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Arthritis, Osteo

Introduction

What should I know about Osteoarthritis?

When Ben Franklin said that death and taxes are life’s only certainties, he might well have added osteoarthritis to the short list. Osteoarthritis is the complete medical name for the condition generally referred to as "arthritis." When your grandmother complained that her arthritis was bothering her, she was actually suffering from osteoarthritis.

The most common joint disease in humans and all vertebrate animals, osteoarthritis is a universal affliction: virtually everyone who lives past age 75 has it to some degree. Nearly 50 percent of the population suffers from osteoarthritis by age 65. (1)

Known to doctors by the simple acronym "OA," osteoarthritis hits hard on the hardest working joints: the knees, the hips, the hands, and fingers. The weight-bearing joints and the spine are especially vulnerable. It is a fundamental fact of life that as we age, our joints lose their youthful flexibility and range of motion. Movement eventually becomes difficult and painful as we slowly, year by year, become less supple and more stiff.

Sometimes described as "degenerative joint disease" (DJD), osteoarthritis was once thought to result mainly from wear and tear on joints. This traditional theory has been largely abandoned with advances in knowledge of joint physiology. Current thinking is that osteoarthritis is not just a single disorder, but a complex pattern of changes in the repair mechanisms that keep joints functioning normally. (2) A number of different factors can impinge upon the health of joint tissue, including biomechanical forces, changes in body biochemistry, inflammatory processes, and altered immune function.

Osteoarthritis can be classified into two major categories: Primary OA and Secondary OA. Primary OA lacks a specific cause such as trauma or disease. Secondary OA is caused by trauma or some known abnormality such as an infectious disease or endocrine disorder. Primary OA, which reflects the majority of cases, is subdivided into local, general, and erosive OA. Local OA usually affects just one or two joints. In generalized OA, three or more joints are involved. Erosive OA damages the bone around a joint. To arrive at a specific diagnosis, rheumatologists look at factors such as joint pain, visible signs of joint deformity, and changes seen on x-rays and in biochemical tests that detect inflammation. (3)

Cartilage is a metabolically active tissue that is continually being reformed and remodeled. Joint cartilage contains a lot of water—75 to 80 percent by weight—and this water content allows the joint to function as a shock absorber between two adjacent bones. The remaining 20 to 25 percent consists of cells called "chondrocytes" which produce the building material for cartilage, and various structural components.

Collagen, a tough protein fiber, provides the structural backbone for cartilage, somewhat like a reinforcing bar in concrete. Collagen gives cartilage its shape, toughness, and amazing tensile strength. This collagen matrix is filled in with large molecules called "proteoglycans" that have a strong attraction for water. Thanks to proteoglycans and the water they hold, cartilage can bear a tremendous amount of weight. Proteoglycans in turn are made out of long, chain-like molecules called "glycosaminoglycans." Chondroitin sulfate, now popular as a supplement for rebuilding joints, is one of the most important glycosaminoglycans in joint cartilage.

Osteoarthritis is characterized by progressive, degenerative changes in cartilage structure. The proteoglycans break down, losing their ability to form tight clusters. The water content of cartilage increases. Chondroitin sulfate shortens in length. Cartilage loses the ability to repair itself and develops clefts and crevices that eventually extend down to the underlying bone. The end result is weak, stiff, and deformed joints.

Statistic

World Health Organization, 2000.

  • OA is the 4th leading cause of disablilty worldwide.
  • Osteoarthritis affects 9.6% of men and 18% of women aged >60 years worldwide.

Arthritis Foundation Malaysia, 2007.

  • The prevalence of OA in Malaysia is 10-20% of the adult population.

National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, 2000.

    More than 20 million people in the United States probably have the disease. Some younger people get osteoarthritis from a joint injury, but osteoarthritis most often occurs in older people. By age 65, more than half of the population has x-ray evidence of osteoarthritis in at least one joint. Since the number of older Americans is increasing, so is the number of people with osteoarthritis. Both men and women have the disease. Before age 45, more men have it, while after age 45 osteoarthritis is more common in women.

Signs and Symptoms

The following list does not insure the presence of this health condition. Please see the text and your healthcare professional for more information.

The severity of symptoms depends upon the duration of the disease and the particular joints involved. Primary OA typically strikes the fingers, the knees, the hip joints, the cervical spine (neck), and lumbar spine (low back.) People with OA often suffer from a feeling of weakness or instability. Flexibility and range of motion are lost. Movement becomes progressively more difficult and painful.

