What You Think You Know about Osteoarthritis
For centuries, humans have equated aging with creaking bones and aching joints. We’re not alone in our suffering: nearly all vertebrates suffer from some form of osteoarthritis-including porpoises, whales, and, long ago, dinosaurs.
Among the more than 100 types of arthritic conditions, osteoarthritis-more properly called degenerative joint disease (DJD)-is by far the most common. It affects some 20 million people in the United States and costs some $125 billion in annual health care expenses and lost productivity, or “the cost of a moderate recession,” according to the American Academy of Orthopedic Surgeons. It’s also the nation’s leading cause of disability (combined with “rheumatism”), says the Centers for Disease Control and Prevention. According to the Arthritis Foundation, some 80% of people with DJD report some form of limitation in movement or activities, and DJD of the knee can be as disabling as any cardiovascular disease, except stroke.
Caused by the breakdown and eventual loss of the cartilage in one or more joints, DJD usually takes a slow and insidious course. In its early stages, the surface of the cartilage becomes swollen and proteoglycans and other tissue components are lost. As the disease progresses, cartilage loses its elasticity and becomes more susceptible to damage from repetitive use and trauma. Ultimately, large amounts of cartilage are damaged or destroyed, leaving the ends of the bone within the joint uncushioned and unprotected.
But despite the fact that when we think of arthritis, we often think of an elderly woman with painfully knotted fingers, or a grandfather struggling to get out of bed on a cold morning, DJD is not just a disease of the elderly. And it’s not an inevitable result of aging. “Most people tend to equate osteoarthritis with getting old, but it’s not an etiological factor of aging,” says Jason Flanagan, DC, dean of academic affairs at Texas Chiropractie College. “People think, Tm supposed to hurt and have difficulty getting around as I get older.’ No, not necessarily.”
It’s true that, by age 65, more than half the population has x-ray evidence of DJD in at least one joint. But DJD, while far more common after the age of 45, can strike just as easily in younger people (under the age of 45, it’s more common in men than in women, while women over 55 tend to develop it more often than men ofthat age). What’s more, just because DJD shows up on an x-ray doesn’t mean that the patient will be experiencing pain. “There’s no statistical correlation between the degree of degeneration and the degree of pain that the patient reports experiencing, unless it’s profound to the point where the patient needs joint replacement,” says Stephen Perle, DC, MS, associate professor of clinical sciences at the University of Bridgeport College of Chiropractic. In other words, many of the things that we traditionally assume about “osteoarthritis” are off the mark.
“What’s amazing about degenerative joint disease is how it varies from person to person,” says Warren Jahn, DC, DACBSP, DABFP, who practices in Roswell, Georgia, and served as a team chiropractor for the 1996 Olympics in Atlanta. “If you take 2 people who have identical jobs, hobbies, and virtually identical stresses on their joints throughout their lifetimes, you might well find one whose joints are in pristine condition at the age of 65, while the other has visibly misshapen and painful joints that barely function.”
What causes this variation? To some extent, that remains unknown. There is clearly a genetic component to at least some cases of DJD of the fingers, the kind that causes the familiar knobby, swollen knuckles. It appears to be familial and most often occurs in women. A wide variety of other factors appear to combine, predisposing some people to DJD more than others. “There are these genetic and hereditary factors, along with poor nutrition and obesity, postural changes, lack of exercise, and wear and tear on the joints that all contribute to DJD,” says Dr. Flanagan.
Taking a More Active Role in Prevention
Dr. Flanagan is concerned that common misconceptions about the disorder-particularly the idea that it is an inevitable “side effect” of aging-cause DJD to be mismanaged. “Because people believe pain is inevitable with age, many of them ignore the signs and symptoms. If they acted on them, they could be worked with a lot earlier. Instead, people wait until irreversible damage occurs to those joints. Once they break down, it’s pretty much permanent,” he says.
Doctors of chiropractic, he notes, are on the front line for detecting the earliest changes. “DCs really see the impact of degenerative changes in the spine, as well as the hips, knees, and other weight-bearing joints, that occur as a result of the remodeling in the degenerative process,” he says. “When we see those changes, it’s the perfect time to say, ‘You’re at risk for degenerative joint disease,’ and present patients with the opportunity to take some action, instead of waiting for signs and symptoms to develop.”
The primary prevention strategy for degenerative joint disease, Dr. Flanagan suggests, is proper diet. “While some people have a genetic predisposition toward DJD or a problem with getting enough nutrients, that’s not really commonplace. Most people are just overweight and/or they don’t eat the proper foods, so their joints experience more wear and tear,” he says. “And, of course, most people don’t exercise-they feel better watching it on TV. But exercise has a significant impact on prevention of DJD through rangeof-motion activity.”
