FitSugar

Get Your Butt in Gear: Heart Rate Monitoring Sports Bra

FitSugar — Tue, 09 Jan 2007 04:00:00 -0800

Some people are against wearing a heart rate monitor while they workout because they feel it would be annoying to wear the strap around your lower chest. While I feel zero discomfort whatsoever wearing my strap, you may want to try going strap free.

The NuMetrex Heart Rate Monitoring Sports Bra ($49.50) works with the Polar WearLink Transmitter and compatible watches. It also connects with most fitness machines like spinning bikes and elliptical trainers with integrated monitoring devices.

The NuMetrex Heart Rate Monitor Sports Bra gives you the power of a heart rate monitor with the freedom of strap-free wear. Buy one on Numatrex.com.

Not sure what your target heart rate is? Check out the Fit Calculator to find out!

Support Breast Cancer Awareness With Beyond Yoga

FitSugar — Fri, 23 Oct 2009 08:00:03 -0700

In honor of Breast Cancer Awareness Month, Beyond Yoga, one of my favorite brands of fitness clothes, is offering some unique pink products. The company is donating 30 percent of the proceeds from the sale of these I Am Beyond . . . Hopeful water bottles ($36) and its Lift and Support Bra ($64) to the Women's Cancer Research Fund. Every sale will support research, education, and outreach for the early diagnosis, treatment, and prevention of female cancers. A minimum of $4 will be donated for every water bottle sold, and a $10 donation will be made for every bra sold.

To hear more about these products and see some other photos, keep reading

Fittingly Green: Armpocket For the iPhone

FitSugar — Thu, 16 Jul 2009 10:00:00 -0700

Since I recently got an iPhone, I was looking for a hands-free case to carry it in while I work out. When I found out this Sport 20 made by Armpocket ($30) was eco-friendly, made of bamboo and 100 percent recycled PET fabric (which is made from discarded plastic water bottles), I had to try it. This case instantly became my new favorite fitness accessory.

To find out the other reasons I love this case, and see some photos of it, read more.

The see-through screen on the front of the case allows you to control the touch screen without having to take the iPhone out of the case. So convenient. The strap is padded so it's comfy and resists slipping, and the Velcro ensures a snug fit. Even when I run, it doesn't shake around. The best feature, though, is that not only does it have a pocket for your iPod or iPhone, but there's another separate pocket behind that - perfect for holding tissues, money, keys, your phone, and a snack. There's a hole on the bottom for headphones, but I just use the speaker on the iPhone. Since the case sits on my upper arm, I can hear my tunes, while still staying aware of noises around me. It makes me feel very safe, especially when trail running. Cases are available in threes sizes: Aero 10 ($23), Sport 20 ($30), and Xtreme 30 ($36). It's affordable, practical, and green. Love it.

View 8 Photos ›

You Asked: I Started Exercising, But Now I'm Breaking Out!

FitSugar — Wed, 10 Jun 2009 16:00:00 -0700

Dear Fit,
I just got on an exercise kick and joined a gym. I've been doing 30 minutes of cardio three times a week and finishing with 30 minutes of strength training and stretching. I feel amazing and am starting to lose weight, but now I have a new problem - acne. And it's not just on my face. I have it on my neck and back too. How can I prevent this?
- Blemished Back

Acne and bacne can be unfortunate side effects of exercise, especially in hot weather. There are definitely ways to prevent breakouts caused by sweating.

Wash your face before working out to remove excess oil and makeup that can clog your pores. Then apply a facial moisturizer that's made for acne-prone skin such as Neutrogena's Oil-Free Anti-Acne Moisturizer.
Always wear clean workout clothes, and choose sports bras and tank tops with shoulder straps rather than racerback style. You want the skin on your back to breathe as much as possible, and if there's material covering it, heat, sweat, and bacteria get trapped, which can lead to bacne. Also, the more your skin is covered, the hotter you'll feel, and the more you'll sweat, which also leads to breakouts.
Wear clothes made of wicking material that pulls sweat off the skin.

To find out what else read more.

After cardio, wash your face before you strength train and stretch. Also dry the rest of your body off. You can even change into a dry bra and top if you're especially prone to bacne.
Shower immediately after you're done exercising. Not only does it rinse the sweat and pimple-causing bacteria off your skin, but the water also helps to cool your body temperature down so you don't continue sweating once you get out. Don't have time to shower? Definitely wash your face and put on clean, dry clothes.
Unclog pores and remove dead skins cells from your skin by exfoliating in the shower with loofah gloves. They're gentle enough to use everyday on your face and the rest of your body. Use the gloves with an antibacterial cleanser such as Cetaphil, or soaps that have acne medicine in them, such as salicylic acid.

Whatever you do, don't stop working out. If acne is still a problem after trying out these tips, see a dermatologist.

Source

Food Review: Five-Cheese Rigatoni by Lean Cuisine

FitSugar — Wed, 01 Apr 2009 11:00:00 -0700

Though I sometimes eat Lean Cuisine products in a pinch, I'm not usually a fan of processed frozen food. A few Lean Cuisine meals arrived at the office the other day, and since I was hungry and strapped for time I thought I would try one with the words "no preservatives" stamped prominently on the box. I chose Five-Cheese Rigatoni, although I don't regularly eat pasta at lunch. The photo on the box looked appealing, like comfort food.

To see if the rigatoni met my expectations, just read more.

The five-cheese rigatoni was actually filling, but two and a half hours a later I was suddenly hungry. The taste was fine, if a little on the sweet side, and the meal was very comforting. While I am still incredulous that a frozen meal could be preservative free, when I read over the ingredients the only one that seemed suspicious was thiamin mononitrate - a B vitamin added to the pasta. There were a couple of different types of "enzyme-modified" cheeses, where enzymes are used to enhance the flavor. Other than that all the ingredients were fairly familiar. Here's the nutritional information.

Serving Size	11.5 ounces
Calories	330
Total Fat	9 g
Saturated Fat	4 g
Cholesterol	20 mg
Sodium	690 mg
Carbs	50 g
Fiber	4 g
Sugar	10 g
Protein	12 g

While this meal was by no means stellar, it did work. Paired with fruit or a salad, the dish might be more satisfying. I so think pasta and cheese for lunch is ultimately a bad idea, and I will be looking of more protein out of my next frozen meal. Any recommendations?

Child safety seats

admin — Thu, 04 Sep 2008 18:50:17 -0700

Illustrations

Rear-facing car seat

Forward-facing car seat

HEALTH GUIDE REFERENCE FROM A.D.A.M

Definition

Child car seats; Infant car seats; Car seats

Information

Automobile accidents are one of the major causes of injury and death in children. In the United States, the law requires car seats for children under 40 pounds. For children over 40 pounds, specific laws vary by state.

Have a spouse or friend bring a car seat with you to the hospital when the child is born. You will need a car seat to bring the baby home from the hospital.

BUYING A CHILD SAFETY SEAT

It is best to use a new car seat. Used car seats often lack instructions and may have cracks or other problems that make the seat unsafe. For example, it may have been damaged during a car accident.

All car seats have expiration dates somewhere on them, usually on the bottom of the seat. Do not use a car seat past its expiration date, as the plastic may no longer be strong enough to support your child safely.

The "best" seat for you depends on your:

Child's age
Child's weight and height
Car

The seat must fit your child's size and be able to be properly installed into your car. A more expensive seat is not necessarily the safest nor easiest to use. All car seats sold in the United States must meet government safety standards.

Make sure you fill out and return the registration card that comes with a new car seat. This way, the manufacturer will contact you if the seat is recalled because of a safety problem or other defect. If you do not have a card, call the company that made the car seat and ask for one.

There are several different types of child safety seats:

Rear-facing seats
Forward-facing seats
Booster seats
Car beds
Built-in car seats

REAR-FACING SEATS

A rear-facing seat is one in which the infant faces the back of the car. Always install a rear-facing seat in the back seat of your car. This is the safest position for an infant. NEVER place a rear-facing seat in the front seat of a vehicle with passenger airbags.

There are two types of rear-facing seats:

Infant-only rear-facing seats
Convertible seats

Infant-only rear-facing seats are for babies up to about 22 to 30 pounds, depending on the specific car seat. You will need a new seat when your child gets bigger. Infant-only seats have handles that allow you to move the seat from the car to the house or other locations. Some have a base that you can leave installed in the car, so you can just click the car seat into place each time you use it.

Convertible seats are for bigger infants and toddlers under age 1 -- up to about 30-35 pounds, depending on the specific seat. The seat can be used as a rear-facing seats for younger children, and switched to a forward-facing seat on the child's first birthday if the child weighs at least 20 pounds. However, experts recommend keeping the child in a rear-facing position until he or she outgrows the weight or height allowed by the safety seat.

FORWARD-FACING ONLY SEATS

A forward-facing only seat is one in which the child sits facing the front of the car. The seat should be installed in the back seat of your vehicle. Most forward-facing only seats are for children between 20 to 40 pounds.

A combination forward-facing booster seat may be used for children between 40 to 65 pounds, depending on the specific seat. You can remove the seat's safety straps (harness) and use the booster alone, so that the car's lap and seat belts correctly fit the child.

BOOSTER SEAT

A booster seat raises your child up so that the car's lap and shoulder belts fit correctly. The lap belt should fall across the upper thighs. The shoulder belt should go across the middle of the shoulder and chest.

A booster seat is used for older children up to about 80 pounds. Some states have passed laws requiring booster seats for children up to age 8 or 80 pounds. Check your state's law.

CAR BEDS

These seats, also called flat car seats, are for premature or other special-needs babies. The American Academy of Pediatrics recommends that a health care provider looks at how your preterm baby fits and breathes in a car seat before leaving the hospital.

BUILT-IN SEATS

Some cars and vans have built-in car seats. Weight and height limits vary. You can get more details of these seats by reading the vehicle's owner's guide or calling the specific car manufacturer.

INSTALLING A CHILD SAFETY SEAT

It is important to use child car seats properly. Studies show that most people do NOT properly install car seats. The seat must fit snugly and be positioned at the proper angle. Many people install a car seat far too loosely, even though they think the seat is tight. The seat should be snug and not move more than 1 inch forward or sideways.

Follow the manufacturer's instructions for the installation and use of your specific car seat. Also, read your car owner's manual to determine the safest place to install a car seat in your car. If the instructions are unclear, call the company that made the car seat.

Contact your local police or first station for help installing your specific seat. Many have free programs to show you how to do this. To find a certified child passenger safety technician in your area go to www.seatcheck.org.

Child safety seats come with safety straps, called harnesses, which secure the child into position. Your safety seat may have a 3-point or 5-point harness system.

A 3-point harness system has two straps at the shoulder and one between the legs.
A 5-point system has two straps at the shoulder, two at the hips, and one between the legs.

The seat is secured into your vehicle using either car's seat belts or the LATCH system.

LATCH stands for lower anchors and tethers for children -- it is designed to make car seat installation easier. A child safety seat that comes with LATCH attaches to anchors in the back seat where the cushions meet and a strap called a tether, which connects the top of the safety seat to the car's frame. The car's seat belts are not used. All child safety seats and vehicles made after September 1, 2002 come with LATCH.

For more information on how to install child safety seats, see the National Highway Traffic Safety Administration web site at www.nhtsa.dot.gov. The NHTSA website also provides a list of all child safety seats recalled since 1990.

References

Quintana EC. Belt-positioning booster seats and reduction in risk of injury among children in vehicle crashes. Ann Emerg Med. 2004; 43(4): 544.

Committee on Injury and Poison Prevention; American Academy of Pediatrics. Selecting and using the most appropriate car safety seats for growing children: guidelines for counseling parents. Pediatrics. 2002;109:550-3.

Biagioli F. Proper use of child safety seats. Am Fam Physician. 2002;65:2085-90.

US National Highway Traffic Safety Administration. Misuse of child restraints. Washington, DC. US Department of Transportation, National Highway Traffic Safety Administration; 2004. DOT HS 809 671.

Review Date: 5/3/2007

Reviewed By: Leisha M. Andersen, M.D., Private Practice specializing in Pediatrics, Denver, CO. Review provided by VeriMed Healthcare Network.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).

A.D.A.M. Copyright

The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997-2009 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.

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Source Doc: 1_001990

Foot pain

FitSugar — Wed, 08 Oct 2008 17:35:02 -0700

In This Report

Highlights
Introduction
Causes
Risk Factors
Treatment: Corns and Callus...
Treatment: Bunions
Treatment: Hammertoes
Treatment: Ingrown Toenails...
Treatment: Forefoot Pain...
Treatment: Heel Pain
Treatment: Flat Feet
Treatment: Abnormally High ...
Treatment: Tarsal Tunnel Sy...
Treatment: Foot Injury
Prevention
Shoes
Insoles and Orthotics
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Treatment for Ingrown Toenail:

Orthonyxia, a surgical technique that implants a small metal brace into the top of the nail, was as effective as traditional surgical techniques for preventing ingrown toenail from recurring, according to one study.
A nonsurgical method for treating ingrown toenail with chemicals uses either sodium hydroxide or phenol, but one study shows that sodium hydroxide procedures have a better outcome and faster recovery than phenol procedures.

Treatment for Forefoot Pain:

Ultrasound-guided injection of alcohol might provide relief from Morton's neuroma, according to one study. Symptoms improved in 94% of patients who had the treatment, a success rate comparable to that of surgery.

Treatment for Heel Pain:

NSAIDs reduce pain and disability in people with plantar fasciitis when used with other techniques, such as night splints and stretching.
Studies show that extracorporeal shockwave therapy provides a very small reduction in heel pain without side effects. It may be a good option for patients who haven't responded well to conservative treatment.

Work-related Foot Problems:

An estimated 120,000 job-related foot injuries occur every year, about a third of them involving the toes. A number of foot problems -- including arthritis of the foot and ankle, toe deformities, pinched nerves between the toes, plantar fasciitis, adult-acquired flat foot, and tarsal tunnel syndrome -- have been attributed to repetitive use at work.

Introduction

Foot pain is very common. About 75% of people in the United States have foot pain at some time in their lives. Most foot pain is caused by shoes that do not fit properly or that force the feet into unnatural shapes (such as pointed-toe, high-heeled shoes).

The foot is a complex structure of 26 bones and 33 joints, layered with an intertwining web of more than 120 muscles, ligaments, and nerves. It serves the following functions:

Supports weight
Acts as a shock absorber
Serves as a lever to propel the leg forward
Helps maintain balance by adjusting the body to uneven surfaces

Because the feet are very small compared with the rest of the body, the impact of each step exerts tremendous force upon them. This force is about 50% greater than the person's body weight. During a typical day, people spend about 4 hours on their feet and take 8,000 - 10,000 steps. This means that the feet support a combined force equivalent to several hundred tons every day.

Foot pain generally starts in one of three places: the toes, the forefoot, and the hindfoot.

The Toes. Toe problems most often occur because of the pressure imposed by ill-fitting shoes.

The Forefoot. The forefoot is the front of the foot. Pain originating here usually involves one of the following bone groups:

The metatarsal bones (five long bones that extend from the front of the arch to the bones in the toe)
The sesamoid bones (two small bones embedded at the top of the first metatarsal bone, which connects to the big toe)

The Hindfoot. The hindfoot is the back of the foot. Pain originating here can extend from the heel, across the sole (known as the plantar surface), to the ball of the foot (the metatarsophalangeal joint).

Condition	Location	Symptoms	Recommended Footwear
Toe Pain
Corns and calluses	Around toes, usually little toe, bottom of feet or areas exposed to friction.	Hard, dead, yellowish skin.	Wide (box-toed) shoes; soft cushions under heel or ball of foot, or customized or gel insoles for calluses. Doughnut-shaped pads for corns.
Ingrown toenails	Toenails.	Nail curling into skin causes pain, swelling, and, in extreme cases, infection.	Sandals, open-toed shoes.
Bunions and bunionettes (tailor's bunion)	Big toe (bunions) or little toe (bunionettes).	The following can occur alone or in combination: Metatarsus primus varus. The first (big toe) metatarsal bone shifts away from the second, and the big toe points inward. Medial exostosis. This is a bony bump at the base of the big toe, which protrudes outward. Area next to bony bump is red, tender, and occasionally filled with fluid. Toe joint may be inflamed. Hallux valgus. This is a deformity in which the bone and joint of the big toe shift and grow inward, so that the second toe crosses over the big toe.	Soft, wide-toed shoes or sandals. Bunion shields or splints. Thick doughnut-shaped moleskin pads, custom-made orthotics or foot slings, if necessary. Avoid shoes with stitching along the side of the "bump."
Morton's neuroma (also called interdigital neuroma)	Inflammation of the nerve, usually between the third and fourth toes and bottom of the foot near these toes.	Cramping and burning pain, or electric-shock sensation. The condition may produce a thick protective sheath around the nerve that feels like a ball. This may be detected by pressing top to bottom on the top of the foot using one hand and moving the other hand from side to side. Morton's neuroma is aggravated by prolonged standing and relieved by removal of the shoes and forefoot massage.	Wide (box-toed) shoes. Orthotic or insole with pad that reduces stress on the painful area.
Hammertoe or claw toe	Usually second toe, but may develop in any or all of the three middle toes.	Toes form hammer or claw shape. In hammertoe, the first knuckle of the toe is mainly affected. In claw toe the entire toe is deformed. No pain at first, but pain increases as tendon becomes tighter and toes stiffen.	Wide (box-toed) shoes. Toe pads or specially designed shields, splints, caps, or slings. (Splints or slings are not for people with diabetes.)
Front-of-the-Foot Pain
Metatarsalgia	Ball of the foot.	Acute, recurrent, or chronic pain without a known cause.	Wide (box-toed) shoes. Orthotic with pad that reduces metatarsal pressure. Gel cushions. Metatarsal bandage.
Stress fracture	Most often in the area beneath the second or third toe.	Sudden pain (which persists) when injury occurs.	Low-heeled shoes with stiff soles.
Sesamoiditis	Ball of foot beneath big toe.	Pain and swelling.	Low-heeled shoe with stiff sole and soft padding inside.
Heel and Back-of-the-Foot Pain
Plantar fasciitis or heel spurs	Back of the arch right in front of heel.	At onset, some people report a tearing or popping sound. Pain is most severe with first steps after getting out of bed. Pain decreases after stretching, returns after inactivity.	Over-the-counter foot insole (cut quarter-size hole surrounding painful area). Possible night splints. Orthotics if necessary.
Bursitis of the heel	Center of the heel.	Pain, with warmth and swelling. Increases during the day.	Heel cup.
Haglund's deformity (pump bump)	Fleshy area on the back of the heel.	Tender swelling aggravated by shoes with stiff backs.	Soft shoes. Heel pads. Possible orthotic to support heel.
Achilles tendinitis	Achilles tendon: area along the back between calf muscles and heel.	Pain worsens during physical activities (particularly running), after which the tendon usually swells and stiffens. If it ruptures, popping sound may occur followed by acute pain similar to a blow at the back of the leg.	Insoles, tendon strap, heel cups.
Arch and Bottom-of-the Foot Pain
Tarsal tunnel syndrome	Anywhere along the bottom of the foot.	Numbness, tingling, or burning sensations, pain, most commonly felt at night.	Specially designed orthotics to relieve pressure.
Flat feet or posterior tibial tendon dysfunction (PTTD)	The arch.	No arch. Often no pain or discomfort. Three stages in PTTD: Pain and weakness in the tendon. The arch flattens but is still flexible. The foot becomes rigid and possibly painful at the ankle. Sometimes people report fatigue, pain, or stiffness in the feet, legs, and lower back.	For children, possible custom-made insoles.
High arches (hollow feet)	The arch.	High arches. Lower back pain, possible tendency to lower limb injuries.

Causes

Nearly all causes of foot pain can be grouped under one of the following:

Ill-fitting shoes. Poorly fitting shoes are a frequent cause of foot pain. High-heeled shoes concentrate pressure on the toes and can aggravate, if not cause, problems with the toes.
Certain medical conditions. Any medical condition that causes a disturbance in the way a person walks can contribute to foot pain. This may include diseases or conditions that lead to pain or numbness in the feet (such as diabetes), leg and foot deformities, spinal problems, and neurological disorders such as Parkinson's disease or cerebral palsy.
High-impact exercise. High-impact exercising, such as jogging or strenuous aerobics, can injure the feet. Common injuries include corns, calluses, blisters, muscle cramps, acute knee and ankle injuries, plantar fasciitis, and metatarsalgia.

Arthritic Conditions. Arthritic conditions, particularly osteoarthritis and gout, can cause foot pain. Although rheumatoid arthritis almost always develops in the hand, the ball of the foot can also be affected.

Diabetes. Diabetes is an important cause of serious foot disorders. [For more information, see In-Depth Report #9: Diabetes - type 1 and In-Depth Report #60: Diabetes - type 2.]

Obesity. Obesity can cause foot and ankle pain.

Pregnancy. Pregnancy can cause fluid buildup and swollen feet. The increased weight and imbalance of pregnancy contributes to foot stress.

Medications. Some medications, such as calcitonin and drugs used for high blood pressure, can cause foot swelling.

Click the icon to see an image of foot inspection.

Risk Factors

A risk factor is anything that increases your chances of getting a disease or condition. The following are factors that increase your risk for foot pain:

Elderly people are at very high risk for foot problems. As you age, your feet widen and flatten, and the fat padding on the sole of the foot wears down. The skin on the feet also becomes dryer. Foot pain in older adults may be the first sign of age-related conditions, such as arthritis, diabetes, and circulatory disease. Foot problems can also impair balance and function in this age group.

Taking fashion to extreme limits, some people have turned to cosmetic surgery as a drastic way to fit into high-heeled shoes. Procedures include surgical shortening of the toes, narrowing of feet, or injecting silicone into the pads of the feet. Such methods may increase your risk for future foot pain. The American Orthopaedic Foot and Ankle Society (AOFAS) and other foot-related medical associations have expressed concern over this trend. The AOFAS strongly advises against cosmetic foot surgery and urges consumers to carefully consider the relative risks and benefits of undergoing unnecessary surgical procedures.

Women are at higher risk than men for severe foot pain, probably because of high-heeled shoes. Severe foot pain appears to be a major cause of general disability in older women.

An estimated 120,000 job-related foot injuries occur every year, about a third of them involving the toes. A number of foot problems -- including arthritis of the foot and ankle, toe deformities, pinched nerves between the toes, plantar fasciitis, adult-acquired flat foot, and tarsal tunnel syndrome -- have been attributed to repetitive use at work.

