and obesity	Associated with development of osteoarthritis (OA) of the hip, knee and hand. Associated with progression of hip OA. Associated with severity/progression of several types of arthritis.	Accepted risk factor for OA Accepted risk for severity/progression of several types of arthritis
Joint injury	Identified risk factor for the development of OA.	Accepted risk factor for OA
Physical inactivity	Associated with increased severity and progression of many types of arthritis.	Accepted risk factor
Smoking	Linked to progression and severity of RA and SLE. Inadequate evidence regarding its association with disease onset.	Under study
Diet	Important role in healthy weight maintenance, which is a key factor in the prevention/reduction of disease progression. Identified risk factor for gout development and management.	Accepted risk factor for gout
Certain occupations	Development of OA: knee, hip, hand.	Under study
Infections	Possible role in the initiation of RA.	Under study

Table 2-1 - Text Equivalent

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What we know about the risk factors of arthritis

Non-modifiable risk factors

"I fatalistically viewed it as a bit of a family curse as rheumatoid arthritis was the ultimate killer of my mother a few years earlier."

— Person living with rheumatoid arthritis

Non-modifiable risk factors include age, sex, female hormones and genetic predisposition. Although their associated risk cannot be altered, understanding them is important for assessing overall risk and may provide an incentive for changing other modifiable risk factors.²

Age

Age is the strongest independent risk factor for arthritis.^{6 7 8 9} While arthritis can affect people of any age, each form of arthritis has a unique peak of onset.^{10 11} For example, the peak age of onset of rheumatoid arthritis (RA) is between 55-64 years in womenand 65-75 years in men. On average, women develop RA ten years earlier than men.^{11 12 13}

Age-related changes such as reduced muscle strength, loosening of ligaments within the joints and the thinning of cartilage cause changes to the joints, making them susceptible to developing arthritis, specifically OA.^{14 15} This is especially evident in the knee, hip and hand joints—the joints that are most commonly affected.^{9 15} After the age of 75 years, the incidence of OA stabilizes.¹⁴

Age of onset may affect the severity of arthritis. For example, childhood-onset systemic lupus erythema- tosus (SLE) may be more severe than adult-onset SLE, while postmenopausal SLE may be milder than pre-menopausal SLE.¹⁶

Sex

Women are affected in greater proportions than men by all types of arthritis, with the exception of psoriatic arthritis (similar between men and women), gout and ankylosing spondylitis (AS) (both higher among men).^{6 9 16 17 18 19 20} For example, 9 out of every 10 people with SLE are women with the peak age at onset occurring during childbearing years.¹⁶ Women consistently report higher rates of both arthritis and arthritis-related physical disability.^{7 12 18}

Being a women seems to amplify the age-related increase in the occurrence of OA in the hand, knee and in multiple joints. After the age of 50, the frequency of OA in these joints is significantly greater in women than in men while the frequency of hip OA increases at about the same rate with age in women and men.¹⁵

The reasons for these differences between men and women are not well understood.⁷

Hormones

The significant increase in some forms of inflammatory arthritis conditions including RA and SLE observed among women during their reproductive years or menopause suggests that female hormones may influence the development or the severity of these forms of arthritis.^{19 20 21 22 23}

The most striking evidence is found during pregnancy in which estrogen and progesterone levels increase greatly during the third trimester. Many studies have documented the reduction or remission of RA symptoms during pregnancy and most profoundly during the third trimester.^{17 22 24} This is followed by an increase in disease activity early in the postpartum period when estrogen and progesterone concentrations fall; the increase is greatest after a first pregnancy.^{7 17 22 25} The return of symptoms during the postpartum period is hypothesized to be associated with the production of prolactin, a pro-inflammatory hormone, during breastfeeding.^{17 22 24 25} Interestingly, men with RA have significantly lowered testosterone concentrations.²⁶ The influence of hormones in individuals with SLE appears to be different from those with RA. The signs and symptoms related to SLE appears to either worsen or remain unchanged during pregnancy.^{27 28 29}

