What causes joint pain?

When a joint is healthy, all of the parts work together and the joint moves easily and without pain. However, diseases or injury can disturb the normal functioning of your joints resulting in:

• Pain
• Muscle weakness
• Limited movement

Arthritis is one of the most common causes of joint disorders. More than 42 million people in the United States are diagnosed with arthritis.* The most common types of arthritis are:

• Osteoarthritis
• Rheumatoid Arthritis
• Post-Traumatic Arthritis
• Paget’s Disease
• Avascular Necrosis

Other causes of joint pain are deformity or direct injury to the joint. And sometimes, regardless of the cause of your pain, it can be made worse when you avoid using your joint altogether. That’s because with less use, the muscles around your joint weaken, which can make it even more difficult and painful to move.

Osteoarthritis (OA)

Osteoarthritis is sometimes called degenerative arthritis because it is a “wearing out” condition involving the breakdown of cartilage in the joints. Joint cartilage is a gel-like protective tissue found at joint surfaces that provides support and lubrication during movement. When cartilage wears away, the bones rub against each other, causing pain and stiffness. OA usually occurs in people over age 50, and often in people with a family history of osteoarthritis.

Rheumatoid Arthritis (RA)

This disease produces chemical changes that cause the synovial membrane (the membrane that surrounds the joint) to become thickened and inflamed. In turn, too much synovial fluid (the fluid that lubricates the joints) is produced. The result of this chronic inflammation is cartilage loss, pain, and stiffness. RA affects women about three times more often than men,* and may affect other organs of the body, including the skin and heart.** *www.mothernature.com **www.jointpainny.com

Post-Traumatic Arthritis

This condition may develop after an injury to the joint in which the bone and cartilage do not heal properly. The joint is no longer smooth, and these irregularities lead to more wear on the joint.

Paget’s Disease

This is a bone disease that often affects the hip, in which bone formation is accelerated. The density and shape of the bone changes, which in turn causes bone pain and inflammation of the joints.

Avascular Necrosis

This disease can result when a bone is deprived of its normal blood supply, which may happen after organ transplantation or long-term cortisone treatment. Without proper nutrition from the blood, the bone’s structure weakens and may collapse and damage the cartilage.

Osteoarthritis – Definition

Osteoarthritis, sometimes referred to as degenerative joint disease, is a type of arthritis that affects the cartilage around joints. Joint cartilage is a gel-like protective tissue found at joint surfaces that provides support and lubrication during movement. When the surface layer of this tissue breaks down, the bones rub together during joint movement, causing pain, swelling, and restricted movement. Although it can occur in any joint, osteoarthritis most often involves the hands, knees, hips, and spine. It is thought that a number of factors cause this condition, including the natural aging process, joint injury, and repetitive stress from certain jobs or sports activities. Diabetes, gout, and some genetic conditions may also put you at risk.

Osteoarthritis Treatment

The treatment for osteoarthritis concentrates on preventing further joint damage. Lifestyle changes such as weight loss, joint strengthening exercises, and assistant devices (orthoses) are recommended. Physical therapy may also help restore joint movement. Your doctor may initially suggest acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) to minimize pain. In later stages of the disease, several surgical options may need to be discussed. Arthroscopy, for example, entails using a camera to examine the joint and repair the cartilage at the joint surface. Arthrodesis involves the surgical fusion of the bony ends of the joint. Replacement with an artificial joint to maintain function is yet another surgical option. If you suspect that you have signs or symptoms of osteoarthritis or have risk factors for osteoarthritis, please see your doctor to discuss further evaluation and treatment.

What is rheumatoid arthritis (RA)?

Rheumatoid arthritis (RA) is an autoimmune disease in which the body’s natural immune response wreaks havoc on the lining of the joints (called the synovial membrane), causing chronic inflammation and pain.¹ The inflammation may eventually damage the joint’s cartilage and bone, weaken the soft tissue around the joint (cartilage, ligaments and tendons) and prevent the joint from working properly.¹

Who does RA affect?

More than two million people in the United States have been diagnosed with RA.² RA can affect anyone at any age, but women appear especially at risk. In fact, women develop RA more than twice as often as men.³ Although the medical community does not know what causes RA, today’s best research has identified a genetic marker, found in white blood cells, that may help doctors determine if a particular person is at an increased risk.^{2, 3}

What are the symptoms of RA?

