Osteoarthritis

Overview

Definition

Osteoarthritis is characterized by degenerative joint changes that cause pain, tenderness, limited range of motion, crepitus, and inflammation. As many as 90% of individuals over age 40 show degenerative changes radiographically, although not all of these individuals have symptoms. Osteoarthritis is the most common form of arthritis and most frequently affects the articular cartilage and subchondral bones of the hands, knees, hips, and spine. Osteoarthritis is characterized as primary if there is no apparent predisposing cause or secondary if it is associated with an underlying medical condition. Primary osteoarthritis can be localized to one or two joints or generalized to three or more joints. Osteoarthritis affects men and women nearly equally; however, under age 45 men are affected more frequently, and over age 55 women are affected more frequently. Approximately 40 million Americans have osteoarthritis.

Etiology

Primary osteoarthritis appears to be caused by the cumulative effects of repetitive occupational or recreational joint use (with professions such as baseball pitchers, ballet dancers, dock workers), which leads to a destruction of the cartilage when individuals are in their 50s and 60s. Degenerative changes are usually age-related, but may also occur as a result of fractures and other mechanical abnormalities.

There may also be a genetic predisposition. Secondary osteoarthritis is associated with an underlying medical condition (e.g., Wilson's disease, acromegaly, hemochromatosis, hypoparathyroidism), which can often be treated, resulting in a resolution of the osteoarthritis.

Risk Factors

• Increasing age
• Genetic predisposition
• Obesity
• Major trauma
• History of inflammatory joint disease
• Metabolic disorders (e.g., hemochromatosis, acromegaly, calcium pyrophosphate deposition disease [CPPD])
• Congenital bone and joint disorders
• Certain occupations (e.g., baseball players, ballet dancers, dock workers)

Signs and Symptoms

• Morning stiffness or stiffness after inactivity for less than 15 minutes
• Joint pain, worsened by movement and improved with rest (in severe cases, constant pain)
• Soft tissue swelling
• Bony crepitus (crackling noise with movement)
• Bony hypertrophy causing gross deformities (e.g., Heberden's nodules of distal interphalangeal joints)
• Limited range of motion
• Subluxation (incomplete or partial dislocation)

Differential Diagnosis

• Rheumatoid arthritis
• Septic arthritis
• Claudication
• Bursitis
• Neuropathy
• Osteoporosis
• Metastatic bone disease
• Gout

Diagnosis

Physical Examination

The patient often presents with pain that is localized to one or more joints, especially after exercise or movement. Bony hypertrophy (enlargement) and inflammation (redness, warmth) often accompany the pain. Loss of function and pain at rest usually indicate severe disease. Observe the patient for the extent of deformity and disability.

Laboratory Tests

Most laboratory values are normal, but they are helpful in ruling out other forms of arthritis and possible underlying precipitating causes (e.g., metabolic disorders associated with secondary osteoarthritis).

• Complete blood count (mononuclear cells usually predominate)
• Erythrocyte sedimentation rate (ESR)
• Urinalysis
• Chemistry panel
• Synovial fluid analysis to rule out CPPD, gout, septic arthritis

Pathological Findings

• Irregular loss of cartilage, especially in weight-bearing joints
• Joint space narrowing
• Synovial inflammation (synovitis)
• Bony sclerosis (eburnation)
• Bone cysts
• Increased number of osteophytes (spurs) at joint margins, the radiologic hallmark of osteoarthritis
• Periarticular muscle wasting
• Areas of cartilagenous repair, but inferior repair tissue
• Gross deformity, loose bodies, and subluxation

Imaging

Magnetic resonance imaging (MRI) has replaced computed tomography (CT) scans and myelography for diagnosis and evaluation of osteoarthritis of the spine. MRI is not particularly helpful in evaluating peripheral osteoarthritis.

• X rays—to detect joint space narrowing as cartilage is lost, bony sclerosis, bony cysts, osteophytosis
• Arthroscopy—to diagnose osteoarthritis
• Myelography—to evaluate patients preoperatively

Other Diagnostic Procedures

Radiographic evidence of osteoarthritis is not always symptomatic; the diagnosis is based on clinical findings, history, and radiographic features. Pain and disability may be associated with atrophy of the muscles around the joints; this is especially true of the knee.

Treatment Options

Treatment Strategy

The goals of treatment are individualized to reduce pain, minimize disability, and maintain range of motion and mobility. Many patients with osteoarthritis are not able to perform even the simple activities of daily living (ADLs), such as bathing and dressing. Patients should be told that therapy is palliative not curative.

Drug Therapies

• Aspirin—as needed for inflammation and analgesia, within tolerance
• Acetaminophen (4,000 mg/day)—to reduce pain
• Nonsteroidal anti-inflammatory drugs (NSAIDs)—ibuprofen (Motrin), 1,200 mg/day, and naproxen (Naprosyn), 1,000 mg/day—to reduce pain and inflammation. Approximately 30% of peptic ulcer disease cases in the elderly (over age 65) can be attributed to NSAID use; in addition, there is some evidence linking NSAIDs with acceleration of the progression of osteoarthritis because they appear to inhibit cartilage repair. However, this is controversial.
• Tramadol (50 to 300 mg/day)—a weak opioid for refractory pain control
• Intra-articular or periarticular glucocorticoids—for symptomatic relief. Oral corticosteroids are contraindicated.
• Capsaicin cream—to reduce pain by depleting nerve endings of substance P

Complementary and Alternative Therapies

The etiology and pathogenesis of osteoarthritis are diverse and somewhat unpredictable. Alternative therapies can help improve joint function and decrease inflammation by providing nutritional, herbal, and lifestyle support.

