May 2019- Arthritis Awareness Month

A note from the author— Hello NCP friends! This month, the weather is beautiful and everyone is getting out of the house and participating in all kinds of activities, from sports and outdoor recreation, to gardening and spring cleaning. But for many, all this activity brings aches and pains that, for some, can be debilitating. This month is Arthritis Awareness Month, so help us celebrate by learning more about this disease below, including signs/symptoms, risk factors, and treatment options.

What is Arthritis? There are many different forms of arthritis: degenerative, inflammatory, infectious and metabolic. Our team of orthopedic surgeons uses the latest advancements in diagnostic and treatment techniques, including joint replacement, to help return patients suffering from damage caused by arthritis to a mobile and full lifestyle What is the Impact of Arthritis? Arthritis is one of the most widespread health conditions in the United States. It affects about one in four adults overall. That’s over 54 million men and women. To recognize this toll on Americans’ health, CDC, the Arthritis Foundation and other partners observe Arthritis Awareness Month in May. Arthritis can come in many different forms and can have a wide range of effects on the body. In fact, arthritis can be used to describe more than a 100 conditions that impact the joints, bones and muscles in different ways. Experts believe that more than 50 million Americans are living with arthritis. Shocking right? This disease has actually become so widespread, it is now the leading cause of disability in this country. This is why every May, we celebrate Arthritis Awareness Month.

Arthritis in Rural Areas Arthritis affects working-age adults, older adults, and even children. The number of adults who live in rural or urban areas and are affected by arthritis was the topic of a recently published CDC analysis. Researchers found that more adults in rural areas are affected by arthritis with nearly 1 in 3 affected, than in urban areas. Adults living in the most rural areas were more limited by their arthritis, too. Over half reported being limited by arthritis. Arthritis limitations can include difficulties with moving and performing daily tasks, as well as social and work limitations.

4 Common Myths about Arthritis

1. Arthritis only affects the aging. Arthritis does not discriminate. Anyone, at any age can be affected, according to the Arthritis Foundation. The most common type is osteoarthritis, the kind due to wear and tear on the joints over time (which is what Montana has), but also rheumatoid arthritis, an autoimmune disease that can occur at any age, juvenile arthritis, an autoimmune disease in children, and other types.

2. Joint health is not a serious issue. The population of those with arthritis in the United States is increasing, with 67 million American predicted to have arthritis by 2030. It has slowly become the number one cause of disability in the United States.

3. Those with arthritis should avoid exercise. The Arthritis Foundation recommends starting out walking or doing water workouts. Montana lifts weights to keep his muscles in shape. “When muscles are strong, it takes pressure off them [joints].” Patience White, MD, and vice president of public health for the Arthritis Foundation says resistance training can provide numerous benefits for those who suffer from arthritis. Dr. White recommends simple exercises, including hamstring and calf stretches, or weightlifting with something as simple as 16-ounce soup cans.

4. There is no treatment for arthritis. “I always thought initially that there was nothing you could do to help to ease your everyday life,” Montana said. There are medication and treatments, as well yoga moves to help ease pain, natural remedies, and new treatments are in the pipeline, according to the Arthritis Foundation. Treatment also varies with the type of arthritis. Doctors often recommend those with rheumatoid arthritis get early treatment with medication that can slow the progress of the autoimmune disease, while osteoarthritis treatments may include weight loss, over-the-counter antinflammatories, and other remedies.

What are different categories of Arthritis? There are over 100 different types of arthritis (which will be discussed in the next section), all of which fall into one of four categories: Degenerative arthritis is also referred to as osteoarthritis, which involves the wearing down of bone cartilage over time. Inflammatory arthritis is occurs when the immune system attacks the joints in the body, causing inflammation, pain, and potential joint and organ damage. Infectious arthritis is brought on by an infectious bacteria, virus or fungus that enters the joint, causing pain, stiffness and swelling. Metabolic arthritis, also commonly referred to as gout, is a form of arthritis that causes severe pain and develops due to high levels of uric acid in the body.

What are Common Symptoms of Arthritis? Arthritis is most commonly characterized by joint pain, which can affect many areas of the body such as the hips, knees, hands, shoulders, feet and ankles. It is often accompanied by swelling, stiffness and mobility difficulty.

What Causes Arthritis? It can be difficult to narrow down the cause of arthritis because it covers a wide array of diseases, but common causes of arthritis conditions are:

Impact Injuries

Genetic Predispositions

Sports

Excessive Physical Activity

Autoimmune Disorders

Obesity

Because it’s so hard to identify the exact cause of arthritis, it also makes diagnosing arthritis pretty difficult. If you have been experiencing chronic pain in your muscles, joints or bones we recommend that you speak with a rheumatologist immediately. Diagnosing arthritis early can help improve your odds of successfully treating your symptoms over the long run. Speaking of which, treating arthritis typically involves a combination of pain relievers, physical therapy and lifestyle adjustments. However, your prescribed treatment may differ depending on the type of arthritis you’re diagnosed with. It is true that there is no cure for arthritis. That’s not an easy pill to swallow, but you can still live a great life by working with your doctor and rheumatologist to develop a course of treatment specific to you. This should go beyond medication and include a dietary and lifesrtyle plan. This can reduce the severity of your symptoms and significantly improve your overall quality of life.