The possibility of a protective effect of past and current use of the oral contraceptive pill (OCP) on RA and SLE has been explored.^{12 16 22 24} OCPs do not appear to prevent RA, but may postpone its development.^{12 22 24} In general, use of OCPs provides a modest protective effect against RA.^{22 24} To date, this protective effect has not been explained, in part due to the limited number of studies that have investigated this relationship in depth.^{12 22 24} While some evidence supports the presence of the role of estrogen in reducing a woman's risk of RA, SLE and Sjögren's syndrome, no evidence supports the use of post-menopausal hormone therapy for risk- reduction purposes.²⁵

Genetic predisposition

"I was not surprised about it; both my parents and my paternal grandmother suffered from arthritis."

— Person living with osteoarthritis

The identification of the genes involved in arthritis will further the understanding of disease mechanisms and biology as well as, the interaction between genes and the environment.³⁰ However, the identification of genes for arthritis is complex. The genes involved may vary among different families or ethnic groups.²⁶ Moreover, even if the same genes were found to be involved, their expression may not be the same in all individuals.^{22 24 30 31}

Specific genes are associated with a higher risk of developing certain types of arthritis. It has been observed that inflammatory types of arthritis tend to run in families and to some extent, most share a similar genetic make-up.^{12 16 20 30 32 33} Most attention has been given to the group of genes called human leukocyte antigens (HLA). The many different HLA gene types are inherited and they are associated with certain autoimmune diseases. People with certain types of HLA genes are more likely to develop autoimmune diseases such as RA, AS, SLE and Sjögren's syndrome.³⁴ Significant evidence also supports the role of genetics in the development of OA.^{8 14 15 35 36}

Genetics are influenced and affected by the indi- vidual's environment: the risk of developing OA following a knee injury increases if the individual has a family history of OA.^{8 12 20 33 37 38 39} Such association confirms the importance of interactions between the environment and an individual's genetic makeup in the development of arthritis.

Modifiable risk factors

"I began seeing a physiotherapist, who suggested I start getting active by pool walking because the buoyancy of the water would lessen the burden of my excess weight. The first time out I managed to take a few steps. The next day, I took a few more, and the day after that, more still. I thought that since I was already in the water, I may as well try swimming. I swam a length, then ten and eventually, a hundred at a time and I didn't want to stop. In order to become more active, I had to lose weight too, by following the basic rules of proper nutrition, I lost 100 pounds. Seven years after my diagnosis, I am a happy man again. I enjoy my new friends, swimming and planning hikes. Although I still experience arthritis pain on excessively humid days, and I don't know how the disease will progress, today, I would rather think about other things, like future goals. I feel strong, even euphoric."

— Person living with osteoarthritis

Some risk factors for arthritis are modifiable, such as physical inactivity, poor diet, excess body weight and joint injury. While they are mainly associated with the onset of OA and gout, they can be altered in populations who have any form of arthritis to reduce pain, improve function and quality of life.²

The level of evidence on how modifiable risk factors contribute to the occurrence of arthritis varies widely, depending on the type of arthritis (see Table 2-1 for more details). Established modifiable risk factors associated with disease occurrence apply predominately to OA and gout. All modifiable risk factors have also been associated with progression or severity of disease; hence their great potential for improving function and reducing disability.

Physical inactivity

Being physically active has the potential to both prevent the onset of some types of arthritis and ease the pain associated with many, if not all, types of arthritis.^{9 14 15 40 41 42}

Canada's Physical Activity Guide to Healthy Living incorporates stronger bones and muscles as part of the messages on benefits of physical activity.⁴³

Canada's Physical Activity Guide to Healthy Active Living for Older Adults also addresses individuals with arthritis, saying

…it is even more important that you make a commitment to doing gentle movements every day to keep your joints flexible. Small amounts of daily activity can make a huge difference and keep you mobile. Flexibility and strength activities are essential to keep your muscles and joints healthy so that you stay mobile. The more sedentary your lifestyle, the stiffer your joints will become. Seek professional help if you are unsure about what is safe for you. ⁴⁴

Even though being physically active is beneficial for the health of all Canadians, in 2007-2008, half (50%) of the general Canadian population reported being physically inactive during their leisure time. The proportion of women who reported being physically inactive was significantly higher than men in the 15-39, and 60+ year age groups (Figure 2-1). The greatest difference occurred among individuals aged 70 years and over, where 66% of women reported being physically inactive compared to 53% of men.