For example, in a study of New York police officers who walked an average of 3 miles a day, 20% experienced foot pain at the end of their workday. (Insoles can relieve much of this pain.) No studies, however, have scientifically distinguished between injuries due to work versus those due to regular use. This is an important issue because of its potential impact on disability claims.

Pregnant women have an increased risk of foot problems due to weight gain, swelling in their feet and ankles, and the release of certain hormones that cause ligaments to relax. These hormones help when bearing the child, but they can weaken the feet.

People who engage in regular high-impact aerobic exercise are at risk for plantar fasciitis, heel spurs, sesamoiditis, shin splints, Achilles tendon, and stress fractures. Women are at higher risk for stress fractures than are men.

Gaining weight puts added stress on the feet and can lead to foot or ankle injuries. The added pressure on the soft tissues and joints of the foot in overweight people increases the likelihood of developing tendinitis and plantar fasciitis.

Treatment: Corns and Calluses

A corn is a protective layer of dead skin cells that forms due to repeated friction. It is cone-shaped and has a knobby core that points inward. This core can put pressure on a nerve and cause sharp pain. Corns can develop on the top of, or between, toes. If a corn develops between the toes, it may be kept pliable by the moisture from perspiration and is therefore called a soft corn.

Corns develop as a result of friction from the toes rubbing together or against the shoe. They often occur from the following:

Shoes, socks, or stockings that fit too tightly around the toes
Pressure on the toes from high-heeled shoes
Shoes that are too loose, due to the friction of the foot sliding within the shoe
Deformed and crooked toes

Calluses are composed of the same material as corns. Calluses, however, develop on the ball or heel of the foot. The skin on the sole of the foot is ordinarily about 40 times thicker than the skin anywhere else on the body, but a callus can even be twice as thick. A protective callus layer naturally develops to guard against excessive pressure and chafing as people get older and the padding of fat on the bottom of the foot thins out. If calluses get too big or too hard, they may pull and tear the underlying skin.

Risk factors for calluses include the following:

Poorly fitting shoes
Walking regularly on hard surfaces
Flat feet

Of note, in people with diabetes, the presence of calluses is a strong predictor of ulceration, particularly in those who have a history of foot ulcers.

Preventing Corns and Calluses and Relieving Discomfort. To prevent corns and calluses and relieve discomfort if they develop:

Do not wear shoes that are too tight or too loose. Wear well-padded shoes with open toes or a deep toe box (the part of the shoe that surrounds the toes). If necessary, have a cobbler stretch the shoes in the area where the corn or callus is located.
Wear thick socks to absorb pressure, but do not wear tight socks or stockings.
Apply petroleum jelly or lanolin hand cream to corns or calluses to soften them.
Use doughnut-shaped pads that fit over a corn and decrease pressure and friction. They are available at most drug stores.
Place cotton, lamb's wool, or mole skin between the toes to cushion any corns in these areas.

Removing Corns and Calluses. To remove a corn or callus, soak it in very warm water for 5 minutes or more to soften the hardened tissue, then gently sand it with a pumice stone. Several treatments may be necessary. Do not trim corns or calluses with a razor blade or other sharp tool. Unsterile cutting tools can cause infection, and it is easy to slip and cut too deep, causing excessive bleeding or injury to the toe or foot.

Medicated Solutions and Pads. There are numerous over-the-counter pads, plasters, and medications for removing corns and calluses. These treatments commonly contain salicylic acid, which may cause irritation, burns, or infections that are more serious than the corn or callus. Use caution with these medications. The following people should not use them:

Patients with diabetes
Patients with reduced feeling in the feet due to circulation problems or neurological damage
Patients who do not have the flexibility or eyesight to use them properly

Treatment: Bunions

A bunion is a deformity that usually occurs at the head of one of the five long bones (the metatarsal bones) that extend from the arch of the foot and connect to the toes. A bunion typically develops in the following way:

Most often it occurs in the first metatarsal bone (the one that attaches to the big toe). A bunion may also develop in the bone that joins the little toe to the foot (the fifth metatarsal bone), in which case it is known as either a bunionette or a tailor's bunion.
A bunion begins to form when the big or little toe is forced in toward the rest of the toes, causing the head of the metatarsal bone to jut out and rub against the side of the shoe.
The underlying tissue becomes inflamed, and a painful bump forms.
As this bony growth develops, the bunion is formed as the big toe is forced to grow at an increasing angle toward the rest of the toes. One important bunion deformity, hallux valgus, causes the bone and joint of the big toe to shift and grow inward, so that the second toe crosses over it.

Several conditions can cause bunions:

Narrow high-heeled shoes with pointed toes can put enormous pressure on the front of the foot.
Injury in the joint may cause a bunion to develop over time.
Genetics play a role in 10 - 15% of all bunions.

Flat feet, gout, arthritis, and occupations (such as ballet) that place undue stress on the feet can also increase the risk for bunions.

Shoes and Protective Pads. Pressure and pain from bunions and bunionettes can be relieved by wearing appropriate shoes, such as the following:

Soft, wide, low-heeled leather shoes that lace up
Athletic shoes with soft toe boxes
Open shoes or sandals with straps that don't touch the irritated area

A thick doughnut-shaped, moleskin pad can protect the protrusion. In some cases, an orthotic can help redistribute weight and take pressure off the bunion. Nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroid injections may offer some pain relief.

Surgery. If discomfort persists, surgery may be necessary, particularly for more serious conditions, such as hallux valgus. There are more than 100 surgical variations, ranging from removing the bump to realigning the toes.

The most common surgery, an office procedure known as bunionectomy, involves shaving down the bone of the big toe joint. In one procedure the surgeon uses a very small incision, through which the bone-shaving drill is inserted. The physician shaves off the bone, guided by feel or x-ray. This technique is not a cure, but patient satisfaction is high and results are long-lasting.

Click the icon to see an illustrated series detailing bunion removal.

More extensive surgeries may be required to realign the toe joint. Although there are variations of each, they generally involve one or more of the following:

Osteotomy (cutting and realigning the joint). Long-term studies on osteotomies report that 90% of patients are satisfied with the procedure.
Exostetectomy (removal of the large bony growth). This technique is only useful when there is no shift in the toe bone itself.
Arthrodesis (removal of damaged portion of the joint, followed by implantation of screws, wires, or plates to hold the bones together until they heal). This is the gold standard procedure for very severe cases or when previous procedures have failed. Most patients report good results.
Arthroplasty (removal of damaged portion of the joint with the goal of achieving a flexible scar). This technique offers symptom relief and faster rehabilitation than arthrodesis, but it can cause deformity and some foot weakness. Arthroplasty tends to be used in older patients. Biologic or synthetic implants for supporting the toes are showing promise as part of this procedure.
Tendon and Ligament Repair. If tendons and ligaments have become too loose, the surgeon may tighten them.

In severe cases, surgeons are testing bone grafts to restore bone length in patients who have had previous bunion surgeries or damage from osteoarthritis.

Complications, though uncommon in even the most complex procedures, can include:

Continued pain
Infection
Possible numbness
Irritation from implants used to support the bone
An excessively shortened metatarsal bone

Recovery from more invasive procedures, such as arthrodesis or osteotomy, may take 6 - 8 weeks, and it can be that long before a patient can put full weight on the foot. In such cases, the patient will need to wear a cast or use crutches. Elderly patients may need wheelchairs.

Treatment: Hammertoes

A hammertoe is a permanent deformity of the toe joint, in which the toe bends up slightly and then curls downward, resting on its tip. When forced into this position long enough, the tendons of the toe shrink, and the toe stiffens into a hammer- or claw-like shape.

Hammertoe is most common in the second toe, but it can develop in any or all of the three middle toes if they are pushed forward and do not have enough room to lie flat in the shoe. The risk is increased when the toes are already crowded by the pressure of a bunion. Risks include:

Lying down for long periods
Diabetes
Diseases that affect the nerves and muscles

Click the icon to see an image of a hammertoe.

Treatment for Hammertoe. At first, a hammertoe is flexible, and any pain it causes can usually be relieved by putting a toe pad, sold in drug stores, into the shoe. To help prevent and ease existing discomfort from hammertoes, shoes should have a deep, wide toe area. As the tendon becomes tighter and the toe stiffens, other treatments, including exercises, splints, and custom-made shoe inserts (orthotics) may help redistribute weight and ease the position of the toe.

Surgery. Patients with severe cases of hammertome may need surgery. If the toe is still flexible, only a simple procedure that releases the tendon may be involved. Such procedures sometimes require only a single stitch and a Band-Aid. If the toe has become rigid, surgery on the bone is necessary, but it can still be performed in the doctor's office. A procedure called PIP arthroplasty involves releasing the ligaments at the joint and removing a small piece of toe bone, which restores the toe to its normal position. The toe is held in this position with a pin for about 3 weeks, and then the pin is removed. One study reported that 92% of patients who had arthroscopy were still pain free after 5 years.

Treatment: Ingrown Toenails

Ingrown toenails can occur on any toe but are most common on the big toes. They usually develop when tight-fitting or narrow shoes put too much pressure on the toenail and force the nail to grow into the flesh of the toe. Incorrect toenail trimming can also contribute to the risk of developing an ingrown toenail. Other causes are:

Fungal infections
Injuries
Abnormalities in the structure of the foot
Repeated impact on the toenail from high-impact aerobic exercise

An ingrown toenail is a condition in which the edge of the toenail grows into the skin of the toe. The big toe is most commonly affected. Symptoms include pain, redness, and swelling around the toenail.

Caring for Toenails. Trim toenails straight across and keep them long enough so that the nail corner is not visible. If the nail is cut too short, it may grow inward. If the nail does grow inward, do not cut the nail corner at an angle. This only trains the nail to continue growing inward. When filing the nails, file straight across the nail in a single movement, lifting the file before the next stroke. Do not saw back and forth. A cuticle stick can be used to clean under the nail.

Treatments. To relieve pain from ingrown toenails, try wearing sandals or open-toed shoes. Soaking the toe for 5 minutes twice a day in a warm water solution of Domeboro or Betadine can help. People who are at increased risk for infections, such as those with diabetes, should have professional treatment.

Antibiotic ointments can treat ingrown toenails that are infected. Apply the ointment by working a wisp of cotton under the nail, especially the corners, to lift the nail up and drain the infection. The cotton will also help force the toenail to grow out correctly. Change the cotton daily, and use the antibiotic consistently.

In severe cases, more intensive treatments are needed. Surgery involves simply cutting away the sharp portion of ingrown nail, removing the nail bed, or removing a wedge of the affected tissue. One study found that orthonyxia, a newer surgical technique that implants a small metal brace into the top of the nail, is as effective as traditional surgical techniques for preventing ingrown toenails from recurring.

Nonsurgical methods can also treat ingrown toenails. One technique uses chemicals to remove the skin. Both sodium hydroxide and phenol may be used, but research shows that sodium hydroxide produces a better outcome and faster recovery than phenol. Other nonsurgical methods include using cauterization (heating), or lasers, to remove the skin.

Treatment: Forefoot Pain

Forefoot pain refers to pain and discomfort felt toward the top of the foot. The rate of forefoot pain and deformity increases with age. When a cause cannot be determined, any pain on the ball of the foot is generally referred to as metatarsalgia.

Forefoot pain may be due to:

Morton's neuroma
Sesamoiditis
Stress fractures

A neuroma usually means a benign tumor of a nerve. However, Morton’s neuroma, also called interdigital neuroma, is not actually a tumor. It is a thickening of the tissue surrounding the nerves leading to the toes. Morton’s neuroma usually develops when the bones in the third and fourth toes pinch together, compressing a nerve. It can also occur in other locations. The nerve becomes enlarged and inflamed. The inflammation causes a burning or tingling sensation and cramping in the front of the foot. Other causes of this condition include:

Tight, poorly-fitting shoes
Injury
Arthritis
Abnormal bone structure

Treatment for Neuromas. Pain from Morton's neuroma can be reduced by massaging the affected area. Roomier shoes (box-toed shoes), pads of various sorts, and cortisone injections in the painful area are also helpful. A combination of cortisone injections and shoe modifications provides better immediate relief than changes in footwear alone. Ultrasound-guided injection of alcohol might also provide relief from Morton's neuroma, research finds.

If these treatments are not effective, the enlarged area may need to be surgically removed. In one long-term study of one surgeon's experience, 85% of patients reported good to excellent satisfaction nearly 6 years after surgery. About 65% were pain free. Some numbness is common afterward, but it rarely bothers patients. Occasionally, the nerve tissue may re-grow and form another neuroma.

Sesamoiditis is an inflammation of the tendons around the small, round bones that are embedded in the head of the first metatarsal bone, which leads to the big toe. Sesamoid bones bear much stress under ordinary circumstances; excessive stress can strain the surrounding tendons. Often there is no clear-cut cause, but sesamoid injuries are common among people who participate in jarring, high-impact activities, such as ballet, jogging, and aerobic exercise.

Treatment for Sesamoiditis. Rest and reducing stress on the ball of the foot are the first lines of treatment for sesamoiditis. A low-heeled shoe with a stiff sole and soft padding inside is all that is usually required. In severe cases, surgery may be necessary.

A stress fracture in the foot, also called fatigue or march fracture, usually results from a break or rupture in any of the five metatarsal bones (mostly the second or third). These fractures are caused by overuse during strenuous exercise, particularly jogging and high-impact aerobics. Women are at higher risk for stress fracture than men.

A fracture in the first metatarsal bone, which leads to the big toe, is uncommon because of the thickness of this bone. If it occurs, however, it is more serious than a fracture in any of the other metatarsal bones because it dramatically changes the pattern of normal walking and weight bearing.

Treatment for Stress Fractures. Patients should seek treatment if pain persists for 3 weeks. In a study of young athletes, treatment after that time reduced the chance that they could return to their sport. Surgery may be needed if conservative measures fail. In most cases, however, stress fractures heal by themselves if you avoid rigorous activities. Some health care providers recommend moderate exercise, particularly swimming and walking. It is best to wear low-heeled shoes with stiff soles. Occasionally, a health care provider may recommend wearing a special wooden shoe and a compressive wrap to make walking more comfortable.

Treatment: Heel Pain

The heel is the largest bone in the foot. Heel pain is the most common foot problem and affects 2 million Americans every year. It can occur in the front, back, or bottom of the heel. Types of heel pain include:

Achilles tendinitis
Bursitis of the heel
Excess pronation
Haglund's deformity
Heel spur syndrome
Plantar fasciitis

Each type of heal pain is described in more detail below. General treatment guidelines are as follows:

The American Orthopaedic Foot and Ankle Society (AOFAS) suggests shoe inserts, medications, and stretching as a first line of therapy for heel pain. One study found that 95% of women who used an insert and did simple stretching exercises for the Achilles tendon and plantar fascia experienced improvement after 8 weeks.
If these treatments fail, the patient may need prescription heel orthotics and extended physical therapy. Surgery may be an option if other methods have failed.

Achilles tendinitis is an inflammation of the tendon that connects the calf muscles to the heel bone. It is caused by small tears in the tendon from overuse or injury. This condition is most common in people who engage in high-impact exercise, particularly jogging, racquetball, and tennis.

People at highest risk for this disorder from these activities are those with a shortened Achilles tendon. Such people tend to roll their feet too far inward when walking, and may bounce when they walk. A shortened tendon can be due to an inborn structural abnormality, or it can develop from regularly wearing high heels.

An inflamed or torn Achilles tendon causes intense pain and affects mobility.

Evidence is uncertain about the best way to treat either acute or chronic Achilles tendinitis. Some approaches include:

Treatments to Relieve Pain and Reduce Inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen (Advil), may help ease pain and reduce inflammation. It is also helpful to apply ice for 20 - 30 minutes, four or five times a day. (Note: Corticosteroid injections are sometimes used, although evidence suggests they don't help very much, and they can pose a risk for rupture of the tendon.)

Gentle Stretching. Gentle calf muscle stretches may also help reduce pain and spasms. If the calf is swollen, elevate the leg. Exercise is safe when the heel is no longer swollen or tender, even if pain is still present. If pain increases with exercise, stop immediately.

Laser Therapy. Low-level laser therapy that emits energy directed at pain trigger points has helped some patients. No strong evidence supports its use to date, however.

Surgery vs. Nonsurgical Treatment. Chronic inflammation may lead to rupture of the Achilles tendon. If pain continues, the ruptured tendon will require a cast and perhaps surgery, called tendon transfer. Although some experts believe a cast without surgery is a sufficient treatment for such rupture, there is a chance the tendon may rupture again in the future, even after it heals. Some experts suggest surgery for active people and nonsurgical treatment for older people.

Surgery requires a long incision with a postoperative period of immobilization that can average 6 weeks. Complications can include a significant surgical scar, infection, and muscle atrophy, although surgery reduces pain and preserves foot function in the long term. Less invasive techniques are being tested. In one study, selected patients with ruptured tendons were hospitalized for about 5 days and fitted with special footgear (Variostabil, which continuously raised the back of the foot). The footgear was effective for most patients, and the tendon ruptured again in only 5% of cases.

Bursitis of the heel is an inflammation of the bursa, a small sack of fluid beneath the heel bone. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen (Advil), and steroid injections will help relieve pain from bursitis. Applying ice and massaging the heel are also beneficial. A heel cup or soft padding in the heel of the shoe reduces direct impact when walking.

Pronation is the normal motion that allows the foot to adapt to uneven walking surfaces and to absorb shock. Excessive pronation occurs when the foot has a tendency to turn inward and stretch and pull the fascia. It can cause not only heel pain, but also hip, knee, and lower back problems.

Haglund's deformity, known medically as posterior calcaneal exostosis, is a bony growth surrounded by tender tissue on the back of the heel bone. It develops when the back of the shoe repeatedly rubs against the back of the heel, aggravating the tissue and the underlying bone. It is commonly called pump bump because it frequently occurs with high heels. (It can also develop in runners, however.)

Treatment for Haglund's Deformity. Applying ice followed by moist heat will help ease discomfort from a pump bump. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen (Advil), will also reduce pain. Your doctor may recommend an orthotic device to control heel motion. Corticosteroid injections are not recommended because they can weaken the Achilles tendon.

In severe cases, surgery may be necessary to remove or reduce the bony growth. According to one study, however, surgery was not effective for more than 30% of patients and, in fact, the condition worsened in 14% of patients who had surgery. A more recent study reported that surgery cured 90% of cases, but patients took 6 months to 2 years to fully recover. Experts advise patients to try all conservative measures before choosing surgery.

Plantar fasciitis is a common foot problem that accounts for 1 million office visits per year. Plantar fasciitis occurs from small tears and inflammation in the wide band of tendons and ligaments that stretches from the heel to the ball of the foot. This band, much like the tensed string in a bow, forms the arch of the foot and helps serve as a shock absorber for the body.

The term plantar means the sole of the foot, and fascia refers to any fibrous connective tissue in the body. Most people with plantar fasciitis experience pain in the heel with their first steps in the morning. The pain also often spreads to the arch of the foot. The condition can be temporary, or it may become chronic if ignored. Resting can provide relief, but only temporarily.

Heel spurs are calcium deposits that can develop under the heel bone as a result of the inflammation that occurs with plantar fasciitis. Heel spurs and plantar fasciitis are sometimes blamed interchangeably for pain, but plantar fasciitis can occur without heel spurs, and spurs commonly develop without causing any symptoms at all.

Causes of Plantar Fasciitis. The cause of plantar fasciitis is often unknown. It is usually associated with overuse during high-impact exercise and sports. Plantar fasciitis accounts for up to 9% of all running injuries. Because the condition often occurs in only one foot, however, factors other than overuse are likely to be responsible in many cases. Other causes of this injury include poorly-fitting shoes, lack of calf flexibility, or an uneven stride that causes an abnormal and stressful impact on the foot.

Treatment Goals. The three major treatment goals for plantar fasciitis are:

Reducing inflammation and pain
Reducing pressure on the heel
Restoring strength and flexibility

Embarking on an exercise program as soon as possible and using NSAIDs, splints, or heel pads as needed can help relieve the problem. Pain that does not subside with NSAIDs may require more intensive treatments, including leg supports and even surgery.

Exercises to Restore Strength and Flexibility. Stretching the plantar fascia is the mainstay therapy for restoring strength and flexibility. One exercise involves the following:

Put the hands on a wall and lean against them.
Place the uninjured foot on the floor in front of the injured foot.
Raise the heel of the injured foot.
Gently stretch the injured leg and foot.

With stretching treatments, the plantar fascia nearly always heals by itself but it may take as long as a year, with pain occurring intermittently. A moderate amount of low-impact exercise (such as walking, swimming, or cycling) also seems to be beneficial.

Treatment. Inflammation and pain is most commonly treated with ice and over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen. NSAIDs reduce pain and disability in people with plantar fasciitis when used with other techniques, such as night splints and stretching.

Corticosteroids are powerful anti-inflammatory agents. An injection of a steroid plus a local anesthetic (such as xylocaine) may provide relief in severe cases of plantar fasciitis. (Steroid injections are not used for pain that is only due to heel spurs). For athletes or performers who need immediate relief, an effective method is to administer the steroid dexamethasone using a procedure called iontophoresis, which introduces the drug into the foot's tissue using an electrical current.

Several non-drug approaches can relieve pressure on the heel, including:

Sturdy Shoes and Insoles. It is important to wear comfortable but sturdy shoes that have thick soles, rubber heels, and a sole insole to relieve pressure. (An insole with an arch support might also be helpful.) Cutting a round hole about the size of a quarter in the sole cushion under the painful area may help support the rest of the heel while relieving pressure on the painful spot. Heel cups are not very useful. When combined with exercises that stretch the arch and heel cord, over-the-counter insoles may offer the same relief as prescribed orthotics.
Night Splints. Some evidence suggests that splints worn at night may be helpful for some people. One device, for example, uses an Ace bandage and an L-shaped fiberglass splint to keep the foot stretched while the patient is sleeping. This allows the muscle to heal. One study reported that nearly any splint, regardless of cost, is equally effective in about three-quarters of patients. Although patient compliance may be better with custom-made prescribed orthotics than with tension night splints, one study found they are equally effective in improving pain.
Elevated Heels. Some people report relief from mild symptoms with the use of shoes or cowboy boots that have elevated heels. This approach, however, may not work in some people and is not recommended for anyone with a moderate-to-severe condition. (Heel cups have not been proven to be very useful.)
Orthotics. For severe conditions, such as fallen arches or structural problems that cause imbalance, insoles, called orthotics, molded from a plaster cast of the patient's foot may be needed. (See "Insoles and Orthotics" section).
Extracorporeal Shock Wave Therapy (ESWT). ESWT may be used as an alternative to surgery for patients who have not responded to other treatments. The therapy uses low-dose sound waves to injure the surrounding tissues in the heel, which is believed to trigger healing of the tissues that are causing the pain. Studies show that the treatment provides a very small reduction in heel pain without side effects. It can be considered as an option for patients who haven't responded well to extensive conservative treatment.
Surgery. Surgery may be needed for some patients, typically those who have disabling heel pain that does not respond to other treatments for at least a year. A typical surgery is called instep plantar fasciotomy. It relieves pressure on the nerves that are causing pain by removing and therefore releasing part of the plantar fascia. A less invasive method uses a procedure called endoscopy, which requires smaller incisions. Wearing a below-the-knee walking cast after surgery for 2 weeks may reduce the need for pain relief and speed recovery time compared to the use of crutches.
Botox. Small studies show that injections of botulinum toxin (Botox), a protein used to temporarily paralyze certain muscles, reduces pain and improves patients' future ability to walk. More research is needed on this treatment.

