The Arthritis Society: A Nationwide Resource for Arthritis Patients

Nariman Malik, BSc
Medical Writer,
Geriatrics & Aging.

Arthritis is a common condition, with over four million Canadians of all ages suffering from some form of the disease. In fact, arthritis is one of the top three chronic conditions in Canada. To date, there are over 100 different conditions that can be classified as forms of arthritis. It is predicted that the number of people with arthritis will increase at a rate of one million people every ten years. It is a debilitating disease that is affecting a large proportion of Canada's aging population. As such, it is an important health issue encountered by primary care physicians on a daily basis.

The Arthritis Society, established in 1948, is Canada's only not-for-profit organization dedicated to funding and promoting arthritis research and care. The Arthritis Society is involved in raising funds for arthritis research, as well as offering a wide range of programs and services to help individuals living with arthritis. The national office is located in Toronto. There are division offices in each province and nearly 1,000 community branches throughout Canada. This article outlines programs and services that are available through The Arthritis Society and are ideal for patients living with arthritis.

1-800- Information Line
In 1992, The Arthritis Society launched its 1-800- Information Line. It is a toll free support and information line run by trained volunteers or staff.

Sore Joints: Impairing Quality of Life in the Elderly

The year 2000 was a memorable one for me, but not necessarily in a positive manner. I woke up on the morning of February 29 (I will never look favourably on leap years again), with pain in the lateral side of my right knee. Being an astute clinician, and one who has considerable expertise in mobility disorders, I did the obvious thing: I ignored the pain, and continued to do everything as I always did (admit it, you would have done the same). By the end of the week, the pain was so severe that I could no longer exercise. Walking from the office to the hospital ward became a daily torture. I consulted an excellent rheumatologist who was puzzled by the lack of physical findings (except tenderness) and unimpressive x-ray results. An MRI, however, revealed severe bone marrow edema and bone loss in the medial femoral condyle. The picture was absolutely typical for a rare disorder called 'transient regional osteoporosis.' In typical physician manner, I had selected an unusual disease that was rarely seen (fortuitously my rheumatologist had written a paper on the topic a decade earlier, the last time he had seen the disease). I was embarrassed to find out that I, an internist, had developed an internal medicine disorder of which I had never even heard! After my films were reviewed by every orthopod and rheumatologist in the hospital, the consensus was that the bone was in great danger of breaking, and I would have to be completely non-weight bearing!

The pain started to ease as soon as I kept off my leg completely, but I was then in the position of so many of my patients: my life was tremendously constrained because of my lack of mobility. Survey after survey has revealed that the single greatest factor impairing quality of life in the elderly is arthritis, usually osteoarthritis. However, as physicians we often ignore these complaints and frequently do not even properly examine the joints. We are more concerned about the life-threatening disorders such as cancer and heart disease, or disabling neurological disorders such as stroke or dementia. These are of course crucial issues, but painful joints also require careful attention. As I struggled up stairs, learned how to use a shower stool, and continuously complained about my restrictions, I began to understand a little more clearly the problems experienced by so many of my patients. I was also surprised that my usual cheerful disposition (okay, there is some dispute about that) evaporated. I was depressed, and even though my ability to do paper work was theoretically unimpaired, my concentration and initiative were clearly decreased. The side effects of drugs I experienced could fill an entire article on their own.

I am, therefore, quite pleased that this edition of Geriatrics & Aging is focussing on arthritic disorders. Several years ago, David Naylor (currently Dean of Medicine at the University of Toronto), in his Gold Medal address to the Royal College of Physicians and Surgeons of Canada, commented on the under utilization of joint replacement in Canada. I suspect that this is still the case. Dr. Mahomed and Dr. Hawker will update us on this valuable surgical approach for the elderly. Most elderly persons will not have surgery for their osteoarthritis, and Dr. Tenenbaum discusses the medical management of these patients. There are articles on new treatments for arthritis (de los Reyes et al.), non-pharmacological therapy (Lineker), innovative programs (Malik) and the treatment of rheumatoid arthritis (Juby and Davis) and polymyalgia rheumatica (Little). In addition, there are articles on psychotropic medication use in the elderly (Conn), herb drug interactions (Dergal and Rochon), pharmacokinetics (Turnheim), and atrial fibrillation (Burstein). Also included in this issue is an article on the global aging phenomenon (Keller and Kalache), and the use of the Internet by seniors (Ryan).