General

  • Pain, deep aching
  • Pain with use (early in disease)
  • Pain at rest (late in disease)
  • Stiffness in joints within the first 15 minutes of use, related to weather
  • Limited joint motion
  • Instability in weight bearing joints, such as knees and hips
  • Crackling, as if bones are rubbing together

Treatment Options

Conventional

The primary treatment goals are to reduce pain, maintain joint function, and prevent further joint destruction. In general, a conservative individualized approach combining rest, exercise, and medications can achieve these goals. The following are some important things to consider:

    Physical therapy can help, with specific exercises to improve range of motion and strengthen muscle around the affected joints. Weight management is important, as excess body weight puts an added burden on weight-bearing joints. NSAIDs, the non-steriodal anti-inflammatory drugs, are the most common medications prescribed for pain relief. These include ibuprofen, ketoprofen, acetaminophen, aspirin, and others. These are available over-the-counter, although a prescription may be needed for higher strengths. These "traditional" NSAIDs are commonly associated with upset stomach, gastro-intestinal bleeding and even the development of gastric ulcers. A new class of NSAIDs have been designed to avoid the stomach and intestinal problems. These drugs are know as COX-2 Inhibitors and are available with a prescription, they include celecoxib and rofecoxib. A new form of drug therapy has recently appeared for OA of the knee that injects sodium hyaluronate directly into the knee joint. Hyaluronate, or hyaluronic acid, is a substance found in joint cartilage. This is intended to help reconstitute the synovial fluid, the fluid that lubricates joints. Hyaluronic acid also helps proteoglycans form the clusters that give strength to cartilage. Several published studies have shown this therapy to be helpful in improving joint function. (4) , (5) , (6)

Nutritional Suplementation


Glucosamine

Glucosamine is another substance produced by the body that is now a widely popular dietary supplement. Healthy joint cartilage is rich in glucosamine. As a key component of the glycosaminoglycans discussed earlier, glucosamine is vitally important for maintaining strong, flexible joints. The body can use orally taken glucosamine to make new glycosaminoglycans.

In OA, the production of glucosamine by the cells that produce the building blocks for cartilage, takes a downturn. Fortunately it can be replaced by glucosamine supplements. Glucosamine has been researched in humans over the last twenty years or so as a treatment for osteoarthritis. Results of controlled trials as well as reports from physicians indicate that glucosamine effectively decreases joint pain and improves joint mobility. (7)

Human studies have given glucosamine in the form of glucosamine sulfate, either orally or by injection into the muscles and joints. While most of these studies have been short-term trials on small numbers of subjects, the results are consistently positive. Taken over a period of two to three months, glucosamine sulfate brings about a gradual reduction in joint pain and tenderness while improving joint flexibility, range of motion, and mobility. In one study, glucosamine sulfate was compared to ibuprofen for pain relief. For the first four weeks ibuprofen was more effective for reducing pain. No surprise there; ibuprofen, after all, is a fast-acting anti-inflammatory medication. By the eighth week of the study, people taking glucosamine sulfate showed greater reductions in pain score than those on ibuprofen. Glucosamine sulfate also caused fewer side effects. Not only that, the benefits of glucosamine sulfate continued for weeks after the study was completed. (8) , (9)

Results from a 3-year trial comparing glucosamine to placebo revealed that glucosamine sulfate prevented the progression of the disease based on the amount of free space measured in the joint. It also reduced the frequency and degree of pain. This study suggests that glucosamine sulfate could actually change the progress of the disease and not just the symptoms of it. (10) A similar 3 year study involving 202 people had similar results. All participants had mild to moderate knee osteoarthritis and were given either 1500mg/day of glucosamine sulfate or placebo. In the glucosamine group, the amount of measurable space in the joint did not drastically change whereas the space narrowed in the placebo group. Glucosamine sulfate also significantly improved symptoms compared to placebo. Again the researchers felt as though the decrease in disease progression could possibly indicate modification of the disease process. (11)

The most common dosage of glucosamine is 500mg taken three times daily. Glucosamine hydrochloride, in combination with condroitin sulfate and magnesium has also been found effective. It may take three to four weeks before glucosamine is effective, so stronger anti-inflammatory medication may be necessary for acute conditions for a short period of time.