Treatment: Flat Feet

Flat foot, or pes planus, is a defect of the foot that eliminates the arch. The condition is most often inherited. Arches, however, can also fall in adulthood, in which case the condition is sometimes referred to as posterior tibial tendon dysfunction (PTTD). This occurs most often in women over age 50, but it can occur in anyone. The following are risk factors for PTTD:

Wearing high heels for long periods of time is a particular risk for flat feet. Over the years, the Achilles tendon in the back of the calf shortens and tightens, so the ankle does not bend properly. The tendons and ligaments running through the arch then try to compensate. Sometimes they break down, and the arch falls.
Some studies have indicated that the earlier a person starts wearing shoes, particularly for long periods of the day, the higher the risk for flat feet later on.
Other conditions that can lead to PTTD include obesity, diabetes, surgery, injury, rheumatoid arthritis, or the use of corticosteroids.

Some research suggests that flat feet in adults can, over time, actually exert abnormal pressure on the ankle joint that can cause damage. One indirect complication of flat arches may be urinary incontinence or leakage during exercise. The less flexible the arch, the more force reaches the pelvic floor, jarring the muscles that affect urinary continence. Nevertheless, whether flat feet pose any significant problems in adults is unknown. For example, one study on athletes with flat feet indicated that they had no higher risk for leg or foot injuries than did athletes with normal arches.

Treatment for Flat Feet in Children. Doctors usually can't diagnose flat feet until a child is 6 years old. Children with flat feet typically don't have symptoms, and often outgrow the condition. Children who are experiencing symptoms might need to change shoes or wear arch supports. In rare cases, minimally invasive joint insert surgery may be an option.

Treatment for Flat Feet in Adults. In general, conservative treatment for flat feet acquired in adulthood (posterior tibial tendon dysfunction) involves pain relief and insoles or custom-made orthotics to support the foot and prevent progression.

In severe cases, surgery may be required to correct the foot posture, usually with procedures called osteotomies or arthrodesis that typically lengthen the Achilles tendon and adjust tendons in the foot. One procedure uses an implant to support the arch. These procedures have potential complications. Conservative methods should be tried first.

Treatment: Abnormally High Arches

An overly-high arch (hollow foot) can cause problems. Army studies have found that recruits with the highest arches have the most lower-limb injuries and that flat-footed recruits have the least. Contrary to the general impression, the hollow foot is much more common than the flat foot.

Clawfoot, or pes cavus, is a deformity of the foot marked by very high arches and very long toes. Clawfoot is a hereditary condition, but can also occur when muscles in the foot contract or become unbalanced due to nerve or muscle disorders.

Claw toe is a deformity of the foot in which the toes are pointed down and the arch is high, making the foot appear claw-like. Claw toe can be a condition from birth or develop as a consequence of other disorders.

Treatment: Tarsal Tunnel Syndrome

Tarsal tunnel syndrome results from compression of a nerve that runs through a narrow passage behind the inner ankle bone down to the heel. It can cause pain anywhere along the bottom of the foot. It can occur with:

Diabetes
Back pain
Arthritis
Injury to the ankle
Abnormal blood vessels
Scar tissue that press against the nerve

Magnetic resonance imaging (MRI) and the dorsiflexion-eversion test can diagnose this syndrome.

Treatment for Tarsal Tunnel Syndrome. Specially designed shoe inserts called orthotics can relieve pain from tarsal tunnel syndrome, because they help redistribute weight and take pressure off the nerve. Corticosteroid injections may also help. Surgery is sometimes performed, particularly if symptoms persist for more than a year, although its benefits are a matter of debate. Tarsal tunnel syndrome caused by known conditions, such as tumors or cysts, may respond better to surgery than tarsal tunnel syndrome of unknown cause. It can take months after this surgery for a person to recover and resume normal activities. Only experienced surgeons should perform tarsal tunnel syndrome surgery.

Treatment: Foot Injury

If you suspect that you have broken or fractured bones in a toe or foot, call a doctor, who will probably order x-rays. Even if you can walk, you still might have a fracture. People are often able to walk even if a foot bone has been fractured, particularly if it is a chipped bone or a toe fracture.

Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat mild pain caused by muscle inflammation. Aspirin is the most common NSAID. Others include ibuprofen (Motrin, Advil, Nuprin, Rufen), ketoprofen (Actron, Orudis KT), naproxen (Aleve, Naprelan), and tolmetin (Tolectin). A gel containing ibuprofen can be applied to sore joints. Acetaminophen (Tylenol) is not an NSAID, and although it is a mild pain reliever, it will not reduce inflammation. It is important to note that high doses or long-term use of any NSAID can cause gastrointestinal disturbances with sometimes serious consequences, including dangerous bleeding. No one should take NSAIDs for prolonged periods of time without consulting a doctor.

The acronym RICE stands for rest, ice, compression, and elevation -- the four basic elements of immediate treatment for an injured foot.

Rest. Patients should get off injured foot as soon as possible.
Ice. This is particularly important to reduce swelling and promote recovery during the first 48 hours. Wrap a bag or towel containing ice around the injured area on a repetitive cycle of 20 minutes on, 40 minutes off.
Compression. Lightly wrap an Ace bandage around the area.
Elevation. Elevate the foot on several pillows.

Minor injuries like sprains may be treated at home if broken bones are not suspected. The acronym RICE is helpful for remembering how to treat minor injuries: "R" stands for rest, "I" is for ice, "C" is for compression, and "E" is for elevation. Pain and swelling should decrease within 48 hours, and gentle movement may be beneficial, but don't put pressure on a sprained joint until the pain is completely gone (one to several weeks).

Prevention

The American Podiatric Medical Association offers the following tips for preventing foot pain:

Don't ignore foot pain -- it's not normal. If the pain persists, see a doctor who specializes in podiatry.
Inspect feet regularly. Pay attention to changes in color and temperature. Look for thick or discolored nails (a sign of developing fungus), and check for cracks or cuts in the skin. Peeling or scaling on the soles of feet could indicate athlete's foot. Any growth on the foot is not considered normal.
Wash feet regularly, especially between the toes, and dry them completely.
Trim toenails straight across, but not too short. (Cutting nails in corners or on the sides increases the risk for ingrown toenails.)
Make sure shoes fit properly. Purchase new shoes later in the day when feet tend to be at their largest, and replace worn out shoes as soon as possible.
Select and wear the right shoe for specific activities (such as running shoes for running).
Alternate shoes. Don't wear the same pair of shoes every day.
Avoid walking barefoot, which increases the risk for injury and infection. At the beach or when wearing sandals, always use sunblock on your feet, as you would on the rest of your body.
Be cautious when using home remedies for foot ailments. Self-treatment can often turn a minor problem into a major one.
It is critical that people with diabetes see a podiatric physician at least once a year for a checkup. People with diabetes, poor circulation, or heart problems should not treat their own feet, including toenails, because they are more prone to infection.

Skin creams can help maintain skin softness and pliability. A pumice stone or loofah sponge can help get rid of dead skin.

Taking a warm footbath for 10 minutes two or three times a week will keep the feet relaxed and help prevent mild foot pain caused by fatigue. Adding 1/2 cup of Epsom salts increases circulation and adds other benefits. Taking footbaths only when the feet are painful is not as helpful.

In addition to wearing proper shoes and socks, walking often -- and properly -- can prevent foot injury and pain. The head should be erect, the back straight, and the arms relaxed and swinging freely at the side. Step out on the heel, move forward with the weight on the outside of the foot, and complete the step by pushing off the big toe.

Exercises specifically for the toe and feet are easy to perform and help strengthen them and keep them flexible. Helpful exercises include the following:

Raise and curl the toes 10 times, holding each position for a count of five.
Put a rubber band around both big toes and pull the feet away from each other. Count to five. Repeat 10 times.
Pick up a towel with the toes. Repeat five times.
Pump the foot up and down to stretch the calf and shin muscles. Perform for 2 or 3 minutes.

Early Development. The first year of life is important for foot development. Parents should cover their babies' feet loosely, allowing plenty of opportunity for kicking and exercise. Change the child's position frequently. Children generally start to walk at 10 - 18 months. They should not be forced to start walking early. Wearing just socks or going barefoot indoors helps the foot develop normally and strongly and allows the toes to grasp. Going barefoot outside, however, increases the risk for injury and other conditions, such as plantar warts.

Shoes. Children should wear shoes that are light and flexible, and since their feet tend to perspire, their shoes should be made of materials that breathe. Replace footwear every few months as the child's feet grow. Footwear should never be handed down. Protect children's feet if they participate in high-impact sports.

Shoes

In general, the best shoes are well cushioned and have a leather upper, stiff heel counter, and flexible area at the ball of the foot. The heel area should be strong and supportive, but not too stiff, and the front of the shoe should be flexible. New shoes should feel comfortable right away, without a breaking-in period.

Well-fitted shoes with a firm sole and soft upper are the best way to prevent many problems with the feet. They should be purchased in the afternoon or after a long walk, when the feet have swelled. There should be 1/2 inch of space between the longest toe and the tip of the shoe (remember, the longest toe is not always the big toe), and the toes should be able to wiggle upward.

Stand when being measured, and have both feet sized, buying shoes that fit whichever foot is largest. Wear the same socks as you would regularly wear with the new shoes. Women who are accustomed to wearing pointed-toe shoes may prefer the feel of tight-fitting shoes, but with wear their tastes may adjust to shoes that are less confining and properly fitted.

Ideally, the shoe should have a removable insole. Thin, hard soles may be the best choice for older people. Elderly people wearing shoes with thick inflexible soles may be unable to sense the position of their feet relative to the ground, significantly increasing the risk for falling.

High heels are the major cause of foot problems in women. Although people believe that foot binding is a problem limited to Chinese women of the past, many fashionable high heels are designed to constrict the foot by up to an inch. Women who insist on wearing high-heeled shoes should at least look for shoes with wide toe room, reinforced heels that are relatively wide, and cushioned insoles. They should also keep the amount of time they spend wearing high heels to a minimum.

The way shoes are laced can be important for preventing specific problems. Laces should always be loosened before putting shoes on. People with narrow feet should buy shoes with eyelets farther away from the tongue than people with wider feet. This makes for a tighter fit for narrower feet and a looser fit for wider feet. If, after tying the shoe, less than an inch of tongue shows, the shoes are probably too wide. Adjust tightness both at the top and bottom of the shoe. When shoes with high arches cause pain, skip eyelets when lacing them to relieve pressure.

If shoes need breaking in, place moleskin pads next to areas on the skin where friction is likely to occur. Once a blister occurs, moleskin is not effective. Change shoes during the day, and rotate between different pairs of shoes. As soon as the heels show noticeable wear, replace the shoes or their heels.

Avoid extreme variations between exercise, street, and dress shoes.

Exercise and Sports. Shoes purchased for exercise should be specifically designed for a person's preferred sport. For instance, a running shoe should especially cushion the forefoot, while tennis shoes should emphasize ankle support. Athletic socks are almost as important as shoes. Experts often recommend padded acrylic socks.

Occupational Footwear. Because a number of occupations put the feet in danger, workers in high-risk jobs should be sure their footwear is protective. For example, non-electric workers at risk for falling or rolling objects or punctures should wear shoes with steel toes and possibly other metal foot guards. Electric workers should wear footgear with no metal parts (or insulated steel toes) and rubber soles and heels. Chemical workers should wear shoes made of synthetics or rubber, not leather.


Aerobic Dancing	Sufficient cushioning to absorb shock and pressure, which should be many times greater than shock from walking. Arches that maintain side-to-side stability. Thick upper leather support. Box toe. Orthotics may be required for people with ankles that over-turn inward or outward. Soles should allow for twisting and turning.
Cycling	Rigid support across the arch to prevent collapse during pedaling. Heel lift. Cross-training or combo hiking/cycling shoes may be sufficient for the casual biker. Toe clips or specially designed shoe cleats for serious cyclers. In some cases, orthotics may be needed to control arch and heel and balance the forefoot.
Running	Sufficient cushioning to absorb shock and pressure. Fully bendable at the ball of the foot. Enough traction on the sole to prevent slipping. Consider insole or orthotic with arch support for problem feet.
Tennis	Allows side-to-side sliding. Low-traction sole. Snug fitting heel with cushioning. Padded toe box with adequate depth. Soft-support arch.
Walking	Lightweight. Breathable upper material (leather or mesh). Wide enough to accommodate ball of the foot. Firm padded heel counter that does not bite into heel or touch anklebone. Low heel close to ground for stability. Good arch support. Front provides support and flexibility.

Insoles and Orthotics

Insoles are flat cushioned inserts that are placed inside the shoe. They are designed to reduce shock, provide support for heels and arches, and absorb moisture and odor. In general, they can be very helpful for many people.

People respond very differently to specific insoles. What may work for one person may not for another. Consider the thickness of socks when purchasing insoles to be sure they do not squeeze the toes up against the shoes. Insoles can be purchased in athletic and drug stores. Shoe stores that specialize in foot problems often sell customized, but more expensive, insoles. In general, over-the-counter insoles offer enough support for most people's foot problems. Most well-known brands of athletic shoes have built-in insoles.

Brands and Materials. There are many types of insoles available. They are composed of various materials, such as cork, leather, plastic foam, and rubber. Very effective insoles are now made from viscoelastic polymers (such as Sorbothane, Airplus, Spenco, Dr. Scholl's Massaging Gel, and others), which are gel-like materials that act both as liquids and solids.

Heel Cushions for Shortened Achilles Tendons. People who have developed short, tightened Achilles tendons (usually women who have worn high-heeled shoes for prolonged periods) should consider using heel cushions. Like insoles, heel cushions are inserted inside the shoes. They should be at least 1/8 inch thick, but not more than 1/4 inch thick.

For severe conditions, such as fallen arches or structural problems that cause imbalance, podiatrists or physicians may need to fit and prescribe orthotics, or orthoses, which are insoles molded from a plaster cast of the patient's foot. Orthotics are usually categorized as rigid, soft, or semi-rigid.

Before seeking prescription orthotics, people with less severe problems should consider testing the lower-priced, over-the-counter insoles.

Types of orthotics include:

Rigid Orthotics. Rigid orthotics are used to control motion in two major foot joints that lie directly below the ankle. They are often used to prevent excessive pronation (the turning in of the foot) and are useful for people who are very overweight or have uneven leg lengths. Some experts warn that rigid orthotics may cause sesamoiditis or benign tumors from pinched nerves.
Soft Orthotics. Soft orthotics are designed to absorb shock, improve balance, and remove pressure from painful areas. They are made from a lightweight material and are often beneficial for people with diabetes or arthritis. Soft orthotics need to be replaced periodically, and because they are bulkier than rigid orthotics, they may require larger shoes.
Semi-Rigid Orthotics. Semi-rigid orthotics are designed to provide balance, often for a specific sport. They are typically made of layers of leather and cork reinforced by silastic.

Resources

www.apma.org -- American Podiatric Medical Association
www.aofas.org -- American Orthopaedic Foot and Ankle Society
www.acfas.org -- American College of Foot and Ankle Surgeons
www.aapsm.org -- American Academy of Podiatric Sports Medicine
www.apta.org -- American Physical Therapy Association
www.diabetes.org -- American Diabetes Association
http://ndep.nih.gov/campaigns/Feet/Feet_overview.htm -- National Diabetes Education Program
www.arthritis.org -- Arthritis Foundation
www.podiatrynetwork.com -- Podiatry Network

References

Bostanci S, Kocyigit P, Gurgey E. Comparison of phenol and sodium hydroxide chemical matricectomies for the treatment of ingrowing toenails. Dermatol Surg. 2007;33:680-685.

Donley BG, Moore T, Sferra J, Gozdanovic J, Smith R. The efficacy of oral nonsteroidal anti-inflammatory medication (NSAID) in the treatment of plantar fasciitis: a randomized, prospective, placebo-controlled study. Foot Ankle Int. 2007;28:20-23.

Frey C, Zamora J. The effects of obesity on orthopaedic foot and ankle pathology. Foot Ankle Int. 2007;28:996-999.

Gollwitzer H, Diehl P, von Korff A, Rahlfs VW, Gerdesmeyer L. Extracorporeal shock wave therapy for chronic painful heel syndrome: a prospective, double blind, randomized trial assessing the efficacy of a new electromagnetic shock wave device. J Foot Ankle Surg. 2007;46:348-357.

Hughes RJ, Ali K, Jones H, Kendall S, Connell DA. Treatment of Morton's neuroma with alcohol injection under sonographic guidance: follow-up of 101 cases. Am J Roentgenol. 2007;188:1535-1539.

Kruijff S, van Det RJ, van der Meer GT, van den Berg IC, van der Palen J, Geelkerken RH. Partial matrix excision or orthonyxia for ingrowing toenails. J Am Coll Surg. 2008;206:148-153.

Malay DS, Pressman MM, Assili A, Kline JT, York S, Buren B, Heyman ER, Borowsky P, LeMay C. Extracorporeal shockwave therapy versus placebo for the treatment of chronic proximal plantar fasciitis: results of a randomized, placebo-controlled, double-blinded, multicenter intervention trial. J Foot Ankle Surg. 2006;45:196-210.

Review Date:
12/14/2007
Reviewed By:
Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M. Copyright

adam.com

Osteoarthritis

FitSugar — Wed, 08 Oct 2008 17:34:56 -0700

In This Report

Highlights
Introduction
Causes
Symptoms
Conditions with Similar Sym...
Risk Factors
Diagnosis
Prognosis
Lifestyle Changes
Medications
Alternative and Complementa...
Surgery
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Pain Medications

Nonsteroidal anti-inflammatory drugs (NSAIDs) and COX-2 inhibitors work equally well for pain management, but both types of drugs increase the risk for heart attacks, according to an important report from the U.S. Agency for Healthcare Quality and Research.
The prescription NSAID diclofenac (Voltaren, Cataflam) may present a higher risk for heart attack than other NSAIDs, suggests a 2006 Journal of the American Medical Association study.
Standard osteoarthritis medications provide moderate pain relief for only 2 - 3 weeks, suggests a 2007 review in the European Journal of Pain.

Acupuncture

Acupuncture may be helpful for people with knee and hip osteoarthritis, according to several 2006 studies:

An Annals of Internal Medicine study of 1,007 people with chronic osteoarthritis knee pain indicated that patients who received acupuncture plus standard care had greater improvement than those who received only physical therapy and anti-inflammatory drugs.
An Arthritis and Rheumatism study of 3,663 patients with chronic osteoarthritis knee or hip pain suggested that acupuncture plus routine care can provide significant improvements in pain relief and quality of life. In both studies, the benefits of acupuncture were sustained for up to 6 months after treatment completion.

Exercise and Knee Osteoarthritis

Weight-bearing exercise (walking, jogging) neither prevents nor increases the risk of knee osteoarthritis in healthy middle-aged and elderly people, suggests a 2007 study in Arthritis and Rheumatism.

Risk of Hip Osteoarthritis

About 1 in 4 Americans can expect to develop osteoarthritis of the hip at some point in life, according to research presented at the 2006 American College of Rheumatology annual meeting. Body weight is a factor. People who are normal weight have a 20% risk, compared to those who are overweight (25%) or obese (39%).

Introduction

Osteoarthritis, also known as degenerative joint disease, is the most common form of arthritis. Scientists now believe osteoarthritis results from a combination of genetic abnormalities and joint injuries. In this disorder, an affected joint experiences a progressive loss of cartilage, the slippery material that cushions the ends of bones.

Osteoarthritis is a chronic disease of the joint cartilage and bone, often thought to result from "wear and tear" on a joint, although there are other causes such as congenital defects, trauma, and metabolic disorders. Joints appear larger, are stiff and painful, and usually feel worse with increased use throughout the day.

As a result, the bone beneath the cartilage undergoes changes that lead to bony overgrowth. The tissue that lines the joint can become inflamed, the ligaments can loosen, and the associated muscles can weaken. The patient experiences pain when using the joint. In addition to humans, nearly all vertebrates suffer from osteoarthritis, including porpoises and whales, as did long-extinct terrestrial travelers such as dinosaurs.

Click the icon to see an animation about osteoarthritis.

Joints are designed to provide flexibility, support, stability, and protection. These functions, essential for normal and painless movement, are primarily supplied by specific parts of the joint: the synovium and cartilage.

Synovium. The synovium is a membrane that surrounds the entire joint. It is filled with synovial fluid, a lubricating liquid that supplies nutrients and oxygen to cartilage.

Cartilage. The cartilage is a slippery tissue that coats the ends of the bones. Cartilage is one of the few tissues in the body that does not have its own blood supply. It has a number of essential components:

Click the icon to see an image of the synovial membrane and cartilage in the knee joint.

Chondrocytes. Chondrocytes, the basic cartilage cells, are critical for balance and function.
Water. Cartilage contains a high percentage of water, although it decreases with age. About 85% of cartilage is water in young people, and about 70% is water in older individuals.
Proteoglycans. These are large molecules that help make up cartilage. Their important value is their capacity to bond to water, which ensures the high-fluid content in cartilage.
Collagen. This is the critical protein in cartilage. It forms a mesh to give support and flexibility to the joint. Collagen is the main protein found in all the connective tissues of the body, including the muscles, ligaments, and tendons.

The combination of the collagen meshwork and the high water content, tightly bound by proteoglycans, creates a resilient and slippery pad in the joint, which resists the compression between bones during muscle movement. The synovial fluid lubricates and provides oxygen and nutrients to the bloodless cartilage.

Deterioration of Cartilage. Osteoarthritis develops when cartilage in a joint deteriorates. The process is usually slow.