What are the most common Types of Arthritis? How much do you know about arthritis? The term “arthritis” can be used to describe more than 100 diseases. These chronic conditions are also referred to as rheumatoid diseases. The most common types of arthritis are:

Rheumatoid Arthritis (RA)

Osteoarthritis (OA)

Osteoporosis

Psoriatic Arthritis

Fibromyalgia

Gout

Spondyloarthritis

Diagnosing and Treating Arthritis Since there are many different types of arthritis caused by several different factors, diagnosis for and treatment of arthritis is very specific to the type of arthritis suffered. You can find more information below about the above listed common types of arthritis, including more detailed information about the following four different types of arthritis (including diagnosis and treatment options): Rheumatoid Arthritis, Osteoarthritis, Osteoporosis, and Psoriatic Arthritis. Rheumatoid Arthritis (RA) Rheumatoid arthritis (RA) is an autoimmune disease in which the body’s immune system – which normally protects its health by attacking foreign substances like bacteria and viruses – mistakenly attacks the joints. This creates inflammation that causes the

tissue that lines the inside of joints (the synovium) to thicken, resulting in swelling and pain in and around the joints. The synovium makes a fluid that lubricates joints and helps them move smoothly. If inflammation goes unchecked, it can damage cartilage, the elastic tissue that covers the ends of bones in a joint, as well as the bones themselves. Over time, there is loss of cartilage, and the joint spacing between bones can become smaller. Joints can become loose, unstable, painful and lose their mobility. Joint deformity also can occur. Joint damage cannot be reversed, and because it can occur early, doctors recommend early diagnosis and aggressive treatment to control RA. Rheumatoid arthritis most commonly affects the joints of the hands, feet, wrists, elbows, knees and ankles. The joint effect is usually symmetrical. That means if one knee or hand if affected, usually the other one is, too. Because RA also can affect body systems, such as the cardiovascular or respiratory systems, it is called a systemic disease. Systemic means “entire body.”

Who’s Affected by Rheumatoid Arthritis? About 1.5 million people in the United States have rheumatoid arthritis (RA). Nearly three times as many women have the disease as men. In women, RA most commonly begins between ages 30 and 60. In men, it often occurs later in life. Having a family member with RA increases the odds of having RA; however, the majority of people with RA have no family history of the disease.

Causes of Rheumatoid Arthritis The cause of RA is not yet fully understood, although doctors do know that an abnormal response of the immune system plays a leading role in the inflammation and joint damage that occurs. No one knows for sure why the immune system goes awry, but there is scientific evidence that genes, hormones and environmental factors are involved. Researchers have shown that people with a specific genetic marker called the HLA shared epitope have a fivefold greater chance of developing rheumatoid arthritis than do people without the marker. The HLA genetic site controls immune responses. Other genes connected to RA include: STAT4, a gene that plays important roles in the regulation and activation of the immune system; TRAF1 and C5, two genes relevant to chronic inflammation; and PTPN22, a gene associated with both the development and progression of rheumatoid arthritis. Yet not all people with these genes develop RA and not all people with the condition have these genes. Researchers continue to investigate other factors that may play a role. These factors include infectious agents such as bacteria or viruses, which may trigger development of the disease in a person whose genes make them more likely to get it; female hormones (70 percent of people with RA are women); obesity; and the body’s response to stressful events such as physical or emotional trauma. Research also has indicated that environmental factors may play a role in one's risk for rheumatoid arthritis. Some include exposure to cigarette smoke, air pollution, insecticides and occupational exposures to mineral oil and silica.

Symptoms of RA In the early stages, people with RA may not initially see redness or swelling in the joints, but they may experience tenderness and pain. These following joint symptoms are clues to RA:

Joint pain, tenderness, swelling or stiffness for six weeks or longer

Morning stiffness for 30 minutes or longer

More than one joint is affected

Small joints (wrists, certain joints of the hands and feet) are affected

The same joints on both sides of the body are affected Along with pain, many people experience fatigue, loss of appetite and a low-grade fever. The symptoms and effects of RA may come and go. A period of high disease activity (increases in inflammation and other symptoms) is called a flare. A flare can last for days or months. Ongoing high levels of inflammation can cause problems throughout the body. Here of some ways RA can affect organs and body systems:

Eyes. Dryness, pain, redness, sensitivity to light and impaired vision

Mouth. Dryness and gum irritation or infection

Skin. Rheumatoid nodules – small lumps under the skin over bony areas

Lungs. Inflammation and scarring that can lead to shortness of breath

Blood Vessels. Inflammation of blood vessels that can lead to damage in the nerves, skin and other organs

Blood. Anemia, a lower than normal number of red blood cells

Diagnosing RA A primary care physician may suspect RA based in part on a person's signs and symptoms. If so, the patient will be referred to a rheumatologist – a specialist with specific training and skills to diagnose and treat RA. In its early stages, RA may resemble other forms of inflammatory arthritis. No single test can confirm RA. To make a proper diagnosis, the rheumatologist will ask questions about personal and family medical history, perform a physical exam and order diagnostic tests. Medical History The doctor will ask about personal and family medical history as well as recent and current symptoms (pain, tenderness, stiffness, difficulty moving). Physical Exam The doctor will examine each joint, looking for tenderness, swelling, warmth and painful or limited movement. The number and pattern of joints affected can also indicate RA. For example, RA tends to affect joints on both sides of the body. The physical exam may reveal other signs, such as rheumatoid nodules or a low-grade fever. Blood Tests The blood tests will measure inflammation levels and look for biomarkers such as antibodies (blood proteins) linked with RA. Inflammation Erythrocyte sedimentation rate (ESR, or “sed rate”) and C-reactive protein (CRP) level are markers of inflammation. A high ESR or CRP is not specific to RA, but when combined with other clues, such as antibodies, helps make the RA diagnosis.

Antibodies Rheumatoid factor (RF) is an antibody found in about 80 percent of people with RA during the course of their disease. Because RF can occur in other inflammatory diseases, it’s not a sure sign of having RA. But a different antibody – anti-cyclic citrullinated peptide (anti-CCP) – occurs primarily in patients with RA. That makes a positive anti-CCP test a stronger clue to RA. But anti-CCP antibodies are found in only 60 to 70 percent of people with RA and can exist even before symptoms start. Imaging Tests An X-ray, ultrasound or magnetic resonance imaging scan may be done to look for joint damage, such as erosions – a loss of bone within the joint – and narrowing of joint space. But if the imaging tests don’t show joint damage that doesn’t rule out RA. It may mean that the disease is in an early stage and hasn’t yet damaged the joints.

Treatment of RA The goals of rheumatoid arthritis (RA) treatment are to:

Stop inflammation (put disease in remission)

Relieve symptoms

Prevent joint and organ damage

Improve physical function and overall well-being

Reduce long-term complications To meet these goals, the doctor will follow these strategies:

Early, aggressive treatment. The first strategy is to reduce or stop inflammation as quickly as possible – the earlier, the better.

