Chapter 2: Life with arthritis in Canada: a personal and public health challenge – Prevention and management

Chapter Two: Prevention and management

• Introduction
• What we know about the risk factors of arthritis
  • Non-modifiable risk factors
    • Age
    • Sex
    • Hormones
    • Genetic-predisposition
  • Modifiable risk factors
    • Physical inactivity
    • Diet
    • Excess weight and obesity
    • Joint injury
    • Smoking
    • Occupation
    • Infections
• Reducing the impacts of arthritis
  • Education and awareness
  • Early symptom recognition, early detection and diagnosis
  • Self-management
  • Medication
    • Rehabilitation
    • Surgery
• Summary

Introduction

Arthritis is often mistaken as an inevitable part of aging— as a disease that affects only older individuals and for which there is no effective treatment or intervention. In reality, interventions can reduce the risk of developing certain types of arthritis, primarily osteoarthritis (OA) and gout, and improve the early detection and management of the disease, leading to improved health and quality of life of people living with arthritis.^{Footnote 1 Footnote 2 Footnote 3 Footnote 4 Footnote 5}

This chapter provides information on risk factors for arthritis and on existing prevention and management strategies. Risk factors are characteristics that are associated with an increased risk of developing a particular disease or condition, or with the progression and severity of that disease. Risk factors associated with arthritis can be modifiable or non-modifiable. Table 2-1 presents a summary of the available literature on the risk factors associated with arthritis. Data on risk factors from the Canadian Community Health Survey (CCHS) 2007-2008 are also presented and show the distribution of arthritis-related risk factors in the Canadian population. The interventions aimed at reducing the risk of developing some types of arthritis and the ways to reduce the progression and negative impacts of all types of arthritis are also discussed.

What we know about the risk factors of arthritis

Non-modifiable risk factors

Non-modifiable risk factors include age, sex, female hormones and genetic predisposition. Although their associated risk cannot be altered, understanding them is important for assessing overall risk and may provide an incentive for changing other modifiable risk factors.^{Footnote 2}

Age

Age is the strongest independent risk factor for arthritis.^{Footnote 6 Footnote 7 Footnote 8 Footnote 9} While arthritis can affect people of any age, each form of arthritis has a unique peak of onset.^{Footnote 10 Footnote 11} For example, the peak age of onset of rheumatoid arthritis (RA) is between 55-64 years in womenand 65-75 years in men. On average, women develop RA ten years earlier than men.^{Footnote 11 Footnote 12 Footnote 13}

Age-related changes such as reduced muscle strength, loosening of ligaments within the joints and the thinning of cartilage cause changes to the joints, making them susceptible to developing arthritis, specifically OA.^{Footnote 14 Footnote 15} This is especially evident in the knee, hip and hand joints—the joints that are most commonly affected.^{Footnote 9 Footnote 15} After the age of 75 years, the incidence of OA stabilizes.^{Footnote 14}

Age of onset may affect the severity of arthritis. For example, childhood-onset systemic lupus erythema- tosus (SLE) may be more severe than adult-onset SLE, while postmenopausal SLE may be milder than pre-menopausal SLE.^{Footnote 16}

Sex

Women are affected in greater proportions than men by all types of arthritis, with the exception of psoriatic arthritis (similar between men and women), gout and ankylosing spondylitis (AS) (both higher among men).^{Footnote 6 Footnote 9 Footnote 16 Footnote 17 Footnote 18 Footnote 19 Footnote 20} For example, 9 out of every 10 people with SLE are women with the peak age at onset occurring during childbearing years.^{Footnote 16} Women consistently report higher rates of both arthritis and arthritis-related physical disability.^{Footnote 7 Footnote 12 Footnote 18}

Being a women seems to amplify the age-related increase in the occurrence of OA in the hand, knee and in multiple joints. After the age of 50, the frequency of OA in these joints is significantly greater in women than in men while the frequency of hip OA increases at about the same rate with age in women and men.^{Footnote 15}

