Often patients are told they have 'wear and tear' in their spines or joints. This is a common way of describing an arthritis called Osteoarthritis, the arthritis that often occurs as we age. The most common joints affected in this arthritis are the hands, spine, knees and hips and it is estimated that just under 9 million people in the UK have been diagnosed with this condition.
But is it all just about how much we've 'worn' our joints? Why do some people suffer much more than others with it?
There are many factors that are involved in this condition but we are now starting to understand that osteoarthritis may be due to inflammation more than we previously thought. In fact, it is now thought that around 90 percent of osteoarthritis may be due to metabolic processes, with only 10 percent actually just due to overuse.
The biochemistry...
Within the joint lining (known as articular cartilage) are MMP's (matrix metaloproteinase enzymes), digestive type proteins. It is seen that within osteoarthritis patients, there is an increase in chemicals such as histamine, PGE2 and cytokines, released by articular chondrocytes. These are pro-inflammatory chemicals which increase the activity of MMP's, causing more degrading of the cartilage.
A small amount of inflammation is needed for normal healing and repair but if this is prolonged/excessive the cartilage can start degrading instead and begin to roughen and thin.
Eventually the joint can grow extra spurs of bone called osteophytes. The bone below the cartilage (subchondral bone) thickens, called 'sclerosis' on x-rays, and the synovial fluid also becomes thickened and lower quality, causing swelling.
As a knock on effect, this means the muscles, tendons and ligaments surrounding the joint have to work harder.
The cartilage itself doesn't have a nerve network of pain receptors (nociceptors) in it, so pain does not come from here. Instead, pain is often generated from the neighboring subchondral bone, synovial membrane, tendons and ligaments.
Many chronic pain conditions are now known to be caused by sensitization of nociceptors, secondary to increased inflammatory markers due to different stresses on the body (see my blog post on 'Chronic pain...').
So it is thought that instead of it just being a 'wear and tear' issue, it may be more appropriate to call it a 'wear and lack of repair' issue!
Risk factors for osteoarthritis...
Obesity/abdominal fat (which acts as inflammatory signalers)
Diabetes (metabolic diseases)
Smoking
Poor diet
Stress
Genetics
Injuries
Surgery
can all add to the risk of pain from osteoarthritis. These factors may be just as important as how much use/'wear' is put on the joint. So unless we're running marathon's each week, 'overuse' isn't always the key risk factor we used to think.
Instead, if our resting level of inflammation is higher due to these other factors, it can accelerate the changes within our joints.
To x-ray or not to x-ray...
X-rays and other scans such as MRI's can often provide us with valuable information in terms of ruling in or out certain structural issues or serious conditions. However, are they useful in telling us about osteoarthritis? In my opinion, they can provide some relevant information but it is very much about taking everything into account on an individual basis, based on examination and history. Some people can have very little osteoarthritic change on imaging yet be a in a lot of pain, while others can have severe changes seen on their imaging but are hardly even aware of any symptoms in that region!
All in all, the joint degeneration seen in osteoarthritis is normal and varying degrees can be expected to be seen in everyone as we age. It is like wrinkles on our face. So, imaging is not the be all and end all when it comes to predicting pain.
How to help osteoarthritis...
Weight loss- both in terms of decreasing the load on the joint when symptomatic and decreasing inflammation.
Diet- eating a more anti-inflammatory diet (see my blog post about 'Fad diets vs Sustainable nutrition...').
Exercise- also provides an anti-inflammatory effect and increases the tolerance of the joint. 150 minutes of moderate intensity aerobic exercise such as fast walking or cycling, alongside two strength sessions is the NHS recommendation. Obviously when in pain this can be the last thing some people want to do. It may be worth speaking to a health professional about how to find ways of getting some exercise in that suits you and creating a program to build it up gradually.
Stop smoking.
Decrease alcohol- ideally to 2-3 units per week.
Psychological support- Depression, anxiety and stress may be caused by or add to symptoms. Getting professional help for this may be of benefit to some individuals. (Some day to day tips for stress can be seen on my blog post 'Stress, sympathetic overdrive and 7 tips to buffer it...').
Hands on treatment- Alongside these lifestyle changes, some patients find that some hands on treatment also helps keep them going. Options that I often use may include... joint manipulation and/or mobilisation, massage, dry needling/acupuncture and taping. As stated above, a home exercise program is key alongside this and can be progressed alongside hands on care. Footwear/orthotics, posture and ergonomic advice may also need to be taken into account.
Supplements?...
On to the tricky topic of supplements and if they work... From my research and experience so far:
Glucosamine/Chondroitin Sulfate- may work if starting it before degenerative changes start taking place. Some of my patients have stated they feel better taking this, even after symptoms occur, others don't feel much different.
Turmeric/Curcumin- shown to have an anti-inflammatory effect, which in one study was shown to be as good as anti-inflammatory medication (NSAIDs) for knee osteoarthritis. More evidence is likely needed still.
Omega-3 fish oils/Cod-liver oil- again associated with decreased inflammation to help joint pains. Potentially worth taking if you don't get much omega-3 in your diet (from fatty fish and other sources).
Vitamin D- very important supplement which can help in decreasing joint pains alongside a number of other symptoms. Especially worth taking in Autumn/Winter and worth having your blood levels checked as many people in the UK are deficient.
Other supplements which may be tried include: Ginger, Boswellia, Capsaicin and more!
Overall, the other lifestyle factors mentioned above are more important to start with as a baseline (and less expensive). If patient's are keen to try supplements I recommend trying them for a few months first to see if they feel it makes a difference for them as an individual.
Other types of arthritis...
There are many different categories of arthritis, so not all arthritis is 'osteoarthritis'.
Other types of arthritis include: Rheumatoid Arthritis, Ankylosing Spondylitis, Psoriatic Arthritis, Enteropathic Arthritis and Reactive Arthritis, which can all affect different joints and systems of the body. Treatment and management therefore differs for these types of arthritis.
Further information:
'The Back Pain Podcast'- great Podcast by two Chiropractor's I was at uni with about all things joint pain related, including arthritis!
The Physio Matters Podcast- 'Wear are we with Osteoarthritis'