Naomi Creekemore, a director of the morning news program at WRC-TV, can tell the station's weatherman Bob Ryan a thing or two. She has heard him predict a beautiful weekend when she knows perfectly well it will rain or snow. He's got all the charts, maps and radar. She's got arthritis.
Folk wisdom holds that arthritics could always predict incoming inclement weather by the painful feeling in their joints, a truism that contemporary research has substantiated.
Creekemore is 30, and she does not regard her ability to predict weather as a fair exchange for the disintegrating cartilage in her shoulders, her hips, her knees. She is able to manage pretty well by taking a lot of aspirin or ibuprofen. She expects eventually, though, to need surgery.
There is no cure for arthritis, but the past decade has seen an explosion in new ways to manage the pain, deformity, lack of mobility, fatigue and depression that are among its most disabling symptoms. Surgical techniques have been refined so that certain patients can be fitted with new joints.
Creekemore is one of an estimated 40 to 50 million Americans who suffer from one of the more than 125 forms of arthritis. Osteoarthritis is the most common, accounting for 16 million people. Rheumatoid arthritis, the most disabling, affects up to about 3 million, mostly women.
Arthritis can strike at any age, but those over age 65 are most vulnerable, and different types of the disease may disproportionately affect one sex or age group.
Osteoarthritis is the gradual wearing away or fraying of the cartilage -- the elastic facing at the ends of bones that permits the joints to move easily. This type of arthritis may affect fingers, wrists, shoulders, the spine or weight-bearing joints, especially hips and knees. Relatively little inflammation is associated with it and often symptoms are mild or transient, but it also can cause unremitting pain and major disability.
Rheumatoid arthritis involves a great deal of inflammation and leads to the destruction of collagen, the body's connective tissue, and eventually the joints themselves. This is the kind of arthritis with which the most disability is associated. According to Lawrence E. Shulman, director of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), half of the people who have rheumatoid arthritis are disabled in some way.
Arthritis is one of the oldest afflictions. Signs of joint deterioration are found in prehistoric fossils. Italian Renaissance artist Sandro Botticelli painted his 16-year-old model's arthritic fingers into his famous "Birth of Venus," irreverently known as Venus on the Halfshell. Creekemore already sees telltale hints of the disease in the joints of her fingers.
Almost as old as the disease are attempts to cure it -- from ancient Egyptian enemas to modern-day visits to uranium mines, copper ornaments and snake venom. None of these remedies worked.
The chief aim of contemporary therapy is to control the disease through changes in lifestyle, drugs, surgery or a combination of these. Arthritis is a capricious and unpredictable disease. Its symptoms can appear or disappear suddenly and might never recur.
Some forms of arthritis appear to single out the young. Up to 200,000 children have some form of arthritis, as do nearly 8 million people under age 60. The Arthritis Foundation estimates that the disease in one form or another accounts for 500 million days of restricted activity and 27 million days lost from work each year. Learning to Cope
For most people with arthritis, the key is learning to live with the disease.
At the Stanford University Arthritis Center in California, James Fries, an associate professor of medicine, and Kate Lorig, a public health nurse, have devised a series of courses for patients at their clinic. People who improved after taking the course did so not just because of what they learned about controlling pain, managing stress and exercising, but "because they realized they weren't helpless in the face of an incurable disease," says Fries, who with Lorig has written two guides to managing arthritis.
"We have been saying right along that it is possible to be both factual and positive when discussing arthritis," he adds. "That was what was lacking before. There were people who were factual, but they were very, very gloomy. And there were people who were very enthusiastic, but they were quacks."
The Stanford course and the Fries books have been incorporated into the hundreds of courses on arthritis management sponsored by the Arthritis Foundation. They are also used at 14 major arthritis centers supported by the National Institutes of Health.
Many patients can control their symptoms with lifestyle changes alone. In the past decade, doctors have recognized that exercise is crucial to managing arthritis. "If you have weak joints, you have to have strong bones and muscles and ligaments if you're going to function," says Fries. "And you can greatly increase function by exercise. In the old days, the advice was, 'Well, you're getting old so you have to cut down on things.' The new advice is that this arthritis is a signal: Your body is telling you that you need more exercise."
Bob Bullock, a 68-year-old retired naval engineer who divides his time between California and Washington, says swimming has helped mitigate his arthritis. His initial bout with the disease occurred when he was 40. Very soon it got worse. "I couldn't put on a jacket because my arm wouldn't reach backward into the sleeve. I couldn't drive a standard transmission car because my left leg didn't lift well enough to work the clutch. I couldn't walk easily. I couldn't work."
Bullock devised his own set of swimming exercises. Eventually, he got involved with the Arthritis Foundation swimming program. Now, he spends much of his time teaching the Arthritis Foundation course on both coasts.