RA is a chronic, persistent disease that seems to take its own course over an affected person’s lifetime. It may progress slowly, sometimes produce “flare ups” of symptoms, and then at times go into “remission” during which the symptoms may greatly diminish or disappear. Unfortunately, RA never seems to go away completely. Doctors sometimes talk about the three stages of RA. Those stages are identified by specific symptoms. In the first stage, RA causes pain, warmth, redness and swelling in affected joints. In the second stage, it causes thickening of the joint lining. In the third, permanent joint damage begins to occur as bone and cartilage are attacked by the enzymes released by the inflamed cells in the affected joint’s once-healthy cushioning fluid (called synovial fluid).^{1, 4} In addition to joint pain, swelling and stiffness, the symptoms of RA commonly include fatigue, weakness, flu-like symptoms accompanied by a low-grade fever, loss of appetite, depression, chronic dry eye or dry mouth and, in people with more advanced RA, bumps (called rheumatoid nodules) under the skin.^{1, 5} Without question, left untreated, RA can greatly reduce your quality of life. You may have already begun to decrease your activity level just to avoid the pain caused by a joint affected by RA. It’s not uncommon for the joint damage caused by RA to lead to a loss of movement, an inability to work, and even the need for surgery to repair the damage.⁴ In order to diagnose you properly, your doctor will consider your symptoms and your medical history, examine your joint(s) and order one or more diagnostic tests. Your doctor may order blood work, X-rays, a CT scan or an MRI to get a clear view of your condition.

How is RA treated?

Your primary doctor will refer you to a rheumatologist, a doctor who specializes in inflammatory diseases like RA. Your rheumatologist may recommend different treatment options depending on the severity of your RA and its impact on your joint(s) and your body as a whole. And while there is no cure, RA can be controlled through the use of new drugs, exercise, joint protection techniques and self-management techniques.

Manage the pain and preserve your joint.

Today, most doctors understand the value of treating RA more aggressively with very specific medications in order to slow the progression of the disease, joint deformity and loss of function.¹ Your doctor may prescribe any one of these medications, or a combination of several: non-steroidal anti-inflammatory medications (NSAIDs), analgesics, steroids, disease modifying anti-rheumatic drugs (DMARDs) or biologic response modifiers that work on the immune system.

Look at the big picture.

Your doctor may recommend that you modify your diet, take certain nutritional supplements, exercise and get adequate sleep. Your doctor may also encourage you to learn about how managing your stress and learning some relaxation techniques may help improve your quality of life and help you to handle your RA symptoms with greater ease.⁶

Understand your surgical options.

If you are still experiencing arthritis pain and joint damage that’s affecting your quality of life even after all other conservative measures have been taken, your doctor may suggest surgery to help relieve your pain and restore your mobility. Your doctor will determine the proper surgical treatment based on the severity of your arthritis. Today, a full range of surgical solutions exist that enable your doctor to customize surgical procedures to your particular needs and anatomy, whether you need arthroscopic debridement (removing inflamed and/or irritating debris from the joint), arthrodesis (fusing the joint for greater support) or arthroplasty (replacing the arthritic joint). Be sure to talk with your doctor about the best treatment option for you.

References: 1. NIAMS: National Institute of Arthritis and Musculoskeletal and Skin Diseases. Handout on Health: Rheumatoid Arthritis. National Institutes of Health, Department of Health and Human Services. Available at: http://www.niams.nih.gov/Health_Info/Rheumatic_Disease/default.asp. Accessed February 6, 2008. 2. Arthritis Foundation. Rheumatoid Arthritis: Overview. Accessed February 5, 2008. 3. Arthritis Foundation. Rheumatoid Arthritis: Who Gets It? Available at: http://www.arthritis.org/disease-center.php?disease_id=31&df=whos_at_risk. Accessed November 5, 2008. 4. Arthritis Foundation. Rheumatoid Arthritis: What Is It? Available at: http://www.arthritis.org/disease-center.php?disease_id=31. Accessed February 6, 2008. 5. Arthritis Foundation. Rheumatoid Arthritis: Symptoms. Accessed February 6, 2008. 6. Haaz S. Patient Education: Counseling RA Patients about Lifestyle and Diet Changes. Arthritis Practitioner. Available at: http://www.arthritispractitioner.com/article/4602. Accessed February 4, 2008. © Stryker Orthopaedics 2008

Understanding Osteonecrosis

Your doctor has provided this information to answer some of the questions you may have about osteonecrosis and how it may affect you. It will also help you better understand what to expect when osteonecrosis has an impact on your joints and requires medical treatment.