In the early stages of the disease the surface of the cartilage, or even the synovium in some people, becomes inflamed and swollen. There is a loss of proteoglycan molecules and other tissue components that cause water loss. Fissures and pits appear in the cartilage.
As the disease progresses and more tissue is lost, the cartilage loses elasticity and fluid. It becomes increasingly prone to damage due to repetitive use and injury.
Eventually large amounts of cartilage are destroyed, leaving the ends of the bone within the joint unprotected.

To compound the process, bone around arthritic joints is not structurally normal. As the body tries to repair damage to the cartilage, problems can develop:

Clusters of damaged cells or fluid-filled cysts may form around the bony areas or near the fissures.
Fluid pockets may also form within the bone marrow itself, causing swelling. The marrow, which runs up through the center of bone, is rich in nerve fibers, and such injuries may be an important source of pain in many patients with osteoarthritis.
Bone cells may respond to damage by multiplying, growing, and forming dense, misshapen plates around exposed areas.
At the margins of the joint, the bone may produce outcroppings, on which new cartilage cells (chondrocytes) proliferate and grow abnormally.

Unlike some other types of arthritis, such as rheumatoid arthritis, osteoarthritis does not spread through the entire body. (In other words, it is not systemic.) Rather, it affects one or several joints. Osteoarthritis affects joints differently depending on their location in the body.

Osteoarthritis is commonly found in joints of the fingers, feet, knees, hips, and spine.
It sometimes occurs in the wrist, elbows, shoulders, and jaw, but is not common in these locations.

Causes

The biologic factors leading to the deterioration of cartilage in osteoarthritis are not entirely understood. Many experts believe that osteoarthritis results from a genetic susceptibility that causes some biologic response to injuries to the joint, which in turn leads to progressive deterioration of cartilage. In addition, the ability to make repairs becomes progressively limited as cartilage cells age.

Although osteoarthritis generally accompanies aging, osteoarthritic cartilage is chemically different from normal aged cartilage. As chondrocytes (the cells that make up cartilage) age, they lose their ability to make repairs and produce more cartilage. This process may play an important role in the development and progression of osteoarthritis.

Researchers report a high correlation of osteoarthritis between parents and children or between siblings. Genetic factors are thought to be involved in about half of osteoarthritis cases in the hands and hips and a somewhat lower percentage of cases in the knee. A number of genes are under investigation that might contribute to an inherited risk.

For example, mutations in the ank gene may be important in some cases. The ank gene regulates pyrophosphate, a chemical that inhibits the formation of mineral deposits, and may protect the cartilage in joints. Mutations in the ank gene then may result in lower pyrophosphate levels in the joint, leading to accumulation of mineral deposits and arthritis. (About 60% of people with osteoarthritis have mineral deposits in their cartilage.)

Another gene, called the osteoprotegerin gene, is important in regulating bone and cartilage formation. Mutations in this gene may play a role in osteoarthritis.

The inflammatory response is an overreaction of the immune system to an injury or other assault in the body, such as an infection. This response causes specific immune factors, called cytokines, to gather in injured areas and cause inflammation and damage to body tissue and cells. The inflammatory response plays an important role in rheumatoid arthritis and other muscle and joint problems associated with autoimmune diseases. It has generally been believed that inflammation plays at most a minor role in osteoarthritis and is more likely to be a result -- not a cause -- of the disease.

However, recent studies suggest that inflammation may play an important role in the progression of osteoarthritis and its chronic nature. For example, a 2003 study found evidence of severe inflammation in the lining of the joints in 30% of patients with osteoarthritis. Still, the effects of the inflammatory response in osteoarthritis are likely to be different from those in rheumatoid arthritis and less severe.

Some theories on how this response may contribute to osteoarthritis involve overproduction of enzymes called matrix metalloproteinases or MMPs (also called collagenases). In large amounts they break down collagen, the building blocks of cartilage. Some studies suggest that immune factors called vascular endothelial growth factor (VEGF) are overproduced during the inflammatory response and in turn increase production of MMPs.

Another theory suggests that the inflammatory response is triggered by the changes and injuries in the bone that occur during osteoarthritis. According to this theory, immune factors released in this process diffuse into the cartilage, where they suppress cartilage cell growth and activate MMPs.

Joint injuries are the starting point in the disease process. Osteoarthritis sometimes develops years after a single traumatic injury to or near a joint. One large study found that by age 65, osteoarthritis developed in almost 14% of those who had joint injuries as young adults, compared to just 6% in those without earlier injuries. Patients with knee injuries were five times more likely to have osteoarthritis in the injured knee than those without injuries, and patients with hip injuries were more than three times more likely to develop arthritis in the injured hip. Proper treatment of injuries, such as surgical repair of ligament tears in the knee with a strong rehabilitation approach, may help to prevent the development of osteoarthritis.

Other causes of osteoarthritis include:

Bleeding disorders such as hemophilia that cause bleeding to occur in the joint
Disorders such as avascular necrosis that block the blood supply near the joint
Complications of persistent, inflammatory arthritic conditions, particularly chronic gout, pseudogout, or rheumatoid arthritis
Conditions that cause iron build-up in the joints such as hemochromatosis

Symptoms

The pain of osteoarthritis typically begins gradually and progresses slowly over many years. People under age 40 may have the condition with no symptoms at all. Osteoarthritis is commonly identified by the following symptoms:

The most common symptom of osteoarthritis in any joint is pain that worsens during activity and gets better during rest. As the disease advances, the pain may occur even when the joint is at rest.
Pain is generally described as aching, stiffness, and loss of mobility.
The pain may behave like a roller coaster, with bad spells followed by periods of relative relief.
Pain seems to increase in humid weather.
Some people experience muscle spasm and contractions in the tendons.
Osteoarthritis in the knee may cause a crackling-like noise (called crepitus) when moved.

Hand. Osteoarthritis of the hand occurs most often in older women and may be inherited within families. The following joints are most frequently affected:

Distal interphalangeal (DIP) joint. The first joint below the fingertips is the most common location of osteoarthritis of the hand. These joints can develop bony growths known as Heberden's nodes.
Carpometacarpal (CMC) joint. The joint at the base of the thumb, where the thumb joint connects with the wrist, is the second most common location.
Proximal interphalangeal (PIP) joint. The middle joints of the fingers can also develop osteoarthritis. These joints may develop small, solid lumps (nodules) known as Bouchard's nodes.

Click the icon to see an image of osteoarthritis.

Recent studies suggest that osteoarthritis of the hand may predict the later development of osteoarthritis in the hip or knee. A 2005 study found that patients with hand osteoarthritis were three times more likely to develop hip arthritis. Osteoarthritis of the hand also slightly increased the risk for knee osteoarthritis.

Knee. Osteoarthritis is particularly debilitating in the weight-bearing joints of the knees. The joint is usually stable until the disease reaches an advanced stage when the knee becomes enlarged and swollen. Although painful, the arthritic knee usually retains reasonable flexibility.

Osteoarthritis can cause loss of cartilage in the knee. The meniscus, the cartilage pad between the joint formed by the thighbone and the shinbone, plays an important role in protecting the joint. It acts as a shock absorber. In knee surgery called meniscectomy, the doctor removes the damaged cartilage. However, a 2006 study suggested that preserving the meniscus, even if it is damaged, is better than removing it. Researchers showed that even a small amount of meniscus helps protect the joint and prevent osteoarthritis from worsening. Experts recommend that patients try lifestyle changes (exercise and weight loss), braces, and medication before undergoing knee surgery.

Click the icon to see an image of the knee joint.

Hips. About 1 in 4 people will develop hip arthritis over the course of their lifetime. Being obese increases the risk. Osteoarthritis frequently strikes the weight-bearing joints in one or both hips. Pain develops slowly, usually in the groin and on the outside of the hips, or sometimes in the buttocks. The pain also may radiate to the knee, confusing the diagnosis. Those with osteoarthritis of the hip often have a restricted range of motion (particularly when trying to rotate the hip) and walk with a limp, because they slightly turn the affected leg to avoid pain.

Click the icon to see an image of the hip joint.

Spine. Osteoarthritis may affect the cartilage in the disks that form cushions between the bones of the spine, the moving joints of the spine itself, or both. Osteoarthritis in any of these locations can cause pain, muscle spasms, and diminished mobility. In some cases, the nerves may become pinched, which also produces pain. Advanced disease may result in numbness and muscle weakness. Osteoarthritis of the spine is most troublesome when it occurs in the lower back or in the neck, where it can cause difficulty in swallowing.

Click the icon to see an image of the spine.

Shoulder. Osteoarthritis is less common in the shoulder area than in other joints, but it may develop in the shoulder joint (the glenohumeral joint). In such cases, it is most often associated with a previous injury, and patients gradually develop pain and stiffness in the back of the shoulder. Osteoarthritis also can develop in the acromioclavicular (AC) joint, which is between the shoulder blade and the collarbone. However, it rarely causes symptoms in this location.

Conditions with Similar Symptoms

Numerous conditions have symptoms of joint aches and pains. Something as benign as sleeping on a bad mattress to the serious afflictions associated with cancer can mirror symptoms of osteoarthritis. Other problems that can cause aches and pains in the joints include physical injuries, infections, tendinitis, and poor circulation. A number of rare genetic diseases attack the joints.

Osteoarthritis can generally be distinguished from other joint diseases by considering several factors together:

Osteoarthritis usually occurs in older people and is located in only one or a few joints
The joints are less inflamed than in other arthritic conditions
Progression of pain is usually gradual.

A few of the most common disorders that can be confused with, or may even accompany, osteoarthritis are discussed below.

Osteoarthritis may be confused with rheumatoid arthritis, particularly when osteoarthritis affects multiple joints in the body. Rheumatoid arthritis begins in the synovial membrane rather than the cartilage. It normally occurs earlier in life than osteoarthritis, often striking people in their 30s and 40s. Rheumatoid arthritis affects many joints, and often occurs symmetrically on both sides of the body. People generally have morning stiffness that lasts for at least an hour. (Stiffness from osteoarthritis usually clears up within half an hour.)

X-rays show changes in the bones that differ from those occurring in osteoarthritis. In rheumatoid arthritis, blood tests often show a specific antibody, known as rheumatoid factor, which is not present with osteoarthritis. In another blood test, levels of a factor called erythrocyte sedimentation rate (ESR) are often elevated in rheumatoid arthritis, but they are generally normal in osteoarthritis. Rheumatoid arthritis also does not usually show up in the fingertips where osteoarthritis is common.

Rheumatoid arthritis is a body-wide (systemic) autoimmune disease that initially attacks the synovium, a connective tissue membrane that lines the cavity between joints and secretes a lubricating fluid.

Click the icon to see an image of osteoarthritis vs. rheumatoid arthritis.

Chondrocalcinosis is a disease in which certain calcium crystals known as CPPD (calcium pyrophosphate dihydrate) are deposited in the joints. It affects about 25% of the population and can accompany and even worsen osteoarthritis. The problem has been called pseudogout or pseudo-osteoarthritis, in the latter case particularly when it affects the knees. A doctor can usually differentiate between the two disorders, however, because chondrocalcinosis usually damages other joints (such as wrists, elbows, and shoulders) that are not usually affected by osteoarthritis. The condition may explain why some patients with osteoarthritis receive benefit from colchicine, a drug used for gout and other crystal-induced joint diseases.

Charcot's joint occurs when an underlying disease, usually diabetes, causes nerve damage in the joint, which leads to swelling, bleeding, increased temperature, and changes in bone. There may be a loss of sensation that leads to an increased risk for injury from overuse.

Risk Factors

Osteoarthritis is the most common type of arthritis. In the U.S., about 12.1% of Americans (21 million people) age 25 and older have osteoarthritis. The prevalence in osteoarthritis increases as people age. Experts estimate that by 2030, 20% of Americans (72 million people) age 65 years and older will be at risk for developing osteoarthritis.

Before age 45, osteoarthritis occurs more frequently in males (although it is not common in younger adults). After age 55, it develops more often in females. In a 2000 study, 33% of women had osteoarthritis compared to 25% of men. Some research suggests that women may also experience greater muscle and joint pain, in general, than men. And, women also tend to be undertreated for pain compared to men. The causes of such differences in pain sensitivity and treatment are largely unknown and most likely are due to a complicated mix of biologic, psychologic, and social factors.

The incidence is highest in lower educational levels. In a 2000 study, 41% of adults with less than a high school education had arthritis compared to 21% of college graduates.

Although the average rate of osteoarthritis among older adults in the U.S. is 60%, it can vary widely in certain geographical regions. In the U.S., the rates in older adults are lowest (34%) in Hawaii and highest (70%) in Alabama. In general, the highest prevalence of arthritis in America occurs in the central and northwestern states.

The rate of osteoarthritis varies by ethnic group. In the U.S., Caucasians and African-Americans have higher rates of arthritis than Hispanics or other ethnic groups. Osteoarthritis also tends to favor specific joints over others in certain ethnic groups. The following are some examples:

Older African-American men are about 33% more likely than Caucasian men to have hip osteoarthritis. In one study, although men in both groups had equal risks for arthritic knees, African-American men were more likely to have arthritis in both knees and to have more severe cases. Although comparable disparities in knee arthritis were observed between African-American and Caucasian women, they might be explained by greater average weight among African-American women. The study could not account for the differences among men, however.
Asians appear to have a higher incidence of osteoarthritis in the knee, an equal risk for osteoarthritis in the spine, and a lower risk for osteoarthritis in the hips than Caucasians.

Genes that determine the angles, amount of force, and other structural factors in the hip joints, or genes that regulate the chemistry in the joints, may account for ethnic differences.

Some researchers suggest that a number of people have anatomical abnormalities, such as mismatched surfaces on the joints, which could be damaged over time by abnormal stress. Legs of unequal length or skewed feet can cause jerky movement and may cause osteoarthritis. One study reported that those whose knees bent inward ("knock-kneed") or outward ("bow-legged"), for example, were more likely to have progressive osteoarthritis of the knee.

Obesity, defined as being 20% over one's healthy weight, places people (particularly women) at increased risk for osteoarthritis. It also worsens osteoarthritis once deterioration begins. This higher risk is due to increased weight on the joints. However, being obese also increases the risk for osteoarthritis in the fingers as well as the knees and hips, suggesting that being overweight may contribute to osteoarthritis in other ways. Some research indicates that obesity may produce an inflammatory response, which is now a major suspect in age-related diseases -- not only osteoarthritis but also heart disease. [See In-Depth Report #53: Weight control and diet.]

Because injuries can trigger the disease process, people whose work or leisure activities place them at risk for muscle and joint injuries may face a higher risk for osteoarthritis later on.

Workers at Higher Risk. Certain occupations that require repeated stressful motions (such as squatting or kneeling with heavy lifting) can contribute to deterioration of cartilage. One study suggested that workers whose jobs require kneeling or squatting for more than an hour a day are at high risk for knee osteoarthritis. (In the study, jobs that involved heaving lifting, climbing stairs, or walking also posed some, but not as high, a risk. Being heavier compounded the chances for osteoarthritis.)

Exercise. There has been some question about the role of strenuous exercise in osteoarthritis. Sports that definitely pose a higher risk for osteoarthritis are those that require repetitive or direct joint impact (such as football), twisting, or both (baseball pitching, soccer).

Marathon runners, however, have a relatively low rate of osteoarthritis. Some scientists speculate that running enhances cartilage health because the rhythmical compression of cartilage expels wastes and promotes absorption of nutrients.

In any case, regular and moderate exercise is important for everyone and does not increase the risk for osteoarthritis. In fact, a 2006 study of middle-aged and elderly people found that recreational weight-bearing exercise (walking, jogging) neither protects against nor increases the risk for osteoarthritis. Furthermore, many factors associated with a sedentary life (muscle weakness, obesity) are associated with a higher risk for osteoarthritis.

Diagnosis

Osteoarthritis is often visible in x-rays. Cartilage loss is indicated by certain images:

If the normal space between the bones in a joint is narrowed.
If there is an abnormal increase in bone density.
If bony projections, cysts, or erosions are evident.
X-rays can also reveal any cysts that might develop in osteoarthritic joints. If other conditions are suspected or if the diagnosis is uncertain, additional tests are necessary.
An MRI may show evidence of osteoarthritis that x-rays miss.

X-rays are a form of electromagnetic radiation (like light); they are of higher energy, however, and can penetrate the body to form an image on film. Structures that are dense (such as bone) will appear white, air will be black, and other structures will be shades of gray depending on density. X-rays can provide information about obstructions, tumors, and other diseases, especially when coupled with the use of barium and air contrast within the bowel.

Blood test results may help diagnose or rule out osteoarthritis. Some examples include:

Elevated levels of rheumatoid factor (specific antibodies in the synovium) and so-called erythrocyte sedimentation rates (ESR or sed rate) indicate rheumatoid arthritis.
Hyaluronic acid (HA), a joint lubricant, is being tested as a potential biomarker for osteoarthritis. High levels of HA may indicate increased risk for osteoarthritis.
Elevated levels of a factor called C-reactive protein, which is produced by the liver in response to inflammation, are proving to be good predictors of osteoarthritic progression in the knee.

If the diagnosis is uncertain or infection is suspected, a doctor may attempt to withdraw synovial fluid from the joint using a needle. There will not be enough fluid to withdraw if the joint is normal. If the doctor can withdraw fluid, problems are likely, and the fluid will be tested for factors that might confirm or rule out osteoarthritis:

Cartilage cells in the fluid are signs of osteoarthritis.
A high white blood cell count is a sign of infection.
High uric acid in the fluid is an indication of gout.

Click the icon to see an animation on gout.

Other factors may be present that suggest different arthritic conditions, including Lyme disease and rheumatoid arthritis.
In people with known osteoarthritis, researchers may look for certain factors in synovial fluid (sulfated glycosaminoglycan, keratin sulfate, and link protein) that can suggest a more or less severe condition.

Prognosis

Osteoarthritis itself is not life-threatening, but a person's quality of life can significantly deteriorate from pain and loss of mobility. The negative effects on activities and physical and mental health are significant regardless of age, educational level, or gender. Only heart disease has a greater impact on work. Five percent of those who leave the work force do so because of osteoarthritis. Unless alleviated by medication or corrected by surgery, advanced osteoarthritis can force the patient to forgo even relatively low-impact activities, such as walking. No treatment can cure osteoarthritis, and none can alter its progression with certainty, but many available therapies can relieve symptoms and significantly improve the quality of life.

Lifestyle Changes

Many doctors suggest first trying lifestyle changes to reduce stress on affected joints. Physical therapy and supportive devices can be helpful. Intensive education on how to protect and care for an osteoarthritic joint may help patients avoid multiple visits to their doctor.

Once osteoarthritis has been diagnosed, patients should reduce shock to the affected joint. Hammering away at deteriorating cartilage is likely to speed up the degeneration. People in occupations requiring repetitive and stressful movement should explore ways to reduce trauma. Adjusting the work area or substituting tasks that produce less stress on joints helps reduce shock.

Joints require motion to stay healthy. Long periods of inactivity cause the arthritic joint to stiffen and the adjoining tissue to atrophy. A moderate exercise program that includes low-impact aerobics and power and strength training has benefits for osteoarthritic patients, even if exercise does not slow down the disease progression. Exercise helps:

Reduce stiffness and increase flexibility. It may also help improve the strength and elasticity of knee cartilage.
Promote weight loss.
Improve strength, which in turn improves balance and endurance.
Reduce stress and improve feelings of well being, which helps patients cope with the emotional burden of pain.

Exercise especially helps patients with mild-to-moderate osteoarthritis in the hip or in the knee. Many patients who begin an aerobic or resistance exercise program report less disability and pain. They are better able to perform daily chores and remain more independent than their inactive peers. Older patients and those with medical problems should always check with their doctor before embarking on an exercise program.

Three types of exercise are best for people with osteoarthritis:

Strengthening exercise
Range-of-motion exercise
Aerobic, or endurance, exercise

Strengthening Exercise. Strengthening exercises include isometric exercises (pushing or pulling against static resistance). Isometric training builds muscle strength while burning fat, helps maintain bone density, and improves digestion.

Some experts encourage patients to emphasize strengthening leg muscles as a first treatment step, before using pain relievers. Patients who rely on painkilling drugs may overuse knees, which do not have muscle tissue sufficiently strong enough to protect the joints from further damage. However, some studies suggest that building up thigh muscles may worsen osteoarthritis in people whose knees are misaligned (for instance those who are "bow-legged" or "knock-kneed"). Such individuals should check with a physical therapist for the best options. Strengthening the thigh muscles is certainly protective for people who have not yet developed osteoarthritis.

Exercise, such as weightlifting, helps build muscle that is usually lost with age and puts stress on bones, helping keep them strong and healthy.

Range-of-Motion Exercise. These exercises increase the amount of movement in a joint and muscle. In general, they are stretching exercises. The best examples are yoga and tai chi, which focus on flexibility, balance, and proper breathing. In one study, older adults who practiced the gentle movement, breathing, and meditation exercises of tai chi for 10 weeks reported less pain than their peers who did not learn the technique.

Click the icon to see an image of cholesterol.

Aerobic (Endurance) Exercise. These exercises help control weight and may reduce inflammation in some joints. Low-impact workouts also help stabilize and support the joint. Cycling and walking are beneficial, and swimming or exercising in water is highly recommended for people with arthritis. (Patients with osteoarthritis should avoid high-impact sports, such as jogging, tennis, and racquetball.)

Click the icon to see an image of exercise.

In addition to exercise, manipulation of muscles and joints by a trained therapist may be helpful. In one study, patients who had a combination of physical therapy and an exercise program reported 30 - 40% improvement after only two to four visits.

Overweight patients with osteoarthritis can lessen the shock on their joints by losing weight. Knees, for example, sustain an impact three to five times the body weight when descending stairs. Losing 5 pounds of weight can eliminate 20 pounds of stress on the knee. The greater the weight loss, the greater the benefit. [See In-Depth Report #53:Weight loss and diet.]

Plant Chemicals. A large study reported significant improvement in symptoms when patients took extracts from avocados and soybeans called saponins. Another study noted that although these substances did not relieve hip pain, they did slow progression of joint deterioration. Soy has chemicals called isoflavones that may have additional benefits, such as preventing bone loss.

Fish Oil and Omega-3 Fatty Acids. Omega-3 fatty acids, which are found in fish oil, canola oil, black currant or primrose seed oils, and flax seeds, have anti-inflammatory properties and may help protect against cartilage deterioration. Supplements of omega-3 fatty acids, such as docosahexaenoic (DHA) and eicosapentaneoic (EPA) acids that are found in fish oil, are available.

Vitamin B3 (Niacin). Some research suggests that vitamin B3 may have some benefits for people with osteoarthritis.

