Information on chronic pain and addicton

Christopher Frandrup, M.D., DABPM, FIPP

Category: Interventional Treatments (Page 1 of 3)

Cortisone Shot In The Knee – What To Expect

Cortisone Shot In The Knee - What To Expect | PainDoctor.com

Cortisone Shot In The Knee – What To Expect

With any type of machine, the longer you use it, the more stress and strain is placed on its moving parts. This holds true with our bodies as we age. A common feature of aging is osteoarthritis. Osteoarthritis affects our joints and is seen as a “wear and tear” condition that is simply a function of our joints being used repetitively for a long period of time. We feel osteoarthritis most keenly in our weight-bearing joints. Knees in particular can be very painful. There are many different types of treatments for knee pain related to osteoarthritis or other conditions. A common procedure after rest, ice, and non-steroidal anti-inflammatory drugs (NSAIDs) is to get a cortisone shot in the knee. If you are considering a knee joint injection, here’s what to expect.

What is a cortisone shot in the knee?

A cortisone shot in the knee is a minimally-invasive procedure that involves injecting a corticosteroid into the knee. Corticosteroids help to suppress the immune response that is triggering inflammation. This inflammation is caused by the rubbing of bone on bone in the knee joint. Rubbing occurs in the joints as cartilage naturally wears thin over time.

A cortisone shot is just one type of knee joint injection. Others may include hyaluronic acid (HA) or platelet rich plasma (PRP). HA injections are generally aimed at restoring lubrication in the knee joint. PRP works to use the patient’s own red blood cells to repair damage. A cortisone shot in the knee focuses on relieving pain and inflammation specifically.

Conditions treated with a cortisone shot in the knee

Osteoarthritis is the most common source of knee pain, but there are other conditions that can affect this complex joint. Four bones make up the structure of the knee: the patella, fibula, tibia, and femur. Cartilage and ligaments connect all of these bones and keep them stable.

The posterior and anterior cruciate ligaments (the PCL and ACL) connect at the center of the knee joint and help stabilize the knee through rotation. The lateral and medial ligaments also help stabilize and support the joint, while the medical meniscus cartilage provides cushioning.

Damage, injury, or deterioration in any part of this joint can cause knee pain. In addition to pain caused by osteoarthritis, some of the most common pain conditions treated with a cortisone shot in the knee include:

  • Cartilage tear
  • Tendinitis
  • Bursitis
  • Gout

Each of these conditions causes inflammation, pain, and limited mobility.

The procedure

Before any treatments occur, a pain management specialist will take a complete medical history. A thorough physical examination that includes range-of-motion tests will be conducted.

In some cases, the doctor may request imaging such as X-ray or MRI to confirm a diagnosis. A cortisone shot in the knee may not be the first treatment offered if the pain is mild and can be managed in other ways.

If a cortisone shot in the knee is recommended, the knee will be thoroughly cleaned and sterilized. A local anesthetic is used most often, but patients may request mild sedation if that is more comfortable.

The pain management specialist uses fluoroscopy (live X-ray) to guide a very thin needle into the joint space of the knee. Proper placement of the injection is important for both patient safety and pain relief. Once located, a corticosteroid is injected into this space.

The entire procedure takes between 15 and 30 minutes. In many cases, pain relief is dramatic and occurs within 24 to 48 hours. Patients need only take minimal time off (usually just the day of the procedure).

Effects from knee cortisone shots

A cortisone shot in the knee is most effective for the first shot, with its pain-relieving effects diminishing slightly with each shot after. The effects of a shot can last from four to six weeks. Results can be improved if other lifestyle and supportive changes are made to manage knee pain.

Cortisone shots will not be injected directly into a tendon. If the pain management specialist believes that an inflamed tendon is the cause of pain, they may choose to place the injection near the tendon instead.

Potential side effects

Although a cortisone shot in the knee is minimally-invasive and non-surgical, there is a slight risk of side effects. Side effects are rare and generally mild. Short-term, less serious side effects can include:

  • Bleeding
  • Swelling, pain, or bruising at the site of the injection
  • Allergic reaction
  • Face flushing
  • Synovium inflammation
  • Insomnia
  • Temporary increase in blood sugar

Over time and with more injections, side effects can become more prevalent and serious. Tendons and cartilage may become weaker. Other long-term side effects of cortisone shots in the knee are:

  • Easy weight gain and puffiness
  • Easy bruising
  • Acne
  • Thinning skin
  • High blood pressure
  • Increased risk of osteoporosis
  • Cataracts
  • Bone damage (avascular necrosis or osteonecrosis)

Is a cortisone shot in the knee effective?

A meta-analysis of high-quality studies in the UK found that a cortisone shot in the knee was effective for relieving inflammation and pain in both the short and long term. The analysis also found that although there is concern for cartilage damage due to the corticosteroids, most cases of damage were due to the underlying disease, not the cortisone shot in the knee.

Another study compared the results of knee injections versus placebo groups and found clinical and statistical evidence that cortisone shots in the knee offered more pain relief at one week than placebo.

Finally, a meta-analysis in 2015 looked at all types of treatments for knee pain and found that a cortisone shot in the knee was the most effective. This meta-analysis included 137 studies with over 33,000 study participants total. The focus was on short-term pain relief, with the reviewers noting that long-term data is not robust enough to include.

In all of the research above, researchers are careful to note that a cortisone shot in the knee may address the symptoms of pain and inflammation in the short-term but underlying causes must be addressed for proper treatment. A knee joint injection may allow pain patients to begin other treatments, such as physical therapy, so that a holistic pain management plan can be implemented.

As with all potential treatments, talking to your doctor is the first step. Have you ever had a cortisone shot in the knee? Was it effective for your knee pain?

Radio Frequency Lesioning

What Is Radiofrequency Lesioning?

