A patient's guide to the latest knowledge about arthritis.
An overwhelming amount of information about arthritis exists on the internet—and sadly, much of it is outdated or just plain wrong. In this booklet, Jarret D. Morrow, MD, president and chief scientific officer of University Health Industries (OTC: UVHI, Dietary Supplement Company), presents an overview of known facts based on current research.
How many types of arthritis are there?
Researchers have identified more than 100 different types of arthritis. The most common are osteoarthritis, rheumatoid arthritis, and gout.
What is osteoarthritis?
The most common type of arthritis, osteoarthritis (OA) is generally associated with aging and joint wear and tear. It can also result from other disorders such as diabetes. OA affects many joints, from the large, weight-bearing joints of the hips and knees to the smaller joints of the spine, hands, feet, and shoulders.
What is rheumatoid arthritis?
Rheumatoid arthritis (RA) is a long-lasting disease where the immune system—the body’s defense against disease—mistakenly attacks itself and causes the joint lining to swell. The inflammation then spreads to the surrounding tissues, where it can damage cartilage and bone. RA can affect joints in any part of the body, but the hands, wrists, and knees are the most common. In more severe cases, rheumatoid arthritis can affect the skin, eyes, nerves, and internal organs.
What is gout?
Gout is a painful condition that occurs when the body cannot eliminate a natural substance called uric acid. The excess uric acid forms needle-like crystals in the joints that cause swelling and severe pain. Gout most often affects the big toe, knee, and wrist joints.
How many people suffer from arthritis?
More than 46 million adults in America suffer from arthritis and chronic pain. Approximately one-half of these individuals suffer from OA, and that number is growing rapidly as the population over age 50 increases. By 2030, the CDC’s National Center for Chronic Disease Prevention and Health Promotion estimates that 67 million Americans will have been diagnosed with an arthritic condition.
What is the societal impact of arthritis?
According to the Centers for Disease Control and Prevention (CDC), arthritic conditions are the main cause of disability in the USA. These conditions cost the U.S. economy more than $128 billion annually, and that figure will continue to increase as the population ages.
What causes osteoarthritis?
In OA, biochemical and metabolic changes in the body result in the breakdown of joint cartilage. Over time, the joint cartilage wears away and bony growths (osteophytes) may form at the edges of joints. The cartilage loses its ability to effectively cushion the area between the two bones, and osteophytes may press on surrounding tissue. This results in pain that may range from mild to disabling.
How do joint injuries result in OA?
Chondrocytes are cells in the joint that produce cartilage. They normally die off (apoptosis) at a rate of less than 1 percent. But within 48 hours of trauma to a joint, the cell death rate shoots up dramatically—sometimes as high as 37 percent. The dying cells stimulate the release of enzymes that destroy cartilage, which in turn can lead to arthritis.
What is the association between allergies and OA?
There is some evidence of a potential link between food sensitivities and joint inflammation in certain individuals. More research in this area is needed to determine the nature of this connection.
What are the risk factors for OA?
· Advancing age
· Insulin resistance or diabetes
· Congenital abnormalities
· Joint injuries
· Lack of physical activity
· Hereditary susceptibility
What is primary OA?
Osteoarthritis is classified as primary (idiopathic) when the exact cause is unknown, and secondary if it is associated with a specific disease or condition such as diabetes. Most primary OA is related to aging. Approximately 80-90 percent of men and women have evidence of OA by the time they reach age 65.
In the vast majority of cases, OA develops silently before causing noticeable pain and stiffness. Affected individuals often do not have any symptoms until after age 50.
What factors increase the likelihood of developing type 2 diabetes, a major risk factor for OA?
Your likelihood of developing type 2 diabetes increases with the number of risk factors. If any of the risk factors below apply to you, please talk to a health care professional about how to lower your risk and determine if testing is needed.
· Obesity. Excessive body weight increases diabetes risk.
· Apple-shaped figure. Individuals whose bodies store fat in the abdominal area have a higher risk of diabetes than those who store excess weight in the hips and thighs.
· Age. Age increases the risk of type 2 diabetes.
· Sedentary lifestyle. Regular physical activity can prevent excess weight, which is a significant risk factor for type 2 diabetes. A second benefit of regular physical activity is improved blood sugar control in people who already have type 2 diabetes.
· Family history. The genetic link for type 2 diabetes is stronger than the genetic link for type 1. Having a blood relative with type 2 diabetes increases the risk. If that person is a first-degree relative, such as a parent, sibling or child, the risk is even higher.
· History of diabetes in pregnancy. If you had diabetes during pregnancy (gestational diabetes), you have an increased risk of developing type 2 diabetes.
· Impaired glucose tolerance (IGT). Also known as pre-diabetes, IGT means that the individual’s blood sugar level is elevated, but still below the level that qualifies as diabetes.
· Ethnic ancestry. Being of Aboriginal, African, Latin, or Asian descent increases the risk of developing type 2 diabetes. Risk levels for these groups are two to six times higher than for Americans of Caucasian origin.