Another swimmer is Dvera Berson, a scrappy determined woman of 77 who lives in Boca Raton, Fla. Twenty years ago, she essentially made her arthritis her life's work. She spent months on cortisone, once briefly regarded as the long-sought cure. Berson also had several courses of treatment with injections of gold salts, still used for severe rheumatoid arthritis, with dramatic benefit in some cases and little or none in others. Neither gold salts nor cortisone helped; both, in fact, made her sicker.
So Berson threw away all her medicines, her braces, splints and corsets and threw herself into a swimming pool. She has been promoting her own swimming program and breezily damning the medical establishment ever since.
In a book and a set of videotapes, Berson outlines a series of water exercises and modified swim strokes that, she maintains, will free the arthritis patient from chronic pain. She has scores of adherents, doctors as well as patients, but no formal studies have been done to demonstrate that her program is better than others. Even so, she has played a role in making exercise, especially aquatic exercise, mainstream therapy for arthritics. Drug Treatment
It is impossible to estimate how many people with arthritis take daily doses of over-the-counter medicines such as aspirin or ibuprofen. Many others -- especially those who have rheumatoid arthritis -- are helped by stronger prescription drugs.
The use of synthetic cortisone in the 1950s to treat arthritis stemmed from the knowledge that the corticosteroids had powerful anti-inflammatory qualities. However, long-term use caused serious side effects, and today cortisone is reserved mainly for short-term use in the most serious cases.
Meanwhile, the last decade has also seen a change in the way rheumatoid arthritis patients are treated, according to Fries.
In the past -- and today in many cases -- physicians followed what was known as "the pyramid approach," beginning with relatively simple drugs like aspirin and the ever-growing cluster of so-called non-steroidal anti-inflammatory drugs (NSAIDS, including ibuprofen and its stronger cousins). Both aspirin and the non-steroidal drugs can reduce inflammation and relieve pain.
If these didn't work, the patient would be given drugs called "disease modifiers," which often, but not always, seemed to arrest the progress of the disease itself. These include gold salts; penicillamine, a cousin of penicillin; an agent used to draw out metals from the blood; the anti-cancer drug methotrexate and sometimes cortisone.
However, says Fries, by that time, people were usually six to eight years into the disease and a lot of damage to joints that might have been averted by the strong medicines had already been done.
Physicians have also now found that the regular use of NSAIDs is not as safe as first believed. NSAIDs can cause painless but potentially life-threatening ulcers and gastrointestinal bleeding. Nor are the disease modifiers as toxic as initially feared. As a result, there is a growing movement to "invert the pyramid," as Fries puts it.
Either gold salts or penicillamine may provide dramatic benefits to about two thirds of people with rheumatoid arthritis and, in about 25 percent of cases, may make the symptoms disappear. Another 25 percent have such severe side effects that they must be taken off the drugs. These two, plus a half dozen new drugs, must be monitored carefully by a rheumatologist, both for side effects and because patients may build up a tolerance to one and need to switch to another. Specialists say they do not know exactly why or how they work.
Lyme disease, which is caused by a microorganism transmitted through the bite of the minuscule deer tick, has reawakened interest in the role of infectious agents in arthritis. Researchers are investigating the possible role of bacteria in other forms of arthritis, as well as treatment with antibiotics. Psychological Stress
The diagnosis of arthritis is daunting, because to some it seems like a lifetime sentence; in the recent past, that is what it often was. Even today, some patients with arthritis are clinically depressed. They feel they have essentially lost control of their bodies and their lives and in some cases give up, a phenomenon known to psychologists as "learned helplessness." But current efforts are directed at keeping these people from becoming disabled and depressed.
Courses based on the Stanford program have helped ease some of the psychological burden arthritics often bear. Stress, it is well known, can exacerbate pain and has a deleterious effect on the immune system. Many forms of arthritis seem to have connections to the immune system, so it is not surprising that stress can worsen not just the pain but the disease process itself. Many patients find that relaxation techniques can help reverse the effects of stress and make chronic pain more bearable.
In addition, new research at the National Institute of Mental Health suggests that the depression that often accompanies arthritis may be more than merely a psychological reaction to a chronic illness. Scientists now suspect that certain biochemical changes in the brain may produce both arthritis and depression. In some experiments with a particular strain of arthritic rat, rheumatologists Esther M. Sternberg and Ronald Wilder, have found a defect in the process that regulates both the stress response and the immune system. The process begins in the brain and ends with the production of the corticosteroid hormones. When this process, called the hypothalamic-pituitary-adrenal immune axis, is interrupted and too few corticosteroids are produced, inflammation and eventually rheumatoid arthritis can result.