Back to my personal problems, you might ask what was the most important lesson I learned from my travails last year. I would sum it up this way: have a wonderful spouse and family to care for you, and tremendous colleagues to shoulder your burden of work. Also, I learned to be very thankful for the word 'transient' in my diagnosis of transient regional osteoporosis.

Enjoy this issue.

Arthritis Models of Care for Non-pharmacological Interventions

Sydney C. Lineker, MSc, BScPT
Affiliated Scientist,
Toronto Western Research Institute;
Research Coordinator,
The Arthritis Society, Consultation and Rehabilitation Service, Toronto;
President, Arthritis Health Professions Association,
Toronto, ON.

Linda C. Li, BSc(PT), MSc
Arthritis & Autoimmunity Research Centre,
University Health Network;
The Arthritis Society,
Consultation and Rehabilitation Service, Toronto; Board Member,
Arthritis Health Professions Association,
Toronto, ON.

Introduction
Arthritis, in its many forms, is the most common cause of long-term disability in the elderly,^1-4 often resulting in functional problems, the loss of leisure, social and vocational activities, isolation and depression. Osteoarthritis (OA) is the most common type of arthritis in this population.¹

Pain, disability and psychosocial and educational needs are often underestimated by health care providers.^5,6 Pain is the most frequently reported symptom6 and is a complex phenomenon requiring a multidimensional approach. Pain may be under-reported by the elderly.^6,7 Signs of inflammation--redness, pain and swelling--may be less marked8 and it may be difficult to attribute pain to a specific cause.² Comorbidity, polypharmacy and complications of pharmacological interventions unique to the elderly add to the mix.

Osteoarthritis: Understanding Pathogenesis May Lead to Innovative Treatment

Jerry Tenenbaum, MD, FRCPC
Rheumatologist,
Mount Sinai Hospital and
Baycrest Centre for Geriatric Care,
Associate Professor,
University of Toronto,
Toronto, ON.

Introduction
Osteoarthritis (OA) is a chronic disease of the joint that results in degeneration of the cartilage and bone. However, in osteoarthritis, it is not uncommon to see intermittent or even chronic evidence of inflammation in the affected joint. Patients may experience stiffness after immobility (in the morning or after sitting for a long time), warmth and erythema of the joint, and soft tissue swelling and/or synovial effusion. On history taking and physical exam, these findings attest to the inflammatory nature of the involved osteoarthritic joint at the time. A microscopic examination of the synovium of patients with osteoarthritis will often show the presence of inflammation. Though cartilage and bone seem to be the primary targets of damage, it is likely that inflammation within the synovium may play an important role in the progressive damage to these joint tissues. Primary involvement of synovium may occur in some patients and secondary synovitis is commonly seen. This is associated with the intermittent or chronic presence of crystals (calcium pyrophosphate dihydrate, hydroxyapatite) or synovitis associated with stimulation by joint damage debris.

The Economic Impact of Bone and Joint-Related Health Problems

A new study by the Institute of Health Economics has estimated that the indirect economic impact of bone and joint problems, including arthritis, totaled $17.9 billion dollars in 1997. Apparently, the main reason for this figure is the lost productivity of people who are unable to work and conduct business. The study reveals that osteoarthritis is two and a half times more prevalent in Canada than is heart disease, and over six times more prevalent than cancer. It is estimated that with Canada's aging population, the number of people with bone and joint-related health problems in Canada will increase by 124% over the next 30 years.

