Norepinephrine and dopamine reuptake inhibitors (NDRIs)

Certain brain chemicals called neurotransmitters are associated with depression, including the neurotransmitters norepinephrine (nor-ep-ih-NEF-rin) and dopamine (DOE-puh-mene). Research suggests that abnormalities in neurotransmitter activity can affect mood and behavior.

Symptoms

Osteoarthritis symptoms often develop slowly and worsen over time. Signs and symptoms of osteoarthritis include:

• Pain in a joint during or after use, or after a period of inactivity
• Tenderness in the joint when you apply light pressure
• Stiffness in a joint, that may be most noticeable when you wake up in the morning or after a period of inactivity
• Loss of flexibility may make it difficult to use the joint
• Grating sensation when you use the joint
• Bone spurs, which appear as hard lumps, may form around the affected joint
• Swelling in some cases

Osteoarthritis symptoms most commonly affect the hands, hips, knees and spine. Unless you've been injured or placed unusual stress on a joint, it's uncommon for osteoarthritis symptoms to affect your jaw, shoulder, elbows, wrists or ankles.

Osteoarthritis of the spine

Osteoarthritis of the spine

In osteoarthritis of the spine, disks narrow and spurs form. Where bone surfaces (facets) rub together, cartilage becomes worn and may be painful.

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Osteoarthritis of the hip

Osteoarthritis of the hip

The hip joint shown on the left side of the image is normal, but the hip joint shown on the right side of the image shows deterioration of cartilage due to osteoarthritis.

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Risk factors

Factors that increase your risk of osteoarthritis include:

• Older age. Osteoarthritis typically occurs in older adults. People under 40 rarely experience osteoarthritis.
• Sex. Women are more likely to develop osteoarthritis, though it isn't clear why.
• Bone deformities. Some people are born with malformed joints or defective cartilage, which can increase the risk of osteoarthritis.
• Joint injuries. Injuries, such as those that occur when playing sports or from an accident, may increase the risk of osteoarthritis.
• Obesity. Carrying more body weight places more stress on your weight-bearing joints, such as your knees. But obesity has also been linked to an increased risk of osteoarthritis in the hands, as well.
• Other diseases that affect the bones and joints. Bone and joint diseases that increase the risk of osteoarthritis include gout, rheumatoid arthritis, Paget's disease of bone and septic arthritis.

Tests and diagnosis

If your doctor suspects you have osteoarthritis, he or she will examine your affected joint and ask you questions about your joint pain. To better understand the cause of your pain, he or she may also recommend:

• X-rays. X-ray images of your affected joint may reveal a narrowing space within a joint, which indicates that the cartilage is breaking down. An X-ray may also show bone spurs around a joint.
• Blood tests. Blood tests may help rule out other causes of joint pain, such as rheumatoid arthritis.
• Joint fluid analysis. Your doctor may use a long needle to draw fluid out of the affected joint. Examining and testing the fluid around your joint can determine if your pain is caused by gout or an infection.
• Examining the joint with a tiny camera (arthroscopy). In some cases, your doctor may recommend arthroscopy to see inside your joint in order to determine the cause of your pain. During arthroscopy, small incisions are made around your joint and a tiny camera is inserted to see inside your joint. Your doctor watches a video screen to look for abnormalities within your joint.

Treatments and drugs

There's no known cure for osteoarthritis, but treatments can help to reduce pain and maintain joint movement so that you can go about your daily tasks. While medications and joint replacement surgery are key components of treatment for osteoarthritis, your doctor will likely recommend you try all other possible solutions before you consider those options. Eventually the pain may become severe so that medications and surgery may be necessary.

Initial treatment options for mild osteoarthritis
For mild osteoarthritis pain that is bothersome, but not enough to have a great impact on your daily activities, your doctor may recommend that you:

• Rest. If you're experiencing pain or inflammation in your joint, rest it for 12 to 24 hours. Find activities that don't require you to use your joint repetitively. Try taking a 10-minute break every hour.
• Exercise. With your doctor's approval, get regular exercise when you feel up to it. Stick to gentle exercises, such as walking, biking or swimming. Exercise can increase your endurance and strengthen the muscles around your joint, making your joint more stable. Avoid exercising tender, injured or swollen joints. If you feel new joint pain, stop. New pain that lasts more than two hours after you exercise probably means you've overdone it.
• Lose weight. Being overweight or obese increases the stress on your weight-bearing joints, such as your knees and your hips. Even a small amount of weight loss can relieve some pressure and reduce your pain. Aim to lose 1 or 2 pounds a week, at most. Talk to your doctor about healthy ways to lose weight. Most people combine changes in their diet with increased exercise.
• Use heat and cold to manage pain. Both heat and cold can relieve pain in your joint. Heat also relieves stiffness and cold can relieve muscle spasms. Soothe your painful joint with heat using a heating pad, hot water bottle or warm bath. Heat should be warm, not hot. Apply heat for 20 minutes several times a day. Cool the pain in your joint with cold treatments, such as with ice packs. You can use cold treatments several times a day, but don't use cold treatments if you have poor circulation or numbness.
• Work with a physical therapist. Ask your doctor for a referral to a physical therapist. The physical therapist can work with you to create an individualized exercise plan that will strengthen the muscles around your joint, increase your range of motion in your joint and reduce your pain.
• Find ways to avoid stressing your joints. Find ways to go about your day without stressing your joints. An occupational therapist can help you discover ways to do everyday tasks or do your job without putting extra stress on your already painful joint. For instance, a toothbrush with a large grip could make brushing your teeth easier if you have finger osteoarthritis. A special seat in your shower could help relieve the pain of standing if you have knee osteoarthritis.
• Apply over-the-counter pain creams. Creams and gels available at the drugstore may provide temporary relief from osteoarthritis pain. Some creams numb the pain by creating a hot or cool sensation. Other creams contain medications, such as aspirin-like compounds, that are absorbed into your skin. Read the label so you know what you're using. Pain creams work best on joints that are close the surface of your skin, such as your knees and fingers.
• Try braces or shoe inserts. Consider trying special splints, braces, shoe inserts or other medical devices that can help reduce your pain. These devices can immobilize or support your joint to help you keep pressure off it.
• Take a chronic pain class. The Arthritis Foundation and some medical centers have classes for people with osteoarthritis or chronic pain. Ask your doctor about classes in your area or check with the Arthritis Foundation. These classes teach skills that help you manage your osteoarthritis pain. And you'll meet other people with osteoarthritis and learn their tips for reducing joint pain or coping with your pain.

Treatment options for moderate osteoarthritis
Osteoarthritis pain that persists despite initial treatment may require medications in addition to initial treatment options. Don't assume that taking a medication is all you need. In order to get the most from your treatment, continue exercising when possible and resting when you need to. If you're overweight, continue working to lose weight.

Medications that may be useful for moderate arthritis include:

• Acetaminophen. Acetaminophen (Tylenol, others) can relieve pain, but doesn't reduce inflammation. It has been shown to be effective for people with osteoarthritis who have mild to moderate pain. Taking more than the recommended dosage of acetaminophen can cause liver damage, especially if you consume three or more alcoholic drinks a day. Ask your doctor for guidance on limiting or abstaining from alcohol if you take acetaminophen regularly. Acetaminophen can also affect other medications you may be taking, so be sure to inform your doctor if you're taking it.
• NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain and reduce inflammation. Over-the-counter NSAIDs include ibuprofen (Advil, Motrin, others) and naproxen sodium (Aleve). Stronger versions of these NSAIDs and others are available by prescription. NSAIDs have risks of side effects that increase when used at high dosages for long-term treatment. Side effects may include ringing in your ears, gastric ulcers, cardiovascular problems, gastrointestinal bleeding, and liver and kidney damage. Consuming alcohol or taking corticosteroids while using NSAIDs also increases your risk of gastrointestinal bleeding.
• Tramadol. Tramadol (Ultram) is a centrally acting analgesic that's available by prescription. Tramadol has no anti-inflammatory effect, but can provide effective pain relief with fewer side effects - such as stomach ulcers and bleeding - than those of NSAIDs. However, tramadol may cause nausea and constipation. It's generally used for short-term treatment of acute flare-ups. Your doctor may recommend using tramadol in combination with acetaminophen to increase pain relief.

