What is Osteoarthritis?
Osteoarthritis is a slowly progressing degenerative joint disease that affects an estimated 12.1% of people aged 25-74 years in the United States. Osteoarthritis can affect any joint however, the most common joints are the hip, knee, lumbar spine, cervical spine, and joints of the hand.
Osteoarthritis is divided into two categories, primary and secondary.
PRIMARY:
The cause of this type of arthritis is unknown however several risk factors predisposing people to this condition have been identified. These risk factors include weight as indicated by a high body mass index, high bone mineral density, genetics, gender (female >45 years old), increased age, physically demanding jobs, prior injury or surgery, and weakness of the quadriceps muscle (located above the knee).
SECONDARY:
The cause of this type of arthritis occurs as a result of infection, trauma, metabolic disorders, anatomic malalignment, or inflammatory conditions.
Articular cartilage is the part of the joint most affected by osteoarthritis. Articular cartilage helps the joint by providing a smooth friction-free surface between boney ends for ease of movement as well as weakens the mechanical load transmitted through the joint during activities.
Despite what type of osteoarthritis is identified, overall there is an imbalance between the destructive and synthetic processes (breaking down and building up) of cartilage accompanied by inflammation.
SYMPTOMS:
Can include but are not limited to: Gradual or sudden pain described as a deep ache that can occur at rest and at night. Stiffness after periods of inactivity, such as sleeping. Loss of movement at the affected joint. Enlarged joint surfaces.
What can I do to minimize my symptoms?
Thorstensson et.al. preformed a study and determined that decreased functional performance in the lower extremities (legs) predicted development of radiographic knee osteoarthritis five years later among people aged 35-55 years old with chronic knee pain and normal base line radiographs. They suggest that people utilize an intervention aimed at improving functional performance. That intervention could include aerobic exercise and strengthening of the lower legs.
Similarly Sharma et. al. determined factors that predict poor function in people with osteoarthritis. These factors included joint ligament (band of strong connective tissue that attaches bone to bone) laxity, proprioceptive inaccuracy, age, body mass index, and knee pain intensity. Due to these findings they studied ways of protecting people with osteoarthritis from a life of poor functioning. Their conclusions were that the higher levels of; strength, psychosocial mental health, social support, and amount of activity level (measured by amount of aerobic exercise per week) the better the person’s function.
Based on these studies it can be deducted that strengthening and exercise are key components in keeping active with osteoarthritis. What exercises and strengthening programs are helpful and where can I get help?
There are many forms of exercise and ways of keeping physically active. Ideally you would pick from those activities that you most enjoy. However, due to factors that are commonly associated with osteoarthritis mentioned above (joint laxity, joint malalignment, weakness of the quadriceps muscle, and proprioceptive inaccuracy) it is advisable to seek recommendations from a professional such as a physical therapist. A physical therapist is trained to help safely and with proper technique improve muscle strength, joint stability, and joint mobility. Physical therapists are also trained to teach patients techniques for improved function, conservation of energy, and protection of the joint during various activities. Physical therapists also have the knowledge to recommend other devices such as assistive devices (cane, walker, braces) as well as orthotics (shoe inserts) to help decrease the effects of joint malalignment.
After a patient has been under a physical therapists care and has learned the necessary tools for safely maintaining an activity level they are discharged to an independent home program. Exercise programs for osteoarthritis of the knee can include strengthening of the quadriceps, hamstring, glutes, hip muscles, and calfs. Stretching of the same muscle groups may be included. Cardiovascular training should also be implemented most likely in ways that provide less stress on the joint such as biking or swimming. Toley et. al. determined that exercises performed either on land or in the water benefited subjects with osteoarthritis to a much greater extent than doing nothing.
Boschert discovered that her osteoarthritis subject group (>60 years old) that performed exercises (aerobic x 30 min and strengthening x 15 min) 3 times a week for 18 weeks as well as adhered to a diet did better than any other group for months to come after the study was concluded. For diet recommendations to meet your specific needs it would be best to contact your physician or nutritionist.
Other ways of Managing Osteoarthritis pain MEDICATIONS: The below mentioned progression of medications is taken from a research article. For your specific medical needs it is highly recommended that you consult your physician. For mild to moderate pain Moskowitz et al recommend acetaminophen in doses up to 4 g per day. If not responding then the use of topical agents such as methylsalicylate or capsaicin could be of benefit. Moderate to severe pain with joint inflammation, glucocorticoids and or oral non-steroidal-anti-inflammitorys (NSAIDs) may be considered. If pain continues then a physician could recommend prescription –strength (NSAIDs) such as a COX-2 inhibitor.