What is osteonecrosis (ON)?

Osteonecrosis is a disease that results from a loss of blood supply to the bone. Without adequate blood flow, sections of bone eventually die, weaken and collapse. Because this is most often seen at the ends of bones, your joints may be greatly affected. This is especially true of the hip joint, as osteonecrosis most commonly appears at the end of the femur (the long bone that extends from the knee to the hip joint). Medical experience has shown that wherever osteonecrosis causes bone to degrade in a joint, arthritis develops.^{1, 2} You may hear osteonecrosis referred to as avascular necrosis, asceptic necrosis and ischemic necrosis. The word osteonecrosis literally means “dead bone”.

Who does ON affect?

Each year between 10,000 and 20,000 men and women develop osteonecrosis.³ Although ON can affect anyone at any age, most people who develop ON are between 30 and 50 years old.¹ Orthopaedic surgeons have found that in as many as ten percent of all people requiring hip replacement, osteonecrosis has led to their joint damage. Even though medical science has learned a lot about osteonecrosis and its potential causes, research into contributing genetic risk factors is ongoing. To date, we know that you may be at an increased risk for developing ON if you’ve dislocated or fractured a hip, suffer with alcoholism, use corticosteroids, or have any number of glandular diseases, including rheumatoid arthritis, Gaucher’s disease, chronic pancreatitis, Crohn’s disease or lupus.³

What are the symptoms of ON?

Patients with early stage osteonecrosis may not have any symptoms. Later symptoms include pain, diminished range of motion and the development of osteoarthritis. Osteonecrosis progresses differently in each person affected by it, however the time between feeling the first symptoms of joint pain and losing joint function is usually anywhere from a few months to over a year.¹ In order to diagnose you properly, your doctor will consider your symptoms and your medical history, examine your joint(s) and order one or more diagnostic tests. Your doctor may order X-rays, a CT scan, bone scan, a biopsy or an MRI to get a clear view of your condition.

How is ON treated?

Your doctor may recommend different treatment options depending on the severity of your ON and its impact on your joint(s) and your body as a whole. Your doctor may be especially interested in the condition of your femur and whether the head of the bone is still intact.

Manage the pain and preserve your joint.

Your doctor’s priorities will include alleviating your pain, improving your function, preventing further joint damage and saving as much of your natural bone as possible. To accomplish this, you may be treated with very specific medications in order to slow the progression of the disease, joint deformity and loss of function.¹ Your doctor may prescribe any one of these medications, or a combination of several: non-steroidal anti-inflammatory medications (NSAIDs), blood thinners (to increase blood flow to the affected bone) or cholesterol-lowering medications (often called statins), especially if corticosteroid use has elevated your cholesterol level.

Get the right support.

Your doctor may recommend that you reduce weight bearing on the affected joint. That may mean that you’ll be asked to use a crutch or limit your activities to permit your joint to heal while you’re under treatment. Your doctor may also recommend some range-of-motion exercises, or even prescribe a course of physical therapy so a trained therapist can guide you through specific movements. Some studies have shown that electrical stimulation (a painless, non-invasive therapy) may promote healthy new bone growth.¹

Understand your surgical options.

If you are still experiencing pain and joint damage that’s affecting your quality of life even after all other conservative measures have been taken, your doctor may suggest surgery to help relieve your pain and restore your mobility. Your doctor will determine the proper surgical treatment based on the severity of your condition. Today, a full range of surgical solutions exist that enable your doctor to customize surgical procedures to your particular needs and anatomy, whether you need core decompression, osteotomy (re-shaping the bone), bone grafting (which may help your body create healthy new blood vessels and bone cells) or arthroplasty (replacing the affected joint). For people diagnosed with osteonecrosis, treatment and medical management of the disease may continue throughout their lifetime. Be sure to talk with your doctor about the best treatment option for you.