Click the icon to see an image of the benefits of vitamin B3.

Click the icon to see an image of the sources of vitamin B3.

Calcium and Vitamin D. Calcium and vitamin D are important for strong bones. Although osteoarthritis is primarily a disease of joints, bone strength is also important, particularly in older people.

Click the icon to see an image of osteoporosis.

Many experts now recommend 1,000 mg of calcium a day for most adults and 1,200 - 1,500 mg for adolescents. Pregnant women, postmenopausal women not on estrogen therapy, and those on corticosteroids should get 1,500 mg per day; breast feeding women should get 2,000 mg/day. Because calcium supplements increase the risk for kidney stones, an upper limit of 2,500 mg is recommended.

Current guidelines recommend 400 IU of vitamin D per day and 600 IU per day after age 60. Lack of sunlight and unhealthy diets contribute to deficiencies in vitamin D. Good dietary sources include fortified milk, sardines, herring, salmon, tuna, liver, dairy products, and egg yolks. Although supplements are often necessary, vitamin D can be toxic in high doses, and no one should take more than 1,200 IU per day.

Selenium. Selenium is a trace mineral found in grains, nuts, vegetables, and some meats and seafood. Preliminary research suggests that people who do not get enough selenium in their diet may be more likely to develop knee osteoarthritis. Researchers are investigating whether selenium supplements may help protect against osteoarthritis and prevent it from worsening.

Ice. When a joint is inflamed (particularly in the knee) applying ice for 20 - 30 minutes can be effective. If an ice pack is not available, a package of frozen vegetables works just as well.

Heat Treatments. Patients afflicted with osteoarthritis of the hands can relieve pain with hot soaks and warm paraffin application. Osteoarthritis of the hip can be treated with heating pads.

Interestingly, moving to a warm climate does not seem to make much difference. According to one study, people who live in warmer places are actually more sensitive to small shifts in temperature than people who live in cold damp climates, and they experience pain as readily as their northern peers do in response to larger temperature shifts.

A wide variety of devices are available to help support and protect joints:

Splints or braces, worn while the joint is at rest or in use, help align joints and properly distribute weight. They are used most frequently to treat arthritic hands, wrists, knees, ankles, and feet. Many of these devices allow some movement within the affected joint and do not restrict nearby joints. They are usually made from lightweight metal, leather, elastic, foam, and moldable plastic with easy-to-use Velcro straps. Any brace, splint, or other device for joint protection should be custom-fitted by a physical or occupational therapist, or an orthotist. Poorly fitting or improperly used orthoses can cause more harm than good.
Using elastic supports on affected joints may benefit some people. For example, in one study, wearing insoles plus elastic straps supporting the ankle joint helped overweight women with osteoarthritis in the knee. It is important to consult with a doctor about how to use elastic supports.
Wrapping the knee with special therapeutic tape that provides support to specific parts of the joint may be effective. In one trial, patients experienced a 40% reduction in pain within a few days. They wore the tape for 3 weeks, and pain relief continued for 3 more weeks following treatment. The tape should be applied by physical therapists or other trained health professionals. Longer-term studies are needed to determine any continuous benefits.
Wearing shock-absorbing soles in shoes or orthopedic shoes can help in daily activities and during gentle exercise. Heel wedges in the shoes can sometimes help patients avoid knee replacement surgery.
A neck brace or corset may relieve back pain.
A firm mattress also often proves beneficial.
In extreme cases of back pain, lying in traction might be necessary.
Canes, crutches, or walkers offer benefits to patients with advanced arthritis.
Specially designed hip protectors, worn under the clothes, can also protect against hip fractures in elderly patients with impaired mobility who are apt to fall.

Medications

Many medications are available for relieving the symptoms of osteoarthritis. A major analysis indicated that drug therapy is generally more effective than non-drug treatments (surgery, acupuncture). However, a 2006 review of knee osteoarthritis studies found that pain-relief medications generally help only for the first 2 - 3 weeks of treatment. The following are some of the medications used in mild-to-severe cases:

Acetaminophen
Nonsteroidal anti-inflammatory drugs (NSAIDs) or COX-2 inhibitors
Capsaicin
Tramadol
Narcotic pain relievers (oxycodone, oxymorphone, or morphine)
Glucosamine and chondroitin (see Alternative and Complementary Medicine section)

Acetaminophen (Tylenol, Anacin-3, Panadal, Phenaphen, Valadol, and others) is currently the first choice for treating osteoarthritis. However, several major analyses report that acetaminophen is less effective than NSAIDs in reducing moderate-to-severe pain. Because acetaminophen has fewer side effects, most experts suggest trying this drug first, then switching to an NSAID if acetaminophen does not provide sufficient pain relief.

Side Effects. Acetaminophen is inexpensive and generally safe. It poses far less of a risk for gastrointestinal problems than NSAIDs and does not appear to increase the risk for miscarriage (as NSAIDs do), even when used regularly.

It does have some adverse effects, however, and the daily dose should not exceed 4 grams (4,000 mg). Patients who take high doses of this drug for long periods are at risk for liver damage, particularly if they drink alcohol and do not eat regularly.

The kidneys are responsible for removing wastes from the body, regulating electrolyte balance and blood pressure, and the stimulation of red blood cell production.

Nonsteroidal anti-inflammatory drugs (NSAIDs) block prostaglandins, the substances that dilate blood vessels and cause inflammation and pain. There are dozens of NSAIDs:

Over-the-counter NSAIDs include aspirin, ibuprofen (Advil, Nuprin, Motrin IB, Rufen), naproxen (Aleve, Naprosyn), ketoprofen (Actron, Orudis KT).
Prescription NSAIDs include ibuprofen (Motrin), naproxen (Naprosyn, Anaprox), flurbiprofen (Ansaid), diclofenac (Voltaren, Cataflam), tolmetin (Tolectin), ketoprofen (Orudis, Oruvail), nabumetone (Relafen), dexibuprofen (Seractil), indomethacin (Indocin), meloxicam (Mobic, generic).
Topical NSAIDs delivered in gels, creams, or patches do not appear to provide any long-term benefits in reducing arthritic pain. A review of clinical trial data, published in 2004, suggested that guidelines that recommend topical NSAIDs for treatment of osteoarthritis should be revised.

Many experts now recommend that patients use oral NSAIDs for only a short period of time. A 2004 review, published in the British Medical Journal, suggested that long-term use of NSAIDs does not actually reduce osteoarthritis pain and may increase patients’ risk of experiencing side effects. High dosages of NSAIDs can cause heart problems (such as increased blood pressure), kidney problems, and stomach bleeding.

In April 2005, the Food and Drug Administration (FDA) asked drug manufacturers of prescription NSAIDs to include with their products the same boxed warning used for the COX-2 inhibitor celecoxib (Celebrex). This boxed warning emphasizes an increased risk for cardiovascular events and gastrointestinal bleeding in people taking these drugs. The FDA also requested manufacturers of over-the-counter NSAIDs to revise their labels to include more specific language concerning potential cardiovascular and gastrointestinal risks. Due to its proven heart benefits, aspirin was excluded from these labeling revisions.

A 2006 comprehensive report from the U.S. Agency for Healthcare Quality and Research indicated that both NSAIDs and COX-2 inhibitors are equally effective for pain relief and pose similar risks for heart attacks. The report found that one particular NSAID, naproxen (Aleve, Naprosyn), presents less risk of heart attack for some patients. A 2006 Journal of the American Medical Association study suggested that diclofenac (Voltaren, Cataflam) may pose a higher risk for heart attack than other NSAIDs. All patients should talk to their doctors before switching any medications.

Long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) is the second most common cause of ulcers, and the rate of NSAID-caused ulcers is increasing. Such ulcers are also more likely to bleed than those caused by the bacteria H. pylori. NSAID-related bleeding and stomach problems may be responsible for 107,000 hospital admissions and 16,500 deaths each year. Because there are usually no gastrointestinal symptoms from NSAIDs until bleeding begins, doctors cannot predict which patients taking these drugs will develop bleeding.

Among the groups at high risk for bleeding are elderly people, anyone with a history of ulcers of GI bleeding, patients with serious heart conditions, alcohol abusers, and those on certain medications, such anticoagulants ("blood thinners"), corticosteroids, or bisphosphonates (drugs used for osteoporosis). Proton-pump inhibitors may help to prevent and heal ulcers caused by NSAIDs. Proton-pump inhibitors include omeprazole (Prilosec), esomeprazole (Nexium), and lansoprazole (Prevacid)

Click the icon to see an image of a gastric ulcer.

Drugs for Prevention NSAID-Induced Ulcers. If you have NSAID-induced ulcers, follow these steps:

Switch to alternative pain relievers. This is the first step in preventing or healing ulcers caused by NSAIDs. If people cannot change drugs, they should use the lowest NSAID dose possible.
Try proton-pump inhibitors (PPIs). These drugs help reduce NSAID-ulcer rates by as much as 80% compared with no treatment. Brands include omeprazole (Prilosec), esomeprazole (Nexium), lansoprazole (Prevacid), rabeprazole (Aciphex), and pantoprazole (Protonix).
Try misoprostol or Arthrotec. If other drugs are inappropriate, misoprostol protects against the major intestinal toxicity of NSAIDs. It was the first drug approved for preventing NSAID-induced ulcers. It is equally, or even more, effective than some of the PPIs, but it does not heal existing ulcers and has more side effects than PPIs. Patients tend to stop using it. Arthrotec is a combination of an ulcer protective drug called misoprostol and the NSAID diclofenac. One study found that patients taking Arthrotec had 65 - 80% fewer ulcers than those who took NSAIDs alone.

Healing Existing Ulcers. A number of drugs are available to heal NSAID-induced ulcers. Treatment takes about 2 - 6 weeks. Proton-pump inhibitors are the most effective drugs. Others that may be beneficial include sucralfate or H2 blockers, such as famotidine (Pepcid AC), cimetidine (Tagamet), ranitidine (Zantac).

Coxibs inhibit an inflammation-promoting enzyme called COX-2. This drug class was initially thought to provide benefits equal to NSAIDs but cause less gastrointestinal distress. However, following numerous reports of cardiovascular events, as well as skin rashes and other adverse effects, the FDA has been re-evaluating the relative risks and benefits of this drug class. Rofecoxib (Vioxx) and valdecoxib (Bextra) have been withdrawn from the United States market. Celecoxib (Celebrex) is still available, but patients should discuss with their doctors whether this drug is appropriate and safe for them.

A newer COX-2 inhibitor, etoricoxib (Arcoxia) is approved in 60 countries but not the United States. A 2006 Lancet study indicated that etoricoxib is similar to the NSAID diclofenac in risks for heart attack and stroke. (However, diclofenac has already been shown to have a higher risk of heart attack than any other NSAID, so some experts do not find this study result reassuring.) Etoricoxib caused more high blood pressure and fluid retention (edema) than diclofenac. Etoricoxib appeared to pose a lower risk than diclofenac for uncomplicated upper gastrointestinal problems, (obstruction, perforation, bleeding, ulcers), but there was little difference between the two drugs for more serious gastrointestinal complications. In 2007, the FDA rejected an application to market etoricoxib in the U.S.

Capsaicin is a component of hot red peppers and may bring pain relief when used as a skin cream (Zostrix). This is the only skin preparation that does more than just mask pain or reduce it temporarily. Capsaicin seems to reduce a substance in the body, known as substance P, which contributes both to inflammation and the delivery of pain impulses from the central nervous system. A small amount of capsaicin must be applied to the area of inflammation about four times a day. During the first few days of use, the patient will experience a warm, stinging sensation when the cream is applied. This sensation goes away, and pain relief usually begins within 1 - 2 weeks.

Tramadol (Ultram) is a pain reliever that has been used as an alternative to opioids. It has opioid-like properties but is not as addictive. (Dependence and abuse have been reported, however.) It can cause nausea but does not cause severe gastrointestinal problems, as NSAIDs can. Some patients experience severe itching. A combination of tramadol and acetaminophen (Ultracet) is now available and provides more rapid pain relief than tramadol alone with more long-lasting benefits than acetaminophen. Side effects are the same as for each of these drugs.

Narcotics, pain-relieving and sleep-inducing drugs that act on the central nervous system, are the most powerful medications available for the management of moderate to severe pain. There are two types of narcotics:

Opiates, which are derived from natural opium (morphine and codeine).
Opioids, which are synthetic drugs. They include oxycodone (Percodan, Percocet, Roxicodone, Oxycontin), hydrocodone (Vicodin), oxymorphone (Numorphan), and fentanyl (Duragesic).

Although the use of narcotics for arthritic pain is controversial, many studies have suggested that they are rarely addictive for pain sufferers except among patients with a history of substance abuse. Some experts believe that opioids have a place in osteoarthritis treatment when milder drugs are not effective or appropriate. For example, a 2006 study suggested that a fentanyl skin patch may offer pain relief and improved function to some patients with severe knee or hip osteoarthritis who have not been helped by, or who cannot tolerate, NSAIDs or weaker opioids.

The use of such drugs may be beneficial when included as part of a comprehensive pain management program. Such a program involves screening prospective patients for possible drug abuse and then regularly monitoring those who are taking it, adjusting the dose as necessary to achieve an acceptable balance between pain relief and side effects. Common side effects include anxiety, constipation, nausea and vomiting, dizziness, drowsiness, paranoia, urinary retention, restlessness, and labored or slow breathing. Unfortunately, opioid abuse among young people is a major concern.

When pain becomes a major problem and less potent pain relievers are ineffective, doctors may resort to corticosteroid (steroid) injections, usually by administering a shot into the affected joint every 3 months. Corticosteroid shots are useful only if inflammation is present in the joint. Relief from pain and inflammation is of short duration, and this treatment is rarely used for chronic osteoarthritis. These drugs may not be as effective for women as for men.

Corticosteroids mask pain, and the patient must be very careful to avoid over-use of the affected joints. Patients are usually advised not to have more than two or three injections a year, since there is some concern that repeated injections over the long term may be harmful. A reassuring study found no greater disease progression in people who had injections every 3 months for 2 years compared to those who were given sham injections on the same schedule. Because long-term use of corticosteroids has many potentially serious side effects, steroid medications are never given orally or systemically for the treatment of osteoarthritis.

Injections of hyaluronic acid (Hyalgan, Synvisc, Artzal, Nuflexxa) into the joint -- a procedure called viscosupplementation -- is now recommended as one of the treatments for osteoarthritis. Hyaluronic acid is a naturally occurring substance in joints that acts as a lubricant for slow movements and a shock absorber for fast motions. In high amounts, it also may have anti-inflammatory effects.

Patients receive a series of three to five injections once a week.
The drug is injected into the joint.
A health care worker will apply local anesthetic because these viscous (sticky) injections require a large needle.
Patients need to avoid weight-bearing activities for about 48 hours after each shot.

Hyaluronic injections appear to be about as effective as NSAIDs and corticosteroid injections for relieving pain, at least in men, and they have no adverse effects in the stomach or intestines. One study reported that between 39 - 56% of patients were at least nearly free of weight-bearing pain up to 24 weeks after the final injection. In another study, response was judged better or much better for 87% of knees after a second course, which was administered about 8 months later. Nevertheless, a number of studies on viscosupplementation have shown little or no benefits, particularly in women, and more research is needed to determine if they are useful. Injections are also expensive. Accurate placement of the needle directly into the knee joint space is important and may be difficult, even for experienced doctors, if there is no fluid build-up in the joint. Best success rates are with a specific approach into the kneecap called the lateral midpatellar.

Side Effects. Serious adverse reactions are rare. The most common side effects, pain at the injection site and knee pain and swelling, are usually mild and temporary. More research is needed to confirm benefits and long-term risks.

Researchers are studying various drugs that may provide pain relief or stop the disease process itself:

Bisphosphonates such as alendronate (Fosamax) and risedronate (Actonel) help prevent bone loss in people with osteoporosis. They are currently being investigated for osteoarthritis as well. A 2005 study reported that risedronate may delay joint destruction in patients with knee osteoarthritis.
Lidocaine, a local anesthetic, is available in patch form (Lidoderm) and has been used specifically for herpes zoster pain. Early studies indicate that it may provide significant pain relief for osteoarthritis.
Tetracycline antibiotics, such as doxycycline, may have a role to play in treating osteoarthritis. At low concentrations, the drug reduces the production of collagenases, which are enzymes critical to disease development and progression. Initial results from clinical trials suggest that doxycycline may help delay joint space narrowing.
Licofelone is a drug that inhibits both the COX enzyme plus an inflammatory substance called lipoxygenase 5. Early trials indicate it may be effective and safer than either NSAIDs or COX-2 inhibitors.
Diacerein inhibits an inflammatory substance in arthritic joints called interleukin-1b. It has shown promise in clinical trials. A 2006 review indicated that diacerein may be slightly better than NSAIDs for pain relief.
Botulinum toxin type A (Botox) injections may provide sustained pain relief for patients with knee osteoarthritis according to research presented at the 2006 American College of Rheumatology annual meeting.
Nitric oxide increases blood flow in the mucous lining and secretions of mucus and bicarbonate. Combining nitric oxide with NSAIDs may reduce the adverse effects on the gastrointestinal tract.
Trials of gene therapies that either fight joint degradation or strengthen cartilage are in very early stages.

Alternative and Complementary Medicine

Glucosamine hydrochloride and chondroitin sulfate are natural substances that are part of the building blocks found in and around cartilage. Extracts have been used in Europe for more than a decade to reduce pain and improve mobility in patients with osteoarthritis. For many years, researchers in the U.S. have been studying whether these dietary supplements really work for relieving osteoarthritis pain.

In 2006, the New England Journal of Medicine published the results from a major trial sponsored by the U.S. National Institutes of Health. Researchers compared the effects of glucosamine and chondroitin, alone and in combination, with the COX-2 inhibitor celecoxib (Celebrex) in nearly 1,600 patients with knee osteoarthritis. The dietary supplements were also compared with placebo (an inactive substance). Patients took the assigned substance once a day for 6 months.

The results indicated that, for most patients, neither glucosamine nor chondroitin were better than placebo in relieving knee pain. However, for patients with moderate-to-severe pain, a combination of glucosamine and chondroitin was significantly more effective than the other remedies. Celebrex worked best for patients with mild pain.

The next stage of the study will evaluate whether glucosamine and chondroitin, alone and in combination, can halt the progression of knee osteoarthritis.

Research presented at the 2006 American College of Rheumatology annual meeting suggested that chondroitin may prevent joint narrowing in patients with knee osteoarthritis.

Dosage. There are no current standard recommended dosages. Patients in the GAIT trial took 1,500 mg of glucosamine and 1,200 mg of chondroitin.

Side Effects. The safety records of both substances appear excellent. Long-term effects are still unknown, but studies of up to 3 years have reported no significant side effects. However, there are some concerns that glucosamine may affect insulin and blood sugar (glucose) metabolism. Patients with diabetes should not take glucosamine without first talking to their doctors.

Oral Enzymes. People in Europe have used natural enzymes -- including bromelain, trypsin, papain, and rutin -- to treat arthritic pain. Such enzymes have been marketed alone and in combinations (Wobenzym, Phlogenzym). They are not painkillers, and any benefits derived from them may take several weeks.

Ginger (Zingiberaceae). A 2001 study of patients with knee arthritis found that an extract of ginger reduced pain while standing and after walking. By using ginger, patients were able to reduce their pain medications after 6 weeks. Side effects included mild digestive upset.

S-adenosylmethionine (SAMe). S-adenosylmethionine (SAMe, pronounced "Sammy") is a synthetic form of a natural byproduct of the amino acid methionine. It has been marketed as a remedy for both depression and arthritis. Some research suggests that it may work as well as NSAIDs for short-term treatment of osteoarthritis. Other studies suggest that it may help rebuild damaged cartilage.

Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been several reported cases of serious and even lethal side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.

Acupuncture is being increasingly used to reduce osteoarthritis pain. The technique is painless and involves the insertion of small fine needles at select points in the body. Several study reviews have found that acupuncture provides at least short-term pain relief for osteoarthritis of the knee. Other studies have suggested that acupuncture’s benefits are mainly due to a strong placebo effect, or to the psychologically beneficial effects of close contact with health care providers.

In 2004, researchers published results from an important clinical trial that studied the effects of acupuncture on nearly 600 people with osteoarthritis of the knee. The results indicated that acupuncture can relieve pain and improve function. Several 2006 studies of thousands of patients with chronic osteoarthritis pain compared acupuncture to conventional treatment (physical therapy, anti-inflammatory drugs). These studies showed positive results and suggested that acupuncture’s benefits may be sustained for up to 6 months after treatment. In any case, acupuncture appears to be a safe and beneficial addition to standard therapy for certain patients, such as pregnant women, who cannot take most pain medications.

Acupuncture, hypnosis, and biofeedback are all alternative ways to control pain. Acupuncture involves the insertion of tiny sterile needles, slightly thicker than a human hair, at specific points on the body.

Transcutaneous electric nerve stimulation (TENS) uses low-level electrical pulses to suppress pain. Patients are barely aware of the sensation. According to one study, the optimal treatment length is 40 minutes. A variant (sometimes called percutaneous electrical nerve stimulation, or PENS) applies these pulses through a small needle to acupuncture points. A review of trials reported that both methods were better than placebo (sham treatments) in treating osteoarthritis of the knee, although additional well-designed studies are needed.

Low-level laser therapy (LLLT) generates extremely pure light in a single wavelength. It does not produce heat and is painless. Some researchers are combining LLLT with transcutaneous electric nerve stimulation (TENS). Studies report widely varying results, with some showing significant reductions in pain and others reporting no effect. The differences may be due to different approaches, and standardized methods are needed to determine any benefits.

Hydrotherapy, also called spa therapy or balneotherapy, is an ancient therapy that uses bathing in mineral baths for soothing pain. Although many studies report positive results, including improved quality of life, very few have been rigorously conducted. A major analysis reported weak evidence on any real effect on pain or quality of life, but some patients may find comfort from this pleasant therapy.

Surgery

Different surgical procedures are available as a final measure to relieve pain and increase function in patients with osteoarthritis. Certain surgical procedures can help relieve pain if medications fail. Even with these procedures, however, joint replacement may still be needed later on.

Arthroscopy is performed to clean out bone and cartilage fragments that, in theory at least, may cause pain and inflammation. More than 650,000 of these procedures are done on arthritic knees each year in the U.S., and about half of patients report less pain after the procedure.