Despite this increased demand, a shortage of orthopaedic surgeons is making it difficult for people to get the care they need. On average, patients are forced to wait more than six months for joint replacement surgery in Canada, and many have to wait longer than a year.

The findings of this study were supported by a parallel phone survey conducted by Decima Research, which found that 42% of Canadians have been affected by bone and joint problems--either personally or through the severe physical pain of a family member or friend.

The Canadian Orthopaedic Association and The Arthritis Society have now developed a comprehensive plan to address the issues that are critical to orthopaedic care in Canada. Entitled Canada in Motion: Mobilizing Access to Orthopaedic Care the plan calls for Canada's federal and provincial ministers of health to work with the medical community to develop a national orthopaedic care strategy.

Please see next month's issue of Geriatrics & Aging for articles on the various options available for the treatment of arthritis in the elderly.

Arthritis University Now Accepting Students

If the thought of packing into a crowded banquet hall this summer to get those CME credits does not excite you, then you may want to consider "studying" at The Arthritis University. Produced by McNeil Consumer Healthcare, in consultation with Canadian Rheumatologists, GPs and The Arthritis Society, the newly launched CD-ROM is designed to support doctors in refining their diagnosis and treatment of musculoskeletal conditions. MAINPRO-M2 accreditation is available.

"With the prevalence of arthritis growing at such a rapid pace, and newer treatments for the disease being developed all the time, we saw a need to provide some context on the critical issues of diagnosis and management," said Dr. J Carter Thorne, Rheumatologist, Medical Coordinator of The Arthritis Program (TAP) at York County Hospital, and chairman of the Teaching Faculty of The Arthritis University. "And when we considered the time constraints that physicians face, we decided to take advantage of the available technology."

The virtual campus has three larger buildings: a lecture hall, where expert faculty provide key insights into arthritis and discuss epidemiology, diagnosis, treatment and patient issues; a library which is filled with practice management tools such as treatment matrices and algorithms, as well as web links and an arthritis prevalence calculator; and a clinic/laboratory where users can access six patient case studies with accompanying video and commentary.

The CD-ROM also in-cludes a campus building for The Arthritis Society outlining its programs and services as well as downloadable patient information, and the McNeil building , which offers physicians an osteoarthritis CME toolkit complete with downloadable slides. "Clearly, one of the benefits of learning via CD-ROM is that it allows physicians to learn at their own pace, and to revisit areas of particular interest," said Dr. Thorne.

According to Dr. Thorne, one of the primary focuses of the CD-ROM is diagnosis, which emphasizes the need for a thorough case history. "Correctly diagnosing patients leads to more appropriate treatment plans. The pain experienced in mild to moderate osteoarthritis, for example, is primarily related to the mechanical nature of the disease as opposed to the presence of inflammation. In these situations, it may be more appropriate to prescribe a simple analgesic."

According to Denis Morrice, President of the Arthritis Society, The Arthritis University is a valuable tool for sorting through the huge volume of information on the disease. "Ongoing research has enabled us to gain a vast amount of knowledge about arthritis. The key now is to ensure that all of this information filters down to the people who need it most…"

To obtain a free copy of The Arthritis University, please call McNeil Consumer Healthcare at 1 800 265-7323.

Treating osteoarthritis--when all else fails try viscosupplementation

When pain killers, exercise, and physical therapy have all failed, a medical technology called viscosupplementation can relieve knee pain caused by osteoarthritis. Viscosupplementation does not replace the need for thigh muscle strengthening, or for overweight patients to lose weight. There are currently two products available in Canada, Sodium Hyaluronate (Hyalagan) and Hylan G-F 20 (Synvisc). These products are made of a biopolymer of a synthetic polysaccharide substance called hyaluranan, which is made to possess elasticity and viscosity like that of young, healthy, synovial fluid. They are delivered through a series of injections, all one week apart, and work by adding "padding" to the joint as well as reducing inflammation and improving mobility. Pain relief appears in a few days, progresses over a few weeks, and often lasts several months. One of the concerns about viscosupplementation is that it is relatively expensive, at least more so than NSAIDs and cortisone injections. Unfortunately, most provincial drug plans do not cover viscosupplements, and it is difficult to predict who will gain long-term benefit (e.g. 3-6 months) versus short-term benefits (2-3 weeks) from the products.