Treatment options for severe osteoarthritis
If you've tried other treatments but are still experiencing severe pain and disability, you and your doctor can discuss other treatments including:

• Stronger painkillers. Prescription pain pills, such as codeine and propoxyphene (Darvon), may provide relief from more severe osteoarthritis pain. These stronger medications carry a risk of dependence, though that risk is thought to be small in people who have severe pain. Side effects may include nausea, constipation and sleepiness.
• Cortisone shots. Injections of corticosteroid medications may relieve pain in your joint. During this procedure your doctor numbs the area around your joint and then inserts a needle into the space within your joint and injects medication. It isn't clear how or why corticosteroid injections work in people with osteoarthritis. Your doctor may limit the number of injections you can have each year, since too many corticosteroid injections may cause joint damage.
• Visco-supplementation. Injections of hyaluronic acid derivatives (Hyalgan, Synvisc) may offer pain relief by providing some cushioning in your knee. These treatments are made of rooster combs and are similar to a component normally found in your joint fluid. Visco-supplementation is only approved for knee osteoarthritis, though researchers are studying its use in other joints. Injections are typically given weekly over several weeks. Pain relief may last for a few months. Possible risks include infection, swelling and joint pain. People who are sensitive to birds, feathers or eggs shouldn't undergo visco-supplementation treatments.

Surgery for osteoarthritis
Surgery is generally reserved for severe osteoarthritis that isn't relieved by other treatments. You may consider surgery if your osteoarthritis makes it very difficult to go about your daily tasks. Surgical treatments include:

• Joint replacement. In joint replacement surgery (arthroplasty), your surgeon removes your damaged joint surfaces and replaces them with plastic and metal devices called prostheses. The hip and knee joints are the most commonly replaced joints. But today implants can replace your shoulder, elbow, finger or ankle joints. How long your new joint will last depends on how you use it. Some knee and hip joints can last 20 years. Joint replacement surgery can help you resume an active, pain-free lifestyle. In smaller hand joints, it can also improve appearance and comfort and may improve your joint's mobility. Joint replacement surgery carries a small risk of infection and bleeding. Artificial joints can wear or come loose, and may need to eventually be replaced.
• Cleaning up the area around the joint (debridement). Your surgeon may recommend removing loose pieces of cartilage and bone from around your joint to relieve your pain. Debridement is most useful if you're experiencing a locking sensation from a torn cartilage or loose debris in your knee joint. Debridement is typically done arthroscopically, meaning only small incisions are made in your body. A tiny video camera is inserted through the incision to allow your surgeon to see inside your joint. The surgeon uses special surgical tools to clean out any debris pieces from your joint.
• Realigning bones. Surgery to realign bones may relieve pain. These types of procedures are typically used when joint replacement surgery isn't an option, such as in younger people with osteoarthritis. During a procedure called an osteotomy, the surgeon cuts across the bone either above or below the knee to realign the leg. Osteotomy can reduce knee pain by transferring the force of the joint away from the worn-out part of the knee.
• Fusing bones. Surgeons also can permanently fuse bones in a joint (arthrodesis) to increase stability and reduce pain. The fused joint, such as an ankle, can then bear weight without pain, but has no flexibility. Arthrodesis may be an option if you experience severe pain in your joint, but can't undergo joint replacement surgery.

Hip replacement

Hip replacement

Gradual deterioration of cartilage that occurs in osteoarthritis is the most common reason for hip replacement surgery. Implanting an artificial joint eliminates pain and restores near-normal movement.

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Knee replacement

Knee replacement

Knee replacement surgery can repair damage from osteoarthritis and other inflammatory conditions. The artificial joint has metal alloy caps for your thighbone and shinbone and high-density plastic to replace eroded cartilage within the joint and on your kneecap.

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Shoulder replacement

Shoulder replacement

Shoulder replacement surgery may be one option for shoulder osteoarthritis. During shoulder surgery, the surgeon removes the head of the upper arm bone (humerus) and replaces it with a prosthesis. The cup-like surface of the shoulder blade (glenoid cavity) is then smoothed and fitted with a prosthesis.

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Coping and support

Medications and other treatments are key to managing pain and disability, but another major component to treatment is your own attitude. Your ability to cope despite pain and disability caused by osteoarthritis often determines how much of an impact osteoarthritis will have on your everyday life. Talk to your doctor if you're feeling frustrated. He or she may have ideas about how to cope or refer you to someone who can help. In the meantime, try to:

• Keep a positive attitude. Make a plan with your doctor for managing your arthritis. This will help you feel that you're in charge of your disease, rather than vice versa. Studies show that people who take control of their treatment and actively manage their arthritis experience less pain and function better.
• Practice relaxation techniques. Hypnosis, guided imagery, deep breathing and muscle relaxation can all be used to control pain.
• Know your limits. Rest when you're tired. Arthritis can make you prone to fatigue and muscle weakness - a deep exhaustion that makes everything you do a great effort. A rest or short nap that doesn't interfere with nighttime sleep may help.

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