· High blood pressure. People with high blood pressure are more likely to have or develop diabetes.
. High cholesterol or other fats in the blood. People with diabetic conditions often have high levels of harmful LDL cholesterol and triglycerides, and low levels of “good” HDL cholesterol.
Symptoms and Diagnosis What are the symptoms of OA?
Pain is the most frequent symptom of OA. Other common symptoms are morning stiffness in the joint, limited range of movement, and crepitus (a crackling sound or feeling) when the joint is moved.
The pain of osteoarthritis is described as a sharp ache or burning sensation that worsens with use. Pain increases as cartilage erodes and bone surfaces lose their protection. The chronic pain and stiffness leads to decreased movement, which in turn allows the muscles to atrophy and ligaments to become lax.
What joints are affected by OA?
Osteoarthritis can affect any joint in the body. The most common are the large weight-bearing joints such as the knees or hips, but OA can also develop in the fingers, hands, feet, shoulders, lower lumbar vertebrae, and the cervical spine.
Could my back or neck problem be related to OA?
Yes, it could. Vertebrae are bones, and areas between them are joints protected by cartilage disks. In addition to the problems resulting from disk erosion, osteophytes can also grow around the vertebrae in the neck or back. These can put pressure on the nerve root or other surrounding tissues (impingement on the spinal foramina), creating symptoms such as
· pain that radiates down the leg or arms (radicular pain)
· muscle spasms
· muscle atrophy
· neurological deficits
How is OA diagnosed?
If you suspect osteoarthritis, your doctor will make a diagnosis based on your medical history, a physical exam, and X-rays of the affected joints. Your physician may also order an MRI (magnetic resonance imaging), an arthroscopy (examining the joint through a small incision), or arthrocentesis (drawing fluid from a swollen joint)
Researchers are currently attempting to identify markers in the blood that are associated with the severity of OA in each patient. A recent study found that patients with especially high levels of TNF alpha (a protein that is part of the immune system) generally had lower physical function, more OA symptoms, and worse knee radiographic scores. (Pennix et al, 2004)
What does the doctor see on an X-ray to diagnose OA?
In a joint affected by osteoarthritis, the space where the two bones meet is abnormally narrow. This condition, known as joint space narrowing, results from the cartilage breakdown that occurs with OA. The radiologist will also look for bony outgrowths at the edges of joints (osteophytes), another characteristic of OA.
What is the association between depressed mood and the chronic pain of osteoarthritis?
Arthritis and depression are common and important health problems, and older adults are more likely to suffer from both. Patients with both conditions generally experience more pain and functional impairment than individuals dealing with pain alone (Bair et al, 2004). Systematic depression management has been demonstrated to be effective in decreasing pain severity among arthritis patients (Lin et al, 2006).
Treatment Options Options
What are some of the treatment options for arthritis?
A multifaceted approach is best for maximum control over osteoarthritis. Every patient is unique and should—in conjunction with a physician—use whatever combination of treatments works best:
· patient education about OA
· weight control
· anti-inflammatory drugs
· non-narcotic analgesics such as acetaminophen
· alternative medicines and natural remedies
· local injections of glucorticoids
· surgery to relieve chronic pain in damaged joints
What is the connection between food and OA?
Although the current consensus within the medical community is that is diet and arthritis are not connected, there is some evidence that certain types of diets, with specific amounts of calories, protein, and fatty acids, may affect the inflammation that occurs with arthritis. An increasing number of physicians recognize the need to re-evaluate this position in light of new knowledge about food and its potential role in treating or preventing chronic conditions such as arthritis.
How does weight loss affect arthritis?
Recent studies indicate that that weight loss through diet and exercise improves physical function in older obese adults with knee OA, and that those with the most weight loss show the greatest improvement (Miller et al, 2006). One clinical study showed that a weight loss of just 10 percent resulted in a functional improvement of 28 percent (Christensen et al, 2005).
A recent meta-analysis demonstrated that patient education and exercise regimens each had a modest, yet clinically important, influence on well-being for OA patients. (Devos-Comby L et al, 2006).
What is evidence based medicine (EBM)?
Evidence based medicine (EBM) is a new paradigm for making decisions about a patient’s health. Rather than relying exclusively on their own professional expertise, physicians using EBM also evaluate current clinical research to help make decisions about medical treatments and patient care. The evidence used may include randomized controlled trials, systematic reviews of series of trials, meta-analyses, and other information collection and research activities.
How effective are NSAIDs at treating the pain associated with OA?
A recent meta-analysis published in the European Journal of Pain concluded that the clinical effects of oral NSAID therapy in patients with moderate to severe arthritis are small and limited to the first three weeks after the start of treatment (Bjordal et al, 2007).
What impact does weight reduction have on OA?
A recent randomized trial concluded that an intensive weight loss intervention program of diet and exercise improved physical function in older obese adults with knee OA (Miller et al, 2006).
