Osteoarthritis/Degenerative Joint Disease
Osteoarthritis or Degenerative Joint Disease is the most common cause of joint problems. Chronic wear and tear on our joints is the underlying mechanism for osteoarthritis. It is inevitable that there will be some degenerative change in our joints over our life time. Up to 85% of people over 65 show some evidence of osteoarthritis on X-ray. About half of these individuals experience symptoms. Symptoms of osteoarthritis include problems of pain, decreased mobility and decreased functional capacity of certain joints. Conventional medicine labels this problem as arthritis. The label given to the arthritis depends on the individuals’ symptoms and physical exam, the laboratory and x-ray findings and the pathological findings on joint fluid analysis or biopsy.
The healthy joint is designed to provide painless movement with stability and flexibility. There are several important joint structures.
- The synovium is a membrane that surrounds the joint. It secretes a fluid called the synovial fluid that lubricates the joint and provides nutritional support for the cartilage.
- Cartilage is a specialized tissue that covers the ends of the bone. It contains a high percentage of water (85%). It is very slippery and thus minimizes the friction that occurs with movement of bone on bone. The high water content is made possible by specialized protein molecules called proteoglycans. Proteoglycans have the special ability to bind water and are one of the primary building blocks of cartilage. As we age our cartilage loses the ability to bind water. It becomes less slippery, stiffer and more brittle.
- Collagen is the main protein of the connective tissue found throughout the body. It is an important structural component of muscles, ligaments and tendons as well as cartilage. The combination of the collagen meshwork (water tightly bound by proteoglycans) creates a compression resistant slippery pad of cartilage.
Osteoarthritis is characterized by degenerative changes that include:
- A change in the chemical structure (fluid accumulation, loss of the building blocks of cartilage)
- This results in a physical change in the cartilage (fissuring and pitting of the surface and a loss of elasticity
- This leads to thinning and progressive destruction of cartilage
- This is often accompanied by inflammation of the synovial membrane and synovial fluid
- Clusters of damaged cells or fluid-filled cysts may form around the bony areas or near the cracked and fissured cartilage
- Bone cells often respond to the damage and stress by overgrowing and forming “spurs” or osteophytes and overgrowth of the joint margins.
Factors that Contribute to Osteoarthritis
Researchers think that genetic factors may be involved in 30-60% of people with osteoarthritis. There may be a genetic defect that results in the breakdown of cartilage.
There appears to be a strong correlation between joint utilization and osteoarthritis. Individuals who do manual labor where there is intense repetitive activity are more prone to degenerative joint disease than white collar workers. Excessive exercise such as high intensity, competitive, athletics is often associated with an increased incidence of degenerative arthritis. Moderate exercise, however, has been shown to prevent osteoarthritis of the knees by maintaining muscle strength of the large thigh muscles (quadriceps).
A significant factor is use and overuse superimposed on structural vulnerability. An imbalance of the weight bearing surfaces of the knees can result in arthritic changes. This may occur as a result of leg length inequality, imbalance of the feet, muscle weakness or prior injuries. Excess body weight is a significant contributor to wear and tear leading to osteoarthritis of the spine and joints of the lower extremities.
Therapies for Osteoarthritis
Common Sense: Avoid the repetitive activities that activate symptoms. Find new ways of doing activities that activate symptoms. Find new activities that accomplish the same goal without activating symptoms.
Exercise: Conventional medicine and integrative medicine agree that exercise can be an invaluable component to a preventive and or treatment program. A wide variety of exercise programs have proven beneficial. Please refer to the section on exercise and activity. Regular walking and light jogging are associated with a reduced incidence of osteoarthritis of the knees. Yoga has been used to help people with osteoarthritis of the hands, spine and lower extremities. Strength training programs have been useful for people with arthritis of the neck, shoulder and low back. Whole body vibration therapy has been shown to be helpful for spinal arthritis and arthritis of the hips, knees, feet and even shoulders.
Biomechanical and Postural issues: Many people create imbalance and stress on their joints from the way in which they sit, stand or perform their daily activities. Individuals who experience joint pain would do well to visit a therapist who can analyze their posture and the way in which they perform their daily activities. Therapists who utilize the Alexander technique are particularly effective in helping people in this way. Orthotic devices to improve foot balance and weight distribution when walking and standing can be very effective in reducing arthritic pain in the feet, ankle, knees, hips and spine.
