FAQs - Diagnosis of and Therapies for Joint Pain and Arthritis

Do I have arthritis?
What is the difference between arthritis and rheumatism?
How many types of arthritis exist?
How do you distinguish between the different types of arthritis?
What is the cause of arthritis?
Is low back pain a form of arthritis?
What should I do when I have a joint pain?
What tests are helpful to diagnose the arthritis?
What is the difference between an X-ray, MRI and ultrasound?
What are the goals and principles of arthritis therapy?
What medicine should I take when I have a joint pain?
Should I exercise if I have arthritis?
What is the role of physical therapy in arthritis?
What is the role of joint injections in the management of arthritis?
Is diet beneficial for arthritis?
When is the right time to think about joint replacement?
Is arthritis preventable?
Can I be cured of arthritis?
Can food supplements and herbs benefit arthritis?
What is your opinion on acupuncture in arthritis?
What is the role of chiropractors in arthritis therapy?
Are there any complementary medicines available for joint injections?
How physicians choose drug to treat arthritis?
What is evidence-based medicine?
What is the role of chiropractors in arthritis therapy?
What is the future of arthritis therapy?

Do I have arthritis?

To answer this question we should start with the meaning of the word “arthritis.” Arthritis is defined as an ailment process affecting joints. Joints represent hinge-like structures connecting two or more bones. Structurally, the joints consist of bone ends covered with a dense sponge-like tissue called cartilage, joint capsule and joint cavity. The internal lining of the joint capsule is called the synovium (synovial membrane). One of the key functions of the synovium is production of various substances lubricating the movement of the joint and nourishing the cartilage. The normal joint space is occupied by a small amount of synovial fluid which in part comes from the blood filtration and produced by the synovium. The joints are stabilized by fibrous bands called ligaments. The movement of the joints is mediated by muscles which are attached to the bones via tendons. In general, ligaments, tendons and muscle surrounding the joints are called soft tissues.

The arthritic process can affect any part of the joint including cartilage, synovial lining and the bone. Certain types of arthritis can also affect soft tissue structures surrounding the joint.

When it is active, arthritis manifests in the form of joint pain, stiffness, swelling, increase in skin temperature and changes in skin color. Some forms of arthritis can be minimally symptomatic during their early stages. Advanced forms of arthritis cause joint deformity and muscle atrophy and eventually result in the function loss. Arthritis can affect any joints in our body.

Therefore, if you have any of the symptoms listed above, there is a high probability that you have arthritis. However, do not make a self-diagnosis. See a physician as soon as you can.


What is the difference between arthritis and rheumatism?

In lay language both terms are often used interchangeably. However, some differences in their meaning do exist. Generally, when we say “arthritis” we mean a disease limited to the joints, and when we refer to ”rheumatism” we mean a systemic autoimmune or systemic inflammatory illness affecting the entire body including the joints.


How many types of arthritis exist?

There are 100 different types of arthritis which can be divided into two large groups: acute and chronic.

Acute arthritis is commonly caused by various infection agents (e.g., viruses, bacteria, etc.), foods (allergic arthritis) or trauma. In most cases it is a self-limited and curable disease.

By definition, chronic arthritis is a disease whose course is characterized by periods of activation (exacerbation) and dormancy (remission). From a simplicity stand point, the chronic arthritis can be further subdivided into inflammatory, degenerative and crystal-induced types.

The term “inflammatory arthritis” encompases a large group of illnesses such as rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, etc. united by the fact that ongoing inflammation serves as a primary force destroying joints.

The classic example of a degenerative arthritis is osteoarthritis. This disease affects almost every human being after the age of 50 and is characterized by slowly progressive cartilage degeneration (wear and tear) and joint deformities as a result of a repetitive trauma and injury. Degenerative arthritis can also be seen in patients with various metabolic and hormonal abnormalities and in patients whose diet is deficient in certain nutrients and minerals. Finally, burned out inflammatory arthritis can get transformed into a degenerative form.

Crystal-induced arthritis is caused by deposition of various poorly soluble organic and inorganic crystals in the joints. Gout is the most known crystal-induced arthritis. Crystal precipitation and local activation of immune responses are the critical events in the development of this type of arthritis.