The reasons for these differences between men and women are not well understood.^{Footnote 7}

Hormones

The significant increase in some forms of inflammatory arthritis conditions including RA and SLE observed among women during their reproductive years or menopause suggests that female hormones may influence the development or the severity of these forms of arthritis.^{Footnote 19 Footnote 20 Footnote 21 Footnote 22 Footnote 23}

The most striking evidence is found during pregnancy in which estrogen and progesterone levels increase greatly during the third trimester. Many studies have documented the reduction or remission of RA symptoms during pregnancy and most profoundly during the third trimester.Footnote 17 Footnote 22 Footnote 24 This is followed by an increase in disease activity early in the postpartum period when estrogen and progesterone concentrations fall; the increase is greatest after a first pregnancy.Footnote 7 Footnote 17 Footnote 22 Footnote 25 The return of symptoms during the postpartum period is hypothesized to be associated with the production of prolactin, a pro-inflammatory hormone, during breastfeeding.Footnote 17 Footnote 22 Footnote 24 Footnote 25 Interestingly, men with RA have significantly lowered testosterone concentrations.Footnote 26 The influence of hormones in individuals with SLE appears to be different from those with RA. The signs and symptoms related to SLE appears to either worsen or remain unchanged during pregnancy.Footnote 27 Footnote 28 Footnote 29

The possibility of a protective effect of past and current use of the oral contraceptive pill (OCP) on RA and SLE has been explored.^{Footnote 12 Footnote 16 Footnote 22 Footnote 24} OCPs do not appear to prevent RA, but may postpone its development.^{Footnote 12 Footnote 22 Footnote 24} In general, use of OCPs provides a modest protective effect against RA.^{Footnote 12 Footnote 22 Footnote 24} To date, this protective effect has not been explained, in part due to the limited number of studies that have investigated this relationship in depth.^{Footnote 12 Footnote 22 Footnote 24} While some evidence supports the presence of the role of estrogen in reducing a woman's risk of RA, SLE and Sjögren's syndrome, no evidence supports the use of post-menopausal hormone therapy for risk- reduction purposes.^{Footnote 25}

Genetic predisposition

The identification of the genes involved in arthritis will further the understanding of disease mechanisms and biology as well as, the interaction between genes and the environment.^{Footnote 30} However, the identification of genes for arthritis is complex. The genes involved may vary among different families or ethnic groups.^{Footnote 26} Moreover, even if the same genes were found to be involved, their expression may not be the same in all individuals.^{Footnote 22 Footnote 24 Footnote 30 Footnote 31}

Specific genes are associated with a higher risk of developing certain types of arthritis. It has been observed that inflammatory types of arthritis tend to run in families and to some extent, most share a similar genetic make-up.^{Footnote 12 Footnote 16 Footnote 20 Footnote 30 Footnote 32 Footnote 33} Most attention has been given to the group of genes called human leukocyte antigens (HLA). The many different HLA gene types are inherited and they are associated with certain autoimmune diseases. People with certain types of HLA genes are more likely to develop autoimmune diseases such as RA, AS, SLE and Sjögren's syndrome.^{Footnote 34} Significant evidence also supports the role of genetics in the development of OA.^{Footnote 8 Footnote 14 Footnote 15 Footnote 35 Footnote 36}

Genetics are influenced and affected by the indi- vidual's environment: the risk of developing OA following a knee injury increases if the individual has a family history of OA.^{Footnote 8 Footnote 12 Footnote 20 Footnote 33 Footnote 37 Footnote 38 Footnote 39} Such association confirms the importance of interactions between the environment and an individual's genetic makeup in the development of arthritis.

Modifiable risk factors

Some risk factors for arthritis are modifiable, such as physical inactivity, poor diet, excess body weight and joint injury. While they are mainly associated with the onset of OA and gout, they can be altered in populations who have any form of arthritis to reduce pain, improve function and quality of life.^{Footnote 2}

The level of evidence on how modifiable risk factors contribute to the occurrence of arthritis varies widely, depending on the type of arthritis (see Table 2-1 for more details). Established modifiable risk factors associated with disease occurrence apply predominately to OA and gout. All modifiable risk factors have also been associated with progression or severity of disease; hence their great potential for improving function and reducing disability.