Chondroitin Sulfate

Chondroitin sulfate is one of the major structural components of cartilage. As another "chondroprotective" agent, it improves the structural integrity of joints in three key ways. Number one, chondroitin sulfate stimulates the production of new, healthy cartilage. Number two, it blocks enzymes that break down cartilage. Lastly, it normalizes synovial fluid, the lubricant that keeps joints moving smoothly by reducing friction between adjacent joints surfaces. (12) Chondroitin helps prevent joints from deteriorating as it supplies the material needed for joint repair.

While the bulk of clinical research studies on chondroitin sulfate have been given by injection, a few trials have tested the oral form as well. In one double-blind study, 800 mg of chondroitin sulfate per day was effective in reducing joint pain and increasing overall mobility. The knee joint space widened, indicating rebuilding of cartilage in the joint. In contrast, subjects taking a placebo showed narrowing of the joint space. (13)

In another double-blind study, 119 patients with osteoarthritis in the fingers took 1200 mg of chondroitin sulfate or a placebo daily for three years. Compared to patients on placebo, those on chondroitin sulfate had much less progression of the disease. (14) In a more long-term trial 80 patients with OA of the knee received 800 mg of chondroitin sulfate or a placebo daily for six months. Subjects taking chondroitin were able to walk longer and needed less pain medication than those on a placebo. Chondroitin sulfate was also very well tolerated. (15)


S-Adenosylmethionine (SAMe)

SAMe is a form of the amino acid methionine that has earned recent popularity as a dietary supplement for depression. Studies indicate SAMe is a good pain-reliever for OA, possibly as effective as ibuprofen (16) or celecoxib. (17) SAMe, in addition to its anti-inflammatory benefits, appears to stimulate proteoglycan production in cartilage, with no side-effects. (18)

In a two-year multicenter open trial, SAMe was administered to 108 patients with osteoarthritis of the knee, hip, and spine. The dose was 600mg daily for the first two weeks and then 400mg daily thereafter. The improvement in clinical symptoms--morning stiffness, pain at rest, and pain on movement-- began after the first few weeks of treatment and continued for up to 24 months. SAMe administration also improved the feelings of depression often experienced by people with osteoarthritis. (19)


Methyl Sulfonyl Methane (MSM)

Methyl sulfonyl methane (MSM), a natural source of dietary sulfur, has been used with success to reduce or even eliminate arthritis pain. MSM has been given to thousands of patients at a university outpatient clinic and found helpful for a variety of health conditions, including arthritis. (20) Most of the evidence for MSM so far comes from case reports rather than controlled studies.


Deer Antler Velvet

Deer antler velvet, which is the soft cartilaginous tissue from red deer or elk (Cervus species), is rich in the structural and nutritional components of cartilage. It contains substantial quantities of glycosaminoglycans, including chondroitin sulfate. (21) Deer antler velvet is claimed to benefit people with OA but this is based on anecdotal reports and observations of physicians. These claims have not yet been tested in scientifically-designed clinical trials, although the leading researcher in this field, Dr. Jeong Sim, is currently conducting three separate studies at Edmonton University in Calgary, Canada. Deer antler velvet products are safe and without side effects. The dosage varies according to the type of product that is used.


Vitamin B3

Niacinamide is a form of vitamin B3. Initial reports about niacinamide’s usefulness in the treatment of osteoarthritis began appearing in the scientific literature in the 1950's. (22) , (23) , (24) Now, a more recent study verifies these earlier observations, suggesting that niacinamide can play a beneficial role. Taking high doses of niacin over a period of weeks can have a negative effect on the liver, so liver enzymes should be periodically checked by a physician. High niacin doses can also cause nausea and gastric upset.


Vitamin C

Evidence from a large study on osteroarthritis revealed that OA sufferers with the highest intake of vitamin C had a reduced risk of cartilage loss and disease progression. Although high intake of vitamin C did not reduce the incidence of osteoarthritis, there was a three-fold reduction in the risk of progression of the disease in individuals with osteoarthritis of the knee. (25) One study found that there was an increased risk of polyarthritis in those with lower dietary intakes of fruits and vegetables, and vitamin C.


Vitamin E

Vitamin E was compared to the pain medication "diclofenac" in 53 patients with osteoarthritis of the hip and knee. In this three-week double-blind study, 26 patients received 400mg of natural vitamin E daily while 27 patients took the drug. The vitamin and the drug provided benefits that were very similar. Vitamin E: reduced or abolished the pain at rest in 77 percent of patients compared to 85 percent of patients on diclofenac; reduced the pain on pressure in 67 percent of patients vs 50 percent in patients on diclofenac; and reduced the pain on movement in 62 percent of patients compared to 63 percent in patients on diclofenac. (26)

Side effects occurred in 7.7 percent of patients taking vitamin E compared to 25.9 percent of patients taking diclofenac.