Targeting remission. Doctors refer to inflammation in RA as disease activity. The ultimate goal is to stop it and achieve remission, meaning minimal or no signs or symptoms of active inflammation. One strategy to achieve this goal is called “treat to target.”

Tight control. Getting disease activity to a low level and keeping it there is what is called having “tight control of RA.” Research shows that tight control can prevent or slow the pace of joint damage.

Medications for RA There are different drugs used in the treatment of rheumatoid arthritis. Some are used primarily to ease the symptoms of RA; others are used to slow or stop the course of the disease and to inhibit structural damage.

Drugs That Ease Symptoms Nonsteroidal anti-inflammatory drugs (NSAIDs) are available over-the-counter and by prescription. They are used to help ease arthritis pain and inflammation. NSAIDs include such drugs as ibuprofen, ketoprofen and naproxen sodium, among others. For people who have had or are at risk of stomach ulcers, the doctor may prescribe celecoxib, a type of NSAID called a COX-2 inhibitor, which

is designed to be safer for the stomach. These medicines can be taken by mouth or applied to the skin (as a patch or cream) directly to a swollen joint.

Drugs That Slow Disease Activity o Corticosteroids. Corticosteroid medications, including prednisone,

prednisolone and methyprednisolone, are potent and quick-acting anti-inflammatory medications. They may be used in RA to get potentially damaging inflammation under control, while waiting for NSAIDs and DMARDs (below) to take effect. Because of the risk of side effects with these drugs, doctors prefer to use them for as short a time as possible and in doses as low as possible.

o DMARDs. An acronym for disease-modifying antirheumatic drugs, DMARDs are drugs that work to modify the course of the disease. Traditional DMARDs include methotrexate, hydroxycholorquine, sulfasalazine, leflunomide, cyclophosphamide and azathioprine. These medicines can be taken by mouth, be self-injected or given as an infusion in a doctor’s office.

Biologics. These drugs are a subset of DMARDs. Biologics may work more quickly than traditional DMARDs, and are injected or given by infusion in a doctor’s office. Because they target specific steps in theinflammatory process, they don’t wipe out the entire immune response as some other RA treatments do. In many people with RA, a biologic can slow, modify or stop the disease – even when other treatments haven’t helped much.

JAK inhibitors. A new subcategory of DMARDs known as “JAK inhibitors” block the Janus kinase, or JAK, pathways, which are involved in the body’s immune response. Tofacitinib belongs to this class. Unlike biologics, it can be taken by mouth.

Surgery Surgery for RA may never be needed, but it can be an important option for people with permanent damage that limits daily function, mobility and independence. Joint replacement surgery can relieve pain and restore function in joints badly damaged by RA. The procedure involves replacing damaged parts of a joint with metal and plastic parts. Hip and knee replacements are most common. However, ankles, shoulders, wrists, elbows, and other joints may be considered for replacement. Osteoarthritis (OA) Sometimes called degenerative joint disease or degenerative arthritis, osteoarthritis (OA) is the most common chronic condition of the joints, affecting approximately 27 million Americans. OA can affect any joint, but it occurs most often in knees, hips, lower back and neck, small joints of the fingers and the bases of the thumb and big toe. In normal joints, a firm, rubbery material called cartilage covers the end of each bone.

Cartilage provides a smooth, gliding surface for joint motion and acts as a cushion between the bones. In OA, the cartilage breaks down, causing pain, swelling and problems moving the joint. As OA worsens over time, bones may break down and develop growths called spurs. Bits of bone or cartilage may chip off and float around in the joint. In the body, an inflammatory process occurs and cytokines (proteins) and enzymes develop that further damage the cartilage. In the final stages of OA, the cartilage wears away and bone rubs against bone leading to joint damage and more pain.

Who’s Affected? Although OA occurs in people of all ages, osteoarthritis is most common in people older than 65. Common risk factors include increasing age, obesity, previous joint injury, overuse of the joint, weak thigh muscles, and genes. One in two adults will develop symptoms of knee OA during their lives. One in four adults will develop symptoms of hip OA by age 85. One in 12 people 60 years or older have hand OA. Symptoms of OA Symptoms of osteoarthritis vary, depending on which joints are affected and how severely they are affected. However, the most common symptoms are pain and stiffness, particularly first thing in the morning or after resting. Affected joints may get swollen, especially after extended activity. These symptoms tend to build over time rather than show up suddenly. Some of the common symptoms include: Sore or stiff joints – particularly the hips, knees, and lower back – after inactivity or overuse.

Limited range of motion or stiffness that goes away after movement

Clicking or cracking sound when a joint bends

Mild swelling around a joint

Pain that is worse after activity or toward the end of the day

Here are ways OA may affect different parts of the body:

Hips. Pain is felt in the groin area or buttocks and sometimes on the inside of the knee or thigh.

Knees. A “grating” or “scraping” sensation occurs when moving the knee.

Fingers. Bony growths (spurs) at the edge of joints can cause fingers to become swollen, tender and red. There may be pain at the base of the thumb.

Feet. Pain and tenderness is felt in the large joint at the base of the big toe. There may be swelling in ankles or toes.

OA pain, swelling or stiffness may make it difficult to perform ordinary tasks at work or at home. Simple acts like tucking in bed sheets, opening a box of food, grasping a computer mouse or driving a car can become nearly impossible. When the lower body joints are affected, activities such as walking, climbing stairs and lifting objects may become difficult. When finger and hand joints are affected, osteoarthritis can make it difficult to grasp and hold objects, such as a pencil, or to do delicate tasks, such as needlework. Many people believe that the effects of osteoarthritis are inevitable, so they don’t do anything to manage it. OA symptoms can hinder work, social life and family life if steps are not taken to prevent joint damage, manage pain and increase flexibility.

How OA May Affect Overall Health The pain, reduced mobility, side effects from medication and other factors associated with osteoarthritis can lead to negative health effects not directly related to the joint disease. Diabetes and Heart Disease Knee or hip pain may lead to a sedentary lifestyle that promotes weight gain and possible obesity. Being overweight or obese can lead to the development of diabetes, heart disease and high blood pressure.