Millions of adults in the United States suffer from various types of chronic pain conditions. The pain associated with these conditions can be severe and can have a detrimental impact to an individual’s personal and professional lives. Additionally, chronic pain has a significant impact on the U.S. economy, resulting in increased healthcare utilization, including rehabilitation and decreased worker productivity.Pain-Doctor-Epidural-Steroid-Injection-Procedure-5Patients suffering with chronic pain are often treated with a combination of medication, physical therapy, as well as epidural steroid injections and other conservative treatment options. However, not all patients experience pain relief from these treatment methods. Radiofrequency lesioning is a minimally invasive procedure that may be used to treat chronic pain that has been unresponsive to conservative measures. Radiofrequency lesioning uses heat to effectively destroy the sensory nerve endings that are believed to be the source of pain. By destroying the nerve endings, pain and other related symptoms are reduced following treatment.Before recommending radiofrequency ablation, diagnostic local anesthetic nerve blocks need to be performed to ensure that the patient is an ideal candidate. A diagnostic nerve block involves injecting a local anesthetic into the area of the nerve that is believed to be causing the patient’s pain. The local anesthetic essentially temporarily numbs the area and should result in reduced pain symptoms. The effectiveness of radiofrequency lesioning can be predicted from a patient’s response to the temporary nerve block procedure.

How Is Radiofrequency Lesioning Performed?

Cervical-Radiofrequency-Ablation-Procedure-6A radiofrequency lesioning procedure is performed in an outpatient setting. Generally, radiofrequency lesioning procedures take approximately 30 to 60 minutes to complete.The nerve supply to the painful structure is targeted during a radiofrequency lesioning procedure. A small needle or radiofrequency cannula is positioned next to the targeted nerves using fluoroscopic guidance. Once the needle is in place, small currents are applied to ensure proper needle placement. Once the proper placement of the needle or cannula is confirmed, a local anesthetic is injected to numb the area. The radiofrequency generator is then utilized which delivers an electrical current that produces radiowaves. These radiowaves heat the targeted nerve ending for up to 90 seconds, which results in destruction of the targeted nerve. The needle is then removed and the procedure is complete.

Pain-Doctor-Radiofrequency-Ablation-Procedure-8After the procedure, patients may experience discomfort around the needle placement site, which usually subsides within a few days. Occasionally, patients may experience temporary burning or numbness, which usually subsides within a few weeks.The risks associated with radiofrequency lesioning include: bleeding, infection, or allergic reaction to the local anesthetic used during the procedure. Rare side effects include: nerve damage, which may lead to permanent altered sensations including numbness, burning, tingling, and possibly extremity weakness.

Radiofrequency lesioning procedures generally provide long-term pain relief; however, the pain pathways may regenerate over time. Therefore, it is possible that the procedure may need to be repeated.

Conditions Related To Radiofrequency Lesioning

There are various conditions that may be successfully treated with radiofrequency lesioning, including:

  • Facet joint pain
  • Discogenic pain
  • Coccydodynia
  • Sympathetically mediated pain

facet joint syndromeFacet joint pain is one of the most common causes of chronic spinal pain.  Radiofrequency lesioning of the medial branch of the posterior primary ramus can denervate the facet joint and effectively provide long-term pain relief for some patients. Successful radiofrequency lesioning for patients suffering with facet joint pain typically lasts for more than a year.Spinal pain that is arising from the intervertebral discs of the spine is another common source of pain, commonly referred to as discogenic pain. Once the painful disc is identified radiofrequency lesioning can be used to partially denervate the intervertebral disc, by either lesioning the rami communicans, or by using intradiscal denervation techniques. The use of radiofrequency lesioning is contraindicated if there is a disc herniation that is causing nerve impingement, if there is disc disease at multiple spinal levels, or if there is advanced degenerative disc disease.

Coccydodynia (tailbone pain) that is the result of organic causes can be treated by radiofrequency lesioning of the coccygeal nerve or the ganglion impar. Prior to using radiofrequency lesioning, a minimum of two blocks are performed to confirm that the pain is organic in nature.

Pain that is transmitted by the sympathetic nerves may be treated using radiofrequency lesioning by lesioning the sympathetic chain at the spinal level or at the stellate ganglion. This results in an interruption of nerve signal transmission.

Additional radiofrequency lesioning can be used to treat trigeminal neuralgia by thermocoagulation of the Gasserian ganglion. It can also be used to treat nociceptive radicular pain by partial rhizotomy of the dorsal root ganglion. Furthermore, it can be utilized to treat cancer pain by lesioning the sphenopalatine ganglion and stereotactic cordotomy.

Conclusion

Cervical-Radiofrequency-Ablation-Procedure-3Millions of adults suffer from chronic pain conditions in the United States. Patients suffering from these conditions not only experience physical symptoms, they often also suffer emotionally and physically if their pain cannot be effectively managed. Radiofrequency lesioning is a minimally invasive method that can be used to effectively treat pain that has been unresponsive to conservative treatment options.The nerves that are believed to be responsible for causing pain are targeted during a radiofrequency lesioning procedure.

The targeted nerves are destroyed by the application of heat. Radiofrequency lesioning can be used to treat a variety of conditions including facet joint pain, discogenic pain, tailbone pain, and sympathetically mediated pain.

Radiofrequency lesioning is generally safe; however, as with any surgical procedure, there are minimal risks involved including mild injection site soreness, bleeding, infection, and temporary altered sensation in the extremities.

Serious side effects are very rare. Patients suffering from unresponsive spinal pain should discuss the possibly of radiofrequency lesioning with their physician, as it may provide effective, long-term relief of their symptoms.

References

  1. Principles and uses of radiofrequency nerve lesioning in chronic pain control – Cabell Huntington Hospital – Huntington, WV. 2015.
  2. Geurts JW, van Wijk RM, Stolker RJ, Groen GJ. Efficacy of radiofrequency procedures for the treatment of spinal pain: a systematic review of randomized clinical trials. Regional Anesthesia and Pain Medicine. 2001;26(5):394-400.
  3. Kawaguchi M, Hashizume K, Iwata T, Furuya H. Percutaneous radiofrequency lesioning of sensory branches of the obturator and femoral nerves for the treatment of hip joint pain. Regional Anesthesia & Pain Medicine. 2001;26(6):576-581.
  4. Kornick C, Kramarich S, Lamar TJ, Sitzman T. Complications of lumbar facet radiofrequency denervation. Spine. 2004;29(12):1352-1354.
  5. Nagda JV, Davis CW, Bajawa ZH, Simopoulos TT. Retrospective review of the efficacy and safety of repeated pulsed and continuous radiofrequency lesioning of the dorsal root ganglion/segmental nerve for lumbar radicular pain.Pain Physician. 2001;14(4):371-376.
  6. Oh WS, Shim JC. A randomized controlled trial of radiofrequency denervation of the ramus communicans nerve for chronic discogenic low back pain. Clinical Journal of Pain. 2004;20(1):55-60.
  7. org. American Academy of Pain Medicine – Get The Facts on Pain. 2015.