Furthermore, chronic arthritis may be a part of generalized autoimmune and systemic illnesses such as lupus, scleroderma, Sjogren’s syndrome, Behcet’s disease, systemic vasculitis, etc.

Various types of chronic arthritis can coexist in the same body. For example, it is not uncommon to diagnose a patient with psoriatic arthritis, gout and osteoarthritis.


How do you distinguish between the different types of arthritis?

It is a goal of a qualified physician to establish the right diagnosis. However, several characteristics may help predict the presence of one or more forms of chronic arthritis.

Inflammatory arthritis is frequently associated with prolonged morning stiffness (30 minutes or longer). The pain from inflamed joints gets worse at rest and better after mild to moderated exertion. The skin over an inflamed joint feels warmer than over non-inflamed ones.

Morning stiffness in patients with osteoarthritis lasts less than 30 minutes. The osteoarthritic joint pain gets better at rest and worse after exertion.

Arthritis due to crystal deposition commonly flares up at night.

Different types of arthritis also have distinct patterns of the affected joints distribution.

Learn about arthritis but do not diagnose yourself.


What is the cause of arthritis?

Development of arthritis is a complex process where interplay of three factors: genetics, environment and causative factor, takes place. The list of causative factors includes infectious agents, certain foods (e.g., alcohol in patients with gout and wheat in patients with gluten intolerance), trauma etc. However, in most of the patients with chronic arthritis the causative factor is unknown.


Is low back pain a form of arthritis?

Low back pain is not a disease but rather a symptom. In some patients, low back pain may be a sign of an underlying arthritis affecting the spine. The most frequent arthritis affecting the spine is osteoarthritis. Other common forms of arthritis affecting the spine include ankylosing spondylitis, psoriatic arthritis and gout.

What is the difference between osteoarthritis and osteoporosis?

Although they sound alike, osteoarthritis and osteoporosis are two completely different illnesses. Osteoarthritis is a chronic degenerative arthritis while osteoporosis is a disease of bones (increased bone fragility due to calcium loss).


What should I do when I have a joint pain?

Join pain is a condition which requires medical attention. There are different medical specialists that can provide you with various degrees of expertise regarding nature and management of joint pain. Initially, patients with a relatively new onset of joint pain should see their primary care physicians who perform the initial work up, including physical examination, x-ray and laboratory tests. In uncomplicated cases, a primary care physician provides patients with appropriate therapy.

In more complex situations, patients with joint pain are referred to orthopedic surgeons, sport medicine practitioners or rheumatologists. Patients with chronic joint pain should see a rheumatologist.

An acute joint swelling is considered a medical emergency and requires medical attention within 24 hours.


What tests are helpful to diagnose the arthritis?

There are no universal tests used to diagnose arthritis. In general, the diagnosis is based on patient’s history, physical examination, results of specific laboratory tests and imaging data. The goal of the diagnostic work up is to establish the accurate diagnosis and to define the disease activity. These are obligatory steps since only the combination of specific diagnosis and disease activity can predict the disease course and help in choosing of optimal therapy.


What is the difference between an X-ray, MRI and ultrasound?

All three diagnostic techniques are complimentary in the assessment of arthritis. X-rays help to examine gross structure of the bones, joint alignment and changes in the joint space. MRI (magnetic resonance imaging) is useful in evaluation of bones, joints and soft tissues as well as nerves (e.g, spinal cord and spinal nerves). Both X-ray and MRI-based approaches are mostly used to define normal versus abnormal anatomy. The ultrasound is utilized to define abnormalities in ligaments, tendons and muscles (the sound waves do not penetrate inside of the bones). It is also used to study real-time joint movement and changes in blood flow in the joints and soft tissues. The ultrasound is the least invasive technique and can be easily performed at the bedside. It is also helpful in the guiding of various procedures including joint aspirations and injections.


What are the goals and principles of arthritis therapy?

The therapy for arthritis is focused on the following goals:
a) pain and inflammation control;
b) preservation of the joint anatomy and mechanics;
c) prevention of the disease exacerbation; and
d) preservation of muscle function.