Falls People with osteoarthritis experience as much as 30 percent more falls and have a 20 percent greater risk of fracture than those without OA. People with OA have risk factors such as decreased function, muscle weakness and impaired balance that make them more likely to fall. Side effects from medications used for pain relief can also contribute to falls. Narcotic pain relievers can cause people to feel dizzy and unbalanced.

Causes of Osteoarthritis Although osteoarthritis was long believed to be caused by the “wear and tear” of joints over time, scientists now view it as a disease of the joint. Here are some of the factors that contribute to the development of OA:

Genes: Various genetic traits can make a person more likely to develop OA. One possibility is a rare defect in the body’s production of collagen, the protein that makes up cartilage. This abnormality can cause osteoarthritis to occur as early as age 20. Other inherited traits may result in slight defects in the way the bones fit together so that cartilage wears away faster than usual. Researchers have found that a gene called FAAH, previously linked to increased pain sensitivity, is higher in people with knee OA than in people who don’t have the disease.

Weight: Being overweight puts additional pressure on hips and knees. Many years of carrying extra pounds can cause the cartilage that cushions joints to break down faster. Research has shown there is a link between being overweight and having an increased risk of osteoarthritis in the hands. These studies suggest that excess fat tissue produces inflammatory chemicals (cytokines) that can damage the joints.

Injury and overuse: Repetitive movements or injuries to joints (such as a fracture, surgery or ligament tears) can lead to osteoarthritis. Some athletes, for example, repeatedly damage joints, tendons and ligaments, which can speed cartilage breakdown. Certain careers that require standing for long periods of time, repetitive bending, heavy lifting or other movements can also make cartilage wear away more quickly. An imbalance or weakness of the muscles supporting a joint can also lead to altered movement and eventual cartilage breakdown in joints.

Others: Several other factors may contribute to osteoarthritis. These factors include bone and joint disorders like rheumatoid arthritis, certain metabolic disorders such as hemochromatosis, which causes the body to absorb too much iron, or acromegaly, which causes the body to make too much growth hormone.

Diagnosing OA To diagnose osteoarthritis, the doctor will collect information on personal and family medical history, perform a physical examination and order diagnostic tests. Health History and Symptoms The information needed to help diagnose osteoarthritis includes:

Description of the symptoms

Details about when and how the pain or other symptoms began

Details about other medical problems that exist

Location of the pain, stiffness or other symptoms

How the symptoms affect daily activities

List of current medications

Physical Examination During the exam, the doctor will examine the joints and test their range of motion (how well each joint moves through its full range). He will be looking for areas that are tender, painful or swollen as well as signs of joint damage. The doctor will examine the position and alignment of the neck and spine. Diagnostic Tests A diagnosis of osteoarthritis may be suspected after a medical history and physical examination is done. Blood tests are usually not helpful in making a diagnosis. However, the following tests may help confirm it:

Joint aspiration. The doctor will numb the affected area and insert a needle into the joint to withdraw fluid. The fluid will be examined for evidence of crystals or joint deterioration. This test can help rule out other medical conditions or other forms of arthritis.

X-ray. X-rays can show damage and other changes related to osteoarthritis to confirm the diagnosis.

MRI. Magnetic resonance imaging (MRI) does not use radiation. It is more expensive than X-rays, but will provide a view that offers better images of cartilage and other structures to detect early abnormalities typical of osteoarthritis.

Treatment of OA Osteoarthritis is a chronic (long-term) disease. There is no cure, but treatments are available to manage symptoms. Long-term management of the disease will include several factors:

Managing symptoms, such as pain, stiffness and swelling

Improving joint mobility and flexibility

Maintaining a healthy weight

Getting enough of exercise Physical Activity One of the most beneficial ways to manage OA is to get moving. While it may be hard to think of exercise when the joints hurt, moving is considered an important part of the treatment plan. Studies show that simple activities like walking around the neighborhood or taking a fun, easy exercise class can reduce pain and help maintain (or attain) a healthy weight. Strengthening exercises build muscles around OA-affected joints, easing the burden on those joints and reducing pain. Range-of-motion exercise helps maintain and improve joint flexibility and reduce stiffness. Aerobic exercise helps to improve stamina and energy levels and also help to reduce excess weight. Talk to a doctor before starting an exercise program. The U.S. Department of Health and Human Services recommends that everyone, including those with arthritis, get 150 minutes of moderate exercise per week.

Weight Management Excess weight adds additional stress to weight-bearing joints, such as the hips, knees, feet and back. Losing weight can help people with OA reduce pain and limit further joint damage. The basic rule for losing weight is to eat fewer calories and increase physical activity. Stretching Slow, gentle stretching of joints may improve flexibility, lessen stiffness and reduce pain. Exercises such as yoga and tai chi are great ways to manage stiffness. Pain and Anti-inflammatory Medications Medicines for osteoarthritis are available as pills, syrups, creams or lotions, or they are injected into a joint. They include:

Analgesics. These are pain relievers and include acetaminophen, opioids (narcotics) and an atypical opioid called tramadol. They are available over-the-counter or by prescription.

Nonsteroidal anti-inflammatory drugs (NSAIDs). These are the most commonly used drugs to ease inflammation and related pain. NSAIDs include aspirin, ibuprofen, naproxen and celecoxib. They are available over-the-counter or by prescription.

Corticosteroids. Corticosteroids are powerful anti-inflammatory medicines. They are taken by mouth or injected directly into a joint at a doctor’s office.

Hyaluronic acid. Hyaluronic acid occurs naturally in joint fluid, acting as a shock absorber and lubricant. However, the acid appears to break down in people with osteoarthritis. The injections are done in a doctor’s office.