Sacroiliac Joint Injections

Sacroiliac Joint Injections

What Is A Sacroiliac Joint Injection?

The sacroiliac joint is a diarthrodial joint that is located lateral to the spine and connects the hip to the sacrum on both sides of the body. There is a sacroiliac joint located on the right and on the left and these joints bear the weight of a patient’s upper body and extremities. Due to the fact that the joint has to be very stable, movement of the joint is limited. A thin layer of cartilage covers the surface of the ileum and sacrum. Synovial fluid fills the space between these two structures, which is enclosed within a fibrous capsule. Sacroiliac joint inflammation and dysfunction can result in chronic low back or leg pain.Sacroiliac joint dysfunction can be difficult to diagnose as the symptoms often mimic other causes of back pain including disc herniation, facet syndrome, and radiculopathy. Sacroiliac joint injections serve two purposes: to diagnose the source of a patients’ pain and to provide pain relief. Various studies have shown that extra-articular and peri-articular steroid injections within the sacroiliac joint are more effective than placebo treatments for pain relief. Additionally, the studies have found that these pain relief benefits are sustained at a one-month follow-up appointment.

How Is A Sacroiliac Joint Injection Performed?

A diagnostic sacroiliac joint injection is performed when sacroiliac joint dysfunction is suspected. The area around the sacroiliac joint is numbed with a local anesthetic and a needle is then inserted using fluoroscopic guidance. Contrast dye is injected once the needle is in place to ensure proper needle placement and proper spread of medication. A numbing medication is then injected into the joint.After the numbing medication is injected, patients are asked to try and reproduce their pain by performing certain movements. If the patient reports a significant reduction in their pain, a diagnosis of sacroiliac joint dysfunction is tentatively made. In order to confirm the diagnosis, a second injection should be performed at a later date.

A therapeutic sacroiliac joint injection is performed when a diagnosis of sacroiliac joint dysfunction has been established and the patient requires pain relief. This procedure is performed in the same manner as the diagnostic sacroiliac joint injection with the exception that a corticosteroid is also injected into the affected joint.

Many patients that are treated with a sacroiliac joint injection are expected to experience immediate pain relief. After the procedure is completed, patients are monitored for pain relief and adverse reactions.

If a patient experiences prolonged pain relief after receiving a therapeutic sacroiliac joint injection, they may start a physical therapy program to further reduce their pain and to help them achieve normal functioning. If a patient experiences significant pain relief following a sacroiliac joint injection, it may be repeated up to three times per year.

As with all medical procedures, there are risks associated with sacroiliac joint injections, including bleeding, infection, and allergic reactions to the medications. Additionally, a patient may experience temporary numbness or weakness in the legs that is caused by the anesthetic that is injected. Some patients may have a temporary increase in pain and injection site tenderness for a couple of days after the injection. Diabetics may notice an increase in their blood sugar levels that is the result of the corticosteroid that is injected.

Conditions Related To Sacroiliac Joint Injections

Sacroiliac joint injections are often used for treating patients that suffer from chronic, non-specific back pain that is the result of irritation, inflammation, or injury of the sacroiliac joint. Sacroiliac joint dysfunction is tough to diagnose as the symptoms overlap with other injuries. Research has shown that up to 40-50% of patients with a confirmed diagnosis of sacroiliac joint pain are able to identify an event that likely contributed to their current episode of sacroiliac pain. These events may include a slip and fall, a motor vehicle accident, or repetitive stress on the joint.It should be noted that acute events are not responsible for all episodes of sacroiliac joint pain. Research has found that there are a number of traits that are associated with an increased risk of developing sacroiliac joint pain, including leg length discrepancy, gait and biomedical abnormalities, transitional anatomy, scoliosis, persistent strain, and pregnancy.

Patients who suffer from sacroiliac pain often describe the pain as diffuse, lower back pain. Of concern when evaluating a patient with sacroiliac joint pain is their current level of impairment (strength, flexibility, balance, etc.). The level of impairment will help the patients’ physician determine whether the patient will be able to engage in a rehabilitation program without experiencing significant pain. Additionally, depending on the current level of impairment, the physician may recommend a trial of conservative treatment options before initiating this type of treatment.

Conclusion

Sacroiliac joint injections are an effective procedure for patients suffering from chronic lumbar back pain that is the result of inflammation or dysfunction of the sacroiliac joint. Sacroiliac joint injections are minimally invasive and can provide pain relief almost immediately for many patients. It is hypothesized that these injections provide pain relief as the result of their anti-inflammatory characteristics; however, the literature remains unclear. Patients suffering from chronic low back pain that originates from the sacroiliac joint should discuss the option of sacroiliac joint injections with their physician to determine if it is an appropriate option for their case.

References

  1. Chou R, Atlas SJ, Stanos SP, Rosenquist RW. Nonsurgical interventional therapies for low back pain: A review of the evidence for an American Pain Society Clinical Practice Guideline. Spine. 2009;34(10):1078-1093.
  2. Cohen SP, Chen Y, Neufeld NJ. Sacroiliac joint pain: A comprehensive review of epidemiology, diagnosis and treatment. Expert Rev Neurother. 2013;13(1):99-116.
  3. Hansen H, Manchikanti L, Simopoulos TT, Christo PJ, Gupta S, Smith HS, Hameed H, Cohen SP. Pain Physician.2012;15(3):E247-78.
  4. Jee H, Lee JH, Park KD, Ahn J, Park Y. Ultrasound-guided versus fluoroscopy-guided sacroiliac joint intra-articular injections in the non-inflammatory sacroiliac joint dysfunction: A prospective, randomized, and single blinded study. Arch Phys Med Rehabil. 2013;9:[Epub ahead of print].
  5. Manchikanti L, Hansen H, Pampati V, Falco FJ. Utilization and growth patterns of sacroiliac joint injections from 2000 to 2011 in the medicare population. Pain Physician. 2013;16(4):E379-90.
  6. Simopoulos TT, Manchikanti L, Singh V, Gupta S, Hameed H, Diwan S, Cohen SP. A systematic evaluation of prevalence and diagnostic accuracy of sacroiliac joint interventions. Pain Physician. 2012;15(3):E305-44.
  7. Spiker WR, Lawrence BD, Raich AL, Skelly AC, Brodke DS. Surgical versus injection treatment for injection-confirmed chronic sacroiliac joint pain. Evid Based Spine Care J. 2012;3(4):41-53.