Figure 2-1 - Text Equivalent

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Physical activity is an important component in the maintenance of healthy weights in all individuals. For people with arthritis and a high body mass index (BMI), weight loss efforts could be beneficial to their overall health and quality of life.^{45 46 47}

People with arthritis who participate in moderate to vigorous physical activity have been shown to improve their functional capacity without increasing disease activity or causing joint damage.^{5 48 49 50 51 52 53} Regular moderate exercise can produce improvements in function, flexibility, muscle strength and endurance, cardiovascular fitness and psychological health.^{3 54 55} Exercise appears to be the most consistently effective method to reducing arthritis-related pain.^{3 55 56} Participation in recreational activities such as running, cycling, walking and dancing have been associated with a positive impact on function, pain and disability.^{9 40 42 48 49 50 51 52 53 56 59} It is important, however, to address several factors — such as pain, fear of injury, joint or muscle stiffness, fatigue or lack of energy, and impaired balance — prior to beginning a regular exercise program.⁵⁵ The key issue is to develop a comfortable balance between rest and activity.

Inactivity can make arthritis worse as a result of reduced joint mobility, strength and fitness, increased fatigue and depression, low pain tolerance and increased risk for developing other chronic conditions such as heart disease and osteoporosis. Individuals with RA report low levels of physical activity, which is a concern since these individuals are at higher risk than the general population for other condition(s) such as heart disease and premature death. Inactivity can also exacerbate muscle wasting and joint stiffness, which further limit their physical function.^{45 60} A similar trend is seen in individuals with OA, where inactivity can lead to joint instability.⁶⁰

Even though physical activity is very important in the management of arthritis, a higher proportion of individuals with arthritis were physically inactive during their leisure time compared to those without arthritis (59% and 49%, respectively).

Physical inactivity among Canadians with and without arthritis increased with age (Figure 2-2). Of concern is the fact that up to 56% of people with and without arthritis between 15 and 39 years of age reported being inactive. Among men aged 60 years and older, those with arthritis were less physically active compared to those without arthritis. The same was true among women aged 40 years and older.

Figure 2-2 - Text Equivalent

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Diet

A healthy diet is a critical component of maintaining a healthy weight for individuals living with arthritis, since being overweight has been identified as a contributor to further progression of the disease.^{49 58 61} A high intake of purine rich foods, such as red meat and seafood, and alcohol consumption are both linked to the development of gout.^{6 62 63} Diet may also play a role in both the onset and the severity of RA, however, the specific diet composition has yet to reach scientific consensus.^{17 22 35 63}

Excess weight and obesity

Being overweight or obese (defined according to the WHO International standards as a body mass index (BMI) of 25–29.9 (overweight) or ≥ 30 (obese)⁶⁴ increases the risk of developing OA and gout. The risk of developing OA and gout increases with increasing weight.^{5 6 7 9 46 47 65 66 67}

A strong association has been demonstrated between obesity and knee OA and a modest association has been shown between obesity and OA of the hip. Those who are obese are 2.5 to 3 times more likely to develop knee OA and 2 times more likely to develop hip OA compared to those with a normal BMI.^{68 69 70} The association between a high BMI and OA of the hand is less certain.⁷¹

Obese individuals who have arthritis are more likely to experience more severe arthritis symptoms and impaired quality of life compared to those with arthritis who maintain a healthy weight.^{8 9 12 15 25 66 72} Furthermore, weight loss interventions decrease pain, improve function in older obese populations with OA of the knee.⁷³

Overweight and obesity may precipitate or lead to progression of OA to the point at which joint replacement needs to be considered. Women and men who are overweight or obese are two times more likely to have a hip or knee replacement than those who have a healthy weight.⁷⁴ Functional recovery after joint replacement surgery is better among those with a healthy weight.⁷⁴

In 2007-2008, approximately one in four boys and one in six girls 12–17 years of age in the general population were overweight or obese (Figure 2-3). Children and youth who are overweight or obese are more likely to be overweight or obese as an adult.