Exercise that combines muscle strengthening and aerobic conditioning can help improve joint stability and function. Weight loss is essential for overweight patients. Proper body mechanics and rest, when indicated, are important considerations.

Nutrition

• Reduce pro-inflammatory foods such as refined foods, sugar, saturated fats (meat and dairy products), and omega-6 fatty acids.
• Omega-3 fatty acids reduce inflammation. Increase cold-water fish, nuts, and seeds or supplement with essential fatty acids (such as fish oil, 1,000 to 1,500 mg bid).
• Increase whole grains, vegetables, and legumes.
• Vitamin C (1,000 mg tid to qid) to support the growth and integrity of the cartilage.
• Vitamin E (400 to 800 IU/day) inhibits breakdown of cartilage and stimulates new cartilage formation.
• Vitamin A (5,000 IU/day) or beta-carotene (50,000 IU/day), zinc (20 to 30 mg/day), and selenium (200 mcg/day) are antioxidants that protect cartilage and reduce oxidative damage secondary to inflammation.
• Boron (3 mg/day) helps slow joint degeneration.
• Glucosamine sulfate (500 mg tid) promotes cartilage synthesis and repair of damaged joints. The overall effect is one of increased joint integrity and significant pain relief. Glucosamine sulfate has, in at least some studies, been shown to be more effective than ibuprofen at relieving pain as well as being better tolerated than ibuprofen or other NSAIDs.
• S-Adenosylmethionine (SAM) (1,200 mg/day for 21 days, then tapered to 200 mg/day). SAM stimulates production of cartilage and is a mild analgesic and anti-inflammatory agent. It has only recently become available in the United States.
• Niacinamide (500 to 1,000 mg tid) increases joint mobility and reduces pain. High doses of niacinamide require that liver function tests and serum glucose be monitored periodically.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

• Hawthorn (Crataegus oxyacantha) and bilberry (Vaccinium myrtillus) are high in flavonoids, especially anthocyanidins and proanthocyanidins, which enhance the integrity of connective tissue. Take 100 to 200 mg dried extract bid to tid.
• Devil's claw (Harpagophytum procumbens), yucca (Yucca bacata), turmeric (Curcuma longa), black cohosh (Cimicifuga racemosa), ginger root (Zingiber officinalis), boswellia (Boswellia serrata), teasel root (Dipsacus asper), and meadowsweet (Filependula ulmaria) may be combined in equal parts as tea (1 cup tid) or tincture (30 to 60 drops tid) to reduce inflammation and relieve pain.

Homeopathy

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

• Arnica montana for arthritis with sore, stiff joints that are worse in damp, cold weather.
• Bryonia alba for arthritic pain that is worse with movement and cold, and is better with heat.
• Pulsatilla for wandering arthritis that is worse on initiating movement but is relieved by continued movement. The pain feels worse with heat and better with cold applications.
• Rhus toxicodendron for arthritis that is worse on waking in the morning, worse in damp and cold weather or before storms, and worse with exertion. The pains feel better with heat, dry weather, and motion.

Physical Medicine

Contrast hydrotherapy. Alternating hot and cold applications brings nutrients to the site and diffuses metabolic waste from inflammation. The overall effect is decreased inflammation, pain relief, and enhanced healing. If possible, immerse the part being treated. Alternate three minutes hot with one minute cold and repeat three times. This is one set. Do two to three sets/day.

Castor oil pack. Used externally, castor oil is a powerful anti-inflammatory. Apply oil directly to skin, cover with a clean soft cloth (e.g., flannel) and plastic wrap. Place a heat source (hot water bottle or heating pad) over the pack and let sit for 30 to 60 minutes. For best results use three consecutive days.

Acupuncture

Acupuncture can do much in the way of pain relief, reducing inflammation, and strengthening overall health.

Massage

Therapeutic massage may be beneficial in enhancing joint mobility, increasing circulation, and alleviating pain.

Patient Monitoring

The disability caused by osteoarthritis varies according to the site of the disease; for example, disease of the interphalangeal joints does not cause the limitation of function or pain that is caused by osteoarthritis in a weight-bearing joint. Joint deterioration is not inevitable but appears to be associated with aging and obesity. Although radiographic features of osteoarthritis may progress with age, the progression appears to be gradual, and treatment in some cases appears to slow progression. Patients should be told that while there is no cure, the disability experienced by patients with rheumatoid arthritis is uncommon in patients with osteoarthritis.

Patients should be monitored for the harmful effects of the NSAIDs, such as gastro-intestinal bleeding. Patients should be instructed to examine their stools for changes in color, and have stools monitored periodically for occult blood. In addition, patients should be monitored for renal failure by checking blood urea nitrogen and creatinine levels.

Other Considerations

Prevention

Since osteoarthritis appears to be exacerbated by obesity, patients can expect a more benign course if they lose weight.

Complications/Sequelae

GI bleeding and decreased renal function with NSAID and aspirin use

Prognosis

Expect a progressive course to the condition. Joint effusions and joint enlargement occur later in the course of the condition. Most advanced stages include full cartilage loss.

Pregnancy

Most women who become pregnant are normally too young to have primary osteoarthritis; however, if they have an underlying condition with which osteoarthritis is associated (secondary osteoarthritis), they should consult their health care provider concerning the safety of the palliative medications.

References

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