The Bare Bones of Arthritis

Dr Eugene Wong   Consultant Orthopaedic & Spine Surgeon

Make no bones about it – arthritis is a prevalent condition that needs to be taken seriously. Over 60% of people over 65 have some form of arthritis, the most common being osteoarthritis (OA). As much as 90% of adults are affected by the age of 40.

Osteoarthritis (OA) occurs when the protective layer at the ends of the bone, called the cartilage, wears out over time. Without a strong layer of cartilage to cushion any friction and pressure that can occur when two bones rub against one another at the joint during movement, a person with OA can experience pain and swelling with each movement involving the affected joint. In time, the person’s mobility becomes restricted.

Currently, arthritis including OA is considered to be a biological process rather than a disease, which may be triggered off by various genetic, biological and environmental factors.

Vulnerable Spots

Do you know? The commonest joints affected by OA include the knees (41%), hands (30%) and hips (19%). The knee is more prone to injury because the entire weight of the body is transferred through the knee to the foot. About 13% of women and 10% of men aged 60 years and older have symptomatic knee OA.

It Starts With the Hand

Recent studies suggest that OA of the hand may predict the later development of OA in the hip or knee.

• Patients with hand osteoarthritis were three times more likely to develop hip arthritis.
• Osteoarthritis of the hand also slightly increased the risk for knee osteoarthritis.

Ladies’ Knees are More at Risk

Studies showed that the prevalence of knee OA in women can be up to as 1.7 times higher compared to men. Although multiple factors may contribute to this increased prevalence, the influence of sex hormones – oestrogen in particular – may be a reason behind this disparity between males and females.  The articular cartilage of the knee has oestrogen receptors, and a decline in oestrogen levels after menopause may contribute to this upsurge in knee OA in older women.

OA Risk Factors for Both Sexes

The hormone leptin may be a factor behind the breaking down of cartilage, the cause of OA

• Chondrocalcinosis, a condition in which a calcium salt called calcium pyrophosphate is deposited in our connective tissues (especially, those in the knees). We are not sure yet what causes this condition, but it has been closely linked to OA.
• Occupational and sports injuries, physical labour that often involves putting great pressure on the knees and obesity can increase the risk of OA.
• Low bone density (often related to an inadequate intake of relevant nutrients such as calcium and vitamin D).

Preventing OA

While OA may seem like an unavoidable result of aging, a healthy lifestyle can help in reducing or even preventing the many risk factors from affecting us. Here are some good practices to adopt:

Keep and maintain a healthy weight.

You can find your healthy weight by calculating your BMI and comparing the result to the normal BMI of people of your age. A healthy weight helps keep extra load off your knees and hips, thus keeping the cartilage in those areas healthy for a little longer. Also, if you are overweight, it is found that your body releases substances called cytokines, some of which would affect and even damage your cartilage, So, eat healthy and balanced meals in just the amount you need – not more, not less. Consult a dietitian if you need more advice.

Control your blood sugar.

A high level of glucose in the blood not only gives rise to type 2 diabetes at bay, it can also cause the cartilage to become stiff and vulnerable to damage. Diabetes can also trigger inflammatory reactions that erode the cartilage. So, let’s cut down on the amount of sugar in your daily meals!

Exercise, exercise, exercise!

People always say that if you don’t use something, you may lose it. When it comes to the joints and cartilage, put them to good use by being physically active at least 30 minutes a day. Such activities strengthen your muscles and help keep your hips and knees stable. If you are usually more sedentary, you can start small by walking more (window shopping a little longer is a good way to do this!), do more housework or gardening and take the steps more. In time, you can step up your activities by joining a gym or an exercise group in your neighbourhood park.

But, exercise wisely.

Take precautions against injuries by wearing protective gear or using exercise equipment correctly. If you also have conditions such as diabetes, heart diseases and such, consult your doctor on the appropriate types of exercise you can take up.

Treating OA

The treatment goals in osteoarthritis include managing pain, preventing disability and improving joint function. The motivation for most OA therapy is pain improvement and relief.

Shedding excess kilos.

Losing weight by monitoring diet is potentially one of the best treatments for controlling pain associated with knee osteoarthritis. Obese people with OA experience a 25% reduction in symptoms just by losing 5% of body weight.

Helpful compounds and food.

Although it has not been proven that glucosamine and chondroitin sulphate can help rebuild cartilage, there is evidence from a small number of patient studies that including these compounds as part of the treatment can reduce pain, usually within several weeks to months after initiating therapy. Some good dietary options include green lipped mussels (which contain omega-3 fatty acids, glycosaminoglycans and marine minerals that can support, repair and provide relief to inflammed joints); fish oil supplements and flaxseed oil (which contain high amounts of omega-3 fatty acids).

Regular exercise.

Exercises should focus on local muscle strengthening, and general aerobic fitness.  Some useful exercises include standing hamstring stretches, straight leg raises, side leg raises, heel raises, seated hip lifts and knee squeezes, chair squats and quadriceps-strengthening exercises concentrating on the vastus medialis oblique muscle.

Swimming is an excellent non-impact exercise.

Regular ‘land’ exercises can also be done underwater. The buoyancy of the water supports most of the body’s weight while the resistance of the water makes the muscles work harder to perform movements.

Keep in mind that activities such as squatting, kneeling, twisting, pivoting, repetitive bending and cycling place excessive pressure on the knee joints and must be limited until knee pain and swelling resolve.

The right support.

Supportive devices, such as finger splints or knee braces, can reduce stress on the joints and ease pain. Canes, crutches, or walkers may be helpful when walking becomes difficult. Shock-absorbing shoes or insoles can be helpful.

Pain relief.

Transcutaneous electrical nerve stimulation, ultrasound and laser are common methods prescribed to relieve pain in OA patients.

Of course, the medications.

Medications are an important strategy for breaking the pain cycle. There are no drugs that can reverse the progression of OA. The main goal of drug therapy is to relieve pain and help patients exercise and keep the joints functioning. There are a variety of treatments that can be applied to the affected joint that will relieve pain such as heat, ice, lidocaine patches, topical non-steroidal anti-inflammatory drugs (NSAIDs) and capsaicin.

Certain herbs such as St. John’s wort, devil’s claw, skullcap, angelica, black and white willows, bogbean, cayenne, dandelion, ginger, wintergreen, Boswellia, and valerian root can be used to reduce pain and inflammation.

NSAIDs can be used to treat pain and reduce inflammation Non-selective NSAIDs include ibuprofen, naproxen and indomethacin. Selective “COX-2” inhibitors are also an option. Diacerein inhibits an inflammatory substance in arthritic joints called interleukin-1b. Botulinum toxin type A injections may provide sustained pain relief for patients with knee osteoarthritis. Hyaluronic acid is used by injection into the joints in patients with severe disease and has many advantages but must also be used sparingly. It is used to replace lost fluid in the joint spaces and keep the joint working to cushion the bones in the joint.

Cartilage repair. Cartilage repair techniques include abrasion, drilling, microfracture and mosaicplasty. Grafting techniques include osteochondral allograft transplantation autologous chondrocyte implantation and autologous matrix induced chondrogenesis. Realignment osteotomy is an option in active patients with symptomatic unicompartmental OA of the knee with malalignment. Arthroscopic lavage and debridement are done for mechanical locking. Knee replacement can be unicompartmental, bicompartmental or total.

Stem cell therapy.

Stem cell usage is experimental as the results are not yet proven and consistently reproducible. The theory behind the action of stem cells is good and if this therapy works would reduce the number of total knee replacements.

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