Figure 2-3 - Text Equivalent

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In 2007-2008, one in two adults aged 18 years of age and older (51%) reported a height and weight that put them in the overweight or obese category. The proportion of men who reported being overweight (BMI between 25 and 29.9) was significantly greater than among women in all age groups (Figure 2-4). The proportion of men in the obese category (BMI≥ 30) was significantly greater than women in all age groups except among those aged 60-69 and 70+ years. The largest proportion of men and women in the obese category was among men aged 50 to 59 years and women aged 60–69 years (23% and 22%, respectively). OA is also common in these age groups.

Figure 2-4 - Text Equivalent

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In 2007-2008, 63% of Canadians aged 18 years and over with arthritis reported a height and weight that put them in the overweight or obese category, versus 49% of those without arthritis (Figure 2-5). This difference was more marked among women than men. For example, among women in the 50 to 59 age group, 62% with arthritis were overweight or obese compared to 49% among those without arthritis. Among men of the same age, there was a smaller difference between those with and without arthritis, with proportions of overweight or obese men being 72% among those with arthritis compared to 66% for those without arthritis. Also, a greater proportion of women with arthritis aged 18-29 years (42%) were overweight or obese compared to 26% of women without arthritis. Among men of the same age, there was less of a difference with proportions of overweight or obese men being 56% for those with arthritis versus 41% for those without arthritis.

Figure 2-5 - Text Equivalent

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Joint injury

Injury is an important risk factor for the development of OA.^{9 57} cruciate ligament tears Meniscal and increase the risk of the subsequent development of OA.^{9 15 75} Factors such as having OA in another joint, increasing age, being a woman, or the continued stress of the injured joint might increase the risk of developing OA following a severe knee injury.¹⁵ While joint injuries may be preventable, once they occur, their impact may not be reversible.

"I began to experience pain in 1967 after a sport accident (missed hurdle and fell wrong way on foot). It was diagnosed as a bad sprain and left at that. However, the pain remained and never went away."

— Person living with osteoarthritis

Smoking

Smoking is associated with both the onset and development of inflammatory types of arthritis, namely RA and SLE.^{16 17 24 33 76 77}

The risk of developing RA is higher among smokers, especially men and it also appears to cause a more active, possibly more aggressive, form of RA. ^{12 22 76 78} Smokers are more likely to have a positive rheumatoid factor (RF), even in individuals who do not yet have RA.^{12 22 24 78 79 80 81 82 83 84} Smoking exacerbates the skin related features of SLE.

The mechanisms by which smoking affects inflammatory types of arthritis, and autoimmunity in general, are multiple and not yet well understood.^{76 81} The interaction of smoking with genetic susceptibility further complicates the understanding of these mechanisms.⁷⁶

Occupation

An occupational exposure to crystalline silica has been identified as a strong risk factor for inflammatory types of arthritis.⁷⁷ Mineral dust and vibration exposure have been suggested as possible risk factors for the development of RA, particularly among men.^{11 82}

A strong association was found between occupational activities such as repeated knee bending, kneeling, squatting, or climbing and knee OA among men.^{9 14} Also, a strong association was found between agriculture (including farm work, dairy, animal breeding and producing animal products) and hip OA; and more recently farming has been associated with OA of the knee.^{9 57 83}

Infections

For many years, infection has been suggested as a possible initiator for inflammatory types of arthritis.^{12 19 20 77} Certain viruses have been suggested as contributors to the development of RA and SLE. It is believed that viruses initiate the inflammatory process at the infected site, which in turn play a role in the initiation of RA.²² Viruses may initiate this process by targeting the cells involved in immune function or by directly impacting joint tissues.⁸⁴ The most consistent evidence has been found with the Epstein-Barr virus (EBV) which has been implicated as a potential risk factor for RA for over 25 years, but it remains unknown as to whether it is a cause or a consequence of RA.^{16 22}

Reducing the impacts of arthritis

"I wasn't happy about the diagnosis, but understood why—my mother had been severely crippled with RA long before the latest generation of DMARDs (disease-modifying anti-rheumatic drugs) became available and was in great pain in her final years."