People may think they’re eating right-but often, they’re not. “Everyone’s focused on fatfree this and low-carb that, but people don’t really read the labels and work to understand the nutritional information. They rely too much on trends,” says Dr. Flanagan. Here is a key area where a well-informed DC with a nutrition background can play an important role in DJD prevention.
Another such area: exercise counseling. “Many people exercise incorrectly: they think that they have to go out and start sprinting and running to really be exercising. Someone who’s already obese ends up putting too much stress on knee and ankle joints,” says Dr. Flanagan. “Instead, an obese person should be doing things like half an hour of brisk walking every day, stair climbing, water aerobics, Theraband workouts, and other exercises that keep the joints mobile without putting undue strain on them.”
When Prevention Isn’t Possible
With many patients, however, the doctor of chiropractic will not get the opportunity to help prevent DJD, and will only become involved once degeneration has already set in.
In these cases, says Dr. Perle, the DC should first make certain that the pain the patient is experiencing is, in fact, a result of degenerative changes before starting a treatment plan. “Often, patients will complain of pain and when the doctor finds DJD on the x-ray, he’ll say, ‘Aha, DJD!’ and treat them based on the assumption that that’s the entire problem,” he says. “If they don’t get better, you can just blame DJD. But honestly, unless somebody’s got really profound DJD to the point that joint replacement is needed, I don’t think it’s usually the reason for symptoms. For me, other treatments have been helpful to alleviate a patient’s pain.”
As an example, Dr. Perle cited the case of a patient he’d seen early that same day. The 48-year-old woman had been diagnosed with DJD by her MD, based on x-rays. The woman’s doctor prescribed nonsteroidal antiinflammatory drugs, as is the case with many DJD patients. “She has intermittent attacks of sharp low-back pain that occur perhaps 3 or 4 times a day, last for a few seconds, and go away,” says Dr. Perle. “Her physician assumed that these had to do with the DJD, but one thing he apparently didn’t know was that she’s had chronic low-back pain for years and has just ignored it. I found that out when I was taking her history, but her MD hadn’t asked about it.”
The chronic back pain, Dr. Perle reports, went away after 1 treatment. “This was simply from stretching her erector spinae muscles and her psoas after performing a Thomas test, which showed that her psoas was extremely tight,” he says. “Now, whether this will make the intermittent pain she reported go away, as well, we don’t know yet. But the pain she used to feel all the time is now gone.”
Clearly, x-rays that show degenerative joint changes don’t necessarily mean that the pain they feel is all due to DJD, or that they must expect and put up with increasing pain as a result of normal aging. “But a lot of patients that I’ve seen have been told precisely that by other doctors: ‘You have degenerative joint disease. Live with it,”‘ Dr. Perle says. “That’s easy. If you focus on that, you don’t have to do anything. You can always use the DJD as an excuse for not getting the result you want, instead of saying, ‘Maybe I have to learn more,’ or, “Maybe I have to try other approaches to treating the patient to get the results the patient and I would like to see.”‘
The question with many cases of DJD, Dr. Perle says, is how much the DC can influence the function of the rest of the joints to relieve some of the stresses on the affected joint or joints to relieve pain. “How can I improve joint function peripheral to the problematic joint, so I take stress off that joint?” he asks. “Dr. Jay Triano of the Texas Back Institute has presented what I think is a marvelous model for what we do as chiropractors: we treat ‘loading disorders.’ There’s too much load or too little load.”
“One thing I’ve often seen in practice is that if someone has a complaint, say, at C5, and I do a manipulation higher up or lower down, it decreases the pain in the primary location,” Dr. Perle says. “If 1 of your joints moves too little, and the global range of motion is normal, that would logically suggest that something’s moving too much.”
He points to some studies that have indicated that manipulation of I joint can affect other joints along the same “kinetic chain.” “In a study presented at the ICSM a couple of years ago, we found that ankle manipulation could change the axis of rotation of the knee or the hip as well,”1 Dr. Perle says. “We didn’t get consistent results across patients-different combinations were affected, and sometimes it was 2 joints, sometimes 3. But it did affect the kinetic chain, providing preliminary evidence of this concept that doctors of chiropractic have noticed that treating I place along the kinetic chain can have effects elsewhere. So if a patient has severe degeneration in the wrist, I might look at manipulating the elbow and shoulder; if the disease is involved in the lower part of the cervical spine, I might look at manipulating other parts of the cervical spine.”