Lumbar Epidural Steroid Injection

Lumbar Epidural Steroid Injection

What Is A Lumbar Epidural Steroid Injection?

Epidural injections for pain relief emerged in 1901. The first epidural injection performed used cocaine to relieve pain that was suspected to emerge from the lumbar nerve roots. Between the 1920s and 1940s, epidural injections contained mostly saline and a local anesthetic agent. The use of corticosteroids in epidural steroid injections began in 1952. The corticosteroid used during this procedure is a synthetic, man-made drug whose function is similar to that of cortisol.Currently, epidural steroid injections are widely used both in diagnosing and treating neuropathic pain. Lumbar epidural steroid injections, in particular, are performed in the lumbar region of the lower back in order to treat pain that occurs within the lower back and legs. More specifically, corticosteroids are injected into the epidural space surrounding the spinal nerves of the lumbar region. This medication functions to reduce pain and inflammation within the area. The procedure itself is minimally invasive and does not require surgery.

The short-term efficacy of lumbar epidural steroid injections has been well documented. Moreover, this procedure has been accepted as an effective treatment option for both radicular and back pain by the United States Department of Health and Human Services and the North American Spine Society. The long-term effectiveness of this procedure is not as clear, however, and more studies are warranted.

The lumbar epidural steroid injection provides some benefits over steroids that are administered orally or other orally dispensed analgesics, such as non-steroidal anti-inflammatory drugs (NSAIDs), as the medication is delivered directly to the affected area. Additionally, successfully completed lumbar epidural steroid injections may also reduce concomitant symptoms of numbness or tingling sensations.

Though quite rare, there is some risk for potential complications associated with the lumbar epidural steroid injection procedure. As with other epidural injections, there is a risk for minor bleeding at the site of the injection, infection, spinal headache, and temporary leg weakness.

In addition, there is a specific risk for additional complications with regard to the lumbar procedure. The more commonly occurring of these include:

  • Backache or a postural puncture headache (occurs in between 0.5 and 1% of patients receiving lumbar injections)
  • Dizziness, neurocardiogenic syncope, nausea, or even vomiting
  • Bleeding at the trajectory of the injection
  • Injury to the nerve root

How Is A Lumbar Epidural Steroid Injection Performed?

During the lumbar epidural steroid injection procedure, the patient is placed in the prone position on the X-ray table (i.e., lying face down flat on the table). Some physicians or pain specialists will have the patient place a small pillow under their stomach, which places a slight curve in the lower back. The surface of the skin in the area of the injection is thoroughly cleansed and sterilized. For most procedures, only a topical local anesthetic is required; however, a small portion of patients may feel too uncomfortable and request that they be sedated for the procedure.The physician will begin by inserting a fluoroscope device into the back, which transmits a video image of the internal structures on to a computer screen. This device is then used as a guide for the physician to ensure proper placement of the injection needle into the affected area. Contrast dye can also be injected in order to confirm placement, as well as to assess the degree of medication distribution.

When the physician has assured correct placement of the injection needle, the steroid solution is injected. In some instances, the patient will report sensations of pressure that are not painful, owing to the build-up of fluid. Once the procedure has been completed, the patient is held for observation for approximately 15 to 20 minutes and is then discharged home.

In terms of needle placement, there are three different methods for performing a lumbar epidural steroid injection, which include:

  • Interlaminar: Needle is placed between the lamina and vertebrae of the middle back and the corticosteroid solution is delivered on either side of the spine
  • Transforaminal: Needle is placed into the neural foramen on the side of the vertebrae and the corticosteroid solution is delivered only to one side of the spine
  • Caudal: Needle is placed in the area of the large sacral canal at the tailbone

Conditions Related To Lumbar Epidural Steroid Injections

The lumbar epidural steroid injection can be effective in managing many forms of acute and chronic pain that occur within the lower back or limbs. In particular, this procedure is most effective in conditions that arise as the result of damage or irritation and inflammation of the nerves within the lumbar region.Some common pain conditions that are treated using lumbar epidural steroid injections include:

  • Synovial cysts: This condition occurs as the result of cysts that form within the facet joint or in the area of the nerve root. These cysts may cause compression of the structures of the spine, which can lead to nerve pain.
  • Lumbar radiculopathy: This is a specific type of pain that emerges as the result of compression or inflammation of the spinal nerves. This pain is unique in that it radiates from the lower back region, down through the back of the leg, into the calf or foot.
  • Degenerative disc disease: This condition occurs when nerve bundles of the spine are impinged as the result of an irritated or damaged and inflamed intervertebral disc. This compression of the nerve tissue causes it to become irritated and transmit exaggerated signals of pain back to the spinal cord and brain.
  • Herniated disc: Similar to intervertebral disc degeneration, herniated discs occur when the intervertebral disc bulges or even ruptures and thereby places compression on the nearby spinal nerves, causing them to send exaggerated signals of pain to the spinal cord and brain.
  • Spinal stenosis: This condition occurs as the result of a narrowing of the spinal canal, which places pressure on the nerves inside the passageway.
  • Spondylosis: This condition occurs as the result of a defect in the link between the vertebrae that make up the spinal column. Over time, this defect can lead to degeneration of the structures that make up the spine and even stress fractures.

Conclusion

Epidural steroid injections have been used to effectively treat neuropathic pain since 1952. Lumbar epidural injections, in particular, can provide patients suffering from chronic or acute lower back and leg pain with some relief from their symptoms. The procedure is minimally invasive and does not require surgery. Previous studies have supported the short-term effectiveness of these injections; however, more work is necessary to examine the long-term benefits of the procedure.

References

  1. Coliman F, Villalobos F. Epidural steroid injections: Evidence and technical aspects. Techniques in Regional Anesthesia and Pain Management. 2010;14;113-119.
  2. Collighan N, Gupta E. Epidural steroids. Brit J Anaesth. 2010;109(1):1-5.
  3. Friedrich J, Hlumbar epidural arrast M. Lumbar epidural steroid injections: indications, contraindications, risks, and benefits. Current Sports Medicine Reports. 2010;9(1):43-49.
  4. Ghai B, Vadajae KS, Wig J, Dhillon MS. Lateral parasagittal veres midline interlaminar lumbar epidural steroid injection for management of low back pain with lumbosacral radicular pain: A double-blind randomized study.Anesth Analg. 2013;117(10):219-227.
  5. Manchikanti L, Cash K, McManus C, Damron K, Pampati V, falco F. Lumbar interlaminar epidural injections in central spinal stenosis: Preliminary results of a randomized, double-blind active control trial. Pain Physician. 2012;15:51-63.
  6. Sukdeb D, Ramsin M, Laxmaiah M. Evidence-based practice of lumbar epidural injections. Techniques in Regional Anesthesia and Pain Management. 2009;13:281-287.