The precise therapy of arthritis begins when the diagnosis is established. One of the key issues in the arthritis therapy is the identification and elimination of the disease root. This is feasible only in certain types of arthritis. For example, normalization of uric acid concentration helps patients with gout and eradication of an infectious agent causing septic arthritis cures the arthritis. In the majority of the patients with arthritis, the therapy is focused on symptom and disease modification. Symptom-modifying therapy mainly is for pain control. Disease-modifying therapy is for control of inflammation as well as preservation of the joint anatomy and function. The drugs used for the disease-modifying therapy are called Disease Modifying Anti-Rheumatic Drugs (DMARDs). The DMARDs include several drugs with antibiotic-like activities and drugs modifying immune responses (immunosuppressants). Most of the DMARDs are used on a chronic basis for many years. Because of this, the continuous administration of DMARDs requires monitoring of their potential side effects by analyzing specific blood test results, episodic eye examination etc. Another class of drugs used for the disease modification is biologic drugs or biologics. These drugs represent biological molecules generated in animals or in the tube via genetic engineering. Typically, biologics are stronger than DMARDs in respect to their disease modification. However, their administration is associated with the higher risk and seriousness of adverse reactions as compared to the DMARDs. As with DMARDs, biologics also require side effect monitoring. Quite frequently, the optimal arthritis control requires simultaneous administration of DMARDs in combination with a biologic.


What medicine should I take when I have a joint pain?

There are no universal drugs which should be taken for joint pain. The choice of a particular medicine depends on the severity of pain, anatomy of painful area/joint, coexistent conditions and pain duration. The agents currently used to treat pain can be divided into categories of systemically administered and topical drugs. Systemic drugs to treat pain include acetaminophen (Tylenol), non-steroidal anti-inflammatory drugs (NSAIDs) (aspirin, ibuprofen, naproxen), COX-2 inhibitors (celecoxib or Celebrex), narcotic-based or so called opioid analgesics, antidepressants and muscle relaxants. Sometimes, other drugs such as anti-seizure medications, hormones and blood-pressure medicines are used in complex pain management. Topical agents to treat pain include prescriptional lidocaine-based patch (Lidoderm), NSAID-containing creams and ointments and various over-the counter remedies containing menthol, eucalyptus oil, etc.

The decision regarding the drug administration for pain control can be made only by a physician on the basis of patient’s history, physical examination and additional tests. In complex and complicated situations, finding the right drug or drug combination takes time and involves empirical trials of several drugs.


Should I exercise if I have arthritis?

Exercises are the key part of a combination therapy for arthritis. Arthritic joints are characterized by joint stiffness and gradual loss of mobility as well as slow progressive muscle atrophy and weakness. Several medications which are used to treat arthritis can also weaken the muscles. Therefore, the main goal of regular exercises is preservation of the muscle strength and function.

Muscles are important producers of energy and regulators of glucose metabolism. Various inflammatory processes can interfere with energetic processes in the body and via complex mechanisms can cause premature diabetes and atherosclerosis. Respectively, another aim of the regular exercises is to normalize energy generation and prevent disturbances in glucose and lipid metabolism.

There are no generic recipes for exercises in arthritis. However, certain rules should be implemented.

It is difficult to exercise when you have joint pain. Therefore, appropriate pain control before starting exercises is a must.

Sustained and repetitive pain after exercises tells you that the physical activity you are doing is not suitable for the type of arthritis you have. Do not push yourself above your pain limits.

Inflamed joints are more prone to injuries than non-inflamed ones. Control of the inflammation is another must before exercises.

Warm up your muscle before exercising.

In general, your physician and/or physical therapist should create a customized exercise program which should be reassessed every 4–6 months. The individual approach typically takes into consideration the specific forms of arthritis, activity of inflammation, degree of the joint deformities and anatomical distribution of the affected joints as well as functional reserve of the body as a whole. In the best medical centers, the exercise programs are also customized on the basis of specific electrical activities of various muscle groups as measured by the electromyography.


What is the role of physical therapy in arthritis?

Physical therapy is another important component of a traditional rehabilitation therapy for arthritis. Typically, it serves as a bridge between the medicamentous therapy and a home based exercise program. Different modalities within the physical therapy include passive and active range of motion, joint mobilization, therapeutic ultrasound, iontophoresis, electrical and thermal therapy, etc. Another part of physical therapy is pool or aquatic therapy where exercises can be performed in a more efficient way due to reduced gravity forces.

