Osteoarthritis is all around, affecting millions of families with more impact than most people realize. According to the Arthritis Foundation, more than 54 million adults are affected by arthritis, and out of this figure, 31 million of the cases are osteoarthritis. (1)
These statistics make osteoarthritis the most prevalent joint disorder and the leading reason for undergoing total hip replacement. What is more worrying is that these figures are expected to rise due to the ageing population and the obesity epidemic. (2)
What is osteoarthritis?
Osteoarthritis is a degenerative joint disease that occurs when the quality of cartilage deteriorates. Cartilage is a resilient rubber-like material that pads and protects the ends of the long bones. It has several functions that include reducing friction to help the joints move smoothly, acting as a cushion during movement to prevent bones from grinding against one another and giving tensile strength to bear body weight. (3)
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It is possible that osteoarthritis can affect any joint in the body, but the knees, hands, hips and spine are the most commonly affected.
What are the causes of osteoarthritis?
Osteoarthritis is caused by inflammation, breakdown and loss of cartilage of the joints. It is a slow process that in the end makes the cartilage becomes rough, wear down and the bones are left rubbing each other. The friction then leads to irritation, pain and stiffness of the joints.
Who is more likely to have osteoarthritis?
Certain factors play a role in the development of osteoarthritis particularly on the weight-bearing joints, thus putting specific people at a higher risk. (4)
- Adults 60 years or older is one of the strongest risk factors for osteoarthritis. It is probably because of the biological changes that come with age. The cartilage thins, muscles become weak, there is limited mobility and oxidative damage by free radicals, which all make the joints less able to cope with adversity and friction.
- Female gender, especially after menopause, has led experts to believe that estrogen plays a crucial role in bone health. (5) It inhibits bone resorption (the process by which bone cells break down to release minerals, to transfer minerals to the blood). Therefore, when estrogen levels go down after menopause, bones resorb more, are left brittle and prone to injury and inflammation.
- Being overweight or obese. The extra weight puts more stress on the weight-bearing joints like the hips and knees and hastens the breakdown of cartilage. In normal circumstances, a force that is almost 3 to 6 times is exerted on the knees when walking. This means that excess weight increases the effect even further. Moreover, fat tissue induces cartilage degradation by releasing harmful proteins that cause inflammation around the joints. (6)
- Knee injury such as when playing sports or in an accident
- Family history of osteoarthritis
- Congenital abnormalities that cause misalignment of the joints
- Bone misalignment problems such as knock-kneed or bow-legged
- Insufficient intake of Vitamin D and calcium makes the bones brittle, thin and misshapen.
- Repetitive use of joints at work such as in cotton mill workers
What are the common signs and symptoms?
The signs and symptoms of osteoarthritis are mostly related to the inflammation process on the joints. (7) They develop slowly and worsen over time if not well managed. Early in the disease process, the joints may just ache after physical work or exercise then later, the pain worsens and becomes more persistent.
Other signs and symptoms include:
- Pain on the affected joint that worsens during or immediately after movement. The joint may also be tender when light pressure is applied to it.
- Stiffness of the joints that is most noticeable after an extended period of inactivity such as when waking up
- Loss of flexibility as one does not enjoy the full range of motion
- Grating sensation when moving
- Hard lumps (bone spurs or osteophytes) may form around the affected joint
How is osteoarthritis diagnosed?
A diagnosis of osteoarthritis is made through a combination of clinical history, physical examination, imaging and laboratory tests. Through taking a clinical history, a clinician asks about the symptoms, when they started, and how they have changed. They may also ask whether there is a history of trauma on the affected joint or if there is a family history of joint problems.
In physical examination, the doctor examines the affected joint(s) by assessing for tenderness, swelling, redness and range of movement.
For imaging tests:
- X-rays are the most useful in confirming a diagnosis of osteoarthritis. They show changes such as degeneration of cartilage, narrowing space between the bones, bone spurs and whether calcium has settled on the joint.
- Magnetic Resonance Imaging shows detailed images of bone tissue and cartilage. The main difference between an X-ray and MRI is that although the X-ray shows cartilage deformations, it does not show the cartilage itself whereas an MRI shows the cartilage, bones and other soft tissues. MRI may therefore be needed to see what cannot be seen on a standard X-ray such as a torn meniscus.
Laboratory investigations that are ordered include:
Arthrocentesis (Joint Aspiration) is done to obtain synovial fluid from the joint, which then undergoes synovial fluid analysis to find out causes of joint pain or arthritis. The procedure is done by inserting a sterile needle into the space between the joints then a viscous fluid is drawn.