Physical inactivity

Being physically active has the potential to both prevent the onset of some types of arthritis and ease the pain associated with many, if not all, types of arthritis.^{Footnote 9 Footnote 14 Footnote 15 Footnote 40 Footnote 41 Footnote 42}

Canada's Physical Activity Guide to Healthy Living incorporates stronger bones and muscles as part of the messages on benefits of physical activity.^{Footnote 43}

Canada's Physical Activity Guide to Healthy Active Living for Older Adults also addresses individuals with arthritis, saying

Even though being physically active is beneficial for the health of all Canadians, in 2007-2008, half (50%) of the general Canadian population reported being physically inactive during their leisure time. The proportion of women who reported being physically inactive was significantly higher than men in the 15-39, and 60+ year age groups (Figure 2-1). The greatest difference occurred among individuals aged 70 years and over, where 66% of women reported being physically inactive compared to 53% of men.

Figure 2-1. Proportion of individuals who reported being physically inactive during their leisure time, by age and sex, household population aged 15 years and over, Canada, 2007-2008

*Source: Public Health Agency of Canada using data from the Canadian Community Health Survey 2007-2008, Statistics Canada.
*Physical activity is defined according to the total daily Energy Expenditure values (kcal/kg/day) expended during leisure time activities. Energy Expenditure is calculated using the frequency and duration per session of the physical activity as well as the MET value of the activity. The MET is a value of metabolic energy cost expressed as a multiple of the resting metabolic rate. Respondents are categorized as being “active” (≥ 3 MET), “moderate” (1.5 to ≤ 3 METS) or “inactive” (0 to < 1.5 METS) based on their total daily energy expenditure value.
*Differences between men and women statistically significant at p<0.05 except among those aged 40-49 and 50-59 years.

Physical activity is an important component in the maintenance of healthy weights in all individuals. For people with arthritis and a high body mass index (BMI), weight loss efforts could be beneficial to their overall health and quality of life.^{Footnote 45 Footnote 46 Footnote 47}

People with arthritis who participate in moderate to vigorous physical activity have been shown to improve their functional capacity without increasing disease activity or causing joint damage.^{Footnote 5 Footnote 48 Footnote 49 Footnote 50 Footnote 51 Footnote 52 Footnote 53} Regular moderate exercise can produce improvements in function, flexibility, muscle strength and endurance, cardiovascular fitness and psychological health.^{Footnote 3 Footnote 54 Footnote 55} Exercise appears to be the most consistently effective method to reducing arthritis-related pain.^{Footnote 3 Footnote 55 Footnote 56} Participation in recreational activities such as running, cycling, walking and dancing have been associated with a positive impact on function, pain and disability.^{Footnote 9 Footnote 40 Footnote 42 Footnote 48 Footnote 49 Footnote 50 Footnote 51 Footnote 52 Footnote 53 Footnote 56 Footnote 59} It is important, however, to address several factors — such as pain, fear of injury, joint or muscle stiffness, fatigue or lack of energy, and impaired balance — prior to beginning a regular exercise program.^{Footnote 55} The key issue is to develop a comfortable balance between rest and activity.

Inactivity can make arthritis worse as a result of reduced joint mobility, strength and fitness, increased fatigue and depression, low pain tolerance and increased risk for developing other chronic conditions such as heart disease and osteoporosis. Individuals with RA report low levels of physical activity, which is a concern since these individuals are at higher risk than the general population for other condition(s) such as heart disease and premature death. Inactivity can also exacerbate muscle wasting and joint stiffness, which further limit their physical function.^{Footnote 45 Footnote 60} A similar trend is seen in individuals with OA, where inactivity can lead to joint instability.^{Footnote 60}

Even though physical activity is very important in the management of arthritis, a higher proportion of individuals with arthritis were physically inactive during their leisure time compared to those without arthritis (59% and 49%, respectively).