– Person living with rheumatoid arthritis

"I know what to expect when one has a chronic illness. The world doesn't fall apart, you develop trust in your health care providers and research, and you make the most of the opportunities it provides, most of all, you focus on your abilities and the exciting things that the future holds."

— Person living with juvenile rheumatoid arthritis

The impacts of all types of arthritis can be minimized through:

• Education and awareness about arthritis;
• Early recognition of symptoms, early disease detection and diagnosis;
• Self-management including education, physical activity and weight control/exercise programs; and
• Appropriate treatment including medication, rehabilitation and surgery.

These interventions aim to stop or slow down the progression of the disease and reduce disability and other health complications from arthritis.

Education and awareness

Studies have shown that the general public is poorly informed about arthritis and that the public perception is permeated by many myths (see 'Common myths about arthritis').^{85 86 88}

A recent study concluded that some of these beliefs endure and continue to exert an impact on the care- seeking behaviours and the uptake of treatment by individuals with arthritis symptoms or with diagnosed arthritis.⁸⁹

Common myths about arthritis

"Arthritis is an old person's disease"

Although the risk for arthritis increases with age, nearly 3 out of 5 with arthritis are younger than age 65. People of all ages are affected, including children and teens. Juvenile rheumatoid arthritis is one of the most common chronic illnesses of childhood.

"Arthritis is just a normal part of aging"

If this were true, the majority of seniors and no children would have arthritis. In reality, 57% of seniors (> 65 years) don't have arthritis. In addition, two thirds of individuals with arthritis are under the age of 65 and arthritis affects children. Furthermore, some forms of arthritis (e.g. OA and gout) can be prevented.

"Arthritis isn't a serious condition; it's just minor aches and pains. It's best to ignore it"

Most of the joint damage associated with inflammatory arthritis occurs within the first few years after its onset; early and accurate diagnosis is crucial to minimizing its effects.

"There is nothing that can be done for arthritis. You just have to learn to live with it"

While there is currently no cure for arthritis, a person can do many things to relieve the pain, reduce disability and help maintain their ability to do the things that they enjoy. Early diagnosis and appropriate treatment strategies can help reduce the disability and quality of life impacts associated with many types of arthritis. Physical activity, healthy weight, self-management education, rehabilitative interventions, medication, and in severe cases, surgery, can make a difference.

"Joints with arthritis should be rested"

The assumption that an inflamed or painful joint requires rest is a common misunderstanding. Too little exercise can cause muscle weakness, pain and stiffness. People with arthritis should undertake some form of physical activity (as recommended by a physician or a physiotherapist/occupational therapist) such as:

• mobility exercises (e.g., stretching) to improve or maintain the joint's range of motion and flexibility;
• strength exercises, such as weight-bearing activities to build muscle strength, provide stability to the joint, and improve function; and
• aerobic exercises, such as walking or cycling, to improve cardiovascular fitness.

Early symptom recognition, early detection and diagnosis

"I feel that the right amount of attention and education in the early stages of diagnosis would expedite treatment, which is what all the latest research is pointing towards. I would like to see a program set up where all newly diagnosed patients are seen by a team of specialists who can educate them and help them work through the denial that comes with such a diagnosis. Also to set them up on a program of lifestyle changes (exercise, diet, joint protection, massage, etc.) that will benefit them and reduce damages throughout their disease."