Arthritis

What Is Arthritis?

Arthritis is a common condition that affects various components of the body including the cartilage, joints, bones, muscles, and connective tissues. Arthritis impairs an individual’s normal movement and functioning. There are over 100 different forms of arthritis that affect people of many different ages. The three most common types of arthritis are: osteoarthritis, rheumatoid arthritis, and juvenile arthritis.Osteoarthritis affects approximately 27 million people in the United States, making it the most common form of arthritis. Osteoarthritis is a degenerative disease that results when the cartilage surrounding the joints begins to wear down. The degeneration of the cartilage causes the bones to rub against each other, leading to joint pain, stiffness, and other issues within the affected joint. The cause of osteoarthritis is not fully understood; however certain risk factors that are associated with an increased risk of developing osteoarthritis have been identified, including increasing age, obesity, previous joint injuries, overuse of a joint, weak musculature, and certain genetic factors. Osteoarthritis can affect any joint in the body however it most commonly affects the joints in the hands, knees, hips, and spine.

The symptoms associated with osteoarthritis tend to develop gradually and usually include joint pain and stiffness that occurs after rest and improves with physical activity. Osteoarthritis is sometimes referred to as a progressive, degenerative joint disease as it is a disease that worsens over time. In the early stages of osteoarthritis, the pain may be moderate and intermittent, and may not have a negative impact on an individuals’ daily functioning. While some patients may not progress past the early stage of the disease, other patients progress to later and more debilitating stages of the disease. In the later stages of the disease the joint pain and stiffness worsens. For individuals with severe cases of osteoarthritis, normal activities such as walking, climbing stairs, and even sleeping can become difficult. At the present time there is no cure for osteoarthritis but maintaining a healthy weight, staying active, and other treatment options may help to reduce pain, improve joint functioning, and slow the progression of the disease.

Rheumatoid arthritis is another common type of arthritis, affecting approximately 1.5 million people in the United States. Women are three times more likely than men to develop this disease. Women are usually affected by rheumatoid arthritis between the ages of 30 and 60, while men are usually affected later in life. Rheumatoid arthritis is a chronic inflammatory disorder that is the result of inflammation of the membranes that make up the joint tissue lining. Rheumatoid arthritis causes joint pain, swelling, stiffness, and the joints are often warm to the touch. Rheumatoid arthritis can often lead to severe joint damage. Rheumatoid arthritis is commonly seen bilaterally, meaning that if a joint on one side of the body is affected by inflammation, the same joint on the other side of the body is usually affected as well. The severity of the symptoms associated with rheumatoid arthritis varies and can also change from day to day. However, if symptoms suddenly increase it is called a flare. When a flare occurs, it can last for several days to months.

Rheumatoid arthritis is considered an autoimmune disease. Under normal circumstances the body’s immune system acts to protect the body by attacking and destroying foreign substances, including bacteria and viruses. However, in patients who suffer with rheumatoid arthritis, the body’s immune system mistakenly attacks joint tissue. This abnormal immune system reaction results in inflammation that cannot only result in joint damage, but in organ damage as well. Early diagnosis of rheumatoid arthritis is essential in order to prevent severe joint damage and organ damage.

Juvenile arthritis is a term that is used to describe various inflammatory and autoimmune diseases that can develop in children below the age of 16. Juvenile idiopathic arthritis is the most common type of juvenile arthritis. In order to be diagnosed with this condition, the child must be experiencing the initial stages of swelling in at least one joint, for at least six weeks. At the present time there is no known cause of juvenile arthritis. Furthermore, there is no evidence to support the idea that certain foods, toxins, or allergies can cause children to develop juvenile arthritis. However, there is some evidence to suggest that there may be a genetic predisposition to developing this disease. An accurate diagnosis of juvenile arthritis is essential for proper treatment.

Epidemiology And Impact Of Arthritis

Approximately 50 million individuals in the United States are affected by arthritis, making it a serious health concern in the country. While many people think that arthritis only affects the elderly, it can affect individuals of any age. It has been reported that two-thirds of individuals who suffer with arthritis are under the age of 65. Moreover, approximately 300,000 children are afflicted by this painful condition. It has been estimated that the prevalence of arthritis will continue to rise over the next two decades. By 2030 it is estimated that approximately 67 million individuals in the United States will develop arthritis.Of the individuals affected by arthritis, approximately 36 million are Caucasian American, 4.6 million are African American, and 2.9 million are Latin American or Hispanic. Arthritis is also the leading cause of disability in the U.S. and results in more mobility issues than heart disease, cancer, or diabetes.

Arthritis has begun to place a burden on the economic and healthcare systems in the U.S. Arthritis is responsible for approximately 44 million physician appointments and over 900,000 hospitalizations each year. Reports investigated patients between 2003 and 2010 and found that certain surgical procedures that are used for the treatment of arthritis are associated with longer hospital stays, especially when they are performed on patients with later stages of the disease. These results may be due to the fact that patients in the later stages of the disease waited too long to seek out treatment, or that they suffered from certain types of arthritis. When arthritis is diagnosed and treated in the early stages of the disease, if surgery is required, it may be done as a day surgery procedure or require a one-day stay as opposed to requiring a hospital stay of a longer duration. Longer hospitalization times result in an increased need for healthcare personnel and equipment, and therefore higher medical costs.

In particular, for patients aged 18 to 64 who suffer from rheumatoid arthritis reports have shown that between 2002 and 2011 there has been a considerable increase in costs for these patients. An increase in prescription medications combined with a decrease in hospitalizations, as well as an increase in other costs such as sick leave and disability may be responsible for the increased costs. Additionally, since 2009 there has been an increase in the cost of medications used to treat rheumatoid arthritis, which may also contribute to the rising costs associated with this particular subset of arthritis patients.