How effective is chondroitin sulfate for treating OA?
A very recent meta-analysis published in the Annals of Internal Medicine concluded that the “symptomatic benefit of chondroitin is minimal or nonexistent. Use of chondroitin in routine clinical practice should therefore be discouraged” (Reichenbach et al, 2007).
How effective is acupuncture for treating OA?
A recent meta-analysis on acupuncture for peripheral joint arthritis concluded that although further studies are needed to adequately evaluate its effectiveness for OA, acupuncture’s favorable safety profile makes it an option worth considering (Kwon et al, 2006).
Which drug is more effective for treating OA: acetaminophen or NSAIDS?
A recent review from the Cochrane Collaboration database concluded that NSAIDS appear to be more effective than acetaminophen for the treatment of arthritis (Towheed et al, 2006).
How effective are physical interventions in the treatment of knee osteoarthritic pain? Osteoarthritis (OA) of the knee is the most common knee joint affected by OA. A recent meta-analysis published in BMC Musculoskeltal Disorders (Bjordal JM, et), concluded that “TENS, EA and LLLT administered with optimal doses in an intensive 2-4 week treatment regimen, seem to offer clinically relevant short-term pain relief for OAK.” [Transcutaneous electrical nerve stimulation (TENS, including interferential currents), electro-acupuncture (EA) and low level laser therapy (LLLT)]. If you suffer from OA of the knees, you may want to talk to your doctor about these treatment options.
How effective are hyaluronic acid injections in relieving knee pain?
“Intra-articular viscosupplementation was moderately effective in relieving knee pain in patients with osteoarthritis at 5 to 7 and 8 to 10 weeks after the last injection but not at 15 to 22 weeks (Modawal et al, 2005).” This study additionally included these practice recommendations:
“1. Consider injections of hyaluronic acid injections only after conservative therapy has been tried for atleast three months or the patient is unable to tolerate NSAIDS. 2. Stress to patients that pain relief may not be fully experienced until 5-7 weeks following the last injection.”
What this means? HA injections should be tried after other treatment options have been explored. In addition, HA injections may offer moderate pain relief, but the pain relief can take up to a month to reach the maximum effect.
How much do HA injections cost? Each injection costs approximately $230 and the recommendations include patients receiving one injection per week for a total of five weeks which amounts to about $1150.
Miller GD, Niclas BJ, Davis C, Loeser RF, Lenchik L, Messier SP. Intensive weight loss program improves physical function in older obese adults with knee osteoarthritis. Obesity (Silver Spring). 2006 July;14(7):1219-30.
Christensen R, Astrup A, Bliddal H. Weight loss: the treatment of choice for knee osteoarthritis? A randomized trial. Osteoarthritis Cartilage. 2005 Jan;3(1):20-7.
Penninx BW, Abbas H, Ambrosius W, Nicklas BJ, Davis C, Messier SP, Pahor M. Inflammatory markers and physical function among older adults with knee osteoarthritis. J Rheumatol. 2004 Oct;31(10):2027-31.
Devos-Comby L, Cronan T, Roesch SC. Do exercise and self-management interventions benefit patients with osteoarthritis of the knee? A metaanalytic review. J Rheumatol. 2006 Apr;33(4):744-56.
Bjordal JM, Klovning A, Ljunggren AE, Slordal L. Short-term efficacy of pharmacotherapeutic interventions in osteoarthritic knee pain: A meta-analysis of randomized placebo-controlled trials. European Journal of Pain. 2007;11:125-138.
Miller GD, Nicklas BJ, Davis C, Loeser RF, Lenchik L, Messier SP. Intensive weight loss program improves physical function in older obese adults with knee osteoarthritis. Obesity. 2006 Jul;14(7):1219-30.
Reichenbach S, Sterchi R, Scherer M, Trelle S, Burgi E, Burgi U, Dieppe PA, Juni P. Meta-analysis: chondroitin for osteoarthritis of the knee or hip. Ann Intern Med. 2007 April 17;146(8):580-90.
Kwon YD, Pittler MH, Ernst E. Acupuncture for peripheral joint osteoarthritis: a systematic review and meta-analysis. Rheumatology (Oxford). 2006 Nov;45(11):1331-7.
Towheed TE, Maxwell L, Judd MG, Catton M, Hochberg MC, Wells G. Acetaminophen for osteoarthritis. Cochrane Database Syst Rev. 2006 Jan 25;1:CD004257.
Bjordal JM, Johnson MI, Lopes-Martins RA, Bogen B, Chow R, Ljunggren AE. Short-term efficacy of physical interventions in osteoarthritic knee pain. A systematic review and meta-analysis of randomised placebo-controlled trials. BMC Musculoskelet Disord. 2007 Jun 22;8:51.
Modawal A, Ferrer M, Choi HK, Castle JA. Hyaluronic acid injections relieve knee pain. J Fam Pract. 2005 Sep;54(9):758-67.
Links: Dr. Jarret Morrow’s Dietary Supplement Research blog