Diet: Food sensitivity can play a role in chronic musculoskeletal pain. A trial of avoidance is an inexpensive and effective way to test for this possibility. We will often recommend a low antigenic diet (Oligo-antigenic diet/Elimination diet) for two to three weeks. It is always pleasantly surprising to see how often people benefit from simplifying their diet. Weight loss can be very effective in reducing the pain and disability from osteoarthritis. It should be an integral part of any therapeutic program.
Prescription Medications: In general, OTC and prescription medications are effective in controlling symptoms but do little to modify the progress of the degenerative joint problem. In addition, these products can produce significant adverse health effects.
Acetaminophen: this is the active ingredient in a variety of OTC medications (Tylenol, Anacin-3). This product has been shown to produce pain relief as effectively as aspirin type medications for many people. It has side effects that must be respected. One study estimates that up to 5,000 cases of kidney failure yearly are related to the heavy use of acetaminophen. Taking just one pill a day over the course of a year can double the risk of kidney disease. The use of this drug can result in liver damage. The risk of liver injury is enhanced if the individual consumes alcohol while taking acetaminophen.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
These are the most commonly used medications for arthritis. They are available OTC and by prescription. They include aspirin, ibuprofen and naproxen along with many other prescription NSAIDs. This family of drugs can be very effective in controlling pain. They do not modify disease progression. They can cause gastrointestinal tract damage with stomach ulceration and bleeding. They can cause kidney damage. They can aggravate high blood pressure and congestive heart failure. Other side effects include dizziness, ringing in the ears, headaches, skin rashes and possibly depression. NSAIDs are responsible for more than 100,000 hospitalizations and 16,500 deaths in the US every year.
A new sub group of NSAIDs are known as Cox-2 inhibitors. This subgroup includes Celebrex. They have been shown to be less likely to cause stomach ulcers. They work as well, but not better than the old group of NSAIDs. They have adverse effects on kidney function, can raise blood pressure and may worsen heart failure in vulnerable individuals. They are considerably more expensive than the older class of medications.
Narcotics: Narcotics may be useful in pain management for individuals who have persistent and disabling pain despite trying the other medications.
Cortisone: Long term, oral cortisone use is not recommended. Injections into local areas may be useful to facilitate recovery or in resistant pain situations.
In general, use of OTC or prescription medications is best on a short term basis when possible.
Complementary/Alternative Strategies to improve joint health:
Glucosamine Sulfate: this product has been studied extensively. It appears to provide significant benefit in people with osteoarthritis in terms of pain relief and the reduction of progression of degenerative changes in the cartilage. The recommended dose is 1,500-2000 mgs per day. It can be taken at one time or in two to three divided doses. It can be taken with food. It takes 8-12 weeks to know if their will be a symptomatic benefit. There is confusion as to whether chondroitin sulfate is better than glucosamine or whether using both together is better than using either one alone. There is no literature to suggest that chondroitin sulfate is better than glucosamine. There is no evidence that taking them together is better than taking either one alone. Glucosamine is less expensive. Glucosamine is the product proven to increase cartilage quantity and quality. I generally advise a trial of Glucosamine alone.
Niacinamide: Niacinamide is a form of Vitamin B3. It is a different molecule from Niacin which is commonly recommended for treatment of elevated cholesterol, low HDL cholesterol and elevated Lipoprotein A. Studies demonstrating the benefit of Niacinamide were first done by William Kaufman, MD fifty years ago. Recent studies done at the National Institutes of Health confirmed that Niacinamide is beneficial for people with osteoarthritis. In that study, 72 patients with OA of at least five years' duration were randomly assigned to receive niacinamide (500 mg six times per day) or a placebo for 12 weeks. Outcome measures included global arthritis impact, pain, joint mobility and erythrocyte sedimentation rate (ESR). Global arthritis impact improved by 29 percent in patients receiving niacinamide and worsened by 10 percent in patients given placebo (p = 0.04 for difference between groups). Although pain levels were no different in the two groups, patients on niacinamide reduced their anti-inflammatory medication by 13 percent, compared with a slight increase in medication in the placebo group (p = 0.014 for difference between groups). Niacinamide reduced the ESR by 22 percent compared with placebo (p < 0.005) and increased joint mobility (as measured by the joint range index) by 8.0 degrees, compared with 3.5 degrees in the placebo group (p = 0.04). Niacinamide's delayed onset of action, its capacity to induce progressive improvement, and its gradual (as opposed to abrupt) loss of effect after treatment is discontinued, suggests this vitamin somehow helps control OA, rather than merely relieving symptoms. Although its mechanism of action is not known, niacinamide does not appear to act merely as an anti-inflammatory agent or analgesic. Kaufman observed niacinamide was most effective when taken in frequent, divided doses. Thus, 250 mg taken six times per day was more effective than 500 mg taken three times per day. The need for frequent dosing is presumably related to the short half-life of the vitamin. Niacinamide’s effect may be enhanced when taken with N-acetyl-cysteine, an anti-oxidant precursor. The recommended dose is 500 mgs taken 4-6 times per day. One must take it for at least 8 weeks to determine benefit. Periodic monitoring of liver function tests is recommended when taking niacinamide. A product called Allopars contains Niacinamide and N-acetyl Cysteine in a balanced dose. The dose is one capsule, three times per day with meals.
