I was very fortunate to be invited along to the Frankston North Rotary club to discuss arthritis. There are a lot of misunderstandings regarding arthritis so I thought posting some of that information here might help to break down some myths and hopefully clarify a few things.
What is arthritis?
Arthritis defines a range of conditions which result in inflammation within the joint.
For some people, this is the result of an autoimmune condition, such as rheumatoid arthritis. We call these conditions inflammatory arthritis. #inflammatory #rheumatoid
The suffix "-itis" describes a condition accompanied by inflammation. These conditions will be accompanied by pain, heat, redness and swelling.
The suffix "-osis" typifies a degenerative condition.
The common osteoarthritis is not inflammatory in its early stages. It is typically associated with a gradual loss of joint cartilage, growth of the bone at the joint margins, changes in the joint capsule, and a reduction in the joint range of movement. This occurs over many years, and in this sense, we really should be calling it arthrosis.
In its more advanced stages, we see cysts form underneath the cartilage, in the bone, as well as swelling. At this point, we can call it arthritis.
For the sake of this blog, we’ll be focusing on Osteoarthritis, but excuse me if I call it arthrosis when I’m discussing the condition in its early forms. So long as we have an understanding of what we are talking about.
You may have Osteoarthrosis in your knee, spend a weekend weeding in the garden and wake up Monday with Osteoarthritis, which has regressed to Osteoarthrosis by the next weekend.
Arthrosis correlates with your age but not your level of disability.
Doctor: "You have the spine of an 80 year-old"
You: "Really? I thought they were my knees"
There is a very poor correlation between the degree of arthrosis and your level of pain.
There is a direct relationship between degenerative changes and age (just like there is with wrinkly skin).
A research group performed magnetic resonance imaging (MRI) on 67 individuals who had never had lower back pain, sciatica, or neurogenic claudication.
Pain-free individuals under 60:
20% had a herniated disc.
1 had spinal stenosis.
35% showed degenerative changes.
Pain-free individuals over 60:
57% showed abnormalities.
36% had a herniated disc.
21% had spinal stenosis.
All but 1 showed degenerative changes.
The research group concluded that abnormalities on MRI must be strictly correlated with age and any clinical signs and symptoms before operative treatment is contemplated.
Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation.J Bone Joint Surg Am. 1990;72(3):403‐408.
Wrinkly skin and joint degeneration correlate with age, neither correlate very well with pain!
What causes arthritis?
There are several known factors that increase the development of arthrosis. Including:
Biomechanics
Altering the fluent motion of the joint will increase strain on the joint cartilage, in the same way a wheel misalignment will create uneven wear on your tyres.
We can split mechanical issues into two categories:
1. Structural changes directly occurring to the joint.
2. Altered biomechanics at other regions of your body, which increase strain on the effected joint.
1. Direct influences include an injury to the joint or to the supporting ligaments.
Example A: You tear your ACL, after which, the usually smooth motion of the knee now occurs with some shearing forces. This unusual force increases the breakdown rate of the cartilage.
Example B: You tear one (or several) rotator cuff tendon(s) whose job is to control the fluent roll and glide mechanics of your shoulder joint. Without them doing this role, the control of the humeral head is disturbed and there is more wear on the cartilage.
2. Biomechanics that increase strain on a joint from outside the joint.
Example A: You have injured your ankle joint and you have weakness in your gluteal muscles. Your ankle rolls in as you walk and your hip shifts to the side. This change alters the mechanics at the knee joint.
Example B: You have a neck injury which alters the muscular control of your shoulder blade. The shoulder blade is the platform from which the shoulder joint moves. A reduction in scapula control will see more demand on the rotator cuff tendons and an increase in strain through the shoulder joint.
Diet
No diet has been proven to cure arthritis.
There is some research to support that some food groups may reduce disease activity, whilst others might promote inflammation and degenerative changes.
Monounsaturated fats: Diets which include monounsaturated fats may reduce disease activity, particularly in Rheumatoid arthritis.