Physical and Occupational Therapy Physical and occupational therapists can provide a range of treatment options for pain management including:

Ways to properly use joints

Heat and cold therapies

Range of motion and flexibility exercises

Assistive devices Assistive Devices Assistive devices can help with function and mobility. These include items, such as like scooters, canes, walkers, splints, shoe orthotics or helpful tools, such as jar openers, long-handled shoe horns or steering wheel grips. Many devices can be found at

pharmacies and medical supply stores. But some items, such as custom knee braces and shoe wedges are prescribed by a doctor and are typically fitted by a physical or occupational therapist. Natural and Alternative Therapies Many people with OA use natural or alternative therapies to address symptoms and improve their overall well-being. These include nutritional supplements, acupuncture or acupressure, massage, relaxation techniques and hydrotherapy, among others. Surgery Joint surgery can repair or replace severely damaged joints, especially hips or knees. A doctor will refer an eligible patient to an orthopaedic surgeon to perform the procedure.

Positive Attitude Many studies have demonstrated that a positive outlook can boost the immune system and increase a person's ability to handle pain.

Osteoporosis Bones are living tissue made up of calcium and other minerals. In people with osteoporosis, bone tissue breaks down faster than it is replaced. The bones become thinner and brittle (lose mass) and are more likely to break (fracture) with pressure or after a fall. Bone loss happens without any warning signs. This is why osteoporosis is called a “silent disease.” Bone tissue is replaced regularly in a process called bone turnover. From childhood into young adulthood, the body produces more than enough cells to replace those that die, resulting in stronger, denser bones. By age 25, bones are at peak bone mass and cell turnover remains fairly stable for several years. At about age 40, bone cells start to die at a more rapid rate than new cells are produced. This starts a slow decline in bone mass, and may lead to the development of osteoporosis. Any bone in the body can be affected by osteoporosis. However, the spine, hips, ribs and wrists are the most commonly fractured when a person with osteoporosis falls. Osteoporosis can also cause a hump in the upper back or loss of height. Osteoporosis is different from osteoarthritis, a form of arthritis in which joint cartilage, the rubbery material that covers the ends of bones, wears away.

Who’s Affected? More than 10 million people have osteoporosis. Each year, this disease contributes to more than 1.5 million fractures of the back, wrists and hips. Approximately 34 million people are at risk for low bone density (osteopenia). Osteoporosis is more common in women. It is the main cause of bone fractures in post-menopausal women and the elderly. However, men can also get osteoporosis. Several studies have shown that men and women who take antidepressants have an increased risk of osteoporosis-related fractures compared with people who don't take these kinds of medications. The association seems to be particularly strong in a class of antidepressants known as selective serotonin reuptake inhibitors, or SSRIs.

Symptoms of Osteoporosis Osteoporosis is a silent disease. Because osteoporosis develops over the years, a person may not be aware they have it until there is a broken bone, loss of height, or noticeable hump in the upper back. Other symptoms of osteoporosis are:

Tooth loss. This may be a sign that osteoporosis has affected the jawbone.

Back pain. A fracture or a collapsed vertebra in the spine may mean you have developed spinal osteoporosis.

It is important to know the risk factors for this disease. They include:

Aging

Drinking too much alcohol

Early menopause

Family history of osteoporosis

Having inflammatory arthritis or other inflammatory disease

Smoking

Taking certain medications, such as corticosteroids During and after menopause, when estrogen (hormone) levels drop, women lose bone mass faster. About 5 to 10 years after menopause starts, women can lose up to one-third of their bone mass. Men also lose bone mass as they age, but women tend to lose it faster. Osteoporosis is the main cause of bone fractures in postmenopausal women and the elderly. The United States Preventive Services Task Force recommends an initial bone-density test at age 65, or age 60 if you are taking corticosteroids. However, if you have rheumatoid arthritis, you should have a baseline test when first diagnosed with RA.

Causes of Osteoporosis The amount of bone mass a person has as a young adult, and the rate at which it is lost with aging, determines one's risk for osteoporosis. In addition to age, gender, family history, certain medical conditions and procedures, lifestyle habits and medication use also play a role. Osteoporosis is more common in:

Women, especially those past menopause or who are elderly

Women who go through menopause before age 45 or who have irregular or missed menstrual periods

Women who have had their ovaries removed through a hysterectomy

Women who don’t exercise regularly, or who exercise so much that menstrual periods stop

Men with low levels of testosterone

Individuals who are thin or have small body frames

Individuals with a family history of osteoporosis, or who are of Caucasian or Asian ancestry

Individuals with a history of bone fractures after a minor injury

Individuals with an inflammatory form of arthritis, such as rheumatoid arthritis or lupus

Individuals with a type of spondyloarthropathy, such as ankylosing spondylitis, reactive arthritis, psoriatic arthritis or spondyloarthropathy

Individuals who take drugs that reduce bone strength such as corticosteroids (cortisone, prednisone or methylprednisolone), anticonvulsants (anti-seizure medications) or heparin, a blood thinner

Individuals with celiac disease (allergy to gluten), inflammatory bowel disease (IBD), hyperthyroidism, chronic obstructive pulmonary disease (COPD) or multiple myeloma (bone marrow cancer)

Individuals who have had bariatric surgery

Individuals who have thyroid or parathyroid disease

Individuals who smoke

Individuals who drink three or more alcoholic beverages a day

Individuals with a history of anorexia nervosa or other eating disorders

Individuals who have had long periods of immobility or bed rest People who have one or more of these risk factors should talk to a doctor about ways to reduce the risk of osteoporosis and whether a bone density test is needed. Diagnosing Osteoporosis Osteoporosis develops slowly over the years. Symptoms such as tooth loss or back pain may be mistakenly attributed to something else. Anyone who has a family history of osteoporosis or risk factors for the disease should discuss their chances of getting it with a doctor. Some doctors have special training and experience that helps them diagnose and treat people with osteoporosis. These doctors include rheumatologists,

endocrinologists and orthopaedic surgeons. Some general internists, radiologists and specialists in women’s health may also have special training in bone density measurement. The doctor bases the diagnosis of osteoporosis on many factors, which are listed below. Health History and Physical The doctor will perform a physical examination and ask questions about the patient's personal and family medical history, medications, diet and fracture history. Laboratory Tests Bood and urine tests can help rule out other diseases that weaken bones. Bone Density Measurement The doctor may recommend a bone density test. Bone-density tests should be done for:

Women age 65 or over who are not taking bone-protecting drugs

Individuals taking have taken long-term corticosteroids or expect to do so

Individuals with a personal history or family history of fractures

Individuals who have diseases that affect calcium absorption or bone strength Bone-density tests may be recommended for some women as early as age 50 if they have a high risk for osteoporosis. Bone-density measurement is quick and painless. The most accurate test is called a dual-energy X-ray absorptiometry (DEXA) scan. It can measure as little as 1 percent to 2 percent loss of bone density. The DEXA scan also is used to track changes in bone density over time and with treatment. Computerized tomographic (CT) scans also can measure bone density. Bone X-rays are useful for finding fractured bones but are not accurate in determining bone density. X-rays cannot detect bone loss until there is a decrease of more than 30 percent.