Physical inactivity among Canadians with and without arthritis increased with age (Figure 2-2). Of concern is the fact that up to 56% of people with and without arthritis between 15 and 39 years of age reported being inactive. Among men aged 60 years and older, those with arthritis were less physically active compared to those without arthritis. The same was true among women aged 40 years and older.

Figure 2-2. Proportion of individuals with and without arthritis who reported being physically inactive, by age and sex, household population aged 15 years and over, Canada, 2007-2008

*Source: Public Health Agency of Canada using data from the Canadian Community Health Survey 2007-2008, Statistics Canada.

Diet

A healthy diet is a critical component of maintaining a healthy weight for individuals living with arthritis, since being overweight has been identified as a contributor to further progression of the disease.^{Footnote 49 Footnote 58 Footnote 61} A high intake of purine rich foods, such as red meat and seafood, and alcohol consumption are both linked to the development of gout.^{Footnote 6 Footnote 62 Footnote 63} Diet may also play a role in both the onset and the severity of RA, however, the specific diet composition has yet to reach scientific consensus.^{Footnote 17 Footnote 22 Footnote 35 Footnote 63}

Excess weight and obesity

Being overweight or obese (defined according to the WHO International standards as a body mass index (BMI) of 25–29.9 (overweight) or ≥ 30 (obese)^{Footnote 64} increases the risk of developing OA and gout. The risk of developing OA and gout increases with increasing weight.^{Footnote 5 Footnote 6 Footnote 7 Footnote 9 Footnote 46 Footnote 47 Footnote 65 Footnote 66 Footnote 67}

A strong association has been demonstrated between obesity and knee OA and a modest association has been shown between obesity and OA of the hip. Those who are obese are 2.5 to 3 times more likely to develop knee OA and 2 times more likely to develop hip OA compared to those with a normal BMI.^{Footnote 68 Footnote 69 Footnote 70} The association between a high BMI and OA of the hand is less certain.^{Footnote 71}

Obese individuals who have arthritis are more likely to experience more severe arthritis symptoms and impaired quality of life compared to those with arthritis who maintain a healthy weight.^{Footnote 8 Footnote 9 Footnote 12 Footnote 15 Footnote 25 Footnote 66 Footnote 72} Furthermore, weight loss interventions decrease pain, improve function in older obese populations with OA of the knee.^{Footnote 73}

Overweight and obesity may precipitate or lead to progression of OA to the point at which joint replacement needs to be considered. Women and men who are overweight or obese are two times more likely to have a hip or knee replacement than those who have a healthy weight.^{Footnote 74} Functional recovery after joint replacement surgery is better among those with a healthy weight.^{Footnote 74}

In 2007-2008, approximately one in four boys and one in six girls 12–17 years of age in the general population were overweight or obese (Figure 2-3). Children and youth who are overweight or obese are more likely to be overweight or obese as an adult.

Figure 2-3. Proportion of individuals aged 12-17 years who were overweight or obese (based on body mass index), by sex, Canada, 2007-2008.

*Source: Public Health Agency of Canada, using data from the Canadian Community Health Survey 2007-2008, Statistics Canada.
*Differences between boys and girls statistically significant at p<0.05.

In 2007-2008, one in two adults aged 18 years of age and older (51%) reported a height and weight that put them in the overweight or obese category. The proportion of men who reported being overweight (BMI between 25 and 29.9) was significantly greater than among women in all age groups (Figure 2-4). The proportion of men in the obese category (BMI≥ 30) was significantly greater than women in all age groups except among those aged 60-69 and 70+ years. The largest proportion of men and women in the obese category was among men aged 50 to 59 years and women aged 60–69 years (23% and 22%, respectively). OA is also common in these age groups.

Figure 2-4. Proportion of individuals aged 18 years and older, who were overweight or obese (based on body mass index), by age and sex, Canada, 2007-2008

*Source: Public Health Agency of Canada using data from the Canadian Community Health Survey 2007-2008, Statistics Canada.