ALTERNATIVE TREATMENTS:
Local intra-articular therapy: This therapy is currently only being performed on osteoarthritis of the knee. Intra-articular therapy involves a series of injections. These injections include agents such as Hyalgan or Supartz a natural sodium hyaluronate. Hyaluronans exist in all body fluids and tissues, their purposes include lubrication, water homeostasis, and a variety of others. These Hyaluroanans are used in osteoarthritic joints as their numbers tend to be decreased with this disease. A physician normally administers Hyalgan in 3-5 injections throughout weekly intervals. Studies have determined that Hyalgan, has a 26-week benefit duration, is well tolerated, and has no published pseudoseptic reports. Precautions included with these injections include: some pain or swelling in joint post injection, avoiding any strenuous activities that include greater than one hour of weight bearing at least 48 hours post injection. People who may not be good candidates for this treatment include those who are allergic to egg products, feathers, and avian proteins (please consult physician).
Glucosamine is another alternative choice used in the symptomatic treatment of osteoarthritis. Glucosamine is a building block comprised of proteins and glycan’s that help to make up connective tissue (cartilage). Glucosamine mainly comes in a pill form and is usually derived from oyster and crab shells. When taken by mouth only about 8-12% of the product is absorbed and stays in cartilage tissue. Glucosamine works to decrease symptoms of osteoarthritis pain by stimulating cartilage cells to create more proteins and glycans in the tissue. Matheson and Perry demonstrated in their 2003 study that Glucosamine provided effective short-term symptom relief of osteoarthritis of the knee.
Many other studies have also shown good results of Glucosamine decreasing symptoms of osteoarthritis pain. Glucosamine studies have not yet demonstrated the products ability to stop the disease process. You can purchase Glucosamine over the counter as a supplement known as Joint FormulaTM or Joint HealthTM. Counter force Brace: The counter force brace is a custom made brace that applies either a valgus or varus (medial or lateral) force depending on which side of the knee needed to be unloaded. The purpose of this brace is for symptomatic pain relief of osteoarthritis and to avoid or delay knee joint replacement. There have been documented studies that demonstrate this braces effectiveness in achieving its purpose. Boswella: Boswella is a gum resin from a tree that grows in India. It comes in the form of a supplement and has demonstrated effectiveness in treating osteoarthritis. It acts as an anti-inflammatory as it demonstrates an ability to inhibit the 5-lipoxygenase pathway. Most studies on Boswella have been performed in India.
Arthroscopy: This is a type of surgery using small incisions called portals. The orthopedic surgeon can use different tools to help clean up frayed or damaged cartilage for pain reduction.
Total joint replacement surgery may also be indicated. It would be necessary to visit with an orthopedic surgeon to determine if surgery is the right option to treat your arthritis.
References: 1) Boschert S. (2003) Family Practice News. 33 (6) 22. 2) Goodman and Boissonnault. (1998). Pathology Implications for the Physical Therapist. 660-661. Chapter 23 3) Kelly, M., Kurzweil, P., & Moskowitz R. (2004). Intra-articular hyaluronans in knee osteoarthritis: rationale and practical considerations. A supplement to American Journal of Orthopedics. 2,15-21. 4) Matheson A.J., & Perry C. M. (2003). Glucosamine: A Review of its Use in the Management of Osteoarthritis. Aging. 20 (14), 1041-60. 5) Moskowitz R., Kelly M., Lewallen D., & Vangsness C. (2004). Nonsurgical approaches to pain management for Osteoarthritis of the knee. A supplement to American Journal of Orthopedics. 2,10-14. 6) Sharma L., Cahue S., Song J., Hayesk, Y.P., & Dunlop D. (2003). Arthritis and Rheumatism. 12, 3359-3370. 7) Thorstensson C., Petersson I., Jacobsson L., Boegard T., & Roos, E. (2004) Annals of the Rheumatic Diseases. 4,402. 8) Toley A., Halbert J., Hewitt T., & Crotty M. (2003). Does hydrotherapy increase strength and physical function in patients with osteoarthritis? Ann Rheum Dis. 12, 1162-1167.
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