Treatment of Osteoporosis Treatment for osteoporosis involves slowing the rate of bone lose or increasing the rate of bone formation. There are two types of medications for this:

Drugs that slow the rate of bone loss are called antiresorptive medications.

Ones that increase the rate of bone formation are called anabolic medications.

Antiresorptive Medications These drugs reduce bone loss by binding to bone and preventing normal bone cells from reabsorbing bone. They include:

Bisphosphonates. These are the most common treatment for osteoporosis. They can stop bone loss and help reduce the risk of fractures by up to 50 percent. They're not hormones, so women who cannot take estrogen can use them. Bisphosphonates approved for the treatment and prevention of postmenopausal osteoporosis include alendronate (Binosto, Fosamax), ibandronate (Boniva), risedronate (Actonel) and zoledronic acid (Reclast).

Denosumab. This drug is approved for postmenopausal osteoporosis. It is injected under the skin every six months at a doctor’s office.

Calcitonin. This is a naturally occurring hormone that decreases bone breakdown. It is FDA-approved for osteoporosis treatment but not prevention. It appears weaker than bisphosphonate medications in preventing fractures.

Calcitonin controls bone breakdown and may ease pain in people with spine fractures. It’s available as a nasal spray (Miacalcin, Fortical).

Selective estrogen receptor modulators (SERMs). These drugs work like estrogen, but with fewer side effects. Raloxifene (Evista) is an FDA-approved SERM for the treatment and prevention of postmenopausal osteoporosis. It can prevent bone loss, especially in the spine and hip. Studies have shown it decreases the rate of spine fractures. It also produces small increases in bone mass and can lower the risk of breast cancer. In 2013, the FDA approved Duavee, a combination product containing the SERM bazedoxifene and conjugated estrogens for menopausal symptoms and osteoporosis.

Until recently, estrogen hormone replacement therapy (HRT) was the traditional way to treat menopausal symptoms and also prevent osteoporosis. However, recent evidence suggests estrogen can increase the risk of breast cancer, strokes and heart attacks. Because of this, estrogen supplementation after menopause is usually not used to prevent osteoporosis. Anabolic Medications Teriparatide (Forteo) is an anabolic medicine approved to treat men and postmenopausal women who have severe osteoporosis with a high risk of fractures. The man-made parathyroid hormone has been shown to stimulate new bone formation, decrease the risk of spinal fractures and improve bone density. It is given as a daily injection for up to two years. Psoriatic Arthritis Some people might hear “psoriasis” and think of the skin disease that causes itchy, scaly rashes and crumbling nails. It's true, psoriasis is an autoimmune disease that primarily affects the skin. But about 30 percent of people with psoriasis also develop a form of inflammatory arthritis called psoriatic arthritis (PsA). Like psoriasis, PsA is an autoimmune disease, meaning it occurs when the body’s immune system mistakenly attacks healthy tissue, in this case the joints and skin. The faulty immune response causes inflammation that triggers joint pain, stiffness and swelling. The inflammation can affect the entire body and may lead to permanent joint and tissue damage if it is not treated early and aggressively.

Most people with psoriatic arthritis have skin symptoms before joint symptoms. However, sometimes the joint pain and stiffness strikes first. In some cases, people get psoriatic arthritis without any skin changes. The disease may lay dormant in the body until triggered by some outside influence, such as a common throat infection. Another theory suggesting that bacteria on the skin triggers the immune response that leads to joint inflammation has yet to be proven. Types of Psoriatic Arthritis There are five types of psoriatic arthritis:

Symmetric psoriatic arthritis. This makes up about 50 percent of psoriatic arthritis cases. Symmetric means it affects joints on both sides of the body at the same time. This type of arthritis is similar to rheumatoid arthritis.

Asymmetric psoriatic arthritis: Often mild, this type of PsA appears in 35 percent of people with the condition. It’s called asymmetric because it doesn’t appear in the same joints on both sides of the body.

Distal psoriatic arthritis: This type causes inflammation and stiffness near the ends of the fingers and toes, along with changes in toenails and fingernails such as pitting, white spots and lifting from the nail bed.

Spondylitis: Pain and stiffness in the spine and neck are hallmarks of this form of PsA.

Arthritis mutilans: Although considered the most severe form of PsA, arthritis mutilans affects only 5 percent of people who have the condition. It causes deformities in the small joints at the ends of the fingers and toes, and can destroy them almost completely.

Who’s Affected? According to the Annals of Rheumatic Disease, between 6 and 42 percent of people who have psoriasis will develop psoriatic arthritis. The disease usually appears between the ages of 30 and 55 in people who have psoriasis, but it can be diagnosed during childhood. Unlike many autoimmune diseases, men and women are equally at risk for developing this condition. Symptoms of Psoriatic Arthritis Symptoms of psoriatic arthritis vary among different people. Many are common to other forms of arthritis, making the disease tricky to diagnose. Here’s a look at the most common symptoms – and the other conditions that share them.

Painful, swollen joints

Psoriatic arthritis typically affects the ankle, knees, fingers, toes and lower back. Pain in the lower back is also a symptom of ankylosing spondylitis, a form of inflammatory arthritis that causes the vertebrae to fuse, or joint together. Also, the joint at the tip of the finger may swell, making it easy to confuse with gout, a form of inflammatory arthritis that typically affects only one joint.

