ARTHRITIS: All about Osteoarthritis

Arthritis: What is it?

So what does the word mean?

Osteoarthritis: Osteon means bone, Arthro means joints, Itis means inflammation. Now this terminology is technically incorrect and OA is actually not an inflammatory condition by nature and this is why some people now call it Osteoathrosis instead. The Osis part actually means degeneration, which is more accurate.

So essentially breaking down the word tells us what it is, which is degeneration of the joint.
More specifically it is degeneration of the articular cartilage of the joint. This is essentially damage and loss of cartilage until the joint is “bone on bone”.

The bone actually starts to thicken and wear in response to the extra load on it, which causes bony outgrowths to form, called osteophytes. The synovium around the joint also thickens and produces extra fluid making the joint swell up, which isn’t actually inflammation. So the joint looks inflamed but actually isn’t.

Arthritis: How common is it?

Firstly, Is Osteoarthritis a modern issue?

Maybe yes because we are living longer but:

Ruffer & Rietti (1912) noted that the majority of skeletal lesions coming from ancient Egypt were typically of Osteoarthritis!

So next time you watch the mummy maybe they have got a bad knee!

Worldwide, osteoarthritis (OA) is estimated to be the fourth leading cause of disability (Fransen et al 2011).

According to Arthritis Research UK your risk of getting it increases past 40 years old

In the UK, 8.75 million people have sought treatment for osteoarthritis.

Of these:

33% were aged 45 years and over

Also women are more likely than men to have sought treatment.

But this could be that men don’t go to the G.P as much, maybe?

What areas are the most common for Osteoarthritis?

In England:

Knee* 18% 4.7 million

Hip** 11% 2.46 million

Hand and wrist* 6% 1.3 million

Foot and ankle* 7% 1.48 million

Two or more sites* 7% 1.46 million

In the USA:

26.9 million adults aged 25 and older have clinical Osteoarthritis (Lawrence et al 2007)

Osteoarthritis of the knee affects more than 1 in 10, or 4.3 million older US adults (Dillion et al 2006)

Can you get it when you are younger?

Yes

Osteoarthritis in young adults is most commonly a result of a previous injury (Roos 2005)

Arthritis: What causes it?

People think that it is caused by overusing your joints but contrary to popular belief overuse of a joint does not appear to cause Osteoarthritis, abnormal use however does.

For example people say “I used to run and this is why I have OA knee” but did you know that running significantly reduced OA and joint replacement risk (Williams 2013).

I actually see more people from an inactive sedentary background with arthritis than from a physical one. Joints like movement and activity and hate the opposite. The synovial fluid inside the joint acts like a lubricant and carries the nutrition for the cartilage. Weight bearing movement gets this working the best, therefore staving off Osteoarthritis rather than bringing it on. Now I can hear the footballers saying “hang on my knees are ruined from football!” Well evidence shows that the prevalence of knee OA in former elite soccer players is higher than the general population. (Kuijt 2012). However the issue with this is a few things, firstly when a player has a cartilage tear at the highest level they immediately have a meniscectomy, which is a removal of some cartilage. This goes against the evidence for this problem. The cartilage could heal over an estimated 6 month period of time with the correct rehab and therefore it should not actually need removal. If you remove cartilage you accelerate OA development as this evidence shows:

89% of patients experience osteoarthritis following meniscectomy (Rangger et al 1997).

The clubs want the quick fix in spite of any long term implications that won’t affect the club when the player is retired. Secondly the players with the OA knees now, played at a time that didn’t have the science behind it and they used to play on injuries and get painkilling injections etc. So provided you train correctly, don’t play through injury and don’t jump into surgery then you will do better than being a couch potato!

Arthritis Research UK states that the causes are as follows:

Age – Osteoarthritis usually starts from the late 40s onwards. This could be the muscles weakening around the joint or the cartilage wearing over time.

Gender – Women get it worse and more commonly than men, especially in the knees and hands.

Obesity – this is a big factor, especially in the knees

Joint injury – A significant injury or even surgery on a joint may lead to osteoarthritis

This is also shown by Roos et al (2005) who found that younger people that had an injury were more likely to get Osteoarthritis earlier.

Physically demanding and repetitive occupations - Normal activity and exercise don’t cause osteoarthritis, but doing very hard activities repetitively or physically demanding jobs can increase your risk.

Joint abnormalities – If you were born with abnormalities or developed them as a child then you can get, earlier and more severe osteoarthritis.