Food groups include vegetable oils (olive oil, canola oil, sunflower oil), avocados, and many nuts and seeds.
Omega-3 fats: Also have some evidence towards their benefit. They may help reduce inflammation. Again particularly in rheumatoid arthritis which is associated with higher degrees of inflammation.
Foods rich in omega-3 fats include oily fish, linseed/flax seed, canola oil (also called rapeseed oil), and walnuts.
Saturated fat: This type of cholesterol has been linked with increased cartilage damage in people with osteoarthritis. These fats can also increase your risk of cardiovascular disease.
Saturated fats are found in red meat, poultry and full-fat dairy products.
Trans fats: Artificial fat is created during hydrogenation, which converts liquid vegetable oils into semi-solid partially hydrogenated oil. Trans fats can be found in foods including fried foods like doughnuts, and baked goods including cakes, pie crusts, biscuits, frozen pizza, cookies, crackers, some margarine's and other spreads. Look for “partially hydrogenated oils.”
For more information on fats and arthritis, visit https://arthritisaustralia.com.au/
For more information on Trans fats and cardiovascular health, visit https://www.heartfoundation.org.au/
Genetics
We do see some familial links, particularly in the group with multiple joints involved. However, in the case of common arthrosis, I urge people not to stress too much about this as it is outside your control. In the case of inflammatory arthritis, it can be worth bringing up with your osteopath because it might help us refer you off to have the appropriate tests, as an earlier diagnosis could help mitigate disease progression.
Causative factors for commonly effected joints:
Knees:
Being overweight
Having a previous knee injury
Jobs involving kneeling
What about running?
You’ve probably all heard the phrase “running is bad for your knees!”. Runners suffer from less knee arthritis than people who don't run. I think the confusion here is that if you run when you have a knee injury, it hurts due to the high impact forces. But if you have always been a runner, your knee surfaces adapt to this. The subchondral bone will be harder, and the muscles which support your knees will be stronger.
Hips:
Being overweight.
Having a previous hip injury.
Jobs involving lifting heavy loads (including farming).
Hands:
A family history of OA.
Repetitive use or previous injuries to the hands.
Injury to a finger – a lot of subchondral fractures to finger joints go undiagnosed.
Spine:
Increased strain on one area of your spine - this may be the result of a job that involves a lot of bending, twisting and heavy lifting, or the result of sitting for 8 hours a day over your working life.
A change in biomechanics within the joint, which might be the result of a previous injury.
Shoulder:
Previous dislocation .
A rotator cuff tendon tear effecting the controlled rotation of the shoulder surfaces through movement .
Biomechanical forces as described earlier.
What are the symptoms of osteoarthritis?
Osteoarthritis will usually feel like a dull ache, and will be associated with a reduction in joint mobility. People with osteoarthritis will typically describe morning stiffness. They will wake up feeling stiff, then notice they improve over the next 30 minutes to an hour, once they have had a shower, had breakfast, or gone for their morning walk.
The reduction in joint mobility with OA will be gradual, occurring over many years.
Arthritic joints will become sore after you do a lot with them. For example, your knees are sore after you have been working in the garden all day, but then improve over the next few days. The key thing here, being that your pain is generally consistent. It follows the same pattern. Avoid blaming every painful experience on arthrosis. Sudden onset of severe pain, unlike your usual pain, is likely to be a sprain/strain of a tissue, which is treatable.
How is osteoarthritis diagnosed?
We usually don’t need imaging to diagnose OA. As primary care practitioners, Osteopaths can make the diagnosis and develop a management plan without needing any additional imaging. Your GP will usually do the same thing.
Imaging is used if we need clarity with the diagnosis, or we are looking for something which could change our treatment plan. An example of this would be if we think someone has a lot of tendon pain, but they are failing to respond to conservative care. In this case, we might get an X-ray to see if the joint is arthritic.
The thing to remember with imaging is that every one of us will develop arthrosis. Just like every one of us has a reduction in our bone density after the age of 30. Imaging can create undue fear of using the painful area, which is counterproductive as this will lead to weakness of the stabilizing structures.