Stiffness Joints tend to be stiff either first thing in the morning or after a period of rest. However, people with osteoarthritis often have similar stiffness.

Sausage-like fingers or toes Many people with PsA have dactylitis, a sausage-like swelling along the entire length of their fingers or toes. This symptom is one that helps differentiate psoriatic arthritis from rheumatoid arthritis (RA), in which the swelling is usually confined to a single joint.

Tendon or ligament pain People with psoriatic arthritis often develop enthesitis, or tenderness or pain where tendons or ligaments attach to bones. This commonly occurs at the heel (Achilles tendinitis) or the bottom of the foot (plantar fasciitis), but it can also occur in the elbow (tennis elbow). Each of these conditions could just as easily result from sports injuries or overuse as from psoriatic arthritis.

Skin rashes and nail changes Psoriatic arthritis occurs with psoriasis so skin symptoms include thick, red skin with flaky, silver-white scaly patches. Nails may become pitted or infected-looking, or even lift from the nail bed entirely. These symptoms are unique to psoriasis and psoriatic arthritis, actually helps doctors confirm a diagnosis.

Fatigue People with psoriatic arthritis often experience general feelings of fatigue. This symptom is a common feature of rheumatoid arthritis.

Reduced range of motion The inability to move joints and limbs as freely as before is a sign of psoriatic arthritis and most other forms of arthritis.

Eye problems People with PsA may get inflammation of the eyes that can cause redness, irritation and disturbed vision (uveitis) or redness and pain in tissues surrounding the eyes (conjunctivitis, or "pink eye").

Flares Many people experience frequent periods of increased disease activity and symptoms, called flares, while others have only infrequent flares. This waxing and waning of symptoms is frequently seen with RA, as well.

Psoriatic arthritis is closely linked with inflammatory bowel disease, especially the form called Crohn’s disease. It causes diarrhea and other gastrointestinal problems The inflammation that causes PsA may also harm the lungs, causing a condition known as interstitial lung disease that leads to shortness of breath, coughing and fatigue. Chronic inflammation can damage blood vessels, increasing the risk for heart attacks and strokes. People with PsA often develop metabolic syndrome, a group of conditions that include obesity, high blood pressure and poor cholesterol levels. Other problems that can accompany PsA include depression, an increased risk for osteopenia (thinning bones) and osteoporosis, and a higher-than-average risk of developing gout. Causes of Psoriatic Arthritis The cause of psoriatic arthritis (PsA) is unknown. Experts believe some people may be predisposed to an autoimmune disease like psoriatic arthritis. In fact, studies show a stronger genetic or family link to this particular disease than other autoimmune rheumatic diseases. About 40 percent of people who are diagnosed with psoriatic arthritis and psoriasis have family members affected by the disease. Not everyone who has psoriasis develops psoriatic arthritis. Psoriasis is not infectious, but the disease might be triggered by a strep throat. In addition to infections, researchers believe PsA also can be triggered by extreme stress or an injury that makes the immune system go into overdrive in people who are genetically more likely to get the disease. Diagnosing Psoriatic Arthritis Diagnosing psoriatic arthritis can be a tricky process because its symptoms frequently mimic those of other forms of inflammatory arthritis, such as rheumatoid arthritis (RA) and gout. It can also be confused with osteoarthritis (OA), the most common form of arthritis. For a proper diagnosis, the primary care doctor will likely provide a referral to a rheumatologist, a type of doctor who specializes in arthritis and musculoskeletal diseases. A diagnosis is based on many things, including a thorough medical history and the results of a physical examination and medical tests. Medical History Because certain conditions can be inherited, the doctor will ask questions about the health history of the patient and his or her relatives.

Additional information needed to help diagnose PsA includes:

A description of the symptoms

Details about when and how the pain or other symptoms began

Location of the pain, stiffness or other symptoms

How the symptoms affect the patient's daily life

Details about medical problems that could be causing these symptoms and a list of currently used medications

Physical Exam The rheumatologist will perform a physical exam, looking for swelling and inflammation of the joints. He’ll also check for signs of psoriasis on the skin or abnormalities on fingernails and toenails. Keep in mind that psoriasis isn’t always readily visible. It can hide on the scalp, behind the ears, in the belly button and in the groove between the buttocks. Diagnostic Tests The doctor may order X-rays to detect changes to the bones or joints. Blood tests will be done to check for signs of inflammation. They include C-reactive protein and rheumatoid factor (RF). People with PsA are almost always RF-negative. If blood tests are positive for rheumatoid factor, the doctor should suspect RA first.

A blood test to measure the sedimentation or "sed" rate is often done. The higher the “sed rate,” the greater the level of inflammation in the body. The doctor may also test joint fluid to exclude gout or infectious arthritis. Because psoriatic arthritis can be tricky to diagnose, people sometimes are initially told they have another form of arthritis only to find out later they have psoriatic arthritis. Ruling Out Other Conditions The symptoms of psoriatic arthritis can mimic other conditions. Common misdiagnoses include osteoarthritis, rheumatoid arthritis and gout. Below are some tips to help avoid a psoriatic arthritis misdiagnosis.

If a single joint becomes swollen and extremely painful almost overnight, it’s probably gout. Gout pain comes on rapidly and is intense.

If there is little or no joint swelling, osteoarthritis is the most likely diagnosis. Osteoarthritis pain tends to be felt after activity.

If joint pain affects the same joint on both sides of the body (is symmetrical), it could be RA. Joint pain in PsA is usually asymmetrical, meaning it's felt on one side of the body. For example, if one knee is affected, the other likely is not.

If joint pain is worse for more than a few minutes in the morning, or after inactivity, consider PsA or RA. If swelling involves the full length of the fingers or toes, think PsA. This condition is called dactylitis, or “sausage fingers.” If there are psoriasis symptoms and nail pitting first, followed by joint pain, PsA is likely the culprit, particularly if there is joint swelling. A person can have psoriasis and a form of arthritis that isn’t PsA.