Blood tests- there are no specific blood tests for osteoarthritis, but there are those that can help to distinguish other forms of arthritis such as rheumatoid arthritis.
- A complete blood count (CBC) evaluates red and white blood cells, and may also be needed to assess the side effects of osteoarthritis treatment.
- Rheumatoid Factor (RF) is the test of choice to differentiate rheumatoid arthritis from other forms of arthritis.
- Erythrocyte Sedimentation Rate (ESR) is not affected in osteoarthritis but is elevated in rheumatoid arthritis.
What are the treatment options for osteoarthritis?
The mainstay of osteoarthritis treatment is to control the signs and symptoms through medications, physical therapy, lifestyle modifications and possibly surgery. The type of approach chosen depends on the severity of pain and whether the condition limits daily activities.
Analgesics to provide pain relief. Acetaminophen (paracetamol) works for mild to moderate pain. However, it should be noted that one should not take more than 4000mg per day as it can cause liver damage. (8) Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, naproxen and diclofenac will reduce inflammation alongside relieving pain. The downside of NSAIDs is that prolonged intake of high doses predisposes one to peptic ulcer disease and cardiovascular conditions. (9) For long-term use, topical NSAIDs may be preferred as they work effectively and have fewer side effects.
Opioids such as codeine and morphine are necessary for moderate to severe pain. They are usually combined with acetaminophen.
Topical capsaicin is a safe, natural alternative to analgesics. (10) It is derived from the active compound of cayenne peppers. That is the compound that is responsible for the spicy hot taste of peppers. Capsaicin works by stimulating the release of Substance P, a chemical that responds to pain stimulation. Topical capsaicin has to be applied 3 to 4 times per day for several weeks, for it to be effective.
Duloxetine (Cymbalta) a drug that is used for depression and anxiety, is also recommended for chronic pain such as neuropathic and osteoarthritis pain.
Corticosteroid injections may be injected into the joint under local anesthesia, to offer quick relief of inflammation, swelling and pain. The injections are limited to 3 to 4 every year since they can cause damage to tendons, bleeding, and skin color changes.
Hyaluronic acid injections deliver hyaluronic acid, a substance that breaks down in people with osteoarthritis. When injected into the affected joint, it aids in lubrication and increases mobility.
Glucosamine and chondroitin supplements: although there is no sufficient scientific evidence backing these supplements, some studies suggest that they can help to alleviate the symptoms of osteoarthritis. (11) Glucosamine and chondroitin are both naturally found in cartilage and synovial fluid, where they maintain flexibility of joints by sustaining fluid quality and building cartilage.
Surgical interventions are necessary when there is severe joint damage, unbearable pain that does not respond to other treatments or when there is very limited mobility. These procedures are thus done with the objective of reducing pain and improving mobility.
Arthroscopic surgery is often performed to visualize, diagnose and treat osteoarthritis. It allows the doctor to view the joint, without making a large incision. Using an arthroscope to guide the surgical instruments, the doctor repairs cartilage tears, removes badly damaged parts and smoothens bone surfaces.
Joint replacement is done to replace damaged joints with artificial ones. The hips and knees are the most commonly replaced, followed by shoulders, fingers, elbows and back joints. The doctor removes the damaged cartilage and bone then places prosthetic material that may be metal, plastic or ceramic.
Knee osteotomy is done to change bone alignment to transfer stress or weight to the healthy side of the joint. That means that osteotomy will be successful if it’s just one side of the joint that is damaged. In knee osteotomy, a wedge of the femur (thighbone) or tibia (the larger bone of the lower leg) is cut then reshaped to distribute weight more evenly. The most common reason for knee osteotomy is usually either in bow-legged alignment or knock-kneed alignment.
Arthrodesis, also known as joint fusion involves joining of two bones on the ends, to get rid of the joint. It is an option when the joint has been severely damaged, and joint replacement will not be effective. After the procedure, the joint loses its flexibility, but it is more stable, bears weight better, and there is no more pain.
Physical therapy helps one to find the balance between movement and rest. Without this balance, the muscles surrounding the knees may become weak, and the joint stiffness worsens. Physical therapy also makes it bearable to walk, sit, squat, bend and kneel. It involves both active and passive treatment approaches. In passive therapy, the therapist does most of the work like applying heat or cold compressions on the joints. In active therapy, the therapist guides and supervises strength and flexibility exercises that help to restore normal joint function.