Genetic factors – Genetic factors play a small part in osteoarthritis of the hip and knee but there are definitive genetic parts to Osteoarthritis. For example Nodal osteoarthritis, which affects the hands of middle-aged women.

Other types of joint disease – Sometimes osteoarthritis is a result of damage from such things as rheumatoid arthritis or gout.

So as you can see the causes are many and it’s not just old age!

Arthritis: What are the symptoms?

Pain:

Especially on movement and weight bearing. Cold damp weather will make the pain worse and warm dry weather will lessen the pain.

Stiffness:

This is worst in the morning and generally eases within 30 minutes and continues to improve as the day goes on. Obviously if you are static for some time then this will also stiffen you up.

Reduced range of movement:

Due to pain and the available joint space in the joint you can lose range of motion in the joint.

Swelling:

As described before the synovium produces more fluid making the joint swell and thicken.

Muscle weakness:

Pain and swelling inhibit the nerve supply to the muscle around the joint, which makes the muscles waste over time. Also due to the symptoms of Osteoarthritis your activity levels drop and the muscles decondition in response to this.

Noises or sensations called crepitus:

When you move the joint you may hear some grinding, creaking and crunching noises or sensations.

Deformity:

In some joints at more advances stages you may see changes in the shape of the joint or angle of the joint too.

Instability:

As the joint space narrows the soft tissues such as ligaments become lax making the joint less stable. Also pain can inhibit the muscles causing giving way.

Secondary effects:

Depression, Anxiety, Diabetes, heart disease, poor sleep, decreased activity levels, occupational issues.

Arthritis: Why does it hurt?

The obvious cause of pain relates to the fact that Articular cartilage has no nerve supply, so weight bearing on the surface of the joint is pain free. However bone has lots of nerve and blood supply so when the cartilage is gone then it will hurt. This is obviously true but pain in OA starts before the cartilage actually exposes any bone. But why?

More recent evidence points to the fact that it is far more complex. For example, chondrocyte cell death and the production of new tissue has been observed in OA. In an attempt to regenerate itself, an increase in protein synthesis by the chondrocytes has been seen, this osteochondral angiogenesis derived from expression of growth factors has been theorised as to a cause of pain in OA (Girbes et al 2013). Muscle spasm is also a factor, as muscle will go into a protective spasm in response to the pain from the OA itself and this will add to the overall pain experienced. This is why evidence shows a reduction in overall pain levels when you treat the muscle especially the trigger points (Girbes et al 2013).

Neuroplastic changes with chronic pain can also occur, which is when the nervous system physically changes itself and actually creates its own pain signal irrespective to the origin of the pain. This is most evident in phantom limb pain, as the origin of pain was the foot or limb, but removal of this doesn’t actually get rid of the pain!

The nerve pain is highlighted when you consider the medications that are most effective at various times with OA. At first Non-steroidal anti-inflammatory drugs (NSAID’s) work best but they eventually become ineffective leading to the use of Gabapentin and Amitriptyline, which are nerve pain relieving medications. Also if pain was simply from the joint itself then you would expect that a joint replacement would cure the pain and this doesn’t happen in reality although it can help.

Baert et al (2016) found that 20% of patients undergoing a Total knee replacement are dissatisfied post-surgical and complain of persisting pain, functional disability and poor quality of life. So as suggested earlier the pain must be relatively non-structural and from the altered pain signals via the central nervous system. 

What Treatments are effective for Arthritis?

Exercise:

Exercise & education are recommended for physical management in Osteoarthritis (Larmer et al 2014). It appears however that the effect is short term rather than long term (Davis & Mackay 2013) & (van Bar et al 2001).

Strengthening, low-impact aerobic & neuromuscular exercise are beneficial forms of exercise for OA knee (Jevsevar et al 2013) & (Brosseau et al 2009). Strengthening with or without weight-bearing & aerobic exercises are effective for pain relief in knee osteoarthritis (Tanaka et al 2013).
Performing land- & water based exercise are helpful for mild-to-moderate knee OA (Golightly et al 2012).

Flexibility exercises are considered important by Uthman et al (2013).

Endurance exercises such as stationary cycling is an effective exercise option for mild to moderate knee osteoarthritis & has been found to improve pain on walking (Salacinski et al 2012).
Lin et al (2009) found that non-weight-bearing proprioceptive training significantly improved outcomes in OA knee.

Tai Chi:  Moderate evidence for short-term improvement of pain, function & stiffness in osteoarthritis of the knee (Lauche et al 2013).

These type of exercises should be done 3 x per week for optimal improvements (Juhl et al 2014).