Causes Of Arthritis

There are a variety of factors that can influence an individuals’ susceptibility for developing arthritis. In order to understand how arthritis often develops, understanding the way a joint works is beneficial. Joints are areas where bones intercept and the ligaments within the joints hold the bones together. Ligaments are comprised of tissue that contracts and expands, similar to elastic. Ligaments help to keep bones in place. Conversely, surrounding muscles contract and relax to allow for movement of the joint. Cartilage is another type of tissue that covers the surface of bones and helps to prevent bones from rubbing against each other and becoming damaged. Synovial fluid fills that space within the joint and helps to encourage mobility by nourishing the cartilage and the joint.The various components of the joint are all susceptible to damage from wear and tear from everyday use as well as from injury or acute traumatic events. When an individual is diagnosed with arthritis it may be indicative of a problem with the cartilage, synovial fluid, or immune system. The type of arthritis that an individual is diagnosed with provides an idea as to whether cartilage has worn away, synovial fluid has deceased, an abnormal immune response has occurred, that an infection is present, or that a combination of these activities has occurred.

Osteoarthritis is a chronic disease that involves damage to the cartilage located within the joint. The cartilage damage may be the result of wear and tear over time or may be the result of an injury. When the cartilage is damaged, it is unable to provide cushioning for the joint. If there is enough damage to the cartilage, there is a significant risk of bone rubbing against bone. This can lead to significant pain, especially with physical activity, in addition to a loss of joint flexibility.

On the other hand, rheumatoid arthritis is characterized by an abnormal immune response within the body to the joints. In particular, the immune system begins to attack the synovial membrane that lines that joint capsule and encloses the structures of the joint. As a result of this abnormal immune response, the synovial membrane becomes inflamed and swollen. If rheumatoid arthritis is left untreated it can progress from mild joint damage to serious organ damage.

While wear and tear, injury, trauma, and abnormal immune responses can lead to arthritis, research has shown that arthritis is often caused by a combination of various factors. The factors that have been associated with an increased risk of developing arthritis, include:

  • Weak muscles
  • Genetic predisposition
  • Overuse of a joint
  • Certain autoimmune conditions
  • Increasing age
  • Female sex
  • Certain allergic reactions or infections
  • Obesity
  • Previous joint injury
  • Physically demanding occupation
  • Repetitive heavy lifting
  • Certain foods

Symptoms Of Arthritis

Typically, patients suffering from arthritis will report joint pain and stiffness. These symptoms tend to get worse with age or as the disease progresses. Other relatively common symptoms of arthritis include:

  • Joint pain or stiffness during or after physical activity
  • Joint pain or stiffness after prolonged rest
  • Joint tenderness
  • Morning joint stiffness
  • Decreased range of motion
  • Grinding sound or sensation within the joint
  • Redness around the joint
  • Swelling of the joint
  • Warmth of the joint
  • Weight loss
  • Tiredness

Symptoms that are common in patients who suffer from osteoarthritis include:

  • Joint pain or stiffness (especially in the lumbar spine, hips, and knees)
  • Joint pain or stiffness that increases with rest or overuse
  • Joint pain or stiffness after rest that begins to resolve with movement
  • Joint pain or stiffness that worsens during or after physical activity or at the end of the day

Symptoms that are common in patients who suffer from rheumatoid arthritis include:

  • Chronic joint pain
  • Fatigue
  • Warmth of the joint
  • Swollen and red joints
  • Prolonged morning joint stiffness
  • Inflammation of the joints of the hand and wrist

Symptoms that are common in patients who suffer from juvenile arthritis include:

  • Chronic joint pain
  • Morning joint stiffness
  • Joint swelling
  • Joint tenderness
  • Irritability
  • Eye pain, eye redness, or blurred vision
  • Rash
  • Fever (persistent)
  • Limping

In patients who are very young, it may seem that the child cannot perform motor skills and activities that they were previously able to perform.

Symptoms of arthritis can vary drastically among patients. Symptoms may be temporary for some patients while others will develop chronic arthritis symptoms. The severity of arthritis pain can range from relatively mild to debilitating, and may be intermittent or constant. At times patients with arthritis will report that they have some days that are better than others when it comes to their arthritis symptoms.

Diagnosis Of Arthritis

osteoarthritis

There are a number of types of arthritis, including osteoarthritis, that are usually diagnosed following a medical assessment by a physician. The assessment typically includes a detailed history of symptoms as well as a physical examination. Diagnostic imaging tests, such as X-ray or magnetic resonance imaging (MRI), may be utilized to visualize the affected joint. If certain types of arthritis, such as rheumatoid arthritis or juvenile arthritis, are suspected, lab testing of urine, blood, or synovial fluid may also be performed to help confirm the diagnosis. Furthermore, lab testing of these body fluids helps to rule out other conditions that may be contributing to a patient’s symptoms.

In regard to rheumatoid arthritis, blood tests that reveal specific markers are necessary to properly diagnosis this condition. The specific markers that are revealed by these tests include various antibodies that are present in about 70 to 90% of individuals who suffer from rheumatoid arthritis. These specific markers sometimes circulate in the blood of individuals who do not suffer from rheumatoid arthritis, however the specific markers are usually present in higher levels in individuals suffering from this painful condition. The results of the lab testing can be used in conjunction with the medical history, physical examination, and any imaging performed to make an accurate diagnosis.

In regards to juvenile arthritis, there is no single lab test that can exclusively confirm this disease. In many patients the lab testing that is used reveals the presence of inflammation or possibly an infection; however, these results do not generally provide a physician with information to help make a clear diagnosis. Therefore in order to make a proper diagnosis of juvenile arthritis a detailed medical history combined with a thorough physical examination that includes special imaging tests is essential.

Early diagnosis of arthritis is essential in order to receive treatment that may help to reverse or prevent disease progression. If arthritis is left untreated it can lead to permanent damage to the joints, ligaments, cartilage, and bones. This damage can result in deformity and decreased mobility that may be irreversible. Moreover, arthritis can damage other structures within the body, including vital organs. Early diagnosis of arthritis can also help to prevent the need for invasive types of treatment, including surgery.

Treatments For Arthritis

At the present time, no cure has been developed for arthritis so treatment focuses on providing pain relief and improving joint functioning. Treatment for arthritis initially includes pain medication and non-steroidal anti-inflammatory drugs (NSAIDs), protective devices (e.g. braces), cold and hot packs, and exercise. Many patients suffering from arthritis pain believe that they should avoid exercise. However, there is a significant amount of research that suggests that certain forms of endurance training and resistance exercises are actually beneficial for individuals suffering from the early stages of both osteoarthritis and rheumatoid arthritis.There is also a body of evidence that has found that weight management, exercise, and avoiding injuries to joints helps to reduce the occurrence of osteoarthritis and may also help to avoid flare-ups of arthritis symptoms. It has been found that weight loss in individuals who are overweight is especially effective. For every pound of weight loss, there is four pounds of pressure being taken off the knees. This can help to prevent or reduce inflammation and joint injury.