In an optimal scenario, the customized physical therapy program is designed by a physician and physical therapist followed by a formal physical reevaluation every one or two months.


What is the role of joint injections in the management of arthritis?

Joint injections are useful modalities in arthritis therapy. Practically speaking, any particular joint in the human body can be reached with the needle. Superficially, localized joints can be injected in a blind way, deeper joints and joints surrounded by major blood vessels and nerves are injected under imaging guidance. It has been well documented that even in the hands of an experienced physician, the accuracy (the exact placement of the needle into the joint cavity) of a blindly performed joint injection is far from perfect (70-75%). Therefore, more physicians perform joint injections under real-time direction such as with ultrasound.

Performance of a joint injection includes several consecutive steps. Initially, the physician will identify the correct anatomical place for the needle insertion. The skin over the selected area is cleaned with antimicrobial soap, disinfectant and alcohol.

The skin and soft tissues are then numbed (anesthesized) with either Lidocaine or Marcaine. If the joint has an extra amount of fluid, the fluid is aspirated (drained). After, aspiration, the joint is injected with the appropriate medicine. It is strongly recommended to immobilize the aspirated and/or injected joint for 12–24 hours and apply a cold pack to the injected area for 10–15 minutes every hour for 6–12 hours. Usually, it takes several days before the injected drug starts working.

Currently, two types of drugs are most commonly used for joint injections: long-acting corticosteroids (depo-medrol, dexamethasone, triamcinolone, etc.) and viscosupplementation or lubrication agents (hyaluronans and hylans).

Corticosteroid (cortisone) injections are helpful in controlling joint pain due to inflammation (synovitis) or fluid accumulation (joint effusion). These injections can be used in various types of arthritis with limited number of inflamed or affected joints. Several joints can be injected simultaneously. Corticosteroid injections are also used to treat inflammation of tendons, ligaments and other soft tissue structures such as bursa. Corticosteroid injections are relatively safe. Rare side effects can potentially include local reaction to the drug in the form of the joint swelling, redness and pain, disappearance of subcutaneous fat, permanent bone damage, intraarticular bleeding, infection, etc. Infrequent systemic reactions include facial flushing, transient hypertension and fatigue. Patients with diabetes should closely monitor their blood sugar levels within the first week followed the injection. It is considered relatively safe to inject a given joint up to four times a year with corticosteroids.

Viscosupplementation therapy relies on intraarticular injections of hyaluronic acid which is a natural molecule lubricating joint movement produced by joint capsule and cartilage. Currently, viscosupplementation therapy is almost exclusively used in patients with osteoarthritis. This is based on the findings that joint (synovial) fluid in patients with osteoarthritis is thinner than normal due to inappropriate production and accelerated degradation of hyaluronic acid. Most of the hyaluronic acid preparations used for the joint injections are extracted from rooster combs; the exception is a product called Euflexxa which contains pure hyaluronic acid extracted from microorganisms.

Viscosupplementation therapy is mainly used for pain control. The efficacy of the injections depends on how advanced the arthritis is as the injections are more efficient in patients with early stages of the osteoarthritis as compared to the advanced ones. Limited observations indicate that early and continuous use of intraarticular hyaluronic acid may delay the progression of joint degeneration. Currently, hyaluronic acid injections are mainly used for knee and shoulder pain. However, any joint affected by osteoarthritis can benefit from viscosupplementation. A cycle of viscosupplementation consists of a series of 3 to 5 weekly injections. Each cycle should be repeated twice a year on a continuous basis. In general, intraarticular injections of hyaluronic acid are safe. Rare side effects include mainly local reactions. One of the preparations called Synvisc represents a chemically modified hyaluronic acid and infrequently causes severe joint inflammation similar to reactions against foreign bodies or infectious microorganisms. Overall, viscosupplementation therapy plays an important role in complex therapy of osteoarthritis and potentially is capable of postponing the joint replacement.


Is diet beneficial for arthritis?

