A study reported in The Journal of Rheumatology (volume 35, page 398) reveals that the dual serotonin and norepinephrine reuptake inhibitor milnacipran (Savella) is a safe and effective treatment for fibromyalgia. Savella was approved in 2009 for use in fibromyalgia.

The trial randomized 888 patients with fibromyalgia to receive 100 mg per day of milnacipran, 200 mg per day of milnacipran, or placebo. Acetaminophen and NSAIDs such as aspirin were the only pain medications allowed during the study.

After 15 and 27 weeks of fibromyalgia treatment, significantly more participants in the medication groups than in the placebo group achieved three treatment goals: a 30% reduction in pain, saying that they were "very much" or "much" improved, and an improvement in physical functioning. Fatigue, which is common in people with fibromyalgia, also improved in people getting the medication for fibromyalgia.

About 42% of the participants discontinued treatment; people assigned to placebo quit most often because they did not get symptom relief, while those taking milnacipran tended to quit because of difficulties with nausea or palpitations. Nausea occurred in 33 to 40% of people taking milnacipran.

If you have fibromyalgia that hasn't responded to other therapies, ask your doctor if you might be a candidate for a dual serotonin and norepinephrine reuptake inhibitor.

Dr. Deborah Sellmeyer, Medical Director of The Johns Hopkins Metabolic Bone Center, talks about preventing osteoporosis by building bone density with exercise.

Q. How does weight-bearing exercise affect bone density?

Dr. Sellmeyer: Physical activity is very important for preventing osteoporosis. The pure bio-mechanical pull of muscle on bone is a stimulus for the bone to grow, incorporate mineral, and become stronger. People who don't get that stimulus -- such as astronauts in space or immobilized people on Earth -- start losing bone at a very rapid rate. Ideally, people should perform weight-bearing activities throughout their lives to build bone and maintain bone density.

Physical activity makes a big difference, even in childhood. For example, there have been trials in which one group of children was assigned to an exercise program in which they jumped up and down off boxes of varying heights. A second group of children was instructed to simply continue their usual daily activities. The researchers reported that the kids in the exercise group gained significantly more bone than the other kids. That's because the jumping activity gave them more weight-bearing stress on their bones.

It's never too late to adopt a bone-friendly exercise program. In one study of postmenopausal women, researchers reported that a regimen of daily brisk walking and simple gymnastic training led to a significant increase in the women's lumbar BMD. Even a minimal amount of weight-bearing activity can help older adults gain bone, but continuous training is needed to maintain the benefits gained through exercise.

Q. What types of weight-bearing exercise do you recommend?

Dr. Sullmeyer: Certain types of exercise are more beneficial than others for preventing osteoporosis. In adults with sufficient physical capacity, running and jumping activities such as playing tennis or jumping rope are excellent. But if you don't have the physical capacity for such vigorous exercise, even daily walks will help strengthen your bones. Your regular exercise routine should include weight-bearing and resistance exercises and ideally should begin in childhood or adolescence -- or at least well before menopause.

In weight-bearing exercises -- such as brisk walking, stair climbing, jogging, and dancing -- the bones and muscles work against gravity and the feet, legs, and spine bear the body's weight. This type of exercise helps strengthen the lower body and spine. (In contrast, while activities such as swimming and bike riding can be good for your muscles, joints and heart, they are not weight-bearing activities and therefore should not be your only form of exercise.)

In resistance exercises, the muscles work against weights. Either free weights (such as dumbbells) or weight machines can be used for resistance training. This type of exercise is especially ideal for building bone mass in the upper body, an area that is weak in most women. Proper instruction and technique for performing the exercises are essential to avoid injury.

Johns Hopkins Health Alerts |

Arthritis | Delay Knee Replacement with Osteotomy

Improved alignment of the knee through osteotomy takes stress off damaged areas and can delay the need for joint replacement by about 10 years for people with osteoarthritis of the knee.

Osteoarthritis often damages the cartilage more on one side of the knee than on the other. When that happens, the leg bones become misaligned, which can put even more stress on the already damaged joint.

Osteotomy is a "bone-cutting” surgical procedure that shifts the individual’s body weight from the damaged area of the knee toward the healthy side. This relieves pain and allows the knee to function more normally -- and that can buy time for a person who would like to delay total knee replacement surgery.

In an osteotomy for knee osteoarthritis, the surgeon removes a wedge of bone from the healthy shinbone (tibia). If the cartilage damage is on the inner side of the knee, bone is removed from the outer part of the shinbone; for damage to the outer side of the knee, bone is removed from the inner shinbone. The bone is taken from an area below the healthy cartilage. This allows the knee joint to open more freely and redistributes the weight across the joint.

Performed under general or regional anesthesia, osteotomy takes about 60–90 minutes to complete. The surgeon makes a 4- to 5-inch incision from just below the kneecap to below the top of the shinbone, and uses guide wires anchored into the top of the shinbone to outline the triangular area to be cut. The wedge is removed with an oscillating saw, and the top of the shinbone is lowered to reposition the joint. The realigned joint is held in place with staples or internal plates, or it may be immobilized with a cast.

Rehabilitation begins almost immediately after surgery with passive-motion exercises to flex and stretch the knee and restore adequate range of motion. You will be fitted with a knee brace (unless your leg is put in a cast) and will be on crutches for at least six weeks.

Physical therapy usually begins at about six to eight weeks, after the bone has had a chance to heal. The therapist will teach you stretching exercises at first and then strengthening and light aerobic activities.