A rigorous 2002 trial, however, found that arthroscopic knee surgery was no more effective than sham surgery, (in which surgeons only pretended to operate on the knee), for relief of osteoarthritic pain or stiffness. The study, which followed patients at a Veterans Affairs hospital for 2 years, has called into serious question whether the popular procedure has any real benefits for osteoarthritis beyond what might be achieved by a placebo response. Research and debate continues on whether arthroscopy provides true benefits for those with osteoarthritis and, if so, which patients it may most help.

Click the icon to see an illustrated series detailing knee arthroscopy surgery.

When osteoarthritis becomes so severe that pain and immobility make normal functioning impossible, many people become candidates for artificial (prosthetic) joint implants using a procedure called arthroplasty. Hip replacement is the most established and successful replacement procedure, followed by knee replacement. Knee replacement, in fact, has a slightly better long-term success rate than hip replacement. Other joint surgeries (shoulders, elbows, wrists, fingers) are less common, and some arthritic joints (in the spine, for instance) cannot yet be treated in this manner. When two joints, such as both knees, need to be replaced, having the operations done sequentially rather than at the same time may result in fewer complications.

Click the icon to see an illustrated series detailing knee joint replacement surgery.

Candidates. The primary indications for surgery are pain and significant limitations of movement, including walking, that cannot be treated by less invasive therapies. Some experts suggest, however, that joint replacement should be considered earlier rather than as a last resort. They argue that patients who wait until they are severely disabled do not recover as completely as those who have the procedure earlier.

Patients who may not be good candidates are those with the following conditions:

Severe neurologic, emotional, or mental disorders
Severe osteoporosis
Other chronic medical conditions
Obesity

Surgeons often prefer to delay prosthetic implantation in younger patients, because implants wear out and they will require at least one revision procedure later on. Newer, more long-lasting materials, however, may help reduce the rate of re-operations.

Procedure Description. Although the following is mostly a description of hip replacement surgery, the principles are similar for other arthroplasties.

The surgeon removes the ball and socket joint that joins the pelvis and thigh bone (femur) and replaces it with an artificial joint (a prosthesis). It is composed of two pieces:

A cup-like device fits in the hip socket (called the acetabula), which has been hollowed out. This ball-and-socket cup is positioned to form the new joint.
A metal shaft, or stem, with a polished metal ball at the top, is inserted into the narrow center of the femur.

The prosthesis is usually made of a metal alloy and plastic. A ceramic implant may prove to last longer than other materials and be a safe option for younger patients.

There are different options available for attaching it to the adjoining bones:

A cement made of polymethylmethacrylate (usually preferred for older patients who generally have thinner bones).
So-called cementless implants, in which the prosthesis is coated with a porous material that allows bone to grow into and eventually adhere to the device. These implants are usually used for patients younger than age 65, who are likely to need repeat surgery in their lifetime.

Click the icon to see an illustrated series detailing hip joint replacement surgery.

Complications. Complications can occur, and, although uncommon, some can be life-threatening. There is a 1% chance of death within 3 months of an initial procedure and a 2.6% risk after a repeat procedure. The risks are highest in the first 3 months. Those at highest risks for complications are elderly adults, men (compared to women), African-Americans, and those with serious medical conditions.

Specific complications include the following:

Deep blood clots (known as deep vein thrombosis) and pulmonary embolism. Deep blood clots can develop in the legs after this surgery. This poses a very small risk (0.9%) for pulmonary embolism -- a dangerous condition in which the clot travels to the lungs. Anticoagulants (blood thinners) are important for preventing blood clots. These drugs include warfarin and low-molecular weight heparin. Anticoagulant therapy is given during the hospital stay and continued for several weeks at home. The patient also wears specially fitted elastic stockings to help prevent clots. Patients who are overweight are at higher than average risk for post-operative blood clots
Infection. Wound infection occurs in about 0.2% of joint replacements and requires prompt removal of the implant to treat the infection. A new prosthesis must be re-implanted at a later time. Any pre-existing infection must be treated and cured before surgery is performed. (Older women should be aware of urinary tract infections, which may require postponing surgery.) After surgery, patients should take certain precautions. For example, they should take antibiotics before invasive dental procedures or other surgery because bacteria can be introduced into the bloodstream and infect the areas around the artificial joints.
Hip dislocation. Occurs in about 3.1% of first hip procedures. The rate is much higher (14.4%) in revision operations.

Click the icon to see an image of a dislocated hip.

Pain. Thigh pain can occur after hip replacement. Porous hip prostheses are more likely to produce thigh pain than cement implants, although advanced techniques using a tapered shaft are reducing this complication.
Failure. The primary reason for implant failure is osteolysis (bone destruction) caused by long-term wear. The main source of wear is from tiny particles released from the prosthesis.
Other complications. These include uneven leg lengths, nerve damage that can cause numbness or weakness, urinary tract infections, delayed healing, and allergic reactions to the metal. Long-term, there have been rare reports of a possible autoimmune response, in which loose particles released from the prosthetic device trick certain immune system factors into attacking healthy cells. Any incidence of unexplained weight loss and fatigue may be symptoms of this uncommon event.

Rehabilitation. Aside from the surgeon's skill and the patient's underlying condition, the success rate depends on the kind and degree of activity the joint receives following replacement surgery.

The patient is urged and aided into getting out of bed and walking the day after surgery. Most hip replacement patients leave the hospital within a week and can walk with crutches within 2 - 4 weeks, recovering fully in about 3 months.

Physical therapy takes about 6 weeks to rebuild adjoining muscle and strengthen surrounding ligaments. Studies suggest that an exercise program started before surgery and resumed afterward can improve recovery. Continuous passive motion (CPM) is an effective regimen for knee replacement patients. It uses a mechanical device that slowly moves the joint through an arc of motion for an extended period of time. It is used to prevent scar tissue from developing. In one review, a combination of physical therapy and CPM were more beneficial than physical therapy alone.

Limitations After Surgery. While many patients find that joint replacement provides remarkable pain relief and restores some mobility, they need time to adjust to the artificial joint.

Limitations after hip surgery include:

Usually patients with new hips are able to walk several miles a day and climb stairs, but they cannot run.
Prosthetic hips should not be flexed beyond 90 degrees, so patients must learn new ways to perform activities requiring bending down (like tying a shoe).

Limitations after knee surgery include:

Walking distance improves in 80% of patients after knee replacement surgery, but patients still cannot run.
Only slightly more than half of patients report improvement in stair climbing. (Artificial knee joints generally have a range of motion of just 110 degrees.)

Failure Rates. Infection is a major cause of early failure and always requires revision. Improper balancing of the ligaments and other tissues surrounding the joint and resulting poor joint stability is also a common reason for failure of arthroplasties. Surgical expertise is important for avoiding this complication.

Older cement prostheses have a particularly high rate of bone loss and loosening due to cement deterioration. In general, studies report reoperation rates of over 30% after 10 years. Fortunately, advances in cement and prosthetic implants are improving the implant survival rates and reducing the need for revision procedures.

Uncemented arthroplasty using porous material has shown good results for the hip, although it may be less successful for knee replacement. In spite of short-term success, longer experience with this method suggests it may not be superior to cement prostheses. Failure of bone to grow into the porous material is a relatively common event, a problem that does not occur with cement prostheses. Some experts recommend cement implants over cementless ones for total knee arthroplasty.

A repair procedure called arthroplasty revision may be used in cases where the original transplant fails. The specific procedure depends on whether the bone defects that occurred are contained or uncontained.

Contained defects can be repaired with small bone grafts, the use of cement, or oversized cementless implants as required.
Uncontained defects are more severe and may require a large bone graft or specially constructed implants to restore bone.

If a second arthroplasty is required, the potential for complications is magnified: more bone is cut, more blood is lost, and the operation takes longer. Patients are also generally older and more vulnerable to complications.

Resection Arthroplasty. In resection arthroplasty, a false joint of scar tissue is created. This procedure is used most often in treating arthritis of the foot.

Osteotomy. If only a certain section (the medial compartment) of the knee is damaged and deformed by osteoarthritis, the surgeon may choose to perform osteotomy:

A surgeon opens the knee.
The surgeon performs a debridement (removal of damaged tissue) in the joint to eliminate the loose or torn fragments that are causing pain and inflammation.
The bone is then reshaped to remove the deformity.
The procedure may ease symptoms and slow disease progression. It is best used in heavier adults who are under 60 years old.

Hemicallotasis. Hemicallotasis is a procedure for the knee that may be a less invasive alternative to osteotomy. The surgeon attaches the knee with pins to an external frame-like device that lengthens the deformed part of the knee over several weeks. The patient is mobile during this period. Infections at the pin site are the most common complications.

Arthrodesis. If the affected joint cannot be replaced, surgeons can perform a procedure called arthrodesis that eliminates pain by fusing the bones together. The patient must understand, however, that fusing the bones makes movement of the joint impossible. Bone fusion is most often done in the spine and in the small joints of the hands and feet.

Unicompartmental Knee Arthroplasty. Unicompartmental knee arthroplasty (also called unicondylar knee arthroplasty) may be a useful procedure in cases of limited knee damage. It is recommended for relatively sedentary patients who are 60 years or older and not obese. It may relieve pain and delay the need for a total knee replacement. The procedure involves a small incision and insertion of small implants. It retains important knee ligaments, which preserve more movement than a total knee replacement.

Cartilage Transplants. Autologous chondrocyte implantation, also called chondroplasty or the Carticel approach, is used for knees damaged by injuries. In this procedure, arthroscopy is used to first remove cartilage in eroded areas. The results have been good to excellent, although long-term benefits are questionable. Whether it has any benefit for older patients with osteoarthritis is not yet known. Other cartilage transplant procedures are also under study.

Hip Resurfacing. Hip resurfacing is a surgical alternative to total hip replacement. It involves scraping the surfaces of the hip joint and femur and placing a metal cap over the bone. The procedure preserves much of the bone, so that a standard hip replacement can be done years later if needed. It may provide more stability, a faster recovery, and greater range of motion, making it a potentially good option for young, physically active patients.

Resources

www.rheumatology.org -- American College of Rheumatology
www.arthritis.org -- Arthritis Foundation
www.niams.nih.gov -- National Institute of Arthritis and Musculoskeletal and Skin Diseases
www.aaos.org -- American Academy of Orthopaedic Surgeons
www.fda.gov/cder/drug/infopage/cox2 -- FDA NSAID and COX-2 Inhibitor Information

References

Bjordal JM, Klovning A, Ljunggren AE, Slordal L. Short-term efficacy of pharmacotherapeutic interventions in osteoarthritic knee pain: A meta-analysis of randomised placebo-controlled trials. Eur J Pain. 2007 Feb;11(2):125-38.

Cannon CP, Curtis SP, FitzGerald GA, Krum H, Kaur A, Bolognese JA, et al. Cardiovascular outcomes with etoricoxib and diclofenac in patients with osteoarthritis and rheumatoid arthritis in the Multinational Etoricoxib and Diclofenac Arthritis Long-term (MEDAL) programme: a randomised comparison. Lancet. 2006 Nov 18;368(9549):1771-81.

Chou R, Helfland M, Peterson K, Dana T, Roberts C. Comparative Effectiveness and Safety of Analgesics for Osteoarthritis. Comparative Effectiveness Review No. 4. (Prepared by the Oregon Evidence-based Practice Center under Contract No. 290-02-0024.) Rockville, MD: Agency for Healthcare Quality and Research. September 2006.

Felson DT, Niu J, Clancy M, Sack B, Aliabadi P, Zhang Y. Effect of recreational physical activities on the development of knee osteoarthritis in older adults of different weights: the Framingham Study. Arthritis Rheum. 2007 Feb 15;57(1):6-12.

Laine L, Curtis SP, Cryer B, Kaur A, Cannon CP; MEDAL Steering Committee. Assessment of upper gastrointestinal safety of etoricoxib and diclofenac in patients with osteoarthritis and rheumatoid arthritis in the Multinational Etoricoxib and Diclofenac Arthritis Long-term (MEDAL) programme: a randomized comparison. Lancet. 2007 Feb 10;369(9560):465-73.

Langford R, McKenna F, Ratcliffe S, Vojtassak J, Richarz U. Transdermal fentanyl for improvement of pain and functioning in osteoarthritis: a randomized, placebo-controlled trial. Arthritis Rheum. 2006 Jun;54(6):1829-37.

McGettigan P, Henry D. Cardiovascular risk and inhibition of cyclooxygenase: a systematic review of the observational studies of selective and nonselective inhibitors of cyclooxygenase2. JAMA. 2006 Oct 4;296(13):1633-44.

Rintelen B, Neumann K, Leeb BF. A meta-analysis of controlled clinical studies with diacerein in the treatment of osteoarthritis. Arch Intern Med. 2006 Sep 25;166(17):1899-906.

Scharf HP, Mansmann U, Streitberger K, Witte S, Kramer J, Maier C, et al. Acupuncture and knee osteoarthritis: a three-armed randomized trial. Ann Intern Med. 2006 Jul 4;145(1):12-20.

Witt CM, Jena S, Brinkhaus B, Liecker B, Wegscheider K, Willich SN. Acupuncture in patients with osteoarthritis of the knee or hip: a randomized, controlled trial with an additional nonrandomized arm. Arthritis Rheum. 2006 Nov;54(11):3485-93.

Review Date:
3/19/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M. Copyright

adam.com

Gear Review: Polar FT40

FitSugar — Wed, 05 Nov 2008 10:00:00 -0800

The folks over at Polar recently sent me a few watches to test out. First up: the FT40 ($160, including chest strap). Being a woman, I was immediately drawn to its great color and design; it's much cooler than my other heart rate monitors of the past. I have even gotten compliments on it outside of the gym (big brownie points there).

The heart rate monitor does all the normal stuff that an average heart rate monitor does, such as showing your heart rate, calories burned, time, stopwatch, etc., but there are a few goodies that this watch also provides. The EnergyPointer calculates the point where training is turning fat-burning into fitness improvement. It also has a fitness test feature, which is able to measures your aerobic fitness at rest in just five minutes. Both features are very useful for someone who is looking to improve their own fitness without hiring an actual personal trainer.

With this watch, you can also upload all your workout information using a Flowlink (sold separately), which transfers data between the watch and PolarPersonalTrainer.com - a free site that allows you to track your workouts and progress and gives you access to helpful training tips and tools. My only complaint is that the software for the Flowlink is not Mac compatible as of yet. But all in all, I love this watch. It's easy to use and provides great information, making me focus on my workouts so I can fine-tune my training.

Sleep apnea

FitSugar — Wed, 08 Oct 2008 17:35:30 -0700

In This Report

Highlights
Introduction
Symptoms
Causes
Risk Factors
Prognosis
Diagnosis
Lifestyle Changes
Treatment
Dental Devices
Surgery
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Sleep Apnea and Heart Attack

Obstructive sleep apnea can increase the risk of heart attack by as much as 30% over the course of 5 years, suggests a study presented at the 2007 American Thoracic Society International Conference. Researchers noted that the risk of developing or dying from heart disease rises with increasing sleep apnea severity.

Sleep Apnea and Diabetes

Obstructive sleep apnea may increase the risk of developing type 2 diabetes, indicates research presented at the American Thoracic Society conference. Patients who had severe obstructive sleep apnea had more than 2.5 times the risk of developing diabetes as those who did not suffer from nighttime breathing problems.
Sleep apnea may also increase the risk for women developing diabetes during pregnancy (gestational diabetes). Pregnancy-associated high blood pressure is also linked with sleep apnea.

Sleep Apnea and Depression

As sleep apnea worsens, the odds for developing depression increase, indicates a 2006 study in the Archives of Internal Medicine.

Continuous Positive Airway Pressure (CPAP)

CPAP is the best treatment for severe sleep apnea. However, according to a 2007 study in Sleep, most patients need to use it for a full night’s duration to achieve optimal benefits. The researchers noted that many patients experience some improvement in daytime sleepiness after 4 - 6 nightly hours of CPAP use, but that the best improvements in quality of life occur mostly after 7.5 hours of CPAP use each night.

Risk Factors for Sleep Apnea Surgery

According to a 2006 study in the Archives of Otolaryngology - Head & Neck Surgery, the risks for complications following uvulopalatopharyngoplasty (UPPP) increase with:

Severity of sleep apnea
Being overweight (higher body mass index)
Having other medical conditions in addition to sleep apnea
Undergoing other surgical procedures at the same time as UPPP

Introduction

Sleep apnea is a disorder in which a person stops breathing during the night, perhaps hundreds of times, usually for periods of 10 seconds or longer and sometimes for as long as a minute. These gaps in breathing are called apneas. The word apnea means absence of breath.

Sleep apnea is usually accompanied by snoring. People might not even know they have the condition. It inevitably causes daytime sleepiness.

Sleep apnea is grouped into three categories:

Obstructive
Central
Mixed

There is also another, less severe form of obstructed breathing, called upper airway resistance syndrome (UARS).

Obstructive sleep apnea (OSA) is the most common form of apnea. It occurs when tissues in the upper throat collapse at different times during sleep, thereby blocking the passage of air. In general, OSA occurs as follows:

On its way to the lungs, air passes through the nose, mouth, and throat (the upper airway).
Under normal conditions, the back of the throat is soft and tends to collapse inward as a person breathes.
Dilator (widening) muscles work against this collapse to keep the airway open. Interference or abnormalities in this process cause air turbulence.
If the tissues at the back of the throat collapse and become momentarily blocked, apnea occurs. Breath is temporarily stopped. In most cases the person is unaware of it, although sometimes they awaken and gasp for breath.
In some cases, the interference is incomplete (called obstructive hypopnea) and causes continuous but slow and shallow breathing. In response, the throat vibrates and makes the sound of snoring. Snoring can occur whether a person breathes through the mouth or the nose. (Snoring also occurs without sleep apnea.)
Apnea decreases the amount of oxygen in the blood, and eventually this lack of oxygen triggers the lungs to suck in air.
At this point, the patient may make a gasping or snorting sound but does not usually fully wake up.

Obstructive sleep apnea is defined as five or more episodes of apnea or hypopnea per hour of sleep in individuals who have excessive daytime sleepiness.

Central sleep apnea is much less common. It is caused by some problem in the central nervous system, most likely a failure of the brain to signal the airway muscles to breathe. In such cases, oxygen levels drop abruptly and usually the sleeper wakes with a start. Often people with central sleep apnea recall waking up. They generally experience less sleepiness during the day than people with obstructive sleep apnea. Heart disease, and in particular heart failure, is the most common cause of central sleep apnea.

Mixed apnea is the term used when the two apneas occur together.

Upper airway resistance syndrome (UARS) is a condition in which patients snore, wake frequently during the night, and have excessive daytime sleepiness. However, UARS patients do not have the breathing abnormalities that characterize sleep apnea and they do not show a reduction in blood oxygen levels. Unlike apnea, UARS is more likely to occur in women than in men. Treatments are similar to those of sleep apnea. It is not known if UARS has any serious health complications.

In sleep studies, subjects spend about one-third of their time asleep, suggesting that most people need about 8 hours of sleep each day. Individual adults differ in the amount of sleep they need to feel well rested, however. Infants may sleep up to 16 hours a day.

The daily cycle of sleeping and waking is called the circadian rhythm. It's commonly referred to as the biologic clock. Circadian means "about a day." Hundreds of bodily functions follow biologic clocks, but sleeping and waking comprise the most prominent circadian rhythm. The sleeping and waking cycle is approximately 24 hours. (People who are confined to windowless homes, with no clocks or other time cues, sleep and wake on a slightly longer cycle.) The 24-hour circadian rhythm typically adheres to the following factors:

Humans are designed for daytime activity and nighttime rest.
There is a natural peak in sleepiness at mid-day, the traditional siesta time.

In addition, daily rhythms mix with other factors that may interfere or change individual patterns:

The firing of nerve cells in the brain may be faster or slower in different individuals.
The monthly menstrual cycle in women can shift the pattern.
Light signals coming through the eyes reset the circadian cycles each day, so changes in season or various exposures to light and dark can unsettle the pattern. The importance of sunlight as a cue for circadian rhythms is dramatized by the problems experienced by people who are totally blind. They commonly suffer trouble sleeping and other rhythm disruptions.

The Response in the Brain to Light Signals

The response to light signals in the brain is an important key factor in sleep:

Light signals travel to a tiny cluster of nerves in the hypothalamus in the center of the brain, the body's master clock, which is called the supra chiasmatic nucleus or SCN.
This nerve cluster takes its name from its location. It sits just above (supra) the optic chiasm, a major junction for nerves transmitting information about light from the eyes.
The approach of dusk each day prompts the SCN to signal the nearby pineal gland to produce the hormone melatonin.
Melatonin is thought to act as the body's time-setting hormone. The longer a person is in darkness the longer the duration of melatonin secretion. Secretion can be diminished by staying in bright light. Melatonin also appears to trigger the need to sleep.

Sleep Cycles

Sleep consists of two distinct states that alternate in cycles and reflect differing levels of brain nerve cell activity:

Non-Rapid Eye Movement Sleep (NonREM). NonREM sleep is also termed quiet sleep. NonREM is further subdivided into three stages of progression:

Stage 1 (light sleep)
Stage 2 (so-called true sleep)
Stage 3 to 4 (deep "slow-wave" or delta sleep)

With each descending stage, awakening becomes more difficult. It is not known what governs NonREM sleep in the brain. A balance between certain hormones, particularly growth and stress hormones, may be important for deep sleep.

Rapid Eye-Movement Sleep (REM). REM sleep is termed active sleep. Most vivid dreams occur in REM sleep. REM-sleep brain activity is comparable to that in waking, but the muscles are virtually paralyzed, possibly preventing people from acting out their dreams. In fact, except for vital organs like lungs and heart, the only muscles not paralyzed during REM are the eye muscles. REM sleep may be critical for learning and for day-to-day mood regulation. When people are sleep-deprived, their brains must work harder than when they are well rested.

The REM/NREM Cycle. The cycle between quiet (NonREM) and active (REM) sleep generally follows this pattern:

After about 90 minutes of NonREM sleep, eyes move rapidly behind closed lids, giving rise to REM sleep.
As sleep progresses the NonREM/REM cycle repeats.
With each cycle, NonREM sleep becomes progressively lighter, and REM sleep becomes progressively longer, lasting from a few minutes early in sleep to perhaps an hour at the end of the sleep episode.

Symptoms

People with sleep apnea usually do not remember waking during the night.