The gastrointestinal system is the main entry for foreign materials (foods) into the human body and the main transitory route for an enormous mass of microorganisms and products of their activity in the form of feces. Food and microbial products are the main stimulants of the immune system and the main external regulator of various metabolic pathways. Accordingly, composition of the consumed food can influence immune responses and inflammatory processes leading to the development of distinct forms of arthritis. Reversely, various types of arthritis are associated with frequent pathological changes in the intestine and colon.

The role of specific diet in therapy of such forms of arthritis as gout, pseudogot, psoriatic arthritis, ankylosing spondylitis and gluten-associated arthritis is a well accepted fact. Dietary interventions in some other forms of arthritis or autoimmune diseases such as lupus, rheumatoid arthritis, Sjogren’s syndrome and osteoarthritis are still poorly defined. There are no universal recommendations regarding diet in arthritis. For example, the diet which is suitable for patients with gout may not be optimal for patients with ankylosing spondylitis.

There are different approaches in the selection of diet for arthritis. Some approaches are based on the known facts regarding the contribution of particular foods or food components to the development of specific forms of arthritis (e.g., high purine foods contribute to gouty attacks). Other approaches are based on highly individualized immunological responses of a particular person to specific foods and utilize complex immunological tests focused on determining food intolerances.

In general, the selection of the diet should be performed by a physician in cooperation with a qualified nutritionist. Complete compliance with the diet is one of the key factors necessary for the successful outcome of dietary interventions in arthritis.


When is the right time to think about joint replacement?

Joint replacement is a consequence of the failed conservative therapy for arthritis. The criteria for the joint replacement include intense joint pain while at rest which is poorly controlled by medications, inability to walk or perform routine daily activities without significant pain, severe impairment of the joint anatomy causing progressive muscle atrophy and marked joint malfunctioning.

The success of joint replacement is far from perfect. Currently, the highest patient satisfaction reported is with replaced (prosthetic) hips, followed by knees, shoulders, small hand joints and ankles, and finally elbows.

Prosthetic joints are not the native joints. Their range of motion and life span are limited, and they are more prone to infection.

Joint replacement does not include replacement of the joint capsule. Therefore, pathological processes causing diseases of the capsule will still exist after joint replacement and can cause joint swelling, pain and loss of the implants.

Consult both a rheumatologist and an orthopedic surgeon before proceeding with the joint replacement.


Is arthritis preventable?

There are two aspects in arthritis prevention: 1) prophylaxis of arthritis development in a healthy person and 2) averting arthritis progression in a person with preexisted disease.

Prophylaxis of arthritis is an ultimate goal of the preventative medicine. In order to make it practical, one needs to know the trigger factor causing a particular form of arthritis. Unfortunately, there is limited knowledge on the specific causes of many forms of arthritis including rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, arthritis of connective tissue diseases, etc. Among arthritis which can be prevented are gout and certain forms of arthritis caused by infectious agents (e.g., post-streptococcal arthritis) or foods (e.g., gluten-associated arthritis). In order to preserve joint structure and function, prophylactic therapy should be started as soon as possible upon identification of the corresponding risk factors. For example, normalization of increased production of uric acid prevents gouty attack and eliminates destruction of bone and joints secondary to deposition of uric acid crystals.

Prevention of certain forms of osteoarthritis is another feasible task which can be achieved by elimination of joint trauma and through modification of physical activity.

In patients with preexisted arthritis, the prevention therapy should be focused on maximal preservation of the residual joint function and anatomy. This can be reached via optimization of medicamentous therapy and inflammation control, physical therapy and customized exercises, and, if necessary, customized orthotics.


Can I be cured of arthritis?

In general, the term “cure” means sustained disease (arthritis)-free existence without the need of continuous medicamentous therapy. The cure of arthritis can be achieved mainly in patients with acute arthritis. In patients with chronic arthritis, the disease-free state is called remission suggesting that the disease is in its dormant form and sooner or later will come back.

You may wonder why chronic arthritis cannot be cured. There are several reasons. First, adult cartilage does not have an ability to regenerate or fill up the damaged areas. Therefore, once damaged, the cartilage lesions persist until the end of the joint life (joint replacement) or death. The second reason is that in a number of chronic conditions the exact causative agent is unknown. Thus, the treatment is tailored mostly toward symptom relief and not toward the elimination of the cause. Third, genetic factors play a crucial role in the development of certain types of arthritis which are difficult to change. Finally, certain forms of arthritis (e.g., gout) are easily treatable with medications. However, the remission is possible only with continuous use of the medications.