If you have ever had a bone density test (DEXA) you will notice that you are given two scores:
T score indicates whether your bone density falls within a normal range for a healthy person in their 30’s.
Z score is a comparison against other individuals of your age, sex and weight.
So when we report on bone density, we report it in perspective.
But when we report on arthritis, we only compare it to a young healthy person.
Would it be smarter to report an X-Ray like this?:
Your degeneration is greater than when you were 30.
Your degeneration is normal for a person of your age and gender.
At what age did your arthritis begin?
When you're born, you are as flexible as an elastic band.
When you're 2 years old, you can walk and to do so, you need an element of rigidity through your body. If you don't develop this, you couldn’t support yourself upright. So a 2 year old is not as flexible as a baby.
When you're 10 years old, you are not as flexible as when you were 2, and when you're 16 you are not as flexible as when you were 10.
When you're 40, you start to notice you are not as flexible as you were when you started your career.
When you're 50, you notice you can’t twist as far as you could when you were 40, and when you're 60, you are…
Given a label…
"Arthritis!!!"
"All the pain you are experiencing in the last few months is because you have arthritis. There is nothing you can do. Look, it’s right here in your x-ray report; 'degenerative changes are seen at the L4/L5 and L4/S1 levels'".
We all know that we get stiffer as we age, and that is because you lose range or movement in your joints. I’m not saying joint arthrosis doesn’t cause pain! For some people it is the sole cause for their pain, but I think it is important to keep in mind that 66 out of 67 pain-free individuals (see the results from the study group mentioned earlier), have arthrosis in their spine.
How do we manage osteoarthritis?
Arthritis is manageable. There might be alterations to your lifestyle that you will need to make, but we can usually keep you participating in the things you love.
Pain can change you, but never let it define you.
The strong evidence-based management approach for an improved long term outlook with osteoarthritis is maintaining an adequate strengthening regimen, along with an active lifestyle.
Movement
Motion is lotion. #motion_is_lotion
There is no blood flow in your joints. Everything the joint cartilage needs gets there via diffusion through the joint fluid. Inflammatory fluid and waste products are removed by the same mechanism. The more you move the joints, the more fluid flow occurs in the joint, the better the joint will function.
Think a stagnant pond, verses a flowing river.
It doesn’t matter how YouMove, so long as you do.
Hydrotherapy
Hydrotherapy is a great option for many people, as the reduced impact through the joints reduces pain associated with exercise, so we can improve your strength and mobility without hurting you.
If you have arthritic pain, I strongly urge you to put aside any concerns you might have about joining a group water therapy class. Everybody else in the pool is in the same boat as you. These classes are usually incredibly friendly and performed in warm water shallow enough to stand in. Give it a go just once, because I’m sure you’ll want to go again and again after that.
The same can be said for walking groups. These group activities always have superior outcomes because they increase the long term adherence rate. On those cold mornings, when you can’t be bothered going out into the cold, or when you have a busy week planned, having a scheduled group activity is often what’s required to get you started.
Strength
Joints are supported by muscles both directly, and indirectly. Strengthening the muscles around the painful joint will make a big difference in reducing the shearing forces on the joint, which increase the rate of cartilage wear. A strength program needs to be targeted towards the individually. You can try a few exercises you see online, so long as they are safe, but this is always going to be inferior to a program designed for you specifically.
Nobody moves like YouMove.
Mobility
Our bodies adapt, so if we always operate within a comfortable joint range, our capacity to perform outside these ranges also reduces. Exercises which improve the range of movement in the joint are always going to have you feeling more free.
Lose weight
We all know that your diet has a big role in weight reduction, and it’s the same dietary modifications which see a reduction in inflammation. Losing weight will see less pressure on your joints.
Which supplements work for arthritis?
The most important management for OA are the 5 points above. You can supplement these key management points (pardon the pun) if you wish, but these are never high on my treatment plan.