— Person living with rheumatoid arthritis

Early diagnosis of inflammatory types of arthritis, such as RA, is particularly important, since early, aggressive therapy may be associated with improved outcomes⁵⁶ Some forms of arthritis, such as lupus, may have a wide variety of clinical presentations that may or may not involve the joints. A complete medical history and physical examination will allow the physician to develop a differential diagnosis, order the appropriate laboratory tests and ultimately formulate a diagnosis and treatment plan.⁵⁶

Public awareness of the value of early recognition of symptoms, diagnosis and treatment is important. Many people with arthritis do not consult with their physician for their symptoms, especially if they are generally in good health and have few activity or work limitations.⁹⁰

Initiatives such as the " Getting a Grip on Arthritis " program have been applied successfully in Canada.⁹¹ They increase the capacity of health providers and people with arthritis to work together to manage the disease by supporting the delivery of arthritis care and emphasizing prevention, early detection, comprehensive care, appropriate and timely access to specialty care, and self-management.

Self-management

"My family tolerated my condition, but I was left home a lot due to pain and not being able to engage in several activities due to pain, discomfort, tiredness and moods. Had to learn to change my lifestyle considerably and do the things I was comfortable with doing. Took the Arthritis Self- Management Program course to help me better cope and later took training to teach others how to self help themselves. This is a most therapeutic and helpful course for those living with arthritis."

– Person living with osteoarthritis

Self-management refers to the tasks that a person must undertake in order to live well with one or more chronic conditions. These tasks include developing the confidence to deal with the medical management, life's roles and emotional management of their conditions.⁹²

Self-management activities, such as participation in education programs and physical activity are central to the non-pharmacological management of arthritis. The American College of Rheumatology* practice guidelines for OA (knee and hip), RA and SLE include self-management programs and patient education as important components of non-pharmacological treatment for these conditions.⁹⁴

Three self-management activities are discussed:

• self-management education, e.g. learning how to control symptoms, medication use, etc;
• maintaining regular, moderate intensity physical activity; and
• controlling weight.⁹⁰

Self-management education is designed to build confidence and skills in managing arthritis on a daily basis. Self-management education programs differ from patient education or skills training in that they are designed to allow people with chronic conditions to take an active part in the management of their own condition.⁹⁵ Program participants learn to gain self- confidence in their ability to control symptoms, how to develop action plans to manage their arthritis, and make connections with others living with arthritis.

* Currently, there are no Canadian practice guidelines for specific types of arthritis.

Many self-management programs are available throughout Canada (for more information visit the Arthritis Society website (www.arthritis.ca) and the Arthritis Consumer Experts website (www.jointhealth. org). Benefits from participating in such programs include:

• reduced pain;
• increased self-care;
• improved functional ability;
• greater confidence in managing the disease;
• increased understanding of arthritis;
• increased coping skills; and
• greater participation in managing the disease.⁹⁸

"The best experience I have had because of my arthritis is that my rheumatologist convinced me to be a contact for the BC Lupus Society and eventually form a Lupus Support Group. I have done this for fifteen years now. I have a whole new circle of friends and have learned so much about SLE. It is a good feeling to be able to be called up to the hospital to talk with a newly diagnosed patient, and say, I have had SLE for over thirty years, and I am still here. You can beat this!"

— Person living with lupus

"Things did eventually get better, I started browsing online and found testimonials from other people struggling with arthritis, on the Arthritis Society's website. This reassured and inspired me. It was such an eye-opening experience for me. I knew I wasn't alone in dealing with this disease in reading these stories, I understood that there was hope. There were steps I could take to relieve my pain and regain my life."

— Person living with osteoarthritis

Medication

For most types of arthritis, treatment often involves the use of medications aimed at reducing pain, maintaining joint function and limiting disease progression. These medications can be used alone or in combination as part of an individual's treatment plan. In recent years, the development of medications for arthritis has advanced and changed significantly. Currently, medications for treating arthritis include analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, disease-modifying anti- rheumatic drugs (DMARDs) and biologic response modifiers (also known as biologics). These medications and their use in the treatment of particular types of arthritis are discussed in more detail in Chapter 7.