References: 1. NIAMS: National Institute of Arthritis and Musculoskeletal and Skin Diseases. Osteonecrosis. National Institutes of Health, Department of Health and Human Services. Available at: http://www.niams.nih.gov/Health_Info/Osteonecrosis/default.asp. Accessed February 6, 2008. 2. Arthritis Foundation. Avascular Necrosis (Osteonecrosis): What causes it? Available at: http://www.arthritis.org/disease-center.php?disease_id=3&df=causes. Accessed February 5, 2008. 3. AAOA: American Academy of Orthopaedic Surgeons. Osteonecrosis of the hip. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=A00216. Accessed February 6, 2008. © Stryker Orthopaedics 2008

What is Osteoporosis?

Osteoporosis is a skeletal disease characterized by low bone mass that results in a reduction in the strength of the skeleton.

Normal Bone

Osteoporotic Bone

The Scope of the Problem

• Osteoporosis affects as many as 44 million Americans
• 80% of those affected are women
• One in two women and one in four men over age 50 will have an osteoporosis-related fracture in her/his remaining lifetime
• While osteoporosis is often thought of as an older person’s disease, it can strike at any age

Consequences of Osteoporosis

• Increased risk of fracture of the hip, spine, and wrist
• Morbidity and mortality from fracture – Over 300,000 hip fractures/year – A 50-year-old white woman has a 15% lifetime probability of suffering a hip fracture
• Healthcare costs – 2002: $18 billion

Fractures of the Hip and Spine

Osteoporosis and Osteoarthritis

Who is at Risk? Risk Factors for Osteoporosis

• Age
• Gender
• Race
• Bone structure and body weight
• Menopause and menstrual history
• Lifestyle
• Medications and disease
• Family history

Following the orthopaedic evaluation, the orthopaedic specialist will review and discuss the results with you. Based on his or her diagnosis, your treatment options may include:

Non Surgical Options

Diet & Exercise

• Average American is 20–40 lbs. overweight.
• Average person takes 5000–7000 steps/day.
• Reduces stress on weight-bearing joints (extra pressure on some joints may aggravate your arthritis).
• A balanced diet helps manage weight and stay healthy.

ROM Exercises

• Maintains normal joint movement.
• Increases flexibility.
• Relieves stiffness.

Strengthening Exercises

• Increasing muscle strength helps support and protect joints affected by arthritis.
• Exercise is an important part of arthritis treatment that is most effective when done properly and routinely.

Aerobic Exercise

• Improve cardiovascular fitness.
• Helps control weight.
• May help reduce inflammation in joints.

Rest & Joint Care

• Short-term bed rest helps reduce both joint inflammation and pain, and is especially useful when multiple joints are affected and fatigue is a major problem.
• Individual joint rest is most helpful when arthritis involves one or only a few joints.
• Heat Therapy (increases blood flow, tolerance for pain, flexibility).
• Cold Therapy — cold packs, ice massage, OTC sprays and ointments (reduces pain by numbing the nerves around the joint).
  

  Physical Therapy

  The goal is to get you back to the point where you can perform normal, everyday activities without difficulty.

  • Preserving good range of motion is key to maintaining the ability to perform daily activities.
  • Physical therapists provide exercises designed to preserve the strength and use of your joints.
    • Show you the best way to move from one position to another.
    • Teach you how to use walking aids.

  Walking Aids

  Your doctor may recommend a cane, walker or brace.

  Medications

  • Analgesics, pain relievers, may provide temporary relief of arthritis pain. Aspirin, ibuprofen and naproxen are traditional pain relievers.
  • Topical pain relievers are another option. Over-the-counter patches, rubs and ointments can provide quick pain relief for people with arthritis that is in just a few joints — such as a hand — or whose pain isn’t severe.

  Glucosamine

  Glucosamine and chondroitin may relieve joint pain.

  • Occur in the body naturally; vital to normal cartilage function.
  • Researchers are also studying chondroitin for use in making medicines more effective and helping to prevent blood clots (anticoagulant).
  • Not FDA approved.
  • Warrant further in-depth studies on their safety and effectiveness, according to the Arthritis Foundation.
  • May help osteoarthritis pain and improve function.^{1, 2}

  Some studies indicate that glucosamine may help as much as ibuprofen in relieving symptoms of osteoarthritis, particularly in the knee, with fewer side effects.³ Side Effects These arthritis supplements are generally well tolerated. However, side effects can occur. The most commonly reported side effects are:

  • Nausea.
  • Diarrhea or constipation.
  • Heartburn.
  • Increased intestinal gas.