Symptoms may include:

Excessive daytime sleepiness
Morning headaches
Irritability and impaired mental or emotional functioning
Snoring (bed partners may report very loud and interrupted snoring)
Heartburn (acid back-up that causes heartburn may be responsible for some cases of sleep apnea)

Sleep apnea occurs in about 2% of children. They may have symptoms that differ from adults, including:

Longer total sleep time than normal in some children, especially obese children or those with severe apnea.
Snoring. (An estimated 3 - 12% of all children snore. However, not all of them have sleep apnea.)
More effort in breathing (flaring nostrils, heaving chests, sweating). The chest may have an inward motion during sleep.
Behavioral difficulties without any obvious cause, such as hyperactivity and inattention. (Some patients may even be misdiagnosed with attention-deficit hyperactivity disorder.)
Irritability
Bed-wetting
Morning headaches
Failure to grow and gain weight

Causes

Any structural abnormality in the face, skull, or airways that causes some obstruction or collapse in the upper airways and reduces air pressure can produce sleep apnea syndrome. Abnormalities in tissues that lie between the back of the mouth and the esophagus (food pipe) are one of the most common structural causes of sleep apnea. Enlarged soft palates (the base of the tongue and surrounding throat walls) are also associated with many cases of sleep apnea.

Researchers have identified several physiologic abnormalities that may play a role in causing sleep apnea or in making it worse. These include an inability to regulate levels of carbon dioxide, impaired brain and nervous system responsiveness to various chemical messengers, and poor reflexes or muscle tone in the upper airways. The underlying reasons for these disturbances and their connection to apnea require further study.

Obesity is strongly associated with sleep apnea and is a cause of it in some cases. Imaging scans have shown fatty cells clogging the throat tissue, which indicates that they narrow the airways. In one study, the more obese a person with sleep apnea was, the higher the pressure on the airway and therefore the greater the obstruction of the airway. (Obstructive sleep apnea may also contribute to obesity itself, however, since a sleepy person tends to be sedentary.)

Snoring. Chronic snoring itself may actually be a cause of sleep apnea. Over time, the vibrations and the increased pressure against the upper airways as snoring people inhale may cause the soft palate to lengthen. This stretched palate is more prone to collapse and obstruction.

It should be stressed that snoring is very common. Snoring occurs in about a third of the population, while apnea, according to one study, occurs in only 6%. Snoring, then, does not always cause apnea, nor is it always a sign of the respiratory disorder. Furthermore, while snoring is also associated with daytime sleepiness regardless of whether apneas are present, snoring alone does not appear to pose any major health risks.

Mouth Breathing. Some evidence suggests that a tendency to breathe through the mouth (rather than the nose) during childhood can actually produce structural changes in the face (longer face, narrow jaw, receding chin). Such facial characteristics may eventually put people at risk for sleep apnea.

Sleep apnea occurs in about 2% of children and can occur even in very young children. The most likely causes are the following:

Facial or skull abnormalities in infants.
Overgrown tonsils, adenoids, or both in small children. (Removal of tonsils or adenoids can free the airways and solve the problem.)
Premature infants also commonly have a form of apnea that may be related to lung or nervous system problems.

Risk Factors

Gender. More men than women appear to have sleep apnea. In the U.S., about 4% of men and 2% of women age 30 - 60 meet the criteria for obstructive sleep apnea. Such people have at lease five episodes of apnea or hypopnea (shallow nighttime breathing) for each hour of sleep plus excessive daytime sleepiness. A much higher percentage has just one of these two conditions.

Sleep apnea actually may be underdiagnosed in women, particularly older women. In general, older women have the same incidence of sleep apnea as men their own age. It is not clear why apnea occurs more often in men than women before menopause and why prevalence equalizes after menopause. Men tend to have larger necks and to weigh more than women and women tend to gain weight and develop larger necks after menopause. However, studies have not found that these physical factors fully explain the differences in risk by gender in young adults or the increase in sleep apnea in postmenopausal women.

Age. Sleep apnea is most common and its symptoms are worse in middle-aged adults age 40 - 60 years old. Nevertheless, it affects people of all ages.

Ethnicity. African-Americans face a higher risk for sleep apnea than any other ethnic group in the United States. Other groups at increased risk include Pacific Islanders and Mexicans.

Obesity, especially having fat around the abdomen (the so-called apple shape), is a particular risk factor for sleep apnea, even in adolescents and children. However, many people with sleep-related breathing disorders, particularly women and small children, are not obese. Also, not all people who are obese have sleep apnea. Specific anatomical and physiological properties in the airways are more likely to be present in obese individuals with apnea.

Having a Larger Neck. Having a large neck is a risk factor for sleep apnea. In fact, larger necks in men may be the primary reason for their higher risk for sleep apnea compared to women. A neck measurement of 17 inches or greater in men or at least 16 inches in women is one indicator that may suggest the condition. Postmenopausal women are more likely than younger women to have sleep apnea, in part because they tend to be heavier and have larger necks.

Specific Facial and Skull Characteristics. Structural abnormalities in the face and skull may be responsible for many cases of sleep apnea. These are likely to be the cause in many non-obese people with early-onset sleep apnea, particularly if they also have a family history of the problem.

Specific physical characteristics that may increase the risk for sleep apnea in both adults and children include:

A long lower part of the face
Brachycephaly, a birth defect in which the head tends to be shorter and wider than average
A narrow upper jaw
A receding chin
An overbite
A larger tongue

Characteristics in the Soft Palate. Some people have specific abnormalities in the soft area (palate) at the back of the mouth and throat that may lead to sleep apnea. These abnormalities include:

The soft palate is stiffer, larger than normal, or both. An enlarged soft palate may be a significant risk factor for sleep apnea.
The soft palate and the walls of the throat around it collapse easily.

Smoking. Smokers are at higher risk for apnea. Those who smoke more than two packs a day have a risk 40 times greater than nonsmokers.

Alcohol. Alcohol use has been associated with apnea, although studies are mixed. A major survey reported that 53% of people who use alcohol to help fall sleep experience symptoms of sleep apnea. Another study found no relationship.

Diabetes. Diabetes is associated with sleep apnea and snoring. It is not clear if there is an independent relationship between the two conditions or whether obesity is the only common factor.

Gastroesophageal Reflux Disease (GERD). GERD is a condition caused by acid backing up into the esophagus. It is a common cause of heartburn. GERD and sleep apnea often coincide. In one study, almost half of apnea patients had symptoms of GERD. Some experts suggest that the backup of stomach acid in GERD may produce spasms in the vocal cords (larynx), thereby blocking the flow of air to the lungs and causing apnea. Or, apnea itself may cause pressure changes that trigger GERD. Some evidence suggests that treating sleep apnea with continuous positive airway pressure (CPAP) may reduce GERD symptoms by nearly 50%. However, obesity is common in both conditions. More research is needed to clarify the association.

Polycystic Ovary Syndrome (PCOS). In a 2000 study, women with PCOS were 30 times more likely than other premenopausal women to have obstructive sleep apnea and excessive daytime sleepiness. Women with PCOS produce high amounts of male hormones, particularly testosterone, which can cause obesity, facial hair, and acne. About half of PCOS patients also have diabetes. Obesity and diabetes are both associated with sleep apnea and may be the common factors.

Chronic Problems in the Upper Airways. A 2001 Swedish study found that people with respiratory tract disorders, including asthma, chronic bronchitis, or seasonal allergies, reported symptoms of sleep apnea more often than those without any of these ailments.

Hypothyroidism. In rare cases, hypothyroidism (low thyroid) has been reported as a possible cause of sleep apnea. In such cases, treating the thyroid condition improves the sleep apnea.

Prognosis

Sleep apnea has a strong association with several diseases, particularly those related to the heart and circulation.

Researchers are intensively investigating why a problem in the upper airways is associated with serious conditions of the heart and circulatory system. Here are some of their findings:

Major known risk factors for hypertension and heart disease (obesity, smoking, and alcohol abuse) are associated with sleep apnea. These factors, however, do not explain all cases of higher heart-related risks in people with sleep apnea. For example, among overweight people, those who have sleep apneas have a greater risk of heart problems than those without them.
When breathing stops during episodes of apnea, carbon dioxide levels in the blood increase and oxygen levels drop. This effect may trigger a cascade of physical and chemical events that can then increase risk for heart problems.
Apnea also causes decreased levels of the gas nitric oxide (NO), a potent substance that causes blood vessels to be elastic and expand. NO plays a crucial role in blood pressure control and heart health.
Apnea may also increase levels of a substance called angiotensin-converting enzyme (ACE), which is known to play a role in high blood pressure and congestive heart failure.
Researchers have reported high levels of certain immune factors called tumor necrosis factor-alpha (TNF-alpha) and interleukin 6 (IL-6) in people with sleep apnea, particularly those who are obese. High levels of TNF-alpha and IL-6 produce a damaging inflammatory response, which can harm cells in the body, including those in the arteries. Elevated TNF-alpha may be associated with fatigue, shortness of breath, and a diminished heart-pumping action.

At this time, however, evidence of a clear causal relationship with any of these health problems is still weak. Some studies have found no significant independent risk for heart disease from obstructive sleep apnea. The following are some discussions on the possible effects of apnea on specific health problems.

High Blood Pressure. A number of studies have found a strong association between sleep apnea and high blood pressure (hypertension). (In the past, the link between sleep apnea and hypertension was thought to be due to obesity, a risk factor for both conditions, but more recent studies contradict that theory.) A 2000 study followed patients for 4 years; the more nightly apnea episodes they had in the first year, the more likely they were to develop hypertension by the fourth year. A weak, but still higher-than-normal, association with high blood pressure has also been observed in those who snore, wake frequently during the night, or have mild sleep apnea.

A 2004 data analysis of over 200,000 patient records revealed that people who took both antidepressants and antihypertensives were 18 times more likely to be diagnosed with obstructive sleep apnea than those who did not take the medications. The probability was highest among adults age 20 - 39 years. These drugs do not cause sleep apnea, but antidepressants may be prescribed to treat hypertensive patients’ complaints of fatigue even if sleep apnea is the real cause. The researchers recommended that patients being treated for high blood pressure, depression, and fatigue should also be evaluated for sleep apnea.

One way that apnea may directly affect blood pressure, regardless of other risk factors:

Blood pressure fluctuates widely and suddenly in response to episodes of apnea and hypopnea (shallow nighttime breathing).
Such fluctuations are possibly due to a sudden surge in the sympathetic nervous system, which controls involuntary muscle responses, importantly those in the blood vessels and heart, and may also play a role in sleep apnea.
These fluctuations lead to transient constriction of blood vessels that, over time, could possibly lead to sustained hypertension and heart damage.
Effective treatment of sleep apnea with continuous positive airway pressure (CPAP) may reduce blood pressure. Sleep apneas must be significantly reduced, however, to have any effect on blood pressure. Even a 50% reduction in apneas has no effect.

Coronary Artery Disease and Heart Attack. Sleep apnea has been associated with heart disease regardless of the presence of high blood pressure or other heart risk factors. In a 2001 study, researchers observed that the more episodes of apnea and hypopnea a patient had, the higher the risk for a heart attack.

Many of the factors associated with stroke and sleep apnea (a risk for blood clots and narrowing of the arteries) may also increase the risk for heart attacks. Research presented at the 2007 American Thoracic Society conference suggested that severe obstructive sleep apnea can increase the risk of dying from a heart attack by as much as 30% over a 4 - 5 year period. Obstructive sleep apnea, however, may have other effects that increase the risk for heart problems:

Some evidence suggests that obstructive apneas cause an increase in stiffness and inflammation in the arteries, which is now proving to be an important aspect of heart disease, particularly in older adults.
A 2002 study reported that the white blood cells of patients with apnea have an increased number of proteins called adhesion molecules on their surface that may bind to the lining of blood vessels and cause inflammation. Increasingly, scientists believe that inflammation plays an important role in the development of coronary artery disease, heart attacks, and many other major ailments.

Stroke. Sleep apnea doubles the risk for stroke. The worse the sleep apnea, the greater the risk; moderate-to-severe obstructive sleep apnea can triple the risk of stroke. Sleep apnea is also associated with high blood pressure, a known risk factor for stroke. However, people who have sleep apnea, but not high blood pressure, are also still at increased risk for stroke. Sleep apnea in stroke patients is also associated with a higher risk for worse symptoms after a stroke, including delirium, depression, poor response to speech, and difficulty conducting daily chores.

A 2000 study observed that blood becomes more viscous (stickier) in the morning in people with obstructive sleep apnea compared to people without the sleep disorder. Such "sticky" blood is more apt to form clots that can lead to strokes. To support this, another 2000 study reported that stroke victims with sleep apnea tended to have higher levels of the blood protein fibrinogen than stroke victims without sleep apnea. Fibrinogen is a factor in blood that causes it to clot. Higher levels of fibrinogen have been linked to both strokes and heart attacks.
A 1998 study reported that the carotid artery, the major artery to the brain, is in far greater danger of becoming sclerotic (hardened and narrower) in people with obstructive sleep apnea than in the average person. People with both diabetes and sleep apnea are at particularly high risk for this effect.

Heart Failure. Studies suggest that 11 - 37% of patients with heart failure also have sleep apnea. Both central and obstructive sleep apnea are linked with heart failure. The evidence for the association between heart failure and sleep apnea includes:

High blood pressure, which is associated with sleep apnea, is a major cause of later heart failure.
Sleep apnea reduces oxygen levels and causes abnormal changes in blood pressure and heart rate that add to the burden of the failing heart.
Obstructive sleep apnea can affect breathing functions that are particularly harmful for patients with existing congestive heart failure.
Sleep apnea is associated with poorer survival in patients with heart failure. Some studies have suggested that treating sleep apnea with CPAP may improve heart function in these patients. However, a 2005 New England Journal of Medicine study found that CPAP did not improve survival in patients with heart failure and central sleep apnea

Atrial Fibrillation. Sleep apnea is more common in people with atrial fibrillation (irregular heartbeat) than in patients with other heart conditions. In a 2005 study published in Circulation, 49% of patients with atrial fibrillation were at risk for developing apnea, compared with 32% of general cardiology patients. An earlier study indicated that patients with untreated obstructive sleep apnea may be at increased risk for recurrence of atrial fibrillation. Patients with atrial fibrillation who received CPAP treatment had a lower risk for recurrence.

Metabolic Syndrome. The metabolic syndrome (also called Syndrome X) is a cluster of abnormalities that cause insulin resistance. Some of these factors, including hypertension and obesity, are also associated with sleep apnea. A 2004 study found that metabolic syndrome was nine times more common among patients with obstructive sleep apnea, independent of obesity.

Diabetes. Severe obstructive sleep apnea may more than double the risk of developing type 2 diabetes. Sleep apnea also increases the risk for diabetes during pregnancy (gestational diabetes).

When it comes to sleep apnea and obesity, it is not always clear which condition is responsible for the other. For example, obesity is often a risk factor and possibly a cause of sleep apnea, but it is also likely that sleep apnea increases the risk for weight gain. Some studies indicate that sleep apnea disrupts rapid eye movement (REM) sleep, which, in turn, increases the risk for obesity. Research indicates that animals deprived of REM sleep tend to eat more. People with apnea may also become too tired to exercise and so put on weight.

Sleep apnea is associated with a higher incidence of many medical conditions, other than heart and circulation. The links between apneas and the conditions are unclear.

Pulmonary hypertension.
Asthma. Sleep apnea may worsen asthma symptoms and interfere with the effectiveness of asthma medications. Treating the apnea may help asthma control.
Kidney failure.
Peripheral nerve damage (tingling, pain, or numbness in the hands and feet).
Liver damage in obese individuals with sleep apnea. Recent research suggests that severe apnea may increase the risk of liver disease regardless of weight.
Seizures, epilepsy, and other nerve disorders. Sleep apnea appears to pose a particularly risk for nocturnal epilepsy, a condition in which seizures occur during sleep.
Headaches. Sleep disorders, including apnea, may be the underlying causes of some chronic headaches. In some patients with both chronic headaches and apnea, treating the sleep disorder has cured the headache, even the very severe and disabling form known as a cluster headache.
High-risk pregnancies. Sleep apnea causes higher rates of pregnancy complications, including gestational diabetes and high blood pressure.
Eye disorders, including glaucoma, conjunctivitis, dry eye, and various other infections and irritations. Findings presented at the 2003 annual meeting of the American Academy of Ophthalmology suggested that patients with sleep apnea may be at increased risk for glaucoma and should be tested for this eye disease. A vision-damaging condition called intracranial hypertension has also been observed in some patients with sleep apnea.

Studies report an association between severe apnea and psychological problems. In one study, 32% of patients had symptoms of depression. According to a 2006 study, the risk for depression rises with increasing severity of sleep apnea. Sleep-related breathing disorders can also worsen nightmares and post-traumatic stress disorder. Certainly, daytime sleepiness interferes with mental alertness and quality of life.

Because sleep apnea so often includes noisy snoring, the condition can also adversely affect the sleep quality of a patient's bed partner. Spouses or partners may also suffer from sleeplessness and fatigue. In some cases, the snoring can disrupt relationships. Diagnosis and treatment of sleep apnea in the patient can help eliminate these problems.

Failure to Thrive. Small children with undiagnosed sleep apnea may "fail to thrive," that is, they do not gain weight or grow at a normal rate and they have low levels of growth hormone. In severe cases, this may affect the heart and central nervous system. Most often, sleep apnea in children is caused by overgrown tonsils or adenoid. Their removal often completely solves all of these problems, including resolution of sleep apnea and restoring weight gain and normal growth hormone levels.

Attention Deficits and Hyperactivity. Problems in attention and hyperactivity are common in children with sleep apnea. There is some evidence that such children may be misdiagnosed with attention-deficit hyperactivity disorder. Snoring, rather than sleepiness, is a stronger risk factor for hyperactivity in many of these children, especially boys under 8 years old. (Even children who snore and do not have sleep apnea may be at higher risk for poor concentration.)

Some researchers believe that sleepiness associated with sleep apnea is the greatest risk factor for car accidents. As many as 200,000 automobile accidents in the U.S. and 1,500 deaths from such accidents are caused by sleepiness. Studies continue to report that drowsy driving is as risky as drunk driving. Several studies have suggested that people with sleep apnea have two to three times as many car accidents, and five to seven times the risk for multiple accidents.

Diagnosis

Not all people with suspected sleep apnea require medical tests. Expensive diagnostic efforts are probably not required for individuals who have no other health risk factors and whose suspected apnea does not affect their quality of life or safety on the road.

Doctors, however, should order diagnostic sleep studies if:

The patient has a serious medical condition that might be worsened or caused by sleep apnea. Such conditions include heart disease, high blood pressure, heart failure, diabetes, chronic headaches, epilepsy, obstructive lung disease, or severe acid reflux (GERD).
A child who shows signs of sleep apnea also has attention deficit problems or fails to thrive.
The sleep apnea is severe enough to impair quality of life, increase the risk for accidents, or both.

In some cases of an uncertain diagnosis, high-risk patients may need to consult a sleep specialist or go to a sleep disorders center. At most centers, patients undergo an in-depth analysis, usually supervised by a multi-disciplinary team of consultants who can provide both physical and psychiatric evaluations. Centers should be accredited by the American Academy of Sleep Medicine.

To help determine the presence of sleep apnea, the doctor will ask the following questions:

Is the patient taking any medications?
How many periods of sleepiness are there each day and when do they occur? (Patients with apnea often do not describe this symptom as feeling "sleepy." They are more apt to describe this feeling as "lack of energy" or "feeling tired all day.")
How restful is sleep?
Do headaches occur regularly in the morning?
Is the patient taking or withdrawing from stimulants, such as coffee or tobacco?
How much alcohol is consumed per day?
Does the patient have any problems with mental or emotional functioning?
Does the patient suffer from heartburn?
What is the normal sleeping position (back, side, or stomach)?
If there is a sleeping partner, does he or she complain about the patient's snoring or gasping for breath? (Many times it is useful to interview the bed partner.)

Keeping a Record of Sleep. To help answer these questions, the patient may need to keep a sleep diary. Every day for 2 weeks, the patient should record all sleep-related information, including responses to questions listed above described on a daily basis. Recording sleep behavior using an extended-play audio or videotape can be very helpful in diagnosing sleep apnea.

To diagnose sleep apnea, the doctor will check for physical indications of sleep apnea, including:

Abnormalities in the soft palate or upper airways, including enlarged tonsils
Upper body obesity
A wide neck measurement

Some evidence suggests that doctors may accurately identify nearly all cases of suspected sleep apnea using physical criteria, including taking measurements of body mass (the indication of obesity), neck circumference, and four areas inside the mouth.

If sleep apnea is not obvious after a physical examination and history, the doctor will need to rule out any other problems. These include sleep disorders, (such as narcolepsy, insomnia, or restless legs disorder), or any medical or psychologic conditions (chronic fatigue syndrome, depression) that may be causing daytime sleepiness.

Polysomnography is the technical term for an overnight sleep study that involves recording brain waves and other sleep-related activity. Polysomnography involves many measurements and is typically performed at a sleep center.

The patient arrives about 2 hours before bedtime without having made any changes in daily habits. Polysomnography electronically monitors the patient as he or she passes, or fails to pass, through the various sleep stages. Polysomnography tracks:

Brain waves
Body movements
Breathing
Heart rate
Eye movements

Changes in breathing and blood oxygen levels are also recorded. In patients with suspected sleep apnea, the sleep expert will track instances of apnea and hypopnea that last longer than 10 seconds. In general, if there are more than five episodes per hour, apnea is significant and if there are more than 15, the condition is serious.

Overnight polysomnography has been the gold standard for diagnosing obstructive sleep apnea in both adults and children. It is very labor-intensive and expensive, however, and also misses snoring-induced arousals. It is not always covered by health insurance, and some centers have waiting lists that are months long.

A number of portable devices are available, or are being developed, so that patients have the convenience of being monitored at home. Experts hope that such monitors eventually will replace the need for overnight sleep clinics or the need for attended monitoring at home. Limited evidence exists, however, on the accuracy of many portable monitors. Patients with serious medical conditions, including heart failure or a history of stroke or respiratory failure, should not use home tests.

The following are descriptions of some home monitoring techniques.

Home Oximetry. Pulse oximetry is a procedure that determines if oxygen levels in the blood are low. This is called hypoxia. Normal levels during the night would generally rule out sleep apnea. With this procedure, a device called a pulse oximeter is attached to the patient's finger. The oximeter transmits red and infrared light through the capillaries in the finger. Hemoglobin, a molecule in the blood that carries oxygen, absorbs part of these light waves. The ratio of the two light beams provides the measurement of oxygen. The test is not always accurate, however. A combination with polysomnography, especially heart rate measurements, may be best for diagnosing sleep apnea.

Home oximetry monitors are available to rule out sleep apnea, but their accuracy is unclear. A 2003 study indicated that home oximetry alone was not very helpful in discriminating between patients with or without sleep apnea. Home oximetry however, may be helpful in identifying patients with unsuspected and seriously low oxygen levels.