Acupuncture:

Generally in OA, acupuncture may lead to small improvements in pain & physical function after 8 weeks (Manheimer et al 2010). However, for osteoarthritis of the knee it doesn't appear to be any better than placebo according to Chen et al (2013). Turner & Igo (2013) found that compared to sham there is inconclusive evidence that acupuncture improves pain or function in knee osteoarthritis.

Electrotherapy:

There were no additional benefits of using TENS alongside current management of osteoarthritis of the knee (Palmer et al 2014).

Electromagnetic field treatment may provide moderate benefit for osteoarthritis sufferers in terms of pain relief (Yu et al 2013).

Overall Davis & Mackay (2013) found that interferential current, short wave diathermy, ultrasound & neuromuscular electrical stimulation did not demonstrate benefit over placebo in OA knee.

Psychological interventions:

Self-management strategies based on cognitive therapy principles are beneficial in knee OA (Davis & Mackay 2013).

Weight loss:

Weight loss is vital for patients with symptomatic OA of the knee & a BMI ≥ 25 (Jevsevar et al 2013).

Medication:

Jevsevar et al (2013) recommends nonsteroidal anti-inflammatory drugs or Tramadol for knee OA.

Supplements:

People with osteoarthritis who take glucosamine: may get reduced pain, improved function & probably won't have side effects (Towheed 2009). That being said Jevsevar et al (2013) doesn’t recommend using glucosamine & chondroitin for OA of the knee.


Orthotics (insoles):

Depending on the issues, insoles can be slightly beneficial but more specifically, guidelines have found that lateral wedge insoles shouldn’t be used for medial compartment knee OA (Jevsevar et al 2013).

Injections:

Steroid injections appear to be safe and effective for OA knee according to Raynauld et al (2003) but both steroid and placebo injections reduced pain in this study but ultrasound imaging showed a reduction in synovial “inflammation” in the steroid group. (Hall et al 2013). If you have a Steroid injection then they will not perform a total knee replacement for 6 months afterwards so be aware of this before deciding.

Viscosupplementation (e.g. hyaluronan) is an effective treatment for knee arthritis benefiting pain & function according to Welch et al (2009). But this was not considered effective by Jevsevar et al (2013).

Massage and trigger point release:

Evidence shows a reduction in overall pain levels when you treat the muscle especially the trigger points (Girbes et al 2013).

Keyhole surgery:

Arthroscopic debridement for osteoarthritis of the knee doesn't improve pain or function compared to placebo (Laupattarakasem et al 2009).

Joint replacement (Total Knee Replacement):

This is the final point, when all other treatment fails and the OA is just too severe. However, between 10 & 35% of patients have a poor outcome following a total knee replacement so don’t think that it’s an easy fix (Beswick et al 2012).

Cryotherapy may improve the range of movement at the knee in the first one to two weeks after joint replacement (Adie et al 2012).

Another benefit found is that joint replacement surgery can boost the economy: Improvements allow patients to return to work & earn & spend rather than be supported (Dall et al 2013).

References:

http://www.arthritisresearchuk.org/

Dillon, Charles F., et al. "Prevalence of knee osteoarthritis in the United States: arthritis data from the Third National Health and Nutrition Examination Survey 1991-94." The Journal of rheumatology 33.11 (2006): 2271-2279.

Fransen, Marlene, et al. "The epidemiology of osteoarthritis in Asia." International journal of rheumatic diseases 14.2 (2011): 113-121.

Lawrence, Reva C., et al. "Estimates of the prevalence of arthritis and other rheumatic conditions in the United States: Part II." Arthritis & Rheumatism 58.1 (2008): 26-35.

Roos, Ewa M. "Joint injury causes knee osteoarthritis in young adults." Current opinion in rheumatology 17.2 (2005): 195-200.

Ruffer, M. A. and Rietti, A., 'On osseous lesions in Ancient Egyptians', J. Path. Bact., 1912, 16,439-465.

Kuijt, Marie-Therese K., et al. "Knee and ankle osteoarthritis in former elite soccer players: a systematic review of the recent literature." Journal of Science and Medicine in Sport 15.6 (2012): 480-487.

Rangger, Christoph, et al. "Partial meniscectomy and osteoarthritis." Sports Medicine 23.1 (1997): 61-68.

Roos, Ewa M. "Joint injury causes knee osteoarthritis in young adults." Current opinion in rheumatology 17.2 (2005): 195-200.