  See your doctor for complete information.

Glucosamine and Chondroitin

Your doctor has provided this information to answer some of the questions you may have about nutritional supplements that may be linked to improved joint health. The possible beneficial effects of glucosamine and chondroitin, two popular supplements for patients with joint pain, have been making news in recent years. This information is intended to help you better understand who might benefit from the supplements and why.

What are glucosamine and chondroitin?

Glucosamine and chondroitin are actually two different molecules found in healthy joint cartilage. The medical theory behind taking these supplements is that they would help the body repair cartilage that has been broken down by osteoarthritis (the most common “wear-and-tear” form of arthritis). Some popular glucosamine supplements are derived from shellfish; chondroitin supplements are often derived from shark or cattle. Both can also be made synthetically. The supplements are sold and packaged much in the same way vitamins are. Like vitamins, they are not subject to review or approval by the U.S. Food and Drug Administration.

Do glucosamine and chondroitin help reduce arthritis pain?

Although the U.S. Food and Drug Administration has tentatively concluded that no studies to date have linked glucosamine and chondroitin to a reduced risk of developing osteoarthritis¹, a large study administered by the National Institutes of Health has shown that glucosamine and chondroitin, when taken together, significantly reduce pain in patients with moderate-to-severe osteoarthritis of the knee.² In fact, the study showed that people taking the supplements experienced the same amount of pain relief as people who took non-steroidal anti-inflammatory medications (NSAIDs)³ – long the go-to medication for people with arthritis pain. What sounds even better, treatment with glucosamine and chondroitin supplements has not been associated with any side effects. NSAIDs, on the other hand, have been associated with gastrointestinal side effects, including bleeding.³

Make a Plan with Your Doctor

Don’t assume that your doctor will not take your interest in nutritional supplements seriously. Many doctors understand how some supplements can complement your current arthritis treatment plan.⁴ Your doctor can also help you determine if a particular supplement is right for you given your overall health. Your doctor can also help monitor the effectiveness of your supplement regimen.

A Word of Caution

Because vitamins and other nutritional supplements are not monitored by any federal agency to assure purity or dosage, you’ll want to do your homework before you purchase or consume anything. Look for a familiar, reputable brand name. If you have questions about the product, write to the manufacturer for more information. Ask your doctor about his or her experience with the supplement. And, most importantly, if you experience any adverse reactions, stop taking the supplement and call your doctor right away. For more information on glucosamine and chondroitin, talk with your doctor or visit the National Institutes of Health website at www.nih.gov.

References: 1. U.S. Food and Drug Administration. Food Advisory Committee: FDA’s Tentative Conclusions. U.S. Department of Health and Human Services. Available at: U.S. Food and Drug Administration. Accessed February 6, 2008. 2. NCCAM: National Center for Complementary and Alternative Medicine. Backgrounder: Questions and Answers: NIH Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT). National Institutes of Health. Available at: http://nccam.nih.gov/research/results/gait/qa.htm#a1. Accessed February 7, 2008. 3. Cluett J. Glucosamine and Chondroitin: What are glucosamine and chondroitin? About.com: Orthopedics. October 24, 2007. Available at: http://orthopedics.about.com/cs/supplements/a/glucosamine.htm. Accessed February 7, 2008. 4. AAOS: American Academy of Orthopaedic Surgeons. Glucosamine and Chondroitin Sulfate. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=A00189. Accessed February 7, 2008

For patients whose joint pain does not improve with medication or physical therapy, “joint grease” injections may provide temporary relief. The joint is injected with a joint fluid supplement that acts as a lubricant for the damaged joint. Joint injection schedules and duration of relief vary according to the treatment chosen and the individual patient. However, these injections do not cure the diseased joint and joint replacement may be needed as the joint worsens with time.

Physical therapy can be helpful in the management of Osteoarthritis (OA) and Rheumatoid Arthritis (RA). For example, a physical therapist may recommend:

• Isometric (“pushing”) exercises to help build muscle strength without subjecting inflamed joints to excessive wear
• Isotonic (“pulling”) exercises to further increase muscle strength and help preserve function
• Daily walking, using a cane or other assistive device as needed

What is osteoarthritis (OA)?