Can food supplements and herbs benefit arthritis?

Food supplements and herbs are important parts of arthritis therapy and typically are intended to fill up certain therapeutic gaps in traditional medicine. The appropriate administration of food supplements and herbs requires a deep knowledge of their biological activities, pharmacological properties, compatibility with western medications and usefulness in the specific types of arthritis.

The common belief that food supplements and herbs are harmless is a misleading one. Similar to the prescription drugs, food supplements and herbs can cause adverse reactions varying from mild gastrointestinal symptoms and skin rash to chronic malfunctioning of internal organs and, in extreme cases, even death. Furthermore, food supplements and herbs can also interact with prescription drugs causing unpredictable outcomes.

Therefore, before buying any food supplements or herbs, you should discuss the appropriateness of their use, the dose and potential side effects and drug interactions with your physician.

There are many groundless statements promising a miracle cure for arthritis from food supplements or herbs. Remember, the miracle cure has not yet been found. Do not become a victim of the gimmicks.


What is your opinion on acupuncture in arthritis?

Acupuncture is one of the oldest therapeutic modalities frequently used to treat pain associated with arthritis. The principle of acupuncture is based on the belief that the body has a system of channels or meridians facilitating the flow of a vital energy called qi (“chee”). The origin of pain is proposed to be linked to the obstruction of the energy flow. Therefore, the purpose of acupuncture is to normalize the energy flow by unblocking the meridians by inserting acupuncture needles into specific points with their subsequent stimulation by hand, heat and/or electricity. Although the science behind acupuncture mechanisms is still quite obscure, its usefulness in therapy of pain is well accepted by MDs and alternative medicine practitioners.

The efficacy of acupuncture in pain relief depends on a number of parameters including pain duration (acute pain is more easily treatable by acupuncture than a chronic pain), the anatomy of the painful area and number of painful joints affected by arthritis, the nature of the consumed drugs for pain (e.g., coadministration of narcotic painkillers and antidepressants significantly diminishes the effectiveness of acupuncture), etc.

The benefits of acupuncture are maximal when it is used in combination with other therapeutic modalities (e.g., drugs, food supplements, herbs, diet, physical therapy, etc.).

Acupuncture does not stop the progression of chronic forms of arthritis, and thus cannot be used as a single/solo therapy in such conditions as rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis and osteoarthritis.

As with any other therapies, you should consult your doctor if you are considering acupuncture for the relief of arthritis pain.


What is the role of chiropractors in arthritis therapy?

Chiropractic care is another form of alternative therapy for arthritis (mainly affecting the spine) which is similar to physical therapy.

Chiropractors, also known as doctors of chiropractic, use a type of "hands-on" therapy called spinal manipulation (or adjustment) as their main clinical procedure. Two common techniques used are the recoil thrust and the rotational thrust. The recoil thrust requires the patient to lie face down on a special table that moves slightly downward as thrusts are made by the practitioner to accomplish adjustments. The rotational thrust requires the patient to lie with the upper body twisted counter to the pelvis. The chiropractor then applies short, fast thrusts to the spine.

Today, the majority of practicing chiropractors mix spinal adjustments with other therapies such as hot or cold treatments, nutrition counseling, and exercise recommendations.

Chiropractic treatments may be valuable when combined with other alternative and traditional therapies for arthritis under physician’s supervision.


Are there any complementary medicines available for joint injections?

There are two groups of complementary agents available for the joint injections: 1) medications for prolotherapy and 2) homeopathic remedies. Both groups of agents are used almost exclusively in patients with osteoarthritis.

It is well recognized that joint degeneration is associated with joint instability and changes in the quality of connective tissue forming ligaments and tendons. The prolotherapy proposes that injection of certain agents capable of forming scar-like tissue can benefit the quality of arthritic ligaments and tendons and therefore stabilize the arthritic joints. The prolotherapy injections are mainly used in patients with chronic low back pain and osteoarthritis. Although prolotherapy is not well accepted in the medical community due to the lack of strong scientific support of its efficacy, certain patients do benefit from it.