Williams, Paul T. "Effects of running and walking on osteoarthritis and hip replacement risk." Medicine and science in sports and exercise 45.7 (2013): 1292.

https://www.nice.org.uk/guidance/cg177

https://cks.nice.org.uk/osteoarthritis

Hunter, David J., Jason J. McDougall, and Francis J. Keefe. "The symptoms of osteoarthritis and the genesis of pain." Medical Clinics of North America 93.1 (2009): 83-100.

Girbés, Enrique Lluch, et al. "Pain treatment for patients with osteoarthritis and central sensitization." Physical therapy 93.6 (2013): 842.

Baert, I. A. C., et al. "Does pre-surgical central modulation of pain influence outcome after total knee replacement? A systematic review." Osteoarthritis and Cartilage 24.2 (2016): 213-223.

Adie, Sam, et al. "Cryotherapy following total knee replacement." The Cochrane Library (2012).

Beswick, Andrew David, et al. "What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients." BMJ open 2.1 (2012): e000435.

Chen, Lan X., et al. "Integrating acupuncture with exercise-based physical therapy for knee osteoarthritis: a randomized controlled trial." Journal of clinical rheumatology: practical reports on rheumatic & musculoskeletal diseases 19.6 (2013): 308.

Dall, Timothy M., et al. "Modeling the indirect economic implications of musculoskeletal disorders and treatment." Cost Effectiveness and Resource Allocation 11.1 (2013): 5.

Davis, Aileen M., and Crystal MacKay. "Osteoarthritis year in review: outcome of rehabilitation." Osteoarthritis and Cartilage 21.10 (2013): 1414-1424.

Golightly, Yvonne M., Kelli D. Allen, and Dennis J. Caine. "A comprehensive review of the effectiveness of different exercise programs for patients with osteoarthritis." The Physician and sportsmedicine 40.4 (2012): 52-65.

Hall, Michelle, et al. "Ultrasound detected synovial change and pain response following intra-articular injection of corticosteroid and a placebo in symptomatic osteoarthritic knees: a pilot study." Annals of the rheumatic diseases (2014): annrheumdis-2014.

Jevsevar, David S. "Treatment of Osteoarthritis of the Knee: Evidence‐Based Guideline." Journal of the American Academy of Orthopaedic Surgeons 21.9 (2013): 571-576.

Juhl, C., et al. "Impact of Exercise Type and Dose on Pain and Disability in Knee Osteoarthritis: A Systematic Review and Meta‐Regression Analysis of Randomized Controlled Trials." Arthritis & rheumatology 66.3 (2014): 622-636.

Larmer, Peter J., et al. "Systematic review of guidelines for the physical management of osteoarthritis." Archives of physical medicine and rehabilitation 95.2 (2014): 375-389.

Lauche, R., et al. "A systematic review and meta-analysis of Tai Chi for osteoarthritis of the knee." Complementary therapies in medicine 21.4 (2013): 396-406.

Laupattarakasem, Wiroon, et al. "Arthroscopic debridement for knee osteoarthritis." The Cochrane Library (2008).

Lin, Da-Hon, et al. "Efficacy of 2 non-weight-bearing interventions, proprioception training versus strength training, for patients with knee osteoarthritis: a randomized clinical trial." Journal of orthopaedic & sports physical therapy 39.6 (2009): 450-457.

Manheimer, Eric, et al. "Acupuncture for peripheral joint osteoarthritis." The Cochrane Library (2010).

Palmer, Shea, et al. "Transcutaneous electrical nerve stimulation as an adjunct to education and exercise for knee osteoarthritis: a randomized controlled trial." Arthritis care & research 66.3 (2014): 387-394.

Raynauld, Jean‐Pierre, et al. "Safety and efficacy of long‐term intraarticular steroid injections in osteoarthritis of the knee: A randomized, double‐blind, placebo‐controlled trial." Arthritis & Rheumatology 48.2 (2003): 370-377.

Salacinski, Amanda J., et al. "The effects of group cycling on gait and pain-related disability in individuals with mild-to-moderate knee osteoarthritis: a randomized controlled trial." journal of orthopaedic & sports physical therapy 42.12 (2012): 985-995.

Tanaka, Ryo, et al. "Efficacy of strengthening or aerobic exercise on pain relief in people with knee osteoarthritis: a systematic review and meta-analysis of randomized controlled trials." Clinical rehabilitation (2013): 0269215513488898.

Towheed, Tanveer, et al. "Glucosamine therapy for treating osteoarthritis." The Cochrane Library (2005).

Uthman, Olalekan A., et al. "Exercise for lower limb osteoarthritis: systematic review incorporating trial sequential analysis and network meta-analysis." bmj 347 (2013): f5555.

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