Is Osteotomy Right for You? Osteotomy may be a good option for people under age 60 who want to delay a total knee replacement. Delaying knee replacement makes sense, because artificial knees wear out over time, often necessitating a second replacement surgery. Osteotomy can delay the need for joint replacement by about 10 years. The procedure is appropriate only when damage to the joint is uneven and no significant inflammation is involved.

Johns Hopkins Health Alerts |

Arthritis | Delay Knee Replacement with Osteotomy

Johns Hopkins Health Alerts |

Arthritis | Evidence Against Glucosamine Use for Osteoarthritis Pain

Do glucosamine chondroitin supplements actually work for osteoarthritis pain, or are their “effects” really just wishful thinking by people desperate to find some relief?

Over 20 million Americans suffer from osteoarthritis -- which means that 20 million Americans are looking for relief from osteoarthritis pain. That’s no small task, especially after the recall of the two COX-2 inhibitors, Vioxx and Bextra.

One popular treatment for osteoarthritis is the supplement glucosamine. Glucosamine, usually made from crustacean shells, contains an amino sugar compound found in cartilage. Supplement manufacturers claim that taking glucosamine supplements will help preserve and repair cartilage in arthritic joints, although it is unknown exactly how the body processes this extra glucosamine -- or even whether it is delivered to the joints. Some glucosamine supplements also contain chondroitin, another natural component of cartilage. Chondroitin is believed to promote cartilage elasticity and prevent cartilage breakdown, but again it’s unknown how or if the chondroitin reaches the joint tissue.

How effective are glucosamine chondroitin supplements? A large-scale study conducted by the National Institutes of Health hopes to answer this question. While the full verdict isn’t in yet, preliminary results suggest that glucosamine chondroitin supplements may not live up to manufacturers’ claims.

The Glucosamine Chondroitin Arthritis Intervention Trial (GAIT) involved almost 1,600 patients with knee osteoarthritis. Participants were assigned to six months of treatment with one of five regimens: 1,500 mg of glucosamine hydrochloride daily, 1,200 mg of chondroitin sulfate daily, a full-dosage combination of both glucosamine and chondroitin sulfate daily, 200 mg of celecoxib daily, or placebo. All study participants were allowed up to 4,000 mg of acetaminophen per day if needed for pain relief, though on average they took less than 1,000 mg per day. Patients reported the intensity of their pain symptoms on a scale from 1 to 5. Effective treatment was defined as a 20% improvement in pain.

Overall, glucosamine and chondroitin supplements were no more effective than placebo: Both groups reported similar improvements. As was expected, people taking celecoxib had the greatest improvement. Glucosamine chondroitin supplements did appear to work better for participants suffering from moderate to-severe pain: 79% of the glucosamine chondroitin supplement group reported an effective reduction in pain, compared with just 54% of the placebo group.

So are glucosamine chondroitin supplements worth the expense? Clifton O. Bingham III, M.D., assistant Professor of Medicine at Johns Hopkins in the Arthritis Center says, “If people are not having any improvement after taking a supplement for some time, our data would suggest that there is little point in continuing.” In the end, proven painkillers— such as acetaminophen, NSAIDs, and celecoxib—will get you the most pain relief for your money. However, Dr. Bingham stresses that pain relievers are only one component of effective osteoarthritis management. "Though most people want a magic bullet, the fact remains that the best responses are seen in people who are willing to engage in regular activity and lose weight.” He also stresses that when discussing treatment options with your doctor, it’s important to mention any medications and supplements you use.

For more Alerts and Special Reports, please visit the Arthritis Topic page.

Johns Hopkins Health Alerts |

Arthritis | Evidence Against Glucosamine Use for Osteoarthritis Pain

Bone spurs -- also called osteophytes -- are benign, bony bumps that usually form on the joints. Most are harmless and never detected. But if they limit your movement or cause pain, treatment is available. Here’s what you should know.

To some extent, bone spurs are just a normal part of aging; your body may produce them to compensate for gradual bone loss that occurs overtime. Bone spurs may also be a result of arthritis or other bone diseases. As cartilage in the joints wears away in arthritis patients, bones begin to rub directly against each other and bone spurs develop. These bumps may protrude into surrounding tendons or break off and float in the space within joints, causing swelling or interfering with range of motion.

In the spine, bone spurs may lead to stenosis (narrowing of the spinal canal) and exert pressure on the nerves, causing muscle weakness, tingling, loss of coordination, or radiating pain in the buttocks, thighs, or shoulders. Bone spurs in the spine's cervical region can push into the throat, making it difficult to swallow or breathe. Symptoms like these may indicate diffuse idiopathic skeletal hyperostosis (DISH), a condition characterized by multiple bone spurs and ossified ligaments, usually in the spine (though DISH can affect other areas of the body).

If you are experiencing symptoms, your doctor will examine you and possibly order x-rays or other imaging tests. The best way to treat a bone spur is by addressing the underlying cause. In addition to arthritis and other medical conditions like DISH, excess weight, bad posture, old athletic injuries, or even shoes that don't fit well may be to blame.

Conservative therapy usually involves rest, icing, stretching, and non-steroidal anti-inflammatory drugs (NSAIDs ). Also, even though your symptoms may seem to worsen with movement, targeted physical therapy exercises can restore range of motion in the joints and promote good posture (which reduces pressure on nerves). For temporary relief of serious pain, you may be given cortisone shots.

Surgical removal is an option for more severe symptoms, particularly if you already require surgery for arthritis. Some people choose to have bone spurs taken out for cosmetic reasons, especially when the hands are affected. Removal can be performed through open or laparoscopic procedures.