In 2007-2008, 63% of Canadians aged 18 years and over with arthritis reported a height and weight that put them in the overweight or obese category, versus 49% of those without arthritis (Figure 2-5). This difference was more marked among women than men. For example, among women in the 50 to 59 age group, 62% with arthritis were overweight or obese compared to 49% among those without arthritis. Among men of the same age, there was a smaller difference between those with and without arthritis, with proportions of overweight or obese men being 72% among those with arthritis compared to 66% for those without arthritis. Also, a greater proportion of women with arthritis aged 18-29 years (42%) were overweight or obese compared to 26% of women without arthritis. Among men of the same age, there was less of a difference with proportions of overweight or obese men being 56% for those with arthritis versus 41% for those without arthritis.

Figure 2-5. Proportion of individuals with and without arthritis aged 18 years and over who were overweight or obese (body mass index ≥ 25), by age and sex, Canada, 2007-2008

*Source:  Public Health Agency of Canada, using the Canadian Community Health Survey, 2007-2008.
*Differences between individuals with and without arthritis significantly at p<0.05, except men 30-49 years of age.

Joint injury

Injury is an important risk factor for the development of OA.^{Footnote 9 Footnote 57} cruciate ligament tears Meniscal and increase the risk of the subsequent development of OA.^{Footnote 9 Footnote 15 Footnote 75} Factors such as having OA in another joint, increasing age, being a woman, or the continued stress of the injured joint might increase the risk of developing OA following a severe knee injury.^{Footnote 15} While joint injuries may be preventable, once they occur, their impact may not be reversible.

Smoking

Smoking is associated with both the onset and development of inflammatory types of arthritis, namely RA and SLE.^{Footnote 16 Footnote 17 Footnote 24 Footnote 33 Footnote 76 Footnote 77}

The risk of developing RA is higher among smokers, especially men and it also appears to cause a more active, possibly more aggressive, form of RA. ^{Footnote 12 Footnote 22 Footnote 76 Footnote 78} Smokers are more likely to have a positive rheumatoid factor (RF), even in individuals who do not yet have RA.^{Footnote 12 Footnote 22 Footnote 24 Footnote 78 Footnote 79 Footnote 80 Footnote 81 Footnote 82 Footnote 83 Footnote 84} Smoking exacerbates the skin related features of SLE.

The mechanisms by which smoking affects inflammatory types of arthritis, and autoimmunity in general, are multiple and not yet well understood.^{Footnote 76 Footnote 81} The interaction of smoking with genetic susceptibility further complicates the understanding of these mechanisms.^{Footnote 76}

Occupation

An occupational exposure to crystalline silica has been identified as a strong risk factor for inflammatory types of arthritis.^{Footnote 77} Mineral dust and vibration exposure have been suggested as possible risk factors for the development of RA, particularly among men.^{Footnote 11 Footnote 82}

A strong association was found between occupational activities such as repeated knee bending, kneeling, squatting, or climbing and knee OA among men.Footnote 9 Footnote 14 Also, a strong association was found between agriculture (including farm work, dairy, animal breeding and producing animal products) and hip OA; and more recently farming has been associated with OA of the knee.Footnote 9 Footnote 57 Footnote 83

Infections

For many years, infection has been suggested as a possible initiator for inflammatory types of arthritis.^{Footnote 12 Footnote 19 Footnote 20 Footnote 77} Certain viruses have been suggested as contributors to the development of RA and SLE. It is believed that viruses initiate the inflammatory process at the infected site, which in turn play a role in the initiation of RA.^{Footnote 22} Viruses may initiate this process by targeting the cells involved in immune function or by directly impacting joint tissues.^{Footnote 84} The most consistent evidence has been found with the Epstein-Barr virus (EBV) which has been implicated as a potential risk factor for RA for over 25 years, but it remains unknown as to whether it is a cause or a consequence of RA.^{Footnote 16 Footnote 22}

Reducing the impacts of arthritis

The impacts of all types of arthritis can be minimized through:

• Education and awareness about arthritis;
• Early recognition of symptoms, early disease detection and diagnosis;
• Self-management including education, physical activity and weight control/exercise programs; and
• Appropriate treatment including medication, rehabilitation and surgery.