Occupational therapy is helpful especially if daily activities like using a kitchen knife or toothbrush are quite painful. The occupational therapist helps in such cases to maximize one’s ability in performing routine activities and improving the quality of life. Occupational therapy involves the use of assistive devices like custom-fitted splints and learning how to perform tasks in ways that protect joints and are less painful. The best time to start seeing an occupational therapist is right after the diagnosis is made.
Yoga– the gentle stretching and meditation done during yoga alleviates pain, helps to maintain flexibility without causing excessive strain, and decreases tension that is routinely held in the muscles. (12) The awareness and breathing techniques in a yoga session calm the stress response that is activated by pain and inflammation. The movements are also helpful in learning proper alignment of the skeleton, thus helping to minimize pressure on the already achy areas.
Exercise is considered to be one of the most effective non-drug treatments for lowering pain and improving movement. This is because regular exercise strengthens muscles around the joints, reduces stiffness and gradually, increases mobility. Even more, to other body parts exercise maintains a healthy level of blood circulation, assists in building endurance, improves sleep and general mood.
The key thing to have in mind before exercising is to ensure that the exercise is done correctly in the right posture since incorrect form will only worsen the condition. It is thus vital to work with a physical therapist or exercise trainer, to determine the level of activity required, and most importantly, to ensure that the exercises are correctly done.
Losing weight through exercise and a well-portioned balanced diet can significantly help to lessen the symptoms and prevent complications of osteoarthritis. Losing even a few kilos relieves a significant level of pressure and pain on the weight-bearing joints. The process may be slow and frustrating, but in the long run, it is worthwhile.
A healthy diet has substantial health benefits for individuals with osteoarthritis. The very first modification is to cut the extra calories by taking smaller portions of food, avoiding high-fat, sugar and sodium foods. Eating more fruits and vegetables increases the level of antioxidants, which protect cells from free radical damage. Omega 3 fats also indirectly help to reduce inflammation and morning joint stiffness.
5.Other home remedies
Heat compressions relieve joint stiffness by promoting vasodilation and relaxation of smooth muscles around the joints. Moist heat pads can be purchased from a drug store, but a cheaper alternative is to slip a wet washcloth in a freezer bag then heat it in the microwave for a few seconds. Then wrap with a towel and gently press on the affected joint for 10 to 20 minutes. A warm bath or shower is also helpful.
Cold compressions relieve muscle spasms by slowing down circulation, reducing swelling and numbing nerve endings that relay pain signals to the central nervous system. If it’s the joints of the hand that are affected, dipping them in a bowl of ice and water works. For other joints, use icy gel packs.
Knee taping is particularly helpful for knee osteoarthritis. A tape is strategically positioned to align the knee in a stable position. The precise location of the tape requires the expertise of a physical therapist who then teaches the patient on self-management at home.
If osteoarthritis makes it hard to walk, then assistive devices such as braces, canes, crutches and walkers may be fitted. Other changes to consider include:
- At home, keep pathways clear and add extenders to doorknobs to make it easy through doors
- Use seats that are well raised by adding raisers if they are too low
- Buy clothes that are easy to wear, have larger buttons and slip on shoes
- For the bathroom, use a raised toilet and install grab bars in the bathroom
- Avoid bending wrists, especially when working on a computer
Can osteoarthritis be prevented?
Modifying the risk factors that we discussed above reduces the possibility of developing arthritis or preventing the subsequent pain and disability that sets in once the joints have suffered some degree of damage. Most of the modifiable risk factors are simple lifestyle changes that can add years to both life and joint health.
Staying active by exercising helps increase endurance and strengthen muscles, making the joints more stable. Focus on getting not less than 300 minutes of moderate intensity exercise (such as walking) each week.
Maintaining a healthy weight that is indicated by a Body Mass Index (BMI) that is within normal ranges (18.5 to 24.9). (13)
Get at least eight hours of rest per day. It helps to maintain a balance between use and disuse of joints.
Eat right by controlling food portions, limiting saturated and trans fats, processed sugars and high-fat dairy. Instead, opt for fresh veggies, fruits, whole grains, lean meats, beans, nuts, and low-fat dairy.
If in sports, wear protective gear to avoid injuries. An injured joint is at higher risk of osteoarthritis compared to a non-injured one.
Use safe lifting techniques both at home and at work. Use the strongest joints and muscles for lifting and carrying. For instance, do not lift by bending forward. Instead, bend the hips and knees then squat down to the load and straighten the legs to raise it.
Use the right sitting posture by ensuring that the back is straight and shoulders back. The buttocks should be touching the back of the chair, knees bent at right angle and feet flat on the floor.
Finally, control blood sugar since diabetes is a significant risk factor for developing osteoarthritis.