Glucosamine for osteoarthritis
Glucosamine has some support for delaying the progression of osteoarthritis, particularly for the knee, however only glucosamine sulphate has evidence towards its benefit. Glucosamine is often combined with chondroitin sulphate and MSM, and it is thought this is the best combination.
You're looking for a daily dose of 1500mg glucosamine, 800mg of chondroitin and 1200mg MSM. The more you balance this throughout the day, the better. Eg. 500mg 3 times a day is better than 750mg twice a day. The disadvantage of spreading out the dose lies in the difficulty in remembering to take them, as well as increasing the cost.
My favourite is Bioceuticals ChondroPlex.
If you try glucosamine for 3 months and you're not seeing any benefit, save your pennies.
Glucosamine is generally well tolerated, however you should speak to your doctor if you are diabetic, asthmatic, take blood thinners, have a bleeding disorder, require a low sodium diet or are allergic to shellfish.
Turmeric or curcumin for osteoathritis
Turmeric contains curcumin, which is a safe and natural anti-inflammatory. However, the dose of Turmeric required to get a therapeutic effect is likely so high, you couldn't possibly consume that much turmeric. The uptake of curcumin can be increased by combining turmeric with black pepper, but most supplement companies will do that for you, as well as isolating the active ingredient so you don't have to consume it by the truckload.
My favourite brand is Nagese Osteo Plus.
Speak to your doctor if you are at risk of developing kidney stones or have an iron deficiency. Otherwise, turmeric is fairly safe. Stop using these supplements if they give you an upset stomach, nausea, abdominal pain, cramps or diarrhoea.
Fish oil for osteoarthritis
The polyunsaturated omega-3 fatty acids found in fish have potent anti-inflammatory properties. As we discussed prior, they are probably more effective for rheumatoid arthritis due to the inflammatory element to that condition.
Fish oils can be expensive so it's better to include them in your diet (disclaimer alert - this is coming from a passionate fisherman).
The NPS (National Prescribing Service) suggests that an intake of 2.7 g/day of eicosapentaenoic acid (EPA), plus docosahexaenoic acid (DHA) is required to achieve anti-inflammatory effects in patients with RA.
How do you know when a joint replacement is required?
"My Osteopath or doctor will tell you when he sees my X-Ray right?"
Wrong!
Imaging is not very accurate in measuring your level of disability as there is a poor correlation between changes on xray and how much pain you have. It’s really a question of how much the arthritic joint is effecting your life. What do you love doing that you can no longer do, or is it the basic activities of daily living? Sleep is a big one for me. If you’re only getting a few hours of sleep because your joint pain is keeping you awake all night, it’s probably time for a chat.
"So I just put up with it until I can no longer bare it, then meet with a surgeon?"
Wrong again, for two reasons:
1. Meeting with your Osteopath early enables us to develop a management plan aimed to reduce pain and disability, as well as strengthen the muscles that support the joints. The earlier we begin this, the better we expect your long term outlook to be.
2. If a joint replacement is a likely outcome, having the discussion early means we can plan the surgery around your life and avoid becoming victim to a lack of choice.
Is there a holiday you want to go on?
Do you want to be dancing at your child’s wedding?
If you are a bit older, should you have the operation now, whilst your bones are strong and your health will tolerate the operation, or are you so young, we should set a goal to get you to a certain age first?
Do you have private health or will you need to go on the public waiting list? In that case, meeting with a surgeon and being placed on the list earlier avoids you waiting several painful months for an operation, whilst your health and muscle conditioning declines.
Osteoarthritis in the spine is a little different. Surgery is not usually recommended for spinal pain. The decision for a specialist opinion is usually made around the presence of any neurological symptoms. Even then, the specialist will usually try other options such as medication or injection therapy before jumping to surgery.
If you are struggling with an arthritic joint, I hope this answers a few questions you might have. If you're ready to seek help, get in touch with YouMove Osteopathy in Mount Eliza. We'll put together a treatment plan that suits your individual needs.
Thanks for reading.
Lachlan Allen,
Osteopath at YouMove Osteopathy in Mount Eliza.
