Five ways to tackle the joint pain of arthritis

Osteoarthritis is the most common form of arthritis, affecting an estimated 10 per cent of men and 18 per cent of women over 60 years old. Photo / 123RF

For Tom Roberts, it began with difficulty walking. "The big toes on both my feet felt like rusty hinges which either didn't want to move at all, or suddenly gave way completely," he says. As a busy secondary school teacher in Coventry, just 48 at the time, he did his best to ignore it until scans finally revealed severe osteoarthritis in both joints. That same year, he was given an operation to break both his toes and reset them at a raised angle to make walking easier.

Roberts has since had a joint replacement in one knee and is heading towards replacing the joint in the other. "It's like walking with a sharp stone in your shoe, except it's in your knee," he says. There's osteoarthritis in his hands and the base of his spine. "Sometimes it's a dull persistent discomfort or ache," he says, "other times, it's a stabbing pain so sharp you feel you might faint."

Osteoarthritis is the most common form of arthritis, affecting an estimated 10 per cent of men and 18 per cent of women over 60 years of age and occurs when the cartilage that cushions the ends of bones gradually thins.

Although the last 20 years have brought big breakthroughs in treatments for inflammatory arthritis (including rheumatoid), osteoarthritis has seen much slower progress. There are still no disease-modifying treatments, only symptom control, and the latest draft of NICE guidelines has recently downgraded long-term use of painkillers in favour of exercise, weight-management and behaviour change.

"I don't go to the GP because the most they can do is offer painkillers," says Roberts, now 75 and retired, "but my whole life is about managing pain. The prime responsibility for my health lies with me – and there are a load of things I can do."

So what are the other options?

1. Keep moving

It's probably the opposite of what you want to do, and of what your osteoarthritis seems to be telling you, but the evidence is rock-solid. Exercise helps in multiple ways. "It improves nutrition and blood flow to the joint, lines up the joints, strengthens muscles, improves stability and restores function," says Dr Benjamin Ellis, consultant rheumatologist and senior clinical advisor for Versus Arthritis. Avoiding activity because of osteoarthritis pain kicks off a vicious "deconditioning cycle". Muscles weaken, joints become less stable and the pain gets worse. Exercise also helps with weight control, which is critical. "For every pound you carry, four times that amount will go to your weight bearing joints," says Dr Wendy Holden, honorary consultant rheumatologist at North Hampshire Hospitals NHS Foundation Trust and medical advisor of Arthritis Action. "If you're just 10kg overweight, that's another 40kg to bear."

Experts advise that any exercise is good, even gardening. "Whatever you enjoy, whatever you're doing, do more," says Holden. "A recent study found that just walking will reduce the pain from early knee osteoarthritis and also make it much less likely to progress – so it's potentially preventative."

Exercise "improves nutrition and blood flow to the joint, lines up the joints, strengthens muscles, improves stability and restores function," says Dr Benjamin Ellis. Photo / Supplied

Versus Arthritis has an online programme, Let's Move With Leon, presented by fitness expert Leon Wormley and his mum Janet who lives with arthritis. There's also Escape-Pain, a national group rehabilitation programme to reduce arthritic pain through exercise.

2. Medical

The latest research suggests that paracetamol performs no better than a placebo for osteoarthritis, while strong and potentially addictive opioids bring more risk than benefits. The first best option, according to NICE, is topical NSAIDS (non-steroidal anti-inflammatory drugs). "Gels that you rub on your skin can work well and stay where you put them, on the joint, unlike oral NSAIDS which end up in the blood stream," says Ellis. Capsaicin is also recommended by NICE – a cream which uses the compound from chilli peppers to numb pain over a period of time. "Capsaicin comes up very often on our helpline and has been the most frequent question in relation to alternative therapies," says Zoë Chivers, director of services and influencing at Versus Arthritis.

It's not something you can use now and again. "You have to really go at it, applying four times a day for three or four weeks to get the effect," says Ellis.

Anti-inflammatories like ibuprofen can help, and weak opioids like codeine have a role for certain occasions – big trips, a challenging day ahead. Corticoid steroid injections bring relief for up to two or three months – the evidence is strongest for pain on hip joints.

"If you have tried all these and can't live with the pain, you're heading into joint replacement territory," says Ellis. Waiting lists there can be several years. The future – the holy grail – could be cartilage transplantation or the injection of stem cells to stimulate new cartilage growth. Research is ongoing, but both have been performed at the Royal National Orthopaedic Hospital in Stanmore.

3. Hot and cold

Soaking in a hot bath, and applying packs that have been heated in the microwave or cooled in the freezer can all help joint pain – and work better than expensive sprays which stay on the skin without reaching the muscle beneath. "It's finding what gives you symptom relief," says Dr Ellis. "Ice can be numbing, heat can help muscles soften and relax."