These interventions aim to stop or slow down the progression of the disease and reduce disability and other health complications from arthritis.

Education and awareness

Studies have shown that the general public is poorly informed about arthritis and that the public perception is permeated by many myths (see 'Common myths about arthritis').^{Footnote 85 Footnote 86 Footnote 88}

A recent study concluded that some of these beliefs endure and continue to exert an impact on the care- seeking behaviours and the uptake of treatment by individuals with arthritis symptoms or with diagnosed arthritis.^{Footnote 89}

Common myths about arthritis

"Arthritis is an old person's disease"

Although the risk for arthritis increases with age, nearly 3 out of 5 with arthritis are younger than age 65. People of all ages are affected, including children and teens. Juvenile rheumatoid arthritis is one of the most common chronic illnesses of childhood.

"Arthritis is just a normal part of aging"

If this were true, the majority of seniors and no children would have arthritis. In reality, 57% of seniors (> 65 years) don't have arthritis. In addition, two thirds of individuals with arthritis are under the age of 65 and arthritis affects children. Furthermore, some forms of arthritis (e.g. OA and gout) can be prevented.

"Arthritis isn't a serious condition; it's just minor aches and pains. It's best to ignore it"

Most of the joint damage associated with inflammatory arthritis occurs within the first few years after its onset; early and accurate diagnosis is crucial to minimizing its effects.

"There is nothing that can be done for arthritis. You just have to learn to live with it"

While there is currently no cure for arthritis, a person can do many things to relieve the pain, reduce disability and help maintain their ability to do the things that they enjoy. Early diagnosis and appropriate treatment strategies can help reduce the disability and quality of life impacts associated with many types of arthritis. Physical activity, healthy weight, self-management education, rehabilitative interventions, medication, and in severe cases, surgery, can make a difference.

"Joints with arthritis should be rested"

The assumption that an inflamed or painful joint requires rest is a common misunderstanding. Too little exercise can cause muscle weakness, pain and stiffness. People with arthritis should undertake some form of physical activity (as recommended by a physician or a physiotherapist/occupational therapist) such as:

• mobility exercises (e.g., stretching) to improve or maintain the joint's range of motion and flexibility;
• strength exercises, such as weight-bearing activities to build muscle strength, provide stability to the joint, and improve function; and
• aerobic exercises, such as walking or cycling, to improve cardiovascular fitness.

Early symptom recognition, early detection and diagnosis

Early diagnosis of inflammatory types of arthritis, such as RA, is particularly important, since early, aggressive therapy may be associated with improved outcomes^{Footnote 56} Some forms of arthritis, such as lupus, may have a wide variety of clinical presentations that may or may not involve the joints. A complete medical history and physical examination will allow the physician to develop a differential diagnosis, order the appropriate laboratory tests and ultimately formulate a diagnosis and treatment plan.^{Footnote 56}

Public awareness of the value of early recognition of symptoms, diagnosis and treatment is important. Many people with arthritis do not consult with their physician for their symptoms, especially if they are generally in good health and have few activity or work limitations.^{Footnote 90}

Initiatives such as the " Getting a Grip on Arthritis " program have been applied successfully in Canada.^{Footnote 91} They increase the capacity of health providers and people with arthritis to work together to manage the disease by supporting the delivery of arthritis care and emphasizing prevention, early detection, comprehensive care, appropriate and timely access to specialty care, and self-management.