Rehabilitation

All types of arthritis are commonly associated with limited function that can be improved using a wide variety of rehabilitation interventions aimed at the whole person and not just the affected structure. They differ depending on the person's condition, needs and health status.

Joint-specific exercises, physical fitness programs, the use of braces, aids and devices, as well as participation in self-management programs can improve activity and participation. They can help an individual develop a more active lifestyle and reduce the pain associated with arthritis, particularly OA and RA.⁹⁹

Surgery

Surgery is normally considered for people with persistent pain despite optimal medicinal, physical and rehabilitative therapies. Several interventions can be performed, depending on the condition, severity, functional limitation or pain. The most well known interventions are arthroscopy, osteotomy and arthroplasty (or joint replacement). Surgery is recommended primarily for people with OA and RA who have end-stage joint damage that is causing unacceptable pain or limitation of function with significant alteration of joint anatomy.⁹⁹ It may also be indicated for spondyloarthropathies such as psoriatic arthritis and AS.⁹⁹ Further discussion about the utilization of surgical services can be found in Chapter 9.

Summary

• Maintaining a healthy body weight and avoiding joint injuries, including sports injuries and occupational-related joint stress, can help to prevent OA.
• Lifestyle changes recommended for the prevention of gout include maintaining a healthy body weight, daily exercise and a reduced consumption of purine-rich foods such as red meat, seafood and alcohol.
• Physical inactivity and obesity can aggravate the progression or severity of many forms of arthritis.
• 50% of the general Canadian population and 59% of Canadians with arthritis reported being physically inactive during their leisure time.
• 51% of the general Canadian population and 63% of Canadians with arthritis reported a height and weight that put them in the overweight or obese category.
• Infections, smoking and diet may play a role in the onset or severity of symptoms in some forms of inflammatory types of arthritis, such as RA or SLE.
• Appropriate management and early diagnosis can help reduce the impact of arthritis. A combination of strategies may be required, including:
  • education about self-management, pain management, and the disease itself;
  • counselling and support;
  • occupational and physical therapy;
  • physical activity;
  • weight reduction;
  • maintenance of a healthy diet;
  • joint protection;
  • prescription and/or over-the-counter medications; and/or
  • surgery.

 

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¹ Bergman S. Public health perspective—how to improve the musculoskeletal health of the population. Best Prac Res Clin Rheumatol 2007;21(1):191–204.

² The Bone and Joint Decade Foundation (BJD), The European League Against Rheumatism (EULAR), The European Federation of National Associations of Orthopaedics and Traumatology (EFORT), and The International Osteoporosis Foundation (IOF). European Action Towards Better Musculoskeletal Health: A Public Health Strategy to Reduce the Burden of Musculoskeletal Conditions—Turning Evidence into Everyday Practice. Bone and Joint Decade, Sweden, 2005. ISBN 91-975284-0-4. URL: www.boneandjointdecade.org/ViewDocument.aspx?ContId=534

³ National Arthritis and Musculoskeletal Conditions Advisory Group (NAMSCAG). Evidence to Support the National Action Plan for Osteoarthritis, Rheumatoid Arthritis and Osteoporosis: Opportunities to Improve Health Related Quality of Life and Reduce the Burden of Disease and Disability. Australian Government Department of Health and Ageing: Canberra, Australia, 2004.URL: www.healthyactive.gov.au/internet/main/publishing.nsf/Content/pq-arthritis-evid

⁴ Rao JK, Hootman JM. Prevention research and rheumatic disease. Curr Opin Rheumatol 2004; 16(2):119–24.

⁵ Felson DT, Zhang Y. An update on the epidemiology of knee and hip osteoarthritis with a view to prevention. Arthritis Rheum 1998;41(8):1343–55.

⁶ Saag KG, Choi H. Epidemiology, risk factors, and lifestyle modifications for gout. Arthritis Res Ther 2006;8(Suppl 1):S2.

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