Two homeopathic preparations, Zeel and Traumeel are also available for the joint injections. They both contain very low concentrations of several herb extracts and salts and labeled for use in patients with mild forms of arthritis. The efficacy of this preparation has not had sufficient study.


How physicians choose drug to treat arthritis?

The choice of a particular drug or drug combination to treat arthritis is a complex process. First, it depends on the diagnosis which includes the specific type of arthritis and arthritis activity. The selection is typically based on the knowledge of mechanisms of disease origin and progression, benefits and potential side effects of the selected drugs, consequences of their long-term drug administration, drug interactions etc. Furthermore, physician’s intuition and personal preferences on the basis of experience play are important parts of this process.


What is evidence-based medicine?

Evidence-based medicine is a medical “movement” which is trying to create standards of therapy, including arthritis therapy, on the basis of meta-analysis of scientific literature, risk-benefit analysis and randomized controlled clinical trials.

Although evidence-based medicine is a progressive trend that is becoming a gold standard for medical practice and therapy, it does not directly answer the question of what is best for a given patient and, to a certain degree, discounts the value of physician personal experience and intuition.

An element of a subjectivism is always present even in the best designed clinical trials which may affect the trial outcome and subsequently negatively influence the decision making process of practicing physicians. These include, predominant funding of trials with predicted beneficial outcome, bias in analysis of the data due to financial rewards, suboptimal selection of patients for clinical studies, bias toward results which are dramatizable, etc.

The more complex the patient population (e.g., severity of condition, co-moribid conditions, etc.) in the study, the more difficult it is to assess the treatment effect (e.g., treatment mean - control group mean). Because of this, a number of studies obtain non-significant results, either because there is insufficient power to show a difference or because the groups are not well-enough "controlled."

In managed healthcare systems, evidence-based guidelines have been used as a basis for denying insurance coverage for some treatments which are held by the physicians involved to be effective, but of which randomized controlled trials have not yet been published or will never be published due to the rareness of the treated illness. Evidence-based medicine has also been criticized for using a very specific, mathematical and statistical derived form of evidence.

Application of evidence-based medicine is not suitable for certain types of complementary therapies such as acupuncture and homeopathic medicine where the diagnostic and even therapeutic procedures are highly customized.


What is the role of chiropractors in arthritis therapy?

Chiropractic care is another form of alternative therapy for arthritis (mainly affecting the spine) which is similar to physical therapy.

Chiropractors, also known as doctors of chiropractic, use a type of "hands-on" therapy called spinal manipulation (or adjustment) as their main clinical procedure. Two common techniques used are the recoil thrust and the rotational thrust. The recoil thrust requires the patient to lie face down on a special table that moves slightly downward as thrusts are made by the practitioner to accomplish adjustments. The rotational thrust requires the patient to lie with the upper body twisted counter to the pelvis. The chiropractor then applies short, fast thrusts to the spine.

Today, the majority of practicing chiropractors mix spinal adjustments with other therapies such as hot or cold treatments, nutrition counseling, and exercise recommendations.

Chiropractic treatments may be valuable when combined with other alternative and traditional therapies for arthritis under physician’s supervision.


What is the future of arthritis therapy?

The future of arthritis therapy is in the development of highly efficient medications with minimal side effects capable of arresting the disease progression. The therapy is customized to the patient’s genetic profile and stages of arthritis. Better understanding of our genetics will also results in a design of preventative therapies. Furthermore, fusion of traditional and complementary therapies will continue and  result in broader introduction of herbal based-medicines into the physician’s daily practice. Advances in stem cell research, cartilage transplantation and sophistication in rehabilitation therapies will facilitate a complete restoration of joint anatomy and function affected by various form of arthritis. The future of arthritis therapies looks promising – the hope is coming.

In conclusion

Arthritis is a condition which squeezes the body, twists the extremities, inflates the joints and bites the muscles. Do not let it dominate your mind and soul. Do not become a slave of the disease. Keep your spirits up. Keep the hope. The help is coming.

A physician is a navigator who helps patients to avoid dire straits of their disease. Trust your physician. Trust is a guarantee for recovery.





GLUTEN-FREE REMEDIES™ are food supplements and herbs selected by Dr. Shikhman and specially manufactured for the Institute for Specialized Medicine. Learn more.

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