Unattended Monitoring with Auto-CPAP. This method is a recent and simple method for detecting impaired breathing. It uses an auto-CPAP machine, which is programmed to apply pressure through the airways via a tube that attaches to a mask that fits the nose. A monitor is attached that digitizes and records on a computer all the information on any apnea episodes during sleep.

Nasal Pressure Recording. One promising technique uses a very simple prong device that attaches to the nostrils. A monitor records the airflow through the mouth and nose.

Peripheral Arterial Tonometry. An investigative technique called peripheral arterial tonometry measures changes in blood flow in the arteries of the fingertips during sleep. Such measurements are proving to be accurate in detecting sleep apnea in 80% of cases.

The Epworth Sleepiness Scale uses a simple questionnaire to measure excessive sleepiness during eight situations.


Situation	Chance of Dozing 0 = no chance of dozing 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing
Sitting and reading.	(Indicate a score of 0 to 3)
Watching TV.	(Indicate a score of 0 to 3)
Sitting inactive in a public place (a theater or a meeting).	(Indicate a score of 0 to 3)
As a passenger in a car for an hour without a break.	(Indicate a score of 0 to 3)
Lying down to rest in the afternoon when circumstances permit.	(Indicate a score of 0 to 3)
Sitting and talking to someone.	(Indicate a score of 0 to 3)
Sitting quietly after a lunch without alcohol.	(Indicate a score of 0 to 3)
In a car, while stopped for a few minutes in traffic.	(Indicate a score of 0 to 3)
Score Results	1-6: Getting enough sleep 4-8: Tends to be sleepy but is average. 9-15: Very sleepy and should seek medical advice. Over 16: Dangerously sleepy

Lifestyle Changes

Sleeping on the back causes sleep apnea in about half of all people with mild sleep apnea. Body position greatly affects the number and severity of episodes of obstructive sleep apnea, with at least twice as many apneas occurring in people who lay on their back as in those who sleep on their side. This may be due to the effects of gravity, which cause the throat to narrow when a person lies on the back. (Indeed, astronauts show a marked reduction in apneas and snoring in the weightlessness of space.) Positional sleep apnea affects people of all ages, including young children.

As a first step in dealing with sleep apnea, the patient should simply try rolling over onto the side. Patients who sleep on their backs and have 50 - 80 apneas per hour can sometimes nearly eliminate them when they shift to one side or the other. (Changing positions is less effective the more overweight a person is, but it still helps.)

Here are some suggestions that might help a person maintain a low-risk sleeping position:

Sew a small pocket to the back of the pajamas and place a tennis ball or other small ball into it.
A special pillow that helps to stretch the neck may reduce snoring and improve sleep for people with mild sleep apnea.
Sleeping in an upright position may improve oxygen levels in overweight people with sleep apnea. Elevating the head of the bed may help.

Over-the-counter nasal strips, such as the Breathe Right strip or other devices that open the nostrils, are inexpensive and useful to prevent snoring. They may significantly improve early-stage sleep in people with sleep disorders associated with nasal obstruction and help reduce morning tiredness. They are not intended as treatments for sleep apnea, however.

All patients with obstructive sleep apnea who are overweight should attempt a weight-reducing program. Weight loss certainly reduces snoring in many people, sometimes stopping it completely. It also improves sleep and significantly reduces daytime sleepiness. A 2000 study suggested that people who lost 10% of body weight experienced an average 26% reduction in risk for developing sleep apnea in the first place. (Gaining 10% of their body weight, on the other hand, increased the odds of sleep apnea 6-fold.)

Smokers should quit, since smoking worsens apnea
Alcohol should be avoided within 4 hours of sleep

Treatment

Treatment for sleep apnea depends on the severity of the problem. Given the data on the long-term complications of sleep apnea, it is important for patients to treat the problem as they would any chronic disease. Simply trying to treat snoring will not treat sleep apnea. Because of its association with heart problems and stroke, sleep apnea that does not respond to lifestyle measures should be treated by a doctor, ideally a sleep disorders specialist.

At this time, the most effective treatments for sleep apnea are devices that deliver slightly pressurized air to keep the throat open during the night. There are a number of such devices available.

The best treatment for severe obstructive and mixed sleep apnea is a system known as continuous positive airflow pressure (CPAP), sometimes referred to as nasal continuous positive airflow pressure (nCPAP). It is safe and effective in sleep apnea patients of all ages, including children. CPAP is not recommended for patients with mild apnea. Patients with apnea but no daytime sleepiness report little or no benefit from this treatment.

CPAP works in the following way:

The device itself is a machine weighing about 5 pounds that fits on a bedside table.
A mask containing a tube connects to the device and fits over just the nose.
The machine supplies a steady stream of air through a tube and applies sufficient air pressure to prevent the tissues from collapsing during sleep.

Effects on Sleep and Wakefulness. A major 2003 analysis confirmed the benefits of CPAP on both objective and subjective measures of sleep. After using CPAP regularly many patients report the following benefits:

Restoration of normal sleep patterns.
Greater alertness and less daytime sleepiness.
Less anxiety and depression and better mood.
Improvements in work productivity.
Better concentration and memory. Some adults with symptoms of attention deficit hyperactivity disorder have improved after CPAP treatments for apnea. In two studies, however, equal improvements were also observed in people on sham CPAP, suggesting that the actual cognitive benefits from CPAP may be modest.
Patients' bed partners also report improvement in their own sleep when their mates use CPAP, even though objective sleep tests showed no real difference in the partners' sleep quality.

If patients do not experience less sleepiness after a period of time and are still complying with the regimen, then the airflow pressure may not be high enough. Patients may require retesting. Many patients report feeling more alert after CPAP treatments even if objective laboratory tests fail to show significant differences in the number of apneas and wake-up periods.

Protection from Accidents. Studies suggest that treatment with CPAP can reduce the risk for accidents. In a 2001 study, untreated patients had a risk for automobile accidents that was three times the risk in the general population. When these patients were treated, their risk fell to normal.

Effects on the Heart and Circulation. Evidence is mixed on whether CPAP treatment may reduce serious heart conditions. Early studies suggested that CPAP could improve heart function, lower blood pressure, and prevent new cardiac events (such as heart attacks) in patients with congestive heart failure and coronary artery disease. However, a 2005 study in the New England Journal of Medicine found that, while CPAP helped improve some heart disease symptoms, it did not affect overall survival in patients with heart failure and central sleep apnea. (Patients with heart failure often have central sleep apnea.)

It is also unclear whether CPAP improves blood pressure. A 2006 study of patients with high blood pressure and sleep apnea indicated that short-term (4 weeks) CPAP treatment has no significant effect on lowering blood pressure. (It is possible that longer-term treatment may be helpful.) Other studies have found blood pressure benefits from short-term CPAP treatment. Treatment for sleep apneas must be very effective, however, to have any benefits on blood pressure. Even a 50% reduction in apneas has no effect.

Effects on Other Medical Conditions. Some studies suggest other benefits with the use of CPAP:

Fewer morning headaches
Reduction in abdominal fat (abdominal fat has been related to a higher risk for diabetes and heart disease)
Lower blood sugar levels in patients with type 2 diabetes
Improved thinking and concentration in people with impaired mental function from sleep apnea
Modest lung improvement in patients with both apnea and chronic obstructive lung disease (such as emphysema)

CPAP works well for both adults and children, but many patients have problems getting used to the device. Unfortunately, CPAP devices are often cumbersome, which can lead to patients becoming discouraged and stopping treatment. All patients should be warned that the first few nights of CPAP therapy are unnerving. The device often produces anxiety, primarily because of the mask. Starting out with low pressure to get used to the mask may help. Patients may actually experience less sleep or sleep of a different quality in the beginning of treatment.

Nearly all patients complain about at least one side effect. Nearly half of complaints are related to the mask. Many of these problems can be reduced with a well-chosen mask that is comfortable and reduces leakage as much as possible. Common complaints include:

Irritation in the nose and throat. The most common complaints are nasal congestion and sore or dry mouth, which are caused by leakage that dries the airway. (This may be severe in elderly people or patients who have had uvulopalatopharyngoplasty, a surgical treatment for sleep apnea. Such patients are more likely to stop using CPAP.) Chin straps, nasal salt water sprays, or humidifiers may prevent these side effects. Heated humidification devices are also now available for CPAP users.
Excessive application of pressure making exhalation difficult.
A feeling of claustrophobia is a major factor in noncompliance. This can be improved by a lightweight and transparent mask or with masks known as nasal pillows, which are used only around the nostrils.
Up to 30% of patients experience irritation and sores over the bridge of the nose. Getting a properly fitted and cushioned mask can help reduce this effect.
Eye irritation or conjunctivitis.
Upper respiratory infections. It is very important to keep the unit clean.
Patients may also experience temporary chest muscle discomfort, which is caused by an increase in lung volume.
Severe side effects are very rare but may include heart rhythm disorders (arrhythmias), severe nose bleeding, and air pockets in the skull.
In addition to initial difficulties with its use, the fixed CPAP needs to be periodically readjusted. Patients can be trained to adjust the CPAP at home, thereby avoiding trips to the sleep professional for machine adjustments and making the process more convenient.

Although studies have reported that long-term compliance with CPAP systems is low, with about one-third of patients giving up the treatment, recent information suggests that it is improving, probably due to better technologies and better education. Patient education and support groups, a dedicated nurse to ensure close follow-up of patients (particularly in the first 2 weeks of therapy), and ready access to doctors to make adjustments as needed have all been shown to greatly improve compliance. (However, sleeping pills do not appear to help patients adapt to the device.) Not surprisingly, patients whose symptoms are noticeably relieved by the procedure early on are more likely to continue the therapy.

Because many patients find CPAP uncomfortable and difficult, they tend not to use it for the duration of the entire night. A 2007 study indicated that while some patients’ daytime sleepiness may improve after 4 - 6 hours of CPAP use each night, maximum benefits in quality of life require at least 7.5 hours of nightly CPAP use. It appears that longer nightly duration of CPAP use is best for achieving normal daytime functioning.

Bilevel Positive Airway Pressure. Bilevel positive airway pressure (BPAP) systems may be particularly helpful for patients with coexisting lung disease and those with excessive levels of carbon dioxide. These devices have a sensing feature that helps determine and vary the appropriate pressure depending on whether a person is breathing in or out. Greater pressure is needed on inhalation and less on exhalation. These machines are more expensive than the CPAP and may not be covered by insurance.

Automatic Titrating (Auto)-CPAP Pressure Devices. Even more sophisticated systems, called auto-CPAP devices, are available. These devices automatically customize air pressure for the individual patient. They usually use one of three methods:

Overall pressure is kept low until a specific problem is detected. At that time the pressure is automatically increased rapidly.
Pressure is low when there are no problems but is raised gradually when they are detected.
Pressure is gradually raised and lowered in response to problems or their absence. In addition, the device can change depending on problems within single breaths.

Brands include AutoAdjust, Virtuoso, and AutoSet. These devices are more expensive than those that provide continuous airflow. A 2003 study indicated that they may improve compliance, particularly in patients who require high CPAP use. They may be especially helpful for patients who require varying levels of pressure due to other conditions, such as seasonal allergies. They may also be useful as home diagnostic tools for sleep apnea. Auto-CPAP devices are not recommended for all patients, particularly those with heart failure or serious lung disease.

In general, drugs have not been very beneficial except for specific situations. Medications that treat accompanying disorders associated with sleep apnea may be helpful. The following may be helpful for certain patients:

Modafinil (Provigil), which is also used to treat narcolepsy, was approved by the FDA in 2004 as the first drug to treat the sleepiness associated with obstructive sleep apnea. However, Provigil is meant to be used in combination with -- not as a substitute for -- standard apnea treatments such as CPAP. Sleep experts stress that patients who take Provigil should adhere to CPAP treatment as the drug treats only the symptom of sleepiness, not the underlying health risks associated with sleep apnea.
Thyroid hormone may help sleep apnea in those with low thyroid (hypothyroidism).
Theophylline, a drug commonly used for asthma management, has shown promise in treating central sleep apnea in patients with heart failure.
Omeprazole (Prilosec), a drug used for patients with severe heartburn, may help patients with both sleep apnea and gastroesophageal reflux disorder (GERD).

Note on Sedatives. Sedatives, narcotics, and anti-anxiety drugs can actually worsen the breathing disturbances and arousal conditions that occur with sleep apnea. These substances cause the soft tissues in the throat to sag and diminish the body's ability to inhale. Apnea sufferers should never use sleeping pills or tranquilizers. Apnea patients undergoing surgery should be sure that their surgeons, anesthesiologists, and other doctors are aware of their sleeping disorder in considering sedatives, anesthetics, and medications taken to relieve pain due to surgery.

Dental Devices

Oral appliances, also called dental appliances or devices, may be an option for patients who cannot tolerate CPAP. The American Academy of Sleep Medicine recommends dental devices for patients with mild-to-moderate obstructive sleep apnea who are not appropriate candidates for CPAP or who have not been helped by it. (CPAP should be used for patients with severe sleep apnea whenever possible.)

Several different dental devices are available. A trained dental professional such as a dentist or orthodontist should fit these devices. Devices include:

Mandibular advancement device (MAD). This is the most widely used dental device for sleep apnea. It is similar in appearance to a sports mouth guard. MAD forces the lower jaw forward and down slightly, which keeps the airway open.
Tongue retraining device (TRD). This is a splint that holds the tongue in place to keep the airway as open as possible.

Patients fitted with one of these devices should have a check-up early on to see if it is working; short-term success usually predicts long-term benefits. It may need to be adjusted or replaced periodically.

MAD and similar devices seem to offer the following benefits:

Significant reduction in apneas for those with mild-to-moderate apnea, particularly if patients sleep either on their backs or stomachs. They do not work as well if patients lie on their side. The devices may also improve airflow for some patients with severe apnea.
Improvement in sleep in many patients.
Improvement and reduction in the frequency of snoring and loudness of snoring in most (but not all) patients.
Higher compliance rates than with CPAP.

According to a 2006 review, dental devices help control sleep apnea in 52% of treated patients. A 2002 report indicated that long-term use of a dental device achieved an 81% success rate in apnea improvement, which was significantly higher than the 53% success rate noted for uvulopalatopharyngoplasty (UPPP), the standard surgical treatment. There were also few complications with the dental device.

Dental devices, including MAD, are not as effective as CPAP therapy. The cost of these devices tends to be high. Side effects associated with dental devices include:

Nighttime pain, dry lips, tooth discomfort, and excessive salivation. In general, these side effects are mild, although over the long term they cause nearly half of patients stop using dental devices. Devices made of softer materials may produce fewer side effects.
Permanent changes in the position of the teeth or jaw have occurred in some cases of long-term use. Patients should have regular visits with a health professional to check the devices and make adjustments.
In a small percentage of patients, the treatment may worsen apnea. Patients should be monitored with polysomnography (sleep lab evaluation) before and after therapy and when apnea symptoms worsen or recur.

An orthodontic treatment called rapid maxillary expansion, in which a screw device is temporarily applied to the upper teeth and tightened regularly, may help patients with sleep apnea and a narrow upper jaw. This nonsurgical procedure helps to reduce nasal pressure and improve breathing.

Surgery

Surgery is sometimes recommended, usually by throat specialists, for severe obstructive sleep apnea. A patient should be sure to seek a second opinion from a specialist in sleep disorders. Few randomized clinical trials, the gold standard of medical research, have been conducted to verify the long-term efficacy of sleep apnea surgery.

The Procedure. Surgery known as uvulopalatopharyngoplasty (UPPP) removes soft tissue on the back of the throat. Such tissue includes all or part of the uvula (the soft flap of tissue that hangs down at the back of the mouth) and parts of the soft palate and the throat tissue behind it. If tonsils and adenoids are present, they are removed. The surgery typically requires a stay in the hospital.

The Goal of Surgery. The goal of UPPP is threefold:

Increase the width of the airway at the throat's opening
Block some of the muscle action in order to improve the ability of the airway to remain open
Improve the movement and closure of the soft palate

Success Rates. Success rates for sleep apnea surgery are rarely higher than 65% and often deteriorate with time, averaging about 50% or less over the long term. Few studies have been conducted on which patients make the best candidates. Some studies suggest that surgery is best suited for patients with abnormalities in the soft palate, which may or may not involve the tonsils. Results are poor if the problems involve other areas or the full palate. In such cases, CPAP is superior. In one study, sleeping on the side (rather than the back) after surgery significantly boosted success rates.

Complications. Uvulopalatopharyngoplasty is among the most painful treatments for sleep apnea, and recovery takes several weeks. It is recommended only for select patients with severe obstructive sleep apnea. The procedure also has a number of potentially serious complications. In fact, in one study, 42% of patients had complaints about the procedure. Some complications include:

Infection. In one study, this complication was so common that 40% of patients needed another operation because of it. Preventive antibiotics administered an hour before surgery can help reduce this risk.
Impaired function in the soft palate and muscles of the throat.
Mucus in the throat.
Changes in voice frequency.
Swallowing problems.
Regurgitation of fluids through the nose or mouth.
Impaired sense of smell.
Failure and recurrence of apnea. In such cases, CPAP is often less effective afterward, although one study found that oral appliances (plastic mouth retainer-like devices) may still help.

Experts estimate that in general about 1.6% of patients experience serious complications. Many of these complications can be avoided with proper technique and experienced surgeons. However, a patient’s health status may also affect outcomes. According to a 2006 study, patients are more likely to experience complications if they have severe sleep apnea, are overweight, have other medical problems, or undergo other surgical procedures at the same time as UPPP.

A variation on UPPP called laser-assisted uvulopalatoplasty (LAUP) is being increasingly performed to reduce snoring. It removes less tissue at the back of the throat than UPPP and can be done in a doctor's office. At this time, however, long-term success rates from LAUP are very modest, particularly for reducing apneas. Some doctors, in fact, are concerned that if LAUP eliminates snoring, they may miss a diagnosis of apnea in patients who have the more serious condition.

More than 50% of patients complain of throat dryness after surgery. Throat narrowing and scarring have also been reported. In a minority of patients, snoring becomes worse afterward.

The pillar palatal implant is a noninvasive surgical treatment for mild-to-moderate sleep apnea and snoring. It helps reduce the vibration and movement of the soft palate. In this procedure, a doctor inserts 3 short pieces of polyester string into the soft palate. The procedure can be performed in a doctor’s office and takes about 10 minutes. Unlike uvulopalatopharyngoplasty (UPPP), the pillar procedure requires only local anesthesia. Studies indicate it works as well as UPPP, with less pain and quicker recovery time.

Tracheostomy used to be the only treatment for sleep apnea. It is quite straightforward:

The surgeon makes an opening through the neck into the windpipe and inserts a tube.
It is almost 100% successful, but it requires a quarter-size opening in the throat. This produces a number of medical and psychological problems associated with recovery.

Today, this operation is performed rarely, usually only if sleep apnea is life-threatening.

A technique called radiofrequency ablation uses radiofrequency energy to shrink tissues in the upper airways:

The radio waves heat, stiffen, and shrink a small amount of tissue at the base of the tongue.
The therapy takes about 20 minutes and can be done in a doctor's office.
It typically requires 10 treatments within five or six sessions. (A newer form requires fewer treatment sessions, and it appears to be effective.)
It is far less invasive than standard surgery and results in far less pain and fewer complications. Discomfort can be controlled with simple pain relievers.

Studies reporting significant improvement in reduced snoring and less daytime sleepiness for some patients although, as with other surgeries, the benefits may be short term in the majority of patients. It may be helpful for mild obstructive sleep apnea.

Other surgical procedures may be appropriate to correct facial abnormalities or obstructions that cause sleep apnea. They may be used alone or combined with each other or with UPPP. They include:

Tongue advancement, in which an opening is cut where the tongue joins the jawbone and the area is pulled forward.
Genioplasty, which is plastic surgery on the chin.
Hyoid surgery, in which the movable bone underneath the chin is moved forward, pulling the tongue muscle along with it.
Maxillary or maxillomandibular advancement (MMA), which moves the upper (maxilla) or lower (mandible) jawbone forward. A survey of patients who had MMA found that the surgery changed their facial appearance, but most people thought it was a change for the better.
Surgery for nasal obstructions (such as a deviated septum) that contribute to snoring and other symptoms.

Adenotonsillectomy, or surgical removal of the tonsils and adenoids, is a first-line treatment for children and adolescents with sleep apnea. It cures the condition in 75 - 100% of cases. Two studies, published in 2005, suggested that adenotonsillectomy can significantly improve quality of life for children with obstructive sleep apnea.

Complications include respiratory illness, which occurs in about 25% of children after the surgery. The highest risk for respiratory complications is associated with:

Age under 3 years old
Severe sleep apnea
Heart complications
Failure to thrive
Obesity
Prematurity
Recent lung infections
Certain facial structures
Neuromuscular disease

The procedure may fail to improve apnea in some patients, such as those with very severe disease. Such children are candidates for continuous positive airway pressure (CPAP) therapy.

Removal of the tonsils and adenoids alone is not an effective treatment for adults with sleep apnea, although the procedure may be effective when combined with UPPP surgery.

Resources

www.sleepapnea.org -- American Sleep Apnea Association
www.nhlbi.nih.gov -- National Heart, Lung, and Blood Institute
www.aasmnet.org -- American Academy of Sleep Medicine
www.sleepfoundation.org -- National Sleep Foundation
www.nhlbi.nih.gov/about/ncsdr -- National Center on Sleep Disorders Research
www.sleepeducation.com -- Sleep Education from the American Academy of Sleep Medicine
www.wfsrs.org -- World Federation of Sleep Research Societies

References

Bradshaw DA, Ruff GA, Murphy DP. An oral hypnotic medication does not improve continuous positive airway pressure compliance in men with obstructive sleep apnea. Chest. 2006 Nov;130(5):1369-76.

Kezirian EJ, Weaver EM, Yueh B, Khuri SF, Daley J, Henderson WG. Risk factors for serious complication after uvulopalatopharyngoplasty. Arch Otolaryngol Head Neck Surg. 2006 Oct;132(10):1091-8.

Peppard PE, Szklo-Coxe M, Hla KM, Young T. Longitudinal association of sleep-related breathing disorder and depression. Arch Intern Med. 2006 Sep 18;166(16):1709-15.

Weaver TE, Maislin G, Dinges DF, Bloxham T, George CF, Greenberg H, et al. Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning. Sleep. 2007 Jun 1;30(6):711-9.

Review Date:
7/18/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M. Copyright

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