Osteoarthritis (OA) is the most common form of arthritis in the world.¹ You may have heard OA referred to as “wear and tear” arthritis. When OA begins to affect one of your joints, a series of reactions take place that actually begin to degrade your once-healthy bone and the “soft tissue” around the joint – tendons and cartilage. Once the cartilage that normally cushions and protects the bones of the joint breaks down, the bones of your joint eventually rub directly against each other. Your body reacts to this by creating bone spurs and the joint capsule itself may thicken and weaken. Inflammation eventually sets in. Doctors talk about two kinds of OA. Primary OA often refers to “everyday wear”; Secondary OA is considered the result of a malaligned joint, being overweight, injury or overuse.^{1, 2}

Who does OA affect?

Twenty-one million people are affected by OA in the United States alone.³ Although OA can affect anyone at any age, it has been linked to the aging process. More than 50% of everyone over 65 has OA symptoms in one or both knees. By 75, virtually everyone suffers with OA in one or more joints. In fact, OA of the knee and hips continues to be the most common cause of arthritis-related disability for Americans. The Arthritis Foundation cites that men and women may develop OA at different times in life. Most people develop symptoms after 45, but, as a group, men under 55 and women over 55 develop OA more frequently.

What are the symptoms of OA?

Although some people who have osteoarthritis say they feel no pain, most people who have OA experience pain, feel joint stiffness (especially in the morning), show signs of swelling and tenderness in one or more joints and may even hear a crunching sound in their joints. For some people, OA can become completely debilitating.³ In order to diagnose you properly, your doctor will consider your symptoms and your medical history, examine your joint(s) and order one or more diagnostic tests. Your doctor may order blood work, X-rays, a CT scan or an MRI to get a clear view of the alignment of your painful joint and its condition.

How is OA treated?

Your doctor may recommend different treatment options depending on the severity of your osteoarthritis and its impact on your joint(s).

Manage the pain.

Your doctor may prescribe or recommend the use of anti-inflammatory medications (like aspirin or ibuprofen) and cold packs that may help to reduce inflammation as well as the pain associated with arthritis. Sometimes a local injection of cortisone helps to further reduce inflammation.

Look at the big picture.

Your doctor may recommend that you lose weight, take certain nutritional supplements and exercise. In some cases, a physical therapist may help provide pain relief and the return of some lost mobility through guided exercise and other techniques.

Get the right support.

Orthotic devices sometimes help. Custom-made shoes and shoe inserts provide support for those with OA in the foot or ankle. Your doctor may recommend a brace or a cane to help take some of the pressure off your affected joint while you walk if OA is affecting your knee or hip.

Understand your surgical options.

If you are still experiencing arthritis pain and joint damage that’s affecting your quality of life even after all other conservative measures have been taken, your doctor may suggest surgery to help relieve your pain and restore your mobility. Your doctor will determine the proper surgical treatment based on the severity of your arthritis and its location. Today, a full range of surgical solutions exist that enable your doctor to customize surgical procedures to your particular needs and anatomy, whether you need arthroscopic debridement (removing inflamed and/or irritating debris from the joint), arthrodesis (fusing the joint for greater support) or arthroplasty (replacing the arthritic joint). Be sure to talk with your doctor about the best treatment option for you.

References: 1. Mayo Foundation for Medical Education and Research. Osteoarthritis: Introduction. Available at: https://www.mayoclinic.com/health/osteoarthritis/DS00019. Accessed February 4, 2008. 2. MedicineNet, Inc. Osteoarthritis. WebMD. Available at: http://www.medicinenet.com/osteoarthritis/page5.htm#minimal. Accessed February 4, 2008. 2. MedicineNet, Inc. Osteoarthritis. WebMD. Available at: http://www.medicinenet.com/osteoarthritis/page5.htm#minimal. Accessed February 4, 2008. 3. Arthritis Foundation. Osteoarthritis: Who Gets It? Available at: http://www.arthritis.org/disease-center.php?disease_id=32&df=whos_at_risk. Accessed November 5, 2008. © Stryker Orthopaedics 2008