If there is no response to initial treatment methods, physical therapy may be recommended. Research has shown that physical therapy; in addition to regular physical activity is beneficial for arthritis sufferers. It has been found that individuals who suffer from arthritis often exercise less than the recommended amount to maintain a healthy lifestyle. Physical therapists often use techniques that alter normal behaviors to address both the biological and psychosocial aspects of an individual’s life. Patients are educated by their physical therapist on arthritis and the benefit of engaging in a healthy lifestyle that includes physical activity. Current statistics show that individuals who are in the later stages of arthritis, on disability, or that have strong familial and social support are more likely to receive the services of a physical therapist.

Often a combination of treatments provides arthritis symptom relief. However, for some individuals their arthritis symptoms fail to respond to treatment or serious damage has occurred and surgery is necessary.

Proper Diet

In addition to a healthy lifestyle consisting of exercise and physical therapy, there is some evidence to suggest that a healthy, nutritious diet can help to minimize the complications that are associated with arthritis. In particular, certain foods including those that contain trans and saturated fats tend to increase inflammation in the body and should therefore be avoided.

It is suggested that the following foods should be limited in the diet or completely avoided:

  • Fatty pork or beef
  • Chicken skin
  • Dairy foods (full fat)
  • High sugar foods
  • Baked goods (made with white flour)
  • White rice
  • White bread
  • Foods that contain palm oil or palm-kernel oil

It is recommended that these foods be replaced by healthier food options, including:

  • Lean cuts of pork and beef
  • Skinless turkey and chicken
  • Fat-free or reduced-fat dairy products

Certain types of fish and nuts contain omenga-3 fatty acids, which have been demonstrated to reduce arthritis symptoms, particularly rheumatoid arthritis symptoms. Furthermore, extra virgin olive oil contains high levels of a naturally occurring compound, oleocanthal, which helps to prevent and reduce inflammation associated with arthritis. Oleocanthal has also been shown to block the inflammatory pathways in the same manner that anti-inflammatory medications, including aspirin and ibuprofen do. Moreover, vitamin C, bioflavonoids, and carotenes are antioxidants that can help to protect the body from the negative effects of inflammatory compounds. Foods containing these antioxidants have the ability to help in the prevention of arthritis, slow the disease progression, and help to reduce pain.

It is recommended that the following healthy food options be added into the diet of individuals suffering with arthritis:

  • Fish (e.g. herring, salmon, sardines, mackerel, rainbow trout, and anchovies)
  • Flax seeds (ground)
  • Chia seeds
  • Soybeans
  • Walnuts
  • Vegetables and fruits with high levels of vitamin C (e.g. oranges, grapefruits, guava, strawberries, lemons, pineapples, bell peppers, broccoli, kale, sweet potatoes, Brussels sprouts, carrots, butternut squash, spinach, and sweet red peppers)

Guided Imagery

Alternative treatment options that are available for individuals suffering with arthritis include relaxation and guided imagery. Visualization, also referred to as mental imagery, is the act of an individual imagining themselves engaging in a certain action. It is also referred to as guided imagery as a professional trained in this technique often helps to guide an individual through the imagined activity.

Studies have shown that by mentally rehearsing an activity prior to actually executing the needed motor skills to complete the activity has the ability to improve future activity performance. The strength of visualization is dramatic, as research has shown that imagining an activity prior to engaging in it has a more significant effect on overall performance than by engaging in motor and strength exercises, when there is no history of guided imagery. Recent research also alludes to the fact that visualization is an effective technique that shows that the mind has the ability to transform mental imagery into improved physical activity performance.

Treatment With Medication

Over-the-counter medication may be recommended for patients suffering from mild to moderate pain due to their arthritis. However, prescription medication may be required for patients suffering with severe or chronic arthritis symptoms. Currently there are over 100 different types of medications available for the treatment of various forms of arthritis. The first-line treatment, from a pharmacological approach, are non-steroidal anti-inflammatory drugs (NSAIDs). Physicians usually recommend NSAIDs due to their ability to reduce joint inflammation, thereby helping to reduce pain. NSAIDs that can be taken orally are a very common prescription for the treatment of inflammation related to arthritis. Analgesic medication may also be recommended to treat pain that is related to arthritis; however, this type of medication does not offer the same anti-inflammatory effects that NSAIDs do.

When inflammation occurs, harmful fluids that contain enzymes that cause pain typically build up. NSAIDs help to reduce the buildup of these pain-inducing enzymes. These medications also help to block the release of pain-inducing enzymes, which enhance inflammatory reactions.

Many patients consider more invasive types of treatment for their arthritis symptoms. There is some evidence that suggests that corticosteroid injections can help reduce the degree of inflammation, in addition to providing pain relief for arthritis sufferers. Corticosteroids, including cortisone and prednisone, may be recommended in an effort to reduce inflammation, and in some cases to suppress an individual’s immune system. This is particularly true in cases where the immune system has begun to attack the joints of the body, as is seen in individuals affected by rheumatoid arthritis. There are a variety of corticosteroid injections and treatment plan regimens that are available that usually involve multiple injections for optimal pain relief.

Joint injections are a common procedure that is often recommended for patients suffering with arthritis. This procedure involves injecting medication directly into a joint, which helps to relieve inflammation and pain. Joint injections usually involve injecting an anesthetic combined with a corticosteroid into the affected area. The anesthetic helps to reduce pain while the corticosteroid helps to reduce inflammation. This procedure is relatively quick and simple to perform and some patients have reported immediate relief of pain symptoms. Joint injections can be repeated multiple times in order to enhance symptom relief. Various studies have shown that patients who receive joint injections report significant pain relief, increased range of motion, and improved quality of life.

Medial branch blocks are another type of treatment that can be offered to patients suffering with arthritis pain. A medial branch block involves injecting medication into the facet joints, which are structures that connect the vertebrae within the spinal column. Within the facet joint are networks of medial branch nerves that are responsible for the transmission of pain signals to the brain when nerve tissue is damaged or inflamed. When an individual begins to experience chronic arthritic pain, a medial branch block is usually recommended to help destroy the medial branch nerves, thereby blocking the transmission of pain signals to the brain. This results in a reduction, or elimination of pain. The use of medial branch blocks to relieve pain associated with arthritis has been well documented as an effective treatment option. The use of medial branch blocks has been shown to provide significant pain relief and improved mobility.