Boron

Boron is a trace mineral that may be important for maintaining healthy bones and joints. Data from numerous areas of investigation indicate that boron has a potentially significant role in the treatment of osteoarthritis. It has been observed that bones of patients using boron supplements are much harder to cut compared to the bones of patients not taking a boron supplement. The synovial fluid of people with osteoarthritis has been found to contain less boron than normal. In areas of the world where the intake of boron is high the incidence of osteoarthritis is relatively low. In laboratory experiments, rats with artificially-induced arthritis benefited from boron administered orally or by injection. Also, in a double-blind placebo-controlled trial, 20 subjects with osteoarthritis responded favorably to 6 mg of boron a day. Fifty percent of subjects receiving boron supplementation improved compared to only 10 percent receiving the placebo. (27)

Herbal Suplementation


Boswellia

Boswellia is a gum resin extract from the stem bark of the Boswellia serrata tree. It is emerging as an effective herbal treatment for symptoms associated with arthritis. (28) Research on Boswellia lends scientific weight to its traditional use as an anti-rheumatism herb. Numerous studies show that Boswellia has effective anti-inflammatory properties. Boswellia contains active ingredients called Boswellic acids that block the production of the enzymes in the body that actually trigger inflammation. (29) , (30) Boswellia appears to protect cartilage as well, by keeping the glycosaminoglycans from breaking down. It is a fact well known in medicine that NSAID's cause cartilage damage when taken over time. (31)


Ginger

Ginger has been used throughout history as both a culinary spice and medicinal herb. Ginger contains oils that promote circulation and acts to clean up the body by neutralize free radicals. It also blocks inflammation. (32) Its anti-inflammatory action is similar to aspirin, without aspirin’s potentially damaging effect on the intestinal tract. (33)

A study involving 56 patients with rheumatoid arthritis, osteoarthritis and muscular discomfort, ginger was effective in more than 75% of the patients. (34) Two-hundred and forty seven patients completed a study lasting 6-weeks evaluating the safety and effectiveness of ginger in osteoarthritis of the knee. The ginger extract group had greater response in reducing knee pain when standing as well as all other measures evaluated. More mild stomach and intestinal upset was experienced by the ginger group. It is important to note that the change in the overall quality of life was equal between the ginger and placebo group. (35) When compared to conventional anti-inflammatory agents, such as ibuprofen, a study found no significant advantage of using ginger root. (36)


Cat's Claw

Cat’s claw has been used as a traditional medicine in South America, possibly dating back as far as the Incan civilization. Cat’s claw reportedly affects the immune system and acts as a free radical scavenger. (37) Cat’s claw contains active ingredients called "glycosides," that reportedly reduce inflammation and water retention. (38) Cat’s Claw contains natural sterols that show anti-inflammatory power in animal studies. The anti-inflammatory effects of cat’s claw are considered to be due to the sum total of the plant’s constituents.


Turmeric

In Ayurvedic medicine, a medical tradition born in India and used for centuries, turmeric root has been used as a tonic for the stomach and liver, as a blood purifier, and externally in the treatment and prevention of skin diseases and in arthritic complaints. (39) Laboratory and clinical research indicates that turmeric and its active ingredients have unique antioxidant and anti-inflammatory properties. (40) , (41) The anti-inflammatory strength of turmeric can be compared to steroidal drugs such as indomethacin. (42) Curcumin reportedly has a similar action to that of aspirin and aspirin-like agents. (43) Curcumin may be preferable as an anti-arthritis remedy for individuals who are prone to venous blood clots.


Grape Seed Extract

Grape seeds contain flavonoid-like substances called "proanthocyanidins" (PCOs) that act as antioxidants in the body. Like other bioflavonoids, PCOs act as synergists with vitamin C. (44) PCOs have been found to keep some of the chemicals that cause inflammation from working. (45)

Diet & Lifestyle

    Identify and eliminate food and/or environmental allergies; especially consider the nightshade food group (potato, eggplant, bell pepper). Weight control; excess weight increases compression on joint cartilage. Water; maximal hydration is imperative since the glycosaminoglycans in the cartilage matrix bind and hold water, which acts like a shock absorber.

References

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