Dr. Perle also suggests the use of manipulation, myofascial trigger point therapy, and other soft-tissue approaches to help relieve the pain and functional limitations of DJD. “Adjusting is really important, but it has its place and time. The more tools we have, the more likely we are to find the one that’s really going to help the patient,” he says. “Something may masquerade as a joint problem, and the joint may be involved in it partially, but that’s not all of it. We need to be open to multiple approaches.”
Dr. Jahn notes that some patients with DJD may be also be overtreated for other conditions. “Let’s say that someone has a traumaa car accident or work-related injury-but he also has underlying osteoarthritis in the spine. When does the soft-tissue injury heal and the sequelae of the trauma on the osteoarthritis continue? That’s a big question,” he says. “The primary objective finding that you monitor is motor or muscle strength (tears/strain). When the muscle heals and strength returns to normal, but the patient continues to report pain, the issue may now be joint-related. In some cases, the DC continues to treat for muscle damage, rather than the underlying or preexisting joint disease, which is now the primary etiology.”
A Supplemental Approach
Over the years, various diets and a wide variety of supplements have been touted as miracle cures for arthritis, or at least as miraculously relieving much of its associated pain, stiffness, and limited movement. Most of these claims remain unproven, but a few popular substances do have some scientific evidence backing their claims.
“Glucosamine and chondroitin sulfate are the two most popular supplements today when it comes to arthritis,” says Alan Adams, DC, MS, DACBN, academic administrator at Florida State University. “A number of randomized, controlled trials have looked at their effectiveness in relieving osteoarthritis symptoms, and they appear to show that glucosamine and chondroitin in combination, over a period of time, tend to reduce pain and increase function. They’ve been compared against placebos and NSAIDs, using standard outcome measures, common in testing pharmacological agents, and have been tested particularly on knee osteoarthritis.”
The caveat, adds Dr. Adams, is that most of the trials of G/C supplements have been done in Europe, and several of them have been sponsored by the pharmaceutical companies that make the products. “But at least 4 systematic reviews and meta-analyses have evaluated these trials, as well,” he says. “If we look at all the different nutrition and supplemental approaches, this one has more evidence than any of the others, and it does show some positive findings.”
One such meta-analysis, published in the Journal of the American Medical Association, examined 15 controlled studies of glucosamine and chondroitin in people with osteoarthritis. The authors concluded that “some degree of efficacy appears probable for these preparations,” but they also pointed out that “quality issues and likely publication bias suggest that these effects are exaggerated.”2
Could glucosamine and chondroitin go beyond simple pain relief and functional improvement to actually arrest or reverse the progression of joint damage seen on x-ray? So far, the scientific jury is out. “Some evidence indicated that this could be possible. A couple of studies have looked at changes in joint space narrowing and radiographie findings, and some animal studies also point to the possibility of its slowing progression,” Dr. Adams says. “But the findings have not been significant enough for us to draw broad conclusions.”
More should be known about glucosamine and chondroitin sulfate’s power against arthritis at the conclusion of a large multi-center trial that’s now in progress, funded by the National Center for Complementary and Alternative Medicine at the National Institutes of Health. “It’s the first such large-scale trial of glucosamine and chondroitin in the United States, and the first multi-center trial anywhere,” says Dr. Adams. The lead institution, the University of Utah School of Medicine, and 8 other study centers in California, Indiana, Kansas, Ohio, Pennsylvania, and Washington have enrolled some 1,200 participants in the trial, which is now in the data analysis phase.
“I think this study, which is focused on osteoarthritis of the knee, will be very helpful to us thanks to its rigor and size,” says Dr. Adams, who expects that the results will be known by sometime next year. “It’s looking at both short-term pain and function and longterm progression, what effect glucosamine and chondroitin may have on pain and function over 6 months, as well as an 18-month treatment regimen to see its effect on the progression of degeneration.”
Whatever the outcomes of the NIH/NCCAM trial, Dr. Adams says, DCs and their patients should be aware of several caveats in the use of these supplements against arthritis:
* Dosage “As with all supplements, the dosage found in a given tablet or caplet varies,” says Dr. Adams. In most studies, 1,500 mg per day of glucosamine and 1,200 mg per day of chondroitin sulfate were used. “If you use a different dosage, you don’t know what effect you’ll get.”
* Time “These don’t work like NSAIDs, which provide more immediate pain relief,” Dr. Adams says. “It usually takes several weeks before you see any relief of pain or improvement in function.”