Joint injections and medial branch blocks may be used in cases where the physician suspects that surgery may be necessary. These treatment options may be used to provide some pain relief to these patients but can also provide physicians with information regarding how the body and nerves may react to certain surgical procedures. Diagnostic injections usually involve nerve blocks where a needle is inserted into the spinal column at specific areas where the affected spinal nerves are located. Fluoroscopy, or X-ray guidance, is used to ensure proper needle placement. Once proper placement is confirmed, a catheter is inserted through the needle to deliver pain medication directly to the spinal nerves that are believed to be responsible for the arthritic pain. An anesthetic and corticosteroid, or a substance that disintegrates nerve tissue, is injected to provide pain relief. This procedure leads to prolonged pain relief by blocking pain signal transmission.

Diagnostic nerve blocks provide the physician with an idea of whether a particular surgery will be effective for reducing arthritic pain for periods longer than the nerve block itself. A diagnostic nerve block is usually performed a minimum of two times. If the patient experiences greater pain relief with repeated injections, there is an increased probability that they will experience positive surgical outcomes. Prior to recommending surgery for arthritic pain, physicians usually like to observe the results of at least two diagnostic nerve blocks.

Osteoarthritis Treatment

Medication can be taken as needed for patients who are suffering from pain that is associated with the early stages of osteoarthritis. If the disease begins to progress, the physician may recommend occupational therapy or physical therapy to help maintain muscle strength and joint functioning. When the pain becomes severe, mobility becomes limited, or the patient becomes unable to perform daily activities, physicians may recommend more aggressive treatment options, including surgery.Patients suffering with osteoarthritis are advised to engage in regular physical activity and maintain a healthy lifestyle. If patients follow these recommendations in the early stages of the disease, it may help to prevent the disease from progressing. Patients who limit their physical activity due to pain may end up with weak joints and increased joint stiffness which can add to the pain that they are experiencing. Engaging in regular physical activity helps to strengthen muscles, which helps to protect the joints. Additionally, avoiding excessive weight gain is also important for patients who suffer with osteoarthritis as extra weight places added pressure and stress on the joints of the body. Other aspects of osteoarthritis management include eating a healthy diet, maintaining a good sleep schedule, and maintaining good mental health.

Rheumatoid Arthritis Treatment

rheumatoid arthritis

The goals of treatment for rheumatoid arthritis are to reduce pain and inflammation, and slow disease progression. Over-the-counter pain medications and prescriptions medication are often quite effective for reducing rheumatoid arthritis symptoms. Medication that specifically works to suppress abnormal immune system responses are also effective for the management of rheumatoid arthritis and may help to lead to a state of remission. This means that the inflammation associated with this disease completely ceases or is extremely low. Even if a patient experiences a state of remission they will still be monitored for inflammatory markers with regular lab testing as well as a physical examinations. Monitoring these patients at regular intervals will help to determine how well the treatment is working for their condition. Additionally, if the symptoms of rheumatoid arthritis begin to re-occur, the physician may adjust the medication dosage or prescribe a new type of medication.

Patients suffering with rheumatoid arthritis are also advised to remain physically active as this will help to keep their joints flexible. Additionally, it is advisable that these patients also receive physical therapy in order to learn appropriate types of exercises that they should perform in addition to learning proper techniques of the exercises to avoid potential injuries. In addition to exercise and physical therapy, patients with rheumatoid arthritis are encouraged to consume a nutritious diet and maintain a healthy weight. Patients that follow these recommendations may notice a dramatic improvement in their pain levels.

Juvenile Arthritis Treatment

The goal of treatment for juvenile arthritis is to reduce inflammation and pain in an effort to improve a child’s quality of life. A combination of a healthy diet, physical activity, medication, and eye care is usually recommended. The treatment plan for a child with juvenile arthritis is developed specifically for their case and often involves multiple healthcare practitioners. The healthcare team may include an ophthalmologist, dentist, pediatric rheumatologist, nurse practitioner, and physical therapist. The healthcare team will evaluate and monitor a child’s condition and adjust the treatment plan as needed. This is vital as each child responds differently to arthritis treatment.Non-steroidal anti-inflammatory drugs (NSAIDs) and analgesic medications as well as disease-modifying anti-rheumatic drugs (DMARDs) are the two types of medications that are commonly used to treat juvenile arthritis. NSAIDs and analgesic medication are used due to the fact that these medications help to relieve pain and inflammation. Disease-modifying anti-rheumatic drugs are used because they may cause the disease to go into a remission state, thereby helping to prevent joint damage. In rare cases medication doses or different types of medications may be prescribed until the child begins to respond positively to treatment. Certain medications that are prescribed to children affected by juvenile arthritis affect the immune system and/or cause undesirable side effects; therefore these children are monitored closely for adverse reactions.

Conclusion

Arthritis is a term that is used to describe over 100 conditions and diseases that affect individuals of all ages. The three most common types of arthritis are osteoarthritis, rheumatoid arthritis, and juvenile arthritis. Common symptoms of all of these conditions include joint pain, swelling, stiffness, and weakness. Osteoarthritis is caused by degeneration that may be the result of normal wear and tear of the joint or by an acute traumatic event. Rheumatoid arthritis is caused by an abnormal immune response, whereby the body begins to attack the joints of the body. The cause of juvenile arthritis is unknown, although most children who develop this disease are genetically predisposed to this condition.There is currently no cure for arthritis, but a variety of treatment options exist to help manage the pain and inflammation associated with this condition. Typically, conservative treatment methods including medication, exercise, physical therapy, and hot and cold compresses are recommended. Patients with more severe or chronic symptoms may be advised to undergo more invasive treatment options including corticosteroid injections, medial branch blocks, and possibly surgery.

Most cases of early stage arthritis can be successfully managed with conservative treatment options. Early diagnosis and treatment of arthritis is essential for optimal treatment outcomes. Receiving early treatment is particularly important for patients with rheumatoid arthritis as it can help to prevent deformities, disability, and organ damage. Symptoms of chronic pain and inflammation should not be ignored; patients are encouraged to speak with their physicians if they begin to experience any joint pain or stiffness as they may be suffering from the early stages of this painful condition.

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