Irregularities in these stress hormones have also been linked to clinical depression, leading to the speculation that the same defect that is implicated in rheumatoid arthritis may also be involved in certain types of depression. This would help explain the prevalence of depression, researchers say.
This hypothesis needs to be tested in people, but some specialists at the National Institute of Mental Health are beginning to find links between hypothalamic irregularities and an assortment of disorders, including multiple sclerosis and other autoimmune disorders. Bionic Future
For thousands of arthritics, extraordinary advances in surgical techniques, especially over the past 10 years, have made joint replacement or other forms of surgery an often successful option.
Michael Lockshin, director of extramural programs for the National Institute of Arthritis, recalls that when he was a rheumatology fellow at Columbia Presbyterian Hospital in New York in 1970, a patient was brought in with every joint in his body distorted, misshapen, twisted from the arthritis. In other hospitals he had served in, Lockshin says, the patient would simply have been shoved in a back room and cared for until he died. But at Columbia, the chief of service told his new fellow confidently that the old man would walk out. "I was truly amazed," Lockshin says. "I watched a series of staged joint replacements take place, and the man did walk out. It took six months of continuous hospitalization, but he walked out."
At that time, the hip replacement operation was just being developed in England. Today, some 300,000 joint replacements are performed every year -- hips, knees, elbows, shoulders, ankles, wrists, fingers. Surgery is usually the treatment of last resort, reserved for those whose joints are so painfully stiff that the individual is unable to walk or even move without pain.
Clement B. Sledge, chief of orthopedic surgery at Brigham and Women's Hospital in Boston, notes that sophistication in surgical techniques has soared, especially in the past decade, making joint surgery less invasive and implants more successful.
In the past few decades, surgeons have learned more about how human joints work. For example, says Sledge, hips and knees operate generally under the same principle, so the replacement techniques are easily transferred from one to the other. But the ankle is so different that attempts at replacements there have, in the words of one of his colleagues, been carried "a joint too far."
Sledge, who wrote the chapter on surgery in the Arthritis Foundation's "Primer on the Rheumatic Diseases," describes a hip joint replacement as a ball attached to a metal prong being inserted into "a kind of mailing tube made of bone." Cement keeps the replacements solid for as long as 15 years in some cases.
A new and popular technique has been developed that uses no cement at all. According to Lockshin, virtually every major academic center has its own version of a cementless, or partially cementless replacement. In this case, the implant inserted into the bone is porous. The theory is that bone cells will grow into the artificial pores, essentially making the implant an integral part of the bone. Some orthopedists, including Sledge, worry that because the cementless hip is too new for its success rate to be determined, the proliferation of the cementless technique may be moving too fast. "You can't even whisper that you've made an improvement for at least five years, and most of the new materials and applications haven't been around that long." he says.
Another innovation for arthritis patients is arthroscopic surgery. With a minimum of hospitalization and invasiveness, physicians can remove pain-causing bone or cartilage fragments. The arthroscope, a rigid light-source instrument, is inserted into a joint -- the knee, for example -- through a tiny incision, permitting surgeons to work inside the joint. The microsurgery is performed often only with a local anesthetic in an ambulatory surgery unit.
Surgery, even surgeons concede, is not the solution for every patient. Many candidates are obvious: those who can no longer walk or work or perform the simplest of the activities of daily living or who are in unremitting pain may have dramatic responses from hip or knee replacements. The Arthritis Foundation warns, however that "potential benefits must be weighed against associated complications" including infection, blood clots, nerve injury and, sooner or later, a failure or loosening of the replacement.
Stanford's Fries is less enthusiastic about surgery. In his book, he points out that for many patients it can relieve pain, restore function and return a patient to employment. But he also warns that it is often expensive, painful and associated with a long recovery period, usually between three and six months, depending on the type of surgery.
As with all major operations, he writes, "not all operations are equal, not all surgeons are equal." As a general rule, surgery for arthritic conditions is elective, so potential candidates should ask for second, even third opinions. The type of surgery and the replacement used depends on the age, weight, activity level and stage of disability in the individual patient.
Here is a pain prescription offered by a doctor in Salem, Mass., in 1659: "Take a lock of Vergins haire On any Part of ye head. Cut it very smale to fine powder then take 12 Ants Eggs dried in an oven . . ." to be taken with "Red cow's milk." If it didn't work, then the owner of the hair wasn't a virgin. If, as arthritis often does, the disease went into a spontaneous remission, then the putative cure must have worked.
Today's doctors may have moved beyond the use of virgin's hair, but they still haven't found a quick, sure cure for arthritis. What they have managed to do is to help people cope with their disease. Arthritis may still be a pain in the joint, but it is no longer a disease of despair.