Further reading

Adams ME, Atkinson MH, Lussier AJ, Schulz JI, Siminovitch KA, Wade JP, Zummer M. The role of viscosupplementation with hylan G-F 20 (Synvisc) in the treatment of osteoarthritis of the knee: a Canadian multicenter trial comparing hylan G-F 20 alone, hylan G-F 20 with non-steroidal anti-inflammatory drugs (NSAIDs) and NSAIDs alone. Osteoarthritis Cartilage 1995;3(4):213-25.

Osteoarthritis: When should joint replacement be considered?

Shechar Dworski, BSc

Osteoarthritis (OA) is common in the elderly, affecting as many as 80% of people aged 55 and over. It is the most common form of arthritis, occurring mostly, but not exclusively, in the elderly. It is also the most common musculoskeletal disease in the elderly. It affects mostly the hands, as well as the major weight bearing joints of the body which are primarily the hips and knees. Please refer to the article on Osteoarthritis: Early Diagnosis Improves Prognosis in the May/June 1999 issue of Geriatrics & Aging for more information on the symptoms and specific aspects of OA. There are several routes one may take to treat OA, as well as many preventive measures. Joint replacement is usually the last step, when all other treatments have been unsuccessful. At this stage of disease, people often have difficulty walking and climbing stairs, and have joint pain at rest and at night. In this case, joint replacement therapy is extremely effective at relieving pain and improving function.

Cox-2 Inhibitors Offer Hope to Arthritis Sufferers

Anna Liachenko, BSc, MSc

Despite potentially serious side effects, non-steroidal anti-inflammatory drugs (NSAIDs) are currently one of the very few options available for alleviating chronic pain and inflammation. Over the past 30 years, scientists searched for safer NSAIDs and managed to create the 20 different drugs and 40 dosing options currently available in Canada. While some of the newer drugs turned out to be safer than others, their design was based largely on trial-and-error. A recent major breakthrough in the understanding of the molecular mechanisms of NSAID action allowed researchers to methodically design a new class of NSAIDs. These new drugs, the Cox-2 Inhibitors or C-2SIs, are not only comparable to the older NSAIDs in efficacy but are also (at least in theory) devoid of some of the most serious side effects. One of these drugs, celecoxib (Celebrex) has just become available in the US and Canada. Another, rofecoxib (Vioxx) is under review by the Food and Drug Administration (FDA) in the US and the Health Protection Branch (HPB) in Canada. Moreover, increased safety of some of the previously approved NSAIDs is now thought to be attributed to the same molecular mechanism. Newly arriving NSAIDs as well as the best NSAID options currently available in Canada are discussed below.

Novel Biological Therapy for Rheumatoid Arthritis Looks Promising

Hand deformity typical of rtheumatoid arthiritis

Ruwaida Dhala, BSc, MSc

Rheumatoid arthritis (RA) is the most common autoimmune disease worldwide. RA primarily affects joints of the extremities, particularly the fingers. The disease is characterized by chronic inflammation of the synovial joints resulting in joint destruction and deformity. RA occurs both in children and adults. The peak incidence of RA is between the ages of 30 and 50 and occurs more frequently in women than in men.¹ The clinical manifestations of the disease include peri-articular soft tissue swelling, joint pain and joint stiffness. Like most autoimmune diseases, there is a genetic susceptibility to RA (see related article on Unravelling the Genetic Mystery of Arthritis). T cells appear to be important in disease initiation whereas monocytes are implicated in disease progression.