Vitamin E has been shown to be beneficial in people with osteoarthritis. In one study, twenty-nine patients with osteoarthritis at various sites were randomly assigned to receive (single blind) 600 mg of Vitamin E (type not specified) per day or a placebo for ten days, and then the alternate treatment for an additional ten days.27 Fifty-two percent of the patients reported a reduction in pain while receiving Vitamin E, compared with only 4 percent receiving placebo (p < 0.01). In another study, 53 patients with osteoarthritis of the hip or knee were treated for three weeks with Vitamin E (d-alpha-tocopherol acetate 400 mg three times per day; equivalent to approximately 600 IU three times per day) or diclofenac (50 mg three times per day).28 Both treatments appeared to be equally effective in reducing the circumference of knee joints and walking time, and in increasing joint mobility. Although the mechanism of action of Vitamin E against osteoarthritis is not known, this vitamin has been reported to have anti-inflammatory activity29 and may also inhibit prostaglandin synthesis. In addition, Vitamin E may help stabilize lysosomal membranes, thereby inhibiting the release of enzymes believed to play a role in the pathogenesis of osteoarthritic joint damage. I recommend that an individual use a mixed Tocopherol rather than the d-alpha tocopherol acetate.
SAMe: S-adenosylmethionine is a metabolite of an essential amino acid called methionine. Studies have shown that SAMe stimulates the production of proteoglycans by human chondrocytes. SAMe has been demonstrated to be as effective as prescription NSAIDs in clinical trials performed in Europe. The dose used is 1,200 mgs. This dose was found to be effective and safe. Unfortunately, it is very expensive. The lowest effective dose in the published literature is 400 mgs per day taken as 200 mgs two times per day. It takes about 4 weeks to see benefit. This is an effective supplement but an expensive one.
Ginger: Ginger is an herb that has medicinal benefits as well as culinary value. Good research has shown that it is as effective as many of the nonsteroidal anti-inflammatory drugs. It has inhibitory effects on cyclooxygenase, lipooxygnease and tumor necrosis factor alpha. These are chemical mediators that promote inflammation and joint destruction. It has no significant side effects or contraindications other than individual intolerance. It is inexpensive. The therapeutic dose is 250 mgs one to three times per day. When taking an herbal product for therapeutic reasons it is best to take it on an empty stomach; on hour before eating or two hours after eating. This is a preferred product because of its safety, effectiveness and low cost. The quality of the product is essential to a good therapeutic outcome.
Curcumin: Curcumin is an herb with both culinary and therapeutic properties. Like ginger, it has been demonstrated to have anti-inflammatory properties. It has been used in CAM for some time. It does not benefit from double blind placebo controlled trials as the use of ginger does. Nevertheless, it is often combined with ginger in formulas that support healthy joint function. The dose is 250 mgs two to three times per day.
Enzyme Therapy: Oral enzyme therapy is used widely in Europe for reducing the pain of arthritis and for reducing the destructive, inflammatory changes of arthritis. The most popular product is Wobenzyme; produced in Germany. The recommended dose is 3-6 tablets 3-4 times per day between meals. A therapeutic trial lasting 4-6 weeks is necessary to achieve benefit.
Pycnogenol is an extract from Maritime Pine Bark. It has excellent double blind studies showing benefit for osteoarthritis in a dose of 50-100 mgs twice daily with food.
The best strategy for the person with osteoarthritis is one that combines appropriate life style changes with the use of products like glucosamine sulfate, ginger, Pycnogenol, SAMe and Wobenzyme. The prescription and OTC NSAIDS can be used for breakthrough symptoms on an episodic basis or in individuals who do not respond to the natural products.