Self-management

Self-management refers to the tasks that a person must undertake in order to live well with one or more chronic conditions. These tasks include developing the confidence to deal with the medical management, life's roles and emotional management of their conditions.^{Footnote 92}

Self-management activities, such as participation in education programs and physical activity are central to the non-pharmacological management of arthritis. The American College of Rheumatology^{Footnote *} practice guidelines for OA (knee and hip), RA and SLE include self-management programs and patient education as important components of non-pharmacological treatment for these conditions.^{Footnote 94}

Three self-management activities are discussed:

• self-management education, e.g. learning how to control symptoms, medication use, etc;
• maintaining regular, moderate intensity physical activity; and
• controlling weight.^{Footnote 90}

Self-management education is designed to build confidence and skills in managing arthritis on a daily basis. Self-management education programs differ from patient education or skills training in that they are designed to allow people with chronic conditions to take an active part in the management of their own condition.^{Footnote 95} Program participants learn to gain self- confidence in their ability to control symptoms, how to develop action plans to manage their arthritis, and make connections with others living with arthritis.

Many self-management programs are available throughout Canada (for more information visit the Arthritis Society website (www.arthritis.ca) and the Arthritis Consumer Experts website (www.jointhealth.org). Benefits from participating in such programs include:

• reduced pain;
• increased self-care;
• improved functional ability;
• greater confidence in managing the disease;
• increased understanding of arthritis;
• increased coping skills; and
• greater participation in managing the disease.^{Footnote 98}

Medication

For most types of arthritis, treatment often involves the use of medications aimed at reducing pain, maintaining joint function and limiting disease progression. These medications can be used alone or in combination as part of an individual's treatment plan. In recent years, the development of medications for arthritis has advanced and changed significantly. Currently, medications for treating arthritis include analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, disease-modifying anti- rheumatic drugs (DMARDs) and biologic response modifiers (also known as biologics). These medications and their use in the treatment of particular types of arthritis are discussed in more detail in Chapter 7.

Rehabilitation

All types of arthritis are commonly associated with limited function that can be improved using a wide variety of rehabilitation interventions aimed at the whole person and not just the affected structure. They differ depending on the person's condition, needs and health status.

Joint-specific exercises, physical fitness programs, the use of braces, aids and devices, as well as participation in self-management programs can improve activity and participation. They can help an individual develop a more active lifestyle and reduce the pain associated with arthritis, particularly OA and RA.^{Footnote 99}

Surgery

Surgery is normally considered for people with persistent pain despite optimal medicinal, physical and rehabilitative therapies. Several interventions can be performed, depending on the condition, severity, functional limitation or pain. The most well known interventions are arthroscopy, osteotomy and arthroplasty (or joint replacement). Surgery is recommended primarily for people with OA and RA who have end-stage joint damage that is causing unacceptable pain or limitation of function with significant alteration of joint anatomy.^{Footnote 99} It may also be indicated for spondyloarthropathies such as psoriatic arthritis and AS.^{Footnote 99} Further discussion about the utilization of surgical services can be found in Chapter 9.

Summary

• Maintaining a healthy body weight and avoiding joint injuries, including sports injuries and occupational-related joint stress, can help to prevent OA.
• Lifestyle changes recommended for the prevention of gout include maintaining a healthy body weight, daily exercise and a reduced consumption of purine-rich foods such as red meat, seafood and alcohol.
• Physical inactivity and obesity can aggravate the progression or severity of many forms of arthritis.
• 50% of the general Canadian population and 59% of Canadians with arthritis reported being physically inactive during their leisure time.
• 51% of the general Canadian population and 63% of Canadians with arthritis reported a height and weight that put them in the overweight or obese category.
• Infections, smoking and diet may play a role in the onset or severity of symptoms in some forms of inflammatory types of arthritis, such as RA or SLE.
• Appropriate management and early diagnosis can help reduce the impact of arthritis. A combination of strategies may be required, including:
  • education about self-management, pain management, and the disease itself;
  • counselling and support;
  • occupational and physical therapy;
  • physical activity;
  • weight reduction;
  • maintenance of a healthy diet;
  • joint protection;
  • prescription and/or over-the-counter medications; and/or
  • surgery.