* Adverse effects and contraindications “These substances haven’t been studied in pregnant women, so since we don’t know what effect they might have, pregnant women probably shouldn’t take them,” says Dr. Adams. “Chondroitin sulfate may interfere with anticoagulant medications. Although no studies have been done to date, there is some anecdotal concern, so those who are on anticoagulant medications should talk to their prescribing physicians before taking glucosamine and chondroitin.” Another serious concern, involving glucose levels for diabetics, seems to have been laid to rest by a study published last year. “This placebo-controlled, double-blind study found that glucosamine and chondroitin supplementation doesn’t affect the hemoglobin A1C levels of type II diabetics, so it appears to be safe within that population,” Dr. Adams adds.3 The only other common side effect of the supplements appears to be mild gastrointestinal upset.
* Are you getting what the label says? Truth in labeling is always a concern with nutritional supplements. A study done at the University of Maryland examined 32 products containing chondroitin: 26 of the products had less than 90% of the amount of chondroitin on the label, 16 contained less than 40% of the amount on the label, and only 5 contained the labeled amount of chondroitin sulfate/ The independent testing organization Consumerlab found similar problems in both glucosamine and chondroitin labeling in a series of tests reported online here: http://www.consumerlab.com/results/gluco.asp.
Has any other supplement shown efficacy in reducing the pain of DJD and improving function? “The other product that has some evidence is MSM (methylsulfonylmethane),” says Dr. Adams. (You might remember actor James Coburn crediting MSM with allowing him to keep working and win a Best Supporting Actor Oscar in the late 1990s.) “It’s in a number of products for people with arthritis, and it also appears to have some effect on pain and function. There isn’t the volume of studies that we have for glucosamine or chondroitin, but there is some evidence.”
Back to Lifestyle Basics
But just as exercise and proper diet play a key role in preventing DJD, they are also important in managing the disease. “These supplements cannot substitute for a good diet and exercise,” says Dr. Adams. “A recent British study found that DJD patients were overusing a whole variety of supplements while underusing exercise and rehabilitation that could help them. I don’t think there’s been nearly enough emphasis on working with patients on the important exercises needed to keep them mobile.”
Dr. Jahn agrees. “Usually, exercise is helpful in several ways: it strengthens the muscular support around the joints, prevents the joints from ‘freezing up,’ and improves and maintains joint mobility,” he says. “The joint is deteriorating, and it’s trying to fix itself in place (ankylosis). You want to maintain the joint in good function.”
And just as with preventing DJD, low-impact or non-weight-bearing activities are particularly good for keeping joints mobile while also alleviating the symptoms of DJD. “Many of the YMCAs have what they call ‘hinges and twinges’ classes in their pools,” Dr. Adams explains. “A number of my patients go several days a week, for about an hour and a half, and they’ve been able to reduce the amount of pain medication they’re taking for their knees.”
He suggests that other exercise options for patients with DJD might include walking, stationary cycling, and light weight training. “In weight training, we’re looking to work the key muscle groups that relate to knee function or the function of the other joint or joints that are affected by the degeneration. If they’re weak, we need to give patients strengthening exercises,” Dr. Adams says. “Many people with moderate to severe DJD won’t comply with these kinds of programs, so once again, a ‘hinges and twinges’ group provides peer support and involvement to encourage the patient to stick with these exercises.”
Maintaining an ideal body weight reduces the risk of joint damage. A healthful diet rich in vegetables, fruits and whole grains and low in saturated fats is recommended. “If there’s inflammation that’s associated with arthritis pain, and that does occur in a number of people, patients should take an anti-inflammatory approach by increasing the number of omega-3 fatty acids in their diet. They can do that by eating more fish, especially oily fish,” Dr. Adams says.
1. Ball KA, Perle SM. Effect of a single manipulation of the tibiotalar (ankle) joint upon lower extremity joint alignment. 2002 International Conference on Spinal Manipulation, 8th Annual Conference on Advancements in Chiropractic, CCCRC Biannual Research Symposium. 2002; Toronto, ONT, Canada: The Foundation for Chiropractic Education and Research, Rosner AL, editor.
2. McAlindon TE, LaValley MP, Gulin JP, Felson DT. Glucosamine and chondroitin for treatment of osteoarthritis: a systematic quality assessment and meta-analysis. JAMA 2000 Mar 15;283(11):1469-75.
3. Scroggie D, Albright A, Harris M. The effect of glucosamine-chondroitin supplementation on glycosylated hemoglobin levels in patients with type 2 diabetes mellitus: a placebo-controlled, double-blinded, randomized clinical trial. Arch Intern Med 2003;163:1587-90.
4. Adebowale A, Cox DS, Liang Z, Eddington ND. Analysis of glucosamine and chondroitin sulfate content in marketed products and the Caco-2 permeability of chondroitin sulfate raw materials. J Am Nutraceut Assoc 2000; 3:37-44.
Copyright American Chiropractic Association Sep 2004
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