"People often tell us how the weather can exacerbate their arthritis," says Chivers. A study by The University of Manchester looked at the impact of weather on long-term pain conditions, particularly arthritis, and found that bad weather days (humid, low pressure, windy) were 20 per cent more likely to coincide with an increase in pain. It also found that people with osteoarthritis were especially sensitive to humidity. While we can't change the weather, recognising triggers and planning more burdensome activities accordingly can make life easier.

4. Diet and supplements

Arthritis Action was formed in 1942 by osteopath Charles de Coti-Marsh, who had very firm ideas about the impact of diet on arthritis. His diet plan awarded points out of 200 to all food types and is highly detailed (0 points for parmesan cheese, 10 for Cheshire and a whopping 180 for brie). The aim is to stick with low scoring foods – as a rough guide, it recommends avoiding red meat and animal fat – and favouring veg, fruit, beans, poultry and fish. There are those who still swear by it, but the advice now from charities and experts is simply to follow a balanced Mediterranean type diet. While eating oily fish can reduce disease activity for those with inflammatory arthritis, the evidence for osteoarthritis is less compelling. Popular supplements include turmeric as an anti-inflammatory, magnesium for bone health, fish oil and Vitamin D – although most rheumatologists will say there is scant proof of benefits.

Ellis believes there is much to uncover about diet and arthritis – and that bacteria in the gut could play an important role, although it's likely that different foods impact different people. "People might find that certain foods seem to help bring down pain or flare it up," he says. "My instinct is that it will be down to your microbiology, and one day we'll understand more. Listen to your body and watch this space."

5. Mind Power

Pain is one part of arthritis, "fatigue" is another, with many sufferers finding the latter hardest to live with. One recent trial, the LIFT study, found that regular cognitive behavioural therapy (CBT) significantly improved fatigue, mental health and sleep patterns. It involved people keeping a daily diary of thoughts, feelings and behaviours and learning ways they might plan better and prioritise, build in regular rest breaks, manage stress triggers and break unhelpful thinking patterns.

"LIFT focused on people with inflammatory arthritis but it seems likely that CBT would help those with osteoarthritis too," says Ellis.

The way we experience pain is complicated. Essentially, the sensation is created by the nervous system when it thinks the body is under threat, but many factors help the brain make that assessment. If you're lonely, isolated, under stress or sleep-deprived, your brain might assess the threat level as greater and make the pain response higher – which is why therapy, tackling sleep problems, learning new ways to manage life and finding support from others can all ease physical symptoms.

Roberts combines many of the above to manage his symptoms. For years, he had the Charles de Coti-Marsh arthritis diet plan on his fridge, but now knows the scores by heart. "I stick with vegetables, fish and cheese," he says.

Weight and exercise are also key. "I weigh around 64kg and if it gets up to 65, I stop eating. I'm a gym bunny now too. I go to the gym twice a week – I can't run but I can row and cycle on the machines – and swim on Fridays. I habitually use baoding balls, little exercise balls to rotate and manipulate in your hands to increase flexibility – the gym doesn't work those little hand muscles."

Regular appointments with both a physiotherapist and an osteopath also help. "If you feel pain, your body unconsciously adapts to avoid it, putting more weight somewhere else and causing more problems," he says. "They know me better than my GP and they straighten me up and keep me balanced."

His greatest pain reliever is a sauna fitted in his garage. "It cost £1600 – and I'm in there every evening at around 37 degrees," he says. "I can read, take my iPad and, there are speakers in the ceiling. It feels like a warm, sunny day, my joints, ligaments and tendons relax and the pain eases away."

He also practises self-hypnotherapy techniques that he learned as part of a trial through Arthritis Action. "I can now zone out and take myself to a healing room which looks like the flight-deck of Concorde. I dial down the stiffness in my back or the pain in my feet. All these things do a little bit and the cumulative effect makes life livable."

The cutting-edge treatments tackling arthritis

Joint 'fillers'

Dr Matteo Bernardotto, consultant in sport and musculoskeletal medicine at University College London Hospitals NHS Trust and the London Clinic, says hyaluronic acid injections into the joint can help.

"This is essentially the same thing as what's used in lip fillers, but in a different concentration," says Dr Bernardotto. "It attracts water and buffs up the cartilage. You need to use the window of better pain control to be more active. If not you will be back to square one when the injection wears off (after six months)." The treatment is available in private clinics and generally covered by medical insurance..

Platelet Rich Plasma (PRP)

"This is when you take your own blood and separate out the plasma, which contains growth factors," says Dr Bernardotto. "If you repeatedly inject growth factors into the joint there is evidence that it improves pain and stiffness to a degree, with the proviso that it works best in early arthritis.". The idea behind both treatments is that they reduce the pain so that you can start moving. "Ultimately it's the exercise that will help."

However, Dr Ellis has strong reservations, "I'm not convinced either treatment is better than a placebo" and NICE has advised that hyaluronic acid should not be used at all, "due to lack of good evidence".