Treatment of Psoriatic Arthritis There are several over-the-counter (OTC) and prescription medicines for psoriatic arthritis. Some treat symptoms of both psoriasis and psoriatic arthritis, others target skin problems, yet others help with joint issues. Many can also modify the disease course by disrupting the overactive immune system. Medications for Psoriatic Arthritis

NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) are usually taken by mouth, although some can be applied directly to the skin. These medicines reduce inflammation along with pain and swelling. Among the most well-known over-the-counter (OTC) NSAIDs are ibuprofen (Advil, Motrin) and naproxen sodium (Aleve), although there are many others. More than a dozen prescription NSAIDs also are available. The most notable risks of NSAIDs are an increased risk of heart attack and stroke, along with stomach irritation and bleeding that could become severe.

Corticosteroids. These drugs are designed to mimic the anti-inflammatory hormone cortisol, which is normally made by the body’s adrenal glands. Corticosteroids taken by mouth, such as prednisone, can help reduce inflammation, but long-term use can lead to side effects such as facial swelling, weight gain, osteoporosis and more. Directly injecting corticosteroids into affected joints can provide temporary inflammation relief.

Topical treatments. Topical medicines are applied directly to the skin to treat scaly, itchy rashes due to psoriasis. Available in creams, gels, lotions, shampoos, sprays or ointments, these drugs are available OTC and by prescription. OTC ones include salicylic acid, which helps lift and peel scales, and coal tar, which may slow rapid cell growth of scales and ease itching and inflammation. Prescription topicals contain corticosteroids and/or vitamin derivatives. Common prescription ones include calcitriol, a naturally occurring form of vitamin D3; calcipotriene, a synthetic form of vitamin D3; calcipotriene combined with the corticosteroid betamethasone dipropionate; tazarotene (a vitamin-A derivative); and anthralin, a synthetic form of chrysarobin, a substance derived from the South American araroba tree.

Light therapy. Another option for treating psoriasis is phototherapy, or light therapy. In light therapy, the skin is regularly exposed to ultraviolet light. For safety reasons, this is done under medical supervision.

DMARDs. Disease-modifying antirheumatic drugs (DMARDs) are a varied group of medications that suppress inflammation-causing chemicals to prevent joint damage and reduce symptoms. Most are taken by mouth. According to the American College of Rheumatology, DMARDs most commonly prescribed for psoriatic arthritis are methotrexate, sulfasalazine, cyclosporine and leflunomide. Azathioprine may also be prescribed. Apremilast is a newer DMARD approved in 2014. It works by blocking an enzyme called phosphodiesterase 4 (PDE4), which is linked to inflammation. Studies have shown it reduces the number of tender and swollen joints.

o Biologics. Technically a subset of DMARDs, biologics are complex drugs that stop inflammation at the cellular level. They are usually given by injection or infusion. Three types of biologics are approved to treat psoriatic arthritis. They include:

• Anti-tumor necrosis factor-alpha (TNF-alpha) drugs that block a specific protein produced by immune cells that signals other cells to start the inflammatory process. These include etanercept, adalimumab, golimumab, infliximab and certolizumab.

• Selective co-stimulation moderators that interfere with the activation of white blood cells called T cells, preventing immune system reactions that result in inflammation. The only drug in this class is abatacept.

• IL-inhibitors that block pro-inflammatory proteins called interleukins. The drug ustekinumab specifically blocks IL-12 and -23.

• While biologics can be very effective, they suppress the immune system and raise the risk of infection.

Fibromyalgia Fibromyalgia is a condition associated with widespread chronic pain, fatigue, memory problems and mood changes. Fibromyalgia is not a single disease, but a constellation of symptoms that can be managed. It is not life threatening and does not lead to muscle or joint damage. Researchers suspect that different factors, alone or in combination, may contribute to the development of the disease. An infectious illness, physical trauma, emotional trauma or hormonal changes may trigger the development of generalized pain, fatigue and sleep disturbances that characterize the condition.

Gout Gout is a form of inflammatory arthritis that develops in some people who have high levels of uric acid in the blood. The acid can form needle-like crystals in a joint and cause sudden, severe episodes of pain, tenderness, redness, warmth and swelling.

Spondyloarthritis Spondyloarthritis is an umbrella term for inflammatory diseases that involve both the joints and the entheses (the sites where the ligaments and tendons attach to the bones). The most common of these diseases is ankylosing spondylitis. Others include reactive arthritis, psoriatic arthritis and enteropathic arthritis, which is associated with the inflammatory bowel disease. Spondyloarthritis, in most cases, primarily affects the spine. Some forms can affect the peripheral joints -- those in the hands, feet, arms and legs.

Improving your Symptoms- Move in May! No matter if you live in a rural area, suburb, or urban neighborhood, walking has been shown to improve arthritis pain, fatigue, function, and quality of life. There is no better time to begin a walking program or recommit yourself to a walking routine than during Arthritis Awareness Month. Walking is a great way for people with arthritis who live in rural areas to be physically active. For those uncertain about walking, proven programs such as Walk With Ease can help people get started. Walking is recommended—All adults, including adults with arthritis, should get 2 hours and 30 minutes (150 minutes) of moderate-intensity aerobic activity (i.e., brisk walking) per week and do muscle-strengthening activities two or more days a week. If you take brisk walks for 30 minutes a day, 5 days a week, you will meet the aerobic activity recommendations from the Physical Activity Guidelines for Americans. Don’t think you can walk for 30 minutes at one time? You can break it up into 10 minute sessions and spread it out during the day—walk the dog 10 minutes in the morning, take a 10 minute walk to the post office, coffee shop, or grocery store in the afternoon, and then take a 10 minute walk after dinner

Resources https://www.cdc.gov/features/arthritisawareness/index.html https://health.gov/news/blog-bayw/2018/05/national-arthritis-awareness-month-arthritis-management-through-parks-and-recreation/ https://www.accordclinical.com/news/arthritis-awareness-month/ https://www.reboundmd.com/news/arthritis-awareness-month https://www.health.com/rheumatoid-arthritis/may-is-national-arthritis-awareness-month https://www.arthritis.org/about-arthritis/types/rheumatoid-arthritis/what-is-rheumatoid-arthritis.php